Spring Creek Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisburg, Pennsylvania.
- Location
- 1205 South 28th Street, Harrisburg, Pennsylvania 17111
- CMS Provider Number
- 395074
- Inspections on file
- 56
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Spring Creek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with an unstageable sacral pressure ulcer did not receive care consistent with professional standards when nursing staff continued to document administration of both a discontinued honey treatment and a newly ordered Santyl ointment. The treatment administration record did not accurately reflect the actual care provided, as staff signed off on both treatments during a period of transition, resulting in a deficiency related to wound care and documentation.
A resident with multiple neurological diagnoses was not adequately monitored or assessed for hyperthermia during a period of elevated indoor temperatures following an HVAC failure. Despite awareness of the heat risk, staff did not document timely vital signs or assessments, and late entries were made after the resident was hospitalized. The resident developed hyperthermia and acute respiratory failure, requiring emergency intervention and ICU admission.
Staff failed to follow infection control policies for several residents on transmission-based precautions, including improper signage for a resident with C. diff, staff entering a room of a resident with a Klebsiella infection without PPE, and unclear precaution signage for two roommates with different infection risks. Additionally, an LPN handled a medication tablet with bare hands after it fell on a non-sterile surface, contrary to policy.
Residents were unable to access grievance forms independently or anonymously, as forms were kept behind the nurses' station and not in accessible locations. Staff confirmed that forms were not available in the hallways near the grievance boxes, and some bins for forms had been removed due to resident behavior. The administrator acknowledged the issue, noting that forms were not within reach for residents, particularly those using wheelchairs.
The facility did not update care plans for two residents after significant changes in their diagnoses and medication orders. One resident's care plan lacked documentation for dementia care despite a longstanding diagnosis, while another resident's care plan failed to reflect the use of an antipsychotic medication and still included a discontinued antianxiety medication. The DON confirmed that care plans should have been revised to address these changes.
The facility did not provide scheduled activities for residents in four areas, as confirmed by resident reports, review of the activity calendar, and direct observation. Residents stated that activities often did not occur due to short staffing, and no activities were observed at the scheduled time. The NHA acknowledged that activities should have taken place but could not specify what was planned.
A resident with diabetes did not have insulin administration or blood glucose monitoring properly documented on the MAR for two days, despite physician orders requiring NovoLog administration based on sliding scale results. The DON confirmed that insulin was given when needed, but the required documentation was missing, resulting in a failure to provide care according to professional standards.
A resident with dementia, anxiety disorder, and glaucoma reported vision problems that interfered with activities. Although a physician ordered an optometry consult for cataract complaints, nursing staff did not arrange the appointment, and the resident experienced worsening vision, including acute vision loss, before being diagnosed with cataracts after an emergency room visit.
A resident with dementia, repeated falls, and a foley catheter was left unattended by staff despite a care plan requiring 1:1 supervision at all times. During the staff member's brief absence, the resident fell, was found undressed on the floor with a dislodged catheter, and required emergency care.
A resident with dementia, urinary retention, and a Foley catheter did not have the catheter removed as ordered by the physician. Nursing staff failed to follow the order, leading to a delay in the scheduled urology appointment and necessary care. The DON confirmed that staff should have followed the physician's instructions.
The facility did not ensure that pureed foods were served at appetizing temperatures, as confirmed by resident interviews and a test tray evaluation. While food portions and taste were adequate, the temperatures of certain pureed items were not palatable when served, with delays in tray delivery contributing to the issue.
A resident with multiple chronic conditions did not receive a prescribed medication, Creon, with breakfast due to insufficient nursing staff coverage. The LPN was delayed by behavioral issues with another resident and additional care duties, while nurse aides were busy with meal service. The RN Unit Manager was unavailable to assist, and no replacement was assigned for an absent manager, resulting in the resident's call light being unanswered for 24 minutes and medication being administered late on consecutive days.
Multiple grievances and direct observations revealed that meals, including chicken, rice, and breakfast items, were frequently served cold, under-seasoned, and unappetizing. A test tray confirmed that food temperatures were below appetizing levels, and residents reported that their meals lacked flavor and warmth. These issues were discussed with facility leadership, but no additional information was provided.
Surveyors found that food items in the main kitchen were not stored, labeled, or sealed according to professional standards or facility policy. Multiple items in the freezer, refrigerator, and dry storage were left open to air, not properly covered, or missing required labeling and dating. The Food Service Director and DON confirmed these practices did not meet facility expectations.
A resident with major depressive disorder and muscle weakness eloped from the facility after a receptionist mistakenly identified him as a visitor and allowed him to exit. The resident was found outside by a passerby, having sustained a fall and knee abrasion. The incident revealed a deficiency in supervision and adherence to protocols for resident safety and elopement prevention.
