Third Avenue Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingston, Pennsylvania.
- Location
- 702 Third Avenue, Kingston, Pennsylvania 18704
- CMS Provider Number
- 395905
- Inspections on file
- 30
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Third Avenue Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cognitive intactness and mobility issues reported not receiving prescribed PRN Oxycodone after requesting it from both a female nurse and a female aide, with conflicting accounts involving a male nurse. The facility failed to identify or interview all staff referenced by the resident, did not obtain written statements from those who documented medication administration, and did not reconcile inconsistencies in the reports, resulting in an incomplete investigation of the alleged misappropriation.
The facility did not provide the required number of nurse aides on multiple shifts, as confirmed by staffing records and the DON, with no additional higher-level staff available to compensate for the shortfall.
The facility did not provide the required minimum number of LPNs per resident on multiple night and evening shifts, as confirmed by staffing records and the DON. No additional higher-level staff were available to compensate for these shortfalls.
The facility did not consistently provide the required minimum of 3.2 hours of direct general nursing care per resident in a 24-hour period, as evidenced by staffing records and confirmation from the DON. On several occasions, the nursing hours per resident fell below the mandated level.
A resident with severe cognitive impairment and a history of recurrent falls experienced multiple unwitnessed falls and serious injuries, including a traumatic subdural hemorrhage and fractures, due to the facility's failure to provide adequate supervision and individualized fall prevention interventions. Despite ongoing unsafe self-transfer attempts and ineffective redirection, the care plan was not updated to include enhanced supervision or appropriate interventions.
Surveyors observed mouse droppings in the main dining room and multiple kitchen areas, including dry storage and meal preparation zones, despite regular pest control services that failed to report rodent activity. The NHA confirmed the facility's responsibility to prevent food contamination, but evidence of rodents indicated a failure to maintain proper food storage and service practices.
Multiple observations of mouse droppings were found in resident rooms, the main dining room, and kitchen areas, despite regular visits from an external pest management company and no documented evidence of rodent activity. Several residents and staff reported seeing mice in the facility over the past few months, and facility leadership confirmed the absence of an effective pest control program.
A resident with chronic pain and osteoarthritis, who was cognitively intact, verbally refused a diuretic medication during a medication pass, expressing concern about its effects. An LPN, unaware that the medication was a diuretic, denied the resident's request and administered the medication despite the refusal, failing to honor the resident's right to participate in care decisions.
A resident with severe cognitive impairment and mobility limitations did not consistently receive restorative ambulation services as planned. Despite a care plan and physical therapy recommendations for regular ambulation with staff assistance, the resident was only ambulated on a few occasions, with missed sessions not being evaluated or addressed by licensed staff.
Surveyors found that two opened multi-dose insulin pens, Insulin Lispro and Insulin Glargine, were stored in a medication cart without being dated when first accessed, contrary to facility policy. An LPN and the Nursing Home Administrator confirmed the lack of required labeling for these medications.
The facility did not meet the required nurse aide to resident ratios on nine shifts, with specific deficiencies in staffing levels on various shifts across several days. The facility lacked the necessary number of nurse aides on the day, evening, and night shifts, and no additional higher-level staff were available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed these staffing shortfalls.
The facility did not meet the required LPN to resident ratios on seven shifts, with insufficient LPN staffing on specific night and evening shifts. For example, one night shift had only one LPN instead of the required 1.2 for a census of 48. The Director of Nursing confirmed the shortfall, and no additional staff were available to compensate.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day. On two occasions, the care hours fell short, with 3.12 and 2.90 hours provided. This was confirmed by staffing reviews and an interview with the DON.
A resident with Alzheimer's disease was mistakenly given insulin intended for another resident due to misidentification by an LPN on orientation. The error was not promptly addressed, and the resident's blood sugar was not monitored. Additionally, two residents did not receive prescribed wound treatments for four days. These deficiencies were confirmed by the DON.
A resident with Alzheimer's was mistakenly given insulin not prescribed to her due to a misidentification by an LPN on orientation. The error was reported internally but not to the physician or the resident's family, violating nursing services regulations.
A resident with Alzheimer's was mistakenly given insulin intended for another resident due to an LPN's failure to verify identity properly. The LPN, new to the facility, administered the medication without completing necessary competencies, leading to a medication error. The facility did not ensure the LPN was adequately prepared for unsupervised medication administration.
