Shippenville Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Shippenville, Pennsylvania.
- Location
- 21158 Paint Boulevard, Shippenville, Pennsylvania 16254
- CMS Provider Number
- 395607
- Inspections on file
- 22
- Latest survey
- June 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shippenville Nursing And Rehab during CMS and state inspections, most recent first.
Over a six-month period, the facility did not resolve repeated concerns from the Resident Council about residents not receiving fresh ice water. Multiple residents confirmed the issue persisted, with one stating they only received ice water when a family member provided it. The DON acknowledged that the concerns raised in Resident Council meetings were not addressed, and no evidence was provided to show timely corrective action.
Multiple residents reported long delays in call bell responses, missed scheduled showers, and infrequent access to fresh ice water, especially when agency staff were present or on weekends. Facility documentation and resident council minutes confirmed these issues, with some residents going extended periods without bathing and experiencing poor hygiene. The DON acknowledged that residents' needs for timely assistance, regular showers, and hydration were not consistently met, indicating insufficient nursing staff and services.
Surveyors identified multiple failures in food storage and sanitation, including expired food in dry storage, improper staff attire during food service, and unclean refrigerators in resident pantries. Food items were found unlabeled, undated, and past their use-by dates, with staff confirming these deficiencies and the presence of ice buildup and spills in refrigeration units.
The facility did not ensure that physician orders and POLST forms were consistent and complete for two residents. One resident's paper record indicated Full Code while the electronic record showed DNR, and a second POLST lacked the required signature. Another resident's POLST was incomplete, with no indication of Full Code or DNR status. Staff and the DON confirmed these discrepancies and acknowledged that advance directives should be consistent and complete in both paper and electronic records.
A resident with multiple chronic conditions was transferred to a hospital without receiving a written notice of the facility's bed-hold policy, including details on duration and cost, and without the necessary clinical information being communicated to the receiving provider. Staff confirmed these omissions and the absence of required documentation.
Three residents with complex medical conditions were not provided with written summaries of their baseline care plans and order summaries within 48 hours of admission, as required by facility policy. Review of clinical records and staff interviews confirmed the absence of documentation showing that these summaries were given to the residents or their representatives.
A resident with hemiplegia and hemiparesis did not receive a physician-ordered left ankle-foot orthosis (LAFO) as required to maintain range of motion. Documentation was lacking to show the device was applied, and repeated observations confirmed the resident was without the LAFO during multiple checks. The Regional Nurse Consultant verified the device was not in use as ordered.
A resident with COPD, diabetes, and hypertension who had a physician's order for oxygen at 2 LPM via nasal cannula was left without oxygen during an activity after an activities assistant removed the nasal cannula and did not reapply it. The resident remained without oxygen until returning to their room, and both the activities assistant and an LPN confirmed the oxygen should have been in use at all times.
Surveyors found that opened bottles of Latanoprost eye drops and Lantus insulin on two medication carts were not labeled with an open date, making it impossible for staff, including LPNs, to determine the correct discard date. This failure to follow facility policy and manufacturer recommendations was confirmed by staff and the Regional Clinical Director.
An LPN performed a wound dressing change for a resident and used scissors to cut away a soiled dressing. The LPN then placed the used scissors on a towel and later put them in their pocket without cleaning or disinfecting them, contrary to facility policy requiring disinfection of reusable items between uses.
A resident with multiple diagnoses received an IV antibiotic based on an incomplete physician order that lacked reconstitution amount and administration rate. The RN administered the medication for two doses without contacting the physician to clarify the order, resulting in administration at the wrong rate and route, in violation of professional nursing standards.
A resident admitted with osteomyelitis, weakness, and type II diabetes did not have a physician's order for an IV antibiotic entered into the EHR system in a timely manner. This delay caused the resident to miss a scheduled dose and receive a subsequent dose late, as nursing staff were not alerted to administer the medication as ordered.
The facility failed to maintain a clean and sanitary environment in the Alzheimer's Care Unit. Observations revealed stained and ripped furniture, a cable box pulling away from the wall, a ripped curtain, and gouges in a wall. The Nursing Home Administrator confirmed these deficiencies, acknowledging the need for clean furniture, secure cable boxes, and well-maintained curtains and walls.