A facility failed to secure controlled medications, resulting in missing Ativan tablets. A resident with bipolar disorder, schizophrenia, and narcolepsy was found with Ativan pills in their room, despite denying taking them. The investigation revealed that the medication was misplaced when a nurse became distracted, and 11 pills remained unaccounted for.
A resident with dementia and severe cognitive impairment was financially exploited when a representative from a financial company obtained unauthorized consent to withdraw $12,000 from the resident's account. The financial POA was not informed of the transaction and only discovered it later. The Nursing Home Administrator confirmed the error, acknowledging that the POA should have provided consent due to the resident's incapacitation.
A resident with severe cognitive impairment was exploited when a financial company representative withdrew $12,000 from their account without notifying the financial POA. The facility failed to report or investigate the incident, contrary to its policy requiring immediate reporting to authorities.
The facility failed to notify the State Ombudsman of hospital transfers for four residents, who had conditions such as Parkinson's, emphysema, and chronic respiratory failure. The Nursing Home Administrator confirmed the oversight, citing staffing changes and email access issues as contributing factors.
The facility failed to develop comprehensive care plans for two residents, omitting critical medical information such as a pacemaker and anticoagulant use for one resident, and an IV catheter for another. These omissions were identified through clinical record reviews and staff interviews, highlighting a lapse in adherence to care planning policies.
The facility failed to adhere to professional standards for respiratory care by not properly storing respiratory equipment for four residents. Observations revealed that a nebulizer mask, CPAP mask, BiPAP mask, and oxygen mask were left uncovered or improperly stored, contrary to facility policies. The DON confirmed the masks should have been bagged when not in use.
A facility failed to discard expired medications and date opened medications on two medication carts. Observations revealed multiple medications without open dates and some with open dates past the recommended usage period. Staff interviews confirmed the facility's policy requires dating opened medications and removing expired ones, which was not followed.
A resident with chronic kidney disease and osteoarthritis was left exposed to the hallway during a bed bath, as staff left the door open while cleaning up spilled water. The resident was unaware of the exposure at the time but later expressed discomfort about the incident. The facility's administration acknowledged the expectation for staff to provide care without leaving residents exposed.
A resident with hypotension and schizophreniform disorder reported that the lock on her bedside stand drawer was non-functional, preventing her from securing personal items. Despite notifying the facility a month prior, the maintenance work order remained unassigned and open, leading to a deficiency in providing a safe environment.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their MDS documentation. A resident with sleep apnea and heel damage was not documented for CPAP use or pressure area presence. Another resident with sleep apnea and COPD was not recorded for non-invasive ventilation use. A third resident with end-stage renal disease was incorrectly marked as not receiving dialysis. These inaccuracies were confirmed by the DON.
The facility failed to follow the menu and provide appropriate dessert substitutions during a meal service. A resident reported not receiving the listed menu items, and observations confirmed that desserts were not served. The Certified Dietary Manager did not inform the dietitian of a necessary substitution until most meal carts were delivered. Multiple residents did not receive desserts, as confirmed by tray tickets and resident interviews.
The facility failed to store food and utilize equipment according to professional standards, with multiple instances of improper food storage and incomplete temperature logs in the main kitchen and nursing unit pantries. Observations revealed unlabeled and expired food items, and interviews confirmed the facility's expectations were not met.
The facility failed to provide adequate staffing, resulting in delayed responses to call bell requests across six units. Residents reported waiting between 45 minutes to over an hour for assistance, with one resident waiting two hours for a shower. The Director of Nursing acknowledged these delays were not timely, and Resident Council meetings highlighted ongoing staffing concerns.
A facility failed to refund $6,210 to a resident's family within thirty days of the resident's discharge. The resident was admitted in August and passed away in October. Despite a refund request being submitted in March, the Business Office Manager did not follow up, causing a delay. The Nursing Home Administrator acknowledged the failure and issued a check in April.
A resident with Diabetes Mellitus Type II and a pressure ulcer did not receive Hibiclens, an antiseptic skin cleanser, as ordered before a scheduled surgery due to its unavailability. Additionally, there was a delay in administering recommended dietary supplements for wound healing, as the attending physician did not address the initial recommendation, causing a delay in the administration of Vitamin C and Zinc Sulfate.
A resident with Alzheimer's and chronic kidney disease suffered a fall and was transferred to the hospital for a suspected fracture. The facility failed to notify the resident's representative until approximately eight hours later, contrary to their policy requiring prompt notification.
Failure to Ensure Accurate Pressure Ulcer Treatment and Documentation
Penalty
Summary
The facility failed to ensure that a resident with an unstageable sacral pressure ulcer received care consistent with professional standards of practice. The resident's clinical record showed changing wound care recommendations over several weeks, including the use of medical grade honey, Santyl ointment, and Dakins-moistened gauze. Despite updated wound care orders, the treatment administration record (TAR) indicated that nursing staff continued to sign off on both the discontinued honey treatment and the newly ordered Santyl treatment for several days. This overlap occurred because the honey order was not immediately removed from the system while the facility awaited the arrival of Santyl from the pharmacy. Nursing staff reported using honey until Santyl became available, then switched to Santyl as per the updated order. However, documentation on the TAR did not accurately reflect the treatments administered, as staff continued to sign off on both treatments even after the order had changed. The DON acknowledged that this was an oversight and that staff should have clarified the treatment order and accurately documented the care provided. This failure to ensure accurate and consistent wound care documentation and administration led to the deficiency.
