Stonebridge Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Duncannon, Pennsylvania.
- Location
- 102 Chandra Drive, Duncannon, Pennsylvania 17020
- CMS Provider Number
- 395785
- Inspections on file
- 19
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Stonebridge Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control policies during medication administration by handling medications with bare hands, did not implement Enhanced Barrier Precautions for a resident with a pressure ulcer during wound care, and did not maintain required infection surveillance records for several months. These actions were confirmed by facility leadership and were in direct violation of established facility policies.
A resident with a history of a stage 3 heel pressure ulcer was observed multiple times not wearing physician-ordered prevalon boots, instead wearing sneakers provided by family. Staff continued to document in the MAR that the boots were in use, and the care plan and physician's order were not updated to reflect the family's request for the resident to wear shoes. The deficiency was identified through observations, record review, and staff interview, revealing a failure to provide care consistent with professional standards for pressure ulcer prevention.
A resident with a history of stroke and limited mobility did not have a physician-ordered hand splint applied as required, despite documentation indicating it was in place. Observations and interviews revealed the splint was not used as ordered, and there was confusion among staff regarding the status of the order, with no evidence of proper discontinuation prior to therapy ending.
Three residents did not receive scheduled medications, including IV antibiotics, pain medications, anti-androgen therapy, and anti-seizure drugs, due to unavailability and delays in pharmacy delivery. Staff did not promptly notify providers or utilize available alternative doses, and documentation of delivery discrepancies was lacking. Interviews confirmed ongoing issues with medication delivery and order discrepancies.
A resident with a right heel pressure ulcer did not receive prescribed wound care treatments on multiple occasions because an LPN withheld care pending order clarification, which was not pursued for several days. The DON confirmed that treatments should have been provided as ordered and clarified promptly if needed.
Two residents with severe cognitive impairment and dependence on staff for ADLs consistently received bed baths instead of scheduled showers, with no documentation of refusals or bathing preferences, contrary to facility policy and expectations communicated by nursing leadership.
A facility failed to reconcile pre-discharge medications with post-discharge medications in a resident's discharge summary, as required by their Discharge Planning Policy. The resident, who had diagnoses of cerebral infarction and anxiety, was discharged without this reconciliation documented. This deficiency was confirmed by the DON.
A resident with limited mobility, diagnosed with hypertension, CHF, and depression, was not consistently assisted with her daily walking program as per her care plan. Despite her requests and documented goals to walk 50 feet daily with assistance, facility records showed multiple instances of non-performance or missing documentation. The DON attributed this to a recent change in electronic medical records, but no further information was provided to resolve the issue.
A resident on contact precautions for MRSA and proteus mirabilis was not properly managed by staff, who failed to use PPE and perform hand hygiene as required. Observations showed that Nursing Assistants entered the resident's room without gloves or gowns and did not sanitize hands after assisting with meals, contrary to facility policy.
