Transitions Healthcare Allens Cove
Inspection history, citations, penalties and survey trends for this long-term care facility in Duncannon, Pennsylvania.
- Location
- 25 Cove Road, Duncannon, Pennsylvania 17020
- CMS Provider Number
- 395915
- Inspections on file
- 23
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Transitions Healthcare Allens Cove during CMS and state inspections, most recent first.
The facility failed to maintain proper temperature controls for medication storage, as observed in the medication room refrigerator. The thermometer was improperly placed in the freezer section, leading to temperatures recorded at 20°F, below the required range of 36°F to 46°F. The temperature log for April showed inconsistent recordings, with several days missing entries. The NHA and DON acknowledged the expectation for proper storage and daily temperature monitoring, which was not met.
The facility failed to maintain food safety and sanitation standards, with expired and improperly stored food items, a soiled dish machine, and inadequate temperature logs. The Dietary Manager lacked a cleaning schedule, and the facility could not provide temperature logs for six months. The NHA expected proper food storage and equipment maintenance, which were not met.
Transitions Healthcare Allens Cove failed to provide a resident with written notice of the bed-hold policy during hospital transfers, as required by federal regulations. Despite the facility's policy, there was no evidence that the resident or their representative received the necessary information during two hospitalizations. The resident had a history of hypertension and Type 1 Diabetes Mellitus.
The facility failed to ensure accurate resident assessments, leading to discrepancies in documentation for two residents. One resident with a Foley catheter was incorrectly noted as occasionally incontinent, while another resident's fall was not recorded in their MDS. These errors were confirmed by the DON.
A resident with spinal stenosis and muscle weakness did not receive scheduled showers as per her preferred schedule, missing multiple dates over several months. The facility's policy requires maintaining independence in ADLs, but the resident reported not receiving a shower for over two weeks at times. The Nursing Home Administrator mentioned refusals by the resident, but there was no documentation of refusals or reapproach attempts, contrary to expectations stated by the DON.
A facility failed to provide care in line with professional standards for a resident with Alzheimer's and a pacemaker. The resident's clinical record lacked current orders for cardiology consults or pacemaker checks, and the last remote check was months overdue. The DON found that appointment letters were sent to the wrong address, and the facility was not the primary contact, leading to missed appointments and checks.
The facility failed to ensure a resident received necessary cardiology follow-ups and did not provide prescribed restorative nursing care for another resident with mobility issues. The oversight in coordinating medical appointments and incomplete range of motion exercises were identified as deficiencies.
The facility failed to maintain effective infection control during medication administration for three residents. An employee did not follow hand hygiene protocols, improperly cleaned a glucometer, and neglected Enhanced Barrier Precautions for a resident with a central line. These actions were confirmed by the NHA and DON, who acknowledged the expectation for staff to adhere to infection control guidelines.
The facility did not follow its policy for TB screening of new employees, as one employee did not receive the required screening before starting their duties. The Nursing Home Administrator acknowledged the issue is being addressed.
Multiple stained ceiling tiles and a wall with a brown liquid stain were observed in common areas and a resident's room, indicating a failure to maintain a clean and homelike environment as required by facility policy. Maintenance staff and the administrator confirmed that these soiled surfaces should have been identified and addressed during regular environmental rounds.
Annual performance evaluations for three nurse aides were not completed or available for review, as required by facility policy and state regulations. The issue was attributed to a recent change in the facility's electronic evaluation system, which resulted in the loss of some records, and was confirmed by both staff interviews and documentation review.
The facility was found to have multiple violations of food service safety standards. Employees were observed working without hairnets, and an open bottle of stir fry sauce was improperly stored without an open date. Additionally, clean utensils were stored in a drawer with dried food particles, and the drawer itself was not clean. These issues were confirmed by the NHA and Food Service Director.
The facility failed to notify the State Long-Term Care Ombudsman of the transfer of four residents to the hospital, as required by regulations. The residents, who had various medical conditions, were transferred between January and April 2024. Interviews with the Nursing Home Administrator confirmed the lack of notification.
A facility failed to provide necessary care and services for a resident's hygiene and bathing needs, as part of their ADLs. The resident, with chronic respiratory failure and hypoxemia, was on a restorative nursing program requiring staff assistance for washing and grooming. However, multiple instances were recorded where these tasks were not completed, and the Director of Nursing could not explain the omissions. The Nursing Home Administrator expected these tasks to be completed, indicating a deficiency in maintaining the resident's ADL capabilities.
