Smith Health Care Ltd
Inspection history, citations, penalties and survey trends for this long-term care facility in Mountain Top, Pennsylvania.
- Location
- 453 South Main Road, Mountain Top, Pennsylvania 18707
- CMS Provider Number
- 395716
- Inspections on file
- 10
- Latest survey
- August 23, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Smith Health Care Ltd during CMS and state inspections, most recent first.
The facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. The interim DON and a cook/assistant food services supervisor confirmed the absence of these key personnel, with the latter assuming additional responsibilities. The facility has been without a full-time qualified dietary services supervisor since early June.
The facility failed to maintain a comprehensive infection control program, lacking a system to monitor and investigate infections. Recurring urinary tract and eye infections were noted without documentation of preventive measures. Additionally, Enhanced Barrier Precautions were not implemented for residents with chronic wounds or indwelling devices, despite CDC and CMS recommendations. The interim DON confirmed the absence of a comprehensive infection prevention program.
A facility failed to use the revised PASRR Level I form (MA 376 3/24) for a resident admitted with COPD, instead using an outdated version. This noncompliance was confirmed by the social services consultant and administrator, leading to a deficiency under Federal PASRR Regulations.
The facility failed to ensure physicians wrote, signed, and dated progress notes at each visit for several residents, including those with Parkinson's, atrial fibrillation, dementia, and heart failure. Additionally, safeguards for rubber stamp signatures were not maintained, as confirmed by the interim DON.
The facility failed to maintain proper food storage and service practices, leading to potential contamination risks. Observations revealed undated food items, improper waste management, and uncovered desserts during meal service. The cook/assistant food services supervisor confirmed non-compliance with sanitary standards.
A resident with a history of stroke and mild dementia, who required assistance for daily activities, was not accommodated in her preference to use a recliner chair after a fall. Despite therapy confirming her ability to use the chair safely, staff continued to place her in a wheelchair, failing to meet her needs for comfort and pain relief.
A facility failed to store oxygen safely and administer it as ordered for a resident with heart failure. An unsecured oxygen tank was observed at the nurses' station, and the resident's oxygen concentrator had a dusty filter and was set at 2 liters per minute instead of the ordered 3 liters. The interim DON and an LPN confirmed these deficiencies.
The facility failed to ensure timely disposition of medications, leading to stockpiling in the medication room. An observation revealed an unopened box of Albuterol ampules for a resident, an unlabeled vial of Ceftazidime, and expired flu vaccines. The interim DON confirmed the facility did not follow its medication disposal policy, contributing to the deficiency.
A resident with a history of falls and cognitive impairment experienced a serious injury after sliding out of a recliner chair. The facility's investigation was incomplete, lacking witness statements and a thorough analysis of the incident's root cause. This deficiency highlighted the facility's failure to implement an effective QAPI program.
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers for three residents, as required by regulations. Although the residents and their representatives were informed, there was no evidence that the Ombudsman received the necessary notifications, as confirmed by the Nursing Home Administrator.
The facility failed to ensure nursing staff had the necessary competencies to properly assess and document a resident's condition following an incident and to administer medications according to professional standards. An LPN was observed pre-pouring medications, and an incident involving a resident being physically restrained was not documented in the clinical record.
The facility failed to consistently implement infection control procedures, as evidenced by the reuse of unclean basins and bedpans and the improper handling of a disposable gown for a resident with diarrhea. Staff provided conflicting information on disinfection protocols and TBP status, indicating a lack of standardized procedures.
The facility failed to honor residents' rights to choose their preferred method of bathing. Despite having both a tub and shower available, residents were only offered bed baths or tub baths. Interviews with three residents confirmed they were not given the option of a shower, even though they required staff assistance and preferred showers. The DON confirmed the lack of evidence for offering shower options.
The facility failed to ensure the timely disposition of resident medications, leading to potential drug diversion and loss. Discontinued medications were found stored without proper labeling or documentation, and the facility's pharmacy policies had not been reviewed or revised in over a year. The DON confirmed that these medications should have been picked up by the pharmacy or destroyed per facility policy.
