Southmont Of Presbyterian Seniorcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Pennsylvania.
- Location
- 835 South Main Street, Washington, Pennsylvania 15301
- CMS Provider Number
- 395671
- Inspections on file
- 19
- Latest survey
- November 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Southmont Of Presbyterian Seniorcare during CMS and state inspections, most recent first.
A resident who required two-person assistance for transfers, as documented in their care plan and on the white board, was transferred by a single CNA, resulting in a left distal fibula fracture. The resident, with multiple diagnoses including osteoporosis, reported pain after the transfer, and the CNA admitted to not following the required protocol. This incident was identified as neglect, as it involved failure to provide necessary services to prevent physical harm.
A resident who required assistance from two staff members for transfers was moved by a single nurse aide, contrary to the care plan and physician orders. This improper transfer resulted in the resident sustaining a leg fracture. Staff interviews and documentation confirmed that the aide had received training on safe transfer methods, but failed to follow established protocols, leading to the injury.
Grievance boxes on three nursing units and in the main lobby were either blocked by equipment or mounted too high, making them inaccessible to residents, particularly those using wheelchairs. Staff confirmed the issue, and the Nursing Home Administrator acknowledged the failure to provide accessible grievance submission options.
Facility staff did not consistently complete required dialysis communication forms for a resident with end-stage renal disease who received dialysis three times weekly. Review showed that 17 out of 47 forms were incomplete, either by the dialysis center or by staff after the resident's return, despite facility policy and care plan requirements for monitoring and documentation.
The facility did not post the required Adult Protective Services (APS) contact information, including agency name, address, email, and phone number, in areas accessible to residents and their representatives. This omission was confirmed by staff and administration during interviews.
A resident with dementia and diabetes eloped from the facility due to inadequate supervision. Initially assessed as not at risk for elopement, the resident left unsupervised after returning from therapy. Staff found the resident at a nearby building on campus, attempting to catch a bus. The incident highlighted a failure in the facility's supervision and risk assessment processes.
A resident with cognitive impairment and Parkinson's disease suffered a second-degree burn when hot soup, served at 184°F, was placed within reach, leading to a spill. The resident's care plan required safety measures like mugs with lids, which were not followed, resulting in the injury.
The facility failed to maintain sanitary conditions and proper labeling in the main kitchen and two kitchenettes, leading to potential cross-contamination risks. Observations revealed undated food items, suspected mold, and unsanitary conditions such as gnats and sticky surfaces. These issues were confirmed by the Director of Dietary and the Nursing Home Administrator.
The facility failed to investigate incidents of possible neglect involving two residents. One resident with multiple diagnoses suffered a worsening skin tear after being bumped during transport, while another resident, requiring a two-person assist, was injured during a transfer with only one staff member. The facility did not conduct investigations into these incidents.
A resident with multiple diagnoses, including dementia and difficulty walking, was injured during a transfer due to the facility's failure to follow physician orders for a two-person assist. The nurse aide involved used an outdated care sheet, as the facility did not update it to reflect the current order. The incident resulted in a skin tear on the resident's forearm, and the facility did not fully investigate or provide accurate information on the report.
The facility failed to properly store and dispose of expired medical supplies on the third floor nursing unit. Expired items found in the emergency cart included suction tubing kits, intravenous catheter start kits, luer lock kits, nasal cannula oxygen tubing kit, and saline bottles. A RN Supervisor confirmed the oversight.
Resident Sustains Fracture Due to Improper Transfer by Single CNA
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members for toileting and transfers as documented in their care plan and on the white board used by nurse aide staff, was transferred by a single Certified Nurse Aide (CNA). The resident, who had diagnoses including arthritis, high blood pressure, depression, and osteoporosis, was alert, oriented, and able to communicate needs. The resident reported pain in the left lower leg/ankle after being transferred by the CNA, who admitted to transferring the resident alone and causing pain during the process. Clinical documentation and staff statements confirmed that the resident's care plan and functional assessment required two-person assistance for transfers due to self-care performance deficits related to arthritis. Despite this, the CNA attempted the transfer alone, contrary to the established plan of care and facility protocols. The resident subsequently sustained a fracture to the left distal fibula, as confirmed by x-ray, after complaining of pain and reporting that their leg had been bumped during the transfer. The incident was identified as neglect, defined by facility policy as the failure to provide goods and services necessary to avoid physical harm. The CNA involved had received training and competencies in safe transfer methods prior to the incident. The failure to follow the resident's care plan and transfer requirements directly resulted in actual harm to the resident, specifically a fractured left fibula.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members for transfers due to arthritis and other medical conditions, was transferred by a single nurse aide. The resident's care plan, physician orders, and Minimum Data Set assessment all specified the need for assistance from two staff members during transfers and toileting. Despite this, the nurse aide attempted to transfer the resident alone, contrary to established protocols and documented requirements. As a result of this improper transfer, the resident experienced pain in the left lower leg and ankle, which was later diagnosed as a fracture to the left distal fibula. The incident was documented in the resident's clinical record, progress notes, and an incident report. The nurse aide involved acknowledged in a written statement that the resident was in pain and that the transfer caused harm. Interviews with facility staff and review of personnel files confirmed that the nurse aide had received training and competency assessments related to safe transfer methods and adherence to care plans. However, the failure to follow the resident's prescribed transfer protocol led directly to the resident's injury. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during interviews.