The facility failed to provide an ongoing activities program to meet residents' needs, with only one activity staff member working weekdays, resulting in no weekend activities. Residents expressed dissatisfaction, noting canceled activities and the need for additional support for the activity director. Facility documents confirmed the absence of scheduled activities on weekends.
The facility failed to provide physician-ordered therapeutic diets for residents on renal/low potassium and consistent carbohydrate diets. The dietary extension sheets did not document these diets, and staff confirmed that the facility did not offer them, leading to a deficiency in dietary management.
The facility failed to provide proper respiratory care for four residents. A resident's nebulizer was not stored correctly, another's equipment was outdated and not covered, a third used oxygen without a documented order, and a fourth had undated distilled water in their room. Staff confirmed these were against facility policies.
The facility failed to meet food safety standards, with issues in food storage and labeling in the kitchen and nourishment pantry. Observations included open and unlabeled food items, such as pasta, hard-boiled eggs, meat, ice cream, nutritional shakes, and soup. Interviews with the Food Service Director and Nursing Home Administrator confirmed these deficiencies.
The facility failed to provide a dignified meal service by not serving meals simultaneously to residents at the same table, as required by their policy. Observations revealed that meals were served at staggered times, and all residents were served on trays, contrary to the facility's policy. The NHA acknowledged the discrepancy during an interview.
The facility failed to provide three residents with the required bed-hold policy notice upon their transfer to a hospital, as per their policy. Despite the policy's requirement for notification at admission and transfer, residents with chronic conditions and pressure ulcers were transferred without receiving this notice. Interviews with the NHA confirmed the oversight, leading to a deficiency in compliance with regulatory requirements.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their clinical records. One resident on hospice services was not documented as such in the MDS due to an oversight in physician orders. Another resident using oxygen was incorrectly marked as not using it in the MDS, despite progress notes indicating otherwise. These errors were acknowledged by the DON and Nursing Home Administrator.
A facility failed to include hemodialysis in a baseline care plan for a resident admitted after hospitalization. The resident, with a history of hemodialysis, protein calorie malnutrition, and diabetes mellitus, lacked documented orders for hemodialysis and related care needs. The Nursing Home Administrator confirmed that these should have been included in the care plan.
A resident with COPD and sleep apnea did not receive a prescribed nicotine patch for several days due to a delay in completing an OTC authorization form. The facility's pharmacy policy required this form for non-stock medications, leading to a delay in the medication's delivery and administration.
The facility failed to provide food and beverages at safe temperatures during a meal service on the South unit. A test tray revealed unsatisfactory temperatures for coffee and milk, and staff interviews highlighted the absence of a policy for checking food temperatures at the point of service. Resident concerns about cold food were documented in previous council meetings.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to store medications under proper temperature controls in the medication room, as required by federal regulations. The facility's policy, last revised in August 2020, mandates that medications be stored within temperature ranges specified by the United States Pharmacopeia (USP) and the Centers for Disease Control (CDC). Specifically, refrigerated medications should be kept between 36°F and 46°F. However, an observation on April 22, 2025, revealed that the thermometer in the medication room refrigerator was placed inside the freezer section, which had significant ice build-up, and the temperature was recorded at 20°F, well below the required range. A review of the facility's medication room refrigerator temperature log for April 2025 showed inconsistent temperature recordings, with several days missing entries. Temperatures recorded on various days were either below the required range or not recorded at all, indicating a failure to maintain and monitor appropriate storage conditions. During an interview, the Nursing Home Administrator and Director of Nursing acknowledged the expectation for medications to be stored at appropriate temperatures and for daily temperature recordings to be maintained, which was not adhered to in this instance.
