Snu Armstrong Co Memorial Hosp
Inspection history, citations, penalties and survey trends for this long-term care facility in Kittanning, Pennsylvania.
- Location
- One Nolte Drive, Kittanning, Pennsylvania 16201
- CMS Provider Number
- 395890
- Inspections on file
- 16
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Snu Armstrong Co Memorial Hosp during CMS and state inspections, most recent first.
The facility did not provide a secure method for residents, family members, friends, or staff to file grievances anonymously, despite policy stating this right. Forms were available in common areas, but the Nursing Home Administrator instructed individuals to hand them to staff, compromising anonymity. This affected all 13 residents involved.
The facility failed to conduct timely state background checks for a Nursing Assistant and a Registered Nurse before their hire. The NA was hired without a completed background check, and the RN's check lacked results. These oversights were confirmed by the Employment Coordinator and the Nursing Home Administrator.
A facility failed to communicate necessary resident information during a transfer to a hospital for a resident with peripheral vascular disease and diabetes. The Director of Nursing confirmed that while paperwork was sent, there was no documentation of the required information being communicated to the receiving provider.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the transfer or discharge of two residents. One resident with coronary artery disease, high blood pressure, and seizures was discharged home, and another with peripheral vascular disease and diabetes was transferred to the hospital, both without the required notifications. The Nursing Home Administrator confirmed that notifications had not been sent since before the COVID pandemic.
A facility failed to notify a resident or their representative of the bed-hold policy during a hospital transfer. The resident, with peripheral vascular disease and diabetes, was transferred to the hospital without documented evidence of receiving written information about the bed-hold policy. The Nursing Home Administrator confirmed the absence of such a policy and acknowledged the notification failure.
A resident with a diagnosis of dependence on renal dialysis did not receive dialysis services as required because the facility failed to secure a contract with a dialysis provider. The resident had a physician's order for dialysis three times a week, but the Nursing Home Administrator confirmed the absence of a necessary contract to facilitate these services.
The facility failed to document the clinical necessity for psychotropic medications for two residents, as required by federal regulations and facility policy. One resident was prescribed Duloxetine and Zolpidem, and another was prescribed Trazodone, without documented justification from a physician. The DON confirmed the absence of necessary documentation, indicating non-compliance with medication regime requirements.
The facility did not submit direct care staffing information in the PBJ system for Quarter 1, from October to December 2023. This was confirmed by the Nursing Home Administrator during an interview, acknowledging the failure to comply with the submission requirement, violating 28 Pa. Code 201.14(a).
The facility's QAPI committee failed to address recurring deficiencies, including a broken elevator button with sharp edges, lack of a posted grievance official, and inadequate infection control during dressing changes. These issues highlight ineffective corrective action and monitoring.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings quarterly with all required members, as the Medical Director and Director of Nursing were absent from a meeting. This was confirmed by the Nursing Home Administrator, violating management regulations.
A facility failed to follow proper PPE protocols during a dressing change for a resident with a surgical wound. An LPN entered the resident's room and performed the procedure without wearing a gown, as required by Enhanced Barrier Precautions. This lapse was confirmed by the Nursing Home Administrator, indicating non-compliance with the facility's infection control policies.
A medication cart was left unattended in a corridor with its computer screen open, exposing resident information. This breach of confidentiality occurred when an RN left the cart to go to the medication room, as confirmed by the Nursing Home Administrator.
The facility failed to maintain a safe environment in one of its elevators, as the number one button was broken with sharp edges exposed. This issue was observed on two consecutive days, and the Nursing Home Administrator confirmed the deficiency.
Failure to Ensure Anonymous Grievance Filing
Penalty
Summary
The facility failed to ensure that residents, family members, friends, or staff could file complaints or grievances anonymously. The facility's policy, dated December 1, 2024, stated that grievances could be filed anonymously, but during a tour of the nursing unit, it was observed that there was no secure location for submitting these forms anonymously. The Resident/Family Concern Forms were available in the Activity/Dining Room and at the Nurses Station, but there was no provision for anonymous submission. During an interview, the Nursing Home Administrator (NHA) indicated that they instructed individuals to give the completed forms to staff, which does not allow for anonymity. The NHA acknowledged the oversight and confirmed that the facility did not ensure anonymous filing for all 13 residents involved.
