Sweden Valley Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Coudersport, Pennsylvania.
- Location
- 1028 East Second Street, Coudersport, Pennsylvania 16915
- CMS Provider Number
- 395699
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Sweden Valley Manor during CMS and state inspections, most recent first.
A resident reported receiving stained coffee cups for hot beverages, and observation confirmed that most cups were stained. Documentation review showed that required weekly de-staining was not consistently performed, and Resident Council Meeting minutes indicated ongoing, unresolved concerns about dirty dining ware. The facility failed to address and resolve these grievances in a timely manner.
A resident with Medicaid coverage was charged for new eyeglasses using her personal needs allowance, despite the service being covered by Medicaid. The facility deducted payments for the glasses and an insurance premium from the resident's trust account, leaving her without personal spending money for several months. The NHA confirmed that these charges should not have been taken from the resident's personal funds.
A resident who was discharged after receiving Medicare A services did not receive the required Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of covered services. Documentation and administrator interview confirmed the absence of timely notification, despite clear discharge planning and transition to home health services.
The facility did not follow its own policies requiring background and reference checks for two newly hired employees, as personnel records for a housekeeper and a cook lacked evidence of any attempt to obtain personal or professional references. This deficiency was confirmed by HR staff and identified during a review of policies, records, and staff interviews.
A resident with Alzheimer's disease and a known history of wandering was able to exit the facility despite wearing a secure care device and was later found at a nearby hospital. The facility did not promptly investigate how the resident eloped, failed to document required frequent checks, and did not immediately educate staff or review door alarm procedures following the incident.
A resident with significant weight loss was identified by the RD, who recommended a nutrition supplement twice daily, but there was a 10-day delay before the supplement was ordered and provided. No evidence was found of the supplement being given during this period, nor of further nutrition follow-up or explanation for the delay.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility's main kitchen and food storage areas were found to be unsanitary, with dried spills, dust, and debris on equipment and surfaces. The coffee station, tray line, and storage areas had significant cleanliness issues, including stained jugs, broken equipment, and improper food storage practices. These conditions were reviewed with the Nursing Home Administrator and DON.
The facility failed to implement restorative nursing programs for maintaining ROM for four residents. A resident with lower extremity ROM limitations did not receive the recommended program, and another resident's plan for active ROM was not documented as completed. Additionally, a resident requiring both active and passive ROM did not receive the prescribed care, and a cognitively impaired resident's upper extremity ROM program was not documented. These deficiencies were confirmed by interviews with facility staff.
A resident experienced inadequate pain management due to the facility's failure to administer pain medication according to the physician's ordered pain scale. Despite having orders for Acetaminophen for mild pain and Tramadol for moderate to severe pain, the resident received Tramadol for lower pain levels, and Acetaminophen was not administered as needed.
A resident was observed self-administering medication without staff supervision, despite a physician's order prohibiting self-administration. The resident's medication administration record indicated that Propranolol, Sinemet, and Seroquel were administered earlier, but the medications were left in the room. The facility's administration confirmed the error.
The facility failed to maintain a clean and homelike environment on the C Nursing Unit, with observations revealing discolored and peeling sealing around a commode, dust accumulation on vents, and debris under heating units in two residents' rooms. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to ensure accurate MDS assessments for a resident admitted with pneumonia. The MDS dated August 17, 2024, incorrectly indicated an active pneumonia infection, despite no evidence of such since April 27, 2024. The DON confirmed the coding error during an interview.
A facility failed to maintain a resident's ambulation abilities as part of a nursing rehabilitation program. The resident was supposed to be ambulated with staff assistance and a wheeled walker, but there was no documented evidence of the program being completed. The DON and Nursing Home Administrator confirmed these findings, resulting in a deficiency under nursing services regulations.
A resident with macular degeneration and diabetes did not receive necessary vision services from the facility. Despite a physician's order allowing visits to eye specialists, there was no documentation of the facility offering or arranging such services. The resident's cognitive and vision impairments were noted, but the facility failed to address these needs, as confirmed by the Nursing Home Administrator and DON.
A resident with diabetes did not receive necessary foot care, resulting in elongated, thick, and yellow toenails that began to curve. The resident had not seen a podiatrist, and there was no documentation of diabetic foot care in the clinical record until after a surveyor's observation. The DON confirmed these findings.
