Shenandoah Senior Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Shenandoah, Pennsylvania.
- Location
- 101 E. Washington St, Shenandoah, Pennsylvania 17976
- CMS Provider Number
- 395556
- Inspections on file
- 28
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Shenandoah Senior Living Community during CMS and state inspections, most recent first.
A resident admitted with COPD, hyperlipidemia, and hypertension had a face sheet from a prior facility indicating Full Code status, but this code status was not entered into the facility’s system. When the resident was later found unresponsive by two CNAs, one of whom was not CPR/AED certified, they summoned an RN instead of starting CPR. The RN documented absent pulse, blood pressure, respirations, and fixed, dilated pupils, and directed staff to check the code status, which was not found in the electronic record, but did not initiate CPR. An RN supervisor subsequently assessed the resident, confirmed absent vital signs and no documented DNR or POLST, contacted the physician about the death, and also did not initiate CPR. Staff interviews and record reviews showed that licensed staff were unaware of key elements of the CPR policy, including signs of irreversible death, and that many other residents had orders for CPR, resulting in an Immediate Jeopardy situation for residents who desired resuscitation.
A resident admitted with COPD, hyperlipidemia, and hypertension had a transferred face sheet indicating Full Code status. When the resident was later found unresponsive, pulseless, and without respirations, staff documented no DNR or POLST and no signs of irreversible death. A CNA present was not CPR/AED certified and did not start CPR, and neither the RN nor the RN supervisor—both current in CPR certification—initiated resuscitation, despite facility policy and state nursing standards requiring CPR in the absence of a DNR. As a result, the resident did not receive CPR or other life-sustaining interventions consistent with their documented Full Code status.
The facility failed to ensure an effective CPR system when a Full Code resident was found unresponsive with no pulse, blood pressure, or respirations, and fixed, dilated pupils, but without any documented DNR, POLST, or irreversible signs of death. Despite facility policy and AHA guidelines requiring CPR initiation when code status is unclear, licensed nursing staff deferred CPR while attempting to verify code status. Staff interviews showed they lacked understanding of irreversible signs of death and were unaware of a functional CPR team, and the DON acknowledged that CPR policies and education did not ensure staff competency. The Administrator and DON, whose roles include ensuring regulatory compliance, quality care, and effective nursing policies, did not administer the facility in a manner that ensured timely CPR in accordance with physician orders and resident wishes, resulting in Immediate Jeopardy.
Surveyors found that physician orders for two residents did not match their most current, signed POLST forms regarding code status. One resident's order indicated Full Code while the POLST indicated DNR, and another's order indicated DNR while the POLST indicated Full Code. These discrepancies were confirmed by the Regional Nurse Consultant.
A resident with an above-the-knee amputation, dementia, and moderate cognitive impairment was transferred by a single nurse aide, despite physician orders and the Kardex requiring two-person assistance. The aide relied on the resident's verbal response rather than the documented care plan, leading to a fall in the bathroom and subsequent pain and swelling in the resident's ankle. Facility records confirmed the staff member did not follow the required transfer protocol.
A resident with cognitive impairment and mobility limitations was transferred by a single nurse aide, contrary to care plan requirements for two-person assistance, resulting in a fall and injury. The incident, determined to be neglect, was not reported to the state agency within the required timeframe, as confirmed by the facility's administrator.
Nursing staff did not ensure that physician orders for lab monitoring and specialist consults were carried out for two residents, resulting in missed PT/INR testing for a resident on warfarin and lack of follow-up with urology and infectious disease for a resident with a Foley catheter and abnormal urine results. Documentation was incomplete and nursing actions were not consistent with professional standards.
The facility did not provide required training on its abuse prohibition policy to an agency LPN before the nurse began resident care duties, nor was there documentation of annual or as-needed training, as required by facility policy. The Nursing Home Administrator confirmed the lack of documentation for this mandated training.
The facility did not meet the required nurse aide to resident ratios on several shifts, as revealed by staffing records. On specific dates, the day, evening, and night shifts had fewer nurse aides than required for the census, with no additional higher-level staff available to compensate. The Director of Nursing confirmed these deficiencies.
The facility did not meet the required LPN to resident ratio on several shifts, as staffing records showed insufficient LPNs on both day and night shifts. The Director of Nursing confirmed the shortfall, and no additional staff were available to cover the deficiency.
The facility did not consistently provide the required 3.2 hours of direct nursing care per resident per day, as evidenced by staffing levels on six out of seven days reviewed. The DON confirmed the shortfall in staffing hours.
A resident with severe cognitive impairment and high fall risk experienced repeated falls from a Broda chair due to inadequate supervision and ineffective fall interventions. Despite known unsafe behaviors and a history of agitation, the facility's measures, such as chair alarms and staff supervision, were insufficient in preventing falls, leading to minor injuries. Interviews with staff confirmed the facility's failure to provide appropriate care and supervision.
The facility failed to provide sufficient nursing staff, resulting in repeated falls for two residents at high risk and long wait times for care for another resident recovering from hip surgery. Staffing records showed consistent failure to meet state minimum requirements for direct care hours and staff ratios. Residents reported long wait times and missed care due to staff shortages.
The facility failed to isolate two residents after one tested positive for COVID-19, leading to the second resident also testing positive. Additionally, a resident was not offered COVID-19 immunization despite no contraindications. The DON, covering infection preventionist duties without certification, confirmed these deficiencies.
The facility failed to follow pharmacy procedures for controlled drug reconciliation on two medication carts. LPNs did not sign the shift change controlled count sheets as required, which was confirmed by staff interviews. The DON expected staff to sign the logs to identify discrepancies.
A facility failed to ensure accurate MDS assessments for a resident who was discharged. The MDS indicated discharge to a hospital, but records and staff confirmed the resident went home. Interviews with the RNAC and Administrator confirmed the inaccuracy.
