Somerset Healthcare & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Somerset, Pennsylvania.
- Location
- 228 Siemon Drive, Somerset, Pennsylvania 15501
- CMS Provider Number
- 395398
- Inspections on file
- 37
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Somerset Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that a resident receiving hospice services and psychotropic medications, including an antipsychotic for anxiety, depression, and dementia, had multiple dose increases of Seroquel ordered without documented evidence that the resident’s representative was informed in advance of the risks, benefits, and treatment alternatives. Facility policy required that residents or their representatives be informed and that this discussion be documented prior to initiating or increasing psychotropic medications, but review of the clinical record and confirmation by the DON showed that no such documentation existed for these Seroquel dose changes.
A cognitively impaired resident who required staff assistance for daily care and was care planned as being at risk for falls experienced multiple falls and related incidents in their room, including being found on the floor and on their knees with a bruised elbow after tripping over oxygen tubing. Although facility policy required notification of the resident’s representative when changes occurred that required notification, there was no documentation that the resident’s daughter, who held power of attorney, was informed of any of these events, and the DON confirmed that notification did not occur.
A resident with cognitive impairment and a history of GI bleed had physician’s orders for staff to obtain three stool samples and test them for occult blood. Review of the Treatment Administration Record showed that no stool samples were collected or tested as ordered. In an interview, the DON confirmed that staff did not perform the ordered stool occult blood testing and acknowledged that it should have been done.
The facility failed to follow its fall prevention policy and ensure residents’ environments were free of accident hazards. One resident with severe cognitive impairment and dependence for care had documented falls and a care plan intervention for a weighted blanket to reduce anxiety and restlessness, yet required fall risk assessments were not completed at the prescribed intervals and the weighted blanket was not in place, with the LPN unaware of the intervention. Another cognitively impaired resident with dementia, a history of falls, and a two-person transfer status using a pivot disc experienced an assisted fall during a transfer, but no witness statements were obtained, no thorough post-fall investigation was completed to identify contributing factors, and no new fall interventions were documented, as confirmed by the DON.
Surveyors found that three cognitively impaired residents, including individuals with hypertension, osteoporosis, hemiplegia, and dementia, did not have documented evidence of receiving their scheduled showers or complete bed baths on multiple days. Each resident’s MDS and task list showed dependence on staff for bathing and specific shower schedules on dayshift, but the bath/shower records lacked entries showing that care was provided, offered, or refused on several scheduled dates. The Interim DON confirmed the absence of documentation for these missed bathing events.
The facility did not consistently serve food at safe and appetizing temperatures, as required by policy and regulation. A resident reported that hot foods were often served cold, and observations during a meal service confirmed that both hot and cold items were not maintained at appropriate temperatures. The Dietary Manager acknowledged that food should be served at correct temperatures and be palatable.
The facility failed to serve food at appetizing temperatures, as residents reported meals being served cold. Observations confirmed that food temperatures were not maintained during service, with lukewarm temperatures recorded. The Dietary Manager was aware of the complaints and the facility's policy.
The facility failed to develop comprehensive care plans for three residents, including one with a feeding tube requiring Enhanced Barrier Precautions, another with smoking permissions lacking a timely care plan, and a third with a PEG tube without a care plan for its management. These deficiencies were confirmed by nursing leadership.
A resident with moderate cognitive impairment and left hemiplegia experienced unplanned weight loss due to the facility's failure to provide a recommended Med Pass supplement. The supplement was not re-ordered after the initial order was completed, leading to a significant weight decrease.
A facility failed to document the application of Gentamicin ointment to a resident's peritoneal dialysis site as ordered by the physician. The resident, who had end-stage renal disease, did not have documented evidence of the treatment on several specified dates, as confirmed by the DON.
A resident with moderate cognitive impairment and right-sided hemiplegia was found without a call bell within reach, contrary to the facility's policy and the resident's care plan. Observations and interviews confirmed the deficiency, highlighting a failure to accommodate the resident's needs for assistance.
A facility failed to maintain the confidentiality of a resident's medical information. A laptop on a medication cart in a hallway was left open, displaying the MAR for a resident, visible to staff, residents, and visitors. A nurse admitted to leaving the screen open while stepping away, and the Nursing Home Administrator confirmed that such information should not be left unattended or viewable by unauthorized individuals.
The facility failed to provide written notification to residents and their legal guardians regarding hospital transfers for three residents. A resident with an elevated white blood cell count, another with a hip fracture, and a third with low oxygen levels were transferred without documented written notices. Staff interviews confirmed the lack of documentation, violating resident rights and discharge policy.
A resident with hypertension, diabetes, and COPD was transferred to the hospital due to low oxygen levels. The facility failed to issue a bed-hold notice to the resident or their representative, as required by policy, during this emergency transfer.
A facility failed to complete a comprehensive significant change MDS assessment within the required time frame for a resident admitted to hospice care due to an end-stage illness. The RAI User's Manual mandates that such assessments be completed no later than 14 days after a significant change in status. Despite physician's orders and a care plan indicating the need for hospice care, there was no documented evidence of the assessment being completed. The Nursing Home Administrator confirmed the oversight.
The facility failed to accurately complete MDS assessments for several residents, leading to incorrect documentation of medications and treatments such as antiplatelet medications, dialysis, and anticonvulsants. These errors were confirmed through staff interviews and a review of clinical records.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan included interventions that were not being applied, and another resident's care plan inaccurately reflected medication administration. Staff confirmed the discrepancies, but the care plans were not revised accordingly.
A facility failed to complete a discharge summary for a resident who was discharged home with Home Health services, including physical therapy, occupational therapy, and nursing. Despite physician's orders and a nursing note indicating the discharge, there was no documented evidence of a discharge summary as of over two months later. This was confirmed by the Assistant DON.
The facility failed to follow physician's orders for medication administration for a resident with septicemia, resulting in incomplete courses of Doxycycline and Erythromycin. Additionally, bowel protocols were not followed for two residents, leading to severe constipation and a moderate colonic ileus for one resident. These deficiencies were confirmed by interviews with nursing staff.
A resident with Alzheimer's and a non-stageable pressure ulcer was not repositioned every two hours as recommended, leading to a deficiency. Despite staff interviews confirming the need for regular repositioning, observations showed the resident remained in the same position for over three hours, and the facility did not document repositioning efforts.
The facility failed to label a multi-use vial of Aplisol properly and secure a medication cart. An open, undated vial was found in the medication room refrigerator, contrary to the manufacturer's guidelines. Additionally, a medication cart was left unlocked and unattended in a hallway. Both incidents were confirmed by staff and the Nursing Home Administrator, indicating non-compliance with facility policies and state regulations.
A facility failed to obtain the required hospice election form for a resident receiving hospice care, as stipulated in an agreement with the hospice provider. Despite the resident's care plan and physician's orders for hospice admission, the form was missing from both the resident's and hospice provider's records. This deficiency was confirmed by a registered nurse, and the form was later faxed by the hospice provider.
The facility's QAPI committee failed to address recurring deficiencies effectively, leading to repeated citations for issues such as personal privacy, abuse policy implementation, resident assessments, care plans, quality of care, and infection control. Despite plans of correction, the facility did not achieve compliance, indicating systemic issues in quality assurance processes.
