Sunbury Skilled Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sunbury, Pennsylvania.
- Location
- 901 Court Street, Sunbury, Pennsylvania 17801
- CMS Provider Number
- 395512
- Inspections on file
- 24
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sunbury Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that a resident's room contained a soiled cart with dust, debris, and a dried white substance, which remained unclean over multiple days while a humidification machine was in use. In the main kitchen, metal shelves inside storage coolers had exposed rust, and cabinets in a dining/activity room were significantly soiled and worn, with food preparation items stored inside. Facility leadership confirmed these conditions.
Staff left computers logged into electronic charting software unattended at the nurse's station, allowing unauthorized access to residents' medical records. Additionally, a box containing medical records with resident identifiers was left unsecured in a hallway, accessible to anyone passing by, including non-clinical staff. These actions failed to ensure the confidentiality and security of residents' personal and medical records.
A resident with atrial fibrillation and hypertension received Metoprolol despite physician orders to hold the medication for low blood pressure or pulse. The medication was administered multiple times when the resident's pulse or blood pressure was below the specified parameters, with no documentation explaining the deviation.
A resident receiving hemodialysis with an AV fistula did not have required emergency supplies, such as sterile gauze, hemostat, needleless connector, or tape, available in their room, closet, or dialysis transport bag. This was confirmed through interviews, observations, and staff checks, including by an LPN.
A resident with a diagnosis of dementia did not have an individualized, person-centered care plan addressing her cognitive loss or specifying how she communicates unmet needs such as pain, discomfort, hunger, thirst, or frustration. The care plans in place lacked specific approaches tailored to the resident's dementia and cognitive status.
A medication error rate above 5% was identified when an LPN administered an ophthalmic solution to both eyes instead of only the right eye as ordered, and gave a lactase enzyme supplement to a resident without a meal, contrary to physician orders and medication instructions.
Staff failed to properly store and secure medications on one unit, with unsecured and unidentified tablets found in a medication cart, and could not identify the loose medications. On another unit, a resident's undestroyed Oxycodone prescriptions were found unsecured in a clinical record accessible to all staff due to inadequate nurse station security.
Survey results, specifically the required Statement of Deficiencies (Form CMS-2567), were not posted in accessible areas such as the main lobby and a nursing unit lounge. Instead, only health survey and complaint deficiency letters were available, and the most recent Statement of Deficiencies in the binders was outdated. This was confirmed through observation and staff interview.
A resident with multiple comorbidities and cognitive impairment did not receive consistent, comprehensive skin and wound assessments as required by facility policy and physician orders. Gaps in documentation and missed evaluations by the wound care nurse led to a lack of timely identification of changes in a sacral wound, resulting in deterioration and the development of a deep, unstageable pressure ulcer.
The facility failed to meet the required LPN staffing ratios across various shifts over a 21-day period. Specifically, the facility did not maintain the minimum staffing levels during the day, evening, and night shifts on multiple occasions, as confirmed by a review of nursing care hours and an interview with the nursing home administrator and DON.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day on two days. Specifically, on one day, 3.01 hours PPD were provided, and on another, 3.15 hours PPD were provided. This was confirmed through a review of staffing hours and an interview with the Nursing Home Administrator and DON.
The facility failed to provide routine dental care for four residents, resulting in missed appointments and lack of necessary treatments. One resident missed multiple prophylactic cleanings, while another required new dentures and cleaning but did not receive them. Two other residents had not received professional dental care for extended periods, despite being on the schedule. The facility lacked documentation to confirm declined services or actions taken to address missed appointments.
The facility's main kitchen was found to have multiple sanitation and food storage deficiencies, including dried food and liquid spills, dust and debris accumulation, and improperly labeled and dated food items. These issues were observed in various areas, such as the dishwashing area, food preparation tables, and storage areas. The findings were reviewed with the Nursing Home Administrator and DON.
A resident with hand contractures did not receive the recommended nighttime application of bilateral splints due to staff forgetting or not knowing how to apply them. The therapy director had recommended the splints, but this was not documented in the resident's clinical record, as confirmed by the DON.
The facility failed to maintain a clean and safe environment on the First Floor Nursing Unit, with a strong urine odor affecting several residents and physical disrepair noted in rooms and common areas. These issues were observed on multiple occasions and discussed with the Nursing Home Administrator and DON.
A facility failed to follow its policy on PEG tube management by not having orders for flushing a resident's tube before and after medication administration. This deficiency was identified during a survey, and the necessary orders were obtained only after the issue was brought to the facility's attention.
