Tremont Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tremont, Pennsylvania.
- Location
- 44 Donaldson Road, Tremont, Pennsylvania 17981
- CMS Provider Number
- 395499
- Inspections on file
- 22
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Tremont Health & Rehabilitation Center during CMS and state inspections, most recent first.
Tremont Health and Rehabilitation Center failed to complete a Minimum Data Set (MDS) assessment for a resident who passed away in the facility. The deficiency was identified during a survey, which revealed that there was no documented evidence of an MDS assessment reflecting the resident's discharge status. The facility's Administrator confirmed the oversight.
The facility failed to implement physician orders for four residents, leading to deficiencies in care. A resident with hemiplegia and multiple sclerosis was not provided with prescribed Prevalon boots, while another with edema did not receive Ace wraps as ordered. Additionally, two residents with hypertension received medication without proper blood pressure assessments or outside prescribed parameters. The Assistant Director of Nursing confirmed these lapses.
The facility did not meet the required nurse aide (NA) to resident ratios as per the regulation effective July 1, 2024. A review of nursing schedules showed non-compliance on several days across different shifts, failing to maintain the mandated NA to resident ratios for day, evening, and night shifts.
The facility did not meet the required LPN to resident ratios over a 21-day period, failing to provide adequate staffing on multiple day, evening, and night shifts as per the regulation effective July 1, 2023.
The facility did not meet the required 3.2 hours of direct resident care per resident on eight days within a 21-day review period. Specific days showed care hours ranging from 2.68 to 3.18, falling short of the regulatory requirement.
The facility failed to provide scheduled showers to four residents, compromising their right to a dignified existence and self-determination. Residents with conditions such as hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, and depression were not offered showers as per their care plans. Despite expressing a preference for twice-weekly showers, they were frequently not provided this opportunity, indicating a failure to adhere to their care plans and preferences.
The facility failed to maintain a safe and sanitary environment in two nursing units and the main dining room. Observations included peeling wallpaper, dirt accumulation, sticky floors, broken furniture, and exposed sharp edges in heating units. Additionally, a missing ceiling tile was noted in the dining room.
A facility failed to provide necessary ear care for a resident with hearing loss. Despite a scheduled appointment and physician's orders for ear cleaning, there was no evidence that the procedure was performed or that the resident attended the appointment. This was confirmed by the Administrator and DON.
A resident with chronic kidney disease, who was at risk of elopement, was found outside the facility due to inadequate supervision. The care plan required a wander guard to be checked every shift, but there was no documentation of these checks for nearly a month. The resident was discovered three blocks away by a staff member, and the DON confirmed the lack of documentation.
Failure to Complete MDS Assessment for Deceased Resident
Penalty
Summary
Tremont Health and Rehabilitation Center was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the encoding and transmitting of resident assessments. The facility failed to complete a Minimum Data Set (MDS) assessment for a resident who was discharged from the facility. This deficiency was identified during a survey that included a review of clinical records and staff interviews. The specific incident involved a resident who passed away in the facility. The clinical record review revealed that there was no documented evidence of an MDS assessment being completed to reflect the discharge status of the resident upon their death. During an interview, the facility's Administrator confirmed that the MDS had not been completed for the resident's discharge, which occurred on the date of the resident's passing.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. MDS for resident # 109 was completed and transmitted at time of survey. 2. To identify like residents that have the potential to be affected, the MDS Nurse/designee will complete a 14-day look back of section Z0500 to ensure completion and transmission. 3. To prevent this from happening again, the Regional Reimbursement coordinator/designee will educate the RNAC on timely completion and transmission of section Z0500. 4. To monitor and maintain ongoing compliance, the RNAC will review 5 MDS weekly x 4 then monthly x 2 to ensure that Section Z0500 is completed and transmitted timely. Results of audits will be submitted to the QAPI committee for further review and recommendation. Allegation of Compliance date: 4/8/2025
Failure to Implement Physician Orders for Residents
Penalty
Summary
