Spiritrust Lutheran The Village At Gettysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Gettysburg, Pennsylvania.
- Location
- 1075 Old Harrisburg Road, Gettysburg, Pennsylvania 17325
- CMS Provider Number
- 395647
- Inspections on file
- 16
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Spiritrust Lutheran The Village At Gettysburg during CMS and state inspections, most recent first.
Surveyors identified that hazardous area doors, including the Sprinkler Tank Room and 1st floor Dietary Storage Room, were not maintained within required gap margins and were held open with unauthorized devices, as confirmed by the Director of Facilities.
The 1st floor Dining Room had its doors removed, leaving the room open to the corridor without any smoke detector protection. This was confirmed by the Director of Facilities, resulting in a failure to provide required fire alarm protection in that smoke compartment.
Surveyors found that several corridor doors, including those to the Kitchen, Linen Closet, and PC Unit Office, failed to positively latch due to obstructions or misalignment. The Director of Facilities confirmed these deficiencies during the inspection.
Surveyors observed that the double smoke barrier door between two compartments did not latch as required, with the hardware failing to function per manufacturer specifications. This issue was confirmed by the Director of Facilities and affected two smoke compartments.
Surveyors found that food and equipment were not stored or maintained according to professional standards, with multiple open and expired food items lacking proper labeling and dating in the kitchen and pantries. Additionally, there were significant cleanliness and maintenance issues, including stained ovens, water damage, and unsanitary shelving in the walk-in freezer, with no cleaning schedule in place. Facility leadership confirmed these practices did not meet their stated expectations.
The facility did not ensure prompt responses to resident call bells, with multiple instances of response times exceeding 20 minutes and some calls going unanswered for over an hour. Several residents reported long wait times for assistance, especially at night and on weekends, leading to discomfort and unmet needs. Staff interviews revealed a lack of clear expectations and consistent monitoring of call bell response times.
A resident with a urostomy and neurogenic bladder independently performed her own urostomy care and requested supplies as needed. However, there was no physician order specifying urostomy care, and documentation of care was missing from the clinical record after a certain date. The DON confirmed that both an order and documentation should have been present, as required by facility policy.
Two residents with complex medical needs did not receive their ordered nutritional supplement, Magic Cup, due to it being on back order. Staff did not notify the physician or dietician about the unavailability, and in one case, provided Ensure as a substitute without an order. This failure to communicate and follow proper procedures was confirmed by staff interviews.
Surveyors found that controlled substances, such as lorazepam, were not double locked in the medication storage room, and multiple open bottles of medications on two medication carts were missing required open dates. Staff confirmed that facility policy requires double locking of controlled substances and dating of opened medications, but these procedures were not followed.
Two residents did not receive care in accordance with professional standards: a nurse left medications at the bedside for a resident without an order for self-administration, and another resident receiving hospice care did not have a physician's order for hospice services documented, despite hospice interventions being in place.
A resident with multiple medical conditions developed a stage 1 pressure ulcer and was evaluated by a wound care provider, who recommended specific daily wound care. The recommended treatment was not entered as a physician order, resulting in the resident not receiving the necessary wound care as required.
Two residents did not receive meals according to their preferences or selected menu items: one was served chicken that was not prepared as requested and found unpalatable, while another was given mashed potatoes instead of the penne pasta with red sauce marked on her meal ticket, despite the correct item being available.
The facility failed to update care plans for three residents, resulting in discrepancies between physician orders and care plans. This included missing updates for supplemental oxygen use, heel protector boots, and a left-hand splint.
The facility failed to change a resident's enteral feeding tubing and water bag as required by policy and physician orders. The tubing and bag were observed to be dated from the previous day, and the DON confirmed they were not replaced on the night shift as expected. The resident had diagnoses including surgical aftercare, dysphagia, and dementia.
The facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for a resident with myasthenia gravis, anxiety disorder, and major depressive disorder. The clinical record did not reveal a medication regimen review by a licensed pharmacist for November 2023, which was confirmed by the DON.
Hazardous Area Door Deficiencies and Improper Hold-Open Devices
Penalty
Summary
The facility failed to maintain hazardous area doors in accordance with required safety standards in two of ten smoke zones. Specifically, during an observation, the Sprinkler Tank Room door (1A29D) was found to have gaps greater than 3/16 inch, which exceeds the allowed gap margins for such doors. This was confirmed by the Director of Facilities at the time of observation. Additionally, the 1st floor Dietary Storage Room rated doors (1B20) were observed being held open with manual hold-open drop downs, which are unauthorized devices. The Director of Facilities confirmed that these doors were being held open in this manner. These findings indicate that the facility did not ensure hazardous area doors were properly maintained to meet fire safety requirements.
