Thornwald Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Pennsylvania.
- Location
- 442 Walnut Bottom Road, Carlisle, Pennsylvania 17013
- CMS Provider Number
- 395802
- Inspections on file
- 23
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Thornwald Home during CMS and state inspections, most recent first.
Surveyors found that sprinkler heads in the Main Kitchen were covered with debris, particularly around vents, and this was confirmed by facility leadership during interviews. The deficiency affected one of nine smoke zones.
Surveyors found that three residents' assessments did not accurately reflect their clinical status. One resident with Parkinson's and another with hemiplegia were both using enabler bars for mobility, but their MDS assessments were incorrectly coded as restraint use. Another resident with a trauma history and adjustment disorder had PTSD omitted from her MDS despite relevant documentation and care planning. These errors were confirmed by facility leadership.
The facility did not verify the professional licensure status of a CNA and an LPN before hiring them, as required by policy. License and certification checks were completed only after the employees began working, and documentation of timely verification could not be found during review of personnel files and staff interviews.
A resident with multiple pressure ulcers did not receive timely or properly monitored use of a recommended air mattress, as there was a delay in implementation, lack of physician order, and inadequate monitoring of the equipment's function and settings, resulting in failure to provide necessary treatment consistent with professional standards.
A resident with hemiplegia had an enabler bar removed and later reinstalled on their bed, but the facility did not perform or document the required safety measurements at the time of reinstallation. Facility leadership confirmed that these checks should have been completed, resulting in noncompliance with regulations for regular inspection and compatibility of bed rails.
A resident with dementia and Down syndrome, who exhibited behavioral symptoms requiring a dignity suit as a physical restraint, did not receive the required 30-day ongoing evaluations for restraint use. Although initial and some follow-up assessments were completed, the facility failed to ensure monthly interdisciplinary reviews as per policy.
A resident with a history of stroke and hypertension, who required two-person assist with a stand aid for transfers, was transferred by a nurse aide alone using a stand pivot. This failure to follow the care plan and facility policy resulted in a severe leg laceration requiring 15 sutures.
Thornwald Home failed to provide required annual abuse training to a contracted Physician Assistant, as revealed by a review of training records. The facility's policy mandates annual education on abuse prevention and reporting for all staff, including contractors, but documentation for this training was missing for Employee 2. This deficiency was confirmed during an interview with the NHA and the Assistant Director of Nursing.
A resident with chronic kidney disease, heart failure, and anxiety disorder reported being assaulted in her genitalia, but the facility failed to report the allegation in a timely manner. Despite the resident's report to a physician, no physical assessment was conducted, and the allegation was not communicated to the administration. The oversight was discovered during a clinical meeting, leading to a delayed investigation.
A facility failed to thoroughly investigate abuse allegations made by a resident with chronic conditions, who reported being assaulted by staff. Despite the resident providing a description and stating she could identify the perpetrators, the facility did not obtain witness statements or ask the resident to identify the alleged perpetrators. The facility's investigation was insufficient, and no staff were suspended during the investigation, compromising the resident's safety.
The facility failed to document catheter care for two residents, leading to UTIs. One resident with urinary retention and a Foley catheter had multiple undocumented shifts of catheter care and was diagnosed with a UTI. Another resident with benign prostatic hyperplasia and chronic kidney disease also lacked documentation of catheter care and was treated for UTIs. The DON confirmed that catheter care should be documented every shift.
A facility failed to provide appropriate mobility support for a resident with Parkinson's Disease and muscle weakness. The resident's care plan required the use of an AFO and specific positioning in a Broda chair, but observations showed inconsistencies in their use. The resident was also on a walking RNP despite being non-ambulatory, with gaps in documentation and provision of care. Interviews with the NHA and DON revealed confusion about the resident's ambulation status and lack of documentation for the AFO.
The facility failed to monitor nutritional status and notify the physician of significant weight changes for two residents. One resident with malnutrition and other conditions lost 20.8 pounds over three weeks without timely re-weighing or physician notification. Another resident did not have a required weekly weight measure recorded. These lapses indicate non-compliance with facility policies on weight monitoring and physician communication.