A resident with COVID-19 did not receive prescribed Paxlovid due to the nursing staff's failure to fax the order and follow up with the pharmacy. The oversight involved six LPNs and one RN, leading to a delay in medication delivery, as confirmed by the DON and Regional Director of Clinical Operations.
A resident with dementia, parkinsonism, and anxiety tested positive for COVID-19 and was prescribed Paxlovid. However, the medication was not received from the pharmacy and was not administered, resulting in a delay in treatment. This was confirmed by the DON and the Regional Director of Clinical Operations.
A resident with dementia and parkinsonism tested positive for COVID-19 and was prescribed Paxlovid, but the medication was not received from the pharmacy, leading to inaccurate documentation in the MAR. Additionally, the facility failed to document the resident's change in condition and did not notify the physician, resident representative, or emergency services about the transfer to the ER, as required by facility policy.
A resident with Alzheimer's and other conditions fell, sustaining rib fractures. The MDS inaccurately reported no falls with major injury, confirmed by the RN Assessment Coordinator.
A facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The facility's policy requires that PRN orders for such medications not be renewed beyond 14 days without a documented rationale. However, a resident's Lorazepam order lacked the required stop date or clinical rationale for continuation, as confirmed by the Assistant Director of Nursing.
The facility failed to discard outdated insulin vials on two medication carts, violating its medication storage policy. Observations revealed an open vial of Lantus Insulin on the A wing cart and both Lantus and Humalog Insulin vials on the B wing cart were beyond the 28-day usage period. LPNs confirmed the outdated status of these vials.
Failure to Address Resident Council Concerns Regarding Ice Water
Penalty
Summary
The facility failed to address ongoing concerns raised by the Resident Council regarding the lack of fresh ice water being provided to residents over a six-month period. Facility policy required the use of a Resident Council Response Form to track and resolve issues, with relevant departments responsible for addressing concerns and the QAPI Committee reviewing feedback as part of quality review. Despite this policy, review of Resident Council minutes and grievance records from January through June 2025 revealed a persistent pattern of complaints about not receiving ice water, with no evidence of timely corrective action taken. Interviews with several alert and oriented residents who regularly attended Resident Council meetings confirmed that the issue of not receiving fresh ice water had not improved, with one resident stating they only received ice water when a family member provided it. The DON confirmed that the facility had not resolved the concerns documented in Resident Council meetings over the six-month period. No documentation was provided to show that the residents' concerns were addressed in a timely manner, as required by facility policy.
Failure to Provide Sufficient Nursing Staff and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of residents, as evidenced by multiple reports of delayed call bell responses, missed showers, and lack of fresh ice water. Facility policies require that call lights be answered within five minutes if possible, showers be provided per schedule or request, and appropriate care for activities of daily living (ADLs) such as bathing and hygiene. However, interviews with residents and review of resident council minutes over a six-month period revealed consistent complaints about slow call bell responses, infrequent passing of ice water, and missed showers, particularly when agency staff were present or on weekends. Specific residents reported waiting up to an hour for call bell responses, not receiving scheduled showers, and not having access to fresh ice water unless specifically requested. Documentation confirmed that some residents did not receive showers according to their schedules, and in some cases, residents went extended periods without bathing. One resident noted that the lack of hot water in a shower room was not addressed by using alternative shower rooms, resulting in missed showers and poor hygiene. Another resident, newly admitted, had not received a bath or shower since admission and complained of discomfort due to unwashed hair. Grievance logs and resident council minutes corroborated these issues, with repeated grievances about call bell response times, missed showers, and lack of fresh ice water. The Director of Nursing confirmed that residents are entitled to timely call bell responses, regular showers, and fresh ice water, but acknowledged that these needs were not consistently met. These findings demonstrate a failure to provide adequate nursing services and staffing to promote the physical and mental well-being of residents, as required by facility policy and state regulations.
Food Storage and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to serve food in a safe and sanitary manner and did not ensure proper storage and labeling of food items in the main kitchen and resident pantries. Observations revealed that expired food products, such as seven bulk packages of instant potatoes, were present in dry storage, and a dietary aide was seen handling food on the tray line without wearing a required hair net or restraint. The Dietary Manager confirmed both the presence of expired food and the lack of appropriate staff attire during food service. Further inspection of resident pantries showed multiple sanitation and labeling deficiencies. The D Wing pantry refrigerator contained visible brown, red, and yellow substances on shelves and drawers, indicating a lack of cleanliness. In the A Wing pantry, a container of watermelon was found without a resident name and was past its use-by date, and an open carton of Med Pass supplement was also beyond its use-by date. Both the A Wing and Skilled Wing pantries had refrigerators with sticky substances on shelves, unlabeled and undated food items, and significant ice buildup in the freezers. Staff interviews confirmed these findings and acknowledged that food items were not properly labeled, stored, or discarded according to facility policy.