A facility failed to ensure timely delivery and administration of medications for a resident with cancer, resulting in a four-day delay in receiving prescribed Oxycodone and Ativan. The Nursing Home Administrator acknowledged the failure to meet the resident's needs.
A resident with Alzheimer's disease was mistakenly given insulin intended for another resident due to a failure in verifying identity. An LPN on orientation administered the medication without proper supervision or identity checks, leading to a significant medication error. The incident was not documented in the resident's clinical record, and the physician was not informed, highlighting a lapse in communication and documentation within the facility.
A resident with Alzheimer's disease was mistakenly given insulin not prescribed to her, and the error was not documented in her clinical records. The incident was reported internally, but the DON advised against documentation due to an upcoming health department revisit. The resident's records did not reflect the administration of glucagon or a high-calorie supplement given to address the error.
A resident with a history of cerebral conditions experienced severe pain following a fall, which was inadequately managed by the facility. Despite reporting pain levels of 10/10, the nursing staff failed to notify the physician for further pain management interventions. The resident's severe pain persisted over several days, and it was only after a new x-ray revealed a fracture that the resident was transferred to the hospital. The facility's Director of Nursing confirmed the failure to address the resident's pain effectively.
The facility failed to maintain a clean and orderly environment in the resident's main dining room. Observations revealed worn chairs, debris and deceased bugs in windowpanes, cobwebs and live spiders on blinds, and a sticky floor with a dirty garbage can. The Nursing Home Administrator confirmed these issues, acknowledging the need for a clean and homelike environment.
A facility failed to prevent the misappropriation of a resident's medication, hydrocodone-acetaminophen, due to inadequate documentation and reporting. Despite receiving the medication, it went missing, and the discrepancy was not reported until days later. The investigation confirmed the misappropriation but did not identify a perpetrator.
The facility failed to update a care plan for a resident with dementia, whose bed was placed against the wall for fall prevention, but this measure was not documented. Additionally, another resident on palliative care lacked an order and care plan. These deficiencies were confirmed by the DON and surveyors.
A facility failed to provide a discharge summary and medication disposition for a resident discharged with MRSA, pneumonia, and heart failure. The resident's record lacked a comprehensive summary of their stay, treatment, and post-discharge care plan. Additionally, there was no documentation regarding the disposition of the resident's medications. The nursing home administrator could not provide evidence of these documents during the survey.
A resident with hypertension was prescribed Metoprolol with specific parameters to hold the medication if certain vital signs were not met. However, the facility failed to document monitoring of the resident's blood pressure and heart rate before administering the medication, as confirmed by the DON.
Two residents in the facility were using Foley catheters without documented clinical justification. One resident had a history of dementia and a UTI linked to catheter use, while the other had kidney disease and failed void trials. Despite these conditions, their records lacked evidence supporting the need for continued catheter use, as confirmed by the DON.
A facility failed to create and implement a person-centered care plan for a resident with Alzheimer's, who showed dementia-related behaviors like spitting and agitation. The care plan did not address the resident's diagnosis or include individualized interventions based on their preferences and history. The facility also lacked evidence of providing necessary non-pharmacological care and specialized services.
A resident with Alzheimer's disease was administered alprazolam as needed for anxiety without documented clinical rationale for its continued use beyond 14 days. The medication was given multiple times over two months, and the physician failed to re-evaluate its necessity, as confirmed by the DON.
A facility failed to follow up on necessary dental services for a Medicaid resident, resulting in delayed dental checks and extractions. Despite a recommendation for continued care, there was no evidence of follow-up or completion of the extractions, impacting the resident's meal intake and nutritional status.
The facility failed to maintain an effective pest control program, as evidenced by open doors providing entry for pests and mice droppings found in the dietary dry storage room. The pest control reports lacked detailed information on services and outcomes. The DON confirmed the presence of rodent activity and the limited information in the pest control reports.
The facility failed to maintain sanitary practices for food storage and service, including improperly stored food items, missing baseboard molding exposing drywall, and mouse droppings in the dry storage room. A personal backpack was also found on a kitchen counter. These issues were confirmed by the Certified Dietary Manager and the Director of Nursing.