The facility did not maintain sprinkler head assemblies per manufacturer specifications, affecting one smoke compartment. Observations revealed missing escutcheons on sprinkler heads in the Laundry and Kitchen Dish Room. The Director of Environmental Services confirmed the deficiency.
Sprinkler Heads Not Maintained Free of Debris in Main Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sprinkler heads in the Main Kitchen area, as they were found to be covered with debris throughout, particularly by all vents and sprinkler heads. This deficiency was identified during an inspection and was confirmed through interviews with the Administrator and Director of Environmental Services, who acknowledged the presence of debris on the sprinkler heads. The issue affected one of nine smoke zones within the component and was documented based on direct observation and staff confirmation. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facilities maintenance department audited the entire facility for other dirty/debris covered sprinkler heads. The affected sprinkler heads will be cleaned. Checking for dirty/debris on the sprinkler heads will be added to the monthly safety committee checklist. Checklists will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Inaccurate Resident Assessments and MDS Coding
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. For one resident with Parkinson's disease and weakness, clinical record review and observation revealed the use of a right-sided enabler bar, which the resident used for mobility in bed. However, the resident's quarterly MDS assessments were incorrectly coded as restraint use related to enabler bars, contrary to the actual use and physician orders for the device as an enabler. Another resident with a diagnosis of adjustment disorder and a history of trauma related to witnessing a choking incident had a care plan that included trauma-informed care and counseling services. Despite documentation in psychology consults indicating significant focus on grief and loss, the resident's quarterly MDS assessment failed to document PTSD, which was relevant to her care needs and supported by her clinical history and care plan. A third resident with hemiplegia was observed with a right-side enabler bar in the room, and physician orders supported its use for bed mobility and independence. However, the resident's quarterly MDS was also incorrectly coded for restraint use related to enabler bars, not reflecting the actual purpose and physician orders for the device. These inaccuracies in the MDS assessments were confirmed by the Nursing Home Administrator, who acknowledged the errors in coding and the need for modification.
Plan Of Correction
1. R 4 and R 14's Minimum Data Set (MDS) were modified on 12/9/25 to accurately reflect that a restraint was not in use. R 12's medical record was reviewed, and no PTSD diagnosis has been identified by the provider. R 12 does have a trauma history which has been care planned, and the CMS 802 roster was updated to reflect the history of trauma on 12/9/25. The provider will be notified to evaluate if a post-traumatic stress disorder (PTSD) diagnosis is warranted. 2. An audit was completed on 12/9/25 for current residents coded as restraints on Section 0 of the MDS, and modifications were completed as necessary. An audit was completed on 12/9/25 to identify residents with a history of trauma and/or PTSD diagnosis. The 802 was manually updated to indicate the history of trauma for identified residents, but no PTSD diagnoses were identified in any resident. No modifications to MDS accuracy were identified. The physician/provider will be notified to review identified residents to evaluate if a PTSD diagnosis is warranted. 3. The RNACs will be re-educated by the Executive Director on proper coding and accuracy of the MDS in its entirety with a focus on proper coding of restraints at Section O. In addition, education will be provided by the Executive Director to the RNACs that PTSD requires a physician diagnosis to be coded in Section I of the MDS and that the 802 rosters should be checked for PTSD diagnosis or identified history of trauma. The 802 roster will be submitted to DON weekly for review of accuracy of triggered items. The Interdisciplinary team completing sections of the MDS will be re-educated on accuracy of coding the MDS by the Executive Director. 4. The Director of Nursing or designee will conduct weekly audits of at least 5 residents per week for 12 weeks to validate accurate coding of Section 0 for restraints and Section I for PTSD. Audits will include at least 1 MDS per week for 12 weeks reviewed in its entirety for accuracy. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Verify Staff Licensure Prior to Hire
Penalty
Summary
The facility failed to ensure that residents were protected from the potential for abuse by not verifying the professional licensure status of two employees prior to their hire. Specifically, the personnel file for a Certified Nursing Assistant (CNA) showed that certification verification was completed after the employee's hire date. Similarly, the personnel file for a Licensed Practical Nurse (LPN) indicated that license verification with the state licensing board was also completed after the employee's hire date. These actions were not in accordance with the facility's own policy, which requires verification of active licensure or certification prior to employment. During interviews, it was revealed that Human Resources is responsible for completing a checklist to ensure all required items, including license verification, are completed and then forwarding this information to the hiring manager. However, the hiring manager discards information not entered into the employee's file, and the facility was unable to locate evidence that licensure verification was completed before the employees began working. This failure to verify licensure prior to hire was identified through review of facility policy, personnel files, and staff interviews.