Plan Of Correction
1. A rated door system will be installed on door 1A29D to maintain proper gap margins to less than 3/16". A recurring work order will be created to inspect the door for proper gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 2. Manual hold open devices will be removed from doors 1B20. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Lack of Smoke Detector Protection in Open Dining Room
Penalty
Summary
Surveyors observed that the 1st floor Dining Room had its doors (1C10 and 1C11) removed, resulting in the room being open to the corridor. Despite this change, there was no smoke detector protection installed in the area. This deficiency was confirmed during an interview with the Director of Facilities, who acknowledged the absence of smoke detection in the room. The lack of smoke detector protection in a room open to the corridor constitutes a failure to provide required fire alarm protection in one of ten smoke compartments within the facility.
Plan Of Correction
Two battery-operated, ten-year smoke detectors will be installed in the Personal Care Dining Room to alert team members of a possible fire event. A procedure will be developed to explain the steps to follow in the event that detectors sound during a fire event. Current team members associated with Personal Care will be educated initially upon installation and then annually on the procedures. New hired team members will be educated and trained during their orientation. A recurring work order will be created to test these detectors monthly for proper operation and audible levels to the end of the Personal Care corridors. Completed documentation will be presented to QAPI for evaluation.
Failure to Maintain Corridor Doors with Positive Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in a manner that ensured they positively latched, as required by NFPA 101 and CMS regulations. Specifically, during an inspection, it was found that the door to the Kitchen near the 2nd floor Dining Room was impeded from closing properly due to a fatigue mat. Additionally, the double doors to the Linen Closet (2E66) had an inactive door that was not latched, and the PC Unit Office (1C06) door was hitting the frame, preventing it from latching. These issues were identified in three out of ten smoke compartments within the facility. The Director of Facilities confirmed during an interview that the corridor doors in these locations failed to positively latch. The report does not mention any specific residents or their medical conditions in relation to these deficiencies. The findings are based solely on direct observation and staff interview, with no mention of corrective actions or follow-up steps taken at the time of the survey.
Plan Of Correction
1. The fatigue mat located at the ice machine in the main kitchen will be reduced in size to prevent interference with the door. A recurring work order will be created to inspect this area for an impediment to the door quarterly for one year. Documentation will be presented to QAPI for evaluation. 2. An automatic bolt assembly and spring-loaded hinges will be installed to the Ellison linen closet right side door 2E66. A recurring work order will be created to inspect the door for automatic positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation. 3. Shims will be removed from door 1C06 to prevent the door from hitting the frame. A recurring work order will be created to inspect the door for positive latching and gap margins quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Smoke Barrier Door Hardware Failed to Latch Properly
Penalty
Summary
During an observation, surveyors found that the double smoke barrier door located between compartments AA and AE did not latch properly when closed. The latching hardware on this smoke barrier door failed to function according to manufacturer specifications. This issue was confirmed in an interview with the Director of Facilities, who acknowledged that the smoke barrier door hardware was not operating as required. The deficiency affected two out of ten smoke compartments within the component. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
Hardware will be repaired and adjusted on smoke barrier doors between compartments AA and AE. A recurring work order will be created to inspect doors for proper operation and positive latching quarterly for one year. Completed work order documentation will be presented to QAPI for evaluation.
Deficient Food Storage, Labeling, and Equipment Maintenance
Penalty
Summary
The facility failed to store food and equipment in accordance with professional standards for food service safety in multiple areas, including the main kitchen, walk-in freezer, and two pantries. Observations revealed several open food items such as chips, bread, rolls, and a bowl with a green flaky substance in the main kitchen that were not labeled or dated as required by facility policy. Additional findings included open containers in refrigerators without open dates, and some items with open dates far exceeding the facility's three-day 'use by' policy. There was also evidence of expired food items, such as Thick It with an expiration date that had passed, and thicken coffee packets with expired dates in the pantries. Staff interviews confirmed that all open and prepared foods should be dated and discarded according to policy, but this was not consistently followed. Further deficiencies were noted in the cleanliness and maintenance of equipment and storage areas. The main kitchen had multi-use ovens with heavy white staining and water damage behind the ice machine due to a leaking water line. The walk-in freezer contained a metal shelving unit with brownish-red discoloration and a significant amount of greenish/brown substance on the shelves and floor, with no cleaning schedule in place. The facility's leadership confirmed the expectation for proper dating, discarding of expired foods, and maintenance of clean equipment, but these standards were not met as observed during the survey.