Plan Of Correction
1. A new thermometer was purchased for the medication room refrigerator. 2. Medication room refrigerator was cleaned and defrosted. 3. DON or designee will provide education to nursing staff in regard to routine checking of temperatures and that all medication should be stored between 36-46 degrees. 4. An audit will be conducted by NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure that all medications are stored between 36-46 degrees. 5. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. In the dry storage area, expired food items, including bags of white bread and undated English muffins, were found. The dish machine in the main kitchen was heavily soiled with a brown substance, and the exhaust vent above it was covered with a fuzzy black substance. The dish machine's temperature logs revealed that the final rinse temperature was below the minimum safe level on multiple occasions, with no corrective actions documented. Additionally, a tub of hard-boiled eggs in the walk-in refrigerator was dirty, improperly sealed, and past its use-by date. Interviews with the Dietary Manager revealed a lack of awareness regarding the source of the substances on the dish machine and the last cleaning of the exhaust hood. The manager also admitted to not having a routine cleaning schedule checklist. Furthermore, the facility was unable to provide dish machine temperature logs for a six-month period. The Nursing Home Administrator expressed expectations for proper food storage, labeling, and equipment maintenance, which were not met according to the observations and findings.
Plan Of Correction
1. All food not stored properly was discarded. 2. Dietary manager will provide education to dietary staff on proper storage of food, proper dishwasher temperatures and cleaning of kitchen equipment. 3. Facility has signed a lease for a new dishwasher on 5/1/25, looking to have installed in the next month. 4. Exhaust vent over top of dish machine was cleaned as well as dishwasher. 5. An audit will be performed on the exhaust vent two times weekly x 4 weeks, then monthly x 2 months. 6. An audit will be performed on the dish machine temperature log weekly x 4 weeks, then monthly x 2 months to ensure final rinse temperatures are above 180 degrees. 7. An audit will be performed to make sure all food is being stored and dated properly in the pantry, walk in refrigerator, dry storage area and freezer three times weekly x 4 weeks, then two times monthly x 2 months. 8. Dietary Manager going forward will have dietary aides perform a checklist for both AM and PM to ensure that the dish machine is cleaned inside and out as well as the vent above dish machine daily. 9. Results will be taken to QAPI for review of findings and further interventions if warranted.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Transitions Healthcare Allens Cove was found to be non-compliant with the federal requirement 42 CFR Part 483 Subpart B, specifically regarding the notice of bed-hold policy. The facility failed to provide written notice of the bed-hold policy to a resident and/or their representative at the time of transfer to a hospital. This deficiency was identified during a review of the facility's policy, clinical records, and staff interviews. The facility's policy mandates that residents be informed of the bed-hold policy upon admission and again at the time of transfer, with the second notice detailing the duration of the bed-hold policy. However, there was no evidence that such notice was provided to Resident 45 during her hospitalizations on two separate occasions. Resident 45, who has a medical history including hypertension and Type 1 Diabetes Mellitus, was transferred to the hospital on two occasions. Despite the facility's policy requiring written notification of the bed-hold policy at the time of transfer, the Nursing Home Administrator confirmed that there was no documentation indicating that Resident 45 or her representative received this notice during her hospitalizations. This oversight was identified during an interview conducted on April 23, 2025.
Plan Of Correction
1. An audit will be conducted on past discharged residents to identify past deficient practice. 2. Any current residents moving forward will have a bed hold policy signed by resident or documentation on bed hold policy that the policy was explained to resident. 3. A copy of the bed hold policy as well as the bed hold agreement will be placed in a binder at the nurse's station. If a resident must be transferred, the facility form will be completed in person or via phone if required, with the original provided to patient or responsible party and a copy to remain in the chart. 4. DON or designee will provide education to nursing staff on the proper procedure for issuing the bed hold notice. 5. DON or designee will audit all transfers three times weekly x 4 weeks, then two times monthly x 2 months to ensure that the proper bed hold policy is initiated and executed. Results will be taken to the QAPI committee for review of findings and further interventions if warranted.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents, leading to discrepancies in their documented status. Resident 9, diagnosed with Multiple Sclerosis and neurogenic bladder, had a physician's order for a Foley catheter. However, the Quarterly MDS inaccurately indicated that the resident was occasionally incontinent of urine, which was confirmed as an error by the Director of Nursing during an interview. This misrepresentation of the resident's continence status was due to incorrect coding on the MDS. Similarly, Resident 32, who had diagnoses of heart failure and chronic kidney disease, experienced an unwitnessed fall resulting in an abrasion on the left thigh. Despite this incident, the Significant Change MDS inaccurately recorded that the resident had not experienced any falls since admission or prior assessment. This error was also confirmed by the Director of Nursing, indicating a failure to accurately document the resident's fall history in the assessment.