The facility failed to justify and re-evaluate the use of PRN psychoactive medications for two residents with dementia. The medications were prescribed without documented clinical necessity, and there was no re-evaluation after 14 days. The DON confirmed the lack of resident-specific documentation.
The facility failed to ensure fresh water was consistently accessible to residents, leading to inadequate hydration. Observations revealed empty or undated beverage containers out of residents' reach, and interviews confirmed that residents had to request water, which was not consistently provided. Staff and administration confirmed the lack of routine water distribution.
The facility failed to maintain a safe and orderly environment in the resident shower room and a resident room. Observations revealed broken and missing tiles in the shower room and an unsecured, loose electrical outlet in a resident room. The NHA and DON confirmed that the environment should be kept in good repair.
A facility failed to ensure a resident was free from abuse by physically restraining them to control their behavior. The resident, with severe cognitive impairment and other conditions, was tied to a wheelchair by an LPN for safety reasons. The incident was not documented in the resident's clinical record, and the facility did not follow its abuse and restraint policies.
The facility failed to provide medically-related social services to a resident with dementia, aphasia, depression, and pain. An anonymous employee reported that a nurse had tied the resident to a chair to restrain them, but there was no documented evidence of this incident in the resident's clinical record. The DON confirmed the incident and acknowledged that social services had not assessed or monitored the resident following the event.
The pharmacist failed to identify drug irregularities in the regimens of two residents, including duplicate drug therapy for anxiety and agitation, and PRN psychoactive drug orders exceeding 14 days without re-evaluation. The DON confirmed the lack of resident-specific documentation to justify the use of these medications, and the pharmacist did not identify these issues during monthly reviews.
The facility failed to maintain complete and accurate clinical records for a resident with dementia, who was restrained by a nurse using a blanket to control their behavior. The incident and the facility's response were not documented in the clinical records, violating professional standards and facility policy.
Deficiency in Dietary Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. This deficiency was identified during a survey conducted on June 25, 2024, when the interim director of nursing acknowledged the absence of both a full-time qualified dietary services supervisor and a full-time qualified dietitian. Employee 3, who served as a cook and assistant food services supervisor, confirmed that the full-time qualified dietary services supervisor had recently resigned, and in their absence, Employee 3 was responsible for overseeing food preparation, service, and storage. Although a qualified dietitian provided oversight, they were not employed full-time at the facility. The interim director of nursing further confirmed on June 27, 2024, that the facility had been without a full-time qualified dietary services supervisor since June 5, 2024.
Inadequate Infection Control Program and Lack of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by the lack of a functional system to monitor and investigate infections. The facility's infection control policy, although reviewed in January 2024, did not reflect an operational system to analyze clusters, changes in prevalent organisms, or increases in infection rates. The infection control logs from January to May 2024 showed recurring urinary tract infections and eye infections, but there was no documentation of staff or resident education, evaluation, or interventions to prevent the spread of these infections. Additionally, the facility had not started tracking infections for June 2024 by the time of the survey ending on June 28, 2024. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as recommended by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS). Observations during the environmental tour revealed no evidence of EBP for residents who met the criteria, and the interim Director of Nursing confirmed the absence of EBP implementation. The facility's infection control tracking logs were incomplete, and there was no evidence of a comprehensive program to monitor and prevent infections, as confirmed by the interim Director of Nursing.
Failure to Implement Revised PASRR Form
Penalty
Summary
The facility failed to accurately complete the PASRR (Preadmission Screening and Resident Review) for a resident, as required by the Pennsylvania Department of Human Service Office of the Long-Term Living Bulletin. The revised PASRR Level I form (MA 376 3/24) was mandated to be used for admissions on or after March 1, 2024. However, the facility used an outdated version of the form (MA 376 11/18) for a resident admitted with a diagnosis of COPD. This oversight was confirmed during interviews with the social services consultant and the administrator, who acknowledged that the facility had not yet implemented the revised form. The deficiency was identified during a review of the resident's clinical record, which showed that the PASRR Level I form dated June 8, 2024, was completed using the outdated version. The facility's failure to use the current form as required by the updated regulations resulted in noncompliance with Federal PASRR Regulations at 42 CFR S 483, potentially affecting the facility's MA reimbursement during the period of noncompliance.
