Spiritrust Lutheran The Village At Luther Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 2781 Luther Drive, Chambersburg, Pennsylvania 17202
- CMS Provider Number
- 396146
- Inspections on file
- 17
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Spiritrust Lutheran The Village At Luther Ridge during CMS and state inspections, most recent first.
A resident with Parkinson's disease, weakness, and dementia, who was care planned to remain in a reclined BRODA chair to prevent falls, was left in an upright position by a PRN therapy staff member after a treatment session. The resident subsequently fell from the chair, sustaining a facial laceration that required sutures, as staff failed to follow the specified fall prevention intervention.
Surveyors found that several residents did not receive ordered medications due to unavailability, and staff failed to notify practitioners as required by facility policy. Additionally, a resident was observed with a lower extremity splint in use without corresponding physician orders or care plan documentation.
Several residents did not receive prescribed medications, including insulin, Gabapentin, Lorazepam, Torsemide, and levothyroxine, due to unavailability or pharmacy delivery delays. Missed doses occurred for residents with conditions such as diabetes, central pain syndrome, dementia, congestive heart failure, and hypothyroidism, with staff and administration confirming the medications were not administered as ordered.
The facility did not update care plans for two residents after significant changes in their conditions. One resident's care plan was not revised after anticoagulant medications were discontinued following hospitalization, and another resident's care plan lacked a current focus on fall risk despite a recent major fall and high fall risk assessment. Staff confirmed that care plans should have been updated to reflect these changes.
A resident with significant mobility impairments and a history of falls was transferred using a mechanical sit-to-stand lift by a CNA without the required second staff member, in violation of both the care plan and facility policy. During a brief change while in the lift, the resident slid out of the device and fell to the floor. Facility documentation and interviews confirmed that proper supervision and assistance were not provided, leading to the fall.
Two residents continued to receive diclofenac gel orders without specific dosing instructions, despite repeated pharmacist recommendations to clarify the dose. Physicians either did not respond or disagreed with the recommendations, and the orders remained incomplete, contrary to facility policy requiring action on pharmacist-identified medication irregularities.
Surveyors found that two open multi-dose vials of Tuberculin solution in a medication room refrigerator were not dated when opened, contrary to facility policy and staff expectations. Both staff and the NHA confirmed that multi-dose vials should be dated upon opening.
The facility did not have all required QAPI Committee members present at any meeting during a quarter, with absences including the Medical Director, DON, Infection Preventionist, and another staff member, as confirmed by review of sign-in sheets and administrator interview.
The facility did not ensure that all nurse aides completed the required 12 hours of annual in-service training, with two aides receiving only 10 and 6 hours respectively, as confirmed by the administrator.
The facility did not timely report allegations of abuse and neglect involving two residents to the required agencies. One resident with significant mobility issues experienced a fall due to a CNA not following the care plan for mechanical lift transfers, and another resident alleged physical abuse by a staff member. In both cases, the facility failed to notify the local Area Agency on Aging and the state survey agency as required by policy.
The facility failed to ensure timely monthly drug regimen reviews and responses to pharmacist recommendations for several residents. Recommendations for evaluating medication appropriateness and alternatives were not acted upon promptly, as evidenced by delayed or missing responses in residents' records. Interviews confirmed the expectation for timely review and response, which was not met.
A resident was subjected to aggressive behavior by a nurse aide, including being told to stop yelling and being sprayed with water. The incidents were reported days later, violating the facility's policy on timely reporting of abuse.
A resident with CHF and edema had a physician's order for daily weights, with instructions to notify the provider of significant weight gains. However, weights were not recorded on several occasions, and significant weight gains were not reported to the practitioner. The DON could not provide additional information on these lapses.
A facility failed to document comprehensive physician orders for a resident receiving dialysis, including treatment details and provider information, as required by their own care standards. This oversight was confirmed by the DON and involved a resident with end-stage renal disease and atrial fibrillation.
A resident with cellulitis and hypertension did not have complete and accurate documentation of Cefazolin administration in their clinical records. The nurse failed to initial doses on two occasions, and the administration time was incorrectly transcribed. The DON confirmed the need for complete documentation and accurate transcription.
A facility failed to maintain an effective infection control program for a resident with C. diff and pressure ulcers. Observations showed no signage or PPE for contact precautions, and an LPN did not follow proper hand hygiene protocols. The DON confirmed that these measures were expected but not implemented.
