Twin Lakes Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 227 Sand Hill Road, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395500
- Inspections on file
- 57
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Twin Lakes Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow and document ordered pressure ulcer treatments for two residents with buttock pressure injuries. One resident with a stage 4 ulcer and a history of stroke had physician orders for daily wound cleansing, iodoform packing, silicone border dressing, and later zinc oxide to the peri-wound, but the TAR lacked evidence that treatments were completed on multiple days. Another resident with dementia and bilateral buttock ulcers had wound care recommendations for cleansing, zinc oxide application, and dry or bordered gauze dressings with daily and PRN changes; instead, documentation showed the wounds left open to air on several days and later recorded treatments three times daily, inconsistent with the ordered frequency. The DON and ADON confirmed the absence of documentation that ordered or recommended wound treatments were carried out as specified.
Emergency exit doors on two units were found secured shut with zip ties and rolled gauze, preventing egress. Staff, including nurses, aides, and maintenance, were unaware of the obstructions, which were likely put in place to stop frequent alarms caused by high winds. The facility's policy required exits to remain unobstructed, but the deficiency was only discovered during a survey, placing residents in immediate jeopardy.
Facility administration and the DON failed to ensure emergency exit doors were accessible, as doors were secured with zip ties and rolled gauze, preventing resident egress during emergencies. This resulted in Immediate Jeopardy and was cited under F689 and state regulations.
A resident did not have their heart rate checked prior to receiving Metoprolol Tartrate as ordered, and was given Insulin Aspart on multiple occasions when their blood glucose was below the physician-ordered threshold. These actions were not in accordance with the facility's medication administration policy and physician's orders, as confirmed by facility leadership.
A resident with respiratory failure and a tracheostomy experienced hypoxia, prompting an LPN and RN to intervene and obtain urgent physician orders for diagnostic tests. However, there was no documentation in the clinical record explaining the change in condition or the rationale for the orders, as confirmed by facility leadership.
The facility did not meet the required NA-to-resident staffing ratios on certain days. On one occasion, the evening shift had 129 residents requiring 11.73 NAs, but only 11.07 were available. Another day, the day shift had 128 residents needing 12.80 NAs, but only 10.73 were present, and the evening shift required 11.64 NAs, but only 9.47 were available. No additional staff were available to cover these deficiencies.
The facility did not meet the required 3.20 hours of direct resident care per resident on two days, providing only 2.99 and 2.83 hours on those days. This was confirmed through nursing schedules and an interview with the Nursing Home Administrator.
The facility failed to meet the required LPN-to-resident staffing ratios on several occasions, with insufficient LPNs available during day, evening, and night shifts. The deficiency was confirmed through a review of nursing schedules and staff interviews, with no additional higher-level staff available to compensate for the shortfall.
Twin Lakes Rehabilitation and Healthcare Center failed to communicate critical lab results for a resident diagnosed with C-diff to the admitting facility during a transfer. The resident, who required assistance for daily care and had debilitating cardiorespiratory conditions, was transferred without the necessary documentation of their positive C-diff test results. This deficiency was confirmed by the DON, highlighting a breach in ensuring a safe and effective transition of care.
A facility failed to notify a physician of abnormal lab results for a resident with debilitating cardiorespiratory conditions. Despite a positive C-difficile toxin result, there was no documentation that the physician was informed, violating the facility's policy and regulatory requirements.
The facility failed to follow physician's orders for two residents with feeding tubes by not documenting the residual volumes during tube placement checks. Despite verifying tube placement, staff did not record the residual amounts as required, which was confirmed by the DON. Both residents were cognitively impaired and needed assistance with daily care tasks.
The facility failed to flush IV catheters according to policy for three residents. A resident with an infection had no documented measurements of catheter length and arm circumference. Two residents receiving IV antibiotics lacked documentation of catheter flushing before and after medication administration. The DON confirmed these documentation lapses.
The facility failed to ensure timely physician visits for three residents, resulting in gaps of over 100 days between visits. A resident with dementia and COPD, another with an indwelling catheter and End-Stage Renal Disease, and a third with dementia and bipolar disorder were not seen by a physician or delegate within the required 60-day intervals. The DON confirmed the lack of documentation and noted the absence of a physician's assistant or nurse practitioner to assist the physician.
The facility failed to provide scheduled showers to two residents, both cognitively intact and requiring assistance with bathing. One resident, with rheumatoid arthritis, was supposed to receive showers twice a week but only received them sporadically, while the other, with a traumatic brain injury, was only given showers once a week despite preferring twice-weekly showers. These failures were confirmed by the DON.
The facility failed to provide appropriate care for residents with indwelling urinary catheters and a nephrostomy tube. One resident lacked documented catheter care on specific shifts, while another had their catheter bag in contact with the floor. Additionally, a resident with a nephrostomy tube had no physician's orders for its care. These deficiencies were confirmed by the nursing staff.
The facility failed to ensure that residents and/or their representatives were informed and assisted in developing advance directives. Four residents, including those with dementia, mental health disorders, and physical impairments, had no documented evidence of being informed about their rights to create advance directives. The Nursing Home Administrator confirmed the oversight and acknowledged the need for improvement in addressing advance directives during care conferences.
The facility did not complete a criminal background check for a newly hired nurse aide, contrary to its policy on abuse prevention. The policy requires background checks to prevent hiring individuals with histories of abuse or neglect. The Human Resource Director confirmed the oversight, as the nurse aide was hired without the necessary check.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers for four residents. These residents, with varying cognitive and medical conditions, were transferred due to acute health issues such as lethargy, emesis with blood, respiratory distress, and sepsis. The Nursing Home Administrator confirmed the lack of documented written notices for these transfers.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in documenting treatments and care needs. Errors included incorrect recording of anticoagulant and opioid administration, oxygen therapy, care rejection, and discharge status. These inaccuracies were confirmed through staff interviews.
The facility failed to develop care plans for two residents, one receiving an anticoagulant and another with complex medical needs including a nephrostomy. The lack of care plans was confirmed by the DON.
The facility failed to update care plans for two residents. One resident's care plan inaccurately reflected ongoing anticoagulation therapy despite a medication change from Eliquis to Aspirin. Another resident's care plan did not reflect the use of a Foley catheter, instead indicating urinary incontinence, despite observations confirming catheter use. These discrepancies were confirmed by the DON.