Deficiency in Physician Documentation and Signature Safeguards
Penalty
Summary
The facility failed to ensure that the physician wrote, signed, and dated progress notes at each required visit for four of the twelve sampled residents. Specifically, for Residents 14, 29, 9, and 15, there were instances where the physician was noted to have visited, but no corresponding progress notes were found in the clinical records. Additionally, the facility did not maintain proper safeguards for rubber stamp signatures used by the physician, as required by regulatory guidance. Resident 14, diagnosed with Parkinson's disease, and Resident 29, diagnosed with atrial fibrillation, had missing progress notes for several visits despite nurse notes indicating physician visits. Similarly, Resident 9, with dementia, and Resident 15, with heart failure, also had missing progress notes for documented physician visits. The interim Director of Nursing confirmed the absence of progress notes and the lack of safeguards for rubber stamp signatures during the survey.
Food Storage and Service Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and service practices, which could lead to contamination and microbial growth, increasing the risk of food-borne illness. During an initial tour of the food and nutrition services department, several sanitation concerns were observed. A container of dried basil was found opened and undated, which is against safe food handling standards. Additionally, a janitor closet within the department contained a garbage can filled with empty fruit and vegetable cans, uncovered, and attracting fruit flies. The mop was improperly stored in direct contact with the floor basin, and the floor itself was visibly soiled. Further observations during a lunch meal service revealed that desserts on residents' trays were not covered when distributed to rooms, which could lead to contamination. An interview with the cook/assistant food services supervisor confirmed that the facility's practices for food storage were not being followed, and all food storage areas should be maintained in a sanitary manner. These findings indicate a failure to adhere to professional standards for food storage and service, as required by the relevant Pennsylvania codes.
Failure to Accommodate Resident's Seating Preference
Penalty
Summary
The facility failed to accommodate the seating preferences of a resident, identified as Resident 26, who had a history of cerebral infarction with left-sided hemiplegia and mild dementia. The resident, who was moderately cognitively impaired, required maximum staff assistance for daily activities. After a fall from her power recliner chair in January 2024, which resulted in a fractured ankle, the resident was hospitalized and later returned to the facility. Despite receiving therapy and demonstrating safety with the recliner chair, the facility staff did not assist her in using the recliner, which she preferred for comfort and pain relief. Interviews revealed that the resident expressed a desire to use the recliner chair, stating it would help alleviate her ankle pain by allowing her to elevate her legs. The director of therapy confirmed that there was no reason the resident could not use the recliner chair for comfort. However, the facility staff continued to place her in a wheelchair throughout the day, contrary to her preferences and needs, thus failing to reasonably accommodate her seating preference.
Oxygen Storage and Administration Deficiency
Penalty
Summary
The facility failed to maintain and store oxygen in a safe and sanitary manner and did not provide supplemental oxygen administration as ordered for a resident. Observations on June 25, 2024, revealed a partially full oxygen tank was left unsecured on the floor at the nurses' station. The interim Director of Nursing confirmed that oxygen should be secured and stored appropriately. Additionally, a review of the clinical record for Resident 15, who was admitted with a diagnosis of heart failure, showed a physician's order for oxygen at 3 liters per minute via nasal cannula due to shortness of breath. However, observations on June 26 and June 28, 2024, revealed the oxygen concentrator's filter was dust-covered, and the oxygen was set at 2 liters per minute instead of the ordered 3 liters per minute. An LPN confirmed the filter was dusty and the oxygen setting was incorrect. The interim Director of Nursing acknowledged the failure to provide the ordered supplemental oxygen and the need for regular cleaning of the oxygen concentrator filters.