Plan Of Correction
F 0606 1. No individual resident has been identified. Employee 3 and Employee 4 license verification were completed on 12/9/25. 2. An audit of current employee files of those with Licenses or Certifications was completed on 12/16/2025 to validate employee licenses or certifications are in good standing, and employees are fit for service. 3. Re-education to HR Payroll Benefit Coordinator, Receptionist, and Nursing Leadership on the facility policy "Admin Freedom from Abuse Policy" will be provided by the Executive Director. The HR Payroll Benefit Coordinator or designee will verify licensure/certification and will print the verification prior to offering any position. This will be maintained in the HR office in the employee file. 4. The Executive Director, or designee will conduct weekly audits x 12 weeks of potential new hires to validate license/certification verification has occurred and is in employee file. Findings of audits will be analyzed to identify/track trends or patterns and will be reported monthly to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Provide Timely and Monitored Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive necessary treatment and services consistent with professional standards of practice to promote healing. The resident had a history of pressure ulcers on the right heel, right buttock, and left heel, as well as diagnoses of type II diabetes mellitus and peripheral vascular disease. Despite weekly wound consults recommending an air mattress for additional pressure relief, there was a three-week delay in applying the recommended air mattress to the resident's bed. There was no documentation to explain this delay, and no evidence of interdisciplinary team discussions regarding the delay was provided. When the air overlay mattress was eventually placed, there was no physician's order for its use, nor was there documentation that staff were monitoring the function or settings of the mattress. Observations revealed that the air overlay mattress pump was repeatedly found turned off, the air hose was disconnected and found on the floor, and the pump was set for an incorrect weight. Additionally, the securing clip for the hose was broken, and the pump was not consistently operational until maintenance intervened. The resident's actual weight was significantly lower than the pump setting, and there was no evidence that staff were ensuring the equipment was functioning as intended. Facility policies required that residents with wounds receive care to promote healing and prevent infection, and that interventions be revised based on their effectiveness. However, the lack of timely implementation of the recommended air mattress, absence of monitoring, and failure to ensure the equipment was functioning properly led to the resident not receiving the necessary treatment and services to promote healing of pressure ulcers. The deficiency was identified through clinical record review, staff interviews, and direct observation.
Plan Of Correction
1. R 10's air mattress connector hoses were immediately replaced on 12/11/25 and set to the proper weight setting. A physician order was obtained to check the mattress for each shift for proper functioning and weight setting. 2. A facility-wide audit was conducted on 12/11/25 to identify any resident with an air mattress. Physician orders will be obtained to check functioning and settings each shift. Most recent wound consultative reports will be reviewed by the Director of Nursing for any air mattress recommendations to validate follow-through. 3. Licensed nurses will be re-educated by the Director of Nursing on checking proper functioning/settings of air mattresses and follow-through of wound consult recommendations to promote healing of pressure ulcers. Licensed Nurses will sign each shift on the treatment record validating proper functioning and settings are in place for air mattresses. Wound consult reports will be reviewed weekly during the daily interdisciplinary team meeting to validate that recommendations have supportive documentation for being addressed. 4. DON or designee will conduct weekly random direct observations of air mattresses across all 3 shifts for proper functioning, settings, and documentation for a minimum of 12 observations per week x 12 weeks. DON or Designee will conduct weekly audits of 5 residents/week x 12 weeks receiving wound consultation for supportive documentation of follow-through of recommendations. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Inspect Bed Rails After Reinstallation
Penalty
Summary
The facility failed to conduct regular inspections of bed rails/enabler bars as part of its maintenance program to identify possible areas of entrapment for a resident with hemiplegia. The resident had a physician order for a right-side enabler bar to assist with bed mobility and independence, and the enabler bar assessment and consent were completed when the device was initially placed. However, the maintenance record for safety measurements was last documented several months prior to the most recent placement of the enabler bar. When the enabler bar was removed at the resident's request and later reinstalled, the facility did not perform or document the required safety measurements at the time of reinstallation. Interviews with facility leadership confirmed that safety measurements should have been completed when the enabler bar was placed back on the bed, but this was not done, resulting in noncompliance with regulatory requirements for regular inspection and compatibility checks of bed rails and related equipment.