Deficiencies in Infection Control Practices and Surveillance
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During medication administration, an LPN was observed preparing and administering medications to two residents by dispensing tablets directly into their bare hands before placing them into medication cups. This practice was in direct violation of the facility's policy, which states that medications should not come into contact with any surface except the medication cup and that staff should avoid touching medications with bare hands. The Nursing Home Administrator confirmed that staff are required to follow this policy. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an unstageable pressure ulcer. Observations revealed that there was no signage on the resident's door indicating EBP, and during wound care, staff wore gloves but did not don a gown as required by the facility's EBP policy. The staff member performing wound care acknowledged uncertainty about the need for a gown due to the absence of signage, and the DON later confirmed that EBP should have been in place for this resident and that a gown should have been worn during wound care. The facility also failed to maintain an accurate infection surveillance data collection system. Review of the Antibiotic Use Tracking Log showed that no tracking was completed for a six-month period, from October 2024 through March 2025, despite the facility's policy requiring monthly documentation of antibiotic use and related infection data. The DON confirmed that the tracking log was not completed for those months.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Residents 18 and 38 had an assessment completed, no ill effects were identified from the cited past deficient medication administration practice. Resident 44 had an assessment completed, no ill effects were identified from the cited past deficient practice regarding failure to follow enhanced barrier precautions. There were no residents affected by the cited past deficient practice related to incomplete Antibiotic Use Tracking Logs. 2. All residents have the potential to be affected by the cited past deficient medication administration practice. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to ensure all residents that require enhanced barrier precautions have an order, signage, and an isolation caddy containing necessary PPE. Any missing necessary items will be immediately corrected. To identify others with the likelihood to be affected, the DON/designee completed an antibiotic order audit from the date of exit to present, ensuring that all new antibiotic orders are captured on the Antibiotic Use Tracking Log. The log will be updated with any orders that were inadvertently missed. 3. To prevent a future reoccurrence, the DON/designee will educate all licensed staff on the proper pouring of medications during med pass, ensuring medications do not come in contact with any other surface except the inside of the medication cup. To prevent a future reoccurrence, the DON/designee will educate all licensed nursing staff on the conditions that require enhanced barrier precautions, to ensure an order, signage, and an isolation caddy are present reflecting same. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. 4. To monitor and maintain ongoing compliance, the DON/designee will observe 3 random licensed nurses administering medications to one resident, ensuring medications poured during med pass do not come in contact with any other surface except the inside of the medication cup. Any deficient practice identified will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents requiring enhanced barrier precautions, ensuring an order, signage, and isolation caddy are present. Any missing items will be immediately corrected. This will occur weekly for 4 weeks and then monthly for 2 months. To prevent a future reoccurrence, the DON/designee will educate the Infection Preventionist on the proper completion of the Antibiotic Use Tracking Log. To monitor and maintain ongoing compliance, the DON/designee will complete an audit of 3 random antibiotics ordered, ensuring the necessary information is present on the Antibiotic Use Tracking Log for the initiation of the antibiotic. Any missing information will be immediately corrected weekly for 4 weeks, and then monthly for 2 months. All findings will be reported to the QA committee monthly for any further necessary recommendations.
Failure to Ensure Accurate Implementation and Documentation of Pressure Ulcer Prevention Orders
Penalty
Summary
A deficiency was identified when a resident with a history of chronic kidney disease and hyperlipidemia, who previously had a stage 3 pressure wound on the right heel, was observed multiple times not wearing prevalon boots as ordered by the physician. Instead, the resident was seen sitting in a wheelchair wearing sneakers during several observations. The physician's order and care plan both specified that prevalon boots were to be worn at all times to promote healing and prevent further skin breakdown. Despite these orders, the Medication Administration Record (MAR) indicated that staff documented the resident as having the prevalon boots on during all shifts, which was inconsistent with direct observations. The care plan also included an approach for the resident to wear prevalon boots at all times, and this was based on a physician's recommendation following a foot and ankle consult. There was no documentation in the clinical record prior to the removal of the order and care plan approach that the resident or family had requested the use of sneakers instead of the boots. The deficiency was further supported by a nursing progress note written after the observations, which stated that the resident's heel wound had healed and that the family had provided shoes for the resident to wear. However, the physician's order and care plan were not updated at the time the family made this request, and staff continued to document that the boots were in use when they were not. The facility administrator confirmed that he would have expected staff to accurately document the use of the boots and to update the physician's order and care plan in response to the family's request.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute and admission of, or agreement with, it is required by State and Federal Law. It is executed and executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 47 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to discontinue prevalon boots, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit of care plans/orders to identify all residents ordered prevalon boots. Assessments were completed on all the Residents identified, need for prevalon boot was reviewed with MD, and care plan was updated with any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed for a Resident reflects the plan of care observed in place. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with a care plan approach for prevalon boots observing that documentation completed reflects the plan of care visualized in place, weekly x 4 and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further necessary recommendations.
