Spiritrust Lutheran The Village At Sprenkle Drive
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 1801 Folkemer Circle, York, Pennsylvania 17404
- CMS Provider Number
- 395612
- Inspections on file
- 21
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Spiritrust Lutheran The Village At Sprenkle Drive during CMS and state inspections, most recent first.
A resident with major depressive disorder and anxiety disorder continued to receive a higher dose of haloperidol for over a month after the physician had ordered a dose reduction, due to a delay in updating the medication orders and administration records. The facility's policy lacked a specified timeframe for acting on such orders, resulting in the resident receiving the incorrect dose until the issue was identified by the consultant pharmacist.
The facility administration did not ensure annual review and approval of care policies by the administration and Medical Director. The NHA could not provide evidence of a recent review, and the last documented review was dated over a year ago. The facility lacked further evidence of a care policy review within the past year.
The facility did not submit required direct care staffing information for FY Q3 2024, as mandated by the ACA and CMS guidelines. The Nursing Home Administrator was unaware if the submission was completed by the previous administration, leading to a deficiency for failing to submit the necessary data.
The facility failed to provide a dignified dining experience for several residents, as observed during meal service. A dietary employee did not complete serving one table at a time, leading to significant delays for some residents. Residents expressed concerns about the uncertainty of meal service timing, which was acknowledged by the Nursing Home Administrator.
The facility failed to develop comprehensive care plans for four residents, omitting essential interventions for conditions such as edema, cataracts, mobility issues, and dental status. This lack of documentation and planning did not meet the residents' specific medical and care needs.
The facility failed to provide timely meal assistance to residents requiring full assistance or supervision. Observations showed delays in staff attending to residents, such as a resident sitting with an untouched meal and another served while sleeping. The Nursing Home Administrator acknowledged the expectation for timely assistance, indicating a gap in management and nursing services.
A resident with limited ROM did not receive the recommended restorative nursing program after discharge from occupational therapy. The facility failed to document or implement the prescribed active ROM exercises, leading to a deficiency in care.
The facility failed to comply with professional standards for food storage and kitchen equipment use, as observed through unlabeled, undated, or expired food items in various areas. Interviews with staff confirmed that facility expectations were not met, indicating a systemic issue with adherence to food service safety standards.
A facility failed to accurately assess a resident's dental status during admission. The resident, with atrial fibrillation and congestive heart failure, was observed to have no natural teeth, confirmed by a physician assessment. However, the Admission MDS was incorrectly coded, not reflecting the resident's edentulous condition. This was confirmed by the Nursing Home Administrator and DON.
A resident with Parkinson's disease experienced a deficiency in care when the facility failed to update the care plan after removing the remote for the resident's electric recliner. The resident, unable to operate the recliner independently, had a fall, and the care plan was not revised to reflect the safety measure of removing the remote.
A facility failed to provide a prescribed nutritional supplement to a resident with dementia and diabetes, substituting it with chocolate milk, which lacked equivalent nutritional value. Additionally, the facility did not notify a physician of a significant weight loss in a resident with dysphagia and Alzheimer's, as required by their policy.
A facility failed to provide trauma-informed care to a resident with a history of childhood trauma. Despite the facility's policy requiring trauma history screening, the resident's care plan lacked documentation of trauma, and psychosocial assessments did not address trauma history. Interviews with staff revealed an inability to locate documentation of trauma assessment.
A facility failed to adhere to its infection control program when two employees did not wear gowns during high-contact care for a resident on Enhanced Barrier Precautions (EBP). Despite clear signage and available PPE, the staff did not follow the protocol, as confirmed by interviews with facility leadership.
A resident with a history of hemiplegia and other conditions suffered a skin tear when a nurse aide trainee transferred them alone using a sit-to-stand lift, against facility policy requiring two-person assistance. The aide felt rushed and proceeded without help, resulting in the resident's arm hitting a door frame.