Failure to Implement Timely Medication Disposition System
Penalty
Summary
The facility failed to implement a system to ensure the timely disposition of resident medications, which could lead to potential drug diversion and loss. During an observation of the medication room, an unopened box of Albuterol nebulizer solution ampules, dispensed for a resident, was found. The resident had a physician order for the medication dated March 12, 2024, to be used as needed for shortness of breath and wheezing. Additionally, an open, unlabeled vial of Ceftazidime and expired flu vaccines were found in the medication refrigerator, indicating a lack of adherence to the facility's policy on medication disposal. The facility's policy, revised in January 2002, requires that discontinued medications be marked and either returned to the pharmacy or destroyed. However, the interim DON confirmed that the facility did not follow these procedures, resulting in stockpiling of medications in the nursing medication room. The failure to periodically review and update pharmacy procedures to align with current regulatory requirements was also noted, contributing to the deficiency.
Deficiency in QAPI Program Due to Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to demonstrate the implementation of an ongoing QAPI program, specifically in investigating and analyzing the root cause of adverse events. This deficiency was evidenced by an incident involving a resident who was admitted with diagnoses including cerebral infarction with left-sided hemiplegia and mild dementia. The resident, who was at risk for falls, experienced an unwitnessed fall from a recliner chair, resulting in a serious injury. The incident occurred when the resident attempted to retrieve a dropped TV remote, inadvertently activating the recliner's controls, which led to the chair elevating and the resident sliding out. The facility's investigation into the incident was incomplete and lacked thorough documentation. The only available witness statement was from the Director of Nursing, who was not present during the incident but was called afterward to assess the resident. The investigation did not include statements from the nurse aide who found the resident or any other potential witnesses. Additionally, there was no evidence that the facility had identified the underlying cause or contributing factors to the incident, such as the availability of the resident's call bell at the time of the fall. The survey revealed that the facility did not have an effective QAPI program in place to ensure quality of care and quality of life outcomes. There was no evidence of a comprehensive investigation into the incident or documentation to support the analysis of data collected. The facility's failure to conduct a thorough investigation and identify the root cause of the incident resulted in a deficiency in their QAPI program.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to a representative of the Office of the State Long-Term Care Ombudsman for three residents. Regulatory requirements mandate that before a facility transfers or discharges a resident, it must notify the resident and their representative(s) in writing, and also send a copy of the notice to the Ombudsman. However, the facility did not comply with this requirement for Residents 9, 15, and 32, who were transferred to the hospital on different occasions. The clinical records showed that Resident 9 was transferred on August 3, 2023, Resident 15 on May 17, 2024, and Resident 32 on May 3, 2024. Although the residents and their representatives received the notices, there was no documented evidence that the Ombudsman was notified. An interview with the Nursing Home Administrator confirmed the absence of such documentation since March 15, 2023, indicating a systemic issue in the facility's notification process.
Deficiencies in Nursing Competencies and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies and skills to properly assess and document a resident's condition following an incident and to administer prescribed medications according to professional standards. Specifically, an LPN was observed pre-pouring medications for multiple residents, which is against the facility's medication administration policy and increases the risk of medication errors. The LPN admitted to pre-pouring medications due to time constraints and acknowledged awareness of the policy and the associated risks. The Director of Nursing confirmed that pre-pouring medications was not consistent with facility policy and standards of nursing practice. Additionally, the facility failed to document an incident involving Resident 3, who was physically restrained by an LPN using a soft blanket to prevent injury due to the resident's agitated behavior. The incident was not recorded in the resident's clinical record, and there was no documentation of the resident's behavior, the nursing assessment, or the interventions attempted prior to the use of the restraint. The Director of Nursing acknowledged the incident and confirmed that it was not common practice and should only be used as a last resort. The facility's investigation into the incident concluded that the LPN acted to prevent injury and remained with the resident during the restraint. However, there was no documented evidence in the resident's clinical record of the assessment and monitoring of the resident following the restraint. The lack of documentation and adherence to proper procedures highlights deficiencies in the facility's nursing services and record-keeping practices.
