Valley Manor Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coopersburg, Pennsylvania.
- Location
- 7650 Route 309, Coopersburg, Pennsylvania 18036
- CMS Provider Number
- 395167
- Inspections on file
- 33
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Valley Manor Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including an internal cardioverter/defibrillator, did not have care plan interventions documented for monitoring and care of the device, despite this need being identified in the assessment.
A resident with dementia, diabetes, and end stage renal disease, who required extensive assistance, did not have geri sleeves applied to both arms as ordered by the physician. Multiple observations showed the resident in bed without the required arm protectors, indicating staff did not follow the physician's instructions.
Two cognitively impaired residents with multiple medical conditions were not provided with required floor mats as specified in their care plans to prevent falls. Despite documented incidents of falls and clear care plan instructions, staff failed to place mats on both sides of the bed while the residents were in bed, as confirmed by observations and staff interview.
The facility did not ensure the kitchen suppression system was inspected and serviced at required intervals. During a document review, it was found that the facility could not provide documentation for two required inspections in the prior year, with only one inspection report available. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain its fire alarm system, affecting the entire facility. Issues included an untested pull station due to missing keys, undocumented smoke detector sensitivity values in the basement, and detectors in Zone 4 not resetting automatically. An exit interview confirmed these deficiencies were unresolved, and the facility lacked documentation for basement smoke detector sensitivity testing.
The facility failed to maintain its sprinkler system, affecting the entire facility. Inspections revealed missing documentation, a corroded sprinkler, pending hydro tests, and low temperatures in the fire pump room risking pipe damage. Additionally, recessed sprinkler heads and a low water alert in the water tower were observed, confirming the facility's failure to ensure proper maintenance.
The facility failed to conduct fire drills once per shift per quarter, affecting the entire facility. A document review revealed missing documentation of staff participation in monthly fire drills for several months in 2024 and 2025. This deficiency was confirmed during an exit interview with the Administrator and Director of Maintenance.
The facility did not ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA standards. A document review revealed the absence of documentation for inspections and tests within the past 12 months, affecting the entire facility. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not conduct the required annual inspection of electrical receptacles in resident care areas, affecting all resident bed locations. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility failed to maintain exit egress doors with delayed egress locking arrangements, as two doors did not release after 15 seconds of pressure. This issue was confirmed by the Administrator and affected two smoke compartments.
The facility failed to maintain documentation verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually on one of its two levels. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
The facility was found to have conflicting exit signage at the Great Room entrance, with one operable sign and another disabled, leading to confusion about the correct emergency exit path. This was confirmed during an exit interview with the facility's administration and maintenance staff.
The facility did not maintain a proper hazardous area enclosure on one level. On the first floor, the soiled utility room door across from room 312 was found with paper towels stuffed into the doorframe strike plate, preventing it from latching. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility did not maintain portable fire extinguishers as per NFPA 10, with 15 out of 32 extinguishers needing replacement. An inspection on January 17, 2025, identified the issue, but the extinguishers had not been replaced by the time of the survey. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain smoke barrier walls, as observed on the first floor above the smoke barrier doors next to the Great Room, where an unsealed MC wire penetration was found. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating.
The facility failed to maintain smoke barrier doors to close tightly and resist smoke passage due to blockage by a berri lift next to room 508. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain HVAC exhaust diffusers, as observed in the soiled utility room of the 500 wing, where a diffuser was dislodged from the ceiling and resting on cabinets. This was confirmed by the Administrator and maintenance staff.
The facility failed to maintain proper accessibility and safety of electrical panels. A supply order was stored against high voltage switch gear handles, an exposed electrical conduit was found in the kitchen, and janitorial equipment blocked access to electrical panels in a mechanical room. These issues were confirmed by facility staff.
The facility was found to be non-compliant with electrical equipment standards due to unauthorized use of power strips and extension cords. A dehumidifier was plugged into an extension cord in the basement, and a microwave, mini-fridge, and toaster were plugged into a power strip in the Admissions Office. These findings were confirmed during an exit interview with facility staff.
A propane tank was found unsecured in the basement at the outdoor dock area, stored in front of the main electrical high voltage switch gear. This deficiency was confirmed by the Administrator and Director of Maintenance, indicating a failure to adhere to NFPA 101 standards for gas equipment storage.
The facility did not comply with smoking regulations, as cigarette butts were found accumulated in mulch beds, outside resident room windows, and along the building's side driveway, outside the designated smoking area. This was confirmed during an exit interview with the Administrator and maintenance staff.
The facility failed to maintain an emergency preparedness training program based on the Emergency Preparedness Plan, lacking documentation of initial and annual staff training. This was confirmed during an exit interview with the Administrator and other staff.
The facility failed to maintain documentation of initial and annual Emergency Preparedness training for staff and volunteers, as revealed during a document review and confirmed in an exit interview with the Administrator and Director of Maintenance.