The facility failed to maintain a safe environment by leaving an unattended and unlocked treatment cart in a resident hallway, exposing prescription creams, ointments, and treatment supplies. Residents were observed ambulating near the cart, and the DON confirmed the cart should not have been left open and unattended.
Incomplete Investigation of Medication Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a complete and accurate investigation into an allegation of misappropriation of medication for a resident who was cognitively intact and admitted with ambulatory dysfunction due to a prosthetic joint infection. The resident reported not receiving prescribed PRN Oxycodone after requesting it from both a female nurse and a female aide during the night, with conflicting information later indicating a male nurse may have been involved. The facility's policy required that all allegations of misappropriation be thoroughly investigated, including identifying and interviewing all involved staff and witnesses, and obtaining written statements from them. Despite these requirements, the facility did not identify the staff members referenced by the resident, nor did it document efforts to determine their identities or reconcile the inconsistencies in the resident's account. The investigation included only a single witness statement from an LPN who was not directly involved in the medication administration. There was no evidence that the staff who documented administering the medication were interviewed or provided written statements. This incomplete investigation did not substantiate or disprove the resident's allegation, failing to meet the facility's own investigative standards.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide to resident staffing ratios on 14 out of 63 reviewed shifts. Staffing records showed that on multiple dates, the number of nurse aides scheduled for day, evening, and night shifts did not meet the regulatory requirements based on the facility's census. For example, on several night shifts, the number of nurse aides was below the required ratio for the number of residents present, and similar shortfalls were noted on day and evening shifts. No additional higher-level staff were available to compensate for these deficiencies on the affected dates. This deficiency was confirmed through a review of weekly staffing records and an interview with the Director of Nursing, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. We are actively recruiting Nurse Aides and offering sign-on bonuses for new employees and referral bonuses to current employees. The facility is advertising job postings on multiple recruiting platforms. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident staffing ratios on 19 out of 63 reviewed shifts. According to the reviewed weekly staffing records, the facility did not provide the mandated number of LPNs per residents on several night and evening shifts, with specific shortfalls noted for each date and census size. The required ratios were 1 LPN per 25 residents during the day, 1 per 30 in the evening, and 1 per 40 overnight, but the actual staffing fell below these thresholds on multiple occasions. No additional higher-level staff were present to compensate for the LPN shortfalls on the affected shifts. The Director of Nursing confirmed during an interview that the facility had not met the required LPN-to-resident ratios on the specified dates. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility is actively recruiting LPNs and offering a sign-on bonus to new employees and referral bonuses to current employees. The facility has posted the job on multiple recruiting sites. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. P 5530
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required 3.2 hours of direct general nursing care per resident in a 24-hour period, as mandated by regulation effective July 1, 2024. A review of staffing levels and resident census revealed that on several specific dates, the facility's direct care nursing hours per resident fell below the required threshold, with recorded hours ranging from 3.11 to 3.18. These deficiencies were identified through documentation review and confirmed during staff interviews. An interview with the Director of Nursing further substantiated that the facility did not meet the minimum general nursing care hours on the dates in question. No additional details regarding the medical history or condition of individual residents were provided in the report. The findings are based solely on staffing records and staff confirmation.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility is actively recruiting for all nursing positions, offering sign-on and referral bonuses. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement individualized fall prevention interventions for a resident with severe cognitive impairment and a history of recurrent falls. Despite being identified as high risk for falls and repeatedly attempting to self-transfer without assistance, the resident's care plan did not include interventions specifically addressing her poor safety awareness, severe cognitive impairment, or persistent unsafe behaviors. The interventions that were in place, such as a call bell reminder sign, anti-rollback devices, and Dycem application, were not sufficient to address the resident's needs, and re-education efforts were repeatedly used despite documentation that the resident was unable to benefit from such interventions due to her cognitive status. Progress notes documented a pattern of unwitnessed falls and self-transfer attempts over a period of several weeks, resulting in multiple injuries, including skin tears, lacerations, and ultimately a traumatic subdural hemorrhage and multiple fractures. Staff consistently noted that redirection was ineffective, and the resident continued to attempt to rise or transfer without assistance. Despite this ongoing pattern, the facility did not revise the care plan to include enhanced supervision, scheduled checks, or the use of assistive technology such as bed or chair alarms. The Director of Nursing confirmed that the facility did not provide adequate supervision or implement appropriate fall prevention interventions based on the resident's assessed needs. The failure to reassess and update the care plan in response to the resident's repeated falls and injuries resulted in significant harm, including hospitalization for serious injuries.