Failure to Follow Care Plan for Fall Prevention Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents, resulting in actual harm to a resident who experienced a fall with a facial injury requiring sutures. The resident had diagnoses including Parkinson's disease, weakness, and dementia, and was identified as being at risk for falls. The resident's care plan specified that she should be seated in a BRODA chair in a reclined position with left lateral support at all times except during meals, to increase comfort and reduce the risk of falls. However, on the day of the incident, the resident was found on the floor in front of her BRODA chair, which was in the upright position, after calling for help. She sustained a 5-centimeter laceration below her right eye, which required 15 sutures at the hospital. Review of staff interviews and facility documentation revealed that a physical therapy assistant, who was a PRN staff member, returned the resident to the television area in her wheelchair in the upright position after a treatment session, failing to follow the care plan intervention requiring the chair to be reclined. Nursing staff confirmed that the resident's wheelchair was not reclined at the time of the fall, and that the reclined position was intended to make it more difficult for the resident to get up unassisted, thereby preventing falls. The failure to follow the care plan intervention directly resulted in the resident's fall and subsequent injury.
Failure to Notify Practitioners of Missed Medications and Lack of Treatment Orders
Penalty
Summary
The facility failed to ensure that practitioners were notified when medications were missed due to unavailability for four residents. For one resident with type II diabetes mellitus and central pain syndrome, Gabapentin was not administered for two consecutive days, totaling six missed doses, without evidence that the practitioner was notified. Another resident receiving hospice care for dementia and anxiety did not receive multiple doses of Lorazepam as ordered, and there was no documentation that the physician was informed of these missed doses. A third resident with congestive heart failure missed a dose of Torsemide, and a fourth resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine, with no evidence of practitioner notification in either case. Additionally, the facility did not provide treatment in accordance with professional standards of practice and physician orders for one resident. This resident, diagnosed with Charcot's joint and gout, was observed wearing a right lower extremity splint. However, there were no physician orders, documentation, or care plan interventions related to the splint at the time of observation. The absence of orders and documentation for the splint was confirmed during interviews and record reviews. These deficiencies were identified through policy review, clinical record review, observations, and interviews with residents and staff. The facility's own policy required staff to notify the pharmacy and the practitioner if a medication was unavailable and a dose would be missed, but this was not followed in the cases reviewed. The lack of documentation and practitioner notification for missed medications and the absence of orders and care planning for the splint constituted failures to provide care and treatment according to orders, resident preferences, and professional standards.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of several residents, resulting in multiple missed medication doses. For one resident with type II diabetes and central pain syndrome, Basaglar insulin was not administered due to the insulin pen being unavailable, and Gabapentin was missed over two days because the medication was out of stock and not delivered by the pharmacy in time. Another resident receiving hospice care and diagnosed with dementia did not receive Lorazepam for anxiety over several scheduled doses because the medication was not accessible following a pharmacy change and a delay in staff training on the new medication unit. A resident with congestive heart failure did not receive a scheduled dose of Torsemide as the medication was not available and was awaiting delivery from the pharmacy. Additionally, a resident with congestive heart failure and hypothyroidism missed two doses of levothyroxine because the medication was not available and was still pending arrival from the pharmacy. In each case, the Nursing Home Administrator confirmed that the medications were not administered as ordered due to unavailability or delays in pharmacy delivery.
Failure to Review and Revise Care Plans After Changes in Resident Status
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and federal regulations. For one resident with a history of long-term anticoagulant use and peripheral vascular disease, the care plan included a focus on potential bleeding and bruising due to aspirin and Plavix use. However, after the resident was hospitalized and both medications were discontinued upon return to the facility, the care plan was not updated to reflect this significant change in medication regimen, despite a comprehensive assessment and care plan review being completed. For another resident with cerebral palsy and spondylosis, a fall with major injury occurred, and a subsequent fall risk evaluation identified the resident as high risk for falls. Despite this, the care plan did not include a current focus on fall risk, and the previous fall care plan had been marked as resolved. Staff interviews confirmed that the care plan should have addressed the resident's ongoing fall risk. These findings demonstrate that the facility did not ensure care plans were consistently reviewed and revised in response to changes in residents' conditions and assessments.
Failure to Follow Transfer Protocols Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, Charcot's joint of the right ankle/foot, and a chronic non-pressure ulcer of the right heel experienced a fall from a mechanical sit-to-stand lift. The resident's care plan required transfer assistance of two staff members when using the mechanical lift, and facility policy also mandated two team members for such transfers. However, a nurse aide attempted to change the resident's brief while the resident was positioned in the lift, and did so alone, contrary to both the care plan and facility policy. As a result, the resident slid out of the lift's secure device and fell to the floor. Facility documentation, incident reports, and staff interviews confirmed that the nurse aide did not follow the established care plan or facility procedures, which led to the fall. The Nursing Home Administrator acknowledged that the staff member failed to adhere to the required protocols for resident safety and supervision during transfers, resulting in the incident.