Failure to Conduct Timely Background Checks for New Hires
Penalty
Summary
The facility failed to properly screen two employees by not completing a state background check prior to their hire. Specifically, the personnel records of a Nursing Assistant (NA) and a Registered Nurse (RN) were reviewed, revealing deficiencies in the hiring process. The NA was hired without a state criminal background check being completed before her start date. This was confirmed during an interview with the Employment Coordinator, who acknowledged that the background check was conducted after the NA's hire date. In the case of the RN, although a criminal background check was completed before the hire date, the report did not indicate whether the RN had a criminal record or not. This oversight was also confirmed by the Employment Coordinator, who admitted that the results were missing from the criminal background check. The Nursing Home Administrator confirmed these findings, indicating a failure to adhere to the facility's policies and procedures for employee screening.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. This deficiency was identified for one out of three residents sampled, specifically for a resident with a history of peripheral vascular disease and diabetes. The resident was transferred to the hospital and did not return to the facility. Upon review, it was found that there was no documented evidence that the facility had communicated essential information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. During an interview, the Director of Nursing acknowledged that while paperwork was sent with the resident, there was no documentation to confirm that the necessary information was communicated. This lack of communication was confirmed as a failure by the facility to meet the requirements for transferring resident information, as outlined in the resident rights regulation 28 Pa. Code 201.29 (a) (c.3) (2).
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer or discharge of two residents. The clinical records for Resident R7 and Resident R12 lacked documented evidence of written transportation notifications to the Ombudsman. Resident R7, who had coronary artery disease, high blood pressure, and seizures, was discharged to home without the required notification on September 16, 2024. Similarly, Resident R12, diagnosed with peripheral vascular disease and diabetes, was transferred to the hospital on July 17, 2024, without the necessary notification to the Ombudsman. During interviews conducted on September 19, 2024, the Nursing Home Administrator admitted that the facility had not been sending notifications to the Ombudsman since before the COVID pandemic. This admission confirmed the facility's failure to comply with the requirement to notify the Ombudsman of resident transfers or discharges, as mandated by 28 Pa. Code 201.29 (a) (c.3) (2) regarding resident rights.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to notify a resident or the resident's representative of the bed-hold policy during a hospital transfer. The clinical record review indicated that the resident, who had been admitted to the facility and had diagnoses of peripheral vascular disease and diabetes, was transferred to the hospital and did not return. There was no documented evidence that the resident or their representative received written information about the facility's bed-hold policy at the time of transfer. During interviews, the Nursing Home Administrator confirmed the absence of a bed-hold policy and acknowledged the failure to notify the resident or their representative about it.
Failure to Secure Dialysis Services for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received such services consistent with professional standards of practice. Resident R68, who was admitted with diagnoses including dependence on renal dialysis, unspecified fall, and gastroesophageal reflux disease (GERD), had a physician's order for dialysis every Monday, Wednesday, and Friday. However, the facility did not have a contract with a dialysis facility to provide these necessary services. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of a contract for the required dialysis services.
Failure to Document Clinical Necessity for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a medication regime was free from potentially unnecessary medications for two residents, as required by federal regulations and facility policy. Resident R71, who was admitted with diagnoses including hyperlipidemia, weakness, and atrial fibrillation, was prescribed Duloxetine and Zolpidem. However, there was no documented evidence from the physician justifying the clinical necessity for these medications in the resident's clinical record. Similarly, Resident R74, admitted with atrial fibrillation, diabetes, and cirrhosis of the liver, was prescribed Trazodone without documented evidence of clinical necessity from the physician. During an interview, the Director of Nursing confirmed the absence of documented evidence for the clinical necessity of the psychotropic medications for both residents. The DON acknowledged that the facility did not comply with the requirement to ensure a medication regime free from potentially unnecessary medications for these residents. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in adherence to the facility's policy and federal regulations regarding psychopharmacologic drugs.