A resident with dementia and a history of falls did not receive proper fall prevention measures as outlined in their care plan. Observations showed the resident's bed was not in the lowest position, floor mats were incomplete, the call bell was out of reach, and the bed alarm was disconnected and non-functional. These deficiencies were confirmed by staff and the NHA.
A resident with mobility issues was not provided restorative nursing services until 10 days after discharge from physical therapy, despite recommendations for continued care. This delay was confirmed by facility staff, highlighting a lapse in maintaining the resident's functional abilities.
A resident experienced significant weight loss, but the facility failed to consistently monitor and record weekly weights as per policy. This oversight was confirmed by both the Registered Dietician and the Nursing Home Administrator, who acknowledged the facility's responsibility to assess and address the resident's nutritional needs.
A resident with dementia was administered Amoxicillin for a UTI despite a urine culture showing resistance to the prescribed antibiotic and no documented symptoms of infection. The DON confirmed the lack of clinical justification for the medication, highlighting a failure to ensure the resident's drug regimen was free from unnecessary antibiotics.
The facility failed to designate a qualified Infection Preventionist (IP), leading to the transmission of COVID-19 between two residents. The Director of Nursing (DON) had been covering IP duties without certification until late August, resulting in inadequate infection control practices.
A resident with cerebral infarction and hemiplegia was found without access to a call bell, which was on the floor and out of reach. The resident was dependent on staff for all care. An LPN confirmed the call bell's inaccessibility, and the DON acknowledged that call bells should be within reach.
The facility failed to provide timely responses to residents' requests for assistance, as reported by six out of eight interviewed residents. Extended wait times for staff assistance, particularly during the night and evening shifts, led to instances of residents soiling themselves and feeling neglected. The Nursing Home Administrator acknowledged the issue but could not provide an explanation for the delays.
The facility failed to address and resolve resident complaints and grievances, particularly those raised during resident group meetings about food temperature and staff response times to call bells. Despite the facility's policy requiring prompt grievance resolution, there was no evidence of action taken to address these concerns, as confirmed by interviews with the DON and NHA.
The facility failed to serve appetizing food at palatable temperatures, as reported by multiple residents. Issues included cold and overcooked food, missing temperature documentation, and unresolved complaints despite being raised in meetings.
The facility failed to promptly resolve and document grievances from a resident who reported being left on a bedpan for 1 hour and 45 minutes and experiencing long wait times for call bell responses. Additional complaints about the quality of food and care were also not logged, indicating a failure in the facility's grievance process.
A resident with cerebral infarction and COPD left the facility without notifying staff and was later found returning from a car wash. The facility staff were unaware of the resident's absence until approximately 12 PM, although the resident was not present for the morning medication pass at 10 AM. The Nursing Home Administrator confirmed that the facility had no knowledge of the resident's departure and could not determine the exact time or duration of the absence.
The facility failed to provide timely intravenous fluids as prescribed for a resident who tested positive for COVID-19 and showed a decline in medical status. Despite the physician's order for 1 liter of 0.9% normal saline solution, the resident received only 320 ml by the following day. The Assistant Director of Nursing confirmed the deficiency.
A resident with dementia and a history of falls experienced multiple falls from her wheelchair due to the facility's failure to develop and implement specific measures for her safety. Despite having a care plan, the resident's unsafe behaviors were not adequately addressed, leading to repeated falls and an injury.
The facility failed to timely identify and address a resident's decline in food and fluid consumption, leading to significant weight loss and clinical decline. Despite poor meal intake records, the dietitian did not re-evaluate or revise the resident's nutrition plan in a timely manner, contributing to the resident's significant weight loss and eventual hospitalization.
A facility failed to obtain prescribed stool samples for occult blood testing for a resident with multiple health conditions, leading to a deterioration in the resident's condition and eventual death. Despite multiple documented bowel movements, the required samples were not collected, preventing proper diagnosis and treatment.
Failure to Initiate CPR for Full Code Resident and Inadequate Staff Adherence to CPR Policy
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) in accordance with a resident’s advance directives, physician orders, facility policy, and American Heart Association (AHA) guidelines. The facility’s CPR policy required that when an individual is found unresponsive and not breathing normally, licensed or certified staff must initiate CPR unless there is a known Do Not Resuscitate (DNR) order specifically prohibiting CPR or obvious signs of irreversible death, such as rigor mortis. The policy also stated that if a resident’s DNR status is unclear, CPR must be started and continued until a DNR or physician order to withhold CPR is confirmed. AHA guidelines referenced in the policy distinguish presumptive signs of death (such as unresponsiveness, absence of respirations and pulse, fixed and dilated pupils, cool skin, and cyanosis) from conclusive, irreversible signs of death (such as livor mortis, decomposition, decapitation, and rigor mortis). Resident CR1 was admitted with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension. A face sheet from the referring facility, scanned into the electronic medical record prior to admission, documented the resident’s code status as Full Code, indicating a preference to receive CPR in the event of cardiac or respiratory arrest. A nursing note at admission documented baseline confusion, oxygen therapy, and dyspnea, and also noted that attempts to complete admission documentation were unsuccessful because family could not be reached to confirm code status and obtain the resident’s CPAP machine. Despite the presence of the referring facility’s face sheet indicating Full Code status, the resident’s code status was not documented in the facility’s system at the time of the incident. At approximately 2:30 AM, two nurse aides entered the resident’s room and found the resident unresponsive. One aide, who was not CPR/AED certified, did not initiate CPR and instead summoned a registered nurse (RN). The RN’s progress note documented that the resident was unresponsive to verbal commands and sternal rub, had no apical pulse, no obtainable blood pressure or oxygen saturation, one observed respiration, fixed and dilated pupils, and warm, dry skin. The RN did not initiate CPR and directed one aide to check the resident’s code status in the electronic record; the aide reported that no code status was documented. The RN then directed staff to call the RN supervisor. When the RN supervisor arrived, she documented that the resident was unresponsive, pale, with no blood pressure, no pulse oximetry reading, no apical or carotid pulse, no respirations, and no response to sternal rub, and that no DNR or POLST was located in the chart or electronic system. The physician was contacted regarding the resident’s death, and no CPR was initiated at any point, despite the absence of documented irreversible signs of death and the lack of any DNR order. Witness statements provided by staff were consistent in describing the resident as unresponsive with absent vital signs and fixed, dilated pupils, and confirmed that neither the RN nor the RN supervisor initiated CPR. The facility was unable to provide justification for the failure of these licensed nurses to initiate CPR for a resident who did not exhibit documented irreversible signs of death and who was later identified in the closed record as Full Code. Additionally, interviews with multiple LPNs revealed they were unaware of the facility’s policy provisions regarding a designated CPR team and could not identify signs of irreversible death, indicating that staff had not effectively received or understood the CPR policy requirements. Review of other residents’ records showed that 47 additional residents had current physician orders to receive CPR, and the facility’s failures placed these residents, along with Resident CR1, in Immediate Jeopardy to their health and safety.