A facility failed to provide comprehensive care for a resident requiring dialysis. The resident, a hemodialysis patient, lacked physician orders for dialysis attendance and AV fistula care. The facility did not document checks for the fistula's function or develop a care plan detailing dialysis schedules, transportation, meal needs, or emergency procedures. Coordination with the dialysis center and physician regarding medication timing was also absent.
A resident with PTSD experienced frequent hallucinations and delusions, but the facility failed to identify or mitigate triggers related to his condition. Despite the resident identifying certain TV shows and songs as triggers, his care plan only addressed symptom management without considering these triggers. This deficiency was noted during a review with the Nursing Home Administrator and DON.
A facility failed to assist a resident in obtaining routine dental services. The resident, admitted with Medicaid benefits, requested dental services in 2019 and last saw a dentist in early 2022. Despite being due for a cleaning six months later, no further visits were documented. Although a cleaning was offered in early 2023 and refused, there was no evidence of routine six-month dental service offers, as confirmed by interviews with the DON and Nursing Home Administrator.
The facility did not notify the State LTC Ombudsman of two residents' transfers to the hospital. A resident with kidney stones and another with physical aggression were transferred without documented notification. The admissions coordinator admitted these residents were missed in monthly reports. This was confirmed by the Nursing Home Administrator and DON.
Failure to Maintain Clean and Homelike Environment in Resident Room and Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment on one of its nursing units and in the main kitchen. In one resident's room, a two-tiered cart beside the bed, which housed a humidification machine, a cardboard box, plastic cups, and a jug of water, was found to be soiled with dust, debris, and a dried white substance. This condition persisted over multiple days, as the cart remained unclean during subsequent observations while the humidification machine was in use. Additionally, in the facility's main kitchen, several metal shelves inside two-door storage coolers were found to have exposed rusted metal where the protective coating had worn off. On the second-floor nursing unit, the large dining/activity room contained lower cabinets that were very worn and significantly soiled with brown debris, dust, crumbs, and sticky residue, with rolling pins, mixing bowls, and measuring cups stored inside. These findings were confirmed through interviews with facility leadership.
Failure to Secure and Protect Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and security of residents' personal and medical records as required by its own policies and state regulations. Observations on multiple occasions revealed that computers at the nurse's station on the North Wing of the First Floor Nursing Unit were left logged into the electronic charting software without staff present, leaving residents' electronic medical records accessible and unsecured. Staff were observed leaving the area for extended periods while the electronic health record system remained open, and multiple unidentified staff were seen passing by the unattended, open charting program. Additionally, an overflowing box containing medical records and clinical documentation with resident identifiers was found unsecured and accessible in a hallway adjacent to the main kitchen. The box was awaiting pick-up by an off-site storage company, but there was no clear timeline for when this would occur, leaving the records exposed to anyone passing by, including housekeeping staff. These actions and inactions directly resulted in a failure to protect residents' rights to secure and confidential personal and medical records.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
Facility staff failed to follow physician-ordered medication parameters for a resident diagnosed with atrial fibrillation and essential hypertension. The resident had a physician order for Metoprolol Succinate ER, with instructions to hold the medication if the systolic blood pressure was less than 100 or the pulse was less than 60. Despite these parameters, the medication was administered on multiple occasions when the resident's pulse was documented below 60, specifically on June 1, 2, 9, 10, and 11, with pulse readings as low as 51. There was no documentation explaining why the medication was given outside of the specified parameters. Additionally, on June 12, the medication was administered when the resident's blood pressure was recorded as 90/54, which was below the physician-ordered threshold. These incidents were confirmed through clinical record review and staff interviews, and the lack of adherence to the medication parameters was discussed with facility leadership. The report does not mention any documentation or justification for administering the medication outside the prescribed limits.
Lack of Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. During interviews and observations, it was found that a resident who attended dialysis outside the facility three days a week and had an AV fistula in his arm did not have emergency supplies, such as sterile gauze, hemostat, needleless connector, or tape, readily available in his room or closet. Multiple checks by staff, including a licensed practical nurse, confirmed that these supplies were not present in the resident's room, closet, bedside drawers, or dialysis transport bag. The deficiency was confirmed through clinical record review, direct observation, and staff and resident interviews.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with dementia. Clinical record review showed that the resident was admitted in 2014 and received a dementia diagnosis in 2022. Despite this, the resident's care plans addressing cognitive loss and behavioral symptoms did not include individualized approaches to address her dementia and cognitive loss, nor did they specify how the resident communicates unmet needs such as pain, discomfort, hunger, thirst, or frustration. This deficiency was identified through clinical record review and staff interviews, and was confirmed during a review with the Nursing Home Administrator.