Inconsistent Implementation of Infection Control Procedures
Penalty
Summary
The facility failed to ensure the consistent implementation of infection control procedures designed to prevent the potential spread of infection. Observations revealed a collection of used basins, bedpans, and urinals under a sink in a bathroom, with visible residues and odors indicating they had not been properly cleaned. Interviews with staff, including an LPN and the Environmental Services Supervisor, confirmed that these items were reused and that there was no consistent or documented procedure for their sterilization. Different staff members provided conflicting information on the cleaning agents used, with one mentioning Sterigent and another mentioning cavi-wipes, indicating a lack of standardized protocol for disinfection. Additionally, a yellow disposable gown was observed hanging on the door of a resident's room without any signage for transmission-based precautions (TBP) or other personal protective equipment (PPE) available. The Director of Nursing (DON) and an LPN provided conflicting information about the resident's TBP status, with the DON stating the gown was a precaution due to the resident's diarrhea episode, but confirming that the resident was not on TBP. The Nursing Home Administrator and DON confirmed the facility's failure to consistently implement infection control procedures, as required by regulations.
Failure to Offer Bathing Preferences
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice in their bathing preferences. Observations, clinical records, and interviews revealed that male and female residents were not offered the option of a shower, despite the facility having both a tub and shower in their common central bathing area. Facility documentation indicated that all male and female residents received either a bed bath or a tub bath, with no evidence of showers being offered. Interviews with three cognitively intact residents (Residents 7, 9, and 19) confirmed that they were not given the choice of a shower, even though they required staff assistance for bathing and expressed a preference for showers over tub baths or bed baths. Resident 19, who is dependent on staff for bathing, was unaware that shower chairs or beds were available and had only been receiving bed baths. Resident 7, who also required assistance, found the tub bath experience unpleasant and resorted to giving himself bed baths as the facility did not offer shower assistance. Resident 9, who needed help from staff for bathing, confirmed that he received tub baths because showers were not offered. The Director of Nursing confirmed that there was no evidence of residents being offered a choice between a tub bath and a shower, violating resident rights and nursing services regulations.
Failure to Implement Timely Disposition of Resident Medications
Penalty
Summary
The facility failed to implement a system to ensure the timely disposition of resident medications, leading to the potential for drug diversion and loss. During an observation of the facility's medication room, two plastic drawers filled with medications were found. These medications were in pre-sealed plastic sleeves with preprinted labels of the medication, dosage, and quantity but lacked labels with residents' names. The medications included antibiotics, diuretics, steroids, thyroid medications, and antidepressants. Additionally, multiple boxes of eye drops and ointments prescribed to current residents in the last two years but no longer with current physician orders were stored along with these unlabeled medications. The LPN confirmed that these were discontinued medications stored for potential future use and that no inventory or documentation was maintained for these medications. The LPN also stated that the pharmacy visits the facility multiple times a week, but the medications had not been returned or disposed of as required by the facility's policy. The Director of Nursing (DON) confirmed that all discontinued medications should have been picked up by the pharmacy or destroyed per the facility policy and not stockpiled in the nursing medication room. The facility's pharmacy policies and procedures had not been reviewed or revised in over a year, contributing to the failure to implement procedures to promote the timely disposition of resident medications. This deficiency was identified during a survey, and it was determined that the facility failed to periodically review pharmacy procedures for continued appropriateness, effectiveness, and compatibility with current regulatory requirements for drugs awaiting final disposition.