Removal Plan
- Employee 1 (RN) and Employee 4 (Agency RN Supervisor) were educated on the Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes and were immediately suspended.
- The facility educated licensed clinical staff on revisions of the CPR policy, including how to respond when someone is unresponsive and when not to initiate CPR (obvious signs of irreversible death) and that if no code status is documented the resident is treated as full code.
- The facility used the payroll system to send the updated CPR policy to staff for electronic review and acknowledgment.
- Nursing education on the updated CPR policy and irreversible signs of death will continue to be completed with licensed staff prior to their next shift starting, beginning with 11pm to 7am shift staff.
- Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes and where to locate code status for each resident in Point Click Care (PCC), on the resident face sheet, and in the orders.
- The facility will ensure each licensed staff member is educated on irreversible signs of death so staff know when it is acceptable not to initiate CPR.
- Education will continue prior to each licensed staff member's next shift.
- Residents’ code statuses were confirmed as reflected in PCC on the resident’s face sheet and in the resident’s orders.
- The Director of Nursing (DON) or designee will audit EMR code status to validate consistency of records for staff reference.
- The DON or designee will audit CPR certification for licensed facility staff.
- The facility conducted a CPR class for employees who were unable to produce up-to-date CPR certification information.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to initiate cardiopulmonary resuscitation (CPR) for a resident who had documented Full Code status. State professional nursing standards and the facility’s CPR policy require licensed or certified staff to initiate CPR when an individual is found unresponsive and not breathing normally, unless there is a valid Do Not Resuscitate (DNR) order or clear signs of irreversible death. The Pennsylvania nursing regulations cited in the report specify that RNs are responsible for nursing care actions that promote, maintain, and restore well-being, and may perform resuscitation when respiration or pulse cease unexpectedly, provided the employer authorizes it by policy and the nurse is competent. The facility’s policy on Emergency Procedure–Cardiopulmonary Resuscitation and Basic Life Support directs staff to initiate CPR in such circumstances in the absence of a DNR or obvious post-mortem changes. The resident, identified as CR1, was admitted with diagnoses including COPD, hyperlipidemia, and hypertension, and was documented as having baseline confusion, requiring oxygen, and experiencing dyspnea. A face sheet from the referring facility, scanned into the electronic medical record one day prior to admission, indicated the resident’s code status as Full Code. A nursing progress note at the time of admission documented that attempts to complete admission documentation were unsuccessful because staff were unable to reach family to confirm code status, but there is no indication that this negated or superseded the Full Code designation on the transferred face sheet. Later that night, at approximately 2:30 AM, two nurse aides entered the resident’s room and found the resident unresponsive. A nursing progress note at 2:30 AM by an RN documented that the resident was unresponsive to verbal commands and sternal rub, had no apical pulse, and that staff were unable to obtain blood pressure or oxygen saturation. One respiration was observed, the pupils were fixed and dilated, and the skin was warm and dry. A subsequent note at 3:55 AM by the RN supervisor documented the resident as unresponsive, pale, without measurable blood pressure, respirations, or detectable apical or carotid pulse. No DNR order or POLST was found in the record at that time, and there was no documentation of rigor mortis, dependent lividity, or other signs of irreversible death. One nurse aide reported not being CPR/AED certified and therefore did not initiate CPR, and stated that neither the RN nor the RN supervisor initiated CPR at any time. Personnel records confirmed that both the RN and RN supervisor held current CPR certification. Based on the record review, staff statements, and training documentation, surveyors determined that the RN and RN supervisor failed to initiate CPR for a Full Code resident who was found unresponsive and pulseless, resulting in actual harm because life-sustaining interventions consistent with the resident’s documented treatment preferences and accepted nursing standards were not provided.