Rodent Activity and Food Storage Deficiency
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, resulting in evidence of rodent activity in multiple areas of the kitchen and main dining room. Observations revealed over 50 mouse-like droppings on the floor underneath a cabinet in the main dining room, as well as additional droppings in the dry storage area under metal storage racks and in the meal preparation area near a wall crevice. These findings were directly observed by surveyors and confirmed by the Nursing Home Administrator, who acknowledged the facility's responsibility to prevent contamination, including rodent activity. A review of facility-provided documents showed that an external pest management company serviced the building about once a month, but their invoices from December 2024 through May 2025 did not report any rodent activity. Despite these regular services, active signs of mouse presence were found during the survey, indicating a lapse in effective monitoring and control of pests within food storage and preparation areas. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of mouse droppings in resident rooms, the main dining room, and kitchen areas. Despite having an external pest management company providing monthly services, there was no documented identification of rodent activity in the facility's records or invoices from December 2024 through May 2025. Direct observations on May 28, 2025, revealed mouse-like droppings in the bedrooms of several residents, including one resident who reported seeing mice in his room over the past few months. Additional droppings were found in the main dining room and kitchen, including under storage racks and near a wall crevice, suggesting possible entry points for rodents. Interviews with residents and staff further confirmed the presence of rodents, with several residents reporting sightings of mice in their rooms and common areas over the past few months. The Director of Maintenance and the Nursing Home Administrator acknowledged the lack of documented evidence of rodent activity and confirmed the facility's responsibility to maintain an effective pest control program. The deficiency was identified through direct observation, review of facility records, and resident and staff interviews.
Resident's Right to Refuse Medication Not Upheld
Penalty
Summary
A deficiency occurred when a resident, admitted with osteoarthritis and chronic pain and assessed as cognitively intact, was not afforded the right to participate in care and treatment decisions. During a morning medication pass, the resident expressed concern about taking a 'water pill' due to its diuretic effects and verbally refused the medication. Despite this, the LPN administering the medications denied the presence of a water pill and proceeded to administer Torsemide, a diuretic, to the resident against his expressed wishes. Further review revealed that the LPN was unaware that Torsemide is a diuretic, commonly referred to as a water pill by residents. The Nursing Home Administrator confirmed that the nurse failed to provide the resident with the opportunity to refuse the medication, thereby not upholding the resident's right to participate in treatment decisions and to be fully informed about their care and treatments.
Failure to Consistently Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for a resident with a history of obstructive hydrocephalus, anxiety, and depression. The resident, who was severely cognitively impaired and non-ambulatory upon admission, received physical therapy and was discharged with the ability to ambulate 25 feet with contact guard assistance. The discharge summary recommended continued ambulation with a rolling walker for short distances, and a care plan was developed to support walking in the resident's room with staff assistance. However, documentation showed that the resident participated in the ambulation program on only four out of eleven days, with reasons for missed sessions including refusal, deferred due to condition, and unavailability. There was no evidence that licensed staff were aware of or evaluated the resident's refusals or missed ambulation sessions at the time they occurred. The Assistant Director of Nursing was unable to provide documentation that the restorative ambulation program was implemented as planned or that missed sessions were addressed to ensure the resident's ambulation goals were met.
