Townview Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canonsburg, Pennsylvania.
- Location
- 300 Barr Street, Canonsburg, Pennsylvania 15317
- CMS Provider Number
- 395823
- Inspections on file
- 23
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Townview Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with MS, chronic pain, depression, and anxiety, who was alert, oriented, and fully dependent on staff for ADLs including eating, experienced choking and subsequent aspiration pneumonia while being assisted with a meal. Facility policies and the resident’s care plan required upright positioning, small bites and sips, and monitoring for aspiration during feeding. During the meal, the resident began coughing, felt food was stuck, and had difficulty breathing, later requiring diagnostic testing and treatment for pneumonia and then aspiration pneumonia. The resident reported being fed with the head of the bed too flat, while the CNA who provided the feeding stated the resident was nearly upright and attributed the event to talking while eating, and also admitted not knowing where to find the resident’s specific feeding care needs, unlike other CNAs who could locate this information in the ECS.
A resident with MS, chronic pain, depression, and anxiety, who was alert and oriented, experienced choking and vomiting, after which a physician was notified and a chest X-ray was ordered. Nursing notes later documented minimal right base atelectasis and an order for Augmentin PO BID for 7 days for pneumonia. Facility policy required that changes in condition be charted and that family communication be documented, but the clinical record contained no documentation that the resident’s family was notified of this change in condition. The resident reported that their son was not informed, and the Nursing Home Administrator confirmed that the family was not notified, resulting in a violation of state regulations regarding management, resident rights, resident care policies, and nursing services.
The facility failed to follow its abuse/neglect reporting policy after a dependent, cognitively intact resident with MS and other chronic conditions experienced a choking episode during a meal while being fed by a CNA. Nursing notes documented coughing, difficulty breathing, choking, and vomiting food, followed by diagnostic testing and treatment for pneumonia, and the resident later reported that her head was too flat during feeding and that she informed staff she could not continue. Although the resident stated Administration interviewed her about the event, the DON confirmed no investigation documentation was completed, the incident did not appear on the incident/accident log, and no report of possible neglect was submitted to the State Survey Agency, despite the Medical Director’s statement that the incident should have been reported per facility policy.
A resident with MS, chronic pain, depression, and anxiety, who was alert, oriented, and dependent on staff for all ADLs including eating, experienced a choking episode during a meal while being fed by a CNA, with documented coughing, difficulty breathing, vomiting food, and subsequent pneumonia treated with Augmentin. The resident reported their head was too flat during feeding and that they told staff they could not do it. Although administration was reportedly aware and interviewed the resident, the DON acknowledged that no incident report or investigation documentation was completed, the choking event was not entered on the Incident and Accident Log, and the Medical Director and NHA confirmed the incident should have been investigated as possible neglect per facility policy.
The facility failed to provide thirteen residents the opportunity to formulate an advance directive, as required by their policy. This deficiency was identified through a review of clinical records and confirmed by staff interviews, revealing a lack of documentation for residents with various medical conditions, including diabetes, dementia, and heart disease.
The facility failed to notify physicians and assess two residents for abnormal blood glucose levels. One resident with Parkinson's disease had a low CBG of 43, and another with diabetes had multiple high CBG readings over 400. Staff did not follow care plan interventions or notify physicians, as confirmed by the DON.
A resident with significant mobility impairments fell from bed due to inadequate supervision, as a CNA failed to follow physician orders requiring two-person assistance for bed mobility. The resident was left unattended during care, leading to a fall and subsequent hospital evaluation.
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a year, as required by regulations. This deficiency was identified through a review of facility documents and information from the State Ombudsman Office, which indicated non-compliance since October 2021. The Nursing Home Administrator confirmed the failure to report these events.
