Sunnyview Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Butler, Pennsylvania.
- Location
- 107 Sunnyview Circle, Butler, Pennsylvania 16001
- CMS Provider Number
- 395788
- Inspections on file
- 46
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 74 (1 serious)
Citation history
Health deficiencies cited at Sunnyview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes and a lower leg fracture, received IV cefazolin via a midline catheter, but the physician orders did not specify the type of IV access, flushing protocol, dressing change schedule, or end-cap changes. Facility policy required specific midline flushing and care procedures, and nursing documentation noted that the midline was flushing easily. During an interview, the DON confirmed that the orders were incomplete and that adequate treatment and care for the midline catheter were not provided.
A resident with high blood pressure, muscle weakness, heart failure, and a stage 2 coccyx pressure injury had a physician’s order for daily wound care, including cleansing with wound cleanser, drying, applying triad paste, and covering with bordered gauze. Review of the TAR showed that this treatment was not administered on two documented days, and the DON confirmed that the ordered pressure ulcer treatments were not provided as required.
A resident with PTSD, multiple sclerosis, and asthma, who was receiving Duloxetine and buspirone for PTSD and anxiety, reported that a male NA repeatedly entered her room in the early morning hours to check if she needed the restroom, which made her very uncomfortable due to a history of being raped at night during military service. Review of her trauma-informed care evaluation and care plan showed no identified PTSD triggers or related interventions. The social worker acknowledged that the facility did not provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization.
The facility did not consistently monitor or record food holding temperatures as required, resulting in multiple meals being served without documentation of safe temperature ranges. Several residents and their representatives reported that food was frequently served cold, and staff confirmed the lack of temperature monitoring, creating a potential risk for foodborne illness.
Resident representatives were unable to reach facility staff or receive responses to their communications over several weeks due to unresolved phone system changes following administrative office relocation. The DON confirmed that the current phone situation prevented effective communication with key personnel.
A resident with an enteral feeding tube did not receive appropriate care, as the feeding bag lacked required labeling and the water bag used for flushes was outdated. An LPN and the DON confirmed these deficiencies, which were not in accordance with facility policy and physician orders.
A nurse aide was re-hired without documented completion of required abuse, neglect, and misappropriation training, as mandated by facility policy. The DON confirmed that training records did not show the employee received this education upon re-hire.
Two residents with cognitive impairments and a history of exit-seeking behaviors were able to elope from the facility due to failures in supervision, incomplete risk assessments, and non-functioning or unchecked electronic monitoring devices. Staff did not consistently update care plans or ensure monitoring systems were operational, resulting in one resident being found attempting to exit the building and another found outside with injuries after a fall.
A poster with Ombudsman contact information was observed to include only a phone number, lacking the required name, address, and email address. The NHA confirmed the omission, resulting in a deficiency for not fully posting all required contact details for the State Long-Term Care Ombudsman program.
A nurse aide trainee was allowed to work for more than four months without obtaining required certification, as confirmed by facility records and staff interview. The individual continued working as a nurse aide trainee well past the 120-day limit set by federal regulations.
Surveyors observed that food items in storage areas were not properly labeled or dated, including snacks, grits, chicken tenders, and soft pretzels. A refrigerator contained a soiled rag, and loose sugar was found on the dry storage floor. Meat was stored touching the freezer ceiling, and large icicles were present on the freezer floor. The hand washing sink lacked towels, and equipment such as the meat slicer and floor mixer were left uncovered, exposing them to contamination. The Food Service Director confirmed these failures in food labeling, sanitation, and hand hygiene supply maintenance.
The NHA and DON did not effectively manage the facility to prevent the elopement of two residents, despite being responsible for maintaining systems to ensure resident safety and regulatory compliance. This failure resulted in an immediate jeopardy situation, as identified through review of job descriptions, clinical records, and staff interviews.
Multiple residents reported delays in receiving meals, infrequent showers, and long wait times for call bell responses due to insufficient nursing staff. Staff confirmed that low staffing levels made it difficult to provide timely care, with some shifts having only three aides for 60 residents. The administrator acknowledged the facility's failure to provide adequate nursing and related services to meet residents' needs.
The facility did not provide required medically related social services to several residents with mental health conditions such as schizophrenia, depression, and anxiety. Documentation and interviews showed that residents did not receive consistent psychosocial support or follow-up, and there was no process in place to identify or track those needing regular psychiatric social services.
The facility did not ensure that monthly medication regimen reviews were reviewed by the attending physician for three residents with complex medical and psychiatric conditions. Instead, CRNPs completed and signed the reviews and made medication decisions, with no documented response from the attending physician as required by policy.
The facility did not employ a qualified Food Service Director for an extended period, with the individual in the role lacking required education or certification, and the RD only performing clinical duties without managing kitchen operations.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating their rights.
A resident with mental health and seizure disorders, who had been placed in a private room for behavioral reasons, was moved to another room so that another resident with similar needs could have the private room. The transfer was made for facility convenience rather than the resident's needs, violating the resident's right to refuse non-requested transfers.
A resident with anemia, muscle weakness, and a need for personal care assistance was found to have their call bell out of reach while in bed. Facility staff confirmed the call bell was not accessible, failing to meet the resident's needs as required by policy.
A resident with anemia and recent weight loss required personal assistance with eating, as requested by a family member. The facility did not document or respond to this grievance, and staff confirmed the concern was not addressed, resulting in a failure to honor the resident's right to voice grievances.
A resident with dementia and a left below-knee amputation, who required staff assistance for toileting, was found lying in bed with a soiled gown and sheets saturated in urine, despite documentation indicating toileting assistance had been provided. The assigned nurse aide confirmed that the resident had not been assisted as required, resulting in neglect.
The facility did not ensure that necessary information, such as care plan goals, advanced directives, and ongoing care instructions, was communicated to the receiving health care provider for two residents who were transferred to the hospital and returned. The DON confirmed that this information was not provided as required.