Failure to Date Opened Multi-Dose Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and accepted professional standards regarding the labeling and storage of multi-dose medications. During an inspection of a medication cart on the Teal Hall unit, two multi-dose insulin pens—Insulin Lispro and Insulin Glargine—were found to be opened and available for use without being dated at the time of initial opening. The facility's policy requires that multi-use vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. This deficiency was confirmed through interviews with the LPN responsible for the cart and the Nursing Home Administrator, both of whom acknowledged that the required labeling practice was not followed.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of twenty-one reviewed shifts. Specifically, on January 30, 2025, the evening shift had 4.33 nurse aides instead of the required 4.36 for a census of 48, and the night shift had 2.97 nurse aides instead of the required 3.2. On January 31, 2025, the day shift had 4.13 nurse aides instead of the required 4.80, and the evening shift had 4.27 nurse aides instead of the required 4.36. Additionally, the evening shift on January 31, 2025, had 3.13 nurse aides instead of the required 3.20. On February 1, 2025, the day shift had 4.6 nurse aides instead of the required 4.7 for a census of 47. On February 3, 2025, the evening shift had 3.9 nurse aides instead of the required 4.27, and the night shift had 3 nurse aides instead of the required 3.13. Finally, on February 4, 2025, the night shift had 2.97 nurse aides instead of the required 3.27 for a census of 49. No additional higher-level staff were available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/ week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
LPN Staffing Deficiency on Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on seven out of twenty-one reviewed shifts. Specifically, the night shifts on January 30, January 31, February 1, February 2, February 3, and February 4, 2025, did not have the minimum required LPN staffing based on the facility's census. For instance, on January 30 and 31, only one LPN was present on the night shift, whereas the required staffing was 1.2 LPNs for a census of 48 residents. Similarly, on February 1, the evening shift had 1.56 LPNs instead of the required 1.57 for a census of 47. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the shortfall in meeting the required LPN to resident ratios on the specified dates. No additional higher-level staff were available to compensate for this deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. On January 31, 2025, the facility provided only 3.12 hours of direct care per resident, and on February 1, 2025, the care hours further decreased to 2.90 per resident. This deficiency was confirmed through a review of the facility's staffing levels and an interview with the Director of Nursing on February 13, 2025, who acknowledged the shortfall in meeting the required nursing care hours.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Medication Error and Wound Treatment Failures in LTC Facility
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality, as evidenced by a significant medication error involving a resident with Alzheimer's disease. The resident, who had severe cognitive impairment, was mistakenly administered insulin intended for another resident. The error occurred when an LPN on orientation misidentified the resident in the dining room and administered 12 units of insulin. The error was reported to the RN and the Director of Nursing (DON), but there was a delay in response and appropriate action. The resident's blood sugar was not monitored, and the physician was not contacted immediately. Instead, glucagon and a high-calorie supplement were administered without a physician's order. Additionally, the facility failed to implement physician's orders for wound treatments for two other residents. One resident with peripheral vascular disease and type 2 diabetes had a venous wound on the left calf, for which the prescribed treatment was not administered for four days. Similarly, another resident with a malignant neoplasm of the vulva had moisture-associated skin damage on the sacrum, and the prescribed treatment was also not administered for four days. These lapses in care were confirmed by the Director of Nursing during an interview. The deficiencies highlight a lack of adherence to professional standards and protocols, including timely assessment and documentation, as well as the implementation of physician's orders. The failure to provide necessary care and services in a timely manner, as well as the lack of proper documentation and communication, contributed to the deficiencies identified in the facility's nursing services.
Failure to Notify Physician and Family of Medication Error
Penalty
Summary
The facility failed to timely notify the physician and the resident's responsible party of a medication error involving a resident who was mistakenly administered insulin, which was not prescribed to her. The resident, who has Alzheimer's disease and a severe cognitive impairment, was given 12 units of insulin intended for another resident. This error occurred when an LPN on orientation misidentified the resident in the dining room, despite being advised that the resident would respond to her name. The LPN administered the insulin after the resident answered to the wrong name, and the error was witnessed by a nurse aide. The incident was reported internally to the RN and the Director of Nursing, but there was no documented evidence that the physician or the resident's representative was informed of the medication error. The facility's failure to notify the appropriate parties was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. This oversight is a violation of the nursing services regulation, as it is crucial to inform the physician and the resident's family of significant medication errors to ensure proper care and response.