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan, affecting the entire facility. Document review revealed the absence of these exercises within the previous 12 months, and the lack of documentation was confirmed by the Administrator and staff during an exit interview.
The facility failed to maintain required egress clearances, with the Northeast Stair Tower being narrower than required and the Basement Level having inadequate headroom clearance. These issues were confirmed by the facility's administration.
The facility was found to have smoke compartments exceeding the maximum allowable size of 22,500 square feet in the 400 wing and First Floor, affecting two of four smoke compartments. This was confirmed through observation, document review, and interviews with facility staff.
The facility failed to maintain required emergency generator components, as the generator set in the basement lacked battery back-up emergency lighting. This deficiency was confirmed through observation and an interview with the Administrator and maintenance staff.
The facility failed to document the rationale for extending PRN anti-anxiety medications for three residents. One resident with anxiety and major depressive disorder received Ativan PRN multiple times without proper documentation. Another resident with bipolar disorder was given Ativan PRN several times, also lacking documentation. A third resident with multiple conditions, including dementia, received Ativan gel and lorazepam PRN frequently, again without the necessary documentation. The administrator confirmed the absence of documentation for extending these PRN orders.
The facility failed to follow infection control policies, leading to deficiencies in implementing Transmission-Based and Enhanced Barrier Precautions. A resident with influenza A was not managed with proper PPE, and staff were unaware of precautionary statuses due to missing signage. Additionally, residents at risk of MDROs were not managed with required protective gowns, indicating systemic issues in infection control practices.
Valley Manor Rehabilitation and Healthcare Center was found non-compliant with regulations for a safe, clean, and homelike environment. Observations included broken fixtures, missing amenities, and structural issues across multiple rooms, such as chipped paint, broken tiles, and stained curtains, indicating a failure to maintain a comfortable environment for residents.
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with ADLs. One resident with dementia and diabetes was observed with long and dirty fingernails, while another resident with a history of stroke and depression had long, dirty fingernails and an unshaved beard. Both residents were able to communicate their needs, and the Director of Nursing confirmed that their grooming needs should have been addressed.
A resident with cognitive impairment and multiple medical conditions, including atrial fibrillation and diabetes, had frostbite wounds on their lower extremities. Despite a physician's order for daily wound care, the facility failed to perform the required treatments on several occasions, as confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide (NA) to resident ratios on three occasions within a 21-day period. Specifically, the day shift failed to maintain one NA per ten residents on two days, and the evening shift did not meet the one NA per eleven residents requirement on another day.
The facility did not meet the required NA to resident ratio during a day shift, failing to provide one NA per ten residents. This was confirmed by the DON after reviewing the nursing schedules.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period, providing only 3.17 hours on one day. This was confirmed by the DON during an interview.
Two residents in the facility were not served meals according to their preferences. A resident with anxiety and hypertension received buttered carrots despite disliking them, and another resident with heart failure and diabetes was served lemonade, which he disliked. Both residents were alert and oriented, and their meal tickets indicated their preferences, which were not followed by the dietary department.
The facility did not comply with the regulation to post menus two weeks in advance. Observations revealed that only meals for two days were posted, and the Registered Dietician confirmed that menus were not distributed to residents or posted in advance. The Nursing Home Administrator acknowledged this deficiency.
The facility did not meet the required nurse aide (NA) to resident ratios as per the regulation effective July 1, 2024. A review of nursing time schedules revealed that the facility failed to maintain the minimum NA to resident ratio during the day shift on multiple occasions and during the night shift on several dates. These deficiencies were noted over a period of seven out of 21 days reviewed.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on six occasions, with care hours ranging from 2.70 to 3.07. This was determined through a review of nursing time schedules.
A resident at high risk for elopement left the facility unattended after staff failed to respond to an alarm. The resident, who was cognitively impaired, was last seen wandering the facility and was found over three hours later, having traveled 5.5 miles away. This incident was identified as an Immediate Jeopardy situation due to inadequate supervision.
The facility failed to maintain an effective pest control program in the North unit, as flies were observed in the hallway and several rooms. The Administrator confirmed the presence of flies, indicating a lapse in pest control measures.
The facility failed to prevent and report resident-to-resident physical abuse involving a resident with a history of behavioral disturbances. Two incidents occurred where the resident pushed other residents, causing harm. These incidents were not reported to the State Licensing Agency as required by facility policy.
Failure to Address Cardiac Device in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all identified needs for one resident. Clinical record review showed that the resident was admitted with diagnoses including atrial fibrillation, multiple wounds, heart disease, and a skin infection, and was dependent on staff for care. The resident also had a history of surgeries, including the placement of an internal cardioverter/defibrillator. Despite this, there was no documentation that the care plan included interventions to monitor and care for the internal cardioverter/defibrillator, as identified in the comprehensive assessment.