A facility's medication error rate was found to be 7.69%, exceeding the acceptable limit of 5%. An LPN crushed extended-release tablets of Potassium Chloride and Metoprolol before administering them to a resident, contrary to guidelines that specify these medications should not be crushed. Both the LPN and the DON confirmed the error.
A resident experienced a delay in receiving a top denture due to a lack of follow-up on dental services and a misunderstanding involving her POA. Despite being cognitively intact, the resident was unaware that her denture process was halted by her POA, leading to a deficiency in timely dental care.
Failure to Address Resident Grievances Regarding Stained Coffee Cups
Penalty
Summary
A resident reported that the cups provided for hot water were stained brown. Upon observation of the kitchen's clean racks, most coffee cups were found to be stained. The dietary supervisor confirmed that evening shift dietary staff are responsible for cleaning and de-staining the cups weekly, with staff required to sign off on this task. However, review of cleaning documentation showed that the cups were only de-stained on two occasions over a six-week period, rather than weekly as required. The dietary supervisor confirmed these findings. Review of Resident Council Meeting minutes over several months revealed ongoing resident concerns about dirty utensils, glasses, and coffee cups, with repeated mentions that these issues had not been resolved. The facility did not address or resolve the residents' grievances regarding the stained coffee cups in a timely manner, as evidenced by continued complaints in multiple council meetings and lack of consistent cleaning as documented.
Improper Charges to Resident's Personal Funds for Medicaid-Covered Services
Penalty
Summary
A deficiency occurred when the facility charged a resident's personal funds for eyeglasses, a service that should have been covered by Medicaid. The resident, who is enrolled in a Medicaid plan, required new glasses following an acute vision problem and was sent to a local eye doctor. The resident reported that she had to pay for the glasses using her monthly personal needs allowance, which left her without personal spending money for several months. Clinical record review confirmed the resident's Medicaid coverage and the need for new glasses as documented by the eye doctor. Review of the resident's trust account showed deductions for medical bills related to the glasses and for an insurance premium that covers ancillary services such as vision. The Nursing Home Administrator confirmed that the charges for the glasses were taken from the resident's personal funds instead of being processed as an allowable medical expense under the resident's patient liability. The facility failed to ensure that the resident's personal needs allowance and trust account were managed in accordance with regulations, resulting in improper charges to the resident's personal funds for services covered by Medicaid.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to a resident whose Medicare-covered services were ending. According to the review, the NOMNC, which informs beneficiaries of the termination of Medicare coverage and their right to appeal, must be delivered at least two calendar days before the end of covered services. For the resident in question, there was no evidence that this notice was given within the required timeframe. Clinical documentation showed that the resident was admitted for Medicare A services and was making progress toward discharge, with plans for home health services upon leaving the facility. Despite clear indications in the record that discharge was anticipated, the facility did not provide documentation that the resident or their representative received the NOMNC two days prior to discharge, as required by regulation. This deficiency was confirmed through both record review and interview with the Nursing Home Administrator.
Failure to Complete Required Reference Checks for New Hires
Penalty
Summary
The facility failed to implement its abuse prohibition policy by not conducting thorough investigations of prospective employees' employment histories for two out of five newly hired staff members. Specifically, the personnel records for a housekeeper and a cook did not contain any evidence that the facility attempted to obtain personal or professional reference information, as required by facility policy. The policies reviewed stated that background and reference checks must be completed and documented prior to employment offers, but these steps were not followed for the two employees in question. These findings were confirmed by the human resources staff member, who acknowledged the lack of reference checks in the personnel files. The deficiency was identified through a review of facility policies, personnel records, and staff interviews, and was discussed with the Nursing Home Administrator. The report cites violations of state code regarding management and personnel policies and procedures.