A resident with multiple health conditions suffered a skin tear during a transfer when a nurse aide trainee used a sit-to-stand lift independently, contrary to facility policy requiring two-person assistance. The aide felt rushed and did not seek additional help, leading to the resident's arm being injured against a door frame.
Delay in Implementing Psychotropic Medication Dose Reduction
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication underwent a timely gradual dose reduction as ordered by the physician. The resident, who had diagnoses of major depressive disorder and anxiety disorder, was prescribed haloperidol 1 mg at bedtime. On July 21, 2025, the physician agreed with the consultant pharmacist's recommendation to decrease the dose to 0.5 mg at bedtime and ordered monitoring for behavioral changes for 14 days following the change. However, the physician's order to decrease the dose was not promptly reflected in the resident's current medication orders. Despite the physician's order, the resident continued to receive haloperidol 1 mg at bedtime for 35 days after the dose reduction was approved. The medication administration record confirmed that the dose was not changed to 0.5 mg until August 28, 2025. The facility's policy did not specify a timeframe for acting on physician orders, and the delay was identified by the consultant pharmacist and brought to the attention of nursing staff. The Nursing Home Administrator acknowledged that physician orders should be acted upon in a timely manner.
Failure to Review and Approve Care Policies Annually
Penalty
Summary
The facility administration failed to ensure that care policies were reviewed and approved by the administration and Medical Director on a yearly basis. During an entrance staff interview, the Nursing Home Administrator (NHA) was unable to provide evidence of a recent care policy review. An electronic communication from the NHA confirmed the absence of a signatory page indicating the last review date. A review of the care policy binder, provided by the Director of Nursing (DON), revealed that the last documented review and approval by the NHA, DON, and Medical Director was dated March 9, 2022. As of the survey date, the facility could not provide further evidence of a care policy review within the past year.
Failure to Submit Staffing Data for FY Q3 2024
Penalty
Summary
The facility failed to electronically submit direct care staffing information for the fiscal year third quarter of 2024, as required by Section 6106 of the Affordable Care Act (ACA) and the State Operations Manual under section 483.70(q). This requirement mandates that long-term care facilities submit complete and accurate staffing information, including agency and contract staff, based on payroll and other verifiable data in a uniform format to the Center for Medicare and Medicaid Services (CMS). The review of the CMS Payroll Based Journal (PBJ) staffing data report revealed that the facility did not submit the necessary data for the specified quarter. During a staff interview, the Nursing Home Administrator indicated that the responsibility for the submission lay with a prior administration and was uncertain whether the submission to PBJ had been completed. As of the following day, the facility had no additional information to provide regarding the submission. This lack of submission triggered a deficiency for failing to submit the required data for the quarter, as noted in the PBJ staffing data reports.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for five residents during meal service in the observed dining room. Observations revealed that the dietary employee, identified as Employee 4, did not complete serving one table at a time, resulting in some residents being served significantly later than others at the same table. For instance, Resident 35 was left without food while others at the table were served, prompting the resident to request food from Employee 4. Similarly, Resident 9, who had been waiting since 11:00 AM, expressed concern about the delay in receiving their meal. Additional observations noted that Resident 17, Resident 64, and Resident 24 also experienced delays in being served, despite their tablemates having already received their meals. These delays were confirmed through resident interviews, where concerns about the uncertainty of meal service timing were expressed. The Nursing Home Administrator acknowledged the expectation that residents should be served with dignity during meal service, aligning with the facility's policy on resident rights.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their specific medical and care needs. Resident 44, diagnosed with chronic venous hypertension with ulcers and type two diabetes mellitus, had physician orders for bilateral lower extremity ace wraps and diuretics for edema, but these were not included in the comprehensive care plan. Similarly, Resident 48, who had bilateral cataracts and hypertension, required cataract surgery, yet her care plan lacked documentation of her visual function and necessary staff interventions. Resident 57, with muscle weakness and mobility issues, used bilateral enabler bars for bed mobility, but this was not documented in the care plan. Additionally, Resident 64, diagnosed with atrial fibrillation and congestive heart failure, was observed to be edentulous, but the care plan did not address his dental status. These omissions indicate a failure to update and include essential care interventions in the residents' comprehensive care plans, as required by the facility's policy.