Failure to Implement Effective CPR System for a Full Code Resident
Penalty
Summary
The deficiency involves the failure of the Administrator and Director of Nursing (DON) to establish, implement, oversee, and enforce an effective cardiopulmonary resuscitation (CPR) system in accordance with federal requirements, facility policy, and American Heart Association (AHA) guidelines. The facility’s CPR policy required licensed or certified staff to initiate CPR when an individual was found unresponsive and not breathing normally, unless a valid Do Not Resuscitate (DNR) order existed or there were obvious irreversible signs of death. The policy also required that if code status was unclear, CPR must be initiated until a DNR or physician order not to resuscitate was confirmed, and that administrative systems ensure CPR readiness through staff education, competency, and adherence to AHA guidelines. AHA guidelines, as cited in the report, distinguish presumptive signs of death (such as unresponsiveness, absent respirations, absent pulse, fixed and dilated pupils, or cyanosis) from irreversible signs of death (such as livor mortis, rigor mortis, decomposition, or decapitation), with only the latter justifying not initiating CPR. Resident CR1 was admitted with diagnoses including chronic obstructive pulmonary disease, hyperlipidemia, and hypertension, and had a physician order identifying the resident as Full Code. A face sheet from the referring facility, scanned into the electronic medical record, confirmed the resident’s preference to receive CPR. On a specified date at approximately 2:30 AM, staff found the resident unresponsive. Nursing documentation showed the resident was unresponsive to verbal and painful stimuli, had no detectable pulse, no obtainable blood pressure or oxygen saturation, and fixed and dilated pupils. There was no documented DNR or POLST in the record at that time, and documentation did not reflect the presence of irreversible signs of death. Despite this, licensed nursing staff did not initiate CPR prior to notifying the physician. Facility-provided witness statements and staff interviews confirmed that licensed nursing staff deferred CPR while attempting to verify the resident’s code status, contrary to the facility policy requiring initiation of CPR when code status is unclear. Staff interviews also revealed a lack of understanding of irreversible signs of death and unawareness of any functional CPR team, despite policy language indicating such systems existed. The DON acknowledged that, at the time of the incident, the CPR policy had not been revised to clarify irreversible signs of death and that staff education had been conducted without ensuring comprehension or competency. As of the date noted in the report, the facility had not demonstrated that staff were competent to initiate CPR in accordance with resident wishes and AHA guidelines. The Administrator’s and DON’s job descriptions showed they were responsible for regulatory compliance, quality care, resident safety, and development and enforcement of nursing policies and procedures, but the failure to ensure timely initiation of CPR for this Full Code resident resulted in Immediate Jeopardy.
Inconsistent Physician Orders with Residents' POLST Code Status
Penalty
Summary
The facility failed to ensure that physician orders accurately reflected the residents' elected code status as documented in their most current, signed POLST forms for two residents. For one resident with dementia and diabetes, the physician order in the electronic health record indicated Full Code status, while the signed POLST indicated DNR status. This inconsistency was only corrected after surveyor inquiry, when a physician order for DNR was entered. Similarly, another resident with dementia and urine retention had a physician order indicating DNR status, while the signed POLST indicated the resident elected CPR and resuscitation. This discrepancy was also addressed only after surveyor questions, with a subsequent physician order for Full Code. The Regional Nurse Consultant confirmed that the physician orders did not align with the most current, signed POLST forms for these two residents.
Failure to Follow Two-Person Transfer Protocol Resulting in Resident Fall
Penalty
Summary
A facility failed to ensure the provision of care and services necessary to prevent a fall and maintain the physical health of a resident with significant medical needs. The resident, who had an above-the-knee right leg amputation, dementia, and a cognitive communication deficit, was assessed as requiring two-person assistance for all transfers according to both physician orders and the Kardex. Despite these documented requirements, a nurse aide transferred the resident alone after asking the resident if he needed one or two-person assistance and relying on the resident's response, rather than following the established care plan. During the transfer, the resident's leg slid, resulting in a fall in the bathroom. The resident experienced pain and swelling in the left ankle, which had not been previously injured, and received pain medication and an x-ray. Facility documentation and a root cause analysis confirmed that the staff member did not adhere to the required two-person assist protocol, directly contributing to the fall. The Nursing Home Administrator verified that the staff member failed to follow established protocols, placing the resident at risk.
Failure to Timely Report Resident Neglect to State Agency
Penalty
Summary
The facility failed to timely report an incident of resident neglect to the State Survey Agency as required by both facility policy and regulatory standards. Specifically, a resident with a history of right above-the-knee amputation, dementia, and cognitive communication deficit, who was assessed as requiring two-person assistance for transfers, experienced a fall in the bathroom after being transferred by a single nurse aide. The aide did not follow the resident's care plan or physician's order, instead relying on the resident's verbal response regarding transfer needs. The fall resulted in pain and swelling in the resident's left ankle, prompting a full assessment and x-ray order. Despite the facility's abuse policy mandating prompt reporting of neglect to appropriate agencies within five working days, the incident was not reported to the state agency at the time of occurrence or by the time of the survey interview. The Nursing Home Administrator confirmed that the event, which was determined through internal investigation to be neglect due to failure to follow transfer protocols, was not reported as required.
Failure to Follow Physician Orders for Lab Monitoring and Specialist Consults
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses properly evaluated and provided care according to physician orders for two residents. For one resident with atrial fibrillation and hypertension, there was a physician's order for warfarin therapy and regular PT/INR monitoring. Although a PT/INR test was ordered to be repeated in one week following a subtherapeutic result, there was no evidence that the required laboratory test was completed or that the result was available as ordered by the physician. For another resident with dementia, urine retention, and an indwelling Foley catheter, there were physician orders for urology consultation due to complications with the catheter and for follow-up with infectious disease after abnormal urinalysis and urine culture results. The clinical record did not show evidence that the required consults were called or that appointments were made, despite documentation of abnormal laboratory findings and physician awareness of these results. The resident later exhibited signs of infection and acute illness, leading to hospitalization for sepsis and renal failure. The deficiencies were confirmed through review of clinical records, facility policy, and staff interviews, which showed that nursing staff did not follow through with physician orders for laboratory monitoring and specialist consultations. Documentation was incomplete regarding the execution of these orders, and there was a lack of evidence that appropriate nursing actions were taken to ensure timely and adequate care as directed by the physicians.