Failure to Investigate and Prevent Resident Elopement
Penalty
Summary
A resident with a history of elopement and severely impaired cognition due to Alzheimer's disease was identified as an elopement risk upon admission. The resident was ambulatory without a device and had previously wandered from home. Despite being assessed as an elopement risk and fitted with a secure care device, the resident was able to leave the facility and was found at a nearby hospital's helipad. Documentation indicated that the secure care device should have prevented exit, but there was no immediate investigation into how the resident was able to leave undetected. There was a lack of timely and thorough investigation following the elopement incident. Documentation of required 15-minute checks was missing, and there was no evidence of staff education or changes in interventions immediately after the event. Staff statements and investigation into the door alarm and secure care system were not completed until two days after the incident. Additionally, there was no documentation of secure care checks on the exit door or evidence that all staff were educated on responding to door alarms in the immediate aftermath.
Delay in Initiating Nutrition Interventions for Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 9.6 pounds, or 7.1 percent, over a 30-day period, as documented in the clinical record. The registered dietitian noted the weight loss and recommended adding a nutritional supplement (Boost) twice daily to address the resident's declining meal intake. However, there was a delay of 10 days before the physician order for the supplement was entered, and there was no evidence that the supplement was provided to the resident during this period. Additionally, there was no documentation of further nutritional follow-up or explanation for the delay in implementing the recommended intervention. The resident also refused to be weighed after the initial weight loss was recorded.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Unsanitary Conditions in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, leading to potential food contamination. Observations revealed multiple areas of concern, including dried brown liquid spills and food splatter on walls and equipment, dust and debris accumulation, and stained and opaque plastic jugs. The coffee station area was particularly unsanitary, with a soiled cardboard box of coffee filters and a trash can covered in dried debris and spills. Further inspection of the kitchen revealed significant issues with food storage and equipment maintenance. Bag-in-box juices had sticky and dusty tubing connections, and an air compressor was covered in thick dust. The two-door cooler had a broken door gasket, and oven mitts were significantly stained with dried food. The tray line area had cracked, worn, and stained lunch trays, and carts used for food service were soiled with dried food debris and had broken or cracked surfaces. The facility's dry storage and walk-in freezer areas also exhibited unsanitary conditions. The dry storage room had thick dust on shelving units, and the walk-in freezer had significant ice buildup on the floor and shelves. Food products were stored without barriers to prevent contamination from mop water or debris. The walk-in cooler had dried food and debris on the floor, and the shelving was covered in dust and debris. The facility's failure to maintain cleanliness and proper food storage practices was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Restorative Nursing Programs for ROM
Penalty
Summary
The facility failed to implement a restorative nursing program as recommended by therapy to maintain range of motion (ROM) for four residents. Resident 22 was assessed with ROM limitations in her lower extremities, and a restorative program was recommended by physical therapy. However, there was no documented evidence that the program was implemented. Similarly, Resident 15's plan of care included a nursing rehab program for active ROM to her lower extremities, but there was no documentation indicating the program was completed. Resident 47 was to receive active ROM for his lower extremities and passive ROM for his upper extremities, as recommended by therapy, but there was no evidence of these programs being carried out. Resident 64, who had severe cognitive impairment, was to participate in an upper extremity active ROM program as tolerated, but there was no documentation of the program being completed or any refusal by the resident. These deficiencies were confirmed through interviews with the Director of Nursing, Nursing Home Administrator, and Director of Therapy.