A resident with hemiplegia and muscle weakness, who required a smoking apron for safety as documented in their care plan, was observed smoking without the apron. The staff member supervising was unaware of this requirement, resulting in the care plan intervention not being implemented.
A resident with dementia and a left below-the-knee amputation, who required staff assistance for toileting, was found lying in bed with soiled clothing and bedding after not receiving the necessary toileting care. Documentation indicated care was provided, but staff later confirmed that assistance had not been given as required by the care plan and facility policy.
Two residents with diabetes experienced either repeated refusals of prescribed insulin injections or had multiple instances of elevated blood glucose levels, but the nursing staff did not notify the physician as required by orders and facility policy. Instead, staff relied on a nurse practitioner to review blood sugar records, resulting in a failure to provide care and treatment according to physician instructions.
A resident with diabetes, hyperlipidemia, and chronic kidney disease was found to have a urinary catheter in use without a corresponding physician order on file, as required by facility policy. Staff confirmed that only a hospital order existed and no new order was obtained upon admission, resulting in a deficiency.
The facility did not consistently complete and send required dialysis communication forms for two residents with ESRD who received hemodialysis at an outside center. Multiple treatment days lacked complete documentation, and staff confirmed these omissions, resulting in incomplete communication between the facility and the dialysis center.
Two residents with PTSD did not have care plans addressing trauma-informed care or identifying triggers that could cause re-traumatization. Staff confirmed the absence of appropriate interventions and documentation for these residents.
A resident with dementia, anxiety, and severe cognitive impairment, who was grieving and exhibiting suicidal ideation, did not receive appropriate one-to-one supervision as required by facility policy. Although staff removed dangerous items and initiated frequent checks, the resident was left without continuous observation during an episode of active suicidal behavior, resulting in a deficiency in mental health care services.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, as required by care standards.
Nursing staff did not consistently document or verify controlled medication counts during shift changes on two medication carts, as required by facility policy. LPNs confirmed that no alternative verification methods were used, resulting in incomplete records for controlled substances.
A medication cart was found to contain an outdated Humalog insulin pen for a resident, despite facility policy requiring removal of expired drugs. An LPN confirmed the medication was not properly removed or stored.
A resident with dementia and a history of hoarding, who was care planned to receive only disposable eating items for infection control, was observed using reusable plate and silverware. An LPN confirmed the facility did not follow the care plan by failing to provide the required special eating equipment and utensils.
A deficiency was identified when the lid of the middle outdoor dumpster was found open during an observation, contrary to facility policy requiring dumpsters to be closed and free of surrounding litter. This was confirmed by the Food Service Director.
Staff did not use required gown and gloves during a wound dressing change for a resident with an order for enhanced barrier precautions. The facility's policy mandates EBP for residents with wounds or indwelling devices, but two LPNs performed the procedure without proper protective equipment, as confirmed by the resident.
A nurse aide did not receive the mandatory annual training on Effective Communication as required by facility policy, which was confirmed by the RN Educator upon review of training records.
A nurse aide did not receive the mandatory annual training on Resident Rights as required by facility policy. Review of personnel records and staff interview confirmed that this staff member missed the required training within the specified timeframe.
A nurse aide did not receive mandatory annual training on abuse, neglect, and exploitation as required by facility policy, a lapse confirmed by the RN Educator during review of staff records.
A nurse aide did not receive mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program as required by facility policy. Review of personnel records and staff interview confirmed the absence of this training for the staff member within the specified timeframe.
A nurse aide did not receive the mandatory annual Infection Control training as required by facility policy, with a review of personnel records confirming the absence of this training for the specified period. The RN Educator verified that the training had not been completed for this staff member.
A nurse aide did not receive the required annual Compliance and Ethics training as mandated by facility policy. Review of personnel records showed the absence of this training within the specified period, and the omission was confirmed by the RN Educator.
The facility did not provide the required annual in-service education and dementia management training for a nurse aide and an LPN, as confirmed by personnel file reviews and staff interviews. This failure was in violation of facility policy and state regulations regarding staff development.
A nurse aide did not receive mandatory Behavioral Health training as required by facility policy, which mandates annual completion of this training for all staff. This lapse was confirmed through personnel file review and staff interview.
The facility did not provide the required minimum number of nurse aides on several day, evening, and night shifts, as confirmed by staffing schedules and the DON. There was no evidence of additional higher-level staff compensating for these shortages.
Facility staff did not provide the required number of LPNs during certain day and night shifts, as confirmed by review of schedules and census data. The DON acknowledged that there were no additional higher-level staff to compensate for these shortages.
Facility staff did not provide the required 3.2 hours of direct nursing care per resident per day on multiple days, as confirmed by review of schedules and census data and acknowledged by the DON.
A dietary employee was observed working in the main kitchen without properly restraining his facial hair by wearing a beard guard, as required by facility policy. This was confirmed by the Food Service Manager, who acknowledged the failure to follow the established hygiene standards for food service staff.
The facility did not follow standardized recipes or serve food at required temperatures, resulting in multiple hot and cold food items being served outside of policy guidelines. A resident and another individual had previously raised concerns about food temperature and quality. Observations confirmed that food items were unappetizing in appearance and taste, with several dishes missing key ingredients or being improperly prepared.
The facility did not consistently provide food according to resident preferences, including serving incorrect vegetables and adding gravy despite documented dislikes, as reported by several residents and confirmed through tray line observation.
The facility did not provide lunch meals in a timely manner, with significant delays between meal delivery carts resulting in some residents waiting nearly two hours to be served. Multiple residents reported that their meals were consistently late, and the Food Service Manager acknowledged the issue, confirming that the delay created an undignified dining experience.
