Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunbury Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to provide complete written transfer notices and timely bed-hold information for multiple residents sent to the hospital. The notices omitted required appeal details such as appeal entity contact information, appeal form instructions, and Ombudsman and advocacy agency contacts, and the bed-hold forms did not include the current daily rate or were not provided to the representative within the required timeframe.
Failure to implement ordered hand splints and ROM devices for two residents with hand contractures. One resident had orders for restorative splints, palm guards, and cone orthotics, but observations repeatedly found no splint in either hand and staff confused soft fabric with the ordered device. Another resident had an order for inter-dry before splint application, yet documentation showed day-shift completion even though the splint was not in use during day shift, and no staff documented the task on evening or night shifts.
Unsafe Food Storage and Unsanitary Kitchen Conditions: Surveyors observed multiple food storage and sanitation issues in the main kitchen, including frozen items without clear dating, an open box of salt not dated after opening, thawing ground beef stored next to milk with one milk container in direct contact with the meat pan, and kitchen equipment and surfaces with dust, stains, and food debris. The hood, fire suppression nozzles, mixer cover, tray cart, sink area, and window coverings were all noted to be in unsanitary condition, and the sanitizer strips in use had expired in 2022.
The facility had incomplete and conflicting clinical records for several residents. One resident’s influenza vaccine documentation showed inconsistent entries about refusal versus verbal consent, and staff confirmed the EHR immunization record could be altered without a date, time, or electronic signature. Three residents also had POLST forms with missing required signatures, including absent resident/responsible party signatures, missing practitioner signatures, and undated staff co-signatures, despite active DNR orders in the chart.
The facility failed to maintain COVID-19 vaccination documentation for four of four employees reviewed. The RN/infection control prevention coordinator said staff immunization records were kept in an electronic system, but she could not retrieve records for the four contracted housekeeping and laundry employees. During interviews, the employees reported varying vaccination histories, including boosters, a last dose in 2024, and one employee who chose not to receive the vaccine, but the electronic record did not contain their COVID-19 immunization status.
Failure to Honor Resident Choice for Food Brought From Home: A resident reported that homemade gluten free spaghetti brought by his daughter was not allowed because staff would not reheat food from home. The facility had removed microwaves from the nursing units, and the DON confirmed the unit pantries did not have a heating device. After being told the food could not be reheated, the resident became agitated and punched the wall, sustaining a small open area to his right hand.
A resident with a left hand contracture had MDS assessments that later no longer identified ROM impairment even though she remained dependent for most ADLs and had ongoing splint-related care, including ordered inter-dry use and documented splint application. On observation, she could not fully open the fingers of her left hand and said she did not know where her splint was stored. The RAC confirmed the resident’s functional limitation, splint treatment, and lack of evidence that the ROM impairment had resolved.
A resident with a pacemaker, sick sinus syndrome, and atrial fibrillation did not have a current comprehensive, person-centered care plan addressing the pacemaker. Surveyors observed a transmittal device on the resident’s dresser, and an LPN said it was used to send pacemaker data for remote monitoring. A later care plan noted risk for complications related to the pacemaker/internal defibrillator, but it still did not address the transmittal device or related care.
Failure to assess side rail entrapment risk and obtain informed consent. A resident with stroke-related weakness and no cognitive impairment used a side rail to get in and out of bed, but the EHR contained no consent for the rail and no entrapment zone measurements. Therapy notes described the bed assist rail as safe and helpful, while a later Bed Safety Evaluation only addressed a limited gap check and staff could not locate any entrapment checks or consent.
The facility failed to document that four nurses, including LPNs and RNs, had the competencies needed for PICC line and catheter care. Records showed five residents with indwelling catheters and one resident with a discontinued PICC line, but the facility could not provide competency documentation for the staff assigned to these needs, and the RN educator confirmed the missing records.
A resident with swallowing issues reported needing gravy or extra sauce with all meals, but staff did not obtain her food and beverage preferences within the required timeframe after admission. Her lunch was observed without the requested gravy or extra sauce, her meal ticket did not reflect her preferences, and the dietary manager confirmed the preference interview had not been completed until after surveyor questioning.
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.