Plan Of Correction
1. R9 and R32 MDS were corrected with accurate coding and resubmitted with modifications. 2. The regional care manager will complete education with the Licensed Practical Nurse Assessment Coordinator on accurate coding of identified sections of MDS per RAI guidelines and appropriate coding with emphasis on accurate coding. 3. An initial audit of MDS's will be completed for the past 30 days on identified residents. The Licensed Practical Nurse Assessment Coordinator will complete all assessments. 4. Licensed Practical Nurse Assessment Coordinator / Designee will complete an audit of 5 resident MDS submissions weekly x 4 weeks, then 5 resident MDS submissions two times monthly x 2 months. 5. When MDS is ready for submission, the Licensed Practical Nurse Assessment Coordinator will coordinate with the RN to verify accuracy of MDS prior to submission. 6. The results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Provide Scheduled ADL Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This deficiency was identified for one of two residents reviewed for ADLs, specifically Resident 23. The facility's policy on ADLs emphasizes maintaining as much independence as possible in daily activities, including hygiene. However, Resident 23, who has diagnoses of spinal stenosis, repeated falls, and muscle weakness, reported not receiving a shower for over two weeks at times, and specifically not for eight days recently. Resident 23's clinical record indicated a preferred shower schedule of Wednesdays and Saturdays during the 2-10 shift, but records showed missed showers on multiple dates in January, February, March, and April 2025. The Nursing Home Administrator noted that Resident 23 sometimes refused to get out of bed for showers, but there was no documentation of such refusals or any reapproach attempts in the clinical record. The Director of Nursing stated that staff are expected to document refusals and reapproach residents later, which was not done in this case.
Plan Of Correction
1. Facility cannot edit old documentation errors. 2. Facility will audit ADL care for dependent residents with regards to hygiene and bathing to identify any baseline opportunities for missed documentation or incorrect documentation. 3. DON or designee will provide education to the nursing staff on reviewing the ADL coding report prior to end of shift to ensure completion and accuracy of hygiene and bathing (showers) and address concerns prior to end of shift. 4. DON or designee will provide education to nursing staff regarding ADL coding and accuracy of coding in regard to hygiene and bathing. 5. Nursing staff will run an ADL coding report prior to end of all shifts with regards to bathing and hygiene (showers) to ensure showers are given and if resident is refusing what other alternatives were offered (bed bath). 6. An audit will be conducted by DON or designee three times weekly x 4 weeks, then two times monthly x 2 months for ADL coding for dependent residents with regards to hygiene and bathing. 7. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Ensure Timely Cardiology and Pacemaker Checks
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for a resident with Alzheimer's disease, atrioventricular heart block, and a cardiac pacemaker. The resident's clinical record did not contain current physician orders for a cardiology consult or pacemaker checks, despite the presence of a remote telephonic pacemaker check device at the resident's bedside. The last documented pacemaker remote check was completed several months prior, and the care plan for the pacemaker had not been revised since July 2022. The Director of Nursing (DON) acknowledged the oversight after being informed of the issue. The DON discovered that the cardiology office had sent appointment letters to an incorrect address and had not listed the facility as the primary contact for the resident. Consequently, the resident missed the scheduled yearly cardiology appointment and the three-month remote pacemaker checks. The cardiology office confirmed that the pacemaker was still transmitting data but had not alerted the facility to any issues due to the contact information error.
Plan Of Correction
1. R24's yearly pacemaker appointment has been scheduled. 2. Facility will audit pacemaker orders and appointments on other residents to identify any baseline opportunities for missed pacemaker checks and/or annual appointments. 3. A Binder will be kept at the nurse's station with all residents that have pacemakers to ensure yearly appointments and regular checks are not missed going forward. 4. DON or designee will provide education to nursing staff on reviewing all pacemaker orders to ensure they are entered correctly, and appointments are made accordingly. 5. An audit will be conducted by DON or designee monthly x 3 months on all cardiac pacemakers to ensure remote checks are taking place and that yearly appointments are made. 6. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Deficiency in Resident Care Coordination and Restorative Nursing
Penalty
Summary
The facility failed to ensure that Resident 24 received her annual cardiology appointment and remote pacemaker checks. The Director of Nursing (DON) confirmed that the facility staff should have followed up with the cardiology office when they did not follow up with the facility. This oversight indicates a lapse in the facility's responsibility to coordinate and ensure necessary medical appointments and checks for their residents. Additionally, the facility did not provide the required restorative nursing care for Resident 29, who was diagnosed with peripheral vascular disease and hypertension, and had a condition of flaccid hemiplegia on the right side. The clinical records showed that the restorative nursing program tasks for both passive and active range of motion exercises were not completed as prescribed. Specifically, there were multiple days in April 2025 where the exercises were either not completed twice daily or marked as "not applicable," contrary to the expectations of the Nursing Home Administrator.