Medication Error Rate Exceeds Regulatory Threshold Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with a calculated error rate of 7.14 percent based on 28 medication opportunities and two errors. During a medication administration pass, an LPN prepared and administered Brimonidine Tartrate-Timolol Ophthalmic Solution to a resident by instilling one drop in each eye, despite the physician's order specifying administration only to the right eye for glaucoma. The LPN confirmed the medication was given in both eyes, contrary to the order. Additionally, the same resident was administered a lactase enzyme supplement without any food present, although the physician's order and medication instructions specified that the supplement should be given with meals to aid in lactose intolerance. Interviews with staff and the resident confirmed that the resident's family had brought breakfast earlier that morning, but the supplement was not administered with the meal as directed. These actions resulted in a medication error rate above the regulatory threshold.
Improper Storage and Security of Medications and Controlled Substance Prescriptions
Penalty
Summary
Facility staff failed to properly store and secure medications on the First Floor Nursing Unit, as observed during a medication pass. Several unsecured and unidentified medication tablets, including a brown oblong tablet, a pink colored oblong tablet, and a white colored oblong tablet, were found loose in the bottom of the medication cart drawers. Additionally, a container of individually wrapped supplemental vitamin chews in the cart contained a pink colored oblong medication tablet and a yellow colored oblong medication tablet. The LPN using the cart was unable to identify the unsecured medications. On the Second Floor Nursing Unit, two loose prescriptions for Oxycodone, a controlled substance, were found in a resident's clinical record. The prescriptions were not defaced and were easily removable from the record, which was stored behind the nurse's station with other resident records. The nurse's station was secured only by a slide-over lock that did not require a key or code, making it easily accessible to all staff. These findings were confirmed through observation and staff interviews.
Failure to Post Most Recent Survey Results in Accessible Locations
Penalty
Summary
The facility failed to ensure that the results of the most recent survey, specifically the Statement of Deficiencies (Form CMS-2567), were posted in a location readily accessible to residents, family members, and legal representatives in both the main lobby and the First Floor North Nursing Unit resident lounge. Observations revealed that while binders were present in these areas, they only contained health survey letters and complaint deficiency letters, not the required Statement of Deficiencies. Additionally, the deficiency letters included specific resident identifiers and names, and the most recent Statement of Deficiencies available in the binders was from 2023, not the most current survey. This failure was confirmed through observation and staff interview.
Failure to Provide Comprehensive Skin Assessments and Timely Wound Care
Penalty
Summary
The facility failed to provide comprehensive skin assessments consistent with professional standards of practice for a resident with significant medical conditions, including protein calorie malnutrition, Type 2 diabetes with chronic kidney disease, and generalized muscle weakness. The resident, who also had cognitive impairment, was under physician orders for weekly body audits and daily wound care for a sacral wound. Despite these orders, there were gaps in wound assessment and documentation, particularly between February 27 and March 12, and again on March 19, when the wound care nurse did not complete required assessments. Nursing and wound care documentation showed that the resident's sacral wound was initially identified and measured, but subsequent assessments were either incomplete or missing. Progress notes and skilled nursing evaluations repeatedly referenced the wound but deferred detailed assessment and measurement to the wound care nurse, who did not consistently document these evaluations. As a result, there was a lack of ongoing, comprehensive assessment of the wound's condition, including its size, tissue status, and signs of infection or inflammation. The deficiency was further evidenced when a significant deterioration in the wound was documented on March 21, with an increase in wound size and missing depth measurement. The resident was later hospitalized for acute kidney injury, and upon return, a third-party wound care consultation identified a deep, unstageable sacral pressure ulcer requiring debridement. The facility's failure to perform and document regular, comprehensive wound assessments led to a delay in identifying changes and promoting healing of the pressure ulcer.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across various shifts over a 21-day review period. Specifically, the facility did not maintain the minimum staffing ratio of one LPN per 25 residents during the day shift on five occasions, one LPN per 30 residents during the evening shift on one occasion, and one LPN per 40 residents during the night shift on twelve occasions. The review of nursing care hours for the weeks of November 24-30, 2024, December 15-21, 2024, and January 1-7, 2025, revealed specific dates where the staffing levels were below the required minimums, with the census and the number of LPNs provided falling short of the regulatory requirements. The deficiency was confirmed through an interview with the nursing home administrator and the director of nursing on January 8, 2025. The interview corroborated the findings from the review of nursing staffing hours, indicating a consistent failure to meet the mandated LPN-to-resident ratios. This deficiency highlights a significant lapse in ensuring adequate nursing care coverage, which is essential for maintaining the quality of care and safety of the residents.
