Sunset Ridge Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomsburg, Pennsylvania.
- Location
- 3298 Ridge Road, Bloomsburg, Pennsylvania 17815
- CMS Provider Number
- 395953
- Inspections on file
- 18
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sunset Ridge Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility's fire alarm system failed to automatically transmit alarms to notify emergency forces during an annual test. This deficiency was confirmed during a survey and remains unresolved.
The facility failed to maintain proper enclosures for three hazardous areas, affecting two smoke compartments. Observations revealed that doors to the Clean Laundry and Medical Records areas needed adjustments to latch properly, and the Oxygen Storage room door was not smoke-tight. These issues were confirmed during an exit conference with the Facility Administrator and Facilities Director.
The facility failed to maintain the automatic sprinkler system, with unsealed penetrations in the West Wing and painted-over sprinkler escutcheons in the Medical Records and East Wing Med room. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
The facility failed to review and update its menu to provide variety, resulting in repetitive meal patterns that did not meet resident satisfaction. Residents reported concerns about the lack of variety, with similar meats served consecutively. The facility's contracted dietary representative and NHA confirmed the menu's repetitiveness, leading to menu fatigue.
The facility's dietary department was found to have unsanitary conditions, including a greasy metal wire rack, a cluttered and dusty windowsill, improperly handled butter, and unclean food preparation equipment. These issues were confirmed with the NHA, indicating a failure to maintain sanitary standards and prevent potential food contamination.
The facility failed to implement a comprehensive infection prevention and control program. A review of policies and infection control logs revealed deficiencies, including the absence of a tracking log for June 2024 and incomplete documentation of critical infection-related details. The ADON confirmed these issues, indicating a lack of support for a comprehensive program.
A facility failed to maintain an effective antibiotic stewardship program, leading to the inappropriate prescription of antibiotics for a resident with a history of cancer and dementia. Despite an elevated WBC, the resident showed no other symptoms justifying antibiotic use. A physician prescribed Bactrim DS before culture results were available, which later confirmed resistance to the antibiotic. The resident received five doses of the ineffective medication, indicating a failure in the facility's monitoring and prescribing practices.
A resident at Sunset Ridge Rehabilitation and Nursing Center experienced multiple falls due to inadequate supervision and ineffective fall prevention measures. Despite being at high risk for falls, the resident suffered injuries from unwitnessed falls in various locations. The facility failed to consistently implement planned interventions, such as frequent visual checks, contributing to the resident's recurrent falls and injuries.
The facility failed to provide adequate pain management for two residents. One resident with rib fractures received narcotic pain medication without documented non-pharmacological interventions in most instances. Another resident with COPD and arthritis had no documented evidence of alternative pain-relief interventions despite continued pain and a new diagnosis of lumbar vertebrae compression fractures. The DON confirmed the facility's failure to implement appropriate pain management interventions.
A facility failed to create an individualized care plan for a resident with dementia, who exhibited agitation, aggression, and delusional behaviors. The care plan lacked specific interventions and did not consider the resident's history or preferences, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a system of records for controlled drugs, as required by policy, leading to a deficiency. A resident discharged against medical advice had no documented accountability record for controlled medications like Oxycodone and Tramadol. The DON confirmed the absence of required documentation, which is necessary to prevent unauthorized use and ensure accurate tracking.
A resident with a history of cancer and dementia received unnecessary antibiotics due to an elevated white blood count but no other infection signs. The physician prescribed Bactrim DS before culture results were available, which later showed resistance to the medication. The resident received five doses of ineffective antibiotics, confirmed by the DON as unjustified.
A facility failed to maintain accurate clinical records for two residents after an incident where one resident kissed another. The records lacked documentation of the interaction, staff intervention, and follow-up assessments, resulting in incomplete and inaccurate records. The Nursing Home Administrator and DON confirmed the documentation failure.
A resident with a history of cancer and dementia was admitted to hospice services, but the facility failed to coordinate care with the hospice agency. The care plan lacked evidence of collaboration to address the resident's daily care needs and terminal diagnosis. The Nursing Home Administrator confirmed the care plan was not coordinated with hospice services.
A facility failed to ensure a physician completed a discharge summary for a resident who was admitted and later expired. The resident's clinical record lacked documentation of a discharge summary upon their death and discharge, as confirmed by the DON during an interview.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one night shift, there were 3.67 nurse aides instead of the required 4.27 for 64 residents. On a day shift, there were 6.17 nurse aides instead of the required 6.40. No additional staff were available to cover these shortages, leading to non-compliance with staffing regulations.
The facility did not meet the required LPN to resident ratio during an evening shift, with only 2.03 LPNs available instead of the required 2.10 for 63 residents. This deficiency was confirmed by interviews with the Nursing Home Administrator and the DON.
The facility failed to protect two residents from sexual abuse by another resident with a known history of inappropriate behavior. Despite staff awareness and documentation of the incidents, the facility did not investigate, report, or implement necessary interventions to prevent further abuse.
The facility failed to report incidents of sexual abuse involving two residents to the State Survey Agency and local law enforcement, despite staff witnessing and documenting the inappropriate behavior by another resident. The facility did not adhere to its own policy or state regulations regarding timely reporting of abuse.