A facility failed to adhere to infection control protocols when an LPN did not wear a gown during wound care for a resident with a pressure ulcer, despite guidelines requiring Enhanced Barrier Precautions (EBP). The resident, with Alzheimer's and a non-stageable pressure ulcer, was dependent on staff for care. The lapse was confirmed by the LPN and the Infection Control Preventionist.
The facility failed to complete necessary background checks and verifications for newly hired nursing staff, including Nurse Aide Registry verifications, nursing license checks, and criminal background checks. This oversight involved two nurse aides and three nurses, with the Nursing Home Administrator confirming the lack of documented evidence for these verifications, which should have been completed prior to hiring.
A facility failed to maintain the confidentiality of a resident's health information during medication administration. An LPN left a medication cart unattended with a computer screen displaying a resident's personal health information facing the hallway. Both the LPN and the DON confirmed that the information should have been secured, as per the facility's policy on electronic health records.
The facility failed to secure medication carts, as observed when an A unit cart was left unlocked and unattended with medications on top, and a C unit cart was also found unlocked. LPNs admitted to leaving the carts unsecured, and the DON confirmed the carts should have been locked.
A resident's food preferences were not honored after new ownership took over the facility. The resident, who was cognitively intact, preferred yogurt and a banana for breakfast but was instead given eggs, which she disliked. The Dietary Manager was instructed not to purchase these items unless needed for nutritional intervention, leading to the resident's preferences being unmet.
The facility failed to provide nightly snacks to residents as per their preferences, despite a policy stating snacks should be available upon request. Interviews and records showed that several residents, including those with diabetes, were not consistently receiving evening snacks. The DON confirmed the issue, acknowledging that snacks should be offered nightly.
The facility failed to monitor intake and output for a resident with a suprapubic catheter and did not follow bowel protocols for another resident with cognitive impairment. Despite care plans and physician's orders, there was no documentation of intake/output monitoring or administration of bowel medications during periods of constipation, as confirmed by nursing staff interviews.
The facility failed to accurately complete MDS assessments for two residents. One resident's assessment incorrectly documented urinary continence and influenza vaccination status, while another resident's assessment inaccurately recorded the reason for not receiving the influenza vaccine. These errors were confirmed by the Assistant Director of Nursing.
A facility failed to include a signed and dated ultrasound report in a resident's clinical record. The ultrasound was ordered for screening the resident's bilateral breasts for lumps or masses. Despite the procedure being completed, the report was not documented in the record, as confirmed by the Assistant DON.
The facility did not follow infection control guidelines for two residents with indwelling medical devices. One resident with a suprapubic catheter and another with a peritoneal dialysis catheter lacked appropriate signage and staff did not use gowns during care. The Assistant Director of Nursing confirmed that Enhanced Barrier Precautions should have been in place.
During a fire evacuation, a resident requiring a mechanical lift was inappropriately transferred by staff, resulting in a hip fracture. Despite knowing the resident's needs, a nurse aide attempted a manual transfer, leading to the resident being lowered to the floor. The resident, who was cognitively impaired and dependent on staff for transfers, suffered a displaced intertrochanteric fracture of the left hip.
A facility failed to monitor and document pressure ulcers for a resident, leading to a deficiency. The resident had existing pressure injuries and was at risk for skin integrity issues. Despite treatment orders and regular dressing changes, the facility did not document weekly assessments as required by policy, resulting in a lack of evidence for proper monitoring.
A resident with cognitive impairments and a history of requiring a mechanical lift for transfers was involved in an incident during a fire evacuation, resulting in a hip fracture. Despite this, the care plan was inaccurately revised to indicate one assist for transfers, contrary to staff and rehabilitation director confirmations of the need for a mechanical lift.
A facility failed to create a comprehensive care plan for a resident with Raynaud's syndrome and gangrene, as required by their policy. Despite assessments indicating the resident's condition, there was no documented evidence of a care plan with specific interventions. This was confirmed by the Nursing Home Administrator and the DON.
A facility failed to follow hospital discharge instructions and physician's orders for a resident with Raynaud's syndrome and an adrenal adenoma. The resident missed a scheduled endocrinologist appointment, and no vascular follow-up was arranged for gangrene in the resident's fingers. The DON noted the endocrinologist appointment was pre-scheduled, and the CRNP was unaware of the need for a plastic surgeon consultation.
A resident with a history of alcoholism ingested hand sanitizer in an LTC facility, resulting in a blood alcohol level of 0.29. Despite being aware of the resident's history, the facility failed to prevent access to hand sanitizer, leading to multiple incidents where the resident was found with hand sanitizer. Initial searches of the resident's room were inadequate, allowing the resident to continue accessing hand sanitizer.
The facility failed to implement its abuse prevention policies by not verifying nursing licenses, completing registry checks, conducting criminal background checks, and obtaining reference checks for new hires. Additionally, three staff members did not receive annual abuse training as required.
The facility failed to complete accurate MDS assessments for five residents, leading to discrepancies in clinical records. Errors included incorrect documentation of antibiotic use, oxygen therapy, hypoglycemic medications, antipsychotic medication dose reductions, and discharge status. Interviews with the RNAC confirmed these coding errors.
The facility failed to update care plans for six residents to reflect their current conditions and needs, including the discontinuation of oxygen therapy and feeding tubes, resolution of pressure injuries, and the need for a sippy cup after an incident.
The facility failed to clarify physician's orders for two residents, one with diabetes and another with a Stage 4 pressure ulcer. This resulted in unverified blood sugar checks and unclear wound care instructions, as confirmed by the DON.
The facility failed to follow a neurologist's recommendation for a follow-up appointment for a resident with Parkinson's disease and did not adhere to physician's orders for three other residents, including medication administration and notifying physicians of elevated blood sugar levels.
The facility failed to obtain physician's orders for dialysis treatments for a resident requiring hemodialysis due to end-stage renal disease. The resident's clinical record lacked documented evidence of such orders, which was confirmed by the DON.
The facility failed to ensure the accountability of controlled medications for three residents. Multiple instances were found where doses of hydrocodone-acetaminophen and Oxycodone were signed out but not documented as administered in the clinical records. These deficiencies were confirmed through interviews with the DON and a review of the controlled drug records.
The facility failed to serve palatable food to residents. Several residents described the food as disgusting and lousy, with one noting that the potatoes were not peeled. Observations confirmed that the oven-browned potatoes were dry, bland, and had the skin intact, contrary to the recipe. The Dietary Manager confirmed the potatoes should have been peeled and seasoned.
The facility failed to maintain sanitary food service conditions, with observations of dust and debris on kitchen air vents and a nurse aide handling a resident's food with bare hands. The Dietary Manager and Nursing Home Administrator confirmed these deficiencies.
The facility's QAPI committee failed to correct recurring quality deficiencies, including inaccurate MDS assessments, failure to revise care plans, not following physician's orders, improper oxygen therapy, lack of medication accountability, and poor infection control practices. These issues were previously cited, indicating ineffective corrective actions.
The facility failed to follow CMS and CDC infection control guidelines for seven residents with chronic wounds and indwelling catheters, and allowed two employees to work without completing required TB testing. This resulted in multiple deficiencies, including the absence of infection control signage and premature staff deployment.