Grievance Boxes Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents in four locations, including three nursing units and the main lobby. During rounds, it was observed and confirmed by a social worker that the grievance boxes on the third, fourth, and fifth floor nursing units were blocked by equipment, making them inaccessible. Additionally, the grievance box on the third-floor nursing unit was mounted at approximately 59 inches above the floor, and the lobby box was at approximately 52 inches, both of which are out of reach for residents using wheelchairs. A review of the facility's grievance policy indicated that grievances could be submitted orally or in writing, including anonymously. However, the physical placement and obstruction of the boxes did not comply with accessibility standards, as confirmed by staff interviews and direct observation. The Nursing Home Administrator acknowledged that the facility failed to make the grievance boxes accessible in all four identified locations.
Failure to Maintain Ongoing Dialysis Communication
Penalty
Summary
Facility staff failed to maintain ongoing communication with the dialysis center for a resident with end-stage renal disease who was dependent on dialysis. According to facility policy, a dialysis communication binder was to be used for all residents receiving dialysis, with specific sections to be completed by nursing staff before transfer, by the dialysis center, and by nursing staff upon the resident's return. Review of the clinical record showed that the resident was readmitted with diagnoses including ESRD and diabetes, and had physician orders for dialysis three times a week. The care plan required monitoring of vital signs before and after dialysis, assessment of the access area, and daily checks for adequate blood flow. However, review of dialysis communication forms from January through April revealed that 17 out of 47 forms were not fully completed, either by the dialysis center or by facility staff after the resident's return. This incomplete documentation was confirmed by the Assistant Director of Nursing, who acknowledged that the required communication forms were not consistently completed pre- and post-treatment between the facility and the dialysis center.
Failure to Post Required APS Contact Information
Penalty
Summary
The facility failed to post the required contact information for Adult Protective Services (APS) in areas accessible to residents and their representatives. Observations conducted on multiple nursing units and the main lobby revealed that the APS agency name, address, email, and phone number were not posted or accessible. This was confirmed by both a social worker and the Nursing Home Administrator during staff interviews. The deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.18(e), which require the posting of such information for resident awareness and access.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia and diabetes. The resident was admitted to the facility with a referral from the hospital indicating these diagnoses. An elopement observation assessment conducted shortly after admission indicated that the resident was not at risk for elopement. However, the resident managed to leave the facility unsupervised and was found at a nearby building on the campus, attempting to catch a bus. The incident occurred when the resident was brought back from therapy to the nurses' station, and shortly after, the chair alarm sounded. Staff searched for the resident for about 10 minutes before being informed by the supportive housing apartments on campus that the resident had walked over to their building. The resident was found with her personal belongings and was unharmed upon assessment. The initial elopement risk assessment had scored the resident as not at risk, which contributed to the lack of preventive measures in place at the time of the incident.
Resident Burned by Hot Soup Due to Inadequate Safety Measures
Penalty
Summary
The facility failed to implement effective safety measures for a resident, resulting in actual harm. Resident R78, who had moderately impaired cognitive ability and required extensive assistance for eating, suffered a second-degree burn on the right upper thigh. This incident occurred when the resident, who had a history of Parkinson's disease, grabbed a bowl of hot soup placed in the middle of the table, causing it to spill onto their lap. The soup was served at a temperature of 184 degrees Fahrenheit, and the resident's care plan indicated the need for mugs with lids to prevent burns. The incident was documented in a nurse progress note and an incident report, which noted blistering on the resident's thigh. Witness statements from nursing assistants confirmed that the resident had knocked the food over, resulting in the burn. The facility's policy on investigating adverse events required measures to prevent serious injury, but these were not effectively implemented in this case, leading to the resident's injury.