Plan Of Correction
1. R 14's bed was inspected by maintenance, and no area of entrapment was identified. 2. An audit was conducted throughout the skilled unit on 12/11/25 to identify current residents that have beds with rails. A Maintenance Bed evaluation and inspection was completed on the identified beds on 12/11/25 with no concerns noted. 3. Environmental Services will be re-educated by the Executive Director on the facility preventative maintenance program to include regular inspection of bed rails/enabler bars, and completion of the Bed Evaluation Tool. Education will include any device being added to the bed or frame requires inspection and completion of the Bed Evaluation Tool immediately upon adding to the bed or frame by maintenance. 4. Weekly audits x 12 weeks of residents with bedrails will be completed by the Director of Nursing or designee to validate current bed rail inspection is documented at least annually at the time of placing rails or enablers on bed if newly added, and when a significant change of condition occurs. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Complete Required 30-Day Restraint Evaluations
Penalty
Summary
The facility failed to complete an evaluation every 30 days for the ongoing use of a restraint for one resident. According to the facility's policy, the interdisciplinary team is required to review and reevaluate the use of all restraints ordered by a physician or their designee at least every 30 days. For the resident in question, who had diagnoses including dementia and Down syndrome, there were physician orders and care plan interventions for the use of a one-piece dignity suit at night to address behavioral symptoms such as smearing and ingesting feces. The initial equipment assessment and consent for the dignity suit were completed, and follow-up assessments were documented on two occasions several months apart. However, the clinical record review revealed that the required 30-day ongoing evaluations for the restraint were not consistently completed. The Nursing Home Administrator confirmed that although an ancillary order for monthly evaluations was entered, it did not populate in a way that ensured completion. As a result, the facility did not meet its own policy or regulatory requirements for regular restraint evaluation for this resident.
Plan Of Correction
1. R 27's dignity jumpsuit was evaluated on 12/9/25. A physician treatment order was obtained 12/9/25 to complete an evaluation every 30 days. 2. A review of current residents reveals that no other residents have been identified as utilizing restraints. 3. Licensed staff will be re-educated on restraints, proper documentation, and evaluations every 30 days for ongoing use of restraints. 4. The Director of Nursing or designee will audit residents with restraints weekly for 12 weeks to validate that evaluations of the restraint are completed every 30 days. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. A resident with a history of stroke and hypertension had a care plan and physical therapy discharge summary indicating the need for transfer with a stand aid and assistance from two staff members. Despite this, a nurse aide transferred the resident from a wheelchair to bed alone, using a stand pivot technique, rather than the required stand aid with two-person assist. This action was not in accordance with the resident's care plan or the facility's 'No Lift Program' policy, which prohibits transfers without the required equipment and staff. As a result of the improper transfer, the resident sustained a significant laceration to the right lower leg, measuring 10 cm x 8 cm x 1 cm, with exposure of the fatty layer, and required 15 sutures at the hospital. The nurse aide involved stated she was unaware of the need for two-person assist with a stand aid for transfers, having only seen the one-assist requirement for toileting in the care guide and not scrolling further to see the transfer instructions. The facility's investigation confirmed that the staff member did not follow the resident's care plan, leading to the injury.