Failure to Inform Resident Representative of Psychotropic Medication Risks and Alternatives
Penalty
Summary
Surveyors determined that the facility failed to inform a resident’s representative in advance about the risks, benefits, and treatment alternatives related to psychotropic medication dose increases. The facility’s policy on psychotropic medications, dated February 4, 2026, required that prior to initiating or increasing such medications, the resident, family, and/or representative be informed of the benefits, risks, alternatives, and any black box warnings, and that this discussion be documented in the clinical record. Review of the clinical record for Resident 4 showed that this required documentation was absent. Resident 4’s quarterly MDS dated January 28, 2026, indicated cognitive impairment, limited ability to be understood, usual ability to understand others, no behavioral symptoms, receipt of hospice services, and use of psychotropic medications including antipsychotic and antidepressant drugs, with diagnoses of anxiety, depression, and dementia. A nursing note on October 30, 2025, documented a new hospice order to increase Seroquel to 50 mg twice daily for behaviors, and physician orders on October 31, 2025, and January 27, 2026, further increased Seroquel to 50 mg twice daily and then 100 mg twice daily. There was no documented evidence that the resident’s representative was informed in advance of the risks, benefits, and treatment alternatives before these dose increases, a lack of documentation confirmed by the DON during interview.
Failure to Notify Resident Representative of Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of changes in condition as required by facility policy. The facility’s notification policy dated February 4, 2026, stated that the resident’s representative would be notified when there was a change requiring notification. A quarterly MDS assessment dated July 26, 2025, showed that Resident 2 was cognitively impaired and required staff assistance for daily care, and the resident’s care plan identified a risk for falls. Nursing notes documented that on August 1, 2025, the resident fell in his room; on August 9, 2025, the resident was found on his knees in his room with a bruised elbow; and on August 15, 2025, the resident was found on the floor in his room after tripping over oxygen tubing. There was no documented evidence that the resident’s daughter, who was the power of attorney, was notified of any of these falls, and the DON confirmed in an interview that the daughter was not notified and should have been. This failure to notify the resident’s representative of multiple fall events for a cognitively impaired resident at risk for falls constituted noncompliance with the facility’s own notification policy and with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Follow Physician’s Orders for Stool Occult Blood Testing
Penalty
Summary
Facility staff failed to follow a physician’s order for a cognitively impaired resident with a history of gastrointestinal bleed who required assistance with care needs. A quarterly MDS assessment dated July 26, 2025, documented the resident’s cognitive impairment and care needs, and physician’s orders dated August 7, 2025, directed staff to obtain three stool samples and test them for occult (hidden) blood. Review of the resident’s August 2025 Treatment Administration Record showed that no stool samples were obtained or tested as ordered. In an interview on February 19, 2026, at 1:34 p.m., the Director of Nursing confirmed that staff did not obtain or test any stool samples for blood for this resident and acknowledged that they should have done so. This failure to carry out the physician’s orders for stool testing constituted noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Follow Fall Prevention Policy and Implement Post-Fall Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention policy and ensure residents’ environments were free from accident hazards. The policy required fall risk assessments every 90 days and with changes in condition, with nurses to identify fall risk and initiate care plan interventions accordingly. For one resident with severe cognitive impairment who was dependent on staff for daily care and transfers, a fall on September 24, 2025 led to the addition of a weighted blanket as a new intervention to decrease anxiety and restlessness, and the care plan was updated to reflect this. However, the clinical record showed fall risk assessments were only completed on January 2 and September 5, 2025, with no evidence of 90‑day reassessments as required. On observation in February 2026, the resident was in bed without the ordered weighted blanket, and the LPN caring for the resident stated she was not aware that the resident was supposed to have a weighted blanket. The Nursing Home Administrator confirmed that fall risk assessments should have been completed every 90 days and that the resident should have had a weighted blanket. The deficiency also includes the facility’s failure to complete a thorough post‑fall investigation and implement fall interventions for another resident. This resident was cognitively impaired, had dementia, a history of falls, was dependent with transfers, and used a pivot disc with two‑person assistance for transfers. A nursing note documented that the resident experienced an assisted fall during a transfer from a recliner to bed when he became weak and was lowered to the floor and then assisted to bed for evening care. The incident report for this fall indicated there were no witness statements and no fall investigation completed to identify contributing factors. There was no documentation that staff transfer technique was evaluated or that any new fall interventions were implemented after the fall to minimize the risk of further falls. The DON confirmed there were no witness statements, no further investigation reports, and no documented evidence of post‑fall interventions for this resident.
Failure to Provide and Document Scheduled Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or complete bed baths for multiple dependent residents as documented in their clinical records and task lists. One resident with cognitive impairment, hypertension, and osteoporosis was assessed as dependent on staff for bathing and had showers scheduled every Wednesday and Sunday on dayshift. Review of this resident’s bath/shower records for December 2025 through January 2026 showed no documented evidence that a shower or complete bed bath was provided on several scheduled dates, specifically December 3, 10, 14, 21, 28, and 31, 2025, and January 11, 2026. A second resident, with severe cognitive impairment and hemiplegia, was also dependent on staff for bathing and had showers scheduled every Tuesday and Saturday on dayshift. Review of this resident’s bath/shower records for November and December 2025 revealed no documented evidence that a shower or complete bed bath was provided on November 11, 18, 25, 2025, and December 6, 2025. A third resident, with severe cognitive impairment and dementia, required supervision and touch assistance for bathing and had showers scheduled every Tuesday and Saturday on dayshift. Review of this resident’s records showed no documented evidence of a shower or complete bed bath on a scheduled date in December 2025. The Interim DON confirmed there was no documentation that these residents were offered, refused, or received their scheduled showers or complete bed baths on the identified dates.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as required by its own policy and state regulations. The policy specified that hot foods should be held above 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit. During resident food committee meetings, attendees reported that foods were only sometimes served at the proper temperature. An interview with a resident revealed that hot foods were often served cold. Observations during a lunch meal service showed that a test tray took 38 minutes to reach a resident area, and temperature checks revealed that the hot entrée and vegetables were below the required temperature, while the milk and juice were above the safe cold holding temperature. The Dietary Manager confirmed that food should be served at correct temperatures and be palatable.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as determined through a review of facility policies, observations, and interviews with residents and staff. The facility's policy, dated February 24, 2025, stated that food should be palatable, attractive, and served at a safe and appetizing temperature. However, Food Committee meeting minutes from February 5 and March 7, 2025, revealed resident complaints about food being served cold. Interviews with several residents confirmed these complaints, with residents reporting that meals were often served cold, whether eaten in their rooms or the main dining room. Observations in the main kitchen on March 11, 2025, showed that food was not maintained at appetizing temperatures during service. The food cart for C-wing left the kitchen at 12:03 p.m. and the last resident was served at 12:15 p.m. At that time, the temperature of the crusted pork was 126.3 degrees Fahrenheit and the peas were 127.7 degrees Fahrenheit, both of which were lukewarm. The Dietary Manager confirmed awareness of the resident complaints and the facility's policy on food temperatures. This deficiency was cited under 28 Pa. Code 211.6(b) Dietary Services.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which is a violation of their policy and professional standards. Resident 38, who is cognitively intact and receives nutrition through a feeding tube, did not have a care plan addressing the need for Enhanced Barrier Precautions (EBP) despite having physician's orders for EBP due to the feeding tube. This was confirmed by the Assistant Director of Nursing, who acknowledged the absence of a care plan for EBP. Resident 57, who is cognitively intact and independent with personal hygiene, had physician's orders allowing smoking but lacked a care plan addressing smoking until several months later. The Assistant Director of Nursing confirmed that the care plan should have been developed when the resident was identified as a smoker. Additionally, Resident 60, who is cognitively intact and dependent on staff for daily care, had orders for PEG tube checks every shift but did not have a care plan for the care and treatment of the PEG tube. The Director of Nursing confirmed the absence of a care plan for the PEG tube as of the survey date.