Plan Of Correction
1. The facility cannot address past missed RNP programs. 2. Therapy department will do a baseline assessment for any adverse reactions from not receiving the RNP for resident 29. 3. Facility will audit residents on a restorative nursing program to identify any baseline opportunities for missed RNP on residents. 4. DON or designee will provide education to nursing staff on providing restorative care as documented in the restorative nursing program. 5. An audit will be conducted by DON or designee on 5 random residents with RNP's weekly x 4 weeks, then 5 random residents with RNP's monthly x 2 months to ensure that all restorative nursing programs are documented as completed. 6. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during the preparation and administration of medications for three residents. The facility's policy on medication administration requires staff to adhere to good hand hygiene, including washing hands before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. However, during a medication pass observation, Employee 2 did not follow these guidelines. After administering an insulin injection to Resident 9, Employee 2 did not cleanse her hands before preparing medications for Resident 27. Employee 2 also failed to follow proper infection control procedures when performing a blood glucose test for Resident 27. She used her gloved hand to close a window and then proceeded with the test without changing gloves. Additionally, she did not properly clean the glucometer according to the facility's policy, which requires cleaning and disinfecting the device after each use. Employee 2 was unsure of the correct cleaning procedure and used an alcohol pad instead of the required germicidal disposable wipe. Furthermore, Employee 2 did not adhere to Enhanced Barrier Precautions (EBP) when attending to Resident 155, who had a central line. Despite the EBP sign indicating the need for hand cleansing and wearing gloves and gowns, Employee 2 entered the room without cleansing her hands and did not wear a gown while flushing the central line. These actions were confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for staff to follow personal protective equipment guidance and hand hygiene protocols.
Plan Of Correction
1. DON will provide education to Employee 2 on infection control practices during medication administration to ensure all infection control procedures are being followed. 2. DON will provide education to Employee 2 on Enhanced Barrier precautions for gown and gloves when giving care to an individual on these precautions. 3. DON will provide education to Employee 2 on proper cleaning and disinfecting of glucometers after each use. 4. DON will provide education to nursing staff on infection control practices during medication passes, Enhanced Barrier Precautions, and proper glucometer disinfecting. 5. Resident's 9, 27 and 155 were all assessed for any adverse effects regarding nonadherence to infection control practices and enhanced barrier precautions. 6. All other residents on Employee 2's medication pass were assessed for any adverse reactions related to not following infection control practices and enhanced barrier precautions. 7. DON/ designee will conduct an audit 2 times a week x 4 weeks on via direct observation of a medication pass, then monthly x 2 months. 8. All findings will be taken to QAPI for review.
Failure to Conduct TB Screening for New Employee
Penalty
Summary
The facility failed to adhere to its policy regarding tuberculosis (TB) screening for newly hired employees. According to the facility's policy, IM-162 Tuberculosis-Employee Screening, revised on June 14, 2023, each newly hired employee must be screened for TB infection and disease after an employment offer has been made but before the employee begins their duties. However, a review of the personnel records revealed that one of the five employees reviewed, referred to as Employee 1, did not receive the required tuberculin screening within the specified timeframe. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the process is currently being worked on.