Incomplete Orders and Care for Midline Catheter
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident’s midline catheter by not ensuring complete and appropriate physician orders for its use and maintenance. Facility policy on Midline Catheter Care and Maintenance, last reviewed 1/27/26, required that midline catheters be flushed with 10 cc normal saline after each intermittent infusion, after discontinuing a continuous IV, or every shift when not in use, and specified that only RNs and LPNs with approved IV certification could perform midline care. The resident, who had diagnoses including hypertension, diabetes, and a left tibia fracture, was admitted on a specified date and later had a nursing progress note indicating that an IV infusion company was notified for midline placement. Subsequent physician orders for this resident’s IV therapy directed cefazolin sodium 2 grams IV every 8 hours for a wound infection for 7 days but did not include the type of IV access, instructions for flushing the IV, dressing change frequency, or changing the IV end cap. A nursing progress note documented that the resident was tolerating the IV and that the midline was flushing easily, but there were no corresponding detailed orders addressing midline care. In an interview, the Director of Nursing confirmed that the physician orders lacked these essential components and acknowledged that the facility failed to provide adequate treatment and care for the midline catheter for this resident.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a stage 2 coccyx pressure injury. The resident was admitted with diagnoses including high blood pressure, muscle weakness, and heart failure, and an MDS assessment was completed. A physician’s order dated 1/13/26 directed staff to cleanse the stage 2 coccyx wound with wound cleanser, pat dry, apply triad paste, and cover with bordered gauze daily. Review of the Treatment Administration Record showed that this ordered treatment was not provided on 1/15/26 or 1/23/26. In an interview on 2/5/26, the Director of Nursing confirmed that the facility failed to provide the pressure ulcer treatments as ordered for this resident. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 211.10(c)(d) Resident care policies, and 211.12(d)(1)(2)(5) Nursing services.
Failure to Provide Trauma-Informed Care for Resident With PTSD
Penalty
Summary
Surveyors found that the facility failed to provide trauma‑informed care to a resident with a diagnosis of PTSD. The resident, who also had multiple sclerosis and asthma and was receiving Duloxetine for PTSD and buspirone for anxiety, reported that a male NA repeatedly entered her room around 3:00 a.m. to ask if she needed to use the restroom. The resident stated this made her very uncomfortable and disclosed that she had been in the military and developed PTSD after being raped in the middle of the night. Review of her Trauma Informed Care Evaluation showed no identified triggers, and her care plan also contained no PTSD triggers or related interventions. During interview, the social worker confirmed that the facility failed to provide trauma‑informed care to eliminate or mitigate triggers that could cause re‑traumatization.
Failure to Monitor and Record Food Holding Temperatures
Penalty
Summary
The facility failed to properly monitor and record food holding temperatures in the Main Kitchen, as required by facility policy. The policy specified that hot foods must be held above 135 degrees and cold foods below 41 degrees. A review of the Food Temperature and Evaluation Log for several days in December revealed that staff did not record the required holding temperatures for multiple breakfast, lunch, and dinner meals. This omission was confirmed by the Food Service Director, who acknowledged that the facility did not document the holding temperatures as required. Multiple resident representatives and residents reported concerns about receiving cold food, with several stating that food was often or always cold, particularly at lunch. These concerns were documented on several occasions and corroborated by resident interviews. The failure to monitor and record food temperatures created the potential for foodborne illness, as confirmed by staff interviews and facility documentation.
Failure to Ensure Resident Communication Rights Due to Phone System Issues
Penalty
Summary
The facility failed to ensure that residents and their representatives had the right to communication and access to persons and services within the facility. Review of facility policy confirmed that residents are entitled to such communication. However, concerns from resident representatives indicated repeated unsuccessful attempts to contact facility staff over a period of weeks, with voicemails and emails going unanswered and no correspondence or returned calls from the administration office. During staff interview, the DON explained that administrative offices had recently been relocated, requiring new phone extensions, but the process was delayed due to maintenance staff absence. The DON acknowledged that the current phone situation did not allow residents or their representatives to easily communicate with facility personnel.
Failure to Ensure Proper Labeling and Maintenance of Enteral Feeding Supplies
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an enteral feeding tube. Review of the facility's policy required that the formula label include initials, date, and time when the formula was hung or administered, and that the label be checked against the order. Clinical record review showed that the resident was admitted with a right hip fracture, post-surgery, and pain, and had physician orders for enteral feeding and water flushes to maintain tube patency. During observation, the resident's enteral feeding bag was found without a label, initials, date, or time, and the water bag used for flushes was three days old. An LPN confirmed the absence of a label on the feeding formula and the outdated water bag. The DON also confirmed that the facility did not ensure appropriate treatment and services to prevent potential complications for the resident with an enteral feeding tube.
Failure to Document Required Abuse Training for Re-Hired Staff
Penalty
Summary
The facility failed to implement its written policies and procedures regarding abuse, neglect, and misappropriation training for staff, as evidenced by the lack of documentation showing that a nurse aide received required abuse training upon their most recent re-hire. Facility policy mandates that all employees complete abuse, neglect, and misappropriation/exploitation training upon hire and at least annually. However, a review of training records for one nurse aide did not include evidence of such training at the time of their re-hire. During interviews, the Director of Nursing confirmed the absence of documentation and acknowledged that the required training could not be verified for this employee.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards, resulting in two residents eloping from the premises. One resident with dementia, severe cognitive impairment, and a history of exit-seeking behaviors was not properly assessed for elopement risk initially, and their care plan was not updated in response to repeated exit-seeking incidents. The resident repeatedly removed their electronic monitoring device, and staff failed to ensure the device was in place and functioning. Documentation showed that the device was not checked on several occasions, and when the resident was found attempting to exit the building, the wander guard was not on their person. Additionally, the facility's monitoring systems, such as the wander guard system on elevators, were not consistently checked or functioning, as evidenced by maintenance records and staff interviews. Another resident with paranoid schizophrenia and moderate cognitive impairment was also identified as an elopement risk and had a history of wandering. Despite being ordered to wear an electronic monitoring device, the resident was able to leave the facility undetected. Staff and witness statements indicated that the wander guard system did not alarm when the resident exited via the elevator, and the resident was later found outside the facility with injuries after a fall. Staff interviews revealed gaps in supervision and a lack of recognition when residents at risk for elopement left the premises. The facility's elopement risk assessment tool was found to be inadequate, lacking a comprehensive scoring system, and staff were not consistently reeducated on elopement prevention following incidents. There were also failures in updating individualized care plans and implementing new interventions after repeated elopement attempts. The combination of insufficient monitoring, lack of timely care plan updates, and failure to ensure the functionality of safety devices contributed to the residents' ability to elope, creating an immediate jeopardy situation.