Failure to Follow Physician's Order for Geri Sleeves
Penalty
Summary
A deficiency was identified when staff failed to implement a physician's order for a resident with dementia, diabetes, and end stage renal disease. The clinical record showed that the resident was cognitively impaired and required extensive assistance with dressing. A physician's order dated April 30, 2025, directed staff to apply geri sleeves (arm protectors) to both of the resident's arms at all times except during hygiene. However, during multiple observations on May 15, 2025, the resident was found in bed without the required geri sleeves on his arms, indicating that the physician's order was not followed.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Residents
Penalty
Summary
The facility failed to implement required safety interventions for two residents who were identified as being at risk for falls. Both residents had significant medical conditions, including dementia, diabetes, end stage renal disease, heart failure, and convulsions, and were assessed as cognitively impaired and dependent on staff for bed mobility and transfers. Their care plans specifically directed staff to place mats on the floor on both sides of the bed while the residents were in bed to prevent falls. However, clinical record reviews and facility documentation showed multiple incidents where one resident slid out of bed or was found on the floor, and observations confirmed that mats were not in place as required. On the day of the survey, both residents were observed in bed without mats on either side, contrary to their care plan interventions. The Administrator confirmed during an interview that mats should have been present. These findings were based on clinical record review, facility documentation, direct observation, and staff interview, demonstrating a failure to provide adequate supervision and implement safety measures as outlined in the residents' care plans.
Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to ensure that the kitchen suppression system was inspected and serviced at the required intervals. During a document review on March 12, 2025, it was found that the facility could not provide documentation showing that the kitchen suppression system had been tested and maintained twice in the prior year, as required. Only one inspection report dated January 17, 2025, was available. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Kitchen suppression system will be tested again and two inspections completed for the year in June. 2. 4/28/25 3. Maintenance staff will conduct quarterly inspections in the kitchen. 4. The Director of maintenance will keep inspection reports and conduct monthly audits x3.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system components in operable condition, affecting the entire facility. During a document review on March 12, 2025, it was found that the fire alarm annual report dated May 15, 2024, listed several issues. The pull station at the nurses' station could not be tested due to the unavailability of keys needed for resetting. Additionally, the smoke detector sensitivity values were not documented for the basement detectors, and the facility needed to contact Simplex to acquire these values. Furthermore, Zone 4 required investigation as the detectors did not automatically reset. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these deficiencies had not been resolved. The facility also failed to provide documentation for sensitivity testing on the basement smoke detectors.
Plan Of Correction
1. Tustin Fire Alarm will be scheduled to come to the facility and complete all testing. A. Keys are now available for reset. B. Tustin visited 3/31/25 and waiting on report for basement detectors. C. Zone 4 was checked when Tustin came out. Waiting on report. 2. 4/28/25 3. Maintenance staff educated on keeping up to date with the scheduling of the fire alarm system. 4. The Director of maintenance will keep all reports up to date.
Facility Fails to Maintain Sprinkler System
Penalty
Summary
The facility failed to maintain its sprinkler system, affecting the entire facility. Documentation reviewed on March 12, 2025, revealed that only two quarterly external water tank inspections and two quarterly wet sprinkler inspections were recorded for the year 2024. During an exit interview, the Administrator, Director of Maintenance, and Assistant confirmed the absence of necessary report documentation. Additionally, the 4th quarter sprinkler inspection report from December 23, 2024, indicated several issues: a corroded sprinkler in the Dietary area needed replacement, a hydro test for the fire department connection was pending, and the fire pump room's temperature was below the required 40 degrees Fahrenheit, risking pipe damage due to potential freezing. Furthermore, the facility was advised to monitor and maintain the water level in the tank consistently. Observations made on March 12, 2025, revealed additional deficiencies. Two sprinkler heads in the basement laundry chute room were recessed into the ceiling, potentially hindering immediate water spread. Moreover, the fire alarm panel indicated a supervisory alert for low water in the water tower. These findings were confirmed during an exit interview with the facility's administration and maintenance team, highlighting the facility's failure to ensure proper maintenance and functionality of its sprinkler system.
Plan Of Correction
1. The Sprinkler system will be scheduled with Tustin for testing annually. Sprinkler heads will be adjusted. At the time of the survey, the fire pump was in test mode and was discharging water, and the facility ensures proper water is filled in the water tower. The facility will inspect the external water tank at least quarterly. 2. A. Facility will schedule replacement sprinkler with Tustin. B. Facility will contact the fire department to get hydro test scheduled. C. Report was from 2024. The temperatures were good during the site visit on 3/12/25. D. Facility currently monitors the water tank daily. E. Water was flowing during the site visit on 3/12/25. 3. Tustin will be scheduled to come in and turn sprinkler heads downwards. 4. The fire alarm panel is working properly and was completing a test which led to the low water notification. The facility has a working heater that maintains adequate temperature throughout.