Plan Of Correction
1. Facility policy has been reviewed and revised in accordance with state regulations. 2. Employee 1 has had a TB questionnaire completed and signs/symptoms were all negative. 3. Employee 1 had a T-Spot done. 4. NHA will provide education to HR Coordinator regarding TB testing completion before a candidate starts on their job duty assignment. 5. Baseline audit will be completed on employee files to determine compliance with TB screening. 6. NHA or designee will conduct an audit monthly x 2 months on all new hires to ensure all have proper TB documentation before the start date of employment. 7. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Maintain Clean and Homelike Environment in Common Areas and Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several common areas and in one resident room. Observations revealed multiple ceiling tiles with brown ring stains in the South and East Hallways, as well as at the Nurse's Station. Additionally, a brown liquid stain was observed dripping down the side of a wall in the East Hallway. In one resident's room, there were stained ceiling tiles at the entrance and in the middle of the room, all with visible brown liquid marks. These findings were inconsistent with the facility's policy, which requires regular cleaning and disinfection of environmental surfaces, especially when visibly soiled. Interviews with the Maintenance Director confirmed that maintenance staff are responsible for conducting regular environmental rounds and room checks to identify issues requiring repair or replacement. The Maintenance Director acknowledged ongoing issues with roof leaks during heavy rain and stated that staff should have identified and replaced the soiled ceiling tiles and cleaned the stained wall. The Nursing Home Administrator also stated that he would expect soiled ceiling tiles to be identified and replaced, and environmental surfaces to be cleaned when soiled.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five nurse aides reviewed, as required by its own Employee Handbook and state regulations. Documentation showed that these nurse aides had been employed for over a year, but their most recent annual evaluations could not be located. The Nursing Home Administrator confirmed that the facility had recently switched electronic systems for employee evaluations, resulting in the loss of some records if they had not been printed prior to the transition. Additionally, one nurse aide confirmed she had not received an annual evaluation. The administrator acknowledged that annual evaluations were expected to be completed and available for review.
Food Service Safety Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen area, as observed during a survey. Employees working in the kitchen were found without hairnets, which is a violation of the facility's policy on food preparation and handling. Additionally, an open bottle of stir fry sauce was found in the dry storage area without an open date, despite instructions on the bottle to refrigerate after opening. This indicates a failure to properly label and store food items as per the facility's food storage policy. Further observations revealed unsanitary conditions in the kitchen, with clean utensils stored in a drawer containing dried food particles. The drawer and its surrounding areas also had dried food stuck on them, which is contrary to the facility's policy that requires kitchen surfaces and equipment to be cleaned and sanitized. These deficiencies were confirmed by the Nursing Home Administrator and the Food Service Director during interviews conducted immediately after the observations.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide the required notification to the Office of the State Long-Term Care Ombudsman regarding the transfer of four residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. The residents involved had various medical conditions, including chronic kidney disease, hypertension, chronic obstructive pulmonary disease, multiple sclerosis, stage 4 pressure ulcer, dementia, and ileus. Each resident was transferred to the hospital due to their medical conditions, but the facility did not notify the Ombudsman as required. Interviews with the Nursing Home Administrator confirmed that the notifications were not made for any of the four residents. The transfers occurred between January and April 2024, and the lack of notification was acknowledged during interviews conducted in May 2024. This failure to notify the Ombudsman is a violation of the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa Code 201.18(b)(3).
Failure to Provide Necessary ADL Assistance to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was provided with the necessary care and services related to hygiene and bathing, which are part of the activities of daily living (ADLs). Resident 32 has a medical history that includes chronic respiratory failure and hypoxemia. Despite having a restorative nursing program in place that required staff to assist the resident with washing and drying her face, hands, and upper body, and performing grooming tasks, there were multiple instances where these tasks were not completed. The resident reported not receiving a wash-up on a specific morning, and the clinical record review showed several dates where the ADL tasks were marked as 'Not Applicable,' indicating they were not performed. During an interview, the Director of Nursing was unable to provide an explanation for why the ADL tasks were not completed on the specified dates. The Nursing Home Administrator expressed an expectation that the resident's ADL tasks should have been completed. This deficiency was identified during a survey, and it highlights a failure in the facility's responsibility to maintain the resident's ability to perform ADLs unless there is a medical reason for the decline, as per the regulatory requirement under 28 Pa code 211.12(d)(1)(5) Nursing services.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program designed to meet the physical, mental, and psychosocial well-being of residents. This deficiency was identified through resident and staff interviews, as well as a review of facility documents. It was revealed that the facility employs only one activity staff member who works Monday through Friday, resulting in no scheduled activities for residents on weekends. Residents expressed dissatisfaction during interviews, noting that scheduled activities are sometimes canceled, and the activity director appears to be overwhelmed and in need of assistance. Further review of the facility's Resident Council Meeting Minutes from March and April 2024 highlighted ongoing concerns about the lack of activities. Residents reported that activities have deteriorated, with the activities director often absent, leaving residents alone in the dayroom with only movies to watch. The minutes also indicated a desire for a volunteer program and more outdoor activities. The facility's activity calendar for March, April, and May 2024 confirmed the absence of scheduled activities on weekends. The Nursing Home Administrator acknowledged the lack of weekend activities and confirmed the activity director's Monday through Friday schedule.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as per physician's orders for residents requiring specific dietary management. Specifically, four residents on a renal/low potassium diet and eighteen residents on a consistent carbohydrate diet did not receive the appropriate dietary modifications. The facility's dietary extension sheets, which guide meal preparation based on diet orders, did not document these therapeutic diets. Instead, they only included regular, dysphagia advanced, and puree diets. This oversight was identified during a review of the facility's diet type report and extension sheets, which revealed discrepancies between physician orders and the diets provided. Interviews with facility staff, including the Food Service Director and the Nursing Home Administrator, confirmed that the facility did not offer renal or consistent carbohydrate diets, and these were not documented on the extension sheets. The Food Service Director acknowledged that dietary restrictions for these diets were communicated verbally to staff, but there was no formal documentation or adherence to the prescribed therapeutic diets. This lack of documentation and adherence to physician orders led to the deficiency, as the facility did not ensure that residents received the necessary dietary management to maintain their health.