A resident in a long-term care facility was left without hearing aids due to a series of communication lapses and inactions by the staff. The resident's right hearing aid was smashed, and both were taken for repair, but no follow-up was conducted. The Social Worker and Business Office Manager were unaware of the resident's need for new hearing aids, and the Social Services Director forgot to follow up with the audiologist, resulting in the resident being unable to communicate effectively.
A facility failed to provide trauma-informed care for a resident with PTSD, anxiety, depression, and schizophrenia. The facility's policy required assessments to identify traumatic triggers, but no such assessment was completed for the resident. This deficiency was confirmed by the DON.
The facility did not complete annual performance evaluations for two nurse aides as required by their policy. The evaluations were due based on hire dates but were not conducted, which was confirmed by the DON.
A resident with dementia and bipolar disorder was on antipsychotic and antidepressant medications. Despite pharmacy recommendations for dose reductions in March and June, there was no evidence that these were addressed. The DON confirmed the lack of documentation.
The facility failed to properly store and label medications, including not having a permanently affixed compartment for controlled drugs, not discarding expired inhalers, and not labeling insulin vials. Additionally, medications were left unsupervised and unlabeled at the bedside of two residents, which was confirmed as inappropriate by the DON.
A facility failed to maintain complete and accurate clinical records for a resident with COPD and GERD. The resident's care plan required monitoring of food intake due to potential weight changes, but documentation was missing for several meals over three months. The DON confirmed the absence of records, violating professional standards.
The facility's QAPI committee failed to address recurring deficiencies effectively, with repeated issues in MDS accuracy, care plan creation and updates, quality of care, and tube feeding management. Despite developing plans of correction, the committee did not successfully implement these plans, leading to ongoing non-compliance with nursing home regulations.
The facility failed to maintain two of three laundry dryers in safe operating condition, as there was an accumulation of lint in the compartment above the dryer drum where the gas line entered the back of the dryer. This was confirmed by the Director of Environmental Services and the Director of Maintenance, who stated that the dryers were last cleaned a month prior.
A resident requested lab work, which was completed, but the results were not reviewed with her. The resident was alert and oriented, and the DON confirmed the oversight.
The facility failed to assess residents for their ability to self-administer medications safely. An LPN left medication unsupervised for a resident without observing its intake, and two other residents were found with unsupervised medication on their overbed tables. The Director of Nursing confirmed that no assessments were conducted to determine if these residents could safely self-administer their medications.
A resident's call bell was found inaccessible, clipped to an electrical cord behind a dresser, contrary to the facility's policy requiring call lights to be within reach. The resident, who has glaucoma and hemiplegia, confirmed he had to search for the call bell. Both a nurse aide and the DON acknowledged the call bell should have been accessible.
An LPN in an LTC facility administered medications to two residents consecutively without preparing them separately, contrary to the facility's policy. The LPN acknowledged the error, and the DON confirmed the breach of protocol.
A facility failed to follow physician's orders for a resident with a Stage 4 pressure ulcer and a medical adhesive-related skin injury. The resident's negative wound pressure therapy (NWPT) was not administered due to missing tubing, and the provider was not notified as required. Additionally, treatment for the resident's skin injury was not documented as completed.
A resident with arthritis was not provided with adaptive eating utensils as ordered by the physician, despite being cognitively intact and having a care plan indicating the need for built-up utensils. Observations revealed the resident using regular utensils, and staff confirmed the oversight.
A resident's room and bathroom were found to be unclean, with dust, dirt, and debris present, violating the facility's policy for a homelike environment. Staff shortages were cited as a reason for the cleanliness issues.
A facility failed to document pressure ulcer treatments for a resident with quadriplegia and a pressure ulcer. Physician's orders required specific wound care, but the Treatment Administration Record lacked evidence of treatment or refusal on two occasions. The DON confirmed the absence of documentation.
A facility failed to follow proper infection control practices during wound care for a resident. A nurse did not change gloves or wash hands after handling a soiled brief, continuing care without adhering to the facility's infection control policy. This was confirmed by both the nurse and the DON.
A facility failed to conduct care plan meetings and involve a resident or their representative in the care planning process, as required by policy. The resident, who has dementia and requires extensive assistance, frequently refused care, and there was no documented evidence of care planning meetings since their admission. The Nursing Home Administrator confirmed the oversight.
A resident, who was cognitively impaired and at risk for falls, experienced two unwitnessed falls while using an air mattress. Despite the falls, the facility failed to conduct a safety assessment for the air mattress after the second incident, resulting in a deficiency. The resident sustained injuries, including a dislodged gastric tube and a head laceration.
The facility did not follow CDC and CMS guidelines for Enhanced Barrier Precautions (EBP) for two residents with medical conditions requiring such measures. Staff provided care using only gloves instead of the required gown and gloves, despite signage and available gowns. Interviews revealed a lack of awareness and forgetfulness among staff regarding EBP requirements.
The facility failed to follow physician's orders for medication administration for two residents. One resident with diabetes was not properly monitored for high blood sugar levels, and a verbal order for additional insulin was not documented or administered. Another resident with Multiple Sclerosis did not receive the correct dosage of Oxycodone for pain management, as only one tablet was dispensed instead of the prescribed two.
A facility failed to account for controlled medications for a resident with chronic pain. The resident was prescribed Oxycodone/Tylenol, and while 60 doses were signed out, only 54 were recorded as administered, leaving six doses unaccounted for. The discrepancy was confirmed by the Nursing Home Administrator and DON, who noted that a non-standard log was used due to the medication being supplied by hospice.
The facility failed to follow physician's orders for a resident who required an orthopedic consult for a right shoulder effusion. Despite discharge instructions, there was no documented evidence of the consult, and staff believed it was deemed unnecessary by the Senior Life Program without proper documentation.