Failure to Provide Timely Meal Assistance to Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to perform activities of daily living received the necessary assistance during meal service. Observations in the dining room revealed that several residents, who required full assistance or supervision with their meals, were not promptly attended to by staff. For instance, Resident 3, who requires full assistance, was observed sitting with her meal untouched for several minutes before a registered nurse began to assist her. Similarly, Resident 11, who also requires full assistance, was served her meal while she was sleeping and did not receive help until much later. Other residents, such as Resident 27 and Resident 37, who require supervision and cueing, were not immediately assisted, leading to delays in their meal consumption. Resident 45, who requires full assistance, was observed asking for help after being served, indicating a lack of timely support. The Nursing Home Administrator acknowledged that residents should not be served until staff are ready to assist them, highlighting a gap in the facility's management and nursing services as per the cited regulations.
Failure to Implement Restorative ROM Program
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, as required to maintain or improve their condition. The resident, identified as having muscle weakness, abnormal gait, and mobility issues, was discharged from occupational therapy with specific recommendations for a Restorative Range of Motion Program. This program included active range of motion exercises for the bilateral upper extremities, specifically targeting the shoulders, elbows, wrists, and fingers. Despite these recommendations, a review of the resident's clinical record showed no documentation of the implementation of the restorative nursing program or the prescribed exercises. An interview with the Nursing Home Administrator confirmed that the program was not initiated following the resident's discharge from occupational therapy, resulting in a deficiency in the care provided to the resident.
Failure to Adhere to Food Storage and Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food storage and kitchen equipment utilization, as evidenced by multiple observations and policy reviews. The facility's policy on labeling and dating food products was not followed, with numerous items in the dry storage area, main kitchen, and refrigerators found unlabeled, undated, or past their use-by dates. Specific examples include undated dinner rolls, a sugar bin, and a can of pimentos, as well as moldy watermelon slices and thawed Readycare Frozen Shakes without thawed dates. Additionally, spices were labeled with incorrect use-by dates, and a test strip used for sanitizer water testing was expired. Interviews with facility staff, including the General Dietary Manager and the Nursing Home Administrator, confirmed that the facility's expectations were not met. The staff acknowledged that expired items should be discarded and that food items should be labeled and dated according to facility policy. The observations and interviews indicate a systemic failure to comply with food service safety standards, as outlined in the facility's policies and professional guidelines.
Inaccurate Dental Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the dental status of a resident, identified as Resident 64, during the admission process. Resident 64, who has diagnoses including atrial fibrillation and congestive heart failure, was observed to have no natural teeth during an interview. A physician assessment conducted earlier confirmed that the resident was edentulous. However, the Admission Minimum Data Set (MDS) for Resident 64, dated October 4, 2024, was incorrectly coded in section L - Oral/Dental Status, failing to indicate the resident's edentulous condition. This discrepancy was confirmed by the Nursing Home Administrator and Director of Nursing during a staff interview.
Failure to Update Care Plan for Resident with Parkinson's
Penalty
Summary
The facility failed to ensure the care plan for Resident 61 was reviewed and revised appropriately. Resident 61, who has Parkinson's disease and a lack of coordination, was using an electric recliner. The facility had removed the remote control for the recliner, preventing the resident from adjusting the chair independently. This action was taken because the resident had a fall after sliding out of the recliner due to an inability to operate the remote and adjust the footrest independently. The Director of Nursing indicated that due to the resident's cognitive level, the recliner could be considered a restraint, leading to the removal of the remote. The comprehensive care plan for Resident 61 included an intervention to recline the chair and place the remote in a pouch attached to the chair. However, the care plan was not updated to reflect the removal of the remote for safety reasons. An email from the Nursing Home Administrator acknowledged that the care plan should have been revised to include elevating the resident's legs as needed and removing the remote from the room. This oversight in updating the care plan contributed to the deficiency identified during the survey.