Deficiencies in Respiratory Care and Oxygen Services
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for four residents. Resident 14, diagnosed with COPD and MS, had nebulizer equipment left on the bedside table instead of being stored in a labeled plastic bag as per facility policy. This was observed on two consecutive days, and staff confirmed the equipment should have been bagged. Resident 31, with chronic respiratory failure and other conditions, had nebulizer equipment that was not covered or removed despite not needing the medication since January. The equipment was dated from January, and the nightstand was observed to have a white powdery residue. Staff acknowledged the equipment should have been bagged or removed, and the nightstand cleaned. Resident 32, with chronic respiratory failure and hypoxemia, was using oxygen without a physician's order documented until May. The care plan did not initially include oxygen use as an intervention, and there were gaps in the treatment administration record for changing oxygen equipment. Resident 111, with COPD and obstructive sleep apnea, had an undated, opened container of distilled water in their room, contrary to facility policy. Staff confirmed the water should have been dated.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in both the kitchen area and the nourishment pantry. Observations revealed multiple instances of improper food storage and labeling. In the dry store room, a half package of pasta was found open and not securely closed. In the walk-in refrigerator, a container of thirty hard-boiled eggs and a 25-pound container of hard-boiled eggs were not securely closed or date marked. Additionally, in the walk-in freezer, several bags of meat, including beef hamburgers, chicken breasts, and pork sausage, were not date marked. Further issues were identified in the nourishment pantry. The freezer contained containers of vanilla ice cream and boxes of chocolate-coated vanilla ice cream cones that were not labeled with a resident identifier or date marked. In the refrigerator, open containers of fortified nutritional shakes and a plastic thermal bowl of tomato soup were not date marked. The soup was improperly stored and should have been discarded after meal service. These deficiencies were confirmed through interviews with the Food Service Director and the Nursing Home Administrator, who acknowledged the concerns but provided no further information.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to ensure each resident's right to a dignified existence during meal service, as observed in one dining room. According to the facility's policy on Resident Rights, meals should be provided to all residents at each table simultaneously. However, during lunch on May 6, 2024, it was observed that Resident 50 was eating her lunch while Residents 6, 10, 17, and 30, who were seated at the same table, had not yet been served. The meals for these residents were served at staggered times, with Resident 30 receiving her meal at 1:04 PM, Resident 6 at 1:08 PM, Resident 17 at 1:12 PM, and Resident 10 at 1:25 PM. Further observations on May 6 and May 8, 2024, revealed that all residents in the dining room were served their meals on trays, contrary to the facility's policy. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 8, 2024, the NHA acknowledged that residents should be provided meals at the same time and should not be served meals on trays. This inconsistency with the facility's policy led to the determination of a deficiency in honoring the residents' rights to a dignified existence.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a copy of the bed-hold policy upon their transfer to a hospital, as required by their own policy. The policy, titled 'Bed Holds and Returns and Therapeutic Leave of Absence,' mandates that residents receive information on bed hold requirements upon admission and again at the time of transfer. However, for three residents reviewed for hospitalization, this policy was not followed. Resident 10, who had chronic kidney disease and hypertension, was transferred to the hospital without receiving the bed hold notice. Similarly, Resident 14, with chronic obstructive pulmonary disease and multiple sclerosis, was also transferred without receiving the notice, despite being an automatic 15-day bed hold under Medicaid. Resident 26, suffering from a stage 4 pressure ulcer and hypertension, was transferred without the notice as well. Interviews with the Nursing Home Administrator (NHA) confirmed the oversight in providing the bed hold notices. The NHA acknowledged that Resident 10 and Resident 26 did not receive the bed hold notice upon their transfer to the hospital. In the case of Resident 14, the NHA stated that the notice was not provided due to the automatic Medicaid bed hold, which was a misinterpretation of the policy requirements. This failure to adhere to the facility's policy resulted in a deficiency as it did not comply with the regulatory requirements to inform residents or their representatives about the duration of the bed hold policy during transfers.