Failure to Act on Pharmacist Recommendations for Medication Dosing
Penalty
Summary
The facility failed to ensure that recommendations made by the licensed pharmacist regarding medication orders were reviewed and acted upon by the residents' physicians for two of five residents reviewed for unnecessary medications. Specifically, for two residents with diagnoses including knee pain, muscle weakness, and right shoulder pain, the pharmacist identified that the orders for Voltaren/diclofenac gel were not specific enough, lacking a clearly defined dose as recommended by the manufacturer. The pharmacist made recommendations on two separate occasions for each resident to clarify the dosing instructions, but the physicians either did not respond or disagreed with the recommendation without providing a revised order that included the required dosing information. Clinical record reviews showed that both residents continued to have medication orders for diclofenac gel that did not specify the dose to be administered, despite repeated pharmacist recommendations. The facility's policy required that such recommendations be acted upon and documented, and if the prescriber did not respond, further follow-up was to occur. During an interview, the Nursing Home Administrator confirmed that the physicians should have provided specific dosing orders for the medication, but this was not done.
Failure to Date Opened Multi-Dose Vials in Medication Room
Penalty
Summary
Surveyor observations, review of facility policy, and staff interviews revealed that the facility failed to place opened dates on medications in one of two medication rooms, specifically in the Arlington Unit. During an inspection of the medication storage room refrigerator, two open multi-dose vials of Tuberculin solution were found without open dates. The facility's policy requires that multi-dose vials be dated when opened to ensure infection control and product stability. Both a staff member and the Nursing Home Administrator confirmed that it is the facility's expectation to date multi-dose vials upon opening.
Failure to Ensure Required QAPI Committee Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance Performance Improvement (QAPI) Committee attended at least one meeting during the fourth quarter of 2024. Review of sign-in sheets and documentation showed that the Medical Director was absent from the October meeting, both the Director of Nursing and Medical Director were absent from the November meeting, and the Infection Preventionist along with one additional staff member were absent from the December meeting. The Nursing Home Administrator confirmed that there was no meeting in the quarter where all required members were present, despite the committee meeting monthly.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that each nurse aide received the required minimum of 12 hours of annual in-service training, as evidenced by a review of personnel training records. Specifically, one nurse aide completed only 10 hours and another completed only 6 hours of the mandated training within the past 12 months. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the expectation that nurse aides meet the required training hours. The deficiency was identified through a review of training records for two out of five nurse aide employees, with no additional information provided regarding the medical history or condition of any residents affected by this deficiency.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the required agencies in a timely manner for two residents. For one resident with muscle weakness, Charcot's joint, and a chronic non-pressure ulcer, a fall occurred when a CNA used a mechanical sit-to-stand lift without following the care plan, which required two staff members for transfers. The incident investigation determined that the CNA neglected to follow both the resident's care plan and facility policy. Despite this, there was no documentation that the incident was reported to the local Area Agency on Aging or the state survey agency, as required by facility policy. In a separate incident, another resident filed a grievance alleging that a staff member had kicked him during care. The facility's investigation found the abuse allegation to be unsubstantiated, but again, there was no evidence that the allegation was reported to the required agencies. Interviews with the Nursing Home Administrator confirmed that both incidents should have been reported according to policy, but were not.