Failure to Justify and Re-evaluate PRN Psychoactive Medications
Penalty
Summary
The facility failed to clinically justify the use of as-needed psychoactive drugs for two residents, Resident 4 and Resident 33. For Resident 4, who was admitted with dementia and a history of falling, a physician order for Clonazepam was noted without any documented clinical necessity. Additionally, there was no re-evaluation of the PRN Clonazepam after 14 days, and no behaviors were documented to justify its use. The Director of Nursing (DON) confirmed the lack of resident-specific documentation to justify the medication's use. Similarly, Resident 33, who was admitted with dementia and other medical conditions, had multiple psychoactive medications prescribed without documented clinical necessity or physician countersignature within 48 hours. The resident's behavior monitoring records did not show evidence of behaviors requiring these medications, and the PRN Alprazolam was not re-evaluated after 14 days. The DON confirmed the absence of documentation justifying the use of these medications for Resident 33 as well. The survey revealed that the facility did not provide individualized non-pharmacological interventions for either resident and failed to document the clinical necessity for the continued use of psychoactive medications beyond 14 days. The attending physician did not document the appropriateness of the PRN orders, and the facility did not ensure that the medications were re-evaluated for continued appropriateness. These deficiencies were confirmed through clinical record reviews and staff interviews, highlighting a significant lapse in the facility's medication management practices.
Failure to Ensure Resident Hydration
Penalty
Summary
The facility failed to ensure that fresh water was consistently readily accessible to residents, which is necessary to meet their preferences and promote adequate hydration. During a tour of resident rooms, it was observed that residents did not have access to fresh ice water at their bedsides. Specific observations included empty personal beverage containers, warm soda cans, and undated small cups of warm water out of residents' reach. Interviews with residents confirmed that they did not have fresh water available at night and had to request it from staff, which was not consistently provided. Residents expressed feelings of thirst and dry mouth due to the lack of readily available water. Interviews with staff, including a nurse aide and the Director of Nursing (DON), revealed that the facility's practice was to collect all cups at the start of the night shift and not provide water unless specifically requested by a resident. The DON confirmed that the facility did not provide routine distribution of fresh ice water throughout the day or night, relying instead on 1:1 encouragement with fluids during the day. This practice was corroborated by the Nursing Home Administrator (NHA), who also confirmed the lack of routine water distribution, leading to the deficiency in ensuring resident hydration.
Failure to Maintain Safe and Orderly Environment
Penalty
Summary
The facility failed to provide maintenance services to maintain a safe and orderly environment in the resident shower room and one resident room. An observation on March 19, 2024, at 5:19 AM revealed broken and missing tiles on the wall of the common tub/shower room, exposing the underlying plaster. Additionally, an observation at 8:54 AM of a resident room revealed an unsecured, loose electrical outlet next to the resident's bed, exposing the outlet box and connecting electrical wires. During an interview, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility's environment should be kept in good repair and maintained in a safe and homelike manner.
Failure to Ensure Resident Free from Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse by physically restraining the resident to control their behavior. The incident involved a resident with severe cognitive impairment, dementia, aphasia, depression, and pain. The resident was admitted to the facility and was dependent on staff for activities of daily living. An anonymous employee reported that a nurse had tied the resident to a chair to restrain them due to their behaviors. This incident was not documented in the resident's clinical record, and the facility's administration was aware of the alleged abuse but did not document it properly in the resident's records. The Director of Nursing (DON) confirmed that the facility conducted an investigation into the allegation, but the incident and the facility's response were not documented in the resident's clinical record. The investigation revealed that a Licensed Practical Nurse (LPN) had tied the resident to a wheelchair with a sweatshirt, claiming it was for the resident's safety. The LPN stated that the resident was agitated and at high risk for injury, and the restraint was applied for approximately 5-7 minutes. However, the facility's policies on abuse and restraints were not followed, as there was no documentation of the resident's increased unsafe behaviors or the alternative interventions attempted before using the restraint. The DON acknowledged that the incident of physically restraining the resident was not common practice and should only be used as a last resort after exhausting all other means to assure the resident's safety. The facility failed to document the resident's behaviors, the nursing assessment, and the interventions attempted to alleviate or reduce the resident's behaviors. Additionally, the LPN involved in the incident continued to work with residents during the investigation, which was confirmed by another staff member. The facility's failure to follow its abuse and restraint policies resulted in the deficiency.