Removal Plan
- The Facility is obligated to provide adequate supervision which does not rely on the Wander guard System and is based on the individual resident's assessed needs and the risks identified in the Exit Seeking Elopement Evaluation/ Wandering Tool, which does not replace an electronic monitoring device.
- Review and revise the elopement evaluation/wandering assessment to include comprehensive scoring system.
- Current residents in-house will be reassessed for exit seeking / elopement by the Director of Nursing/designee.
- Residents will be assessed for exit seeking/elopement by the admitting RN upon admission.
- Elopement binder will be revised upon completion of all assessments by the Director of Nursing/designee.
- Per results of assessments, care plans will be updated and implemented with resident-specific interventions by Director of Nursing/designee as warranted.
- Elopement policies will be reviewed and revised as necessary by Nursing Home Administrator/designee.
- Wander guard system will continue to be audited by Environmental Director/designee.
- Education of all facility staff will be conducted by Director of Nursing/designee on Elopement Risk and Supervision of residents.
- QA/QAPI will be conducted related to plan of correction for F689. Meetings will be conducted regularly.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program as required. During an observation on Roseview Hallway, a poster was found displaying only the Ombudsman’s phone number, without the name, address, or email address. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required information was not fully posted. The report cites this as a failure to meet regulatory requirements for providing residents with access to pertinent State agencies and advocacy groups.
Nurse Aide Trainee Worked Beyond Certification Timeframe
Penalty
Summary
The facility failed to ensure that a nurse aide trainee, Employee E28, became certified within the required four-month period as mandated by federal regulations. Documentation showed that Employee E28 was hired as a nurse aide trainee and completed the facility's nurse aide training program, but continued to work as a nurse aide trainee from July 2024 to July 2025, exceeding the 120-day limit for uncertified nurse aides. This was confirmed by a review of personnel records, timecards, and an interview with the Human Resource Director, who acknowledged that Employee E28 worked past the allowed timeframe without obtaining certification. The deficiency was identified for one of four nurse aides reviewed.
Deficiencies in Food Storage, Labeling, Sanitation, and Hand Hygiene in Main Kitchen
Penalty
Summary
The facility failed to comply with its own policies and professional standards regarding food storage, labeling, sanitation, and hand hygiene in the Main Kitchen. During observations, surveyors found that food items in various storage areas, including refrigerators and freezers, were not properly labeled or dated. Specifically, a meat and cheese stick snack, an opened box of grits, chicken tenders, and soft pretzels were all found without labels or dates. Additionally, a rag with brown and black substances was found in a refrigerator, and loose sugar was scattered on the floor in the dry storage area. Meat was stored in a way that it touched the ceiling of the walk-in freezer, and large icicles were found on the freezer floor. Further deficiencies included the lack of essential supplies at hand washing stations, as the hand washing sink in the Main Kitchen did not have towels for drying hands. Equipment such as a meat slicer and floor mixer were observed to be uncovered and not in use, leaving them exposed to potential contamination. These findings were confirmed by the Food Service Director, who acknowledged the failures in labeling, dating, sanitation, and hand hygiene supply maintenance.
Failure to Prevent Resident Elopement Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of two residents. Review of job descriptions confirmed that the NHA was responsible for establishing and maintaining efficient and effective systems to safely meet residents' needs in compliance with regulations, while the DON was responsible for the organization and oversight of all nursing operations and supervision of resident care. Despite these responsibilities, the facility did not prevent the elopement of two residents, which created an immediate jeopardy situation. This failure was identified through review of job descriptions, clinical records, and staff interviews, and it was determined that the NHA and DON did not fulfill their essential job duties to ensure adherence to federal and state guidelines and regulations.
Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, as well as direct observations. Residents reported delays in receiving meals, with food often arriving cold due to late distribution. Several residents stated that they did not receive regular showers, particularly on weekends, and had to wash themselves or argue with staff to receive basic hygiene care. Residents also reported long wait times, up to 15-20 minutes, for staff to respond to call bells. Seven residents in a group interview expressed concerns about chronic understaffing. Staff interviews corroborated these concerns, with nurse aides reporting that they were sometimes responsible for as many as 60 residents with only three aides available. Staff stated that this level of staffing made it impossible to answer call lights promptly or provide showers as scheduled. The nursing home administrator confirmed that the facility did not have enough nursing staff to provide necessary care and services to maintain the highest practicable well-being of the majority of residents reviewed. These findings were cited as violations of state regulations regarding staffing and resident care.