Failure to Ensure Timely Drug Regimen Reviews and Responses
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, and that irregularities were reported and acted upon in a timely manner. This deficiency was identified for four of five residents reviewed for unnecessary medications. The facility's policy, revised in February 2023, mandates that comments and recommendations concerning medication therapy be communicated in a timely fashion, allowing for a response before the next medication regimen review. However, this policy was not adhered to, as evidenced by the lack of timely responses to pharmacist recommendations. For Resident 2, the pharmacist recommended evaluating the clinical appropriateness and alternative therapy for extended usage of Macrobid on multiple occasions, but the practitioner failed to provide timely responses. The recommendation made in November 2023 was not addressed until March 2024, and a similar recommendation in June 2024 was not responded to at all. Resident 13's records showed recommendations to discontinue PRN Ondansetron and evaluate Hydroxyzine usage, but these were not acted upon in a timely manner. Additionally, a recommendation to consider alternatives due to a high Anticholinergic Burden score was also ignored. Resident 17's medication regimen review for December 2023 could not be located, and a recommendation made in January 2024 was not responded to until March 2024. For Resident 29, a recommendation to adjust Colace dosing was not addressed in a timely manner. Interviews with the Director of Nursing confirmed the expectation that pharmacy recommendations should be reviewed and responded to promptly, which was not the case for these residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse involving a resident, as required by their policy. The incident involved Resident 38, who was subjected to aggressive behavior by Employee 4, a nurse aide. On March 21, 2024, while providing care, Employee 4 aggressively told Resident 38 to stop yelling and used a washcloth to hush her. When the resident continued to scream, Employee 4 placed her fingers in the resident's mouth and nose while mocking her. This incident was reported by Employee 3 to Employee 5, a Registered Nurse Supervisor, on March 24, 2024, three days after it occurred. Additionally, another incident involving Employee 4 was reported by Employee 6, a nurse aide, on the same day. This incident occurred on March 18, 2024, during a bath when Employee 4 sprayed Resident 38 in the face with water out of frustration. Both incidents were reported to the Director of Nursing, who acknowledged that the allegations should have been reported immediately, as per the facility's policy. The delay in reporting these incidents constitutes a failure to adhere to mandatory reporting requirements for suspected abuse.
Failure to Monitor and Report Weight Changes
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and localized edema. The resident had a physician's order for daily weights, with instructions to notify the provider if there was a weight gain of more than three pounds in a day or more than five pounds in a week. However, the Treatment Administration Records for June and July 2024 showed that weights were not recorded, nor was there documentation of refusal to be weighed on several dates. Additionally, significant weight gains were recorded on two occasions, but there was no evidence that the practitioner was notified of these changes. The Director of Nursing was unable to provide further information regarding the missed weights or the lack of practitioner notification.
Deficiency in Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis treatment was provided care in accordance with professional standards of practice. The deficiency was identified through a review of the facility's policy, clinical records, and interviews with staff and the resident. The facility's policy, titled Hemodialysis Resident Care Standard, mandates the safe medical management of residents receiving dialysis at an external clinic. However, the clinical record of a resident with end-stage renal disease and atrial fibrillation revealed a lack of comprehensive physician orders related to dialysis treatment. The resident, who undergoes dialysis three times a week at an outside facility, did not have physician orders specifying the dialysis treatment, the name of the facility, the frequency of the treatment, or contact information for the dialysis provider. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that such orders should have been documented. The absence of these critical details in the resident's care plan constitutes a failure to adhere to the facility's own policies and professional standards of practice.
Incomplete Medication Documentation for a Resident
Penalty
Summary
The facility failed to document completely and accurately on the clinical records for a resident, identified as Resident 86. The facility's policy, titled Accountability of Medications and Controlled Substances, requires staff to document the administration of all medications given to residents. However, a review of Resident 86's medication administration record revealed that the nurse did not initial the doses of Cefazolin on two occasions, specifically on July 16, 2024, at 7:00 PM, and on July 19, 2024, at 4:00 AM. Additionally, the ordered time for the 7:00 PM dose was incorrectly transcribed and should have been recorded as 8:00 PM based on the every 8-hour administration schedule ordered by the physician. Resident 86, who is cognitively intact with a BIMS score of 15 out of 15, has a physician order for Cefazolin 2 grams intravenously every 8 hours for cellulitis. An observation on July 22, 2024, revealed an empty bag of Cefazolin at the resident's bedside, indicating administration at 8:00 AM as per physician orders. The Director of Nursing confirmed with the pharmacy that three doses are delivered daily, and there were no extra doses on the unit, nor had the resident refused any doses. The DON acknowledged that documentation should be complete and transcription of times should be accurate on resident clinical records.
Inadequate Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of appropriate precautions for a resident diagnosed with Clostridium difficile (C. diff) infection and pressure ulcers. The facility's policy required specific precautions, including hand hygiene and the use of personal protective equipment (PPE), for residents with C. diff infections. However, observations revealed that there was no signage indicating contact precautions or Enhanced Barrier Precautions (EBP) in place for the resident, and no PPE was available for use. Additionally, the resident's comprehensive care plan indicated a need for contact precautions, which were not implemented. During a wound care observation, a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene before donning a gown and gloves and after removing soiled dressings. The LPN also used alcohol-based hand rub, contrary to the facility's policy for C. diff infections, which prohibits its use. The Director of Nursing (DON) acknowledged that signage and PPE should have been in place and that proper hand washing was expected during wound care and when caring for residents on contact precautions for C. diff.
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.