Failure to Provide Nutritional Supplement as Recommended
Penalty
Summary
The facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for a resident with moderate cognitive impairment and left hemiplegia following a stroke. The resident had a care plan indicating the potential for nutritional problems, and a registered dietician was to evaluate and make diet change recommendations as needed. The resident was to receive a Med Pass supplement, a fortified nutritional shake, to provide additional calories and protein. However, a review of the Medication Administration Record (MAR) revealed no documented evidence that the resident was provided the Med Pass supplement between February 10, 2025, and March 11, 2025. The resident's weight decreased from 177.8 pounds on February 4, 2025, to 162.4 pounds on March 4, 2025. An interview with the Assistant Director of Nursing revealed that the Med Pass supplement order was not re-ordered per the dietician's recommendation after it was completed on February 9, 2025.
Failure to Document Dialysis Treatment
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease who required peritoneal dialysis. The resident, who was cognitively intact, had physician's orders for the application of 0.1 percent Gentamicin ointment to the peritoneal dialysis site every day shift and to receive peritoneal dialysis every night shift. However, the Treatment Administration Records for February and March 2025 showed no documented evidence that the Gentamicin ointment was applied on multiple specified dates. This deficiency was confirmed through an interview with the Director of Nursing, who acknowledged the lack of documentation for the treatment on the mentioned dates.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call bells were within reach for a resident, identified as Resident 8, who was reviewed during a survey. The facility's policy, dated February 24, 2025, mandates that call lights be accessible to residents to allow them to call for assistance. Resident 8, who had moderate cognitive impairment and right-sided hemiplegia following a stroke, required assistance from staff for care needs. The resident's care plan, updated on March 7, 2025, highlighted the risk for falls and instructed staff to ensure the call light was within reach and to encourage its use. On March 10, 2025, an observation revealed that Resident 8 was lying in bed without the call bell in sight or within reach. When asked how he would call for help, the resident shrugged his shoulders, indicating a lack of awareness or ability to access the call bell. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the call bell should have been within the resident's reach, as per the facility's policy and the resident's care plan.
Confidentiality Breach of Resident's Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of medical information for one resident. The facility's policy, dated February 24, 2024, requires employees to ensure computer screens with health information are minimized or closed to protect resident confidentiality. On March 12, 2025, at 8:00 a.m., a laptop on a medication cart in the hallway outside a resident's room was observed with the Medication Administration Record (MAR) for a resident visible to staff, residents, and visitors. No nurse was present near the cart. A Registered Nurse admitted to leaving the laptop screen open while she stepped away, acknowledging that she should have minimized the screen. The Nursing Home Administrator confirmed that laptop screens with confidential information should not be left unattended or viewable by unauthorized individuals.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization for three residents. Resident 27, who was cognitively intact, was transferred to the hospital due to an elevated white blood cell count and symptoms of abdominal pain, nausea, and chills. However, there was no documented evidence that a written notice of this transfer was provided to the resident's representative. Similarly, Resident 49, who was cognitively impaired and had a left hip fracture, was sent to the hospital without documented evidence of written notification to the resident or their responsible party. Resident 71, who had diagnoses including hypertension, diabetes, and COPD, was transferred to the emergency department due to lethargy and low oxygen saturation levels. Despite the critical nature of the transfer, there was no documented evidence that a written notice was provided to the resident or their responsible party. Interviews with facility staff, including the Assistant Director of Nursing, Director of Nursing, and Nursing Home Administrator, confirmed the lack of documentation for these notifications, which is a violation of resident rights and discharge policy as per 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Failure to Issue Bed-Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to issue a bed-hold notice at the time of an anticipated leave of absence for one resident. According to the facility's policy, in the event of an emergency transfer, a written notice of the bed-hold policy should be provided to the resident or their representative within 24 hours. The policy also requires documentation of attempts to notify the representative and a signed copy of the notice to be kept in the resident's file. However, there was no documented evidence that such a notice was issued to the resident or their representative when the resident was transferred to the hospital. The resident involved was understood to have conditions including hypertension, diabetes, and COPD. On the day of the incident, the resident was lethargic and had a low oxygen saturation level, prompting a CRNP to increase oxygen support and eventually send the resident to the emergency department for further evaluation. Despite these actions, the facility did not provide the required bed-hold notice, as confirmed by the Nursing Home Administrator.
Failure to Complete Timely MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive significant change Minimum Data Set (MDS) assessment within the required time frame for a resident who experienced a significant change in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the Assessment Reference Date (ARD) and the significant change comprehensive MDS assessment should be completed no later than 14 calendar days after determining a significant change in the resident's status. In this case, a care plan dated July 24, 2024, indicated that the resident required hospice care due to an end-stage illness, and physician's orders dated July 23, 2024, confirmed the resident's admission to hospice. However, there was no documented evidence that the required MDS assessment was completed following the resident's admission to hospice care. The Nursing Home Administrator confirmed on March 11, 2025, that the assessment was not completed within the mandated time frame.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The inaccuracies were identified in various sections of the MDS assessments, which are crucial for evaluating residents' care needs and abilities. For instance, several residents who were prescribed and received aspirin, an antiplatelet medication, during the assessment period were incorrectly coded as not having received it. This error was confirmed through interviews with the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator. Additionally, a resident who was undergoing hemodialysis was not accurately documented in the MDS assessment, as the section indicating dialysis treatment was incorrectly coded. This discrepancy was confirmed by the RNAC during an interview. Another resident's MDS assessment inaccurately reflected the administration of as-needed pain medication, despite records showing no such medication was given during the look-back period. Furthermore, a resident receiving gabapentin, an anticonvulsant medication, was incorrectly coded as not having received it in the MDS assessment. This error was confirmed by the Director of Nursing. These inaccuracies in the MDS assessments highlight a failure in the facility's assessment processes, as the documentation did not accurately reflect the residents' medical treatments and needs during the specified assessment periods.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents, leading to deficiencies in their care. For one resident with moderate cognitive impairment and right-sided hemiplegia, the care plan included the application of TED hose and a right-hand thumb splint. However, there was no documented evidence that these interventions were being applied, and observations confirmed the resident was not wearing them. The Director of Nursing acknowledged that these items had been discontinued, but the care plan was not updated to reflect this change. Another resident, who was cognitively intact and had diagnoses including Spina Bifida with hydrocephalus, had a care plan indicating the use of anticoagulant and antidepressant medications. However, there was no evidence that these medications were being administered, and the Nursing Home Administrator confirmed that the resident was not receiving them. The care plan should have been revised to reflect the current medication regimen, but it was not.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. Physician's orders for the resident, dated January 4, 2025, included instructions for the resident to be discharged home with Home Health services, including physical therapy, occupational therapy, and nursing. A nursing note from the same date indicated that the resident was discharged at 11:15 a.m. with all possessions. However, as of March 13, 2025, there was no documented evidence of a completed discharge summary for the resident. This was confirmed during an interview with the Assistant Director of Nursing on March 13, 2025.