Medication Administration Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the necessary skills and competencies to administer medications accurately and safely, as evidenced by an incident involving a resident who was given medication not prescribed to them. The incident involved a resident with Alzheimer's disease who was mistakenly administered 12 units of insulin intended for another resident. This error occurred because the LPN, who was new to the facility, did not verify the resident's identity properly and relied on the resident's response to a name call, which led to the wrong resident receiving the medication. The LPN involved in the incident had only been employed at the facility for a few days and was on orientation. Despite this, she was left alone to manage the medication cart and administer medications without having completed the necessary competencies for medication administration. The LPN admitted to not checking the resident's photo for identification and did not seek assistance from other staff members to confirm the resident's identity before administering the insulin. The facility's failure to complete the medication administration competencies for the LPN before allowing her to administer medications unsupervised was confirmed by the Nursing Home Administrator and the Director of Nursing. This oversight led to the medication error, highlighting a deficiency in ensuring that nursing staff were adequately prepared and competent in their roles, particularly in medication administration.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of medications for a resident who was readmitted with a diagnosis of malignant neoplasm of the vulva. Physician orders dated September 13, 2024, included Oxycodone for pain management and Ativan for anxiety, both to be administered as needed. However, the medications were not delivered by the pharmacy until September 17, 2024, resulting in a four-day delay. Consequently, the resident did not receive the prescribed medications during this period. An interview with the Nursing Home Administrator confirmed the facility's failure to provide medications as ordered, which did not meet the needs of the resident. This deficiency was identified through a review of pharmacy documentation, clinical records, and staff interviews.
Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of insulin to the wrong resident. Resident 1, who was admitted with a diagnosis of Alzheimer's disease and had severe cognitive impairment, was mistakenly given 12 units of insulin intended for another resident, Resident 2. This error occurred because Employee 2, an LPN on orientation, did not verify the resident's identity properly before administering the medication. The incident unfolded when Employee 2, LPN, was preparing medication for Resident 2 and asked another LPN, Employee 1, for the resident's location. Employee 1 informed Employee 2 that Resident 2 was in the dining room and would respond to her name. Employee 2 called out Resident 2's name, and Resident 1, who was not the intended recipient, responded. Without verifying the resident's identity through other means, such as checking a photo or asking for assistance, Employee 2 administered the insulin to Resident 1. This error was witnessed by Employee 3, a nurse aide, who questioned Employee 2 about the resident's identity. The error was reported to Employee 4, RN, who informed the Director of Nursing (DON). However, there was a delay in addressing the situation, as the DON advised not to document the error due to an upcoming Department of Health revisit. Additionally, there was no documentation of the incident in Resident 1's clinical record, nor was the physician informed or orders obtained to monitor the resident's blood sugar or provide appropriate treatment. This lack of documentation and communication further compounded the facility's failure to prevent significant medication errors.
Failure to Document Medication Error and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident diagnosed with Alzheimer's disease. On September 15, 2024, the resident was mistakenly administered short-acting insulin, which was not prescribed to her. The error was not documented in the resident's clinical record, and the facility's investigative report did not specify the insulin type, dosage, or the intended recipient of the medication. Additionally, there was no documentation of the resident's physician being notified or any side effects experienced by the resident. The incident was reported by a nurse aide to an LPN, who confirmed the error with the LPN responsible for the medication administration. Despite the error being communicated to the Director of Nursing (DON), the DON advised against documenting the incident due to an upcoming Department of Health revisit. The resident's Medication Administration Record for September 2024 did not reflect the administration of glucagon or Boost high-calorie supplement, which were given to counteract the insulin error. Interviews with the Nursing Home Administrator and DON confirmed the failure to document accurately and consistently in the resident's clinical records.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide timely and effective pain management for a resident, identified as Resident 52, who experienced severe pain following a fall. The resident, who had a medical history including cerebral infarction, transient cerebral ischemic attack, and cerebral atherosclerosis, was admitted with orders for acetaminophen to manage mild to moderate pain. On June 18, 2024, the resident fell and complained of left knee and thigh pain. Despite negative x-ray results for fractures, the resident reported severe pain levels of 10/10, which were not adequately addressed by the nursing staff. The occupational therapist documented the resident's severe pain and informed nursing staff, but there was no evidence that the nursing staff notified the attending physician to adjust the pain management plan. The resident continued to report severe pain over several days, yet the facility's records showed that only mild pain was documented and treated with Tylenol. It was not until June 25, 2024, that a new x-ray revealed an intertrochanteric fracture of the left femur, prompting the resident's transfer to the hospital for further evaluation. The Director of Nursing confirmed that the facility did not respond timely or effectively to the resident's increased reports of severe pain. The lack of appropriate documentation and communication regarding the resident's pain levels and the failure to notify the physician for further pain management interventions contributed to the deficiency in care provided to Resident 52.