Incomplete transfer notices and bed-hold information
Penalty
Summary
The facility failed to provide written transfer notices to the responsible parties for three residents at the time of hospital transfer, and the notices did not include all required appeal-related information. For one resident, nursing documentation showed the resident had frank blood in the Foley tubing and collection bag, lower pelvic and mid abdominal pain, a firm and tender abdomen, emesis, and bilateral upper extremity tremors, and the physician instructed staff to send the resident to the ER. Although documentation stated that written transfer and bed-hold information was provided at the time of transfer, the actual transfer notice was not dated until four days later and did not include the name and address of the appeal entity, instructions for obtaining an appeal form, or contact information for the State Long-Term Care Ombudsman and the agencies responsible for protection and advocacy for individuals with developmental disabilities and mental disorders. For another resident, clinical documentation showed hematemesis and an order to send the resident to the ED, with return to the facility later that day. The written transfer notice for that resident was dated the following day and also lacked the required appeal information, including the appeal entity contact information, appeal form instructions, Ombudsman contact information, and protection and advocacy agency contact information. For a third resident, documentation showed shortness of breath and transfer to the hospital for evaluation, with return to the facility several days later. The written transfer notice for that resident was dated two days after the transfer and likewise did not include the required appeal-related details. The facility also failed to provide timely and complete written bed-hold policy information for two residents. For one resident, the bed-hold notice was documented as distributed to the resident on the day of transfer but to the representative four days later, rather than within 24 hours for an emergency transfer. The bed-hold form stated that if hospitalization exceeded 15 days or was not covered, the resident could choose to guarantee the bed hold through private pay, but it did not include the current daily bed-hold rate. The same bed-hold form issue was identified for the third resident, whose document also lacked the current daily rate for bed hold.
Failure to Implement Ordered Hand Splints and ROM Devices
Penalty
Summary
The facility failed to implement ordered range of motion devices for two residents with hand contractures. One resident had diagnoses of contracture in both hands and an active physician order for restorative splints, with care plan instructions calling for bilateral upper extremity passive ROM, palm guards at all times, and terry cloth cone orthotics to both hands in the morning and removal in the evening. Although documentation showed the cone orthotics were applied and removed on some days, observations on multiple dates found no splint in either hand. During interview, a nurse aide stated she had placed splints in the resident’s hands but described soft fabric that was identified as inter-dry, and she denied knowledge of cone splints. A white hand splint device was later observed on the top of the bedside stand in the resident’s room. A second resident had a diagnosis of left hand contracture and an active physician order for staff to apply inter-dry to the left palm prior to splint application every day shift. The treatment record showed licensed staff initialed the inter-dry as completed on day shift in March, April, and May 2026, and nurse aide documentation also indicated splint application on day shift during those months. However, when the resident was observed, she could not fully open the fingers of her left hand from a fist position and had no splint or fabric in her left hand. The resident stated she did not know where staff stored her splint device. Interviews with staff revealed that the physician order for the second resident’s hand splint had been transcribed incorrectly as an intervention for day shift nurse aides, while evening and night shift nurse aides were expected to implement the task. The interview confirmed that day shift nurse aides were initialing the intervention as completed even though the device was not in use during day shift, and that evening and night shift nurse aides were not documenting the implementation of the task. Licensed staff also documented completion of the treatment before splint application, but no staff documented splint application on evening or night shifts.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain kitchen equipment in a sanitary condition in the main kitchen. During an initial tour with the Dietary Manager, surveyors observed a package of waffles in a freezer with no evidence of a date showing when they were placed there, opened, or needed to be used by. A package of frozen fish had a smudged and unreadable written date. An open box of salt stored with spices was not dated with an open date, and the shelf surface had a granule-like substance on it. Surveyors also observed four packaged rolls of ground beef thawing in a stainless-steel pan on the bottom shelf of a refrigerator next to four one-gallon plastic containers of milk, with one milk container in direct contact with the pan holding the meat. A black bag covering a mixer had dust, hair, and food particles on it. The hood over the stove had dust on the inner vents and on the fire suppression nozzles. The three-compartment sink was filled with various cookware to be washed, sanitizer strips used for testing had expired in July 2022, an empty food tray cart identified as clean had dried stains on the underside of the tray supports, and the curtain above the sink and the top of the window frame had stains, discoloration, and a significant build-up of dust.