Failure to Provide Medically Related Social Services for Residents with Mental Health Needs
Penalty
Summary
The facility failed to provide medically related social services to four residents with significant mental health diagnoses, including schizophrenia, major depressive disorder, mood disorder, anxiety disorder, and seizure disorder. Documentation review revealed that these residents did not receive consistent psychosocial support or follow-up for their mental health needs, despite recommendations for regular therapy and psychiatric follow-up. For example, one resident with paranoid schizophrenia and major depressive disorder had no current psychosocial support documented, while another with multiple mental health diagnoses had no consistent psychosocial reviews or follow-up after a physician appointment. Another resident was recommended for weekly psychiatric visits but had no documented interventions following behavioral incidents, and a fourth resident had no clinical documentation of psychosocial support after a recommendation for weekly therapy. Interviews with the facility's social worker confirmed that there was no established process for identifying residents in need of additional psychiatric social services, nor was there a maintained list of residents requiring regular psychosocial support. The social worker acknowledged that while a personal list was kept, it was not reflected in the clinical records of the affected residents and was not provided upon request. This lack of documentation and process resulted in the failure to provide necessary medically related social services as required by facility policy and regulatory standards.
Lack of Attending Physician Review of Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide evidence that monthly medication regimen reviews (MRR) were reviewed by the attending physician for three residents. For each resident, the clinical records showed that the MRRs were completed and signed by a Certified Registered Nurse Practitioner (CRNP), but there was no documented response or review from the attending physician as required. Specifically, for one resident with dementia, anxiety, and cognitive decline, the MRR did not include the attending physician's response, and the CRNP made decisions regarding gradual dose reduction for multiple psychotropic medications. Another resident with adult failure to thrive, hypertension, and dementia also had an MRR lacking the attending physician's review, with the CRNP making medication discontinuation decisions. A third resident with dementia, anxiety, depression, and Alzheimer's disease similarly had their MRR reviewed and signed by a CRNP, with decisions made about not completing gradual dose reductions for several medications, but without the attending physician's documented involvement. During staff interviews, it was confirmed that the facility did not ensure the attending physician reviewed the MRRs monthly for these residents, and that the reviews were instead conducted by nurse practitioners. This practice was not in accordance with facility policy and regulatory requirements, as the attending physician's review and response were missing from the medical records for all three residents involved.
Unqualified Food Service Director Employed
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) to manage the daily operations of the Dietary Department for nine out of twelve months. The individual serving as FSD during this period stated she had no relevant education or certification, specifically not being a Certified Dietary Manager. The Registered Dietitian (RD) employed at the facility confirmed her role was limited to clinical duties and did not include management of the kitchen operations. The Nursing Home Administrator acknowledged that there was no documented evidence to show that the FSD met the required qualifications for the position, as required by regulation.
Failure to Honor Resident's Roommate Choice and Provide Written Notice
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made regarding their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.
Resident Rights Violation: Unwarranted Room Transfer for Staff Convenience
Penalty
Summary
A resident with diagnoses of schizophrenia, anxiety disorder, and seizure disorder was admitted to the facility and had been residing in a private room for an extended period due to behavioral reasons. According to the clinical record and census review, the resident occupied the private room from 6/21/24 to 7/10/25. Staff interviews revealed that the resident was moved out of the private room to accommodate another resident who also required a private room for behavioral reasons. The social worker confirmed that the decision to move the resident was based on facility needs rather than the resident's needs, and that the resident was not able to pay for the private room. The facility failed to ensure that the room change was not completed for staff convenience, as required by resident rights regulations. The social worker acknowledged that the move was made to meet facility needs and not the needs of the resident, despite being aware that both residents had similar behavioral concerns necessitating a private room. This action resulted in a deficiency related to the protection of the resident's right to refuse certain types of non-requested transfers within the facility.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the call bell needs of one resident. According to facility policy, the call system must be accessible to residents while in bed or other sleeping accommodations. A review of the clinical record showed that the resident had diagnoses of anemia, muscle weakness, and required assistance with personal care. During an observation, the resident's call bell was found hanging from the wall unit at the head of the bed, out of the resident's reach. A registered nurse confirmed that the call bell was not accessible or available for the resident's use, indicating the facility did not meet the resident's needs for call bell accessibility.
Failure to Address Resident Grievance Regarding Assistance with Eating
Penalty
Summary
The facility failed to follow up on a grievance raised by a resident's family member regarding the need for assistance with eating due to the resident's recent weight loss. Documentation review showed that the family member requested help for the resident, who had anemia and required personal assistance, but there was no evidence in the clinical record that the facility responded to this concern. Staff interviews, including with the Nursing Home Administrator, confirmed that the concern was not addressed, indicating a failure to honor the resident's right to voice grievances and to ensure prompt resolution as required by federal and state regulations.
Failure to Provide Required Toileting Assistance Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, left below-knee amputation, and anxiety, who required staff assistance for toileting due to an activity of daily living (ADL) self-care deficit, was not provided the necessary care. The resident's care plan and facility policy required assessment and provision of appropriate transfer and toileting assistance. Documentation by a nurse aide indicated the resident was incontinent and received toileting hygiene assistance in the morning. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. Further review confirmed that the assigned nurse aide did not assist the resident with toileting as required, despite documentation stating otherwise. The aide acknowledged that the resident was saturated in urine and that the sheets needed to be changed. This failure to provide necessary toileting assistance and hygiene resulted in the resident being left in a soiled condition, constituting neglect as defined by the facility's policies and state regulations.
Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two of three sampled residents. For both residents, the clinical records showed that they were transferred to the hospital and later returned to the facility. However, there was no documented evidence that the facility provided the receiving health care provider with essential information, including the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. One resident had diagnoses of high blood pressure, hyperlipidemia, and required assistance with personal care, while the other had high blood pressure, hyperlipidemia, and muscle weakness. Despite these medical needs, the required communication and documentation were not present in the clinical records for either transfer. The Director of Nursing confirmed during an interview that the necessary information was not communicated for these residents.
