Transitions Healthcare Gettysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Gettysburg, Pennsylvania.
- Location
- 595 Biglerville Road, Gettysburg, Pennsylvania 17325
- CMS Provider Number
- 395798
- Inspections on file
- 22
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Transitions Healthcare Gettysburg during CMS and state inspections, most recent first.
The facility did not have a process in place to allow residents to submit grievances anonymously, despite policy requirements. Several residents were unaware of how to file grievances or do so anonymously, and posted instructions only directed residents to submit forms to staff or management, with no anonymous option available.
A resident with obstructive sleep apnea and other neurological conditions did not have a complete physician order for CPAP therapy, as required settings were missing. The resident's care plan lacked documentation of respiratory care or CPAP use, and repeated observations showed the CPAP mask was stored hanging on a wall hook, directly touching the wall. Facility policy did not address proper mask storage, and staff confirmed these deficiencies during interviews.
Surveyors identified that several residents' MDS assessments did not accurately reflect their clinical status, including conflicting documentation of pressure ulcers, incorrect reporting of tobacco use, and misrepresentation of speech clarity for residents with expressive aphasia. These inaccuracies were confirmed through interviews, record reviews, and direct observation.
The facility did not ensure that two residents had comprehensive care plans addressing all of their needs. One resident using a CPAP machine for sleep apnea did not have respiratory care or CPAP use documented in the care plan, despite physician orders and ongoing use. Another resident receiving antipsychotic medication for dementia and delusional disorder had no care plan interventions addressing this medication, even though assessments indicated it should be care planned. Staff confirmed these omissions were not in line with facility expectations.
A resident with hemiplegia, hemiparesis, and malnutrition developed a Stage 3 pressure ulcer, which later resolved. Despite a quarterly MDS showing no pressure ulcers, the care plan was not updated to reflect the healed condition, contrary to facility policy requiring timely care plan revisions.
Multiple residents reported that food, coffee, and tea were not consistently served at appropriate temperatures, with some meals and beverages being cold or not hot enough. Direct observation and a test tray confirmed that hot foods and drinks were below the required temperature, and cold beverages were above the acceptable range, with both types being served in the same style of mug. Staff interviews revealed a lack of clarity regarding proper service ware and temperature standards.
A resident with muscle weakness and diabetes did not receive care consistent with professional standards to prevent pressure ulcers. Despite a physician's order for blue off-loading boots to elevate the resident's heels, observations showed the resident was not wearing the boots on multiple occasions.
The facility failed to properly label and store medications in two medication carts, with several insulin products exceeding their recommended discard periods. The Nursing Home Administrator acknowledged the expectation for compliance with manufacturer's guidelines.
A resident with dysphagia and hemiplegia did not receive the ordered Dycem, a non-slip mat, during meals over three consecutive days. Despite facility policy and physician's orders requiring the use of adaptive equipment to prevent decline, observations showed the absence of the Dycem, which was confirmed by the Nursing Home Administrator's expectations.
A facility failed to follow its policy for reporting an allegation of neglect when a resident reported that a nurse did not change her soiled brief. The LPN informed the day shift supervisor, but the supervisor did not notify the NHA immediately. The NHA learned of the allegation the next day, and an investigation was conducted, ultimately finding the neglect unsubstantiated.
The facility failed to adhere to professional standards in medication administration for three residents. A resident with diabetes received insulin despite low blood sugar levels, another resident did not receive insulin as per a sliding scale order, and a third resident had medication left in their room despite not being authorized to self-administer. These deficiencies were confirmed by facility staff.
A facility failed to adhere to professional standards of practice by not ensuring weekly cleaning of a CPAP machine for a resident with chronic kidney disease and pulmonary fibrosis. Despite daily use of the CPAP, there was no documentation of cleaning or maintenance until new orders were established, highlighting a lapse in care.
A resident in an LTC facility sustained a leg laceration requiring 13 sutures due to neglect during a transfer. Despite needing two-person assistance, a staff member transferred the resident alone, leading to the injury. The facility confirmed the neglect and barred the staff member from returning.