Failure to Follow and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered pressure ulcer treatments were provided and documented for two residents with pressure injuries. For one resident, an admission change MDS dated December 30, 2026, showed the resident was cognitively intact, had a stage 4 pressure ulcer on admission, required staff assistance for daily care, and had a medical history including stroke. Physician orders dated January 6, 2026, directed that the left buttock wound be cleansed with wound cleanser, patted dry, packed with iodoform packing strip, and covered with a silicone border every dayshift. Review of the January 2026 Treatment Administration Record (TAR) showed no documented evidence that these treatments were completed as ordered on January 12 and January 18, 2026. Subsequent physician orders for the same resident dated January 19, 2026, added application of zinc oxide paste to the peri-wound area while continuing cleansing, packing with iodoform, and covering with a silicone border every dayshift. Review of the January 2026 TAR again revealed no documented evidence that these updated treatments were completed as ordered on January 24 and January 25, 2026. The Director of Nursing confirmed on February 4, 2026, that there was no documented evidence that the resident’s wound treatments were completed on the identified dates. For another resident, a quarterly MDS dated December 20, 2025, indicated the resident was cognitively intact, required staff assistance for daily care, had pressure ulcers, and had dementia. Skin and wound notes dated December 22, 2025, January 2, 2026, and January 9, 2026, documented wound care recommendations for right and left buttocks pressure ulcers: cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with a dry dressing, and change daily and as needed. However, the January 2026 TAR showed that from January 1 through January 12, the wounds were documented as being left open to air with no dry dressing. A skin and wound note dated January 26, 2026, revised recommendations to cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with bordered gauze, and change daily and as needed, but the January 2026 TAR documented the treatment as being completed three times a day from January 26 through February 3, 2026, rather than as ordered. The Assistant Director of Nursing confirmed there was no documented evidence that the wound care consultant’s recommendations were followed as ordered.
Emergency Exit Doors Obstructed with Zip Ties and Gauze
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.
Removal Plan
- Removed the zip ties and rolled gauze that secured the emergency exit doors shut
- Inspected all doors to ensure proper functioning
- Educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed
- Maintenance checks all exit doors for proper functioning
Failure to Maintain Accessible Emergency Exits Creates Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator and Director of Nursing (DON), failed to ensure that emergency exit doors were accessible to residents, thereby not allowing egress to the outside during an emergency situation. This was determined through a review of policies, employee job descriptions, observations, and staff interviews. The job description for the Administrator included responsibilities such as maintaining a safe environment and implementing an effective accident prevention program, while the DON was responsible for ensuring compliance with safety regulations and maintaining safe resident care areas. Despite these outlined duties, emergency exit doors were found to be secured shut with zip ties and rolled gauze, preventing their use in emergencies. This failure to maintain accessible emergency exits was observed on specific units and resulted in Immediate Jeopardy to the health and safety of residents. The deficiency was cited under federal and state regulations, specifically referencing F689 (Accidents) and relevant Pennsylvania codes. The report does not mention any specific residents or their medical conditions, but it clearly documents a systemic lapse in administrative oversight and resource allocation necessary to ensure resident safety during emergencies.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, staff are required to verify specific information, such as medication allergies and vital signs, prior to administering medications. For a resident with diagnoses including diabetes and hypertension, physician's orders specified that Metoprolol Tartrate should be held if the resident's heart rate was less than 60, and that Insulin Aspart should be held if the resident's blood glucose was less than 120 mg/dL. Review of the resident's Medication Administration Record (MAR) showed that there was no documented evidence that the resident's heart rate was checked prior to administering Metoprolol Tartrate over a period of several weeks. Additionally, Insulin Aspart was administered multiple times when the resident's blood glucose was below the threshold specified in the physician's order. These findings were confirmed by the Assistant Director of Nursing during interviews.
Failure to Document Change in Condition and Physician Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, as required by accepted professional standards. A resident with a history of hemiplegia, COPD, respiratory failure, and a tracheostomy experienced a significant change in condition, including hypoxia with pulse oximetry readings between 78 and 80 percent, which did not improve above 90 percent despite interventions such as suctioning and increased oxygen. Staff, including an LPN and an RN, responded by notifying the physician and obtaining orders for a STAT chest x-ray, CBC, CMP, and sputum culture. Despite these actions, there was no documented evidence in the resident's clinical record explaining the reason for obtaining the physician's orders or describing the change in the resident's condition on the date in question. Both the LPN and RN stated in interviews that they had communicated and acted upon the resident's declining status, but a review of the clinical record confirmed the absence of required progress notes or documentation regarding the incident. The Nursing Home Administrator and Director of Nursing also confirmed the lack of documentation.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not provide the necessary number of NAs during the day and evening shifts on certain days. On April 4, 2025, the facility had a census of 129 residents during the evening shift, necessitating 11.73 NAs, but only 11.07 NAs were available. Similarly, on April 6, 2025, with a census of 128 residents, the day shift required 12.80 NAs, yet only 10.73 NAs were present, and the evening shift required 11.64 NAs, but only 9.47 NAs were available. There were no additional higher-level staff to compensate for these staffing deficiencies. The Nursing Home Administrator confirmed the shortfall in meeting the required staffing ratios.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Deficiency in Direct Resident Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for two out of five days reviewed. Specifically, on April 5, 2025, the facility provided only 2.99 hours of direct care per resident, and on April 6, 2025, it provided 2.83 hours. This deficiency was identified through a review of nursing schedules and confirmed during an interview with the Nursing Home Administrator on April 7, 2025.