Removal Plan
- In-service training provided to dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, on following facility policy and procedures for abuse neglect and serving hot beverages.
- Reviewed like residents for non-compliance with hot beverages and meal service.
- Audited all residents' meals for accuracy.
- Adjusted employee workflow to allow for increased supervision of the dining area while meals are being served.
- Ordered protective aprons for residents in the dementia unit in case of spills of hot liquids.
- Implemented a plan of correction and achieved compliance to ensure residents are provided hot liquids in a manner that promotes safety.
Sanitation and Labeling Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and properly label and date food products, leading to potential unsafe conditions and cross-contamination risks. During an observation in the main kitchen, several issues were noted, including undated food items such as opened mayonnaise, water bottles, chocolate syrup, and a beverage dispenser with red liquid. Additionally, cooler #2 had fans with white splotches, suspected to be mold, and cooler #3 contained undated bags of chicken tenders and potatoes. These observations were confirmed by the Director of Dietary, who acknowledged the failure to adhere to required labeling and maintenance standards. Further observations in the 4th and 5th floor kitchenettes revealed unsanitary conditions, including gnats flying, sticky cabinet handles, and food debris in the cabinets. The lower freezers in both kitchenettes had ice build-up, indicating possible seal malfunctions. Moldy bread and buns were found in the cabinets, along with undated condiments such as ketchup, mustard, relish, and chocolate syrup. The Nursing Home Administrator confirmed these findings, acknowledging the facility's failure to maintain the kitchenettes in a sanitary manner, which could lead to cross-contamination.
Failure to Investigate Incidents of Possible Neglect
Penalty
Summary
The facility failed to identify and investigate incidents of possible neglect and abuse for two residents, as required by their policy. Resident R27, who has diagnoses including heart failure, kidney failure, and stroke with right-sided hemiplegia, suffered a skin tear when staff bumped their elbow on a doorframe during transport. The initial treatment was a Tegaderm dressing, but the wound worsened over time, requiring a Xeroform dressing. Despite the worsening condition, the facility did not conduct an investigation into the incident. Resident R35, diagnosed with dementia, difficulty walking, restless leg syndrome, anxiety, and diabetes, was involved in an incident where they were transferred with the assistance of one staff member, contrary to the physician's order for a two-person assist. This resulted in a skin tear and bruise on the resident's left forearm. The facility did not identify, investigate, or report this potential neglect. The Director of Nursing confirmed the facility's failure to address these incidents appropriately.
Failure to Follow Physician Orders Results in Resident Injury
Penalty
Summary
The facility failed to provide person-centered care consistent with professional standards of practice by not following physician orders for the proper transfer of a resident, resulting in an injury. Resident R35, who has diagnoses including dementia, difficulty walking, restless leg syndrome, anxiety, and diabetes, was supposed to be transferred with the assistance of two staff members as per the physician's order. However, during a transfer with only one staff member, the resident sustained a skin tear on her left forearm after hitting a walker. The incident report noted that a skin flap needed to be placed before treatment was applied, and the injury was documented as a bruise measuring 7.5 cm x 2.5 cm. Interviews revealed that the nurse aide involved followed the Southmont 5th Floor Need to Know Care Sheet, which had not been updated to reflect the physician's order for a two-person assist transfer. The Nursing Home Administrator confirmed that nurse aides do not have access to the kardex, and the care sheet was not updated due to a lapse in communication when the night nurse did not update the sheet after taking the order. The Director of Nursing acknowledged that the facility failed to fully investigate and review the incident, and the information on the report was inaccurate, leading to the failure to provide the correct transfer order to the nurse aide.
Expired Medical Supplies in Emergency Cart
Penalty
Summary
The facility failed to ensure that medical supplies were properly stored and disposed of on the third floor nursing unit. During an observation, surveyors identified expired items in the emergency cart, including five suction tubing kits, three intravenous catheter start kits, two intravenous luer lock kits, one nasal cannula oxygen tubing kit, and two 100 cc saline bottles for oxygen use. These items were past their expiration dates, indicating a lapse in the facility's management of medical supplies. A Registered Nurse Supervisor confirmed the failure to properly dispose of these expired emergency cart biologicals.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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