Inaccurate Resident Assessments in Clinical Records
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in their clinical records. Resident 21, diagnosed with dementia, Parkinson's disease, moderate protein-calorie malnutrition, and psychosis, was on hospice services since November 15, 2023. However, the quarterly Minimum Data Set (MDS) dated February 7, 2024, did not document the hospice services. This oversight occurred because the physician's order for hospice services had an end date of November 19, 2023, causing it to fall off the physician orders. The Director of Nursing confirmed this during an interview, and the facility later provided an amended MDS to include hospice services. Resident 32, diagnosed with chronic respiratory failure and hypoxemia, was observed using oxygen at 2 liters on multiple occasions. Despite this, the quarterly MDS indicated that the resident had not used oxygen during the lookback period. Progress notes from February 26 and February 28, 2024, documented the resident's continued use of oxygen. During an interview, the Director of Nursing and the Nursing Home Administrator acknowledged that the MDS should have indicated oxygen use, and a modification MDS was completed to correct this error.
Failure to Include Hemodialysis in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who had been admitted to skilled nursing care following hospitalization. The resident, who had a history of hemodialysis, protein calorie malnutrition, and diabetes mellitus, did not have an order for hemodialysis or related care needs documented in their physician orders. Additionally, the baseline care plan did not include hemodialysis and the necessary care surrounding it. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that hemodialysis and related care should have been included in the baseline care plan.
Failure to Provide Timely Medication Due to Administrative Oversight
Penalty
Summary
The facility failed to provide routine drugs to its residents, specifically failing to ensure the timely acquisition and administration of a nicotine patch for a resident with chronic obstructive pulmonary disease and obstructive sleep apnea. The resident had an order for a nicotine patch starting on May 1, 2024, for smoking cessation, but the medication was not administered from May 1 to May 6, 2024. The medication administration record indicated that the nicotine patch was not available, and nursing notes confirmed that the medication was on order and pending delivery from the pharmacy. The delay in providing the nicotine patch was attributed to the requirement for an over-the-counter (OTC) authorization form, which was not completed in a timely manner by the nursing staff. The Director of Nursing confirmed that nicotine patches are not stocked in-house and require an OTC authorization form for the pharmacy to send them. This oversight resulted in a delay in the resident receiving the prescribed medication until May 7, 2024, when the patch was finally applied by a Licensed Practical Nurse.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The facility failed to provide food and beverages at a safe and appetizing temperature during a meal service on the South unit. This deficiency was identified through observation, review of facility policy, and interviews with residents and staff. The facility's policy on Hazard Analysis Critical Control Points and Food Safety, dated 2021, requires staff to handle potentially hazardous foods carefully, with specific temperature guidelines for cold and hot foods. However, during a test tray conducted on May 6, 2024, the temperatures of coffee and milk were found to be unsatisfactory, measuring 134 degrees Fahrenheit and 51 degrees Fahrenheit, respectively. These temperatures did not meet the standards set by the facility's policy or the United States Department of Health and Human Services Food Code. Interviews with staff revealed a lack of a test tray form or policy for checking food temperatures at the point of service. Employee 6, a Dietary Aide, confirmed the expected temperatures for coffee and milk, while Employee 5, the Food Service Director, acknowledged the absence of a formal procedure for monitoring these temperatures. The Nursing Home Administrator noted that the meal service on May 6th was the first day the main dining room was closed for renovations, resulting in all residents being served on meal trays. Resident council meeting minutes from February and March 2024 also documented concerns about cold food, indicating ongoing issues with food temperature management.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