A resident with a history of anorexia nervosa and failure to thrive required a two-person assist for transfers. However, a nursing assistant attempted a transfer alone, resulting in the resident sustaining a laceration on the right shin that required hospitalization and 13 sutures. The facility failed to provide adequate supervision and assistance, leading to actual harm.
Failure to Provide Anonymous Grievance Submission Process
Penalty
Summary
The facility failed to ensure that residents' rights to file grievances anonymously were honored, as required by their own grievance policy. The policy stated that grievances could be reported anonymously and that the facility could not require a signature on a grievance. However, during a resident group meeting, several residents indicated they did not know how to file a grievance or how to do so anonymously. Most residents reported that they simply told the Social Worker, nurses, or management if they had a concern, rather than using a formal or anonymous process. Observations of the posted grievance process information on all three living areas revealed instructions to return completed grievance forms to the RN Supervisor or Nurse Manager, or to contact the Nursing Home Administrator or Grievance Coordinator directly. There was no drop box or other method available for residents to submit grievances anonymously. During staff interviews, the Nursing Home Administrator confirmed that there was no process in place for anonymous grievance submission at the time of the survey.
Failure to Provide Appropriate Respiratory Care and Documentation for CPAP Therapy
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards of practice for a resident requiring CPAP therapy. The facility's policy required physician orders for CPAP to include pressure settings and hours of use, but did not specify how the CPAP mask should be stored when not in use. For a resident with diagnoses including obstructive sleep apnea, hemiplegia, hemiparesis following a stroke, and legal blindness, the physician's order for CPAP therapy lacked the required machine settings. Additionally, the resident's care plan did not include a respiratory care plan or documentation of CPAP use. Observations over several days revealed that the resident's CPAP mask was consistently stored hanging on a hook on the wall above the bed, with the mask directly touching the wall. Staff interviews confirmed the absence of required CPAP settings in the physician's order and the lack of a respiratory care plan in the resident's documentation. The facility's policy also did not provide guidance on proper storage of CPAP masks when not in use.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of four residents, as required by policy and regulatory guidelines. For one resident with hemiplegia and moderate protein-calorie malnutrition, the Minimum Data Set (MDS) assessment contained conflicting information regarding the presence of a pressure ulcer. Specifically, the assessment indicated both the absence and presence of a pressure ulcer, with further details showing a Stage 3 pressure ulcer documented. The Director of Nursing (DON) confirmed the inaccuracy in the MDS coding for this resident. Another resident with nicotine dependence and hypertension was care planned for regular evaluation of safe smoking practices. However, the annual MDS assessment incorrectly indicated that the resident was not a current tobacco user, despite the resident's own statement and care plan documentation confirming daily supervised smoking. Similarly, a different resident with nicotine dependence and diabetes mellitus was also care planned for safe smoking but had their MDS assessment marked as not using tobacco and did not have nicotine dependence listed in the active diagnoses section, contrary to the clinical record and care plan. A further deficiency was identified for a resident with expressive aphasia and a history of stroke. The quarterly MDS assessment coded the resident's speech as clear, while observations, care plan documentation, and staff interviews indicated that the resident's speech was slurred and communication was primarily conducted through writing on a whiteboard. The DON acknowledged that the MDS should have reflected unclear speech based on the resident's documented status and care plan notes.
Failure to Develop Comprehensive Care Plans for Residents Using CPAP and Antipsychotic Medications
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by policy. For one resident with diagnoses including obstructive sleep apnea, hemiplegia, hemiparesis following a stroke, and legal blindness, clinical records and observations confirmed the use of a CPAP machine at bedtime per physician order. However, review of the resident's care plan revealed no documentation or respiratory care plan addressing the use of the CPAP, despite its ongoing use being documented in both annual and quarterly MDS assessments. Staff interviews confirmed the expectation that CPAP use should be included in the care plan. For another resident with dementia, behavioral disturbances, and delusional disorders, physician orders indicated the use of Seroquel for management of these conditions. Both annual and quarterly MDS assessments documented the use of antipsychotic medication, and the care area assessment summary indicated that antipsychotic medication use had triggered for care planning. Despite this, the resident's comprehensive care plan did not address the use of antipsychotic medication. Staff interviews confirmed that comprehensive care plans were expected to be developed accurately for all residents.