Inconsistent and Incomplete POLST Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that physician orders and residents' Pennsylvania Orders for Life Sustaining Treatment (POLST) were consistent and complete for two residents. For one resident with diagnoses including diabetes, dementia, and chronic obstructive pulmonary disease, the paper clinical record contained a POLST indicating Full Code status, while the physician's order in the electronic record indicated Do Not Attempt Resuscitation (DNR). Additionally, a second POLST in the clinical record indicated DNR but lacked the required signature from the resident or their representative. For another resident with hypertension, hyperlipidemia, and hypothyroidism, the POLST was incomplete, with the section indicating Full Code or DNR status left blank. Staff interviews revealed that during emergencies, staff refer to the paper chart to determine residents' life-sustaining treatment preferences. The DON confirmed the inconsistencies between the paper and electronic records and acknowledged that advance directives should be complete and consistent across all records, clearly indicating the resident or representative's wishes. The facility's policy requires that information about advance directives be prominently displayed and that appropriate orders be documented, which was not followed in these cases.
Failure to Provide Bed-Hold Policy Notice and Transfer Information
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice of the facility's bed-hold policy, which should include an explanation of how long a bed can be held during a leave of absence and the cost per day. Additionally, the facility did not ensure that the necessary clinical information was communicated to the receiving health care provider when the resident was transferred to the hospital. These requirements are outlined in the facility's own policy, which mandates that both the bed-hold notice and relevant clinical information be provided during any transfer. The deficiency was identified for a resident with diagnoses including diabetes, dementia, and chronic obstructive pulmonary disease, who was transferred to the hospital. Review of the clinical record showed no evidence that the bed-hold policy was given to the resident or their representative, nor that the required clinical information was sent to the receiving provider. Staff interviews confirmed these omissions, and the lack of documentation was verified by the Regional Nurse Consultant.
Failure to Provide Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to three residents and/or their representatives within 48 hours of admission, as required by facility policy. The policy specifies that residents and their representatives must receive a summary including initial goals, medications, dietary instructions, services and treatments, and any updates based on the comprehensive care plan. Review of clinical records for three residents revealed no evidence that these written summaries were provided following their admissions. The residents involved had complex medical histories, including conditions such as sacrococcygeal disorders, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, dementia, atrial fibrillation, orthostatic hypotension, and nasal bone fracture. Staff interviews confirmed the absence of documentation showing that the required written summaries were given to the residents or their representatives, resulting in noncompliance with state regulations regarding resident care plans and nursing services.
Failure to Apply Physician-Ordered LAFO for Resident with Limited Mobility
Penalty
Summary
A resident with diagnoses including hemiplegia, hemiparesis, hypertension, and sleep apnea was admitted to the facility and had a physician order for a left ankle-foot orthosis (LAFO) to be applied in the morning and removed with evening care, with skin checks before and after application. The resident's care plan also included this intervention to address self-care deficits related to impaired mobility. However, documentation in the clinical record did not provide evidence that the LAFO was applied as ordered. Multiple observations over several days showed the resident sitting in a wheelchair without the LAFO on the left foot/leg during both morning and afternoon hours. During an interview, the Regional Nurse Consultant confirmed that the resident did not have the LAFO in place as per the physician's orders and acknowledged that it should have been applied. This failure to follow physician orders and provide the prescribed treatment and services resulted in a deficiency related to maintaining or improving the resident's range of motion.
Failure to Provide Oxygen Per Physician's Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, diabetes, and hypertension, who had a physician's order for oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath, did not receive oxygen as ordered. The facility's policy requires verification and adherence to physician's orders for oxygen administration. On the day of the incident, the resident was observed with supplemental oxygen in place and the concentrator set correctly at 2 LPM. However, an activities assistant removed the resident's nasal cannula and assisted the resident to an activity without reapplying the oxygen. The resident remained without oxygen until returning to their room over an hour later. Both the activities assistant and a licensed practical nurse confirmed that the resident did not have oxygen during this period and that the oxygen should have remained in place at all times, as per the physician's order.