The facility failed to investigate timely and thoroughly the sexual abuse of two residents by another resident. Staff witnessed inappropriate behavior but did not follow the facility's policy, including arranging medical attention, documenting evidence, or obtaining witness statements. The Director of Nursing and the Nursing Home Administrator confirmed the lack of investigation.
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical needs, including constipation, incontinence, sexually inappropriate behaviors, and management of medical devices and respiratory therapy.
The facility failed to promptly assess two residents after instances of sexual abuse and did not follow physician's orders for bowel protocols for two other residents. Staff witnessed and reported the abuse, but no nursing assessments were documented. Additionally, prescribed bowel regimens were not administered, and physicians were not notified of the lack of bowel movements.
The facility failed to provide routine evening snacks to residents, resulting in more than 14 hours between supper and breakfast. Observations and interviews revealed that snacks and beverages were not consistently available or offered, and there was no documented evidence to support the routine offering of evening snacks.
The facility failed to maintain accurate and complete clinical records for three residents, leading to deficiencies in documentation and care. A resident exhibited inappropriate behaviors towards other residents, but the clinical records lacked detailed documentation. Two residents were victims of sexual abuse by the same resident, but their clinical records did not document the incidents or include nursing assessments for injuries. Staff interviews confirmed the failure to document complete and accurate information.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with conditions requiring such measures, including a resident with a stage 3 pressure ulcer and Foley catheter, another with venous and diabetic foot ulcers, and a third with a tracheal stoma. Observations confirmed the lack of EBP, despite facility policy and CDC guidelines.
The facility failed to notify the physician and the resident's representative of an incident where a resident with dementia was inappropriately touched by another resident. Despite the incident being witnessed by a nurse aide, there was no documented evidence of notification, which was confirmed by the Director of Nursing and the Nursing Home Administrator.
The facility failed to timely train an agency nurse aide on the abuse prohibition policy and procedures. The employee started working without receiving the necessary orientation or training, and there was no documented evidence of such training in her file. The Nursing Home Administrator confirmed the lack of documentation.
The facility failed to provide written notices for hospital transfers to residents and their representatives, affecting five residents. Clinical records and staff interviews confirmed the absence of required notifications, including transfer reasons, effective dates, and contact information for relevant advocacy agencies.
The facility failed to provide residents or their representatives with written information about the bed hold policy upon hospital transfer. This deficiency was identified in five residents, including one who expired at the hospital. The DON confirmed the lack of documented evidence.
Fire Alarm System Deficiency
Penalty
Summary
The facility failed to maintain the fire alarm system for the entire building, as evidenced by the annual fire alarm system testing documentation from January 13, 2025. The documentation revealed that the fire alarm system did not automatically transmit the alarm to notify emergency forces in the event of a fire. This deficiency was observed during a survey on March 17, 2025, at 9:30 a.m., and it was confirmed during an exit conference with the Facility Administrator and Facilities Director at 11:30 a.m. on the same day that the issue still persisted.
Plan Of Correction
1. The fire alarm system will transmit the alarm automatically to notify emergency forces in the event of a fire. 2. The facility has an agreement in place for the work to be completed. 3. The fire alarm system will be audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facility's Q.A.P.I. meeting for review and recommendation.
Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain proper enclosures for three hazardous areas, affecting two of three smoke compartments. During an observation on March 17, 2025, it was noted that the door to the Clean Laundry area required adjustment to ensure it positively latched into the frame. Similarly, the door to the Medical Records area also needed adjustment for proper latching. Additionally, the door to the Oxygen Storage room in the East Wing was found not to be smoke-tight when latched into the frame, located at the nurses' station. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The Clean Laundry, Medical Records, and East Wing Oxygen Storage room doors have been adjusted to be smoke tight and latch into the frame. 2. The Maintenance Director/Designee will check doors in the facility to ensure they are smoke tight and latch into the frame. 3. Facility doors will be randomly audited to ensure ongoing compliance. Audits will be completed by the Maintenance Director/Designee. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by observations and interviews conducted during a survey. On March 17, 2025, between 10:12 a.m. and 10:20 a.m., it was observed that the West Wing had an unsealed penetration of a corridor ceiling tile near Resident Room 109, and the Med room at the Nurses' station had an unsealed penetration of the wall around two blue IT cables. Further observations between 10:39 a.m. and 10:55 a.m. revealed that the Medical Records area had two sprinkler escutcheons that had been painted over, and the East Wing Med room at the Nurses' station also had a painted-over sprinkler escutcheon. These deficiencies were confirmed during an exit conference with the Facility Administrator and Facilities Director.
Plan Of Correction
1. The ceiling tile on West Wing has been replaced. The Medication rooms IT cables have been sealed. The paint has been removed from the escutcheons in the Medical Records room. 2. The Maintenance Director/Designee will check area of the facility to ensure smoke compartments are sealed. 3. Audits of smoke compartments will be audited to ensure ongoing compliance of the automatic sprinkler system. 4. Audits will be reviewed at the facilities Q.A.P.I. meeting for review and recommendation.