Failure to Provide Nutritional Supplements and Notify Physician of Weight Loss
Penalty
Summary
The facility failed to provide nutritional supplements as ordered by the physician for a resident diagnosed with dementia and type II diabetes. The physician had ordered a dietary supplement to be given three times a day between meals due to poor meal intake. However, during medication administration observations, an employee was seen substituting the prescribed nutritional shake with chocolate milk, which did not offer equivalent nutritional value. The Nursing Home Administrator confirmed that chocolate milk should not have been used as a substitute for the ordered supplement. Additionally, the facility did not notify the physician of a significant weight change for another resident diagnosed with dysphagia, muscle weakness, and Alzheimer's disease. The resident experienced a 5.7% weight loss over one month, and the clinical record indicated that the physician was to be notified. However, there was no documentation to confirm that the physician was informed of this weight loss, and the Nursing Home Administrator was unable to provide evidence of such notification.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident identified as a trauma survivor. The facility's policy on trauma-informed care, effective since November 1, 2019, requires initial screening on admission and during care plan reviews to identify any history of trauma. However, the care plan for a resident with diagnoses of major depressive disorder and anxiety disorder did not include any notification of a history of trauma, despite the resident becoming tearful when discussing childhood trauma during an interview. The facility's psychosocial assessment document, dated December 13, 2022, did not include questions about a history of trauma, and the resident's PsychoGeriatric Services notes from May and September 2024 also lacked any mention of trauma history. Interviews with the Nursing Home Administrator and Social Services Director revealed that they could not find documentation indicating the resident was assessed for trauma history. The facility has moved away from using the form mentioned in their trauma-informed care policy, opting instead for a different psychosocial assessment form, but no further information was provided.
Inadequate Use of PPE During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) during care for a resident on transmission-based precautions. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, during an observation of wound care and dressing change for a resident with Parkinson's disease and muscle weakness, two employees did not wear gowns as required by the facility's policy. The resident in question had physician orders for wound care and EBP, and signage in the room indicated the need for PPE, with a caddy containing gowns and gloves available. Despite these precautions, the employees failed to don gowns during the procedure. Interviews with the involved staff and facility leadership confirmed that the expectation was for employees to wear appropriate PPE, highlighting a lapse in adherence to infection control protocols.
Neglect During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. A nurse aide trainee, Employee 1, independently transferred a resident using a sit-to-stand lift, contrary to the facility's policy requiring two staff members for such transfers. This action led to the resident's arm being rubbed against a door frame, causing a 4.5 cm x 4 cm skin tear. The resident involved had a medical history that included hemiplegia and hemiparesis following a cerebral infarction, congestive heart failure, and Type 2 Diabetes Mellitus. The resident's care plan specified the need for a two-person assist during transfers using a sit-to-stand lift. Despite this, Employee 1 proceeded with the transfer alone after failing to find another staff member and feeling rushed by the resident. The incident was documented in the resident's nursing progress notes and a facility-reported incident. Interviews with the resident and Employee 1 confirmed that the resident questioned the need for assistance, but Employee 1 proceeded alone. The facility's investigation revealed that Employee 1 admitted to not following the care plan, leading to the resident's injury.
Inadequate Supervision During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance during resident transfers, resulting in actual harm to a resident. The incident involved a resident with a history of hemiplegia, hemiparesis, congestive heart failure, and Type 2 Diabetes Mellitus. The resident was being transferred using a sit-to-stand lift by a nurse aide trainee, who acted independently without the required assistance of a second staff member. This action was contrary to the facility's policy, which mandates a two-person assist for all mechanical lift transfers. During the transfer, the resident's arm was rubbed against a door frame, causing a 4.5 cm x 4 cm skin tear. The nurse aide trainee admitted to feeling rushed and decided to proceed with the transfer alone, despite the resident questioning the need for additional help. The facility's investigation confirmed that the nurse aide trainee did not attempt to find another staff member to assist, leading to the resident's injury.
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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