Failure to Implement Smoking Safety Intervention per Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who required safety interventions while smoking. According to the resident's care plan and quarterly smoking assessment, the resident, who had diagnoses including high blood pressure, hemiplegia, and muscle weakness, was required to wear a smoking apron during smoking activities. However, during an observation, the resident was seen smoking in the designated area without the required smoking apron, despite this intervention being clearly documented in the care plan. Further investigation revealed that the staff member supervising the smoking session, a receptionist, was not aware that the resident was supposed to wear a smoking apron. The receptionist confirmed during an interview that they had never been informed of this requirement and acknowledged that the resident was not wearing the apron as indicated in the care plan. This failure to communicate and implement the care plan intervention resulted in noncompliance with facility policy and state regulations regarding resident care policies and nursing services.
Failure to Provide Required Toileting Assistance
Penalty
Summary
A deficiency was identified when a resident with a left below-the-knee amputation, dementia, and anxiety, who required staff assistance for toileting due to an activities of daily living (ADL) self-care deficit, did not receive the necessary care. According to the resident's care plan and facility policy, staff were required to provide assistance with toileting and document any refusals. On the date in question, documentation by a nurse aide indicated the resident was incontinent and had been provided with toileting hygiene assistance. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. The nurse aide assigned to the resident confirmed that the resident was saturated in urine, the sheets needed to be changed, and that toileting assistance had not been provided. The Nursing Home Administrator also confirmed the failure to provide toileting assistance for this resident.
Failure to Notify Physician of Insulin Refusal and Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician as required when two residents either refused prescribed insulin injections or experienced elevated capillary blood glucose (CBG) levels, as specified in physician orders and facility policy. For one resident with diagnoses including schizophrenia, anxiety disorder, seizure disorder, and type 2 diabetes mellitus, there were multiple documented refusals of prescribed Humalog insulin injections. However, the clinical notes did not indicate that the physician was notified of these refusals, contrary to facility policy and physician orders. For another resident with diabetes mellitus, hyperlipidemia, and PTSD, physician orders required notification if CBG levels exceeded certain thresholds. The resident's records showed several instances of CBG readings well above the specified threshold, but there was no documentation that the physician was notified of these elevated levels as required. The facility's policy on hyperglycemia management and the specific physician orders both mandated physician notification under these circumstances. Interviews with facility leadership confirmed that the nursing staff did not notify the physician as required, and instead relied on the nurse practitioner to review printed blood sugar records. The lack of timely physician notification for both medication refusals and elevated CBG levels constituted a failure to provide care and treatment according to physician orders and resident needs.
Failure to Obtain Physician Order for Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to obtain appropriate physician orders for a urinary catheter for one resident. The facility's policy requires that any resident admitted with an indwelling catheter, or who subsequently receives one, must be assessed for removal unless clinically necessary, and that proper physician orders must be obtained. Review of the resident's admission and care plan records indicated the presence of a catheter, but there was no corresponding physician order for its use after admission. The only order on file was from the hospital prior to admission. During observation, the resident was found with a catheter in use, and staff interviews confirmed that there was no specific physician order for the catheter in the facility's records. The Assistant Director of Nursing acknowledged that the required physician order had not been obtained as mandated by facility policy and state regulations. The resident had a medical history including diabetes, hyperlipidemia, and chronic kidney disease, and was being monitored for incontinence at the time of the deficiency.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required hemodialysis. According to facility policy, a communication form must be completed and sent with the resident to dialysis, and upon return, the form should be reviewed and post-dialysis information documented. For one resident with diagnoses including high blood pressure and End Stage Renal Disease, clinical records showed missing or incomplete dialysis communication forms on three separate treatment days within a specified period. A registered nurse unit manager confirmed these omissions. For another resident with similar diagnoses, the clinical record lacked complete communication forms for eight treatment days within a one-month period. Some forms were missing dates, and one treatment day had no form at all. A registered nurse confirmed the absence of these required forms, indicating the facility did not maintain consistent and complete communication with the dialysis center as required by policy.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with a diagnosis of post-traumatic stress disorder (PTSD). Facility policy requires the identification of triggers that may re-traumatize residents with a history of trauma. However, a review of the clinical record for one resident revealed the absence of a PTSD care plan with identified triggers, despite documentation of agitation, yelling profanities, and aggressive behavior. The resident's diagnoses of PTSD, depression, and insomnia were current at the time of review. Similarly, another resident with a diagnosis of PTSD did not have a care plan developed with goals and interventions related to PTSD. The care plan review did not include any trauma-informed strategies or identification of triggers. During staff interviews, it was confirmed that the facility failed to provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization for both residents.
Failure to Provide Appropriate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed mental and psychosocial adjustment difficulties, specifically suicidal ideation. The resident, who had diagnoses of dementia, anxiety, and cognitive decline, was grieving the loss of their spouse and had a history of severe cognitive impairment as indicated by a BIMS score of 4. On the day of the incident, staff removed potentially harmful objects from the resident's room after the resident expressed suicidal thoughts and behaviors, including statements about self-harm and intent to die. The resident's family confirmed concerns about suicidal ideation. The resident became agitated, and their roommate was relocated for safety. The resident was placed on every 15-minute checks for suicide prevention until being transferred to the hospital. Despite these interventions, the facility did not implement a one-to-one observation for the resident when they were actively suicidal, as confirmed by both the Nursing Home Administrator and the Nurse Practitioner. Facility policy and staff interviews indicated that one-to-one observation is expected in such situations to ensure the resident is not left alone. The failure to provide this level of supervision constituted a deficiency in ensuring the resident received appropriate treatment and services for their mental and psychosocial needs.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs. This deficiency was identified during the survey process, indicating a lapse in the delivery of care specific to dementia management for the affected resident.
Failure to Accurately Account for Controlled Medications on Medication Carts
Penalty
Summary
The facility failed to implement its own procedures for the accurate accounting of controlled medications on two medication carts, specifically the Cardinal East and Cardinal Southwest carts. According to the facility's policy, controlled medications are required to be counted by two professional nurses at the beginning and end of each shift, with documentation of the count and signatures to verify accuracy. However, a review of the narcotic count record logs revealed that nursing staff did not sign the records during shift changes on multiple occasions for both medication carts. Specific dates were identified where outgoing nurses failed to sign off, indicating that the required verification of controlled drug counts was not completed as per policy. Interviews with LPNs confirmed that there was no alternative method in place to verify narcotic counts other than the paper log, and that the required documentation was not completed. The deficiency was communicated to the Nursing Home Administrator, confirming that the facility did not follow its established procedures for controlled medication management as required by state regulations.