Repetitive Meal Patterns in Facility Menu
Penalty
Summary
The facility failed to ensure that the planned menu was sufficiently reviewed and updated to provide variety and avoid repetitive meal selections, as required by §483.60(c). During a Resident Council meeting, multiple residents expressed concerns about the lack of variety in the menu, noting that the same meats were served for consecutive meals. The Resident Council President mentioned that these concerns had been raised in food committee meetings with the Certified Dietary Manager but were not addressed, as the facility's menu was provided by a contracted vendor and reportedly could not be modified. A review of the Fall/Winter 2024-2025 menu revealed multiple instances of repetitive meal patterns over the 4-week cycle, with similar meats being served for consecutive meals. Interviews with the facility's contracted dietary food/menu representative and the Nursing Home Administrator confirmed that the facility's menu was repetitive and did not offer variety, leading to menu fatigue and reduced meal satisfaction among residents. The facility's failure to review and modify the planned menus resulted in repetitive meal patterns that did not meet the satisfaction of the residents.
Plan Of Correction
The facility cannot retroactively correct the menu schedule as observed during survey. Current menu will be reviewed, altered, and updated to reflect variety to assist in deterring menu fatigue and increasing menu satisfaction. Certified dietary manager, Registered Dietician and kitchen staff will be re-educated on meal rotation/variety. Audits will be completed on resident satisfaction of meal variety weekly x 4 weeks, then monthly x 2 months. Audit findings will be reviewed at monthly QAPI meeting, resident council and food committee.
Unsanitary Conditions in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions in the dietary department, as observed during an inspection. In the cook's area, a metal wire rack used for storing clean cooking equipment was found to be greasy with a significant buildup of debris, indicating inadequate cleaning practices. Additionally, the windowsill above the microwave and open bread loaves was cluttered and covered in dust and debris, posing a potential source of contamination. A storage container of butter was improperly handled, with a dirty, uncovered butter spreader resting on it, and the butter itself was discolored, had crumbs adhered to its surface, and appeared soft and melting. Further observations revealed that the interior of the microwave contained food splatter and peeling surfaces, which could lead to cross-contamination. A food prep station had an industrial can opener with a sticky blade, which had been used earlier to open cans of tuna fish and had not been cleaned afterward, failing to meet sanitary standards for food preparation equipment. These findings were confirmed with the facility's Nursing Home Administrator, highlighting the need for maintaining the dietary department in a sanitary manner to prevent potential food contamination and foodborne illness.
Plan Of Correction
Areas of concern noted during tour on 3/11/25 were cleaned/corrected that same day, 3/11/25. New microwave has been purchased to replace the current microwave noted as a concern during survey. Food prep, storage and hard surface areas will be placed on a routine cleaning schedule to prevent food contamination and food-borne illness. CDM and kitchen staff will be re-educated on new routine cleaning schedules. Audits of food prep, storage and hard surface areas will be completed by NHA/designee weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program as required by regulations. A review of the facility's policies and infection control logs revealed significant deficiencies in the program's execution. The facility's policy on 'Infection Prevention and Control Program' outlined the need to identify, investigate, control, and prevent infections, but the actual practice did not align with these objectives. Specifically, the facility lacked an effective system to analyze infection clusters, track changes in prevalent organisms, or identify increases in infection rates in a timely manner. Further investigation into the facility's infection control logs from May 2024 through March 2025 showed that there was no tracking of infections for June 2024. Additionally, the logs were incomplete, missing critical infection-related details such as the location of infections, whether they were community-acquired or facility-acquired, symptoms experienced by residents, and the onset date of infections. An interview with the Assistant Director of Nursing, who also serves as the facility's Infection Preventionist, confirmed the absence of a tracking log for June 2024 and acknowledged the incompleteness of the logs, indicating a failure to support a comprehensive infection prevention and control program.
Plan Of Correction
Facility logs for June 2024 were located and are present in the facility. Current system utilized for infection prevention and control will be reviewed. Processes not meeting policy guidelines will be updated and implemented. Nursing staff will be re-educated on facility infection prevention and control program and policies. Audits will be completed on new infections to determine that criteria in facility policies have been followed weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective system for monitoring antibiotic usage as part of its antibiotic stewardship program. This deficiency was identified during a survey, which revealed that the facility did not adhere to its own policies regarding antibiotic prescribing and monitoring. Specifically, the facility's policy required that antibiotics be prescribed based on clinical indications of active infection or suspected sepsis, and that antibiotic usage and outcomes be documented and reviewed by the infection preventionist. However, the facility did not provide evidence that prescribing practitioners were informed of their prescribing practices, nor did it demonstrate actions to optimize infection treatment through improved antibiotic prescribing and management. The deficiency involved a resident who was admitted with a history of malignant neoplasm of the bladder and dementia. Despite having an elevated white blood cell count, the resident showed no other symptoms justifying antibiotic use. Nevertheless, a physician ordered a urinalysis with culture and sensitivity, and subsequently prescribed Bactrim DS before the culture results were available. The culture later confirmed the presence of an antibiotic-resistant strain of E. coli, rendering the prescribed antibiotic ineffective. The resident received five doses of the unnecessary antibiotic, highlighting a failure in the facility's antibiotic stewardship program. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
The facility cannot retroactively correct the administration of antibiotic to resident 1. Current residents on antibiotic therapy for a UTI will be reviewed to determine antibiotic necessity and verification of MD notification. Nursing staff and in-house physicians will be re-educated on antibiotic stewardship policy. Audits will be completed on residents who are ordered a UA C&S to determine the necessity of antibiotic and verification of MD notification weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed in monthly QAPI meeting.