Failure to Follow Assisted-Feeding Care Needs Resulting in Aspiration Pneumonia
Penalty
Summary
The facility failed to prevent an accident and ensure safe supervision during feeding for a resident who was dependent on staff for all ADLs, including eating. Facility policies on Fall and Accident Prevention and Restorative Nursing-Eating/Swallowing required a safe environment free from hazards and specified that residents needing assistance with eating should be kept upright, observed for aspiration, and given small bites and sips. The resident’s MDS documented multiple sclerosis, chronic pain, depression, and anxiety, with the resident being alert, oriented, and fully dependent on staff for ADLs. The resident’s care plan and ECS documentation specified dependence on staff for eating and the need for upright positioning and monitoring for aspiration. On the identified dinner meal, the resident began coughing, felt food was stuck, and had difficulty breathing while being fed by a CNA. Nursing notes documented choking and vomiting of food, followed by physician notification and diagnostic testing that led to treatment for pneumonia and then aspiration pneumonia, including antibiotics, respiratory treatments, and oxygen as needed. During an interview, the resident reported that at the time of the choking event the head of the bed was too flat compared to the current 45-degree elevation, and expressed distress about the incident. In a separate interview, the CNA who fed the resident stated the resident had been positioned “damn near 90 degrees,” attributed the coughing to talking while eating, and admitted not knowing where to find the resident’s specific care needs for eating, only knowing the resident as a “feed.” Other CNAs interviewed were able to locate and describe the resident’s eating-related care needs in the ECS. The Nursing Home Administrator confirmed the facility failed to prevent an accident that resulted in actual harm of aspiration pneumonia for this resident.
Failure to Notify Family of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family of a significant change in condition as required by facility policy and state regulations. Facility policy and nursing documentation dated 3/26/25 state that changes in a resident’s condition must be charted and that communication with family should be documented. The clinical record shows that a resident with multiple sclerosis, chronic pain, depression, and anxiety, who was alert, oriented, and able to understand and be understood, was admitted on an unspecified date and had an MDS dated 5/2/25. A nurse progress note dated 1/11/26 documented that the resident experienced choking and vomiting of food, was assessed, the physician was notified, and a chest X-ray was ordered. A subsequent nurse progress note dated 1/12/26 documented that the X-ray showed minimal right base atelectasis and that Augmentin 875/125 mg PO BID for 7 days was ordered for pneumonia. During an interview on 1/18/26, the resident stated that their son was not notified and that they had pneumonia for a week. Review of the progress notes did not show any documentation that the resident’s family was notified of this change in condition. In a later interview on 2/18/26, the Nursing Home Administrator confirmed that the facility failed to notify the family of the resident’s change in condition, resulting in noncompliance with 28 Pa. Code 201.18(b)(1), 201.29(d), 211.10(c)(d), and 211.12(d)(1)(2)(3)(5).
Failure to Report and Investigate Possible Neglect After Choking Incident
Penalty
Summary
The facility failed to implement its abuse/neglect reporting policies by not reporting and investigating a possible neglect incident involving one resident. Facility policy dated 3/26/25 required that alleged violations involving abuse/neglect be reported immediately to the Administrator and that results of all investigations be reported to the Administrator and the PA Department of Health within five working days. The resident involved had multiple diagnoses including MS, chronic pain, depression, and anxiety, was alert and oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. On the date of the incident, nursing progress notes documented that during dinner the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the following day the X-ray showed minimal right base atelectasis, with Augmentin ordered for pneumonia. During a later interview, the resident reported that a CNA had been feeding her, that her head was too flat while eating, that she said she could not do it, and that she subsequently developed pneumonia. The resident stated that Administration was aware of the incident and had interviewed her the following day. However, the DON acknowledged that no investigation documentation was completed, and the January incident and accident log did not include the choking incident. Documentation submitted by the facility to the State Survey Agency did not include any report of possible neglect related to this event. The Medical Director stated that the choking incident should have been reported per facility policy, and the Nursing Home Administrator confirmed that the facility failed to implement its policies and procedures to report possible neglect for this resident.