Failure to Conduct Quarterly Fire Drills on Each Shift
Penalty
Summary
The facility failed to conduct fire drills once per shift per quarter, which affected the entire facility. During a document review on March 12, 2025, it was revealed that the facility could not provide accurate documentation of shift participation in monthly fire drills for several months, specifically March, May, June, August, and October of 2024, and February of 2025. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of accurate documentation.
Plan Of Correction
1. The facility will conduct fire drills immediately on all three shifts. Going forward, the facility will create a schedule for fire drills to ensure they are completed as required. 2. 4/28/25 3. The Maintenance Director was educated on conducting the fire drills once per shift per quarter and intermittently throughout the year on different dates and times. 4. The Director of maintenance will complete random audits.
Failure to Inspect and Test Fire Door Assemblies Annually
Penalty
Summary
The facility failed to ensure that rated fire door assemblies were inspected and tested annually, as required by NFPA 101 and NFPA 80 standards. During a document review conducted on March 12, 2025, it was discovered that the facility could not provide documentation proving that the rated fire door assemblies had been inspected and tested within the previous 12 months. This deficiency affects the entire facility, as confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Conducted rated fire door testing and inspection of fire doors. 2. 4/28/25 3. Maintenance staff educated on completing rated fire door testing. 4. Director of maintenance will audit fire doors quarterly.
Failure to Perform Annual Electrical Inspections
Penalty
Summary
The facility failed to maintain the required inspections of electrical wiring and receptacle systems, which affected all resident bed locations. During a documentation review on March 12, 2025, it was revealed that the annual inspection of receptacles in resident care areas was not performed. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
Facility will conduct annual receptacle testing in resident care areas. 4/28/25 Maintenance staff educated on receptacle testing. The Director of maintenance will conduct random facility audits.
Delayed Egress Door Malfunction
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors equipped with delayed egress locking arrangements. During an observation on March 12, 2025, it was noted that two exit doors did not release after 15 seconds of applying pressure against the crash bar, as required. These doors were located on the first floor, specifically door # EM-1 next to the basement stairwell and door # E4 in the dining room. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged that the doors did not release as expected. This issue affected two of the four smoke compartments in the facility, indicating a failure to comply with the necessary safety standards for egress doors.
Plan Of Correction
1. Door # EM1 repaired and released on egress and requesting a TLW for EM4 as a door repair may be necessary to be made by an outside vendor. 2. 4/28/25 3. Doors will be checked on a monthly basis. 4. Director of maintenance or designee will conduct monthly audits to ensure doors are released after 15 seconds of applying pressure.
Emergency Lighting Documentation Deficiency
Penalty
Summary
The facility failed to maintain proper documentation for emergency lighting testing and inspection on one of its two levels. During a review conducted on March 12, 2025, it was observed that the facility did not have records verifying that emergency backup lights were tested monthly and that a 90-minute test was performed annually. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, who acknowledged the lack of documentation for the emergency backup lighting tests.
Plan Of Correction
1. Facility will resume testing monthly test and completed a 90-minute test. 2. 4/28/25 3. The new director of maintenance will create a new PM binder. Maintenance staff educated on testing. 4. Audits will be conducted monthly x 3.
Conflicting Exit Signage in Facility
Penalty
Summary
The facility failed to maintain proper exit signage, as observed on March 12, 2025. At the entrance to the Great Room from the corridor, there were two exit signs providing conflicting instructions for the nearest emergency exit. One sign was operable, while the other was disabled, leading to confusion about the correct exit path. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day.
Plan Of Correction
1. Exit signage corrected and operable. The other exit sign removed. 2. 4/28/25 3. Director of maintenance will check exit signs on monthly basis. 4. Audit will be conducted monthly x 3.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain a proper hazardous area enclosure on one of its two levels. During an observation on the first floor, it was noted that the soiled utility room across from room 312 had paper towels stuffed into the doorframe strike plate. This obstruction prevented the door from latching properly, compromising the integrity of the hazardous area enclosure. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. Soiled utility room door repaired to fully close and latch. 2. 4/28/25 3. Staff education completed on regulation for NFPA 101 Standard (section 8.4) stating that "doors shall be self-closing or automatic closing." 4. Director of maintenance will conduct audits monthly x 3.
Failure to Maintain Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10, affecting 15 out of 32 extinguishers. During a documentation review on March 12, 2025, it was revealed that an annual inspection had been conducted on January 17, 2025. However, the report indicated that 15 fire extinguishers required replacement. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that these extinguishers had not been replaced at the time of the survey.
Plan Of Correction
1. The facility will replace the 15 fire extinguishers. 2. 4/28/25 3. The maintenance director will be educated on tracking and replacing fire extinguishers as needed. 4. Monthly audits will be conducted on fire extinguisher expiration dates and that they are in good working condition.