Plan Of Correction
Licensure Nursing Services (LPN Staff Ratios) The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency within. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. There were no adverse effects to the residents of our facility as a result of decreased staffing ratios. 2. The Administrator, Director of Nursing, Scheduler and Human Resource Director will be educated on the state requirement for LPN to resident staffing ratios by the Quality Clinical Consultant/designee. 3. Staffing meetings will be held 5 days a week to review LPN ratios from the previous day and the projected LPN staff ratios for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state requirement for LPNs, then the facility will reach out to current staff and staffing agencies to meet the minimum requirement. The facility will continue to recruit staff through all platforms. 4. Audits of LPN staff ratios will be completed randomly by the DON/designee to ensure LPN staff ratios meet the state minimums. Results of the audits with trends will be reported through QA&A. 5. Date of Compliance February 20, 2025.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per patient day (PPD) on two specific days during the review period. On December 15, 2024, the facility provided only 3.01 hours PPD, and on December 16, 2024, it provided 3.15 hours PPD. This deficiency was identified through a review of nursing staffing hours for the weeks of November 24-30, 2024, December 15-21, 2024, and January 1-7, 2025. An interview with the Nursing Home Administrator and Director of Nursing on January 8, 2025, confirmed the failure to meet the required staffing levels on the specified dates.
Plan Of Correction
Licensure Nursing Services (HPPD) The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency within. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction. 1. There were no adverse effects to the residents of our facility as a result of decreased HPPD. 2. DON will re-educate the staffing coordinator/designee on the 3.2 HPPD staffing requirement and will provide education on calculating HPPD and adjusting staffing to attain the 3.2 HPPD. 3. Staffing meetings will be held 5 days a week to review HPPD from the previous day and the projected HPPD for the current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the 3.2 minimum, then the facility will reach out to current staff and staffing agencies to meet the minimum requirement. The facility will continue to recruit staff through all platforms. 4. The staffing coordinator will conduct an audit of HPPD levels randomly to ensure HPPDs meet the minimum 3.2 HPPD. Results of the audits with trends will be reported through QA&A. 5. Date of Compliance February 20, 2025.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining routine dental care, as evidenced by the cases of four residents. Resident 1 was recommended to have prophylactic dental cleaning every six months, with the next scheduled visit on March 8, 2024. However, there was no evidence that this cleaning occurred, and the resident's responsible party reported missed appointments in July and August 2024. Despite the notification, the facility did not act upon the missed appointments, and the next available appointment was scheduled for December 2024, more than 15 months after the last cleaning. Resident 2 had a denture on the top jaw and natural teeth on the bottom jaw. She reported needing a new denture and had not received professional cleaning for her natural teeth. The facility's records indicated a treatment plan for new dentures and prophylactic cleaning, but there was no evidence of these services being provided since October 2023. Although documentation suggested that Resident 2 declined dental services, there was no consent form or progress note to confirm this. Resident 6 had natural teeth and had not received professional cleaning for a significant period. While records showed she declined services in late 2023, a request for services was made in April 2024, with no further documentation of services offered. Resident 7, with upper and lower natural teeth, reported loose teeth and had not received routine dental care. Her last assessment was in December 2023, with no evidence of an oral exam in the following nine months. The facility confirmed that both Residents 6 and 7 were on the dental schedule for September, but there was no evidence of services offered in the interim.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed during a survey. A large garbage can in the dishwashing area was covered in dried food and liquid spills, with similar conditions on the wall behind it. The dish machine area had dried food splatter on the ceiling, and dust was visible on the light covers and ceiling vent. A metal cart in the tray line area had cereal scattered around bowls, and a cart near the steam table was surrounded by dust and debris. The metal hood above the cooking area had a buildup of dust and grease, and the lower shelves of food preparation tables were covered in dust, dried food debris, and liquid spills. A clear container with an unlabeled white powdery substance, identified as a food thickening agent, was found with a scoop inside. A two-compartment sink used for dumping ice had brown stains and buildup around the faucet and sides. The facility also failed to properly label and date food items in storage. A two-door upright freezer contained unlabeled bags of food, including a clear bag with oval-shaped patties identified as chicken fried steak. A plastic container labeled as pork had a date range of 6/19-7/19, and a container labeled sloppy joe had a date range of 6/18-7/18, but there was no evidence of a cool down log for these items. Bread products in the dry storage area were undated, and the area had stained ceiling tiles directly over boxes of food service paper products. These findings were discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Apply Recommended Splints for Resident
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with contractures in her bilateral hands. During an interview and observation, the resident stated that staff were supposed to apply splints to her hands at night, as recommended by therapy, but they often forgot or did not know how to apply them. The rehab therapy director confirmed that he had recommended the application of bilateral splints on May 24, 2024, and provided documentation supporting this recommendation. However, a review of the resident's clinical record showed no documentation that the splints were applied during nighttime hours. An interview with the Director of Nursing confirmed that the therapy's recommendation for the application of bilateral splints was never added to the resident's clinical record. This oversight resulted in the failure to provide the necessary care as per the therapy's recommendation.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and orderly environment on the First Floor Nursing Unit, affecting several residents. Observations made on multiple occasions revealed a strong smell of urine upon entry to the floor, particularly near the rooms of several residents. The intense odor was especially noticeable in one resident's room, causing physical discomfort to the surveyor, such as burning and watering of the eyes and nose. This indicates a significant lapse in housekeeping and maintenance services, compromising the residents' right to a safe and comfortable living environment. Additionally, the facility exhibited signs of physical disrepair. In one resident's room, the paint was chipped and peeling, and the baseboard was detaching from the wall. Furthermore, a rough, unpainted drywall patch was observed on the hallway wall near the dining room. These observations were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide adequate maintenance services, as required by regulatory standards.