Failure to Investigate Choking Incident as Possible Neglect
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy requiring prompt and thorough investigation of all alleged violations involving abuse or neglect after a resident experienced a choking incident. The resident, who had multiple sclerosis, chronic pain, depression, and anxiety, was alert, oriented, able to understand and be understood, and was dependent on staff for all ADLs, including eating. The facility’s electronic charting system identified the resident as dependent on staff for meals. Nurse progress notes documented that during a dinner meal the resident began coughing, felt like food was stuck, had difficulty breathing, and was choking and vomiting food. The resident was assessed, the physician was notified, a chest X-ray was ordered, and the subsequent nurse note documented minimal right base atelectasis and an order for Augmentin for pneumonia. During a later interview, the resident reported that a CNA had been feeding the meal, that their head was too flat while being fed, that they said they could not do it, and that they subsequently developed pneumonia. The resident stated administration was aware of the incident and interviewed them the following day and was tearful about the event. When surveyors requested investigation documents and an incident report for the choking event, the DON stated no documentation had been completed. The facility’s Incident and Accident Log for the relevant month did not list the choking incident. The Medical Director stated the choking incident should have been investigated per facility policy, and the Nursing Home Administrator confirmed the facility failed to implement its policies and procedures to investigate this incident of possible neglect.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care, for thirteen out of eighteen residents reviewed. This deficiency was identified through a review of the facility's policy on advance directives, clinical records, and staff interviews. The facility's policy, last reviewed on March 27, 2024, mandates compliance with maintaining written policies and procedures regarding advance directives, including informing and providing written information to all adult residents about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. The clinical records of several residents, including those with serious medical conditions such as diabetes, dementia, chronic obstructive pulmonary disease, and Alzheimer's, were reviewed. These records failed to show any documentation that the residents were given the opportunity to formulate an advance directive upon admission or readmission to the facility. The absence of such documentation was confirmed during an interview with the Social Worker and the Assistant Director of Nursing (ADON), who acknowledged that the clinical records did not include evidence that the residents were afforded this opportunity. The deficiency was noted for residents with a range of medical diagnoses, including diabetes, dementia, chronic kidney disease, and heart conditions, among others. The lack of documentation and opportunity for these residents to formulate advance directives indicates a failure to adhere to the facility's policy and regulatory requirements. This oversight was identified as a violation of specific Pennsylvania Code regulations related to clinical records and nursing services.
Failure to Notify Physicians and Assess Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R27, who was readmitted with diagnoses including Parkinson's disease, depression, and high blood pressure, had a CBG level of 43 on a specific date. Despite having a care plan that included observing for hypo/hyperglycemia and notifying the physician if symptoms occurred, the staff did not assess the resident for hypoglycemia, monitor the effectiveness of treatment, or notify the physician of the abnormal result. Resident R46, admitted with diagnoses including diabetes, depression, and anxiety, had multiple instances of CBG levels exceeding 400, with one instance as high as 524. The care plan for this resident included performing Accuchecks as ordered and observing for signs of hypo/hyperglycemia. However, the staff failed to assess the resident for hyper-/hypoglycemia, did not follow the care plan interventions, did not recheck blood sugar levels, and did not notify the physician of the abnormal results. Interviews with various nursing staff, including RNs and LPNs, revealed inconsistencies in following the facility's protocols for managing abnormal blood glucose levels. Staff members described different actions they would take in response to low or high blood glucose readings, but the documentation and actions taken did not align with these descriptions. The Director of Nursing confirmed the facility's failure to notify the doctor of changes in condition and to document assessments or interventions related to blood glucose for the affected residents.
Failure to Provide Adequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for Resident R51, who required extensive assistance for bed mobility due to conditions such as morbid obesity, neuromyelitis optica, and paraplegia. The resident's care plan and physician orders specified the need for assistance from two staff members for mobility tasks. However, on the day of the incident, CNA Employee E9 attempted to provide care alone, contrary to the established care plan and physician orders. During the incident, CNA Employee E9 positioned Resident R51 on her side and left the bedside to retrieve additional supplies, leaving the resident unattended. While unattended, Resident R51 attempted to stabilize herself by holding onto the bed's siderail, which resulted in her legs sliding off the bed and her falling to the floor. The fall led to complaints of pain in the resident's head and left shoulder, and she was subsequently sent to the hospital for evaluation. The facility's investigation revealed that CNA Employee E9 did not adhere to the physician's orders requiring two-person assistance for bed mobility. This breach of protocol was acknowledged by the facility, and the CNA received a written warning for not following professional standards. Interviews with other staff members confirmed that the facility's policy for ADL care and resident mobility was communicated at the start of each shift, indicating a failure in individual compliance rather than a systemic issue.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for the period from October 2023 through October 2024, as required by regulations. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. Additionally, information from the State Ombudsman Office indicated that the facility had not been notifying them of transfers and discharges since October 2021. The Nursing Home Administrator confirmed the failure to report these events for the specified year.
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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