The facility failed to implement physicians' orders for four residents, leading to deficiencies in care. Resident 5, diagnosed with hemiplegia, hemiparesis, and multiple sclerosis, was observed multiple times without the prescribed Prevalon boots, which were ordered to prevent skin breakdown. The Assistant Director of Nursing confirmed the boots were not in place as required. Resident 21, with diagnoses including edema and reduced mobility, was not provided with Ace wraps on her lower extremities as ordered by the physician. The resident confirmed she was not asked about the application of the wraps, and the Assistant Director of Nursing acknowledged the failure to apply them. For Resident 33, who had hypertension, the facility staff administered blood pressure medication without documenting the required blood pressure assessments prior to administration, as per the physician's order. Similarly, Resident 56, also diagnosed with hypertension, received medication outside the prescribed blood pressure parameters. The Assistant Director of Nursing confirmed the lack of documentation for blood pressure checks and the administration of medication outside the established parameters for these residents.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Resident # 33 physician orders were clarified on 3/14/2025. Resident # 56 physician orders were clarified on 3/14/2025. Resident # 5 Prevalon boot applied and now in place on 3/14/2025 and Resident # 21 physician ordered ace-wraps are being applied per the physician order. 2. To identify like residents, an audit conducted by DON/designee for residents with parameters to ensure physician orders being followed. Residents with orders for Prevalon boots reviewed to ensure physician orders being followed. Residents with orders for ace wraps audited to ensure ace wraps being applied per the physician orders. 3. To prevent this from happening again, the DON/designee educated nursing staff on implementation of physician ordered Prevalon boots, ace wraps, and medications with parameters. The education will be completed by 4/8/2025. 4. To monitor and maintain ongoing compliance, the DON/designee will conduct an audit of 5 residents daily to ensure physician orders being followed for 4 weeks, then monthly for 2 months to ensure professional standard of practice and timely follow-up. Results of audits will be submitted to the QAPI committee for further review and recommendation. Allegation of Compliance date: 4/8/2025
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios as mandated by the regulation effective July 1, 2024. A review of nursing schedules from November 20 through December 10, 2024, revealed that the facility did not comply with the minimum staffing requirements on multiple occasions. Specifically, the day shift ratio of one NA per 10 residents was not met on November 30 and December 7 and 8, 2024. The evening shift ratio of one NA per 11 residents was not met on November 22, 23, 28, and 30, and December 8 and 9, 2024. Additionally, the night shift ratio of one NA per 15 residents was not met on November 23, 25, 27, and 29, and December 1, 5, and 6, 2024. These deficiencies were identified based on a review of the nursing time schedules for the specified period.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. 1) The facility cannot retroactively correct the past C.N.A Ratios. 2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One NA to 10 residents on day shift; one NA to 11 residents on evening shift and one NA to 15 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply aides to meet requirements but call offs and no-show result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for nurse aides. The facility offers bonuses to staff to encourage staff to pick up additional shifts. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one NA to 10 residents on days, one NA to 11 residents on evenings and one NA to 15 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on multiple occasions over a 21-day period from November 20 through December 10, 2024. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on five days, one LPN per 30 residents during the evening shift on two days, and one LPN per 40 residents during the night shift on six days. These deficiencies were identified through a review of nursing schedules, indicating a consistent shortfall in staffing levels required by the regulation effective July 1, 2023.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. 1) The facility cannot retroactively correct the past LPN Ratios. 2) Moving forward, the facility will continue to make good faith effort to schedule staff to meet or exceed the mandated ratios of One LPN to 25 residents on day shift; one LPN to 30 residents on evening shift and one LPN to 40 residents on night shift. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. The facility contracts with agencies to supply LPN's to meet requirements but call offs and no-shows result in unmet ratios. The facility is working to hire and train staff to achieve the minimum staffing ratios for LPN's. The facility offers bonuses to staff to encourage staff to pick up additional shifts. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the minimum ratio of one LPN to 25 residents on days, one LPN to 25 residents on evenings and one LPN to 40 residents on nights. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum ratios. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum NA ratios. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period from November 20 through December 10, 2024. On eight specific days within this period, the total nursing care hours fell below the required minimum. The specific days and the corresponding care hours per resident were as follows: November 23 (2.68 hours), November 27 (3.15 hours), November 28 (3.07 hours), November 29 (3.18 hours), November 30 (2.90 hours), December 1 (2.94 hours), December 7 (3.12 hours), and December 8 (3.11 hours). These findings indicate a consistent shortfall in meeting the mandated care hours for residents on these days.