Plan Of Correction
1. The hours of direct care staffing noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of direct care staffing will be completed and reviewed daily for accuracy by the scheduler or designee. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding direct care staffing regulations. 3. Facility scheduler, Director of Nursing, Human Resources and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Direct care staffing will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions during the review period from December 8, 2024, to January 11, 2025. Specifically, the facility did not provide the minimum number of LPNs needed for the day shift on three days, the evening shift on one day, and the night shift on four days. For instance, on December 11, 2024, the facility's census required 5.20 LPNs during the day shift, but only 5.03 LPNs were available. Similarly, on December 25, 2024, the day shift required 5.08 LPNs, but only 4.88 LPNs were present. These discrepancies were confirmed through a review of nursing schedules, staffing information, and staff interviews. The deficiency was further highlighted by the lack of additional higher-level staff to compensate for the shortfall in LPNs. On December 9, 2024, the night shift required 3.10 LPNs, but only 2.22 LPNs were available. On December 23, 2024, the night shift required 3.15 LPNs, but only 2.56 LPNs were present. The Nursing Home Administrator confirmed on January 17, 2025, that the facility did not meet the required staffing ratios on the specified days, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Failure to Communicate Critical Lab Results During Resident Transfer
Penalty
Summary
Twin Lakes Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding the transfer and discharge of residents. Specifically, the facility failed to update the admitting facility with critical laboratory information for a resident who was transferred. The resident, who was cognitively intact and required assistance for daily care, had been diagnosed with debilitating cardiorespiratory conditions and was experiencing recurrent watery stools. A physician ordered a test for Clostridioides difficile (C-diff), which returned positive results. However, there was no documented evidence that this information was communicated to the receiving facility upon the resident's discharge. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the communication of the resident's laboratory results to the admitting facility. This oversight violated the requirements for ensuring a safe and effective transition of care, as outlined in the federal regulations and the Pennsylvania Long Term Care Licensure Regulations. The failure to provide this critical information could potentially impact the ongoing care and safety of the resident at the new facility.
Plan Of Correction
F0622 Transfer and Discharge Requirements 1. Resident 2 no longer resides in the admitting facility that she was discharged to. 2. A 30 day look back audit was completed of discharged residents to ensure that abnormal laboratory results were communicated to the admitting facility. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that abnormal results received proximal to date of discharge were communicated to the admitting facility. The Director of Nursing will educate the Intradisciplinary team and Registered Nurse Supervisors to notify the admitting facility of a discharged resident of abnormal laboratory results received proximal to the date of discharge. 4. The Director of Nursing or designee will complete audits to ensure abnormal laboratory results are received for discharged residents are communicated to the receiving facility. This audit will be completed weekly times 4 weeks. The results of the audit will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for a resident, leading to a deficiency in compliance with regulatory requirements. The facility's policy, dated July 26, 2024, mandates that laboratory results must be reported in writing to the resident's attending physician or the facility, with the Director of Nursing Services or charge nurse responsible for notifying the physician of such results. However, in the case of a resident with debilitating cardiorespiratory conditions, the facility did not adhere to this policy. The resident, who was cognitively intact and required assistance for daily care, had physician orders dated September 4, 2024, for a Clostridioides difficile (C-diff) toxin stool test due to frequent watery stools. The laboratory results, dated September 5, 2024, confirmed the presence of the C-difficile toxin, with the sample collected on September 4, 2024. Despite the positive result, there was no documented evidence in the resident's clinical record that the physician was notified or reviewed the abnormal laboratory results. An interview with the Director of Nursing on December 3, 2024, confirmed the lack of documentation regarding the notification of the physician about the abnormal results. This oversight indicates a failure to comply with the facility's policy and regulatory requirements for notifying physicians of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
F0773 Lab Services Physician Order/Notify of Results 1. Resident 2 no longer resides at the facility. 2. A 30 day look back audit was completed of laboratory study orders to ensure that laboratory studies were obtained, results were received and reviewed with the physician. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that laboratory studies were obtained, results were received and reviewed by the physician. The Director of Nursing or designee will complete education with Registered Nurse Supervisors to ensure laboratory studies that are ordered are obtained, results are received and then reviewed with the physician. 4. The Director of Nursing or designee will complete audits to ensure that laboratory studies that are ordered are obtained, results are received and then reviewed by the physician. This audit will be completed weekly times 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.
Failure to Document Residual Volumes for Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents with feeding tubes. For Resident 88, the physician's orders required the staff to check the placement of the feeding tube by assessing the residual volume once a day. If the residual was 150 mL or less, the staff were to reinsert the volume into the stomach and continue the feeding; if greater than 150 mL, they were to hold the feeding and notify the physician. However, the Medication Administration Records (MARs) for August, September, and October 2024 showed that while staff verified the placement of the feeding tube, they did not document the amount of residual present during these checks. This lack of documentation was confirmed by the Director of Nursing. Similarly, for Resident 109, the physician's orders also required the staff to check the residual volume once a day with the same instructions regarding the residual volume. The MARs for the same period indicated that staff verified the tube placement but failed to document the residual volume. This omission was also confirmed by the Director of Nursing. Both residents were cognitively impaired and required assistance with daily care tasks, highlighting the importance of adhering to physician's orders to ensure their safety and well-being.
Failure to Flush IV Catheters as per Policy
Penalty
Summary
The facility failed to ensure that long-term intravenous catheters were flushed according to their policy for three residents. The policy, dated July 19, 2024, required that peripheral or midline catheters be flushed with 10 cc's of normal saline before and after each use. For Resident 101, who was cognitively intact and had an infection in his left shoulder, there was no documented evidence that the external catheter length and circumference of the upper arm were measured as ordered on specific dates in September and October 2024. This was confirmed by the Director of Nursing during an interview. Resident 104, who was cognitively impaired and had a stroke, was receiving IV Meropenem for sepsis. The MAR for October 2024 showed no documented evidence that the IV catheter was flushed before and after medication administration as per facility policy. Similarly, Resident 136, who was cognitively intact and had a PICC line for administering IV antibiotics for osteomyelitis, also lacked documentation of catheter flushing before and after medication administration from late September to early October 2024. The Director of Nursing confirmed the absence of documentation for both Residents 104 and 136.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for three residents. Resident 8, who was cognitively impaired and had diagnoses including dementia with behaviors and COPD, was not seen by a physician or physician delegate for 155 days between February 26, 2024, and July 29, 2024. Resident 13, who was cognitively intact and had an indwelling catheter, received dialysis, and had diagnoses including neurogenic dysfunction of the bladder and End-Stage Renal Disease, was not seen by a physician or physician delegate for 116 days between October 26, 2023, and February 29, 2024, and for 155 days between February 29, 2024, and July 29, 2024. Resident 61, who was cognitively intact and had diagnoses including dementia, Wernicke's encephalopathy, bipolar disorder, and depression, was not seen by a physician or physician delegate for 144 days between October 6, 2023, and February 28, 2024, and for 148 days between February 28, 2024, and July 24, 2024. The Director of Nursing confirmed the lack of documented evidence for these visits and noted that the physician responsible for these residents does not have a physician's assistant or certified registered nurse practitioner to assist in overseeing their care.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths to two residents, leading to a deficiency in care. Resident 36, who is cognitively intact and dependent on staff for bathing due to rheumatoid arthritis, was supposed to receive showers twice a week. However, records show that the resident was only given bed baths on different days and only received showers on three specific dates over a two-month period. The resident expressed dissatisfaction, stating that showers were not offered as preferred, and staff provided excuses such as the unavailability of hot water. This was confirmed by the Director of Nursing. Similarly, Resident 68, who is also cognitively intact and requires assistance with bathing due to a traumatic brain injury, was scheduled to receive showers twice a week. However, documentation revealed that the resident was only given showers once a week. The resident expressed a preference for twice-weekly showers, which was not met. This discrepancy was also confirmed by the Director of Nursing, indicating a failure to adhere to the residents' bathing schedules and preferences.