Failure to Timely Train Agency LPN on Abuse Prohibition Policy
Penalty
Summary
The facility failed to provide timely training on its abuse prohibition policy and procedures to one agency LPN out of four employees reviewed. According to the facility's own policy, training on abuse prevention, identification, and reporting requirements must be provided at the time of hire, annually, and as needed. A review of the personnel file for the agency LPN, who began employment on November 19, 2022, showed no evidence that the required training was completed prior to the LPN assuming resident care responsibilities, nor was there documentation of annual or as-needed training thereafter. During an interview, the Nursing Home Administrator confirmed the absence of documentation verifying that the LPN received the mandated training at any point before or after starting assigned duties.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on multiple occasions, as evidenced by a review of staffing records. Specifically, on the day shift, the facility did not provide the minimum required number of nurse aides on December 4, 7, 8, and 10, 2024. The staffing levels were below the required ratios for the census on these dates, with the facility having fewer nurse aides than needed to meet the 1:10 ratio. Similarly, on the evening shift, the facility did not meet the 1:11 ratio on December 4, 7, and 9, 2024, with staffing levels again falling short of the required number of nurse aides for the census. Additionally, the night shift staffing was inadequate on December 7 and 10, 2024, where the facility failed to meet the 1:15 ratio. On these dates, the number of nurse aides was insufficient for the census, and no additional higher-level staff were available to compensate for this deficiency. An interview with the Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the specified dates.
Plan Of Correction
P5520 CNA Staffing Ratios 1. The facility is unable to correct CNA staffing ratios for December 4, 2024, December 7, 2024, December 8, 2024, December 9, 2024 and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and scheduler to ensure the CNA staffing ratios are adequate for the census. Staffing will be based on current census and supervisors or scheduler will contact other staff to cover call offs. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor or maintain ongoing compliance, the DON/designee will audit the schedule weekly x 4 weeks and biweekly x 4 to ensure the CNA staffing ratio has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on multiple occasions, as evidenced by a review of staffing records and staff interviews. Specifically, on December 8, 2024, the facility had only 3.00 LPNs on the day shift, whereas 3.68 LPNs were required for a census of 92 residents. Additionally, on December 5, 8, 9, and 10, 2024, the night shift was staffed with only 2.00 LPNs, falling short of the required 2.3 to 2.4 LPNs for resident censuses ranging from 92 to 96. The Director of Nursing confirmed these staffing deficiencies during an interview on January 3, 2025, and no additional higher-level staff were available to compensate for the shortfall.
Plan Of Correction
P5530 Nursing Services 1. The facility is unable to correct LPN staffing ratio on December 5, 2024, December 8, 2024, December 9, 2024 and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the Nursing supervisors and the scheduler to maintain LPN ratio with current census. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4, biweekly x 4 and monthly x 2 to ensure the LPN ratio has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the required minimum of 3.2 hours of direct nursing care per resident per day on six out of seven days reviewed. Specifically, on December 4, 5, 7, 8, 9, and 10, 2024, the facility provided between 2.84 and 3.11 hours of direct care per resident, falling short of the mandated requirement. This deficiency was confirmed through a review of the facility's staffing levels and an interview with the Director of Nursing on January 2, 2025, who acknowledged the failure to meet the staffing requirements consistently.
Plan Of Correction
P5640 Nursing Services 1. The facility is unable to correct PPDs for December 4, 2024, December 5, 2024, December 7, 2024, December 8, 2024, December 9, 2024, and December 10, 2024. 2. No other dates were identified during the survey. 3. To prevent this from reoccurring, the DON/designee completed education with the nursing supervisors and the scheduler to maintain a PPD of 3.2. If call offs occur, the supervisor needs to call staff and post on agency sites for the open shift. Recruitment of nursing staff will continue via facility website, indeed, social media websites, job fairs, and off-site recruiters. Agency will be utilized for open shifts as needed and available. 4. To monitor and maintain ongoing compliance, the DON/designee will audit the schedule weekly x4, biweekly x4, and monthly x2 to ensure the PPD has been met. Results will be reviewed at the QAPI meeting. 5. 1/16/2025
Inadequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and effective fall interventions for a resident identified as a high fall risk with known unsafe behaviors. The resident, who had severe cognitive impairment due to dementia, experienced repeated falls from her Broda chair. Despite being at high risk for falls, the facility's interventions, such as chair alarms and non-skid footwear, were insufficient in preventing these incidents. The resident's care plan included measures like chair alarms and staff supervision, but these were not effectively implemented or adjusted in response to the resident's ongoing falls and behaviors. The resident's clinical records and behavior progress notes indicated frequent agitation, anxiety, and restlessness, which contributed to her falls. On multiple occasions, the resident was found on the floor after falling from her chair, sometimes resulting in minor injuries such as skin tears and hematomas. Staff interventions, including attempts to redirect the resident and provide closer supervision, were ineffective in preventing further falls. The facility's documentation revealed that the resident's falls were often unwitnessed, and the alarms intended to alert staff were not always effective. Interviews with facility staff, including the Director of Nursing, confirmed the lack of sufficient supervision and the failure to develop and implement effective fall prevention strategies for the resident. Despite the resident's history of delusions, hallucinations, and agitation, the facility did not adequately address these factors in their fall prevention efforts. The repeated falls and the facility's inability to provide appropriate interventions highlight a deficiency in the care provided to the resident.
Inadequate Staffing Leads to Falls and Delayed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate supervision and care. This deficiency was evident in the cases of three residents who experienced repeated falls despite being identified as high fall risks. Resident 7, with dementia and severe cognitive impairment, continued to fall from her Broda chair despite interventions like chair alarms and non-skid footwear. Similarly, Resident 70, also with dementia and a history of falls, experienced multiple falls despite interventions such as bed alarms and floor mats. Additionally, Resident 90, who is cognitively intact and recovering from hip replacement surgery, reported experiencing long wait times for assistance, sometimes over an hour. This was corroborated by staff who confirmed that there were not enough personnel to meet the residents' needs promptly. The facility's staffing records showed that they consistently failed to meet the state's minimum requirements for direct care hours per resident, as well as the required ratios for nurse aides and licensed practical nurses. During a resident group interview, several residents expressed concerns about the lack of nursing staff affecting their care. They reported long wait times for assistance, missed showers, and not receiving snacks due to staff shortages. The Nursing Home Administrator acknowledged the facility's failure to meet staffing requirements and the responsibility to provide adequate supervision and care to prevent falls and ensure timely assistance for all residents.