Failure to Revise Care Plan After Resolution of Pressure Ulcer
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of hemiplegia, hemiparesis, muscle weakness, and moderate protein-calorie malnutrition following a stroke. The resident developed a Stage 3 pressure ulcer, which was present from early July to mid-August. Despite the resolution of the pressure ulcer, the care plan continued to list an active focus on altered skin integrity related to limited mobility and an open area to the coccyx, with no updates or revisions made after the ulcer healed. A quarterly MDS assessment completed at the end of August indicated that the resident no longer had any pressure ulcers. However, the care plan was not updated to reflect this change, as confirmed by the DON during an interview. Facility policy requires care plans to be reviewed and updated at least quarterly or when there is a significant change in the resident's condition, but this was not done in this case.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and beverages at appetizing and safe temperatures, as evidenced by multiple sources including food committee meeting minutes, grievance logs, resident and staff interviews, and direct observation. Residents reported that vegetables were served cold, tea and coffee were not hot enough, and food temperatures were inconsistent, sometimes requiring staff to reheat meals. One resident specifically filed a grievance about the temperature of her tea, and several others confirmed during a group meeting that both food and coffee were often not served hot. During an interview, a resident also stated that his food was not always served hot. Observation of meal tray line service revealed that both hot and cold beverages were served in the same type of mug, and a test tray showed that creamed corn and coffee were served at 115°F, below the expected standard of above 135°F for hot foods and beverages. Iced tea was served in a hot beverage mug, was only half full, and measured 57°F, above the expected standard of below 50°F for cold beverages. The Dietary Manager acknowledged uncertainty about the use of mugs for both hot and cold drinks and confirmed that the process had not changed since her employment. The Nursing Home Administrator was made aware of the concerns regarding food and beverage temperatures and the inappropriate service ware for cold beverages.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident diagnosed with muscle weakness and diabetes. The facility's policy on Pressure Ulcer Prevention and Management required pressure relief measures such as elevating or floating heels. A physician's order dated July 22, 2024, specified the use of blue off-loading boots for the resident's bilateral heels. However, observations on three separate occasions revealed that the resident was not wearing the prescribed off-loading boots to elevate her heels off the bed.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store drugs in accordance with accepted professional principles, as observed in two medication carts. The Annex 1 North medication cart contained an Ozembic pen that was in use but not labeled with the date it was opened, a Levemir pen that was not refrigerated and lacked a date indicating when it was removed from refrigeration, and a Basaglar pen that was open without a date of opening. These observations indicate a failure to adhere to the facility's policy on medication storage, which requires medications to be stored safely and properly following the manufacturer's recommendations. The Annex 1 South medication cart contained a vial of Lantus insulin labeled with an open date of 51 days prior and another vial labeled 31 days prior, both exceeding the manufacturer's recommended discard period of 28 days. Additionally, two insulin Aspart pens were labeled with open dates of 31 days prior, also exceeding the recommended discard period. The Nursing Home Administrator acknowledged the expectation that medications should be labeled, stored, and disposed of according to the manufacturer's guidelines, highlighting a lapse in compliance with these standards.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for a resident with specific medical conditions, including dysphagia and hemiplegia. The facility's policy on restorative adaptive equipment, revised in 2016, mandates the use of such devices to promote individual resident functional levels and prevent decline. Despite this, observations over three consecutive days revealed that the resident did not have the ordered Dycem, a non-slip rubber mat, present during meals in his room. The resident's care plan and physician's orders specified the use of Dycem during meals, but it was not provided, as confirmed by the Nursing Home Administrator's expectation that the adaptive equipment should have been available at all meals.
Failure to Report Allegation of Neglect Immediately
Penalty
Summary
The facility failed to adhere to its policy for reporting an allegation of neglect involving a resident. The policy, last revised in June 2024, mandates that any report or suspicion of an incident be immediately reported to the charge nurse or supervisor, who must then notify the Nursing Home Administrator (NHA) or Director of Nursing. In this case, a resident, who is cognitively intact with a BIMS score of 13, reported to a Licensed Practical Nurse (LPN) that a nurse on the night shift did not change her soiled brief. The LPN reported this allegation to the day shift supervisor the following morning. However, the Registered Nurse Supervisor, who was informed of the allegation, did not report it to the NHA immediately as required by the facility's policy. The NHA only became aware of the allegation the day after it was reported to the supervisor. An investigation was initiated, and statements were collected from the staff and the resident. The resident's statement indicated that she was changed, but the staff was slow to respond. The facility ultimately found the allegation of neglect to be unsubstantiated.