Unsealed MC Wire Penetration in Smoke Barrier
Penalty
Summary
The facility failed to maintain smoke barrier walls, which is a requirement for ensuring fire safety. During an observation on March 12, 2025, at 3:00 p.m., it was noted that on the first floor, above the smoke barrier doors next to the Great Room, there was an unsealed MC wire penetration. This deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day. The unsealed penetration in the rated smoke wall compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating as per NFPA 101 standards.
Plan Of Correction
1. Unsealed wire penetration was corrected and sealed using an UL approved stop gap penetration system for sealing the penetration. 2. 3/13/25 3. The maintenance director will be educated on unsealed penetrations. 4. Audits will be conducted monthly random checks behind ceiling tiles to ensure any unsealed penetrations are not found. If found, they will be corrected at that time.
Smoke Barrier Doors Blocked by Equipment
Penalty
Summary
The facility failed to ensure that smoke barrier doors were properly inspected and maintained to fully close and resist the passage of smoke in one of two wings. During an observation on March 12, 2025, at 2:50 p.m., it was noted that the smoke barrier doors next to room 508 on the first floor did not close tightly. This issue was caused by the doors being blocked by a berri lift, which prevented them from closing smoke tight. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed that the doors were indeed blocked, inhibiting their ability to close properly. This deficiency was identified as a failure to comply with the requirements for smoke barrier doors as outlined in NFPA 101, which mandates that such doors must be self-closing or automatic-closing and able to resist the passage of smoke.
Plan Of Correction
1. The Bari lift was removed; doors close properly. 2. 3/13/25 3. Staff educated on not blocking doors. 4. Director of maintenance will conduct a round audit to ensure doors are clear once a week for 2 weeks.
HVAC Exhaust Diffuser Maintenance Deficiency
Penalty
Summary
The facility failed to maintain HVAC exhaust diffusers on one of its two levels. During an observation on the first floor, inside the soiled utility room of the 500 wing, an HVAC exhaust/intake diffuser was found dislodged from the ceiling. It was powered and resting on top of wall-mounted cabinets, positioned on the intake side. This issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
1. HVAC exhaust/intake diffuser placed back in the ceiling. 2. 4/28/25 3. Maintenance staff educated on ensuring exhaust system is back in place. 4. Director of maintenance will audit soiled utility rooms once a month.
Electrical Panel Accessibility and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that electrical panels were protected and accessible, as required by NFPA standards. During an observation in the basement at the outdoor dock area, a large central supply order was found stored, leaning on, and blocking the main electrical high voltage switch gear handles. Additionally, in the kitchen, an exposed three-wire electrical conduit was observed hanging above the dishwasher drying rack discharge, with wire nuts and electrical tape on the wires, not properly terminated into an appliance. Furthermore, janitorial equipment was found obstructing access to electrical panels in the mechanical room on the first floor, across from room 330. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Plan Of Correction
Order removed from the front of the main electrical panel. A. Wires capped off and placed away from the dishwasher drying rack discharge on the same day. Housekeeping director educated on not having janitorial equipment in front of electrical panels. The Director of maintenance will conduct rounds to ensure nothing is covering the panels once a month.
Unauthorized Use of Power Strips and Extension Cords
Penalty
Summary
The facility failed to maintain proper electrical wiring and equipment usage, leading to unauthorized use of power strips and extension cords. Observations on March 12, 2025, revealed that in the basement, a dehumidifier was plugged into an extension cord powered from a ceiling receptacle. Additionally, in the Admissions Office, a microwave, mini-fridge, and toaster were plugged into a power strip. These actions were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant, indicating non-compliance with the required standards for electrical equipment usage.
Plan Of Correction
Extension cords removed from both locations. 3/13/25 Staff educated on extension cords in facility. The Director of maintenance will conduct random facility audits.
Unsecured Propane Tank Found in Facility
Penalty
Summary
The facility failed to ensure the security of portable gas cylinders, specifically a propane tank, which was found unsecured in the basement at the outdoor dock area. This propane tank was stored in front of the main electrical high voltage switch gear, posing a potential safety hazard. The observation was made on March 12, 2025, at 12:35 p.m. During the exit interview conducted on the same day at 3:15 p.m., the Administrator, Director of Maintenance, and Assistant confirmed that the portable tank was not adequately protected. This deficiency affected one of the two levels within the facility, indicating a lapse in the facility's adherence to the NFPA 101 standards for gas equipment storage and security.
Plan Of Correction
Propane tank removed from being stored in front of main electrical panel. 4/28/25 Staff educated on not storing propane tanks in front of electrical panels. The director of maintenance will conduct random facility audits.