Incomplete and Inaccurate Clinical Records and POLST Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for four residents reviewed. For Resident 5, the EHR Immunization tab showed that education about the risks and benefits of the influenza vaccine was provided and that the resident refused the immunization, while the MAR documented a refusal two weeks earlier. A separate informed consent document signed by the RN/infection control prevention coordinator stated that verbal consent had been obtained to administer the influenza vaccine, creating conflicting documentation about whether the vaccine was refused or consented to and when the education occurred. Staff also confirmed that the immunization information in the EHR could be changed without any date, time, or electronic signature showing when the entry was altered. For Resident 10, the chart contained an active DNR physician order and a POLST signed by the CRNP, but the POLST did not include the resident’s signature or the responsible party’s signature. Staff confirmed the missing signature and stated that if the resident transferred out in an emergency, the facility would send the POLST even though it lacked the responsible party’s acknowledgement of the end-of-life decisions. For Resident 3, the chart contained an active DNR/comfort care order and a POLST signed only by the medical practitioner, with no resident or responsible party signature and no staff co-signatures attesting to participation in the form’s development. A revised POLST later provided by the facility included two staff signatures, but they were not dated. For Resident 83, the POLST in the physical chart was signed by the resident’s sister/responsible party but did not include a practitioner signature or staff signatures. Staff confirmed the missing practitioner signature and stated that the POLST available to convey end-of-life wishes in an emergency did not contain the required signatures. The record also showed an active DNR physician order for Resident 83. The survey findings cited 28 Pa. Code 211.5(f)(i)-(xi)(i) and 28 Pa. Code 211.12(d)(1)(3)(5).
Missing COVID-19 Immunization Documentation for Contract Staff
Penalty
Summary
The facility failed to maintain documentation of the COVID-19 vaccination status for four of four employees reviewed, identified as Employees 4, 5, 6, and 7. The deficiency was identified during staff interviews and review of available employee immunization records, when the surveyor requested documentation of the facility’s tracking of current COVID-19 immunization status from the DON, NHA, and the RN/infection control prevention coordinator. The facility stated that staff immunization records were maintained in an electronic record keeping system, but the surveyor was unable to obtain documentation for the four employees reviewed. During interviews, Employee 4 reported having received two or three COVID-19 boosters, with the last immunization on September 14, 2022. Employee 5 reported two boosters and estimated his last immunization was in 2021. Employee 6 stated she believed she was fully vaccinated and reported her last COVID-19 immunization was received at a local grocery store in 2024, but denied receiving a 2025-2026 season immunization. Employee 7 stated he chose not to receive COVID-19 immunizations. When the RN/infection control prevention coordinator attempted to access the electronic records, she was unable to retrieve COVID-19 immunization documentation for Employees 4, 5, 6, and 7, and confirmed they were contracted housekeeping and laundry staff. The electronic system contained Employee 8’s own documentation, but not the names or records of the four employees reviewed.
Failure to Honor Resident Choice for Food Brought From Home
Penalty
Summary
The facility failed to promote resident choice regarding food brought in from home for Resident 65. The facility policy stated that food and beverages may be brought in from outside the facility for individual residents, must be handled and stored safely and sanitarily, and may be reheated in microwaves by staff only. However, the facility had removed the microwaves from the nursing units, and the pantries on the first and second floor nursing units did not contain a device for heating food, as confirmed by the Nursing Home Administrator and DON. Resident 65 stated that his daughter brought him homemade gluten free spaghetti, but the facility would not let him eat it because they would not reheat food brought in from home. Nursing documentation showed that the interdisciplinary team reviewed Resident 65's behavioral incident after he became agitated when told the outside food could not be reheated per facility infection control and food safety guidelines. The documentation further stated that Resident 65 punched the wall in his room and sustained a small open area to the right hand.
Inaccurate MDS Assessment for Resident with Left Hand Contracture
Penalty
Summary
The facility failed to ensure Resident 12’s assessments accurately reflected her status. Resident 12 had a diagnosis of left hand contracture and an active physician order for staff to apply inter-dry to her left palm prior to splint application every day shift. March, April, and May 2026 TAR and documentation survey report entries showed licensed staff and nurse aide staff documenting splint-related care, including application of inter-dry and a splint to the resident’s left hand. However, during observation on May 6, 2026, Resident 12 could not fully open the fingers of her left hand from a fist position, and she stated she did not know where staff stored her splint device. The resident’s MDS assessments showed inconsistency over time. A Medicare five-day MDS and an admission MDS assessed Resident 12 with ROM impairment of both upper extremities and dependence on staff for eating, oral hygiene, toileting, dressing, personal hygiene, transfers, and bed mobility. Quarterly MDS assessments dated June 8, 2025, September 7, 2025, and December 7, 2025, and an annual MDS assessment no longer assessed ROM impairment for her upper extremities, while she remained dependent for most ADLs and required supervision/touching assistance for eating. A plan of care created January 7, 2026, noted that the patient could not apply and remove the splint/brace related to functional deterioration. During interview, the RAC confirmed the resident had a left hand contracture, functional limitation, staff-assisted ADLs, splint documentation, and ordered treatment, and stated there was no information or evidence that her ROM impairment had resolved until June 2025.