Failure to Properly Date and Discard Opened Medications
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner, as required by facility policy and manufacturer recommendations. During observations of two medication carts, surveyors found an opened bottle of Latanoprost eye drops and an opened vial of Lantus insulin, both lacking an open date. This omission made it impossible for staff to determine the appropriate discard date for these medications. Staff members, including LPNs, confirmed at the time of observation that the medications were not labeled with an open date and that the discard date could not be determined. The facility's policy requires all medications to be stored according to manufacturer recommendations, which for Latanoprost is to discard six weeks after opening and for Lantus insulin is to discard after 28 days at room temperature. The Regional Clinical Director confirmed that insulins and eye drop medications should be properly labeled with an open date to ensure timely disposal. The failure to label these medications as required was observed on two separate medication carts during the survey.
Failure to Disinfect Reusable Scissors After Wound Care
Penalty
Summary
During a wound dressing change for Resident R75, an LPN used scissors to cut a soiled dressing from the resident's right foot. After use, the LPN placed the contaminated scissors on a towel covering the resident's bedside table and, upon completing the dressing change, put the scissors into their pocket without cleaning or disinfecting them. Facility policy requires that reusable supplies, such as scissors, be wiped with alcohol and that reusable items be cleaned and disinfected or sterilized between residents. The LPN confirmed during an interview that the scissors were not cleaned before being placed in their pocket, acknowledging that this was not in accordance with facility policy.
Failure to Clarify Incomplete Medication Order Before Administration
Penalty
Summary
The facility failed to follow nursing standards of practice by not ensuring that a physician was contacted regarding an incomplete medication order prior to administering medication to a resident. Specifically, a resident with diagnoses including osteomyelitis, weakness, and type II diabetes was admitted and had a physician's order for Piperacillin Sodium-Tazobactam Sodium Intravenous Solution. The order did not specify the amount for reconstitution or the rate of administration. Despite this incomplete order, the RN administered the medication for the first and second doses without clarifying these critical details with the physician. Documentation in the resident's clinical record showed that the medication was administered at specific times, and it was later noted that it was given at the wrong rate and route. Facility documents confirmed that the RN did not contact the physician to clarify the incomplete order before administering the medication. The Nursing Home Administrator acknowledged that this failure did not adhere to professional nursing standards, as required by both state regulations and the facility's own job descriptions for RNs.
Delayed Entry of Physician's Orders Resulting in Missed and Late Antibiotic Doses
Penalty
Summary
The facility failed to enter a physician's order for an antibiotic medication into the electronic health record system in a timely manner for a resident admitted with osteomyelitis, weakness, and type II diabetes. The resident arrived at the facility in the morning, but the medication order for Piperacillin Sodium-Tazobactam was not entered, which prevented nursing staff from being alerted to administer the medication as scheduled. As a result, the resident missed the noon dose and received the 6:00 p.m. dose late. The Nursing Home Administrator confirmed that the delay in entering the physician's order led to the missed and late administration of the antibiotic.
Deficiency in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Alzheimer's Care Unit (ACU), as observed during a survey. The common area contained three sitting chairs and a couch with cushions that had several brown stains, likely from moisture, and the arms of the furniture were ripped with stuffing exposed. Additionally, a television cable box was observed pulling away from the wall. In a resident room, a curtain was found ripped and hanging down, and the wall below the window had gouges. The Nursing Home Administrator confirmed these observations, acknowledging that the furniture should be clean and without tears, the cable box should be securely attached to the wall, and the curtains and wall should be in good repair.
Failure to Obtain Timely Medication for Resident
Penalty
Summary
The facility failed to adhere to nursing standards of practice by not ensuring that medications were obtained from the pharmacy in a timely manner for a resident. The resident, who was diagnosed with dementia, parkinsonism, and anxiety, tested positive for COVID-19 and was prescribed Paxlovid, an antiviral medication. Despite the physician's order to start the medication on a specific date, the facility did not receive the medication from the pharmacy due to the nursing staff's failure to fax the original order and follow up on the medication's status. The review of facility documents revealed that six LPNs and one RN did not ensure the pharmacy received the order for Paxlovid, resulting in the medication not being available for several days. This deficiency was confirmed during an interview with the Director of Nursing and the Regional Director of Clinical Operations, who acknowledged the oversight in communication with the pharmacy. The failure to obtain the medication as ordered compromised the facility's compliance with professional standards of nursing practice.