Failure to Ensure Prompt Call Bell Response Times
Penalty
Summary
The facility failed to ensure prompt response times to resident call bells for four residents over a three-month period, as evidenced by call bell monitoring system reports and resident and staff interviews. The facility's policy requires all staff to be aware of and respond promptly to call lights, regardless of assignment, and to only turn off the call light once the resident's needs are met. However, multiple instances were documented where response times exceeded 20 minutes, with some calls going unanswered for over an hour. Residents reported variable and often lengthy wait times, particularly at night and on weekends, and described situations where they remained on a bedpan for extended periods or avoided drinking fluids due to anticipated delays in assistance. Staff interviews revealed that the Nursing Home Administrator reviews call bell reports only when a grievance is filed or a concern is voiced, focusing on average response times rather than individual incidents. The NHA could not confirm whether staff had responded to the residents in a timely manner and was unable to specify expectations for response times. The Director of Nursing also could not provide clear expectations for call bell response. The facility was cited for failing to reasonably accommodate the needs and preferences of residents, as required by state regulations.
Failure to Document and Order Urostomy Care for Resident
Penalty
Summary
The facility failed to provide proper urostomy care for a resident with a diagnosis of neurogenic bladder and a urostomy. Review of the facility's policy indicated that documentation of ostomy care should include the date and time care was provided, the name and title of the caregiver, any skin issues or signs of infection, the resident's tolerance of the procedure, refusals and interventions, and the signature of the person recording the data. However, the resident's clinical record did not contain documentation of urostomy care after March 23, 2025, and there was no physician order specifying the details of urostomy care. The care plan referenced care as ordered by the physician, skin nurse, or charge nurse, but lacked current, specific interventions or documentation. Interviews with the resident revealed that she independently performed her own urostomy care and was comfortable doing so. Staff interviews confirmed that the resident managed her own care and requested supplies as needed to maintain independence. Despite this, the DON acknowledged that there should have been a physician order detailing urostomy care and that the provision of care should have been documented in the clinical record, in accordance with facility policy and regulatory requirements.
Failure to Notify Physician/Dietician of Unavailable Nutritional Supplement
Penalty
Summary
The facility failed to notify the dietician or physician regarding the unavailability of an ordered nutritional supplement, Magic Cup, for two residents with significant medical needs. One resident, with diagnoses including diabetes mellitus and dementia, experienced a weight loss over three months and had a physician's order for Magic Cup twice daily. Progress notes indicated that the supplement was not available on multiple occasions due to a back order, and there was no documentation that the physician or dietician was informed of this issue. Another resident, admitted with dementia and a stage 4 pressure injury, also had an order for Magic Cup twice daily for a low BMI. Documentation showed repeated instances where the supplement was unavailable, and in some cases, Ensure was provided as a substitute without a physician's order. Staff interviews confirmed that the supplement was on back order and that appropriate notifications to the dietician or physician were not made, as required.
Failure to Secure Controlled Substances and Appropriately Label Opened Medications
Penalty
Summary
Surveyors observed that controlled substances, specifically lorazepam, were not properly secured in the medication storage room refrigerator in Arlington Hall. One bottle of lorazepam was found lying on top of the non-removable lock box, and the lock box itself was not locked, containing seven additional vials of lorazepam. Facility policy requires that controlled substances be double locked, and staff confirmed that the lorazepam should have been stored inside the locked box. Additionally, during inspection of two medication carts (2-AE and 2-A hall), multiple open bottles of medications, including acetaminophen, cranberry tablets, calcium with vitamin D, multivitamins, and prosource powder, were found without open dates. Facility policy mandates that all multi-dose vials be dated when opened. Staff interviews confirmed that the expectation is for medications to be dated upon opening, but this was not followed in the observed instances.