Failure to Monitor and Provide Care During Elevated Temperatures Resulting in Resident Harm
Penalty
Summary
The facility failed to monitor and provide appropriate care and services to residents during a period of elevated temperatures in resident care areas, resulting in actual harm to a resident. When the rooftop HVAC system malfunctioned, the facility experienced high temperatures, particularly in certain units where temperatures reached up to 90°F in common areas and 87°F in resident rooms. Although portable air conditioning units were rented and some residents were moved or offered extra fluids, documentation shows that not all residents were adequately monitored for symptoms of heat-related illness. A resident with a history of Alzheimer's disease, traumatic brain injury, vascular dementia with behaviors, and epilepsy was affected during this period. Despite the facility's awareness of the elevated temperatures, there was no evidence of timely or thorough assessment for hyperthermia or documentation of vital signs, including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation for this resident. Progress notes documenting the resident's status prior to the change in condition were entered as late entries after the resident had already been sent to the hospital, and did not reflect real-time monitoring or assessment during the period of risk. The resident was eventually found to be lethargic, with shortness of breath, a high temperature (103.3°F to 103.4°F), and altered mental status, leading to emergency transfer to the hospital. Upon arrival at the emergency department, the resident was critically ill, with a temperature of 107.1°F and acute respiratory distress, requiring intubation and ICU admission. The facility was unable to provide documentation of appropriate monitoring or interventions for hyperthermia prior to the resident's decline, resulting in significant harm as evidenced by hyperthermia and acute respiratory failure.
Failure to Implement Infection Control Policies and Proper PPE Use
Penalty
Summary
The facility failed to implement and enforce infection prevention and control policies for residents on transmission-based precautions and during medication administration. For a resident with a confirmed Clostridium difficile (C. diff) infection and ongoing diarrhea, the facility posted Enhanced Barrier Precautions (EBP) signage instead of the required contact precautions. The resident's care plan did not include the use of a gown during care or when touching surfaces, and the EBP signage limited gown use, contrary to facility policy and CDC guidelines. Both the Infection Control Preventionist and the Director of Nursing confirmed that the correct signage should have indicated contact precautions. Multiple staff members were observed entering the room of a resident on contact precautions for a Klebsiella urinary infection without donning any personal protective equipment (PPE), such as gloves or gowns, as required by facility policy. The resident's care plan and physician orders specified contact precautions, but staff failed to comply during several observed interactions. The Director of Nursing acknowledged that staff were expected to use appropriate PPE in these situations. Signage outside a shared room for two residents—one with C. diff and one with a wound—was unclear, failing to specify which infection control practice (EBP or transmission-based precautions) applied to each resident. This lack of clarity was confirmed by staff interviews and review of care plans. Additionally, during medication administration, an LPN was observed picking up a dropped medication tablet with bare hands and placing it in a medication cup, contrary to facility policy, which requires staff to avoid direct hand contact with medications and to discard any contaminated tablets. The Director of Nursing confirmed this was not in accordance with policy.
Failure to Provide Accessible Grievance Forms to Residents
Penalty
Summary
The facility failed to provide residents with accessible grievance forms in three of eight identified areas, as required by their own grievance policy. According to the policy, concern forms and boxes should be available in designated locations throughout the facility. However, during a resident group meeting, multiple residents reported that they could not file grievances anonymously because they had to request blank forms from staff, which were kept behind the nurse's station and out of reach, especially for those who use wheelchairs. Observations confirmed that on three units, locked grievance boxes were present in hallways, but no blank grievance forms were available nearby or in prominent, accessible locations. Staff interviews corroborated that blank grievance forms were stored behind the nurses' station or in locations inaccessible to residents, with one staff member noting that a bin for forms had been removed due to resident behavior and had not been replaced. The Nursing Home Administrator acknowledged that while bins were intended to be accessible, issues with resident behavior had led to their removal, and forms remained out of reach for residents. These findings demonstrate that the facility did not ensure residents' access to grievance forms as required by policy and regulation.