Inadequate Infection Control and Immunization Practices
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by the case of two residents, Resident 77 and Resident 83, who were not adequately isolated following a positive COVID-19 test. Resident 77 tested positive for SARS-CoV-2 on September 3, 2024, but there was no documented attempt to isolate them in a single room or with other COVID-19 positive residents. Consequently, Resident 83, who shared a room with Resident 77, was not informed of the risks associated with sharing a room with a COVID-19 positive individual, nor were they given the opportunity to make an informed decision about changing rooms. Resident 83 subsequently tested positive for SARS-CoV-2 on September 5, 2024. Additionally, the facility did not offer or provide COVID-19 immunization to Resident 2, who had been admitted with a diagnosis of dementia. There was no evidence in the clinical records that Resident 2 or their representative received education about the benefits and potential side effects of the COVID-19 vaccine, nor was there any indication that the vaccine was medically contraindicated. The facility had not offered the vaccine to Resident 2 since May 19, 2022, despite the absence of any documented contraindications. The Director of Nursing (DON), who was covering the duties of the infection preventionist without certification until August 27, 2024, confirmed the lack of documentation and actions regarding the isolation of Resident 77 and the immunization offer to Resident 2. The Nursing Home Administrator also confirmed the absence of a certified infection preventionist in the facility, which contributed to the oversight in infection control practices and immunization offerings.
Failure to Implement Controlled Drug Reconciliation Procedures
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on two of three medication carts reviewed, specifically on the A and C halls. According to the facility's policy on Controlled Substances, nursing staff are required to count controlled medications at the end of each shift, with both the on-coming and off-going nurses participating in the count and signing off on the count sheet. However, during observations on September 10 and 11, 2024, it was found that the required signatures were missing on the shift change controlled count sheets for the C medication cart on September 4 and 5, 2024, and for the A medication cart on September 3, 2024. Interviews with the LPNs responsible for the medication carts confirmed the absence of signatures and acknowledged the expectation to sign the count verification at shift changes. The Director of Nursing also confirmed that it is her expectation for nursing staff to sign the Control Substance logs at shift changes to ensure timely identification of any discrepancies. This deficiency was identified through a review of facility policy, controlled drug records, observations, and staff interviews.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the MDS assessment for a resident who was discharged from the facility was found to be inaccurate. The resident was admitted to the facility and later discharged on August 16, 2024. The Discharge MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while the skilled nursing note and physician orders confirmed that the resident was discharged home with all appropriate medications. Interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator confirmed the inaccuracy of the MDS assessment.
Failure to Implement Fall Prevention Measures for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a person-centered care plan to meet the specific needs of a resident diagnosed with dementia, who has a documented history of falls. The resident was admitted with conditions that impair cognitive functioning and physical mobility, making them at high risk for falls. Despite the care plan initiated in September 2023, which included interventions such as keeping the bed in the lowest position, using bilateral floor mats, a bed alarm, and ensuring the call bell is within reach, these measures were not consistently implemented. Observations on two separate occasions in September 2024 revealed that the resident's bed was not in the lowest position, a floor mat was only on one side, the call bell was not within reach, and the bed alarm was disconnected and non-functional. These observations were confirmed by a nurse aide and the Nursing Home Administrator, who acknowledged the facility's responsibility to implement the care plan interventions to mitigate the resident's risk for falls and injury.
Failure to Provide Timely Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services to maintain the mobility and functional abilities of a resident, identified as Resident 77, after discharge from physical therapy. Resident 77 was admitted with diagnoses including unsteadiness on feet, muscle weakness, and difficulty in walking. The resident was moderately cognitively impaired with a BIMS score of 10. After receiving physical therapy from August 12 to August 29, 2024, the resident was discharged with recommendations for restorative nursing services, including bi-lateral active range of motion exercises and ambulation with a roller walker and caregiver assistance. Despite these recommendations, the facility did not provide the necessary restorative nursing services until 10 days after the resident's discharge from physical therapy. This delay was confirmed through interviews with the resident, a physical therapist, and the Nursing Home Administrator. The failure to promptly include Resident 77 in the restorative nursing program was acknowledged by the facility staff, indicating a lapse in maintaining the resident's mobility and functional abilities as required by the facility's responsibilities.
Failure to Monitor Resident's Weight
Penalty
Summary
The facility failed to consistently and accurately monitor the weights of a resident, identified as Resident 31, who experienced significant weight loss. According to the facility's Weight Assessment and Intervention Policy, residents are to be weighed on admission and then weekly for four weeks, with any weight changes of five pounds or more requiring confirmation. However, Resident 31's weight records showed a significant weight loss of 9.72% over nine days, followed by further losses of 9.4% and 14.1% in subsequent periods. Despite these changes, there was no documented evidence that weekly weights were obtained to identify and address the resident's nutritional needs. Interviews with the Registered Dietician and the Nursing Home Administrator confirmed the failure to obtain and record the resident's weekly weights as planned. This oversight prevented the facility from accurately assessing the resident's nutritional status and needs, as well as evaluating the adequacy of the resident's nutritional intake. The Nursing Home Administrator acknowledged the facility's responsibility to monitor the nutritional parameters of residents with significant weight loss, which was not fulfilled in this case.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic medication. A resident was admitted with a diagnosis of dementia and had a urine sample collected from her Foley catheter without documented symptoms or clinical justification for a culture and sensitivity test. The urine culture revealed the presence of multiple organisms resistant to the Ampicillin class of antibiotics. Despite this, the physician ordered Amoxicillin, an aminopenicillin, for a urinary tract infection, and the resident began receiving the medication without any documented symptoms of a UTI. The Director of Nursing confirmed that the organisms were resistant to the prescribed antibiotic and was unable to provide clinical justification for the administration of Amoxicillin. The facility's responsibility to ensure residents' drug regimens are free of unnecessary antibiotics was acknowledged, but not adhered to in this instance. The deficiency was identified under the relevant Pennsylvania Code sections for medical director, pharmacy services, and nursing services.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) to be responsible for the infection prevention and control program, resulting in the transmission of the COVID-19 virus between two residents. The Nursing Home Administrator (NHA) confirmed that the facility did not have an IP at the time of the incident, and the Director of Nursing (DON) had been covering the IP duties since July 18, 2024. Although the DON completed the Nursing Home Infection Preventionist Training Course on August 27, 2024, the facility did not have a certified IP until then. The lack of a dedicated IP led to inadequate infection control practices, contributing to the spread of COVID-19 between residents on September 5, 2024.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, identified as Resident 79, by not ensuring access to the call bell system for requesting staff assistance. Resident 79 was admitted with diagnoses including cerebral infarction with hemiplegia and hemiparesis on the right dominant side, dysphagia, and muscle weakness, and was dependent on staff for all care and activities of daily living. During an observation, the resident's call bell was found on the floor and not within reach, which was confirmed by an LPN. The Director of Nursing acknowledged that call bells should be within reach to alert staff of the need for assistance.