Failure to Ensure Professional Standards in Medication Administration and Hospice Orders
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For one resident with myasthenia gravis and muscle weakness, a nurse left medications (acetaminophen and ferrous sulfate) on the bedside table and exited the room to retrieve additional medication. The resident partially took the medications left at the bedside, despite not having a physician's order for self-administration of these medications. The resident's record only approved self-administration of saline nasal spray, and facility policy required an order and evaluation for self-administration of any medication. For another resident with Huntington disease who was admitted for respite hospice care, the clinical record did not contain a physician's order for hospice services, even though the care plan included interventions and contact details for hospice care. The facility's expectation, as stated by the NHA, was that physician orders for care and services should be entered, but this was not done at the time of review.
Failure to Implement Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cervicalgia and acute diastolic congestive heart failure developed a stage 1 pressure ulcer on the right buttock. The resident was evaluated by a contracted wound care provider, who recommended daily treatment with a superabsorbent gelling fiber with silicone border. However, a review of the clinical record and physician orders revealed that the recommended wound care orders were not entered for the resident's pressure ulcer. This omission resulted in the resident not receiving the necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection, as required by facility policy and regulation.
Failure to Provide Palatable Food and Correct Menu Items
Penalty
Summary
The facility failed to provide food that was palatable and prepared according to resident preference for one resident, and failed to serve the correct menu item for another. One resident did not eat her chicken at lunch because it was not prepared as she requested; she had marked her meal ticket for plain, well-done chicken, but the chicken served lacked grill marks, appeared undercooked, and did not meet her texture and appearance preferences. The Director of Dining Services confirmed that the chicken was not prepared as requested and acknowledged the deviation from the resident's preference. Another resident, who was unable to select her own food, was served mashed potatoes with chicken and yellow gravy instead of the chicken and penne pasta with red sauce that was marked on her meal ticket. Staff interviews revealed that the dietary staff served mashed potatoes because the resident generally eats them well, but the selected pasta dish was available and should have been served. Continued observation confirmed that the resident was not provided with the selected pasta dish during the meal service.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure the care plan was reviewed and revised for three residents. Resident 17 had a care plan that did not reflect the current physician's orders for supplemental oxygen use and the updated order for the hinged elbow brace to be worn only at night. The care plan still indicated that the brace should be worn at all times, and there was no mention of the supplemental oxygen use, despite the physician's orders being updated in March 2024. The Director of Nursing (DON) confirmed that the care plan should have been updated to reflect these changes. Resident 19's care plan did not include the use of heel protector boots, which were observed on the resident and confirmed by the DON to be necessary for preventing skin breakdown. The care plan was only updated to include this intervention on April 30, 2024, despite the resident's need for the boots being evident earlier. Similarly, Resident 29's care plan failed to include the use of a left-hand splint, which was ordered by the physician in January 2024. The DON acknowledged that the care plan should have been updated in a timely manner to include this intervention. These deficiencies indicate a failure to maintain accurate and current care plans for the residents, as required by the facility's policy and regulatory standards.
Failure to Change Enteral Feeding Tubing and Bags
Penalty
Summary
The facility failed to provide appropriate care and services for a resident receiving a tube feeding. The facility's policy required that feeding solution bags and tubing be replaced daily, and irrigation syringes be labeled with the resident's name and date, and changed daily on the night shift. However, an observation revealed that Resident 19's enteral feed tubing and the hanging bag of water for flushing were not changed as required. The tubing and water bag were dated from the previous day, indicating they were not replaced on the night shift as per the physician's order and facility policy. The Director of Nursing confirmed that the tubing was not changed on the specified night shift and acknowledged that it should have been done according to the policy and physician's order. Resident 19 had diagnoses including surgical aftercare following digestive system surgery, dysphagia, and dementia.
Failure to Ensure Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician reviewed and responded to pharmacy review recommendations for one of five residents reviewed for unnecessary medications. Specifically, for Resident 24, who has diagnoses including myasthenia gravis, anxiety disorder, and major depressive disorder, the clinical record did not reveal a medication regimen review completed by a licensed pharmacist for the month of November 2023. This was confirmed during an email correspondence and follow-up interview with the Director of Nursing (DON), who was unable to locate the pharmacy recommendation for that month and acknowledged that such recommendations should be available and reviewed by the physician. The facility's policy titled Drug Regimen Review, last revised in February 2023, mandates that a record of the consultant pharmacist's observations and recommendations be made available to nurses, physicians, and the care planning team. The policy also requires documentation of the date each medication regimen review is completed and notation of the findings in the medical record or other designated site. The failure to adhere to this policy for Resident 24 was identified during a clinical record review on April 30, 2024, and confirmed by the DON on May 1, 2023.
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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