Failure to Adhere to Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for three residents. Resident 14, diagnosed with type 2 diabetes mellitus and a history of traumatic brain injury, had a physician's order for Insulin Glargine to be administered at bedtime, with instructions to hold the insulin if blood sugar levels were below 150. However, the facility did not adhere to this order, as insulin was administered on multiple occasions despite blood sugar levels being below the threshold. Additionally, there was a lack of documentation for blood sugar levels corresponding with the insulin administration time. Resident 20, who has major depressive disorder and hypertension, had a physician's order for insulin administration based on a sliding scale for blood sugar levels. Despite having blood sugar levels that required insulin administration, the facility failed to administer insulin on several occasions as per the physician's order. This oversight was acknowledged by the Nursing Home Administrator, who expected the insulin to be administered as ordered. Resident 51, diagnosed with cerebral infarction and hemiplegia, had a physician's order for Trolamine Salicylate cream to be applied topically as needed for muscle pain. During an observation, it was found that the cream was left in the resident's room, despite the resident not being authorized to self-administer the medication. This was confirmed by the Regional Nurse, who stated that the cream should not have been left in the room.
Failure to Provide Proper CPAP Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who required the use of a CPAP machine. The facility's policy required the CPAP system to be cleaned weekly. However, upon review of the resident's clinical record, there was no documentation indicating that the CPAP mask, tubing, filter, and water supply had been cleaned or changed. The resident had a physician's order for CPAP use at bedtime and during naps, and the Medication Administration Record confirmed daily use of the CPAP machine. The resident had diagnoses including stage 3 chronic kidney disease and pulmonary fibrosis, necessitating the use of a CPAP machine. Despite the resident's condition and the facility's policy, there were no cleaning orders in place for the CPAP equipment until new orders were established with an active date set for a future date. The Nursing Home Administrator acknowledged that cleaning orders should have been in place earlier and expected the CPAP to be cleaned weekly, indicating a lapse in adherence to the facility's policy and professional standards of care.
Neglect During Resident Transfer Results in Injury
Penalty
Summary
The facility failed to protect a resident from neglect during the provision of care, resulting in actual harm. A staff member, Employee 1, did not verify the resident's transfer status and proceeded to transfer the resident independently, despite the care plan indicating that the resident required assistance from two persons and a rolling walker. This oversight led to the resident sustaining a laceration on the right lower leg, necessitating hospital transfer and 13 sutures. The resident, who had been admitted with diagnoses including anorexia nervosa and failure to thrive, was supposed to be transferred with two-person assistance. However, Employee 1, who was instructed to wash and dress the resident only, mistakenly attempted to weigh the resident and transferred her alone. During the transfer, the resident's leg was injured when it was caught on the wheelchair, causing a significant laceration. Interviews and statements from staff confirmed that Employee 1 was aware of the transfer requirements but failed to adhere to them. The facility's policy on abuse and neglect was not followed, as the staff member did not provide the necessary care to prevent harm. The incident was reported, and the facility substantiated the neglect, resulting in the decision that Employee 1 should not return to the facility.
Failure to Provide Adequate Assistance During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide the necessary assistance required for a safe transfer of a resident, resulting in actual harm. The resident, who had a history of anorexia nervosa and failure to thrive, required a two-person assist with a rolling walker for transfers as per their care plan. However, during a transfer from bed to wheelchair, only one staff member assisted the resident, leading to a laceration on the resident's right shin. This injury required hospitalization and 13 sutures. The incident occurred when the nursing assistant attempted to transfer the resident alone, contrary to the care plan that specified a two-person assist. The resident's leg was caught on a metal piece of the wheelchair during the transfer, causing the laceration. The Director of Nursing confirmed that the facility did not provide adequate supervision and assistance during the transfer, which resulted in harm to the resident.
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.