Failure to Administer Prescribed COVID-19 Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with dementia, parkinsonism, and anxiety, resulting in a delay in treatment. The resident, who tested positive for COVID-19, was prescribed Paxlovid, an antiviral medication, to be administered orally twice a day for five days starting on November 5, 2024. However, a review of facility documents revealed that the medication was never received from the pharmacy and thus was not administered to the resident during the specified period. This was confirmed during an interview with the Director of Nursing and the Regional Director of Clinical Operations, who acknowledged the delay in treatment due to the pharmacy's failure to deliver the medication.
Inaccurate Medication Documentation and Lack of Communication for Resident Transfer
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident R1, who was diagnosed with dementia, parkinsonism, and anxiety. The clinical record indicated that Resident R1 tested positive for COVID-19 and was prescribed Paxlovid, an antiviral medication. However, the Medication Administration Record (MAR) inaccurately documented that the medication was administered on specific dates, despite the pharmacy records showing that the medication was never received by the facility. This discrepancy highlights a failure in the facility's medication administration and documentation process. Additionally, the facility did not document the change in Resident R1's condition that led to their transfer to the emergency room. There was no evidence in the clinical record that the attending physician, resident representative, emergency transport, or the receiving emergency department were notified of the resident's change in condition. This lack of documentation and communication is contrary to the facility's policies and accepted professional standards, as confirmed by the Director of Nursing and the Regional Director of Clinical Operations during an interview.
Inaccurate MDS Assessment for Resident with Fall Injury
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, identified as Resident R50, which led to a deficiency. Resident R50, who was admitted with diagnoses including Alzheimer's disease, anxiety, depression, diabetes, and high blood pressure, experienced a fall on April 16, 2024, resulting in a large bruise and a fracture of the right 8th anterior rib, with a possible fracture of the 7th rib. Despite these injuries, the Annual MDS under the Health Conditions Section J1900 incorrectly indicated that Resident R50 had no falls with major injury. This error was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged the incorrect coding of the MDS regarding falls with major injury for Resident R50.
Failure to Provide Clinical Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a clinical rationale and duration for the continued use of a PRN psychotropic medication beyond 14 days for a resident. The facility's policy on antipsychotic medication use, dated January 19, 2024, requires that PRN orders for such medications not be renewed beyond 14 days unless a healthcare practitioner evaluates the resident for the appropriateness of the medication and documents the rationale for continued use. Additionally, the duration of the PRN order must be indicated. However, the clinical record of a resident with diagnoses including dementia, arthritis, and cerebral atherosclerosis revealed a physician order for Lorazepam, an anti-anxiety medication, that lacked the required stop date within 14 days or a clinical rationale for continuation beyond this period. During an interview, the Assistant Director of Nursing confirmed the absence of the required stop date and clinical rationale for the continued use of Lorazepam beyond 14 days for the resident. This oversight was acknowledged as a failure to adhere to the facility's policy, which mandates a clinical rationale and specified duration for PRN psychotropic medication orders extending beyond 14 days.
Failure to Discard Outdated Insulin Vials
Penalty
Summary
The facility failed to appropriately discard outdated medications on two of the three medication carts reviewed, specifically the B wing skilled and A wing medication carts. The facility's policy on medication storage, dated January 19, 2024, mandates that outdated, contaminated, or deteriorated medications must be immediately removed from stock and disposed of according to procedures. However, during an observation on July 8, 2024, it was found that an open vial of Lantus Insulin on the A wing medication cart had an open date of June 9, 2024, which exceeded the 28-day usage period recommended by the manufacturer's guidelines. Additionally, the B wing skilled medication cart contained an open vial of Lantus Insulin with no recorded open date and an open vial of Humalog Insulin with an open date of April 24, 2024, both of which were beyond the 28-day usage period. During interviews conducted at the time of observation, LPN Employee E1 confirmed the Lantus Insulin on the A wing cart was outdated, and LPN Employee E2 confirmed the absence of an open date on the Lantus Insulin and the outdated status of the Humalog Insulin on the B wing cart. These findings indicate a failure to adhere to the facility's medication storage policy and the manufacturer's guidelines for insulin usage.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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