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
The facility failed to adhere to smoking regulations as observed on March 12, 2025. During an inspection at 9:00 a.m., it was noted that there was an accumulation of cigarette butts in the mulch beds, outside resident room windows, along the building's side driveway, and outside the designated smoking area. This indicates a lack of proper disposal and management of smoking materials in the designated smoking area. The issue was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant at 3:15 p.m. on the same day.
Plan Of Correction
1. Cigarette butts were cleaned out of the mulch. 2. 4/28/25 3. Staff were educated on cigarette smoking area. There are appropriate ashtrays and appropriate metal self-closing device to empty the ashtrays. 4. Director of maintenance will audit grounds 1x a week for 2 weeks.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
The facility was found deficient in maintaining an emergency preparedness training program as required by regulations. During a document review on March 12, 2025, it was discovered that the facility failed to provide documentation of an emergency preparedness training program that is based on the Emergency Preparedness Plan. This program should include initial and annual training for all staff members, but the necessary documentation was not available. An exit interview with the Administrator, Director of Maintenance, and Assistant confirmed the facility's failure to develop an Emergency Preparedness Plan that includes a training program. This lack of documentation and development of a comprehensive training program indicates a significant oversight in the facility's emergency preparedness efforts.
Plan Of Correction
Facility conducted an annual in-service for staff on the emergency preparedness plan and training program. 4/28/25 Staff will be educated annually to remain in compliance. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date.
Failure to Document Emergency Preparedness Training
Penalty
Summary
The facility was found to be deficient in maintaining documentation of initial and annual Emergency Preparedness training for staff and individuals providing services, including volunteers. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility failed to provide maintained annual documentation of Emergency Preparedness training for staff members, which is necessary to demonstrate their knowledge of emergency procedures. The deficiency was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant on the same day. The interview corroborated the findings that the facility did not have the required annual records of employee training in emergency preparedness. This lack of documentation indicates a failure to comply with the regulatory requirement to provide and document such training annually. The report does not mention any specific incidents involving patients or any immediate consequences resulting from this deficiency. The focus is solely on the facility's failure to maintain proper records of emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. Facility conducted an annual in-service for staff on the emergency preparedness plan. 2. 4/28/25 3. Staff will be educated annually to remain in compliance. 4. Director of maintenance will audit the emergency binder monthly x3 to ensure it is up to date 8/25. Director will keep record in maintenance binder.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required annual full-scale exercise and an additional exercise to test the emergency preparedness plan. This deficiency was identified during a document review conducted on March 12, 2025, at 3:15 p.m. The review revealed that the facility did not perform these exercises within the previous 12 months, which is a requirement under the emergency preparedness regulations. The deficiency affects the entire facility, as the exercises are crucial for ensuring that the emergency preparedness plan is effective and that staff are adequately trained to respond to emergencies. The lack of documentation confirming the completion of these exercises indicates a significant oversight in maintaining compliance with regulatory requirements. During the exit interview on March 12, 2025, the Administrator, Director of Maintenance, and an assistant confirmed the absence of documentation for the required exercises. This confirmation further substantiates the finding that the facility did not meet the necessary standards for emergency preparedness testing.
Plan Of Correction
1. Facility conducted a tabletop exercise on an active shooter event. 2. 4/28/25. 3. The Director of maintenance will create a schedule to have tabletop exercises annually. 4. Director of maintenance will complete random facility audits.
Egress Clearance Deficiencies
Penalty
Summary
The facility failed to maintain the minimum required clearances along the means of egress, affecting both levels of the building. During an observation, it was noted that the Northeast Stair Tower had a width of 33 inches, which is below the required width of 36 inches. Additionally, the Basement Level was found to have inadequate headroom clearance along the exit access corridor, with a height of approximately six feet, six inches, which is less than the required six feet, eight inches. These deficiencies were confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the subdivision of building spaces into smoke compartments. Specifically, the smoke compartments on the 400 wing (zone two) and the First Floor (zone three), encompassing Rooms 101-111 and 101-302, exceeded the maximum allowable size of 22,500 square feet. This deficiency was identified through a combination of observation, document review, and interviews conducted on March 12, 2025. During the exit interview, the Administrator, Director of Maintenance, and Assistant confirmed that the smoke compartments were larger than permitted by the regulations.
Emergency Generator Lacks Battery Back-Up Lighting
Penalty
Summary
The facility failed to maintain the required emergency generator components, which affected the entire facility. During an observation on March 12, 2025, at 12:45 p.m., it was noted that the emergency generator set, located in the electrical room in the basement, did not have battery back-up emergency lighting. This deficiency was identified through direct observation and was confirmed during an exit interview with the Administrator, Director of Maintenance, and Assistant later that day. The absence of battery back-up emergency lighting in the generator set location is a critical oversight in maintaining the essential electrical systems as required by NFPA standards. The lack of this back-up lighting could potentially compromise the facility's ability to respond effectively in an emergency situation where power is lost, although the report does not explicitly state the consequences. The deficiency was confirmed through both observation and interview, indicating a lapse in the facility's adherence to established maintenance protocols for emergency power systems.