Failure to Ensure Proper Use of Splint for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility, as required by regulation. The resident, who had a history of stroke and elevated blood pressure, had a physician's order and care plan in place for a left hand splint to be worn at all times, with removal only for care and skin monitoring. Despite these orders, multiple observations over two days revealed that the resident's left hand splint was not in place, and the resident confirmed that staff had not applied the splint. The splint was observed in a basket on the resident's bedside dresser during this time. Documentation in the Medication Administration Record (MAR) indicated that the splint was signed off as being on during each shift, except for a few instances marked as refused by the resident. However, interviews with facility leadership revealed confusion regarding the status of the splint order, with the DON referencing a progress note from two months prior about the splint being on hold due to swelling, but no current orders or documentation supporting discontinuation of the splint prior to the most recent therapy note. Occupational therapy documentation indicated the splint should continue until therapy was discontinued, and there was no evidence of a physician order to discontinue the splint before July. This discrepancy between documentation, staff actions, and physician orders led to the deficiency.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission of, or agreement with, it is required by State and Federal Law. It is executed and implemented as a means to continuously improve the quality of care to comply with the state and federal requirements. 1. Resident 48 had no ill effects from the cited past deficient practice. During the survey, Attending Physician was contacted for clarification, order was obtained to remove splint on left hand, care plan was updated. 2. To identify others with the likelihood to be affected, the DON/designee completed a house-wide audit to identify all residents ordered splints. Assessments were completed on all residents identified, to ensure any splints ordered are in place and not causing skin impairment. Splint was reviewed with the therapy dept and attending physician, plan of care was updated reflecting any further recommendations received. 3. To prevent a future reoccurrence, the DON/designee will educate all nursing staff to ensure documentation completed on splinting for a resident reflects the plan of care observed in place, and follows physician orders. If splint is held by physician, order will be transcribed to current plan of care ordered. 4. To monitor and maintain ongoing compliance, the DON/designee will audit 5 random residents with splints to ensure the resident is free of skin impairment related to splint, and the documentation completed reflects plan of care observed, weekly x 4 weeks and then monthly x 2. Any inaccurate findings will be corrected immediately, and findings will be reported to the QA committee monthly, for any further recommendations.
Failure to Provide Timely Pharmaceutical Services and Medications
Penalty
Summary
The facility failed to provide routine drugs and biologicals to meet the needs of three residents, as required by policy and regulation. For one resident admitted with orbital eye cellulitis and lower back pain, there were missed doses of IV antibiotics and pain medications due to unavailability upon admission. The medication administration record (MAR) documented four missed IV antibiotic doses and several missed doses of morphine-based pain medications, with notes indicating the medications were unavailable. Nursing progress notes showed that the provider was not notified of the missed doses until the following day, and the pharmacy later reported that one medication was on backorder, leading to a change in the pain management plan. Another resident, admitted with malignant neoplasm of the prostate and generalized weakness, had a physician order for Casodex that was not administered for two scheduled doses due to unavailability. The MAR reflected these missed doses, and corresponding notes indicated the medication was not available on the first two days after admission. Similarly, a third resident with epilepsy and multiple sclerosis did not receive two scheduled doses of Lacosamide, an anti-seizure medication, because the medication was not delivered with the initial pharmacy shipment. Nursing notes confirmed the delay and documented communication with the provider and pharmacy regarding the missing medication. Interviews with staff, including a registered nurse, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), revealed ongoing issues with delayed medication deliveries and order discrepancies. Staff acknowledged that it was their responsibility to address these issues with the pharmacy and provider when discovered. Facility documentation showed scheduled pharmacy deliveries, but the NHA and DON were unable to provide specific reasons for the delays or documentation of delivery discrepancies. The DON noted that an alternative dose of a medication was available onsite but was not utilized because the provider was not contacted promptly.