Outdated Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications in one of its medication carts, specifically the Dogwood [NAME] Medication Cart. During an observation, an outdated Humalog insulin pen belonging to a resident was found in the cart, with an open date of 6/17/25 and an expiration date of 7/14/25. Facility policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not followed. A Licensed Practical Nurse confirmed the presence of the outdated medication and acknowledged the failure to adhere to proper medication storage procedures.
Failure to Provide Special Eating Equipment as Care Planned
Penalty
Summary
A resident with diagnoses including dementia, acquired absence of the left leg below the knee, and anxiety was care planned to receive all disposable eating items from dietary services due to hoarding behaviors, which posed an infection control concern. Despite this care plan, the resident was observed using a reusable plate and silverware during a meal service. Staff confirmed that the facility failed to provide the required special eating equipment and utensils as specified in the resident's care plan, resulting in noncompliance with the established infection control measures for this individual.
Improper Containment of Outdoor Garbage Dumpster
Penalty
Summary
The facility failed to properly contain and dispose of garbage in one of three outside dumpsters, specifically the middle dumpster. Review of the facility's policy indicated that outside dumpsters must be closed and free of litter around the area. During an observation, it was noted and confirmed by the Food Service Director that the lid on the middle dumpster was not closed, which did not comply with the facility's garbage and rubbish disposal policy.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) during a wound dressing change for one resident who had a physician order for EBP. According to the facility's Transmission Based Precautions policy, EBP requires the use of gown and gloves during high-contact care activities for residents at increased risk, such as those with wounds or indwelling medical devices. During an observed dressing change, two LPNs did not don gowns and gloves as required. The resident involved confirmed that staff do not wear gowns during such procedures. This failure to follow established infection control protocols created the potential for cross contamination.
Failure to Provide Required Effective Communication Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Effective Communication to one of five direct care staff members, specifically a nurse aide (Employee E6). According to the facility's Staff Development Training Program policy, all employees are required to attend training on several topics, including Effective Communication, upon hire and at least annually. A review of Employee E6's personnel file showed that this staff member did not receive the required Effective Communication training during the specified annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the training had not been provided as required by facility policy and state regulations.
Failure to Provide Required Resident Rights Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Resident Rights to one of five staff members, specifically a nurse aide (NA) identified as Employee E6. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Resident Rights upon hire and at least annually. A review of Employee E6's personnel file showed that, despite being hired on 12/2/14, there was no documentation of Resident Rights training between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged the lapse in required training for this staff member.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to one of five staff members, specifically a nurse aide who was employed during the review period. According to the facility's Staff Development Training Program policy, all employees are required to attend training on these topics upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of this required training within the specified annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the required training had not been provided as stipulated by facility policy and state regulations. No information regarding residents' medical history or condition at the time of the deficiency was included in the report.
Failure to Provide Required QAPI Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to one of five staff members, specifically a nurse aide. According to the facility's Staff Development Training Program policy, all employees are required to attend training on QAPI upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of QAPI training within the required annual period. This deficiency was confirmed by the Registered Nurse Educator during an interview, who acknowledged that the required QAPI training had not been provided to the staff member as stipulated by facility policy.
Failure to Provide Required Infection Control Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory annual Infection Control training to one of five staff members, specifically a nurse aide who was employed since 12/2/14. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Infection Control upon hire and at least annually. Review of the nurse aide's personnel file showed no documentation of Infection Control training for the period between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged that the required training had not been provided to the staff member as stipulated by facility policy.
Failure to Provide Required Compliance and Ethics Training to Staff Member
Penalty
Summary
The facility failed to provide mandatory Compliance and Ethics training to one of five staff members, specifically a nurse aide who was hired on 12/2/14. According to the facility's Staff Development Training Program policy, all employees are required to attend training on Compliance and Ethics upon hire and at least annually. A review of the nurse aide's personnel file showed no documentation of Compliance and Ethics training between 12/2/23 and 12/2/24. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged that the required training had not been provided as stipulated by facility policy.
Failure to Provide Required Annual Training for Staff
Penalty
Summary
The facility failed to ensure that nurse aides and licensed practical nurses received the required annual training, including a minimum of 12 hours of in-service education and specific training on dementia management. Review of personnel files revealed that one nurse aide did not receive any in-service education or dementia management training during the specified annual period. Additionally, a licensed practical nurse also did not receive the required annual dementia management training within the designated timeframe. These findings were confirmed by the Registered Nurse Educator during staff interviews. Facility policy mandates that all employees must attend annual training on several topics, including dementia care, accident prevention, infection control, resident rights, and abuse prevention. The personnel files reviewed showed non-compliance with these requirements for the identified staff members, as there was no documentation of completed training for the relevant periods. The deficiency was cited under state regulations regarding staff development and the responsibility of the licensee.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to one of five nurse aides, as evidenced by a review of staff development records and facility policy. The facility's policy mandates that all employees must complete training on Behavioral Health upon hire and at least annually. Documentation for one nurse aide showed no record of Behavioral Health training within the specified annual period. This deficiency was confirmed during an interview with the Registered Nurse Educator, who acknowledged the lapse in required training for the identified staff member. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing levels as mandated by regulation. Specifically, on one day during the day shift, the number of NAs present was below the required ratio of one NA per 10 residents. On five separate days during the evening shift, the facility did not provide the minimum of one NA per 11 residents. Additionally, on two nights, the night shift did not meet the minimum requirement of one NA per 15 residents. These deficiencies were confirmed through a review of nursing time schedules, facility census data, and staff interviews, including confirmation by the Director of Nursing. There was no indication that additional higher-level staff were present to compensate for the NA shortages on these shifts. No information was provided regarding specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7.16.2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, and split shifts. We call/text unscheduled staff were contacted, and supplemental staffing were contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. Our Human Resource Clerk is scheduled to attend the Career link job fair and meet with the organizer on 7/21/25. An off-shift scheduler continues to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure CNA ratios are being met on day and night shifts. Audit results will be reviewed with QAPI Committee meeting monthly to determine the need for further audits.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
Facility administrative staff failed to meet required minimum staffing levels for licensed practical nurses (LPNs) on several occasions. Specifically, on one day during the reviewed period, the facility did not provide at least one LPN per 25 residents during the day shift, and on two separate nights, did not provide at least one LPN per 40 residents during the night shift. Review of nursing time schedules and census data confirmed these staffing shortages, and the Director of Nursing acknowledged that there were no additional higher-level staff present to compensate for the deficiency on those shifts. No information was provided regarding the involvement or condition of specific residents during the times of the staffing shortages.