Failure to Provide Appropriate Catheter and Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for three residents with indwelling urinary catheters. For one resident, there was no documented evidence of catheter care being provided during specific shifts in August and October, despite the requirement for catheter care every shift. The Director of Nursing confirmed the lack of documentation for these dates. Another resident was observed with their catheter collection bag in direct contact with the floor, which was against facility policy. The Assistant Director of Nursing confirmed this observation, and there was also a lack of documented catheter care for this resident on several dates across August, September, and October. Additionally, a third resident with a nephrostomy tube had no documented physician's orders for the care and treatment of the nephrostomy, despite having a history of urinary tract infection and obstructive uropathy. The Director of Nursing confirmed the absence of orders for the nephrostomy care. These deficiencies indicate a failure to adhere to facility policies and ensure proper catheter and nephrostomy care, potentially increasing the risk of urinary tract infections for the affected residents.
Failure to Ensure Residents' Rights to Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives, as required by regulations. This deficiency was identified during a review of clinical records and staff interviews, which revealed that four residents did not have advance directives documented in their records. Specifically, there was no evidence that these residents or their representatives were informed of their rights to create advance directives, nor was there any documentation showing that they were provided assistance in formulating such directives. Additionally, the facility did not address advance directives with the residents or their representatives periodically throughout their stay. The residents involved in this deficiency included individuals with varying cognitive and physical conditions. One resident had a diagnosis of dementia, another was cognitively intact but had mental health diagnoses such as schizophrenia and bipolar disorder, a third resident had glaucoma and hemiplegia following a cerebral vascular accident, and the fourth resident was cognitively intact. Despite these conditions, there was no documented evidence that the facility engaged with these residents or their representatives regarding advance directives. The Nursing Home Administrator confirmed the lack of documentation and acknowledged that the facility had not been addressing advance directives regularly at care conferences, which was a requirement they needed to improve upon.
Failure to Conduct Background Check for Nurse Aide
Penalty
Summary
The facility failed to adhere to its policy on abuse, neglect, exploitation, and misappropriation prevention by not completing a criminal background check for a newly hired nurse aide. The policy, dated July 19, 2024, mandates that employee background checks be conducted to ensure no individual with a history of abuse, neglect, exploitation, or misappropriation is employed. However, upon review of the personnel file for Nurse Aide 3, it was found that he was hired on June 6, 2024, without a completed criminal background check as of October 8, 2024. This was confirmed during an interview with the Human Resource Director, who acknowledged the absence of documented evidence of a background check for the nurse aide prior to his hiring.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital for four residents. Resident 13, who was cognitively intact and required assistance for care needs, was transferred to the hospital after experiencing increased lethargy during dialysis. There was no documented evidence that a written notice of this transfer was provided to the resident's representative. Resident 88, who was cognitively impaired and had a feeding tube, was transferred to the hospital after a large emesis with blood-like appearance was noted. Similarly, Resident 109, who was cognitively impaired and had multiple medical conditions including aphasia and Parkinson's disease, was transferred multiple times to the hospital for various acute conditions such as hyponatremia, respiratory distress, and sepsis. In each instance, there was no documented evidence of written notification to the resident's representative regarding the reasons for these transfers. Resident 131, who was cognitively intact and required oxygen, was transferred to the hospital due to increased work of breathing and cyanosis. Again, there was no documented evidence that a written notice of this transfer was provided to the resident's representative. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, leading to discrepancies in the documentation of their care needs and treatments. For Resident 6, the MDS assessment did not reflect the administration of Pradaxa, an anticoagulant, despite physician orders and medication administration records indicating its use during the assessment period. Similarly, Resident 13's MDS inaccurately recorded the administration of intravenous Vancomycin, which was not given during the seven-day period as it was intended for dialysis administration. Resident 51's MDS assessment incorrectly indicated the receipt of oxygen therapy, which was not administered according to the medication administration records. Resident 78's assessment failed to document multiple instances of care rejection, such as refusing dressing, getting out of bed, and meals, which were noted in nurse aide documentation. Additionally, Residents 80 and 88's assessments did not accurately reflect the administration of Tramadol, an opioid, despite records showing its use during the assessment period. Lastly, Resident 128's discharge status was incorrectly recorded in the MDS as a discharge to the hospital, while nursing notes confirmed the resident was discharged home. These inaccuracies were confirmed through interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing, highlighting a pattern of errors in the facility's MDS assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which is a requirement according to their policy dated July 19, 2024. For one resident, who was cognitively intact and receiving an anticoagulant, there was no documented care plan addressing the use of the blood thinner Xarelto, despite a physician's order for its daily administration. This oversight was confirmed by the Director of Nursing during an interview. Another resident, who had moderate cognitive impairment and was dependent on staff for daily hygiene, had multiple medical conditions including an indwelling catheter, an ostomy, and a nephrostomy. Despite these complex needs, there was no care plan developed to address the care and treatment required for the nephrostomy. This deficiency was also confirmed by the Director of Nursing during an interview.