Untimely Staff Response to Resident Requests
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for staff assistance. This was evidenced by the experiences reported by six out of eight interviewed residents. These residents expressed concerns about extended wait times for staff to respond to their requests for assistance, including untimely responses to the nurse call bell system. Resident 62 reported consistently waiting over 15 minutes, sometimes up to an hour, for assistance and mentioned that this issue has persisted despite raising it during resident meetings. Resident 81 indicated that she refrains from using the call bell because she knows staff are busy and will not respond promptly. Resident 69 reported waiting 30 minutes for assistance, particularly during the night shift, and mentioned instances of soiling herself while waiting for help with toileting. Resident 49 and Resident 39 also reported long wait times, with Resident 39 specifically noting waits of up to an hour, mostly during mealtimes. Resident 61 reported 30-minute waits, primarily during the evening shift. An interview with the Nursing Home Administrator confirmed the expectation that all residents be treated with dignity and respect. However, the administrator was unable to explain why multiple residents reported untimely staff response times, which negatively affected their quality of life. The report cites specific Pennsylvania Code violations related to management, resident rights, and nursing services, indicating a systemic issue with staffing and response times in the facility.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve resident complaints and grievances, particularly those raised during resident group meetings. The facility's policy on grievances, last reviewed on June 30, 2023, specifies that residents can expect a completed review of grievances within five to seven business days, including a summary statement of the grievance, steps taken to investigate, findings, and any corrective actions. However, the facility did not adhere to this policy, as evidenced by the lack of documented responses to grievances raised in resident group meetings in March and April 2024 regarding food temperature and staff response times to call bells. Resident 62, who is cognitively intact with a BIMS score of 15, reported consistently waiting over 15 minutes for staff to respond to his call bell, sometimes up to an hour. He expressed frustration that his complaints during resident meetings were not addressed, leading him to stop raising the issue. Similarly, Resident 81, with a BIMS score of 13, reported ongoing issues with the temperature and quality of food, particularly breakfast, and noted that her complaints were not resolved despite being raised repeatedly. Resident 21, with a BIMS score of 15, also reported unresolved concerns about food temperature and a malfunctioning bedroom window. The Resident Council meeting minutes from March 21, 2024, and April 18, 2024, documented residents' concerns about food temperature and staff response times to call bells. However, there was no evidence that grievances were filed or that the facility took action to address these concerns. Interviews with the DON and NHA confirmed that the facility did not respond to the residents' concerns raised during group meetings, nor did they provide follow-up actions or rationale to the residents. This failure to address and resolve grievances is a violation of the residents' rights and the facility's own policies.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve appetizing food at palatable temperatures, as reported by five of eight residents interviewed. Resident 21 stated that the food served is often cold and the vegetables are overcooked and mushy. Resident 101 mentioned that the breakfast meal is mostly served cold. Resident 61 also expressed that the food could be warmer. Resident 69, during a meeting with the Assistant Director of Nursing, therapy, Social Services, and her POA, complained about being served a raw hamburger and cold food. Despite these complaints, the issue remained unresolved. Resident 81 consistently raised concerns about the temperature and quality of food during group meetings, specifically mentioning that her breakfast eggs are cold nine out of ten times. A review of the kitchen's temperature logs revealed multiple instances of missing documentation for breakfast and lunch temperatures in March, April, and May 2024. Additionally, the logs showed that temperatures for the supper meal on May 15, 2024, were documented in advance. The Dietary Manager confirmed the lack of temperature documentation and acknowledged awareness of the resident complaints but had no explanation for the pre-documented temperatures. The Nursing Home Administrator was also unable to explain the numerous resident complaints about cold food temperatures and unpalatable food.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to demonstrate prompt efforts to resolve resident grievances and maintain accurate and complete evidence of the implementation of the facility's grievance process. Resident 69, who was cognitively intact, voiced complaints through her power of attorney (POA) about being left on a bedpan for 1 hour and 45 minutes and not receiving proper care after using the bathroom. These complaints were not logged in the facility's grievance/concern log. Additionally, during a care plan meeting, further concerns about the resident's care, including issues with a nurse aide and the quality of food, were raised but not documented in the grievance log. Interviews with Resident 69 revealed ongoing issues with long wait times for call bell responses, particularly during the night shift, leading to instances where the resident soiled herself while waiting for assistance. The resident also reported that the food served was often cold and unpalatable. Despite these complaints being communicated to the staff and the facility, they were not logged or addressed in the grievance records. The Nursing Home Administrator confirmed that no grievances or complaints filed by or on behalf of Resident 69 were logged, indicating a failure in the facility's grievance process.