Failure to Revise Care Plans Following Changes in Resident Status and Medication Orders
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to reflect changes in residents' status and care needs for two residents. For one resident with diagnoses including dementia and type 2 diabetes mellitus, the care plan was not updated to include a dementia care plan, despite the diagnosis being present since admission. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to address the resident's dementia. For another resident with diagnoses of dementia, anxiety disorder, and depression, the care plan did not document the use of an antipsychotic medication, even though there was a current physician order for olanzapine. Additionally, the care plan still included an antianxiety medication that had been discontinued, and did not reflect the change in medication orders. The Director of Nursing confirmed that the care plan should have been updated when the medication orders changed. These findings were based on facility policy review, clinical record review, and staff interviews.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of residents in four of eight resident areas. During a resident group meeting, multiple residents reported that activities did not always occur as scheduled, citing short staffing as a contributing factor. Review of the facility's activity calendar showed a scheduled activity for the afternoon, but direct observations on the specified date and time revealed that no activities were occurring on South 2, South 3, South 4, or [NAME] 4 units. The Nursing Home Administrator confirmed that scheduled activities are expected to occur but was unable to describe what the scheduled 'activity on unit' entailed for those resident areas.
Failure to Document and Administer Insulin per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with diabetes mellitus did not receive care and services in accordance with physician orders and professional standards. The resident was prescribed NovoLog insulin to be administered via a sliding scale based on blood glucose readings, with specific instructions for administration and documentation. On two consecutive days, the Medication Administration Record (MAR) did not document the administration of NovoLog or the monitoring of blood sugar, despite blood glucose readings being recorded elsewhere in the clinical record. On one of those days, the resident's blood sugar was elevated to a level that required insulin administration per the sliding scale order. Interviews revealed that the expectation was for all medication administration and monitoring to be documented on the MAR. The Director of Nursing confirmed that, according to a conversation with the nurse on duty, the insulin was administered on the day required, but this was not documented as required. The lack of documentation and failure to follow established protocols resulted in the facility not providing care and services in accordance with professional standards for the resident's physical, mental, and psychosocial needs.
Failure to Arrange Timely Vision Services for Resident with Cataract Complaint
Penalty
Summary
A resident with a history of dementia, anxiety disorder, and glaucoma reported vision problems that affected his ability to participate in recreational activities. The clinical record shows that a physician ordered an optometry consult for the resident's bilateral cataract complaint, but there is no evidence that an optometry appointment was scheduled or completed between the time the order was given and the resident's emergency room visit several months later. During this period, the resident continued to experience vision issues, including an episode of acute vision loss, which ultimately led to an emergency room evaluation and a diagnosis of cataracts in both eyes. Staff documentation and communication indicate that the nursing staff did not arrange the required optometry consult as ordered by the physician. The DON confirmed that she had no additional information regarding the resident's vision concerns and stated that she would have expected nursing staff to set up the appointment when the consult order was issued. The failure to ensure timely access to vision services resulted in a lack of proper treatment to maintain the resident's vision abilities.
Failure to Provide Required 1:1 Supervision Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, dementia, adjustment disorder with anxiety, and urinary retention requiring an indwelling foley catheter was not provided with adequate supervision as required by their care plan. The care plan specified 1:1 observation at all times due to the resident's fall risk. Despite this, a staff member left the resident unattended in the room after providing care, believing the resident was asleep and would not be at risk during her brief absence. During the staff member's absence, the resident fell and was found on the floor undressed, without anti-skid socks, and with a dislodged foley catheter. The incident resulted in the resident being sent to the emergency room for catheter reinsertion. Staff interviews confirmed that the resident was supposed to be under continuous 1:1 supervision for safety, regardless of whether the resident was awake or asleep, but this protocol was not followed at the time of the incident.
Failure to Follow Physician Order for Foley Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with diagnoses including repeated falls, dementia, benign prostatic hyperplasia, and urinary retention with an indwelling Foley catheter did not receive care in accordance with physician orders. The resident had an order for the removal of the Foley catheter on a specified date, with instructions for nursing staff to perform intermittent bladder scans and to consult urology or send the resident to the emergency room if urinary retention was extreme. However, the night shift nurse did not remove the catheter as ordered, expressing concern about the resident being without a catheter for an extended period. As a result of the nurse's failure to follow the physician's order, the scheduled urology appointment for catheter removal and evaluation had to be rescheduled. Both the Registered Nurse and the Director of Nursing confirmed that the nurse should have adhered to the physician's instructions regarding catheter removal. This lapse resulted in the resident not receiving timely and appropriate treatment and services as required.
Failure to Serve Palatable and Properly Heated Pureed Foods
Penalty
Summary
The facility failed to provide foods that were palatable, attractive, and at appetizing temperatures during one observed meal service. Resident interviews revealed concerns regarding the temperature of hot food. A test tray evaluation on the South 3rd floor showed that, while portion sizes and taste were adequate for a puree diet, the temperatures of the puree barbecue chicken and puree lima beans were not palatable. The test tray was delivered 18 minutes after preparation, and food temperatures were recorded as 129.9°F for the puree barbecue chicken and 120°F for the puree lima beans. These findings were confirmed by the Food Service Manager at the time of service. The deficiency was identified through review of food service committee meeting minutes, direct observation, a test tray, and resident and staff interviews.