Failure to Update Care Plans for Anticoagulation and Catheter Use
Penalty
Summary
The facility failed to update and revise care plans to reflect the specific care needs of two residents. For one resident, the care plan for anticoagulation therapy was not updated after the resident's anticoagulant medication, Eliquis, was discontinued and replaced with Aspirin. Despite the physician's note indicating the change in medication, the care plan continued to reflect that the resident was taking an anticoagulant. This discrepancy was confirmed by the Director of Nursing during an interview. For another resident, the care plan was not revised to accurately reflect the resident's current condition. The resident, who had moderate cognitive impairment and an indwelling catheter due to obstructive uropathy, had an active care plan indicating urinary incontinence. However, observations confirmed the presence of a urinary drainage bag, and the Director of Nursing acknowledged that the care plan should have been updated to reflect the use of a Foley catheter instead of urinary incontinence.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure that a resident had proper assistive devices to maintain adequate hearing. Resident 14, who was understood and able to understand others, required assistance with daily care needs and used hearing aids. A social services note indicated that the resident's right hearing aid was smashed, and both hearing aids were taken by audiology for repair. However, during an interview, Resident 14 expressed that she needed a new pair of hearing aids and had not received any updates. Observations confirmed that the resident did not have any hearing aids, making communication difficult due to her hearing impairment. Interviews with facility staff revealed a lack of follow-up and communication regarding the resident's hearing aids. The Social Worker was aware of the situation but had not confirmed payment options for repairs. The Business Office Manager was unaware of the resident's need for new hearing aids and expressed uncertainty about the feasibility of obtaining them due to the resident's limited funds and lack of family support. The Social Services Director admitted to forgetting to follow up with the audiologist and only learned that the hearing aids could not be repaired after speaking with them. This series of inactions and communication lapses led to the resident being without necessary hearing aids, impacting her ability to communicate effectively.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate potential triggers. The facility's policy, dated July 19, 2024, required universal screenings and assessments to identify possible traumatic exposures and triggers. However, for one resident, there was no documented evidence that the facility identified specific triggers or implemented measures to prevent or minimize these triggers. The resident in question was cognitively intact and required assistance for daily care needs, with diagnoses including anxiety, depression, PTSD, and schizophrenia. Despite these conditions, the facility did not complete a trauma-informed care assessment for the resident. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of assessment.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, for two of the three nurse aides reviewed, Nurse Aides 8 and 9, there was no documented evidence of performance evaluations being conducted. According to the facility's policy dated July 19, 2024, these evaluations were to be completed annually based on the hire dates. The evaluations for these nurse aides were due between April 8 and July 1, 2024, but were not completed. This was confirmed during an interview with the Director of Nursing on October 8, 2024.
Failure to Address Pharmacy Recommendations for Medication Dose Reduction
Penalty
Summary
The facility failed to ensure timely physician response to pharmacy recommendations for a resident. The resident, who was cognitively intact and required minimal assistance, was taking antipsychotic and antidepressant medications for conditions including dementia, Wernicke's encephalopathy, bipolar disorder, and depression. The pharmacy conducted monthly medication regimen reviews and recommended gradual dose reductions for Risperidone and Sertraline in March and June 2024. However, there was no documented evidence that these recommendations were addressed or that any dose reduction was attempted. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the pharmacy's recommendations for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, as evidenced by several deficiencies observed during a survey. In one of the medication rooms, the refrigerator used for storing controlled drugs did not have a permanently affixed, separately locked compartment, which is a requirement for controlled substances. This unsecured compartment contained both opened and unopened bottles of Ativan, a medication that is tightly controlled due to its potential for abuse. Additionally, the facility did not properly manage the expiration and labeling of medications. An expired multi-dose inhaler was found on a medication cart, which should have been discarded according to the manufacturer's instructions. Furthermore, a multi-dose vial of Lantus insulin was not labeled with the date it was opened, contrary to the manufacturer's guidelines that require such labeling to ensure timely disposal. The survey also revealed that medications were left unsupervised and unlabeled at the bedside of two residents. One resident, who was cognitively intact, was found with an unsupervised medicine cup containing two unlabeled pills, which he was unaware of. Another resident, who had bipolar disorder and surgical wounds, had nine unlabeled pills left on her overbed table. In both cases, the LPNs involved did not ensure the residents took their medications, leaving them unsupervised, which was confirmed by the Director of Nursing as inappropriate practice.
Incomplete Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and accurately documented. Specifically, the deficiency involved Resident 130, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD). The resident's care plan indicated a potential for weight loss or gain, requiring staff to provide diet and supplements as ordered. However, there was a lack of documented evidence regarding the amount of food consumed by the resident during specific meals in June, July, and August 2024. The absence of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record for Resident 130 did not include the necessary information about meal consumption on the specified dates. This failure to document the resident's food intake contravenes accepted professional standards for maintaining complete and accurate clinical records, as required by 28 Pa. Code 211.5(f).
Repeated Deficiencies in Quality Assurance and Care Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccuracies in Minimum Data Sets (MDS), inadequate creation and implementation of care plans, failure to update care plans, poor quality of care, and improper tube feeding management. These issues were identified in surveys conducted on November 9, 2023, March 5, 2024, and May 30, 2024, with the most recent survey ending on October 9, 2024, highlighting the facility's inability to maintain compliance with nursing home regulations. The facility had previously developed plans of correction for these deficiencies, which included conducting audits and reporting the results to the QAPI committee for review. However, the current survey findings revealed that the QAPI committee did not successfully implement these plans to ensure ongoing compliance. Specific deficiencies were cited under F641 for assessment accuracy, F656 for comprehensive care plan development, F657 for updating care plans, F684 for quality care, and F693 for tube feeding management, indicating a systemic failure in the facility's quality assurance processes.
Failure to Maintain Laundry Dryers in Safe Condition
Penalty
Summary
The facility failed to maintain two of three laundry dryers in safe operating condition. According to the manufacturer's directions for use, the area around the exhaust opening and adjacent surrounding area should be kept free from the accumulation of lint, dust, and dirt. Additionally, the interior of the tumble dryer and exhaust duct should be cleaned periodically by qualified service personnel. During an observation in the laundry department, it was noted that there was an accumulation of lint in the compartment above the dryer drum where the gas line entered the back of the dryer. This was confirmed by the Director of Environmental Services and the Director of Maintenance, who stated that the dryers were last cleaned on September 9, 2024.