Failure to Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for Quarter 1, covering the period from October 1, 2023, through December 31, 2023. This deficiency was identified during a review of the PBJ staffing data reports, which revealed the absence of the required data submission for the specified quarter. The issue was confirmed during an interview with the Nursing Home Administrator on September 19, 2024, at 11:19 a.m., who acknowledged the facility's failure to comply with the submission requirement. This non-compliance is a violation of 28 Pa. Code 201.14(a), which outlines the responsibility of the licensee.
Facility Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively. The deficiencies identified during the State Survey and Certification included a failure to maintain a safe, homelike environment due to a broken number one button with sharp exposed edges on Elevator 1. Additionally, the facility did not ensure that a grievance official was posted with contact information, and the grievance policy did not meet federal guidelines. Another deficiency was observed in the facility's infection control measures during a dressing change observation. The staff failed to implement required infection control measures, which included proper hand hygiene, changing of gloves, prevention of cross-contamination, appropriate use of personal protective equipment (PPE), and decontamination of equipment. These deficiencies indicate a lack of effective corrective action and monitoring by the facility's QAPI committee.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of the three quarterly meetings during the period from October 2023 through December 2023. The facility's Quality Assurance and Performance Improvement (QAPI) Program policy, dated September 1, 2024, emphasizes a multidisciplinary team approach to maintaining an effective and comprehensive QAPI program. However, a review of the QAPI quarterly meeting attendance records from January 15, 2024, revealed that the Medical Director and Director of Nursing did not attend the meeting. During an interview on September 19, 2024, the Nursing Home Administrator confirmed the facility's failure to meet the requirement of conducting QAA meetings with all necessary committee members. This deficiency is in violation of 28 Pa Code: 201.18(e)(1)(2)(3)(4) Management.
Failure to Follow PPE Protocols During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) for a resident identified as R65. The facility's policy on infection control, dated 11/1/23, aims to maintain a comprehensive program to reduce infection risks. However, during an observation of a dressing change, it was noted that an LPN, identified as Employee E5, entered the resident's room without donning the required isolation equipment. The LPN performed a dressing change without wearing a gown, which is a requirement under Enhanced Barrier Precautions (EBP) for high-contact care activities such as wound care. Resident R65 was admitted with diagnoses including cellulitis, weakness, and a urinary tract infection, and had a surgical wound on the left shin. The resident's care plan included daily wound care with specific instructions for cleaning and dressing the wound. Despite these precautions, the LPN's failure to wear a gown during the dressing change was confirmed by the Nursing Home Administrator, indicating a lapse in following the facility's infection control policies. This deficiency was identified during a survey, highlighting the need for adherence to PPE protocols to prevent infection risks.
Breach of Resident Confidentiality on Medication Cart
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of its medication carts. During an observation, it was noted that a medication cart, located in the corridor outside a resident's room, was left unattended with the computer screen open. This exposed identifiable resident information to any passerby. The facility's policy on Security Codes/Passwords/Confidentiality Compliance, last reviewed on 9/1/24, emphasizes the importance of protecting computerized data and warns against breaches of patient privacy. Registered Nurse Employee E1 admitted to leaving the cart unattended with the screen open while running to the medication room. The Nursing Home Administrator confirmed the breach of confidentiality on the medication cart.
Unsafe Elevator Environment Due to Broken Button
Penalty
Summary
The facility failed to maintain a safe, homelike environment for one of its two elevators, specifically Elevator 1. On two separate observations, the number one button in Elevator 1 was found to be broken, with the center of the button missing and sharp edges exposed. These observations occurred on consecutive days, indicating that the issue was not addressed promptly. During an interview, the Nursing Home Administrator confirmed the presence of the broken button with exposed sharp edges, acknowledging the facility's failure to maintain the required safe environment.
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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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