Failure to Provide Sufficient Nursing Staff Results in Delayed Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in a resident not receiving a prescribed medication, Creon, with his breakfast meal as ordered by his physician. The resident, who had diagnoses including pancreatitis, heart failure, and hypertension, had a care plan indicating a risk for malnutrition and required Creon to be administered with meals. On the day of the incident, the resident's call light was on for 24 minutes as he waited for his medication and lactose-free milk to take with his cereal. The medication was not administered until after breakfast, and the resident reported the delay to staff. The LPN responsible for medication administration was delayed due to managing a resident with behavioral issues and assisting another resident with dressing, while nurse aides were occupied with meal trays and rounds. The RN Unit Manager was unable to assist due to being on a lengthy phone call, and there was no replacement for another RN Unit Manager who was on vacation. Review of records showed a similar delay in medication administration the previous day. The DON confirmed that medications and call bells should be addressed timely and acknowledged that the lack of adequate staffing contributed to the delay.
Failure to Serve Palatable and Appetizing Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at appetizing temperatures, as evidenced by multiple grievances and direct observations. Two grievances filed on the same day reported that meals, including chicken noodle soup, tomato soup, French toast, and bacon, were served cold and, in one instance, the soup was watery and the portion was insufficient. A resident also stated that food is frequently cold. Review of the facility menu and recipes indicated that the preparation methods should have resulted in properly cooked and seasoned food, but this was not achieved in practice. A test tray evaluation conducted with the Food Service Director revealed that the chicken and rice served for lunch were below appetizing temperatures, with the chicken at 121.4°F and the rice at 114.7°F. The chicken was also described as under-seasoned, under-browned, and the rice as undercooked and lacking flavor. Resident interviews confirmed that meals lacked flavor and were not warm enough. These findings were discussed with the Nursing Home Administrator and the DON, but no further information was provided.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the main kitchen. Observations in the walk-in freezer revealed multiple food items, including a box of mixed vegetables, a bag of fish patties, pans of biscuits and lasagna, a tub of rigatoni pasta, a pan of french fries, bags of hash brown potatoes, and a pan of garlic bread, that were either left open to air, not properly sealed, or not labeled and dated as required by facility policy. The rigatoni pasta appeared freezer burned, and several items had ripped coverings, exposing the food to air. In the dry storage area, a bin of breadcrumbs was not labeled or dated, a bin of white rice had a scoop stored inside, and a box of hashbrown potatoes was left open to air. In the walk-in refrigerator, an open bag of parmesan cheese was found without an open date or use by date. Interviews with the Food Service Director confirmed that these storage practices did not meet facility policy, which requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, and dry foods in bins to be labeled and dated. The Director of Nursing also stated that her expectation is for food items to be labeled and dated per facility policy and stored in accordance with professional standards.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, which resulted in harm. The incident involved a resident with diagnoses including major depressive disorder and generalized muscle weakness. The resident was able to leave the facility after a receptionist mistakenly identified him as a visitor and allowed him to exit through the front door. This occurred at 3:45 AM, and the resident was found outside by a passerby at 4:38 AM, who assisted him back into the facility. The resident sustained a fall and an abrasion to the left knee during the elopement. The receptionist, who was responsible for monitoring the front door, did not recognize the resident and allowed him to leave without verifying his status. This lapse in supervision and failure to adhere to the facility's procedures for resident access and egress contributed to the resident's elopement. The receptionist was startled by the resident's request to be let out and did not follow the protocol of confirming the resident's identity or checking for any leave of absence (LOA) documentation. The incident highlighted a deficiency in the facility's supervision and monitoring processes, particularly during the early morning hours. The resident's confusion and subsequent fall outside the facility underscored the need for vigilant supervision and adherence to established protocols to prevent such occurrences. The facility's failure to ensure that staff were adequately trained and aware of procedures for resident safety and elopement prevention was a significant factor in this incident.
Removal Plan
- Investigation initiated and interviews conducted with staff on the unit and the receptionist.
- Receptionist re-educated and disciplinary action taken.
- Resident 1 moved to the building where a monitor was in place to prevent elopements.
- Resident's POA and physician notified, and new orders received.
- Physician review conducted for recent medication changes.
- Resident's care plan updated for elopement risk, and information added to the risk of elopement book.
- Audit conducted to determine like residents with elopement risk.
- Residents with exit seeking behaviors reviewed to confirm that facility procedures are followed.
- Education detailing the process of LOAs including the form that should be used provided and signed by all nursing staff members.
- Email sent from the Assistant Director of Nursing to Unit Managers to review all residents for change in condition and possible elopement risks.
- Risk forms completed for all units.