Failure to Provide Annual Abuse Training to Contracted Staff
Penalty
Summary
Thornwald Home was found to be non-compliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. The facility failed to ensure that all staff, including contracted personnel, received the required annual training on abuse prevention and reporting. Specifically, a review of the training records revealed that a contracted Physician Assistant, referred to as Employee 2, did not receive the mandatory annual abuse training in 2024. This omission was confirmed during an interview with the Nursing Home Administrator and the Assistant Director of Nursing. The facility's policy, titled "Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property," mandates that all employees, including consultants and volunteers, receive education on abuse prevention and reporting upon hire and annually thereafter. The policy also requires an annual acknowledgment from vendors and contractors. However, the facility could not provide documentation of such training or acknowledgment for Employee 2, indicating a failure to adhere to their own policy and regulatory requirements.
Plan Of Correction
1. No individual resident has been identified. E2 has received training and education on the facility's abuse policy which covers the seven components of abuse. 2. The Executive Director/designee will review training records to validate that contracted care providers including UPMC Post Acute Providers have evidence of Annual or New Hire Abuse training within the previous year. 3. UPMC Post Acute Providers will be re-educated by the Executive Director/designee on the facility's abuse policy. 4. Monthly audits will be conducted for 3 months by the Executive Director or designee on facility training records to validate contracted care providers and UPMC Post Acute providers have completed annual abuse training or new hire abuse training within the previous year. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or further recommendation.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The facility's policy requires that any incident of abuse be reported immediately to the Executive Director or designee and thoroughly investigated. However, the facility did not adhere to this policy when a resident reported being assaulted in her genitalia. The resident, who had diagnoses including chronic kidney disease, heart failure, and anxiety disorder, reported the alleged assault to a physician on January 9, 2025. Despite the report, there was no documentation of a physical assessment of the resident's genitalia, and the allegation was not reported to the facility's administration. The physician's progress notes from January 9 and January 14, 2025, documented the resident's allegations of being assaulted and having delusional thoughts. However, the facility staff, including a Licensed Practical Nurse, did not recall any specific comments regarding the alleged assault. The physician believed the resident's thought content was delusional, and no physical examination was conducted to investigate the claims. The lack of immediate reporting and investigation of the resident's allegations was a significant oversight. The Assistant Director of Nursing discovered the documentation of the alleged assault during a clinical meeting on January 22, 2025. It was only then that an investigation was initiated. The Nursing Home Administrator confirmed that neither she nor any other administrative staff were made aware of the resident's allegations on January 9 or January 14, 2025. This failure to report and investigate the allegations promptly was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
R1's initial allegation documented on 1/9/25 was identified by the facility on 1/14/25, and reporting requirements to the Department of Health, Area of Aging, Local Police, and the PA Department of Aging occurred immediately. 2. The Executive Director spoke with E2 and the Medical Director about reporting immediately any allegations of abuse/neglect. An audit was conducted of Physician progress notes dated 12/9/24-1/30/24. No other documented allegations of abuse were identified. 3. UPMC Post Acute Providers and facility staff will be re-educated by the Executive Director on immediate abuse reporting requirements. Physician Progress notes will be reviewed during daily clinical meetings for three months to ensure that there are no entries of risk, including allegations of abuse that have been unreported to the facility. 4. Weekly random audits of physician progress notes conducted by the Executive Director or designee of at least 5 residents will occur x 3 months to validate any documented allegations have been immediately reported to the Executive Director. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident 1, who had chronic kidney disease, chronic heart failure, and an anxiety disorder. The resident reported being hit on the head and dragged by two staff members, whom she described as 'two black girls,' and stated she could identify one if seen again. Despite this, the facility did not take adequate steps to identify the alleged perpetrators or obtain witness statements from nursing staff. The facility's investigation documentation was insufficient, lacking any evidence of attempts to verify the resident's claims or protect her during the investigation. The facility's policy required immediate and thorough investigations of abuse allegations, including obtaining signed statements from the resident, witnesses, and the accused. However, the facility did not follow these procedures. The Assistant Director of Nursing confirmed that no investigation or witness statements were obtained, and the resident was not asked to identify the alleged perpetrators, despite providing a description. The facility's failure to suspend any staff members during the investigation further compromised the resident's safety. The Nursing Home Administrator acknowledged that the facility did not thoroughly investigate the allegations and confirmed that the resident was not asked to identify the alleged perpetrators. The facility's electronic health record system was unable to retrieve past 24-hour reports, hindering the investigation process. The lack of a comprehensive investigation and failure to protect the resident during the investigation period resulted in a deficiency in meeting the regulatory requirements for investigating and preventing abuse.