Inadequate Supervision Leads to Recurrent Falls
Penalty
Summary
Sunset Ridge Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations due to inadequate safety measures and supervision for a resident identified as high risk for falls. The facility failed to implement effective fall prevention interventions, resulting in multiple recurrent falls for a resident with severe cognitive impairment and a history of impulsiveness and poor safety awareness. Despite being identified as high risk for falls, the resident experienced 14 falls over a period of several months, many of which were unwitnessed. The resident, admitted with diagnoses including dysphagia, abnormalities of gait and mobility, repeated falls, hypertensive heart disease, and urinary tract infection, continued to fall in various locations such as their room, bathrooms, and common areas. The facility's documentation revealed a lack of consistent implementation of planned interventions, such as frequent visual checks, which were added to the resident's care plan but not consistently conducted. The resident's falls resulted in injuries, including abrasions, hematomas, and a head wound, and were often associated with attempts to self-transfer or use the bathroom. Interviews with facility staff, including the Director of Nursing, confirmed the failure to provide adequate supervision and follow through with planned interventions. The facility's inaction and lack of effective supervision contributed to the resident's recurrent falls and injuries, highlighting a significant deficiency in meeting the required standards for resident safety and care.
Plan Of Correction
Resident 50 frequent visual checks evaluated and removed from tasks and care plan. Fall interventions reviewed and verified as effective. Facility will continue to implement interventions to assist with prevention of recurrence of falls/injury. Current residents care plans will be reviewed to verify presence of safety interventions to assist in the prevention of falls. Nursing staff will be re-educated on the implementation of effective fall prevention interventions. Audits will be completed on fall incident reports weekly x 4 weeks, then monthly x 2 months to ensure the implementation of fall prevention interventions. Results will be reviewed at monthly QAPI meeting.
Failure in Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, as evidenced by the lack of non-pharmacological interventions prior to administering narcotic pain medication for one resident and the failure to implement appropriate interventions for another resident's continued pain. Resident 60, admitted with multiple rib fractures, had physician orders for as-needed Oxycodone. However, in January 2025, staff administered the medication 30 times, with 23 instances lacking documented evidence of non-pharmacological interventions. Similar patterns were observed in February and March 2025. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the inconsistency in attempting non-pharmacological interventions before administering narcotic pain medication. Resident 15, admitted with chronic obstructive pulmonary disease and emphysema, had a care plan for pain related to arthritis, which included non-pharmacological interventions such as repositioning and therapy evaluation. Despite complaints of pain and a new diagnosis of lumbar vertebrae compression fractures, there was no documented evidence that the resident was offered as-needed acetaminophen or other alternative pain-relief interventions. The Director of Nursing confirmed the facility's failure to develop and implement appropriate pain management interventions for Resident 15's continued pain.
Plan Of Correction
The facility cannot retroactively correct the nonpharmacological intervention documentation presence prior to as needed oxycodone administration for resident 60 for 1/13/25-1/26/25 and 2/13/25. All other administrations have nonpharmacological interventions documented in the Medication Administration Record. Resident 15 has remained free of verbal/nonverbal complaints of pain since 1/13/25, with dates of pain documented only on 1/12-1/13/25. Facility will assess current residents with as needed pain medications to verify presence of nonpharmacological intervention(s) documentation prompt prior to medication administration in the medical record and administer as needed/indicated. Nursing staff will be re-educated on documentation and implementation of nonpharmacological intervention(s) prior to medication administration. Audits will be done on new admissions with as needed pain medication to ensure presence of nonpharmacological intervention(s) documentation prior to medication administration in the MAR weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Implement Individualized Care Plan for Dementia-Related Behaviors
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with dementia, who exhibited behavioral symptoms such as agitation, aggression, and delusional ideation. The resident, admitted with dementia and agitation, displayed recurrent episodes of increased agitation, aggressive and argumentative behaviors, verbal threats, and delusional beliefs, including thinking another resident was her daughter and that staff had taken her daughter. These behaviors were documented in multiple progress notes over several months, indicating a pattern of distress and confusion. Despite these documented behaviors, the resident's care plan did not identify specific behavioral symptoms or include individualized interventions tailored to address each behavior. The care plan also failed to incorporate the resident's preferences, social and past life history, customary routines, and interests to support behavior management. An interview with the Nursing Home Administrator confirmed the absence of an individualized, person-centered care plan to manage the resident's dementia-related behaviors, leading to the deficiency finding.