Deficiency in Dining Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a safe, sanitary, and orderly environment in the resident's main dining room area. Observations made on two separate occasions revealed that four grey-patterned chairs with leather-like seats were significantly worn. Additionally, the dining room windowpanes contained significant debris and deceased bugs, while the white-colored blinds covering the exit door window had cobwebs and live spiders adhered to the surface. The grey garbage can inside the dining room had splatter and debris adhered to the lid, and the floor was sticky. An interview with the Nursing Home Administrator confirmed these observations and acknowledged that the resident's dining area should be maintained in a clean and homelike environment.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to implement procedures to prevent the misappropriation of resident property, specifically medications, for one resident. Resident 49, who was admitted with diagnoses including a wedge compression fracture, anxiety, and dysphagia, had a physician order for hydrocodone-acetaminophen for pain management. However, the controlled substance inventory sheet did not properly document the receipt and verification of the medication, leading to a discrepancy in the medication count. On June 17, 2024, the facility received 30 tablets of hydrocodone-acetaminophen for Resident 49, but by June 25, 2024, both the medication and the controlled drug sign-out sheet were missing. The investigation revealed that the nursing staff failed to consistently complete shift-to-shift narcotic reconciliation according to facility policy. There was no evidence that the discrepancy in the narcotic medication count was reported to administration until several days later when a nurse attempted to administer the medication. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the misappropriation of the medication was not identified or reported in a timely manner. The investigation concluded that the misappropriation was confirmed, but a perpetrator was not identified. The facility's failure to adhere to its own policies and procedures contributed to the deficiency.
Failure to Update Care Plans for Fall Prevention and Palliative Care
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for Resident 26, who was admitted with a diagnosis of dementia and was severely cognitively impaired. The resident required assistance for activities of daily living, as indicated by a BIMS score of 0. An observation on July 30, 2024, revealed that the resident's bed was placed against the wall as a fall prevention measure. However, the resident's care plan, initially dated May 15, 2024, did not include this intervention. The Director of Nursing confirmed that the care plan did not accurately reflect the current fall prevention measures. Additionally, another resident, identified as Resident #37, was noted to be on palliative care without an order or a corresponding care plan. This indicates a failure to develop and implement appropriate care plans for residents receiving specialized care. The deficiencies were confirmed during interviews and reviews conducted by the surveyors, highlighting lapses in the facility's care planning processes.
Failure to Provide Discharge Summary and Medication Disposition
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to home. The clinical record review revealed that the resident was admitted with diagnoses including MRSA infection, pneumonia, and heart failure, and was discharged without a comprehensive discharge summary. The summary should have included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan. Additionally, there was no evidence regarding the disposition of the resident's prescription medications upon discharge. The record did not indicate whether the medications were exhausted, returned to the pharmacy, destroyed, or sent home with the resident. Furthermore, there was no documentation that the resident or their representative received a summary of the resident's stay, medication tips, treatments, functional mobility, nutrition, and activities. During an interview, the nursing home administrator could not provide documented evidence of a completed discharge summary or medication disposition for the resident.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication to a resident. The resident, who was admitted with diagnoses including stroke, hypertension, and anxiety, had a physician's order for Metoprolol tartrate to be administered twice daily with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. Upon review of the Medication Administration Record for June and July 2024, there was no documented evidence that the nursing staff monitored the resident's blood pressure or heart rate prior to administering the medication, as required by the physician's order. This lack of documentation was confirmed by the Director of Nursing, indicating that the medication was not administered according to the prescribed parameters.
Lack of Clinical Justification for Foley Catheter Use
Penalty
Summary
The facility failed to clinically justify the use of Foley catheters for two residents, identified as Resident 7 and Resident 24. Resident 7 was admitted with diagnoses including dementia, dysphagia, and major depressive disorder. A hospital urology consult indicated a urinary tract infection due to the use of a Foley catheter, with recommendations for follow-up. However, the resident's clinical record lacked documented evidence to justify the continued use of the catheter, despite a urology consult noting failed void trials and the need to maintain the catheter. Similarly, Resident 24, admitted with kidney disease, was also using a Foley catheter without documented clinical justification. The resident's medication administration record showed admission from the hospital with a catheter, and nursing progress notes indicated failed void trials and an attempt to contact urology. However, there was no evidence of a scheduled urology appointment or clinical justification for the catheter's use. The Director of Nursing confirmed the absence of clinical diagnoses to justify the chronic use of Foley catheters for both residents.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with Alzheimer's disease, who exhibited dementia-related behavioral symptoms such as spitting, striking out, biting, and agitation. Despite the resident being severely cognitively impaired, as indicated in the Quarterly Minimum Data Set Assessment, the care plan in place did not address the resident's Alzheimer's diagnosis or the associated behaviors. The care plan lacked individualized interventions based on an assessment of the resident's preferences, social history, customary routines, and interests, which are essential for managing and modifying dementia-related behaviors. Furthermore, the facility did not provide evidence of necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful activities, and specialized services tailored to the resident's abilities and behaviors. There was no documentation of specialized activities, nutrition, or environmental modifications being provided to enhance the resident's well-being. An interview with the Nursing Home Administrator confirmed the absence of an individualized person-centered plan to address the resident's dementia-related behaviors, highlighting a deficiency in meeting the resident's care needs.