Inadequate Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 48, consistent with professional standards of practice. Resident 48 reported experiencing pain in the tailbone area following a recent fall. The clinical records indicated a physician's order for Acetaminophen 325 mg, two tablets every six hours as needed for a pain level of 1-5, and Tramadol HCL 75 mg every six hours as needed for a pain level of 6-10. However, the medication administration record (MAR) for August and September 2024 showed that Tramadol was administered for pain levels of 4 and 5, which were outside the prescribed pain scale for this medication, and there was no evidence of Acetaminophen being administered on those occasions. The deficiency was confirmed through interviews with Resident 48 and a review of the MAR, which revealed that the facility staff did not adhere to the physician's ordered pain scale. This resulted in the resident receiving Tramadol for pain levels that should have been managed with Acetaminophen, according to the physician's orders. The issue was discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to administer pain medication as per the prescribed guidelines.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication per physician's orders for one resident. On September 17, 2024, a surveyor observed a resident lying in bed with a medicine cup containing pills on the bedside table. The resident, upon noticing the surveyor, ingested the pills without any staff present. The clinical record for this resident showed a physician's order from April 9, 2023, indicating that the resident was not permitted to self-administer medication. Despite this, the medication administration record for the same day documented that the resident was administered Propranolol, Sinemet, and Seroquel at 1:25 PM. The Nursing Home Administrator and Director of Nursing confirmed that the resident should not have had medications left in the room for self-administration.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on the C Nursing Unit, affecting two residents. Observations on September 18, 2024, revealed that the external sealing around the base of the commode in the C Unit shower room was discolored and peeling, with a significant accumulation of dust on a ceiling vent. Further observations on September 20, 2024, showed extensive dust build-up on the heating unit vents in the rooms of two residents, along with debris accumulation under the units. These findings were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident, identified as Resident 60. Resident 60 was admitted with a diagnosis of pneumonia from a hospital setting. A review of the clinical record revealed an MDS assessment dated August 17, 2024, which incorrectly indicated that the resident still had an active pneumonia infection. However, there was no documented evidence in the clinical record to support the continuation of an active pneumonia infection since April 27, 2024. An interview with the Director of Nursing on September 19, 2024, confirmed that the pneumonia diagnosis was coded in error on the MDS.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to maintain a resident's ability to ambulate as part of a nursing rehabilitation program. Resident 15 was on a program that required ambulation with the assistance of one staff member and a wheeled walker, as ordered on November 7, 2023. A therapy recommendation form dated October 31, 2023, confirmed this program. However, there was no documented evidence that the ambulation program was being completed for Resident 15. The Director of Nursing and the Nursing Home Administrator were informed of these concerns and confirmed the findings on September 19, 2024. This failure to provide the necessary restorative or rehabilitation services resulted in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Vision Services to Resident
Penalty
Summary
The facility failed to provide necessary vision services to a resident with a history of macular degeneration and diabetes mellitus. The resident, who was admitted in 2019, expressed concerns about worsening vision and was unsure of her last vision appointment. Despite having a physician's order from February 2020 allowing visits to an optometrist and ophthalmologist, there was no evidence in the clinical records that the facility offered or arranged for vision services for the resident. The resident's Minimum Data Set Assessment indicated cognitive impairment and vision impairment, yet the facility did not document any efforts to address these needs. During a survey, the Nursing Home Administrator and Director of Nursing were unable to provide documentation showing that the resident or her responsible party was offered vision services. The facility's records lacked any indication of an eye exam being offered or conducted since the resident's admission. This deficiency was identified under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, highlighting the facility's failure to ensure the resident received appropriate care for her vision concerns.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide necessary foot care and treatment to a resident, leading to a deficiency. The resident, who was admitted with a diagnosis of diabetes, had not received diabetic foot care to manage his toenails and prevent medical complications. During an interview, the resident reported not having seen a podiatrist for his left foot. Observation revealed that the resident's toenails were elongated, with the nails on the first and second toes being thick, yellow, and beginning to curve. There was no documented evidence in the resident's clinical record indicating that the facility had initiated appropriate foot care until the surveyor's observation and interview prompted action. The Director of Nursing confirmed these findings.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.69 percent error rate based on 26 medication opportunities with two errors. During a medication administration pass, an LPN prepared to administer Potassium Chloride 20 MEq ER and Metoprolol 100 mg ER to a resident by crushing the extended-release tablets, which is against the guidelines provided by The Institute for Safe Medication Practices. These guidelines specify that both medications should not be crushed due to their slow-release formulation. The LPN confirmed the error during an interview, and the Director of Nursing also acknowledged that the medications should not have been crushed.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident, identified as Resident 29, who had been waiting for her top denture since at least June 2024. The process began with dental impressions made in August 2023, followed by several consults indicating ongoing treatment and adjustments needed for the denture. However, after a dental consult in March 2024, where changes to the denture were noted, there were no further records of dental visits or updates on the denture delivery. The resident expressed concern about not receiving her denture and was unaware of any issues until a recent interview. The situation was further complicated by a misunderstanding involving the resident's power of attorney (POA). An email from the consulting dental clinic indicated that the denture process was halted because the POA declined further services, despite the resident being cognitively intact and capable of making her own decisions. The resident was not informed of this decision, which contradicted her expressed wishes to continue with the denture process. The facility's failure to communicate effectively and ensure the resident's dental needs were met led to the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