Failure to Secure Controlled Medications Leads to Missing Ativan
Penalty
Summary
The facility failed to properly secure controlled medications, resulting in missing Ativan tablets prescribed to a resident. The facility's policy on controlled substances, revised in September 2022, mandates that only authorized licensed nursing and pharmacy personnel have access to controlled substances, which must be separately locked in permanently affixed compartments. However, this policy was not adhered to, leading to the incident involving the missing medication. A resident with a history of bipolar disorder, schizophrenia, and narcolepsy was found with Ativan pills in their room, despite denying taking them. The resident was alert and oriented, with no acute distress, but was noted to be drowsy, which could be attributed to their narcolepsy diagnosis. A search of the resident's room revealed 19 Ativan pills, an empty pill pack in the bathroom garbage, and another pill in a glove box on the bedside table. The resident's progress notes indicated that they refused to go to the hospital and continued to deny taking the medication. The investigation revealed that a pharmacy driver delivered the Ativan tablets for another resident, which were initially signed for by a nurse. The medication was supposed to be transferred to another unit but was misplaced when a nurse became distracted. The medication card was later found in the resident's room, but 11 pills remained unaccounted for. Despite thorough searches and monitoring, the facility could not prove that the resident had stolen or ingested the missing tablets.
Failure to Protect Resident from Financial Exploitation
Penalty
Summary
The facility failed to protect a resident from financial exploitation, as evidenced by an incident involving a representative from a contracted financial company. This representative entered the resident's room and obtained a signature on an authorization form to withdraw money from the resident's bank account. The resident, who had a clinical diagnosis of dementia and age-related cognitive decline, had a BIMS score indicating severely impaired cognitive status. The financial power of attorney (POA) for the resident was not notified about the authorization form or the withdrawal of $12,000 from the resident's account. The POA only became aware of the transaction when attempting to make a withdrawal for payment to the facility. During an interview, the Nursing Home Administrator confirmed that the consent for the withdrawal was obtained in error, acknowledging that due to the resident's incapacitation, the financial POA should have provided the consent. The facility's policy on abuse, neglect, exploitation, or misappropriation requires immediate reporting of such suspicions to the administrator and other officials according to state law. This incident highlights a failure to adhere to the policy, resulting in financial exploitation of the resident.
Failure to Report and Investigate Resident Exploitation
Penalty
Summary
The facility failed to adhere to its policy for reporting and investigating suspected resident exploitation, as evidenced by the case involving a resident with severe cognitive impairment. The resident, diagnosed with dementia and age-related cognitive decline, had a BIMS score indicating severe cognitive impairment. A representative from a contracted financial company entered the resident's room and obtained a signature on an authorization form to withdraw $12,000 from the resident's bank account. This transaction occurred without notifying the resident's financial power of attorney (POA), as required. The facility was informed by the resident's family about the existence of a financial POA who should have been contacted for consent. Despite being informed of the unauthorized withdrawal, the facility did not report the incident to the appropriate authorities, including the Pennsylvania Department of Health, nor did it conduct an investigation. Interviews with the Business Office Manager and the Nursing Home Administrator confirmed the lack of reporting and investigation. The facility's policy, last revised in September 2022, mandates immediate reporting of such suspicions to various officials and agencies, but this protocol was not followed in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers in writing, including the reason for the transfer or discharge, date of transfer, and location of transfer, for four residents. These residents were transferred to the hospital and returned to the facility without the required notification being sent to the Ombudsman. The residents involved had various medical conditions, including Parkinson's disease, emphysema, hydronephrosis, atrial fibrillation, hypertension, chronic respiratory failure, throat cancer, and aphasia. The Nursing Home Administrator confirmed during interviews that the facility did not send the required notices for the transfers of these residents. The failure to notify was attributed to staffing changes and issues accessing a particular staff member's electronic mail. The Pennsylvania State Ombudsman confirmed that the facility had not provided notice of transfers for March 2024 until May 21, 2024. The NHA acknowledged the deficiency and had no additional information to offer.
Deficiency in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, addressing their medical, physical, mental, and psychosocial needs. For Resident 57, the care plan did not include the presence of a pacemaker or the use of anticoagulant medication, nor did it outline the necessary safety precautions associated with these conditions. This oversight persisted since the resident's original admission and subsequent readmissions following hospital stays. The deficiency was identified during a review of the resident's clinical records and confirmed through interviews with facility staff, including the Director of Nursing, who acknowledged that such information should have been included in the care plan. Similarly, Resident 185's care plan lacked a focus area addressing the presence of an intravenous (IV) catheter, which was being used for administering antibiotics to treat bacteremia and sepsis. The absence of this critical information in the care plan was discovered during an observation and review of the resident's clinical records. The Director of Nursing confirmed that the facility's expectation was for care plans to be completed accurately, indicating a lapse in adherence to the facility's policy for comprehensive person-centered care planning.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for four residents. Resident 13, diagnosed with congestive heart failure, had a physician's order for Ipratropium-Albuterol inhalation solution to be administered twice daily. However, observations revealed that the nebulizer mask was left uncovered on the nightstand, contrary to the facility's policy requiring it to be stored in a plastic bag. Similarly, Resident 57, with obstructive sleep apnea and cerebral infarction, had a CPAP mask that was observed hanging off the nightstand and not bagged, despite the facility's policy. Resident 139, diagnosed with sleep apnea and chronic obstructive pulmonary disease, had a BiPAP mask that was left on top of a plastic bag on the nightstand, rather than being stored inside the bag as required. Resident 605, with acute respiratory failure and muscle weakness, had an oxygen mask that was observed lying on the bed and later on the floor, instead of being cleaned and bagged when not in use. These observations were confirmed by the Director of Nursing, who acknowledged that the masks should have been properly stored according to the facility's policies.