Plan Of Correction
Resident 10 care plan has been updated to reflect specific behavioral symptoms, interventions, resident preferences and interests. Residents with dementia diagnosis will be audited to ensure the presence of personalized interventions related to resident specific behaviors. Nursing staff will be re-educated on resident specific care plans and behaviors related to dementia. Audits will be completed on new admissions with diagnosis of dementia to ensure the presence of resident specific behaviors and interventions in the care plan weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Maintain Controlled Medication Records
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, which is necessary for accurate accounting and to prevent possible diversion. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy on Discharge Medications requires that controlled substances not be released upon discharge unless permitted by state law and authorized by the resident's attending physician. Additionally, the policy mandates that a nurse reconcile pre-discharge medications with post-discharge medications and document the reconciliation, including a detailed medication disposition record. In the case of Resident 62, who was admitted with acute cystitis and weakness, there was a failure to document the accountability record for controlled medications, including Oxycodone and Tramadol, upon the resident's discharge against medical advice. The nursing note indicated that the resident signed out against medical advice, and while the attending physician and Nursing Home Administrator were notified, there was no documented evidence of a controlled medication accountability record. The Director of Nursing confirmed the absence of this documentation, which is required by facility policy to prevent unauthorized use and ensure accurate tracking and disposition of controlled medications.
Plan Of Correction
The facility cannot retroactively correct the absence of the medication disposition on resident 62. Residents discharged home in the last 30 days will be reviewed to determine the presence of medication disposition form. Nursing staff will be re-educated on completion of the medication disposition form upon discharge home. Audits will be completed on residents discharging home from the facility to ensure the presence of the medication disposition form weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. A resident, admitted with a history of malignant neoplasm of the bladder and dementia, had an elevated white blood count but no other signs of infection. Despite this, the physician ordered a urinalysis with culture and sensitivity to assess for possible infection. The resident was catheterized to obtain a urine sample, and the results were pending. However, before the culture and sensitivity results were available, the physician prescribed Bactrim DS, an antibiotic, to be administered every 12 hours for five days. The laboratory report later revealed that the urine culture identified Escherichia coli ESBL, which was resistant to the prescribed antibiotic, rendering the treatment ineffective. The resident received five doses of Bactrim DS before the culture and sensitivity results confirmed the medication's ineffectiveness. During an interview, the Director of Nursing confirmed that the administration of Bactrim DS was not clinically justified, as it was ineffective against the identified organism, resulting in the resident receiving an unnecessary medication.
Plan Of Correction
The facility cannot retroactively correct the ordered administration of the antibiotic to resident 1. Lab culture results will be reviewed on all current residents receiving antibiotic therapy for a UTI to ensure that the ordered antibiotic is clinically justified. Nursing staff will be re-educated on medication necessity related to evidence-based infection control and antimicrobial stewardship practices. Audits will be completed on new antibiotics for UTIs to determine the necessity weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at the monthly QAPI meeting.
Failure to Document Resident Interactions and Behaviors
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, Resident 8 and Resident 44, as required by professional standards of practice. Resident 8, who was admitted with hypertensive heart disease, was cognitively intact according to a recent assessment. Resident 44, admitted with multiple sclerosis, was severely cognitively impaired. An incident occurred where Resident 44 kissed Resident 8 in the hallway, which was observed by staff. Despite the incident, there was no documentation in Resident 8's clinical record regarding the interaction, staff intervention, or any follow-up assessments to determine potential emotional or psychological effects. Similarly, Resident 44's clinical record lacked documentation of the behavior, assessments following the event, or any interventions to prevent recurrence. This lack of documentation resulted in incomplete and inaccurate clinical records for both residents. The Nursing Home Administrator and Director of Nursing confirmed that the nursing staff failed to consistently and accurately document residents' interactions and behaviors in the clinical records. This failure to document significant events and follow-up actions is a deficiency in maintaining accurate and complete clinical records, as required by the regulations.
Plan Of Correction
Medical records were updated on resident 8 and resident 44 to include investigation summary and outcome. Last 3 PB22's will be reviewed to ensure the presence of documentation in the medical record. Nursing staff will be re-educated on maintaining accurate and complete clinical records related to PB 22's. Audits will be completed on new PB22's to verify accurate and complete documentation weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure proper coordination of care and services between the long-term care facility and the hospice agency for one resident. This deficiency was identified during a review of clinical records and staff interviews. The resident in question was admitted to the facility with a history of malignant neoplasm of the bladder and dementia, and later admitted into hospice services. However, the care plan for this resident did not reflect the necessary collaboration between the facility and the hospice agency. The resident's care plan, initially dated shortly after admission, lacked documented evidence of collaboration in addressing the resident's daily care needs and specific care and services related to the resident's terminal diagnosis. This indicates a failure to integrate hospice care into the resident's overall care plan, which is essential for ensuring that the resident's needs are met comprehensively. An interview with the Nursing Home Administrator confirmed that the resident's care plan was not coordinated with hospice services. This lack of coordination could potentially impact the quality of care provided to the resident, as the care plan did not adequately address the resident's terminal diagnosis and the necessary hospice services.
Plan Of Correction
Resident 1 care plan has been reviewed and updated to reflect the coordination of care and services between the facility and hospice agency. Current residents on hospice will have care plans reviewed to verify the presence of coordination of care and services between the facility and hospice agency. Nursing staff will be re-educated on the need of care plan coordination of care and services between facility and hospice. Audits will be completed on new hospice admissions to ensure the presence of coordination of care and services between facility and hospice in the care plan weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at monthly QAPI meeting.
Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure that a discharge summary was completed by the physician for one resident. The clinical record review of a resident revealed that the resident was admitted to the facility and later expired and was discharged. However, there was no documented evidence in the resident's clinical record that a discharge summary was completed by the physician upon the resident's death and discharge. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the required documentation.
Plan Of Correction
The facility cannot retroactively correct the presence of a physician discharge summary on resident 63. Residents who discharged in the last 30 days will be reviewed to determine the presence of a physician discharge summary. Nursing staff and physicians will be re-educated on completion of a discharge summary. Audits will be completed on residents who discharge to ensure completion of a discharge summary by the physician weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two specific shifts out of 63 reviewed. On September 4, 2024, during the night shift, the facility had 3.67 nurse aides instead of the required 4.27 for a census of 64 residents. Similarly, on December 29, 2024, during the day shift, the facility had 6.17 nurse aides instead of the required 6.40 for the same census. No additional higher-level staff were available to compensate for these deficiencies, resulting in non-compliance with the staffing regulations effective July 1, 2024, which mandate a minimum of 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight.
Plan Of Correction
The facility cannot retroactively correct past Nursing Aide ratios. The facility will continue to take measures to adequately provide nurse-aide staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required nurse aide to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.
LPN Staffing Deficiency on Evening Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratio on one occasion during the evening shift. Specifically, on December 25, 2024, the facility's staffing records showed that there were only 2.03 LPNs available, whereas the required number was 2.10 for a census of 63 residents. This deficiency was confirmed through interviews with both the Nursing Home Administrator and the Director of Nursing on March 13, 2025. No additional higher-level staff were available to compensate for this shortfall, leading to a failure in meeting the regulatory staffing requirements.
Plan Of Correction
The facility cannot retroactively correct past LPN ratios. The facility will continue to take measures to adequately provide LPN staff to ensure the needs of the residents are met. Measures will be put in place to adequately provide staff with the required LPN to resident ratios. These measures include continuing our retention committee, increased advertising efforts, utilization of agency staff, and sign-on bonuses. The Director of Nursing/designee will continue to educate minimum staffing ratios to RN Supervisors, HR, and the nursing scheduler who are responsible to maintain adequate staffing ratios. The Director of Nursing/designee will audit the daily schedules to ensure that the minimum number of nurse aide staff to resident ratios have been scheduled. The results of the audits will be reviewed at the facilities QAPI meeting for recommendations.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two residents, Resident 45 and Resident 42, were free from sexual abuse perpetrated by Resident 6. Resident 45, who was moderately cognitively impaired due to dementia, was touched inappropriately by Resident 6 in the dining room. Despite being aware of Resident 6's history of sexually inappropriate behavior, the facility did not document the incident in Resident 45's clinical record, nor did they fully investigate or report the incident. Staff interviews confirmed that Resident 6's behaviors were a known issue, yet necessary interventions were not implemented to prevent further incidents. Resident 42, who was also moderately cognitively impaired and diagnosed with multiple sclerosis, was another victim of Resident 6's inappropriate behavior. Staff members witnessed Resident 6 groping Resident 42's breasts, but the facility failed to document this incident in Resident 42's clinical record. Similar to the case with Resident 45, the facility did not investigate or report the incident, nor did they take adequate measures to prevent further abuse. Interviews with various staff members, including nurse aides and an LPN, revealed that Resident 6's sexually inappropriate behavior was a recurring issue that was frequently discussed in staff reports. Despite this, the facility did not take sufficient action to protect the residents from abuse. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to ensure the safety of Residents 45 and 42 from sexual abuse by Resident 6.
Failure to Report Sexual Abuse Incidents
Penalty
Summary
The facility failed to timely report incidents of sexual abuse involving two residents, Resident 45 and Resident 42, to the State Survey Agency and local law enforcement. According to the facility's policy, all incidents of abuse must be reported electronically to the Pennsylvania Department of Health within 24 hours and a completed investigation must be submitted within five working days. Additionally, the police should be contacted immediately in cases of sexual abuse. However, the facility did not adhere to these protocols in the cases of Resident 45 and Resident 42, who were both moderately cognitively impaired and subjected to inappropriate sexual behavior by Resident 6, who has a history of such behaviors known to the staff and administration. Resident 45, diagnosed with dementia, was inappropriately touched by Resident 6 in the dining room, as witnessed by multiple staff members including nurse aides and an LPN. Despite the staff's awareness and documentation of the incident, the facility did not report the abuse to the State Survey Agency or the local police. Similarly, Resident 42, diagnosed with multiple sclerosis, was also subjected to inappropriate sexual behavior by Resident 6, which was witnessed and documented by staff. Again, the facility failed to report this incident to the appropriate authorities. Interviews with various staff members, including nurse aides, an LPN, and an RN Supervisor, confirmed that the incidents were known and reported internally to the Director of Nursing. However, the facility did not follow through with the required external reporting. The Nursing Home Administrator and Director of Nursing confirmed the failure to report these incidents to the State Survey Agency and local law enforcement, violating multiple Pennsylvania Code regulations regarding the responsibility of the licensee, management, resident rights, and nursing services.