Lack of Clinical Rationale for PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not providing a clinical rationale for the continued use of an as-needed psychotropic medication. Resident 29, who was admitted with Alzheimer's disease, had a physician's order for alprazolam to be administered as needed for anxiety, starting in April 2024, with no specified end date. The medication was administered multiple times in June and once in July 2024. Upon review, it was found that the physician did not document the clinical rationale for the continued use of the medication beyond 14 days, nor was there any re-evaluation of its necessity. This lack of documentation was confirmed during an interview with the Director of Nursing. The deficiency was noted under the regulations concerning pharmacy services, medical records, and the role of the medical director.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to follow up with required dental services for a Medicaid resident, identified as Resident 37, who was admitted to the facility and had not received necessary dental care. Documentation from May 9, 2024, indicated that mobile dental services were delayed, resulting in the postponement of the resident's dental check and two extractions. The facility was informed that the dental service provider would reschedule, but there was no evidence of follow-up or completion of the extractions by the survey's end on July 31, 2024. The resident's last dental visit was on October 26, 2022, and although an Oral Hygiene Consult Sheet from May 16, 2024, showed no dental complaints, it recommended continued care and routine cleanings. The resident's meal intake and nutritional status were affected by the need for extractions, but there were no documented complaints of pain or discomfort related to this need.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. During an environmental tour, it was observed that the doors to the kitchen, dry storage room, and mechanical room were open, including the door leading outside, providing entry for pests. Mice droppings were found on the floor and on a pest glue trap in the dietary dry storage room. The pest control company's invoice/report from March 6, 2024, lacked information on services provided and inspection results. The April 3, 2024, report indicated services were completed but did not identify the outcome of checks and bait stations related to rodent activity. The Director of Nursing confirmed the presence of rodent activity and the limited information in the pest control reports.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During a tour of the dry storage room, it was observed that the door was open, and a 5 lb. bag of chicken bread coating and a 25 lb. bag of flour were opened without any noted dates and were not securely closed. Additionally, a ziplock plastic bag containing an opened package of walnuts was found in a brown box on a metal shelf, along with another bag of opened walnuts and loose walnuts at the bottom of the box. The baseboard molding along the bottom of the wall of the dry storage room was missing, exposing drywall and a 1/2 inch gap between the wall and the floor, where mouse droppings and a glue trap were also observed. The dry storage room is located next to the kitchen, where a personal backpack was found on the metal kitchen counter next to the toaster and below the kitchen knives mounted on the wall. These observations were confirmed with the facility's Certified Dietary Manager and the Director of Nursing, who acknowledged that the kitchen and all food storage areas should be kept in a sanitary manner. The failure to maintain these areas in a sanitary condition and to properly store food items as per professional standards was identified as a deficiency, increasing the potential for contamination and microbial growth in food, which could lead to food-borne illness.
Unattended Treatment Cart Creates Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on one of three resident hallways (Rooms 9-16). During an environmental tour, an unattended and unlocked treatment cart was observed in the hallway. The cart had its second and sixth drawers open, exposing prescription creams, ointments, and treatment supplies. Additionally, a laptop and unopened curettes were found on top of the cart. Residents were seen ambulating and self-propelling in wheelchairs near the unattended cart. The Director of Nursing confirmed that the wound care consultant was performing wound care in a resident's room at the time and acknowledged that the cart should not have been left open and unattended, creating a potential accident hazard.
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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