Plan Of Correction
Director of maintenance working on finding an electrician to install a battery back-up light for the emergency generator. 4/28/25 Once electrician is scheduled, director of maintenance will continue to audit the emergency generator weekly.
Lack of Documentation for PRN Psychotropic Medications
Penalty
Summary
The facility failed to document the rationale for the continued use of PRN anti-anxiety medications for three residents who were on psychotropic medications. Resident 47, diagnosed with anxiety, major depressive disorder, and end-stage renal disease, was administered Ativan PRN multiple times from January to March 2025 without documentation from the physician to extend the PRN order beyond 14 days. Similarly, Resident 106, with peripheral vascular disease, diabetes mellitus, and bipolar disorder, received Ativan PRN several times from January to February 2025, again without the necessary documentation for extending the PRN order. Resident 128, who had major depressive disorder, metabolic encephalopathy, Parkinson's disease, type 2 diabetes mellitus, anxiety, and unspecified dementia, was administered Ativan gel PRN numerous times from November 2024 to March 2025. Additionally, this resident received lorazepam PRN frequently from January to March 2025. In both cases, there was no documentation from the physician to justify extending the PRN orders beyond the initial 14 days. The facility's administrator confirmed the lack of documentation to support the rationale for extending these PRN psychotropic medications.
Plan Of Correction
1. Orders for resident 47, resident 106, and resident 128 were reviewed by the physician and end dates for PRN psychotropic medications were applied on 3/6/25. 2. DON/ADON will audit all PRN psychotropic medication orders to ensure end dates are in place. 3. DON or Designee will educate nurses on PRN end dates and reassessment after 14 days. Education will be given to provider to document rationale for any continuation for PRN psychotropic medication. 4. DON or designee will complete audit on PRN psychotropic medication orders weekly x3, and monthly x2. Results will be presented at QAPI.
Infection Control Deficiencies in PPE and Precautionary Measures
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in deficiencies in the implementation of Transmission-Based Precautions (TBPs) and Enhanced Barrier Precautions (EBPs) for several residents. Specifically, Resident 12, who tested positive for influenza A, was not properly managed under Droplet Precautions. Observations revealed that an environmental services worker and a registered nurse entered the resident's room without the required personal protective equipment (PPE), such as gowns and eye protection, and the nurse was unaware of the resident's precautionary status due to the absence of appropriate signage. Additionally, the facility did not implement EBPs for residents at risk of Multi-Drug Resistant Organisms (MDROs). Resident 19, with a history of open wounds, and Resident 49, with a suprapubic catheter, were not managed with the necessary protective gowns, and there was no signage indicating their precautionary status. Similar lapses were observed for Resident 86, who had a permanent catheter, and Resident 131, with an indwelling catheter, as staff entered their rooms without the required protective gowns. The Director of Nursing confirmed that the facility's policies for Droplet and Enhanced Barrier Precautions were not being followed by the staff. This lack of adherence to infection control protocols was observed across two of the three nursing units, affecting five of the 28 sampled residents, and highlights a systemic issue in the facility's infection control practices.
Plan Of Correction
1. DON/Admin rounded the facility to ensure all staff were wearing proper PPE. Signage applied to identified rooms. 2. Educated staff on donning and doffing PPE. 3. Full house re-education will be provided to all staff on the proper usage of PPE, infection control, donning and doffing PPE. 4. DON or designee will complete audits weekly x2 to ensure appropriate signs are displayed outside of resident rooms and staff are wearing proper PPE while providing care. Results will be reviewed at QAPI.
Deficiencies in Safe and Homelike Environment
Penalty
Summary
Valley Manor Rehabilitation and Healthcare Center was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During the survey conducted on March 4, 2024, several deficiencies were observed across multiple rooms in the facility's Central nursing unit. These included broken fixtures, such as a doorknob in room 103 and a closet door in room 209, as well as missing amenities like paper towels in room 103. Additionally, numerous rooms had walls that were heavily marred with chipped paint, including rooms 105, 106, 107, 111, 113, 201, 202, 209, 211, 213, and 215. Other issues included window curtains being off the rod in rooms 106, 202, and 211, and privacy curtains stained in room 211. Structural problems were also noted, such as a large hole along the baseboard in room 201, broken and missing tiles in rooms 213 and 215, and closet doors peeling and separating in rooms 107, 209, and 213. These observations indicate a failure to maintain the facility in a manner that ensures a safe and comfortable environment for residents, as required by federal and state regulations.