Failure to Discard Expired Medications and Date Opened Medications
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in expired medications not being discarded and opened medications not being dated. During a survey, it was observed that one of the eight medication carts contained expired medications, and two of the eight medication carts had medications without open dates. Specifically, the M3 medication cart had an open Humalog Kwik pen with no open date, while the S2 medication cart had multiple medications, including Humalog Kwik pen, Lantus Solostar pen, Levemir multidose vial, Lantus multidose vial, Bupivacain 25% multidose vial, and Humalog multidose vial, all without open dates. Further observations of the S2 medication cart revealed medications with open dates that were past the recommended usage period, including a Lantus Solostar pen, Insulin Glargine -yfgn multidose vial, and Fiasp multidose vial. Interviews with staff, including Employee 6, the Nursing Home Administrator, and the Director of Nursing, confirmed that the facility's policy requires multidose vials and pens to be dated when opened and expired medications to be removed and disposed of. The failure to comply with these procedures was acknowledged by the Director of Nursing.
Resident Dignity Compromised During Care
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of the residents observed. Specifically, Resident 76, who has chronic kidney disease stage 3 and osteoarthritis, was left exposed to the hallway while receiving a bed bath. During the observation, the resident's door was open, and the resident was unclothed with the backside of her body visible from the hallway. Resident 76 reported during an interview that she was unaware her door was left open while she was unclothed and rolled to her left side. The incident occurred after staff spilled water on the floor during the bed bath, necessitating cleanup. The resident expressed that it bothered her to be exposed to the hallway, although she did not realize it at the time due to not facing the doorway. The Nursing Home Administrator and Director of Nursing acknowledged that they would expect staff to provide care that did not leave the resident exposed.
Failure to Provide Secured Lock Drawer for Resident
Penalty
Summary
The facility failed to provide a homelike environment for Resident 88 by not ensuring the functionality of a secured lock drawer for personal items. Resident 88, who has diagnoses including hypotension and schizophreniform disorder, reported during an interview that the lock on her bedside stand drawer was non-functional, preventing her from securing personal possessions such as her wallet and credit card. The resident had notified the facility about the issue approximately one month prior to the interview. A review of the facility's maintenance work order revealed that a request was submitted on April 29, 2024, to address the non-functional lock on Resident 88's bedside stand. However, the work order was not assigned to anyone, and at the time of review, it remained open, indicating that the issue had not been resolved. This lack of action led to the deficiency in providing a safe and secure environment for Resident 88.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to discrepancies in their medical records. Resident 57, who was diagnosed with obstructive sleep apnea and pressure-induced deep tissue damage to the right heel, was not accurately assessed in their Minimum Data Set (MDS). The MDS did not reflect the presence of the pressure area upon admission and failed to document the use of CPAP therapy, despite physician orders and medication administration records indicating its use. The Director of Nursing confirmed these inaccuracies during an interview. Similarly, Resident 139, with diagnoses of sleep apnea and chronic obstructive pulmonary disease, was not accurately documented in their MDS regarding the use of non-invasive mechanical ventilation, such as CPAP/BiPAP, despite physician orders and medication records confirming its use. Modifications to the MDS were made after the surveyor's review. Additionally, Resident 168, who has end-stage renal disease and has been on dialysis for three years, was incorrectly marked as not receiving dialysis services in their MDS, contrary to physician orders. The Director of Nursing acknowledged this error during an interview.
Failure to Provide Desserts as per Menu
Penalty
Summary
The facility failed to ensure that the menus were followed and appropriate substitutions were provided for desserts not available during a meal service. During an interview with a resident, it was revealed that the resident did not always receive what was on the menu or listed on their meal tickets. Observations during a tray line meal service showed that desserts were not being served on trays. The Certified Dietary Manager admitted that vanilla wafers, which were supposed to be served as a dessert for the consistent carbohydrate restricted diet, were not available, and a cookie was to be substituted instead. However, the dietitian was not informed of this substitution until it was too late, with only three delivery carts left to be delivered. Multiple residents on the 2nd floor reported not receiving desserts with their lunch, which was confirmed by reviewing their tray tickets. The Nursing Home Administrator was informed of the issue, and it was noted that the dietitian signed off on the substitution after most of the meal carts had already been delivered. The report highlights a failure in communication and execution of dietary plans, resulting in residents not receiving the desserts they were supposed to have with their meals.