Failure to Monitor Resident's Whereabouts
Penalty
Summary
The facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of Resident CR1. The resident, who was admitted with diagnoses including cerebral infarction and COPD, was assessed as a low risk for elopement and was cognitively intact with a BIMS score of 14. Despite this, on May 1, 2024, Resident CR1 left the facility without notifying staff and was later found returning from a car wash by a passerby. The facility staff were unaware of the resident's absence until approximately 12 PM, although the resident was not present for the morning medication pass at 10 AM. Interviews with various staff members revealed that the resident was last seen around 10:00 AM and was not located until after 12:00 PM. The receptionist, who monitors the entrance and exit of the building, did not see the resident leave or sign out. The nurse aides and LPNs on duty were also unaware of the resident's whereabouts until he was seen exiting a vehicle in front of the building. The Nursing Home Administrator confirmed that the facility had no knowledge of the resident's departure and could not determine the exact time or duration of the absence. The facility's elopement report and subsequent interviews indicated that the resident was appropriately dressed and had no injuries upon return. However, the facility's failure to monitor the resident's whereabouts and activities led to a lapse in supervision. The resident was later discharged to a personal care setting on May 10, 2024. The Nursing Home Administrator acknowledged the facility's responsibility to provide necessary supervision and implement effective safety measures, which were not adequately met in this instance.
Failure to Administer IV Fluids Timely
Penalty
Summary
The facility failed to provide timely intravenous fluids as prescribed for Resident C1, who tested positive for COVID-19 and showed a decline in medical status and meal intake. On February 23, 2024, a Registered Nurse (RN) assessed Resident C1 and noted hypotension and foul-smelling, tarry stools. The attending physician ordered 1 liter of 0.9% normal saline solution (NSS) to be administered intravenously. However, the medication administration record (MAR) and intake and output (I & O) report revealed that the IV fluids were not timely initiated, and the resident did not receive the total volume of fluids ordered. By February 24, 2024, the resident had only received 320 ml out of the prescribed 1000 ml of fluids. Further review of the clinical records and interviews with facility staff confirmed the deficiency. A nursing progress note on February 24, 2024, indicated that the resident was awake, confused, and requested something to drink, but the IV fluids had not been properly administered. The Assistant Director of Nursing (ADON) confirmed that the facility could not provide documented evidence that the IV fluids were timely initiated or that the resident received the prescribed fluid volume. This failure to administer IV fluids as ordered is a violation of professional standards of practice and nursing services regulations.
Failure to Implement Person-Centered Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop and consistently implement a person-centered care plan to address a resident's known risk factors for falls. Resident B1, who was admitted with diagnoses of dementia, difficulty walking, and a history of falls, experienced multiple falls from her wheelchair. Despite the resident's care plan including interventions such as wearing non-skid footwear, using auto lock brakes and anti-tippers on the wheelchair, and ensuring a safe environment, the resident fell on three separate occasions. These incidents occurred when the resident leaned forward in her wheelchair to pick up items or attempted to self-transfer, resulting in falls and, in one instance, an abrasion on the back of her head. The facility did not timely develop and implement specific measures to address the resident's wheelchair safety, including increased supervision or alternate seating arrangements to prevent repeated falls. Interviews with the ADON and NHA confirmed the resident's unsafe and impulsive behaviors while seated in a wheelchair and acknowledged that the care plan did not specifically address the need for increased supervision or timely plans for alternate seating arrangements or adaptive devices. The facility's failure to address these issues resulted in repeated falls and demonstrated a lack of consistent implementation of the resident's care plan to ensure her safety.
Failure to Address Resident's Decline in Food and Fluid Consumption
Penalty
Summary
The facility failed to timely identify and address a resident's decline in food and fluid consumption, leading to significant weight loss. Resident C1, who had multiple diagnoses including congestive heart failure, dysphagia, and cognitive communication deficit, was admitted with a diet order that included a consistent carbohydrate heart-healthy diet with mechanical soft texture and thin liquids. Despite the resident's poor meal intake from February 15, 2024, through February 23, 2024, there was no documented evidence that the registered dietitian assessed the adequacy of the resident's oral intake of food and fluids during this period. The dietitian only assessed the resident on February 20, 2024, following a physician-ordered diet consult due to low albumin levels. The resident's meal intake records showed that they refused or consumed 0-25% of meals for a significant number of meals over several days. Despite this, the dietitian did not re-evaluate or revise the resident's nutrition plan of care in a timely manner. The resident's weight dropped significantly from 146.5 pounds to 127 pounds, indicating a weight loss of 19.2 pounds since admission. The dietitian's failure to timely re-evaluate and revise the nutrition plan contributed to the resident's significant weight loss and clinical decline. The resident was eventually admitted to the hospital on February 29, 2024, with diagnoses of septic shock, volume depletion, and hypotension. During an interview, the Assistant Director of Nursing confirmed that the facility could not provide documented evidence that the resident's nutrition plan of care was timely re-evaluated and revised based on the consistently poor meal intakes and consecutive meal refusals that contributed to the significant weight loss and clinical decline.
Failure to Obtain Prescribed Laboratory Services
Penalty
Summary
The facility failed to timely obtain prescribed laboratory services for a resident diagnosed with multiple conditions including congestive heart failure, cardiomyopathies, dysphagia, and cognitive communication deficit. The resident tested positive for COVID-19 and experienced a fall, after which the attending physician ordered stool samples for occult blood testing due to large incontinent episodes of foul-smelling and tarry stools. Despite multiple documented bowel movements, there was no evidence that the facility obtained the required stool samples for testing as ordered by the physician. The resident's clinical record showed low hemoglobin and hematocrit levels, and the resident's condition deteriorated, leading to an altered mental status. The resident was transferred to the emergency department, where they were diagnosed with septic shock, volume depletion, and hypotension. The emergency treatment plan included a blood transfusion, IV fluid resuscitation, and administration of various medications. Unfortunately, the resident expired at the hospital. During the survey, the Assistant Director of Nursing confirmed that the facility did not attempt or obtain the stool samples needed for occult blood testing. This failure prevented the physician from diagnosing the resident's low hemoglobin levels and contributed to the resident's deteriorating condition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