Failure to Follow Physician's Orders for Medication and Bowel Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for Resident 27, who was cognitively intact and diagnosed with septicemia. The resident was prescribed Doxycycline for cellulitis and Erythromycin ointment for blepharitis and bacterial conjunctivitis. However, the initial doses of these medications were not administered on time due to delays in pharmacy delivery, and there was no documentation indicating that the courses of these medications were extended to fulfill the prescribed duration. This was confirmed by the Assistant Director of Nursing. Additionally, the facility did not follow the bowel protocol for Residents 9 and 60. Resident 9 had physician's orders for a bowel protocol involving Milk of Magnesia, Bisacodyl suppository, and Fleets enema, which were not administered despite the resident not having bowel movements for several days. Similarly, Resident 60, who was cognitively intact and dependent on staff for daily care, did not receive the prescribed bowel protocol medications over a 10-day period, resulting in severe constipation and a moderate colonic ileus, as confirmed by x-ray results. Interviews with the Director of Nursing confirmed that the bowel protocols were not followed for both residents on the specified dates. The facility's failure to administer medications as ordered and to adhere to bowel protocols resulted in deficiencies in providing appropriate treatment and care according to physician's orders and resident needs.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide the necessary pressure ulcer interventions for a resident, leading to a deficiency in care. The resident, who had Alzheimer's disease and non-traumatic brain dysfunction, was dependent on staff for all care and had a non-stageable pressure ulcer on the left heel that was not present upon admission. Despite recommendations from a skin and wound practitioner to turn and reposition the resident every two hours, observations revealed that the resident remained in the same position for over three hours without being repositioned. This lack of adherence to the recommended care plan contributed to the deficiency. Interviews with staff confirmed that the resident was supposed to be turned and repositioned every two hours using pillows or a wedge cushion. However, the facility did not document these repositioning efforts, as it was considered a nursing measure. The Nursing Home Administrator acknowledged that the resident should have been repositioned, indicating a lapse in the implementation of the care plan. This failure to follow through with the recommended interventions for pressure ulcer prevention and management resulted in a deficiency as identified by the surveyors.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to properly label and secure medications as required by their policies and professional standards. During an observation in the A-wing medication room, a multi-use vial of Aplisol was found open and undated in the refrigerator. The manufacturer's directions specify that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. A Licensed Practical Nurse confirmed the vial was not dated and should be discarded. The Nursing Home Administrator also confirmed that the vial should have been dated when opened. Additionally, an observation revealed an unlocked and unattended medication cart in the hallway outside a resident's room. A Registered Nurse admitted to leaving the cart unlocked while she stepped away for a few minutes. The Nursing Home Administrator confirmed that medication carts should be locked when not in use. These findings indicate a failure to adhere to the facility's medication labeling and storage policies, as well as state regulations regarding pharmacy and nursing services.
Failure to Obtain Required Hospice Election Form
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required hospice election form from the contracted hospice provider for a resident receiving hospice care. An agreement between the facility and the hospice provider, dated April 8, 2024, stipulated that the hospice provider would supply the hospice election form to the facility to facilitate coordination of care. However, as of March 11, 2025, there was no documented evidence in the resident's clinical record or the hospice provider's clinical record that the facility had obtained this form. The resident in question, identified as requiring hospice care due to an end-stage illness, had a care plan dated July 24, 2024, and physician's orders dated July 23, 2024, for admission to hospice. Despite these orders, the hospice election form was missing from the records. This deficiency was confirmed during an interview with a registered nurse on March 11, 2025, who acknowledged the absence of the form in both the resident's and the hospice provider's clinical records. The hospice provider subsequently faxed the form to the facility on the same day.
Repeated Deficiencies in Quality Assurance and Care Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. These deficiencies included issues related to personal privacy and confidentiality of records, abuse and neglect policy implementation, accuracy of resident assessments, comprehensive care plans, and care plan revisions. Despite developing plans of correction that involved audits and QAPI committee reviews, the facility did not achieve compliance with the cited regulations. The deficiencies also extended to the quality of care provided, including the treatment and prevention of pressure ulcers, management of accident hazards, and provision of dialysis services. The facility was cited for failing to label and store drugs and biologicals properly, as well as for not maintaining the nutritive value, appearance, preferred temperature, and palatability of food. Infection prevention and control practices were also found lacking, with repeated citations indicating ongoing non-compliance. The repeated nature of these deficiencies across several surveys suggests systemic issues within the facility's quality assurance processes. The QAPI committee's inability to implement effective corrective actions and maintain compliance with regulations highlights significant challenges in the facility's management and oversight of care and services.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) during wound care for a resident. The Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy require the use of Enhanced Barrier Precautions (EBP), including gowns and gloves, during high-contact care activities for residents with chronic wounds or indwelling medical devices. However, during an observation of wound care for a resident with an unstageable pressure ulcer, a Licensed Practical Nurse (LPN) did not don a gown, only wearing gloves, contrary to the established guidelines and facility policy. The resident involved had a history of Alzheimer's disease and non-traumatic brain dysfunction, was dependent on staff for all care, and had a non-stageable pressure ulcer on the left heel. The resident's care plan and physician's orders specified the use of EBP due to the pressure ulcer. Despite these directives, the LPN failed to adhere to the required infection control measures, as confirmed by both the LPN and the Infection Control Preventionist during interviews. This oversight highlights a lapse in the facility's adherence to infection control protocols, potentially compromising the safety and well-being of the resident.