Failure to Inform Resident of Lab Results
Penalty
Summary
The facility failed to honor a resident's right to make informed choices and participate in their treatment. Resident 84, who was alert, oriented, and able to understand and be understood, requested lab work to be done. The lab work was completed, but there was no documented evidence in the clinical record that the results were reviewed with the resident. An interview with Resident 84 confirmed that she was not informed of her lab results. The Director of Nursing acknowledged the lack of documentation and confirmed that the results should have been reviewed with the resident.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to self-administer medications safely. For Resident 19, a Licensed Practical Nurse (LPN) left a cup containing polyethylene glycol on the resident's overbed table without observing the resident take the medication. The Director of Nursing confirmed that there was no assessment to determine if Resident 19 was safe to self-administer medications. Similarly, Resident 78, who was cognitively intact but dependent on staff for daily care needs, was found with a medicine cup containing pills on his overbed table. The resident was unaware of the pills, and the LPN admitted to leaving them there without supervision. Resident 108, who required assistance for daily care needs and had a diagnosis of bipolar disorder, was found with a medicine cup containing nine pills on her overbed table. The LPN believed the resident had taken the medication, but the pills were left unsupervised, and the resident had not taken them. The Director of Nursing confirmed that there were no assessments conducted to determine if Residents 78 or 108 could safely self-administer their medications. These actions were in violation of the facility's policy, which requires an interdisciplinary team assessment to determine if self-administration is clinically appropriate and safe.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for a resident, identified as Resident 59, which is a requirement according to their policy. The facility's policy, dated July 19, 2024, mandates that call lights must be accessible to residents when they are in bed. However, during an observation on October 5, 2024, it was noted that Resident 59's call bell was clipped to an electrical cord behind his bedside dresser, making it inaccessible. This was confirmed by both the resident, who stated he had to search for the call bell, and Nurse Aide 4, who acknowledged that the call bell should have been within reach. Resident 59 had a quarterly Minimum Data Set (MDS) assessment dated July 31, 2024, which indicated that he was able to understand and communicate with others, required assistance for care needs, and had diagnoses including glaucoma and hemiplegia/hemiparesis following a cerebral vascular accident. His fall risk care plan, dated October 2, 2023, highlighted his risk for falls due to impaired vision and mobility decline, with an intervention to keep his call bell within reach. The Director of Nursing confirmed that the call bell should have been accessible to Resident 59, aligning with the facility's policy and the resident's care plan.
Medication Administration Protocol Breach
Penalty
Summary
The facility failed to ensure that medication administration was conducted in accordance with professional standards for two residents. The facility's policy, dated July 19, 2024, mandates that medications be administered safely, timely, and as prescribed, with the individual administering the medication required to initial the Medication Administration Record after each administration. However, during an observation on October 7, 2024, a Licensed Practical Nurse (LPN) was seen preparing medications for one resident and then administering medications to two residents consecutively without preparing them separately, which is against the facility's policy. The LPN acknowledged immediately after the incident that she was aware of the correct procedure and admitted to not following it during the observed administration. The Director of Nursing confirmed that the LPN should have prepared and administered medication for one resident at a time, as per the facility's policy. This incident highlights a deviation from the established medication administration protocol, which was confirmed through staff interviews and policy review.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to follow physician's orders for Resident 80, who had moderate cognitive impairment and was dependent on staff for personal hygiene care. The resident had a Stage 4 pressure ulcer and was receiving negative wound pressure therapy (NWPT). Physician's orders required that the provider be contacted for new wound care orders if the NWPT was off for more than two hours. On October 7, 2024, the NWPT treatment was not administered due to a lack of tubing, and an abdominal pad was applied instead. Observations on October 8, 2024, revealed that the NWPT device was not functioning, and there was no documentation that the provider was notified about the interruption in treatment. Additionally, Resident 80 had a medical adhesive-related skin injury (MARSI) above his nephrostomy, for which new orders were obtained for specific dressings. However, a review of the Treatment Administration Record for September 2024 showed no evidence that the treatment for the MARSI was completed as ordered. Interviews with the Director of Nursing confirmed that the physician was not notified about the NWPT issue and that the MARSI treatment was never administered.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment as ordered by the physician for a resident who required it due to arthritis in his hands. The resident, who was cognitively intact, had requested adaptive silverware to alleviate cramping in his hands caused by using standard utensils. A therapy screen and care plan both indicated the need for built-up utensils, and a physician's order confirmed this requirement. During an observation, the resident was found eating with regular utensils instead of the prescribed built-up utensils. The resident's meal ticket did not include the necessary adaptive equipment. Interviews with a nurse aide and the Director of Nursing confirmed that the resident should have been provided with built-up utensils as per the care plan and physician's orders.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, identified as Resident 10, who was cognitively intact and required assistance with most daily care needs. The resident had diagnoses including COPD, quadriplegia, and drug abuse. During an observation, the resident's room was found to have an accumulation of dust, dirt, and debris on the bed, floor, and in the bathroom. Items such as dried-up alcohol wipes, straws, straw papers, crumbs, and a large amount of generalized dirt and debris were scattered throughout the room. The bathroom floor had bits of paper and dirt, the garbage can was overflowing with paper towels, and the toilet was dirty with dried pieces of a brown substance. Interviews with Housekeeper 1 and the Director of Housekeeping confirmed the unclean state of the resident's room and bathroom, acknowledging that it should not have been in such a condition. They attributed the cleanliness issues to the departure of four staff members since August, which made it difficult to maintain the facility's cleanliness standards. The Nursing Home Administrator also confirmed the deficiency, acknowledging that the resident's room and bathroom were not clean as required by the facility's policy and resident rights regulations.