Failure to Develop a Comprehensive Pacemaker Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a cardiac pacemaker. The resident’s clinical record listed a pacemaker, sick sinus syndrome, and atrial fibrillation. Medical provider documentation noted that the resident had a pacemaker, and cardiology documentation stated the resident had a leadless pacemaker implanted in May 2022. Review of the resident’s care plan showed no current comprehensive, person-centered care plan addressing the pacemaker. A follow-up observation of the resident’s room found a transmittal device on the dresser next to the bed. An LPN stated that the device was used to transmit data from the resident’s pacemaker for remote monitoring. A later review of the care plan showed a care plan created after the initial surveyor findings that noted the resident was at risk for complications related to the pacemaker/internal defibrillator, but it did not address the transmittal device or associated care.
Failure to assess side rail entrapment risk and obtain informed consent
Penalty
Summary
The facility failed to appropriately assess a side rail for entrapment zone risks and failed to obtain informed consent for side rail use for one resident reviewed for accident hazards. The resident had diagnoses including muscle weakness, hemiplegia, and hemiparesis following a cerebral infarction affecting the left non-dominant side. A quarterly MDS dated February 10, 2026, showed a BIMS score of 15, indicating no cognitive impairment. During observation and interview on May 6, 2026, the resident had a side rail attached to the right side of the bed, positioned in the down position but still several inches above the mattress, and stated that she used the side rail to get in and out of bed. When documentation was requested, the facility reported the records should be in the EHR, but no documentation was found for consent to use the side rail or for entrapment zone measurements. Therapy documentation from May and June 2025 noted the resident had received a bed assist rail and had been assessed as able to place and remove it safely, with improved bed mobility and good safety and management of the railing. However, a Bed Safety Evaluation dated March 19, 2026, only addressed whether there was a gap between the head or foot board and mattress and indicated that all questions had been answered yes, with rails/devices not required, and no further entrapment zone assessment was documented. Staff interviews confirmed therapy handled bed rail safety assessments but not entrapment zone assessments, and maintenance staff could find no entrapment zone checks or informed consent related to the resident's side rail.
Missing Nursing Competency Documentation for PICC Line and Catheter Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to care for residents with a PICC line and residents with indwelling catheters. Facility documentation showed five residents with indwelling catheters and one resident with a discontinued PICC line. When competencies for PICC line and catheter care were requested, the facility could not provide documentation for Employees 1 and 24, both LPNs, or Employees 22 and 23, both RNs. The RN educator confirmed that there was no documentation showing that these four employees had specific competencies and skill sets to care for the residents' needs related to PICC line and catheter care.
Failure to Obtain and Follow Resident Food Preferences
Penalty
Summary
The facility did not provide food in accordance with resident preferences for one of 26 residents reviewed, Resident 47. The facility policy stated that individual dining, food, and beverage preferences are to be identified for all residents, with a food preference interview completed within 72 hours of admission and entered into the medical record and menu management software. Resident 47 was admitted on April 1, 2026, and later told staff that she needed gravy or extra sauce with all meals because of swallowing issues. She stated that she frequently could not eat the meal provided and had to ask for a toasted cheese because the kitchen did not provide the extra sauce or gravy she needed. During interview, Resident 47 said no one had talked to her about her food preferences since admission. Observation of her lunch meal showed she did not receive any gravy or extra sauces, and her meal ticket did not note her preferences. The dietary manager confirmed that no one interviewed Resident 47 regarding her food preferences until after the surveyor’s questioning, and that she was asked to add extra gravy to the meal ticket earlier that day. Nursing documentation later showed the RD spoke with Resident 47 regarding her meal preferences, and the NHA and DON confirmed the facility failed to obtain her meal and beverage preferences within 72 hours of admission.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sunbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nursing And Rehabilitation At The Mansion | 0.2 mi | ★★★★★ | 9 | 0 |
| Nottingham Village | 3.5 mi | ★★★★★ | 8 | 0 |
| Manor At Penn Village, The | 5.2 mi | ★★★★★ | 16 | 0 |
| Buffalo Valley Lutheran Villag | 9.7 mi | ★★★★★ | 19 | 0 |
| Oak Glen Healthcare And Rehabilitation Center | 10.4 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.