Plan Of Correction
The Center continues to have retention and recruitment activities in place, which met on 7/16/2025. Nursing leadership did all things reasonably possible to meet the required ratios through bonuses, a day off on another day, split shifts, etc. All unscheduled staff were contacted, and supplemental staffing was contacted to send replacement staff. Ancillary staff were available and assisted in various tasks such as call bell attendant, delivery and removal of meal trays, delivery of water, bed making, and performance of other tasks within their scope of practice. Our Human Resource Clerk is scheduled to attend the Career Link job fair and meet with the organizer on 7/21/25. The facility will continue to ensure the schedule reflects the required staffing ratios and address call-offs. An off-shift scheduler was hired to perform scheduling duties after hours to maintain ratio. Staff and supplemental staffing have been reminded of the importance of them reporting to work as assigned. A weekend Manager program has been implemented, which will add extra monitoring on the weekends. No residents were affected. To monitor and maintain ongoing compliance, the DON/designee will audit 5 staffing sheets x 4 weeks to ensure LPN night shift ratios are being met. Audit results will be reviewed with the QAPI Committee meeting monthly to determine the need for further audits.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on nine out of twenty-one reviewed days. Review of nursing time schedules and census data showed that on these dates, the provided nursing hours per patient day (PPD) ranged from 2.72 to 3.18, falling short of the regulatory requirement. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
DON/designee completed education with the scheduler to schedule the staffing for 3.20 and above to maintain required PPD. An off-shift scheduler continues to perform scheduling duties after hours in an attempt to maintain PPD. Nursing supervisors will be educated to make phone calls to replace call-offs and no-shows. To monitor and maintain ongoing compliance, the DON/designee will audit 5 schedules weekly for 2 weeks to ensure staffing PPD is 3.20 or above. Audit results will be reviewed with the QAPI Committee during the monthly meeting to determine the need for further audits. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Ensure Proper Hair Restraint in Kitchen
Penalty
Summary
A deficiency was identified when a dietary employee in the main kitchen was observed not properly restraining his facial hair by failing to wear a beard guard as required by facility policy. The facility's Personal Hygiene policy, dated 4/1/25, specifies that dietary staff must properly restrain their hair by wearing hair nets and beard guards. During an observation, the employee was seen without a beard guard while working in the kitchen. This was confirmed in an interview with the Food Service Manager, who acknowledged that the employee did not comply with the policy, creating the potential for food borne illness.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to follow its own policies and standardized recipes regarding food preparation and service, resulting in food being served at improper temperatures and with poor palatability. During a lunch meal, a test tray audit revealed that multiple hot food items, including herb rubbed pork, beef and rice stuffed pepper casserole, mashed potatoes, apple bread stuffing, broccoli, and carrots, were served below the required minimum temperature of 135°F. Cold items such as fruit cup and milk were served above the maximum allowable temperatures. Additionally, coffee was served below the required temperature for hot beverages. These findings were confirmed by the Food Service Manager, who acknowledged that the food products did not meet point of service temperature standards. Observations and interviews further indicated that the food was not only served at incorrect temperatures but also failed to meet standards for appearance and taste. The herb rubbed pork did not appear oven roasted or properly seasoned, the apple bread stuffing lacked the expected flavors, and the beef and rice casserole was missing key ingredients and did not resemble a casserole. Broccoli was overcooked and mushy, failing to maintain its color and texture. Residents had previously voiced concerns about the temperature and quality of the food, as documented in interviews and the facility's grievance log.
Failure to Honor Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to provide food products according to resident preferences for four residents. Facility policy required trays to be checked for accuracy and resident dislikes, but observations and interviews revealed multiple failures. One resident reported not receiving requested food items on her menu. During tray line observation, two residents who were supposed to receive pureed broccoli were instead served pureed carrots, despite tray cards indicating their preference. Another resident, who preferred not to have gravy and whose tray card was marked 'NO GRAVY,' was served food with gravy. These incidents demonstrate that the facility did not consistently follow resident food preferences as documented and requested.
Delayed Meal Service Resulting in Undignified Dining Experience
Penalty
Summary
The facility failed to provide timely lunch meal service to residents across all five nursing units, resulting in an undignified dining experience. Facility policy required meals to be served in a timely manner, but review of the Meal Delivery Log showed a delay of approximately 50 minutes between the arrival of the first and second meal delivery carts. Observations confirmed that on the day in question, the first cart arrived at 11:50 am and the second at 1:26 pm, with the last resident receiving their meal at 1:47 pm, nearly two hours after the first trays were served. Multiple residents voiced concerns about consistently late meal delivery, and the Food Service Manager confirmed the failure to deliver trays in a timely manner.
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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