Failure to Document Pressure Ulcer Treatments
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered by the physician for a resident. The resident, who was cognitively intact and required assistance with daily care, had diagnoses including quadriplegia, drug abuse, and a pressure ulcer. Physician's orders specified that the resident's pressure ulcers on the right ischium, right iliac crest, and right medial buttocks should be cleansed with Dakin's solution, packed with Dakin's wet to moist gauze, and covered with abdominal pads. Additionally, any dermatitis around the wounds was to be treated with ketoconazole cream. However, the Treatment Administration Record for August 2024 showed no documentation of the dressings being completed or refused on two specific dates. The Director of Nursing confirmed the lack of documentation for these treatments.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during the care of a resident, specifically during wound care. The facility's policy on perineal care required staff to discard disposable items into designated containers, remove gloves, wash and dry hands thoroughly, and make the resident comfortable. However, during an observation of wound care, a wound care nurse did not adhere to these procedures. The nurse completed the treatment for the resident's coccyx wound, which involved handling a heavily soiled brief. Instead of discarding the soiled brief immediately, the nurse placed a clean brief, rolled the resident, and allowed the soiled brief to fall to the floor before picking it up and disposing of it in a garbage can. The nurse continued to provide care without changing gloves or performing hand hygiene, which was confirmed during an interview with the nurse and the Director of Nursing. The nurse adjusted the resident's position and covered them with a sheet and blanket without removing the contaminated gloves or washing her hands, contrary to the facility's infection control policy. This lapse in protocol was acknowledged by both the nurse and the Director of Nursing, highlighting a failure in maintaining proper infection control practices during resident care.
Failure to Conduct Care Plan Meetings for Resident
Penalty
Summary
The facility failed to routinely conduct care plan meetings and invite the resident or their representative to participate in the development and implementation of the resident's person-centered plan of care. This deficiency was identified for one of the six residents reviewed, specifically Resident 6. The facility's policy, dated January 10, 2024, mandates that residents and their representatives are encouraged to participate in the assessment and care planning process, including the right to request meetings and revisions to the care plan. However, there was no documented evidence of such meetings for Resident 6 since their admission on April 7, 2022. Resident 6, who was admitted to the facility with diagnoses including dementia, anxiety, and mood disturbance, was noted to be confused and required extensive assistance with activities of daily living. An interview with the resident's daughter revealed that Resident 6 frequently refused care and had specific skin care needs that were not being addressed due to the lack of a care planning meeting. The Nursing Home Administrator confirmed the absence of a care planning meeting with the resident or her representative since admission, acknowledging that such meetings should have occurred.
Failure to Conduct Safety Assessment for Air Mattress
Penalty
Summary
The facility failed to complete safety assessments for a resident who used an air mattress, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who was cognitively impaired, totally dependent on staff, and at risk for falls, had multiple pressure ulcers and a feeding tube. Despite being at risk for falls, the resident's care plan did not include an updated safety assessment for the air mattress after an unwitnessed fall occurred. The resident was found on the floor on two separate occasions, once on March 30, 2024, and again on June 7, 2024, with the latter incident resulting in a dislodged gastric tube, a head injury, and a laceration. The Director of Nursing confirmed that no air mattress safety assessment was conducted following the June 7, 2024, fall, as an assessment had been completed the day before, and no changes were noted. However, there was no documented evidence of an assessment for potential safety hazards related to the continued use of the air mattress after the fall. This oversight contributed to the deficiency, as the facility did not adequately assess and address the safety needs of the resident, who was at high risk for falls and injury.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the CDC and CMS, specifically regarding the use of Enhanced Barrier Precautions (EBP) for residents with certain medical conditions. Resident 1, who had a Foley catheter, was observed receiving a bed bath from Nurse Aide 1 and Nurse Aide 2, who were only wearing gloves instead of the required gown and gloves. This was despite the presence of signage indicating the need for EBP due to the catheter. Interviews with the nurse aides revealed a lack of awareness about the requirement to wear gowns during such care activities. Similarly, Resident 4, who was cognitively impaired and had multiple pressure ulcers and a feeding tube, was also observed receiving a bed bath from Nurse Aide 3 and Nurse Aide 4, who were only wearing gloves. Although there was a visual reminder and gowns available at the bedside, the aides admitted to forgetting to use them. The Infection Prevention Nurse confirmed that both residents required EBP, and the staff should have been wearing both gowns and gloves during the care activities.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for two residents, leading to deficiencies in care. For one resident with diabetes, the facility did not notify the physician when the resident's blood sugar levels exceeded 400 mg/dl on multiple occasions, as required by the physician's orders. Additionally, a verbal telephone order for an extra dose of insulin was not documented or administered as instructed. These lapses were confirmed by the Director of Nursing during an interview. Another resident, who had a diagnosis of Multiple Sclerosis and required pain management, did not receive the correct dosage of Oxycodone as prescribed. The narcotic accountability sheet indicated that only one tablet was dispensed, while the Medication Administration Record inaccurately documented that two tablets were given. This discrepancy was also confirmed by the Director of Nursing, highlighting a failure to follow the prescribed medication regimen.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for a resident. A significant change Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required assistance for all daily care needs, and had a diagnosis of chronic pain. Physician's orders included an order for the resident to receive one 5-325 mg tablet of Oxycodone/Tylenol every four hours as needed for pain. The controlled drug record for April 2024 showed that the facility received 60 tablets of the medication. However, the controlled drug log indicated that 60 doses were signed out for administration, while the Medication Administration Record (MAR) showed that the resident received only 54 doses, leaving six doses unaccounted for. An interview with the Nursing Home Administrator and Director of Nursing confirmed the discrepancy of six missing doses. They noted that the controlled drug log used was not the facility's regular log, as the medication was supplied by hospice, and the facility typically uses a different log that makes it easier to track when each dose is signed out.
Failure to Follow Physician's Orders for Orthopedic Consult
Penalty
Summary
The facility failed to ensure that physician's orders were followed for Resident 5. A quarterly Minimum Data Set (MDS) assessment dated February 22, 2024, revealed that Resident 5, who was cognitively intact and required substantial to maximum assistance for personal hygiene needs, had a diagnosis of chronic obstructive pulmonary disease. Discharge instructions from the hospital dated November 27, 2023, indicated that the resident was to follow up with orthopedics in one to two weeks regarding a right shoulder effusion. However, there was no documented evidence in the clinical record that the resident had an orthopedic consult. Interviews with the Nursing Home Administrator and Director of Nursing on March 5, 2024, revealed that the resident was a participant in the Senior Life Program, and all consults had to be approved and scheduled through them. They believed that Senior Life's physician decided an orthopedic follow-up was not required, but there was no documentation to support this decision in the resident's clinical record.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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