Failure to Complete Required Staff Verifications and Background Checks
Penalty
Summary
The facility failed to adhere to its own policies and procedures designed to prevent abuse, neglect, and theft by not completing necessary background checks and verifications for newly hired nursing staff. Specifically, the facility did not conduct Nurse Aide Registry verifications for two newly hired nurse aides, nor did it verify nursing licenses with the Pennsylvania State Board of Nursing for three newly hired nurses. Additionally, criminal background checks were not completed for four out of five newly hired nursing staff members. The personnel files reviewed revealed that these verifications and checks were not completed even months after the staff members were hired. Interviews with the Nursing Home Administrator confirmed the absence of documented evidence for these required verifications and checks, which should have been completed prior to the hiring dates. This oversight is a violation of the facility's abuse policy, which mandates background, reference, and credential checks for all potential employees.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On December 30, 2024, at 9:05 a.m., it was observed that a Licensed Practical Nurse (LPN) left her medication cart unattended, with the computer screen displaying Resident 2's personal health information facing the hallway. This was confirmed during an interview with the LPN at 9:11 a.m., where she acknowledged that she should have secured the computer screen to cover the resident's information when leaving the medication cart. The Director of Nursing also confirmed at 12:31 p.m. that the computer screen should have been covered when unattended, in accordance with the facility's policy on electronic health records dated March 19, 2024, which mandates that residents' health information remain private.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by observations and staff interviews. On December 30, 2024, the medication cart for the A unit long hall was found unlocked and unattended in the hallway, with a medication cup containing various medications left on top of the cart. A Licensed Practical Nurse (LPN) confirmed that she was called away by a nurse aide, leaving the cart unsecured and the medications exposed. The Director of Nursing (DON) also confirmed that the cart should have been locked and the medications should not have been left unattended. Similarly, the medication cart for the C Unit was observed to be unlocked and unattended. An LPN admitted to leaving the cart unsecured while attending to a resident. The DON confirmed that the cart should have been secured when staff were not present. These incidents demonstrate a failure to adhere to the facility's policy on medication administration, which requires that medication carts be kept closed and locked when out of sight of the medication nurse.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 5, who was cognitively intact and able to communicate her needs clearly. According to a quarterly Minimum Data Set (MDS) assessment, Resident 5 was independent with her care needs. During an interview, Resident 5 expressed dissatisfaction with the breakfast options provided, stating that she was no longer able to receive yogurt and a banana, which she preferred over eggs. This change occurred after new ownership took over the facility. The Dietary Manager confirmed that she was instructed not to purchase yogurt and bananas unless they were needed for nutritional intervention, not for preference. Resident 5's preference for yogurt and bananas was initially listed on her special request list, but the banana was replaced with canned fruit, and no replacement was provided for the yogurt. The Dietary Manager later received permission to order a case of yogurt and bananas, but this was not the standard practice at the time of the deficiency.
Failure to Provide Nightly Snacks to Residents
Penalty
Summary
The facility failed to provide nightly snacks to residents in accordance with their preferences, as evidenced by a review of facility policies, clinical records, and interviews with residents and staff. The facility's policy dated March 19, 2024, stated that snacks should be provided between meals and at nighttime per resident request. However, resident council meeting minutes from November and December 2024 indicated that residents were not receiving evening snacks as desired. Clinical records for seven of nine residents reviewed showed multiple instances where residents did not receive evening snacks on specific dates in November and December 2024. Interviews with residents revealed dissatisfaction with the availability and consistency of evening snacks. Residents expressed that snacks were not offered regularly, and some residents with specific dietary needs, such as those with diabetes, were not receiving snacks as needed. The Director of Nursing confirmed that residents were requesting evening snacks but were not consistently receiving them, acknowledging that snacks should be provided upon request and offered nightly. This deficiency was noted under 28 Pa. Code 201.29(i) Resident Rights.
Failure to Monitor Catheter Output and Follow Bowel Protocols
Penalty
Summary
The facility failed to monitor intake and output for a resident with an indwelling urinary catheter and did not follow physician's orders related to bowel protocols for another resident. Resident 3, who had a suprapubic catheter due to a neurogenic bladder, was admitted to the facility with a care plan that required monitoring and documenting intake and output. However, a review of the resident's clinical records, including the Medication Administration Record and Treatment Administration Record, showed no evidence that the facility measured and recorded the resident's intake and output as per the care plan. This was confirmed by an interview with the Director of Nursing. Additionally, the facility did not adhere to the bowel protocol for Resident 6, who was cognitively impaired and frequently incontinent of bowel. The resident's physician's orders included administering Milk of Magnesia, Biscolax suppository, and Fleets enema as needed for constipation. Despite the resident not having a bowel movement for extended periods in November and December, there was no documented evidence that the staff administered any of the bowel protocol medications. This was confirmed by an interview with the Assistant Director of Nursing.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS assessment inaccurately coded the resident's urinary continence status despite having an indwelling urinary catheter, and incorrectly indicated that the resident received the influenza vaccination when they did not. The Assistant Director of Nursing confirmed these inaccuracies during an interview, acknowledging that the MDS assessment should have reflected the resident's actual condition and vaccination status. For another resident, the MDS assessment inaccurately documented the reason for not receiving the influenza vaccination. The assessment stated that the vaccine was not offered, while the clinical record showed that the resident was offered and declined the vaccine. This discrepancy was confirmed by the Assistant Director of Nursing/Infection Preventionist, who acknowledged that the assessment should have indicated that the resident declined the vaccination.
Missing Signed and Dated Diagnostic Report in Resident's Record
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained signed and dated reports of radiologic and other diagnostic services. Specifically, for one resident, there was an absence of a documented ultrasound report that was ordered by a physician on June 20, 2024, for screening of the resident's bilateral breasts for any abnormal lumps or masses. Despite the ultrasound being completed, as confirmed by the Assistant Director of Nursing during an interview, the clinical record did not contain the necessary signed and dated report, which is a requirement under the relevant regulations.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the CDC and CMS, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 3, who was admitted with a suprapubic catheter, did not have appropriate infection control signage in her room, and staff were observed not wearing gowns during catheter care. This oversight was confirmed by the Assistant Director of Nursing/Infection Preventionist, who acknowledged that EBP should have been in place for Resident 3 due to the presence of the suprapubic catheter. Similarly, Resident 7, who had a peritoneal dialysis catheter, also lacked the necessary infection control signage and precautions in her room. Observations revealed that EBP measures were not implemented, which was again confirmed by the Assistant Director of Nursing/Infection Preventionist. The facility's failure to implement EBP for these residents with indwelling medical devices represents a breach of infection control protocols designed to prevent the spread of multidrug-resistant organisms.
Inappropriate Transfer During Evacuation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe transfer techniques were used for a resident requiring a mechanical lift, resulting in a left hip fracture. During an active fire evacuation, staff attempted to transfer the resident to a wheelchair without the necessary mechanical lift and adequate assistance. The resident, who was cognitively impaired and dependent on staff for transfers, was lowered to the floor by two staff members after an unsuccessful attempt to transfer him to a wheelchair. The facility's fire response and emergency evacuation plans required staff to use good judgment and appropriate techniques for resident transfers. However, during the evacuation, a nurse aide attempted to transfer the resident by bear-hugging him, despite knowing the resident required a mechanical lift. The resident's legs buckled, and he was lowered to the floor, causing pain and later diagnosed with a displaced intertrochanteric fracture of the left hip. Interviews with staff revealed that the nurse aide was aware of the resident's need for a mechanical lift but proceeded with an inappropriate transfer method. The Director of Rehabilitation confirmed that the resident always required a mechanical lift for transfers. The Director of Nursing and the Nursing Home Administrator were not fully aware of the inappropriate transfer method used during the evacuation.
Failure to Monitor and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of pressure ulcers for a resident, leading to a deficiency in care. The facility's policy required weekly assessments and documentation of pressure injuries, including measurements and observations. However, for one resident, there was no documented evidence of weekly measurements or assessments of a pressure wound on the left heel from admission until a specific date. The resident had a history of pressure injuries, including a Stage 1 pressure injury and an unstageable pressure injury upon admission, and was at risk for skin integrity issues due to decreased mobility and fragile skin. Despite physician orders for wound care and treatment administration records indicating regular dressing changes, the facility did not document the required weekly assessments. Interviews confirmed the lack of documentation for the pressure wound measurements and assessments, highlighting a failure to adhere to the facility's policy and ensure consistent monitoring of the resident's condition. This oversight in documentation and monitoring contributed to the deficiency identified by the surveyors.