Plan Of Correction
1. A thorough investigation has been completed for R1's allegations to include written witness statements of nursing staff. R1 was interviewed by the Executive Director on 2/3/25 and confirms feeling safe in the facility. 2. The Executive Director/designee will review 24-hour report and physician/other practitioner progress notes over last 7 days to ensure that there are no unreported allegations of abuse. In addition, an audit will be conducted on any allegations occurring over the last 7 days to ensure thorough investigations are in place. 3. Licensed staff will be re-educated by the Executive Director on the facility's abuse policy which includes recognizing documentation that constitutes initiation of the facility's abuse policy, and on the steps for an immediate, thorough investigation to include interviewing and obtaining signed statements from any witness or individual who has knowledge of the alleged incident. 4. Weekly audits of abuse investigations will be conducted by the Executive Director or Designee x 3 months to validate thorough investigations have been completed to include immediate measures implemented to protect resident safety, identification of perpetrator, if able and written statements are in place. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.
Failure to Document Catheter Care Leads to UTIs
Penalty
Summary
The facility failed to ensure that residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections (UTIs). Specifically, for Resident 65, there was a lack of documentation indicating that catheter care was provided on multiple shifts from October through December 2024. This resident, diagnosed with urinary retention and using an indwelling Foley catheter, was found to have a UTI on October 25, 2024, with a urine culture indicating the presence of E. coli. The Nursing Home Administrator and Director of Nursing confirmed that catheter care should be provided and documented every shift. Similarly, Resident 72, who had diagnoses including benign prostatic hyperplasia and chronic kidney disease, also did not have documented catheter care on several shifts during the same period. This resident had physician orders for catheter checks every shift starting September 27, 2024. Despite this, there was no documentation of catheter care on numerous occasions, and the resident was treated with antibiotics for UTIs in October and December 2024. The Director of Nursing confirmed that catheter care should be completed and documented per facility protocol daily on every shift.
Plan Of Correction
1. R 65 has been evaluated and is currently experiencing no signs and symptoms of infection. R72 is currently being treated on antibiotic therapy and is showing no signs or symptoms of urinary tract infections. 2. Residents with indwelling catheters will be identified, and will be evaluated for signs and symptoms of urinary tract infections. In addition, documentation will be reviewed to validate catheter care has been completed. Physician will be notified for follow-up as needed. 3. Certified Nursing Assistants will be re-educated on completion of catheter care and proper documentation. Licensed Nurses will be re-educated on role and responsibility of oversight of completion of CNA documentation for each shift. 4. Director of Nursing or designee will conduct audits on at least 3 residents/per week with catheters to validate care documentation is complete. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Failure to Provide Appropriate Mobility Support for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. Resident 27, diagnosed with Parkinson's Disease and muscle weakness, had a care plan that included specific interventions such as the use of an Ankle Foot Orthotic (AFO) for transfers and proper positioning in a Broda chair. However, observations revealed inconsistencies in the use of the AFO and leg rests, with the AFO often found on the floor rather than in use. Additionally, the resident's care plan indicated they were non-ambulatory, yet they were on a walking Restorative Nursing Program (RNP), which was not consistently documented or provided. The Physical Therapy Discharge Summary recommended a Restorative Nursing Program for sit-to-stand transfers and therapeutic exercises, but there was no mention of the AFO. Documentation from November 22 to December 11 showed gaps in the provision of range of motion and ambulation programs. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed confusion regarding the resident's ambulation status and the lack of documentation for the AFO. The NHA confirmed that the care plan should have been followed, and range of motion exercises should have been documented, highlighting a deficiency in the facility's adherence to the resident's care plan.