Failure to Implement PEG Tube Flushing Protocol
Penalty
Summary
The facility failed to implement appropriate treatment and services to prevent potential complications of a feeding tube for a resident. The facility's policy on medication administration through enteral tubes requires that the tubes be flushed with at least 15 milliliters of water before and after administering medications. However, a review of the clinical records for a resident revealed that there were no current orders related to flushing the resident's PEG tube before or after medication administration. This oversight was identified during a surveyor's review. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the necessary physician orders for PEG tube flushes were obtained only after the surveyor highlighted the issue. This indicates that the facility did not adhere to its own policy regarding the safe and effective administration of medications through enteral tubes, potentially putting the resident at risk for complications associated with improper PEG tube management.
Failure to Provide Comprehensive Dialysis Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident requiring dialysis services. The resident, admitted on March 7, 2024, was a hemodialysis patient with scheduled dialysis sessions on Tuesday, Thursday, and Saturday. Despite this, the facility did not have physician orders for the resident to attend dialysis or for the care of her AV fistula. There was no documentation indicating that staff checked for bruit and thrill to ensure the fistula was functioning properly since the resident's admission. Additionally, the facility did not develop a comprehensive plan of care for the resident's dialysis needs. The plan of care lacked details such as the days and times of dialysis, transportation arrangements, pre-dialysis meal requirements, monitoring of the AV fistula site, and emergency procedures. There was also no evidence of coordination with the dialysis center or the resident's physician regarding medication administration on dialysis days. These deficiencies were confirmed by the Director of Nursing during an interview.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Chronic Post-Traumatic Stress Disorder (PTSD). The resident, admitted on January 26, 2023, was documented to experience frequent episodes of hallucinations, delusions, paranoia, yelling out, and refusing care. Despite these symptoms, the facility did not attempt to identify the resident's history of trauma or potential triggers that could exacerbate his condition. During an interview, the resident identified certain television shows and songs as triggers, yet there was no evidence in his care plan or clinical record that the facility had taken steps to identify or mitigate these triggers. The resident's care plan for PTSD only included interventions for managing symptoms such as hallucinations and delusions, without addressing the underlying triggers. This oversight was confirmed during a review with the Nursing Home Administrator and Director of Nursing. The lack of a comprehensive approach to understanding and managing the resident's PTSD symptoms indicates a deficiency in providing culturally competent, trauma-informed care, as required by the relevant nursing services code.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental services, as required. Resident 2, who was admitted on November 3, 2019, with Medicaid benefits, requested dental services on November 21, 2019. The resident last saw a dentist on January 20, 2022, and was due for a prophylactic dental cleaning six months later. However, there were no further dental visits documented. Although the facility offered a cleaning on January 9, 2023, which the resident refused, there was no evidence that routine dental services were offered every six months as allowed by the State plan. Interviews with the Director of Nursing and Nursing Home Administrator confirmed these findings.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding the transfer of two residents to the hospital. Resident 14 was transferred and admitted to the hospital for kidney stones, but there was no documented evidence of notification to the Ombudsman. Similarly, Resident 114, who was admitted to the facility and later sent to the hospital due to physical aggression, did not have a documented notification to the Ombudsman regarding their transfer and subsequent non-return to the facility. Employee 3, the admissions coordinator, acknowledged that these residents were missed in the monthly reports provided to the Ombudsman. These findings were confirmed in an interview with the Nursing Home Administrator and Director of Nursing.
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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