Failure to Revise Care Plan for Resident Requiring Mechanical Lift
Penalty
Summary
The facility failed to revise the care plan for a resident with individualized interventions to address their care needs. The resident, who had cognitive impairments and required a mechanical lift with the assistance of two staff for transfers, was involved in an incident during an active fire evacuation. Staff attempted to transfer the resident to a wheelchair but were unable to do so safely without additional assistance, resulting in the resident being lowered to the floor and then transferred to the chair by four persons using a draw sheet. Following the incident, the resident complained of pain, and an x-ray revealed an acute displaced intertrochanteric fracture of the left hip. Despite this, the care plan was revised to indicate that the resident required one assist with transfers, contrary to the consistent requirement for a mechanical lift as confirmed by multiple staff members and the Director of Rehabilitation. This discrepancy in the care plan highlights the facility's failure to accurately update and individualize the resident's care plan based on their current needs and condition.
Failure to Develop Comprehensive Care Plan for Resident with Raynaud's Syndrome
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with Raynaud's syndrome and gangrene. The facility's policy requires the interdisciplinary team, along with the resident and their family or legal representative, to create a person-centered care plan that includes measurable objectives and timeframes. This care plan should describe the services needed to achieve or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, for one resident, the facility did not document a care plan that included specific and individualized interventions for managing Raynaud's syndrome with gangrene. The deficiency was identified during a review of the resident's clinical records and staff interviews. The resident's admission Minimum Data Set assessment indicated that the resident was understood, could usually understand others, and had a diagnosis of Raynaud's syndrome with gangrene. A nursing note and a CRNP assessment confirmed the presence of gangrene in the resident's fingers. Despite these findings, there was no documented evidence of a comprehensive care plan addressing these specific medical needs. The Nursing Home Administrator and the Director of Nursing confirmed the absence of such a care plan during an interview.
Failure to Schedule and Document Follow-Up Appointments
Penalty
Summary
The facility failed to adhere to hospital discharge instructions and physician's orders for a resident diagnosed with Raynaud's syndrome with gangrene and an adrenal adenoma. The resident was scheduled for a follow-up appointment with an endocrinologist on August 21, 2024, as per hospital discharge instructions and physician's orders dated July 11, 2024. However, there was no documented evidence in the clinical record that the resident attended this appointment or refused to go. Additionally, the facility did not schedule a follow-up appointment with a vascular specialist for the gangrene in the resident's fingers, as ordered by the physician on July 12, 2024, and reiterated on July 31, 2024. The Director of Nursing indicated that the endocrinologist appointment was scheduled before the resident's arrival at the facility, and it was assumed the resident would attend after discharge. Furthermore, the CRNP was unaware that the resident needed to see a plastic surgeon before the vascular follow-ups. This lack of coordination and failure to follow through with necessary medical appointments resulted in the facility not meeting the required standards of care for the resident.
Resident Ingests Hand Sanitizer Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide an environment free of accident hazards for a resident who ingested hand sanitizer, resulting in a blood alcohol level of 0.29. The resident, who had a history of alcoholism and frequent ingestions of hand sanitizer, was admitted to the facility from the hospital. Despite being aware of the resident's history, the facility did not adequately prevent access to hand sanitizer, leading to multiple incidents where the resident was found with hand sanitizer in her possession. Upon admission, the resident's care plan indicated that hand sanitizer should be kept out of her room. However, a nurse aide found an empty bag of hand sanitizer in the resident's bed, and a cup of hand sanitizer was later discovered on her nightstand. Despite these findings, a thorough search of the resident's room and belongings was not conducted immediately, allowing the resident to continue accessing hand sanitizer. The facility's management was aware of the resident's history and had removed hand sanitizer from her room and the isolation cart. However, the staff only performed a visual search after the initial discoveries, and it was not until additional bags of hand sanitizer were found that a more thorough search was conducted. This oversight allowed the resident to ingest hand sanitizer, resulting in a high blood alcohol level and necessitating one-on-one supervision.
Failure to Implement Abuse Prevention Policies and Ensure Annual Training
Penalty
Summary
The facility failed to implement its written abuse prevention policies by not ensuring that the status of nursing licenses was checked with the State Board of Nursing for three newly hired nurses. Additionally, the facility did not complete a nurse aide registry verification for one newly hired nurse aide, failed to ensure that criminal background checks were completed prior to hire for one employee, and did not obtain reference checks for four employees before their start dates. These lapses were confirmed through personnel file reviews and interviews with the Human Resources/Scheduler and the Assistant Director of Nursing/Infection Control Preventionist. Furthermore, the facility did not ensure that staff received annual abuse training as required. Specifically, three staff members did not have documented evidence of receiving the facility's resident abuse and abuse reporting training during the specified time periods. These deficiencies were confirmed through education record reviews and interviews with the Assistant Director of Nursing/Infection Control Preventionist.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their clinical records. For Resident 3, the MDS assessment incorrectly indicated that the resident did not receive antibiotic medications during the assessment period, despite physician's orders and Medication Administration Records (MARs) showing that the resident was receiving Methenamine Hippurate. Similarly, Resident 14's MDS assessment failed to reflect the use of oxygen, which was documented in both physician's orders and MARs. Resident 29's MDS assessment also contained errors, as it did not record the administration of Polytrim ophthalmic solution and Metformin HCl, despite clear documentation in the MARs and physician's orders. Additionally, Resident 35's MDS assessment did not document a gradual dose reduction (GDR) of Seroquel, which was recommended and agreed upon by the physician, and there was no date recorded for the GDR. Lastly, Resident 70's discharge MDS assessment incorrectly indicated that the resident was discharged to an acute care hospital, while nursing notes confirmed that the resident was discharged home with her son. Interviews with the Registered Nurse Assessment Coordinator (RNAC) confirmed these coding errors in the MDS assessments.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated or revised to reflect their specific care needs. For Resident 5, the care plan indicated the need for glasses, but the resident did not have glasses, and this was not updated in the care plan. Resident 10's care plan included interventions for a feeding tube and oxygen therapy, but both were discontinued, and the care plan was not updated to reflect these changes. Resident 28's care plan indicated a Stage 1 pressure injury that had resolved, but the care plan was not updated to reflect this resolution. Resident 41 had a Stage 2 pressure ulcer that resolved, and was not on anticoagulation therapy, but the care plan was not updated to reflect these changes. Resident 43's care plan did not reflect the use of a hearing aid in the right ear or that the resident was deaf in the left ear. Resident 55 had an incident where she spilled coffee on herself, leading to an intervention for a sippy cup, but this intervention was not updated in the care plan. Interviews with the Director of Nursing and other staff confirmed that the care plans for these residents were not updated to reflect their current conditions and needs. The facility's policy required care plans to be reviewed and updated when there was a significant change in the resident's condition, but this was not followed for the six residents reviewed.