Failure to Investigate Sexual Abuse Allegations
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into the sexual abuse of two residents, Resident 45 and Resident 42, by Resident 6. The facility's policy on investigating allegations of abuse, neglect, or misappropriation of resident property was not followed. Specifically, the Registered Nurse Supervisor or Department Head did not immediately initiate an investigation, remove the alleged perpetrator, or notify the administrator/designee as required. Additionally, the facility did not arrange for medical attention for the victims, document and preserve evidence, or obtain written statements from all appropriate individuals on duty at the time of the incidents. Resident 45, who was moderately cognitively impaired and diagnosed with dementia, was touched inappropriately by Resident 6 in the dining room. Multiple staff members, including nurse aides and an LPN, witnessed the incident but did not follow the facility's policy for handling such situations. Similarly, Resident 42, who was also moderately cognitively impaired and diagnosed with multiple sclerosis, was groped by Resident 6. Staff members were aware of this behavior but failed to document it properly or initiate an investigation. Interviews with various staff members, including nurse aides and an RN, revealed that they were aware of the inappropriate behavior but did not take the necessary steps to address it. The Director of Nursing and the Nursing Home Administrator confirmed that the facility did not complete investigations into the sexual abuse of Resident 45 and Resident 42 by Resident 6. The facility's failure to follow its own policies and procedures resulted in a lack of proper investigation and response to the allegations of sexual abuse.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for five residents, leading to deficiencies in addressing their specific medical needs. Resident 2, who was admitted with a diagnosis of constipation, had multiple physician orders for managing constipation, including medications and interventions. However, the resident's care plan did not include these prescribed bowel regimens, failing to address the resident's diagnosed condition and necessary interventions. Similarly, Resident 60, who had functional incontinence and was placed on a prompted voiding program, did not have this condition or the required interventions included in their care plan, leading to inadequate management of their incontinence needs. Resident 6, admitted with hypertensive heart disease, exhibited sexually inappropriate behaviors towards female residents. Despite multiple incidents and new orders to monitor and document these behaviors, the resident's care plan did not address these behaviors or include specific interventions to manage them and protect other residents from potential abuse. This oversight resulted in continued inappropriate interactions, including an incident where Resident 6 touched another resident inappropriately in the dining room. Resident 61, with complex medical conditions including pancreatic cancer, ischemic cardiomyopathy, and an AICD device, had care needs related to potential complications and emergency care of the Mediport and AICD device that were not addressed in their care plan. The facility failed to document necessary interventions for monitoring and managing these devices. Similarly, Resident 14, diagnosed with obstructive sleep apnea and congestive heart failure, had physician orders for BiPAP and oxygen therapy, but these were not included in the care plan, leading to inadequate documentation and management of their respiratory needs. The Nursing Home Administrator and Director of Nursing confirmed these deficiencies during the survey.
Failure to Assess Residents After Sexual Abuse and Follow Bowel Protocols
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed and professional nurses promptly assessed residents following instances of sexual abuse. Specifically, two residents, one with dementia and another with multiple sclerosis, were victims of sexual abuse by another resident. Despite staff witnessing and reporting these incidents, there was no documented nursing assessment to identify potential trauma, skin injuries, bruising, or pain in the affected areas of the victims' bodies. Additionally, the facility did not follow physician's orders for administering a bowel protocol to promote bowel activity for two residents. One resident with a diagnosis of constipation did not receive the prescribed bowel regimen over a period of three days without a bowel movement. Similarly, another resident with pancreatic cancer and muscle weakness did not receive the ordered bowel regimen over four consecutive days without a bowel movement. There was no documented evidence that the staff notified the physician about the lack of bowel movements. Interviews with staff and a review of clinical records confirmed these deficiencies. The Director of Nursing acknowledged that the physician's orders were not followed to promote normal bowel activity. The failure to promptly assess residents after instances of sexual abuse and to follow physician's orders for bowel protocols were confirmed by the Nursing Home Administrator and Director of Nursing.