Failure to Administer Ordered Pressure Ulcer Treatment Due to Lack of Order Clarification
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Clean Dressing Change Policy, wounds are to be dressed using a clean technique, with new dressings applied as ordered and findings documented. The resident in question had a diagnosis of a right heel pressure ulcer and osteoarthritis, with physician orders specifying a wound care regimen involving cleansing, application of betadine and calcium alginate, and securing with an ABD pad three times daily. Clinical record review showed that the prescribed wound treatments were not administered during several night shifts, as documented in the Medication Administration Record. An LPN reported not administering the treatments because the evening shift had noted the need for order clarification, but no clarification was sought throughout the week, resulting in continued omission of care. The DON confirmed that wound treatments should have been administered as ordered and clarified in a timely manner if needed.
Failure to Provide and Document Required Showers for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal grooming for two residents who were dependent on staff for assistance with activities of daily living. Both residents had significant cognitive impairments, including dementia and severe communication limitations, and were scheduled to receive showers on specific days. However, clinical record reviews showed that both residents consistently received bed baths instead of showers on their scheduled shower days over a period of more than a month. There was no documentation in the clinical records or progress notes indicating that either resident refused showers on those days, nor was there evidence that their bathing preferences were assessed or documented as required by facility policy. Interviews with facility leadership confirmed that staff are expected to ask residents about their bathing preferences and to document any refusals, with non-verbal residents to be provided showers unless they give non-verbal cues of refusal. Despite these expectations, the records for both residents lacked documentation of refusals or alternative arrangements, and the required communication and documentation protocols were not followed. This resulted in a failure to adhere to facility policy and regulatory requirements for providing and documenting appropriate personal care services.
Failure to Reconcile Medications in Discharge Summary
Penalty
Summary
The facility failed to include a reconciliation of all pre-discharge medications with the resident's post-discharge medications in the discharge summary for one of the closed records reviewed. The facility's Discharge Planning Policy, revised on September 24, 2020, mandates that a discharge summary should include a reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescribed and over-the-counter. However, upon reviewing the clinical record of a resident diagnosed with cerebral infarction and anxiety, it was found that the discharge summary dated May 31, 2024, did not contain this required medication reconciliation. This deficiency was confirmed during an interview with the Director of Nursing on June 13, 2024.
Failure to Assist Resident with Mobility Goals
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. Resident 22, who has diagnoses including hypertension, congestive heart failure, and depression, expressed a desire to walk at least once a day. However, she reported that staff did not always assist her in doing so. This concern was reiterated during a resident group interview. The resident's care plan and restorative nursing orders included a goal for her to ambulate 50 feet per day with assistance, but documentation revealed multiple instances where this was not performed or not documented. The facility's records showed that on several occasions in April, May, and June 2024, there was either no documentation or it was noted that the walking program was not performed for Resident 22. During interviews, the Nursing Home Administrator and Director of Nursing were informed of the resident's statements and the lack of documentation. The Director of Nursing suggested that the recent change in electronic medical records providers might have contributed to the missing documentation. Despite being made aware of the issue, no additional information was provided to address the resident's concerns.
Inadequate Infection Control Practices Observed
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) and inadequate hand hygiene practices by staff members. Specifically, the facility's policy on Transmission-Based Precautions was not adhered to, as observed with Resident 46, who was on contact precautions due to a Methicillin-resistant Staphylococcus aureus (MRSA) infection and proteus mirabilis. Despite the presence of a contact precaution sign on the resident's door, staff members, including Nursing Assistants, entered the room without donning gloves or gowns and failed to perform hand hygiene after exiting the room or after assisting the resident with meal setup and clothing protectors. Observations revealed that staff members repeatedly neglected to follow proper infection control protocols, such as wearing gloves and gowns when necessary and performing hand hygiene after resident contact or potential contamination. Interviews with the Registered Nurse and Director of Nursing confirmed that the expected procedures were not followed, particularly during meal service for Resident 46. The failure to utilize PPE and complete hand hygiene was acknowledged by the facility's administration, but no additional information or corrective measures were provided at the time of the survey.
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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