Plan Of Correction
1) The facility cannot retroactively correct the staffing PPD issues. 2) The facility utilizes staffing agencies, bonuses for staff and actively recruiting for new staff. Management staff is utilized to achieve mandated staffing requirements. 3) To prevent this from reoccurring, the RDCS re-educated the NHA; DON and Scheduler on the updated staffing regulations in relation to the daily PPD of 3.2 hours. The staffing is reviewed each day for the subsequent day(s) by the NHA and/or DON to ensure adequate staff to meet or exceed the minimum PPD. Needs are posted each week for internal staff to pick up extra shifts as well as posted with outside agencies. The deployment sheets are developed in advance so staffing challenges can be addressed. A good faith effort is made to achieve the mandated staffing requirements. Supervisors are educated on the importance of filling call offs to meet requirements. 4) To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum PPD. Audits will be completed 5x weekly x4 weeks; 3x weekly x1 month and weekly x1 month. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers to four out of six sampled residents, compromising their right to a dignified existence and self-determination. Resident 1, diagnosed with hypertension and chronic obstructive pulmonary disease, was admitted to the facility with a care plan that included receiving showers twice a week. However, documentation revealed that the resident only received two showers since admission. Similarly, Resident 2, with congestive heart failure and hypertension, was not offered showers on eight out of 18 scheduled occasions over the past 90 days. Resident 3, who has diabetes mellitus and chronic obstructive pulmonary disease, expressed a preference for twice-weekly showers but was not offered this opportunity 14 out of 17 times in the past 90 days. Resident 4, diagnosed with hypertension and depression, also preferred twice-weekly showers but was not offered them eight out of 18 times in the past 90 days. Both residents stated they would not refuse showers if offered. These findings indicate a failure by the facility to adhere to the residents' care plans and preferences, as required by 28 Pa. Code 211.12(d)(5) Nursing services.
Environmental Deficiencies in Nursing Units and Dining Room
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment in two of its nursing units and the main dining room. On the B nursing unit, the wallpaper was peeling in the common area, and there was a significant accumulation of black dirt on the floor outside the janitor's closet. Several rooms had sticky floors with a dull black/brown coating of dirt. In one room, the heating unit had peeling paint and cobwebs, and the shared bathroom had a dirt ring around the toilet, a loose grab bar, and peeling walls. Another room had a cracked floor with missing tiles, and another had broken and misaligned furniture. On the C nursing unit, a room had a heating unit with a broken cover exposing a sharp edge, and another room had a chair with a peeling cushion. In the main dining room, a ceiling tile was missing. These observations indicate a failure to provide a clean and safe environment for residents, staff, and the public.
Failure to Provide Ear Care for Resident
Penalty
Summary
The facility failed to provide necessary care and services to meet the needs of a resident with hearing loss. The resident, who was admitted with diagnoses including hypertension and chronic obstructive pulmonary disease, had a care plan indicating the use of hearing aids. A progress note from August 15, 2024, indicated a scheduled appointment for ear cleaning by a physician on September 6, 2024, to be conducted at the facility. However, a subsequent physician's progress note dated August 22, 2024, showed no evidence of the ear cleaning being addressed. On August 28, 2024, the physician ordered ear drops for the resident, with plans to flush the ears afterward. Despite these orders, there was no documented evidence that the physician cleaned or flushed the resident's ears, nor that the resident attended the scheduled appointment. This was confirmed in an interview with the Administrator and Director of Nursing on September 11, 2024.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate interventions and supervision to prevent the elopement of a resident identified as being at risk. The resident, who had a diagnosis of chronic kidney disease and was able to walk without staff assistance, was supposed to have a wander guard applied to her left wrist as per her care plan. A physician's order required staff to check the placement and function of the wander guard every shift and daily, respectively. However, there was no documented evidence that these checks were performed from April 9, 2024, through May 3, 2024. Consequently, on May 3, 2024, the resident was found outside the facility, approximately three blocks away, by a staff member on their way to work. The Director of Nursing confirmed the lack of documentation regarding the wander guard checks during this period.
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
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