Failure to Clarify Physician's Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician's orders were clarified for two residents. For one resident with diabetes, the physician's orders required blood sugar checks on specific days and administration of Lantus insulin if the blood sugar was above a certain level. However, there was no documented evidence that the staff clarified with the physician whether blood sugar checks should be conducted on the other days to determine if the insulin should be held. This oversight was confirmed by the Director of Nursing during an interview. For another resident with a Stage 4 pressure ulcer, the physician's orders included a specific wound care regimen and later the application of a wound vac. Despite the wound vac being applied, there was no documented evidence that the physician was contacted to clarify whether the previous wound care orders should be discontinued. This lack of clarification was also confirmed by the Director of Nursing. These failures indicate that the facility did not meet professional standards of quality in ensuring physician's orders were properly clarified and followed.
Failure to Follow Physician's Orders and Schedule Follow-Up Appointments
Penalty
Summary
The facility failed to follow recommendations from a neurologist for a follow-up appointment for one resident and did not adhere to physician's orders for three other residents. Resident 5, diagnosed with Parkinson's disease, was supposed to have a follow-up neurology appointment three months after a consultation. However, the appointment was not scheduled, and the resident missed it. The resident's wife confirmed that she was not informed about the appointment, and the facility's scheduler was unaware of the follow-up requirement, indicating a lapse in communication and documentation within the facility's processes. Resident 29 had a physician's order to receive Midodrine HCl for orthostatic hypotension, with instructions to hold the medication if the systolic blood pressure was greater than 130 mmHg. Despite this, the medication was administered multiple times when the resident's systolic blood pressure exceeded the specified limit. The Director of Nursing could not confirm that the physician's orders were followed on these occasions, highlighting a failure in medication administration and monitoring. Resident 34, who had schizophrenia, anxiety, and depression, was prescribed Haldol Decanoate Solution to be administered intramuscularly every three weeks. However, there was no documented evidence that the medication was given as ordered on one occasion. Additionally, Resident 43, who had diabetes, had elevated blood sugar levels on several occasions, but there was no documented evidence that the physician was notified as required. The Director of Nursing was unable to confirm that the physician was informed about these elevated blood sugars, indicating a failure in following the physician's orders and ensuring proper communication regarding the resident's condition.
Failure to Obtain Physician's Orders for Dialysis
Penalty
Summary
The facility failed to ensure that physician's orders were obtained for dialysis treatments for a resident, as required by their policy. Resident 42, who was cognitively intact and required hemodialysis due to end-stage renal disease, had no documented evidence of physician's orders for dialysis treatments, appointment locations, dates, or times in their clinical record. This deficiency was confirmed by the Director of Nursing during an interview. The facility's policy, dated March 19, 2024, mandates that an order from the resident's primary care physician is necessary for dialysis treatments, which was not adhered to in this case.
Failure to Ensure Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents. For Resident 15, who was cognitively intact and had a diagnosis of diabetes with diabetic neuropathy, a dose of hydrocodone-acetaminophen was signed out for administration on a specific date and time, but there was no documented evidence in the resident's clinical record that the medication was administered. This was confirmed by the Director of Nursing during an interview. Similarly, Resident 33, who was also cognitively intact and had orders for Oxycodone for severe pain, had multiple instances where doses of the medication were signed out but not documented as administered in the clinical records. Resident 43, who was cognitively intact and had a care plan for pain management, also had numerous instances where Oxycodone was signed out but not documented as administered. These deficiencies were confirmed through interviews with the Director of Nursing and a review of the controlled drug records and clinical records.
Failure to Serve Palatable Food
Penalty
Summary
The facility failed to serve food that was palatable to residents. During interviews with several residents, they expressed dissatisfaction with the food, describing it as disgusting and lousy. One resident specifically mentioned that the potatoes were not peeled when served. Observations in the kitchen revealed that the lunch meal included chicken breast with gravy, oven-browned potatoes, corn, and sliced pears. A test tray was prepared and tasted, revealing that the oven-browned potatoes were dry, bland, and had the skin intact. The recipe for the potatoes indicated they should be peeled, diced, and seasoned with garlic powder, paprika, and salt. The Dietary Manager confirmed that the potatoes were supposed to be served with the skins removed and properly seasoned.
Failure to Maintain Sanitary Food Service Conditions
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions. Observations in the main kitchen revealed a thick accumulation of dust and debris on multiple air vents, which had not been cleaned since January 10, 2024. This was confirmed by the Dietary Manager, who acknowledged the maintenance department's responsibility for cleaning the vents. Additionally, during lunch meal tray delivery, a nurse aide was observed handling a resident's food with bare hands, which is against the facility's policy. The nurse aide admitted to the mistake and acknowledged that staff should not touch food with bare hands. The deficiency was further highlighted by the case of a cognitively intact resident who required supervision or assistance with eating. The resident's care plan indicated the need for set-up help from staff. The unsanitary conditions and improper food handling practices were confirmed by both the Dietary Manager and the Nursing Home Administrator, who reiterated that staff should not touch food with their bare hands.
Recurring Quality Deficiencies and Ineffective QAPI Committee
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effective. The deficiencies identified in the current survey included issues with completing accurate Minimum Data Set (MDS) assessments, revising residents' care plans to include current care needs and interventions, following physician's orders, providing oxygen therapy as ordered, medication accountability, and following proper infection control practices. These deficiencies were previously cited in surveys ending May 18, 2023, November 17, 2023, and February 22, 2024, indicating a pattern of non-compliance and ineffective corrective actions by the QAPI committee. The facility's plans of correction for these deficiencies included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee was ineffective in maintaining compliance with the regulations. Specific deficiencies cited included inaccurate MDS assessments (F641), failure to revise care plans to reflect current needs (F657), not following physician's orders (F684), improper administration of oxygen therapy (F695), lack of medication accountability (F755), and failure to follow infection control practices (F880). These repeated deficiencies highlight the QAPI committee's inability to implement and sustain effective quality assurance systems.
Failure to Follow Infection Control Guidelines and Employee Screening Policies
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC, leading to deficiencies in the care of seven residents. These residents had various conditions, including venous ulcers, indwelling catheters, and pressure ulcers, which required specific infection control measures. However, the facility did not implement Enhanced Barrier Precautions (EBP) or post appropriate infection control signage at the entrances to the residents' rooms, as observed during multiple inspections. This lack of adherence to updated guidelines was confirmed by the Assistant Director of Nursing and Infection Preventionist, who was unaware of the new EBP guidance effective April 1, 2024. Additionally, the facility failed to ensure proper infection control practices and techniques for newly hired employees. Two employees, a registered nurse and a nurse aide, were allowed to work on resident care units without completing the required tuberculosis (TB) testing. The registered nurse worked on a resident care unit before receiving her first and second step PPD tests, while the nurse aide had no documented evidence of receiving either test before working in a resident care unit. This was confirmed by the Assistant Director of Nursing/Infection Control Preventionist. The facility's non-compliance with infection control guidelines and employee screening policies resulted in multiple deficiencies. These included the absence of infection control signage for residents with chronic wounds, indwelling catheters, and multidrug-resistant organisms, as well as the premature deployment of staff without proper TB testing. These actions and inactions contributed to the facility's failure to meet established infection control standards, as documented in the survey findings.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