Deficiencies in Food Storage and Equipment Utilization
Penalty
Summary
The facility was found to have failed in storing food and utilizing equipment according to professional standards for food service safety in both the main kitchen and eight nursing unit pantry areas. Observations revealed multiple instances of improper food storage, including bins of rice and flour with scoops left inside, and various food items in the walk-in refrigerator and freezer that were either not labeled or dated, or had expired use-by dates. Additionally, temperature logs for the walk-in refrigerator and freezer were incomplete, missing recorded temperatures for several shifts. Further observations in the pantry areas across different floors showed numerous food items, such as puddings, sherbet cups, and thickened juices, that were not labeled with use-by dates. Some frozen dinners were found to be expired, and there were instances of heavily freezer-burned ice cream. The facility's policy required that all food items be labeled and dated, and that perishable foods brought by family or visitors be stored in resealable containers with tight-fitting lids, labeled with the resident's name and use-by date. Interviews with the Certified Dietary Manager and the Nursing Home Administrator confirmed that the facility's expectation was for food and beverages to be labeled and dated per policy, and for food items and kitchen equipment to be stored and utilized in accordance with professional standards. However, the observations during the survey indicated a failure to adhere to these standards, resulting in the identified deficiencies.
Inadequate Staffing Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide adequate staffing levels to ensure timely responses to call bell requests across six of its eight units. The facility's policy, last revised in September 2022, mandates immediate responses to resident call systems. However, multiple resident interviews revealed significant delays in call bell responses, with wait times ranging from 45 minutes to over an hour. Specific instances included a resident waiting 40 minutes for assistance, and another reporting a two-hour wait for a shower. These delays were corroborated by observations and interviews with residents and staff. The Director of Nursing acknowledged that a 40-minute wait was not considered timely. Resident Council meeting minutes from February to April 2024 consistently highlighted residents' concerns about insufficient staffing and staff being reassigned from one unit to another, exacerbating the issue. The facility's failure to maintain adequate staffing levels and respond promptly to call bell requests constitutes a deficiency under 28 Pa code 211.12(d)(1)(5) Nursing services.
Failure to Timely Refund Overpayment to Resident's Family
Penalty
Summary
The facility failed to refund all monies owed to a resident's family within thirty days of the resident's discharge, as required. Resident 3 was admitted to the facility on August 11, 2023, and passed away on October 14, 2023. A review of the facility's records showed that a refund request form was submitted on March 19, 2024, to the facility's Corporate Office, requesting a refund of $6,210 to Resident 3's spouse due to an overpayment. The Business Office Manager confirmed that the facility bills one month in advance and that Resident 3's family had paid the bill timely. However, the Business Office Manager admitted to not following up on the refund request, resulting in a delay. The Nursing Home Administrator acknowledged the facility's failure to refund the monies owed to Resident 3's family and provided a copy of a check dated April 16, 2024, for the amount owed.
Failure to Administer Pre-Surgical Antiseptic and Timely Dietary Supplements
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered plan of care. The resident, who had diagnoses including Diabetes Mellitus Type II and a pressure ulcer, was scheduled for an outpatient surgical procedure. A physician's order required the application of Hibiclens, an antiseptic skin cleanser, to the resident's entire body prior to the surgery. However, the Medication Administration Record showed no documentation of the Hibiclens application before the procedure. The Director of Nursing confirmed that the Hibiclens was not applied because it was not available for staff to use. Additionally, the facility did not promptly administer dietary supplements recommended to aid in wound healing. A dietary recommendation was made to the attending physician to add Vitamin C and Zinc Sulfate to the resident's regimen. However, these supplements were not administered until after a second request was made, resulting in a delay from the initial recommendation. The Director of Nursing confirmed that the attending physician had not addressed the recommendations initially, leading to the delay in administering the supplements.
Failure to Notify Resident's Representative of Emergency Transfer
Penalty
Summary
The facility failed to notify a resident's representative of an accident that resulted in an emergency transfer immediately. Resident 3, who has Alzheimer's dementia and chronic kidney disease stage 3, suffered an unwitnessed fall at approximately 11:00 PM. The resident was found on the floor in front of the bed, experiencing severe pain and unable to bear weight on her right leg. The physician was notified at 11:15 PM and ordered an emergency transfer to the hospital. However, the resident's responsible party was not notified until the following morning at 7:31 AM, approximately eight hours after the incident. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their attending physician, and their representative. Despite this policy, there was a significant delay in notifying Resident 3's family. The Director of Nursing confirmed that the delay was not considered timely and did not meet the facility's expectations. The incident report and progress notes corroborate the timeline of events and the delay in communication.
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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