Failure to Provide Routine Evening Snacks
Penalty
Summary
The facility failed to ensure the provision of a nourishing evening snack when more than 14 hours elapsed between the supper meal and breakfast the next day for several residents. The facility's Snacks Policy, last reviewed in January 2024, indicated that bulk snacks and beverages should be available upon request, and bedtime snacks should be provided to all residents. However, observations and interviews revealed that snacks and beverages were not consistently available or offered to residents in the evenings. Specifically, Resident 56 mentioned that evening snacks were not always offered, and a group of six alert and oriented residents confirmed that snacks were not routinely provided in the evenings unless specifically requested. Resident 27 noted that while a snack was provided upon request, it was not offered otherwise. An observation of the resident pantry on the [NAME] Unit showed that snacks and beverages such as milk and juice were not available as per the facility policy. The foodservice director confirmed that snacks are sent each evening for nursing staff to offer to residents, but there was no documented evidence to show that residents were routinely offered and provided with a bedtime snack. The administrator also failed to provide documentation supporting the routine offering of evening snacks. This deficiency was identified under 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, leading to deficiencies in documentation and care. Resident 6, who was admitted with hypertensive heart disease, exhibited inappropriate and sexually inappropriate behaviors towards other residents. However, the clinical records lacked detailed documentation of these incidents, including the identities of the affected residents, the nature of the behaviors, and the dates of the interactions. This lack of documentation hindered the ability to monitor and address Resident 6's behaviors effectively. Resident 45, diagnosed with dementia, was a victim of sexual abuse by Resident 6. Despite staff witnessing and reporting the incident, Resident 45's clinical record did not document the abuse or include a nursing assessment for physical signs of injury. Similarly, Resident 42, diagnosed with multiple sclerosis, was also a victim of sexual abuse by Resident 6. Staff reported witnessing the abuse, but Resident 42's clinical record did not document the incidents or include a nursing assessment for injuries. Interviews with staff confirmed that the facility's licensed and professional nursing staff failed to document complete and accurate information in the residents' clinical records. The records did not accurately represent the residents' experiences, leading to a failure in providing appropriate care and monitoring. The facility's failure to maintain accurate and complete clinical records is a violation of professional standards and state regulations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection control practices to prevent the spread of infection for three residents. Resident 1, who had a stage 3 pressure ulcer and a Foley catheter, did not have Enhanced Barrier Precautions (EBP) implemented as required. Observations on two separate dates revealed no evidence of EBP for this resident. Similarly, Resident 56, who had venous ulcers and diabetic foot ulcers, also did not have EBP implemented, as observed on two different occasions. Resident 59, with a tracheal stoma, was also found without the necessary EBP during two separate observations. The facility's infection preventionist confirmed that EBP were not implemented for these residents, despite the facility's policy and CDC guidelines requiring such measures for residents at higher risk of infection. The facility's policy, last reviewed in March 2024, mandates the use of gowns and gloves for residents with conditions like MDRO colonization, indwelling medical devices, and chronic wounds. However, the observations and clinical records indicate that these precautions were not followed for the three residents mentioned.
Failure to Notify Physician and Representative of Sexual Abuse Incident
Penalty
Summary
The facility failed to timely notify the physician and the resident's representative of an incident involving potential sexual abuse. Resident 45, who has dementia, was touched inappropriately by Resident 6, who has hypertensive heart disease, in the dining room. This incident was witnessed by a nurse aide, Employee 3, who observed Resident 6 touching Resident 45 under her nightgown in the upper thigh area near her private area. Despite this observation, there was no documented evidence that the facility notified Resident 45's representative or attending physician about the incident of sexual abuse. An interview with the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not notify the resident's representative and attending physician of the incident. This failure to communicate a significant change in the resident's condition and potential harm is a violation of the facility's policy on Notification of Changes, which mandates that any change in a resident's condition must be reported to the attending physician and the resident's representative.
Failure to Train Agency Employee on Abuse Policy
Penalty
Summary
The facility failed to timely train one agency employee on the facility's abuse prohibition policy and procedures. An interview with the agency nurse aide revealed that it was her first day working in the facility, and she had not received an orientation or training on the facility's abuse policy before working with residents. A review of the employee's file showed no documented evidence of abuse training prior to her working on the nursing units. The Nursing Home Administrator confirmed that there was no documentation of the required training for the employee before she assumed her job duties.
Failure to Provide Written Notices for Hospital Transfers
Penalty
Summary
The facility failed to ensure that written notices regarding facility-initiated transfers to the hospital were provided to the residents and their representatives. This deficiency was identified for five residents (Resident 27, 7, 59, 66, and 29) based on clinical record reviews and staff interviews. The clinical records revealed that these residents were transferred to the hospital on various dates and, in some cases, returned to the facility. However, there was no documented evidence that written notifications, including the reason for the transfer, effective date, location, contact information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities, were provided to the residents and their representatives upon each transfer. An interview with the Nursing Home Administrator confirmed that there was no evidence of written notifications being provided for these facility-initiated transfers. This failure to provide the required written notices is a violation of resident rights as stipulated by 28 Pa. Code 201.29 (c.3)(2). The deficiency was identified through a combination of clinical record reviews and staff interviews, highlighting a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Written Bed Hold Policy Information
Penalty
Summary
The facility failed to provide residents or their representatives with written information about the facility's bed hold policy upon transfer to the hospital. This deficiency was identified in the cases of five residents out of 19 sampled. Specifically, Resident 27, Resident 7, Resident 59, Resident 66, and Resident 29 were transferred to the hospital on various dates and returned to the facility without documented evidence that they or their representatives received written notice of the bed hold policy. Resident 66, who was transferred to the hospital on February 24, 2024, expired at the hospital on February 28, 2024, and there was still no documented evidence of the bed hold policy being provided in writing. An interview with the Director of Nursing (DON) confirmed that the facility was unable to provide documented evidence of the provision of written notice of the facility's bed hold policy upon hospital transfer. This failure to provide the required written information is a violation of 28 Pa Code 201.18 (e)(1) Management and 28 Pa Code 201.29 (b) Resident rights.
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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