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services to promote the mental and psychosocial well-being of a resident diagnosed with dementia, aphasia, depression, and pain. The resident was admitted to the facility with severe cognitive impairment and was dependent on staff for activities of daily living. An anonymous employee reported that a nurse had tied the resident to a chair to restrain them due to their behaviors, but there was no documented evidence of this incident in the resident's clinical record. The Director of Nursing (DON) confirmed that the facility was aware of the alleged abuse and had conducted an investigation, but the incident and the facility's response were not documented in the resident's clinical record. The investigation revealed that the nurse had restrained the resident with a soft blanket for 5-7 minutes to prevent injury, and the DON and Nursing Home Administrator (NHA) concluded that the incident was free of abuse or neglect. However, the DON acknowledged that physically restraining the resident was not common practice and should only be used as a last resort. There was no documentation in the resident's clinical record of the resident's increased unsafe behaviors, the nursing assessment of the resident's status, or the interventions attempted to alleviate the resident's behaviors. Additionally, there was no documented evidence that social services had assessed the resident following the adverse event to identify any therapeutic social services that may be required to assist the resident in maintaining their mental and psychosocial health. The DON confirmed that social services had not monitored the resident for any changes in mood, behaviors, or affect. The facility failed to provide the required social services to support the resident's psychosocial well-being.
Pharmacist Failed to Identify Drug Irregularities
Penalty
Summary
The pharmacist failed to identify drug irregularities in the drug regimens of two residents, including duplicate drug therapy for anxiety and agitation, and PRN psychoactive drug orders exceeding 14 days without re-evaluation of continued necessity. Resident 4, who was admitted with dementia and a history of falling, had a physician order for Clonazepam 0.5 mg PRN for anxiety, restlessness, and agitation. There was no physician documentation of the clinical necessity for initiating Clonazepam or its re-evaluation after 14 days. The monthly behavior monitoring records showed no behaviors justifying the use of this medication, and the Director of Nursing (DON) could not provide resident-specific documentation to justify its use. The pharmacist did not identify this irregularity during the monthly drug regimen review in February 2024. Resident 33, admitted with dementia, intracranial abscess, and granuloma, had multiple PRN orders for psychoactive medications, including Alprazolam, Ativan, and Risperdal, without documented clinical necessity or re-evaluation after 14 days. The monthly behavior monitoring records did not show evidence of behaviors requiring these medications. The DON confirmed the lack of resident-specific documentation to justify the use of these medications. The pharmacist did not identify these drug irregularities, including duplicate drug therapy and the use of PRN psychoactive medications without stop and re-evaluation dates, during medication reviews. The DON confirmed that the pharmacist had not identified these irregularities in the residents' drug regimens.
Failure to Document Restraint Use and Resident Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not documenting the actual experiences, interventions used, the resident's response to those interventions, and the assessment and monitoring following an adverse event. The incident involved a resident with dementia, aphasia, depression, and pain, who was admitted to the facility and was severely cognitively impaired. The resident was dependent on staff for activities of daily living and was restrained by a nurse using a blanket to control the resident's behavior, which was not documented in the clinical records as required by professional standards and facility policy. An anonymous employee reported that a nurse had tied the resident to a chair to restrain them due to their behaviors. The Director of Nursing (DON) confirmed that the facility was aware of the incident and had conducted an investigation, but the incident and the facility's response were not documented in the resident's clinical record. The investigation concluded that the nurse had attempted different interventions before using the restraint and stayed with the resident during the restraint, which lasted for approximately 5-7 minutes. However, this information was not included in the clinical records. The DON acknowledged that the incident of physically restraining the resident was not common practice and should only be used as a last resort. There was no documentation in the resident's clinical records of the resident's increased unsafe behaviors, the nursing assessment of the resident's status, or the interventions attempted to alleviate the behaviors. Additionally, there was no documentation of the resident's physical assessment or monitoring following the restraint. The lack of documentation violated the facility's policy and professional standards of practice.
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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