Plan Of Correction
1. R27's Restorative Nursing Program and nurse aide task documentation has been reviewed and revised to reflect discontinuation of ambulation and to continue with Transfers and ROM programming. Certified Nursing Assistants providing care on December 9, 2024, and December 10, 2024 have been re-educated on R 27's Care plan, and responsibility to provide equipment, devices and services in accordance with the resident care plan. 2. Residents receiving Restorative Nursing have been identified to validate current programs and nurse aide task documentation is reflective of current program needs and resident status. 3. The Registered Nurse Assessment Coordinators will be re-educated on role and responsibility of the Restorative Nursing Program to include revision of the resident care plan and validating proper documentation of devices and programming is in place. Nursing Staff will be re-educated on providing equipment, devices, and services in accordance with the resident care plan and on completing accurate documentation of care provided. Therapy staff will be educated in including functional devices and equipment in discharge summaries. A Weekly Restorative Committee has been established to review current programs, resident status, and documentation. 4. Weekly audits of at least 5 residents receiving Restorative Nursing per week will be conducted by the Director of Nursing or designee to validate current programming and task documentation is accurate and reflective of status. In addition, Director of Nursing or designee will conduct random observations of at least 5 residents per week to validate equipment and devices are in place per the resident care plan. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Failure to Monitor Nutritional Status and Notify Physician
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status and did not notify the physician of significant weight changes for two residents. Resident 38, who had diagnoses including moderate protein-calorie malnutrition, dementia, and congestive heart failure, experienced a significant weight loss of 20.8 pounds over a period of three weeks. Despite the facility's policy requiring re-weighs and physician notification for significant weight changes, Resident 38 was not re-weighed until a week later, and the physician was not notified of the weight loss until December 10, 2024, several weeks after the initial weight loss was recorded. The dietitian's note on November 26, 2024, acknowledged the weight loss but did not document any communication with the physician. Resident 79, who had diagnoses including hypertension, hyperlipidemia, and osteoporosis, did not have a weekly weight measure recorded for the week of September 15 through 21, 2024, as required by physician orders and facility policy. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of the weight measure and acknowledged the expectation for weekly weights to be obtained. These deficiencies highlight lapses in the facility's adherence to its own policies regarding weight monitoring and physician notification, potentially impacting the residents' health management.
Plan Of Correction
1. R 38's provider was notified of weight loss identified from 11/3-11/26/24 on 12/10/24. R 79 no longer resides in the facility. 2. Residents with orders for weekly weights will be audited that weights were completed as orders, reweighs obtained as necessary, and follow-up with physician and dietitian notification has occurred as appropriate. The facility has reviewed and revised its current procedure for weights for obtaining weights/reweights and to include notification of the physician and dietitian as appropriate. 3. The facility will re-educate Nursing Staff and the Dietician on the revised weight procedure to include weekly weights, reweights, and to include physician and dietitian notification of identified weight changes. A weekly weight committee has been established to include a review of weekly and monthly weights to validate reweighs and notification to physician and dietitian has occurred. 4. The Director of Nursing or designee will perform audits of at least 5 residents/week and documented weights to validate weight procedure has been followed to include re-weighs and proper notifications as necessary. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Sprinkler System Deficiency Due to Missing Escutcheons
Penalty
Summary
The facility failed to maintain sprinkler head assemblies according to manufacturer specifications, affecting one of nine smoke compartments. During an observation on December 10, 2024, between 10:33 AM and 10:55 AM, it was noted that sprinkler heads in specific locations were missing an escutcheon. These locations included the Laundry area by the dryers and the Kitchen Dish Room. An interview with the Director of Environmental Services confirmed that the sprinkler head assembly did not meet the required specifications.
Plan Of Correction
The escutcheons in the laundry dryer room and the kitchen dish room were replaced. The facilities maintenance department audited the entire facility for any other missing escutcheons. Checking for missing sprinkler escutcheons has been added to the safety committee's safety checklist and performed monthly. Findings will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation.
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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