Plan Of Correction
1. Rooms were addressed during the visit. 2. The maintenance Director and Housekeeping Director will conduct environmental rounds together to ensure room issues are rectified and addressed. 3. The maintenance director will create a painting schedule for each room and coordinate with nursing and housekeeping until completion. Housekeeping will provide deep clean/target room schedules. Staff will be educated on utilizing maintenance work order forms to report any issues identified. Maintenance director will address work order forms as received. 4. Administrator or designee will conduct weekly audits on room rounds to ensure progress is being made in rooms and issues corrected. Data will be reviewed at QAPI.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents who required extensive assistance with activities of daily living (ADLs). Resident 49, diagnosed with dementia, diabetes mellitus, and polyneuropathy, was observed with long and dirty fingernails on two consecutive days, despite the care plan indicating that staff should trim nails on shower days. The resident was able to communicate his needs and expressed that his fingernails needed to be cut. Similarly, Resident 63, who had a history of stroke, chronic pain, and depression, was also observed with long and dirty fingernails and an unshaved beard. The care plan for this resident included interventions for nail trimming and facial hair grooming on shower days. The resident communicated his desire for his fingernails to be cut and his beard shaved. The Director of Nursing confirmed that the residents' grooming needs should have been addressed during bathing and as needed.
Plan Of Correction
1. Resident 49 fingernails were cut during survey. Resident 63 fingernails were cut, and his beard was trimmed on evening shift on 3/5/25. 2. DON/ADON did a house-wide audit on current residents listed as dependent with ADL. 3. Educated Unit managers on ADL care policy, as well as CNA's and LPNs. 4. DON or designee will conduct weekly audits during rounds to sample five dependent residents on each unit to ensure they receive nail care and facial hair grooming on shower days. Audits will be conducted weeklyx3 for two weeks, and then weeklyx4. Results will be reviewed at QAPI.
Failure to Implement Physician's Orders for Wound Care
Penalty
Summary
The facility failed to implement physician's orders for a resident with multiple medical conditions, including atrial fibrillation, chronic obstructive pulmonary disease, and diabetes mellitus. The resident, who also had cognitive impairment, was found to have multiple bilateral lower extremity wounds from frostbite. A physician's order required daily wound care, including soaking the feet, applying betadine, and using specific dressings. However, the Treatment Administration Records indicated that the wound care was not performed as ordered on several occasions. This was confirmed by the Nursing Home Administrator during an interview.
Plan Of Correction
1. Wound care was completed for resident 249 on 3/4/25. Nurses on assignment were re-educated. Wound doctor assessed residents wound on 3/5/25 and there were no signs of an infection, or any harm caused to the resident. 2. DON/ADON conducted an audit on all wounds in-house to ensure they were completed and orders followed on 3/4/25. 3. IDT reviewed and updated the facility wound care policy. DON/designee provided education on the updated wound policy to licensed nursing staff. 4. DON or Designee will complete weekly wound audits to ensure wound care is being provided as ordered. Audits will be conducted weekly x2, and monthly x1. Results will be reviewed at QAPI.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing schedules over a 21-day period from February 13, 2025, to March 5, 2025, it was found that the facility did not meet the required staffing levels on three occasions. Specifically, on February 16 and February 23, 2025, the day shift (7:00 a.m. to 3:00 p.m.) did not have the minimum one NA per ten residents. Additionally, on March 3, 2025, the evening shift (3:00 p.m. to 11:00 p.m.) failed to maintain the required one NA per eleven residents. These deficiencies indicate a failure to adhere to the staffing regulations set forth for ensuring adequate care for residents.
Plan Of Correction
1. The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff callouts, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. 2. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. 3. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. 4. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Non-compliance with NA to Resident Ratio
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratio on one of the seven days reviewed. Specifically, on January 11, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. This deficiency was identified through a review of nursing schedules covering the period from January 10 through January 16, 2025. The Director of Nursing confirmed during an interview on January 17, 2025, that the facility did not meet the required staffing ratios on the specified day.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. Facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules for the week of January 10 through January 16, 2025. Specifically, on January 11, 2025, the facility provided only 3.17 hours of care per resident, falling short of the mandated minimum. This shortfall was confirmed by the Director of Nursing during an interview conducted on January 17, 2025.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. NHA or designee will educate DON/ADON/ and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit PPD weekly X4; bi-weekly X 2 and monthly X 1. The results will be reviewed at the QAPI meeting.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to their preferences, as evidenced by the experiences of two residents. Resident 2, who has a diagnosis of anxiety and hypertension, was served a lunch that included buttered carrots, despite her meal tray ticket indicating a dislike for carrots. The resident confirmed that she was not offered a substitute and often received items she did not prefer. This incident was observed on January 3, 2025, and the resident was alert and oriented at the time. Similarly, Resident 3, who has heart failure and diabetes, was served lemonade with his meal, even though his meal ticket specified that he disliked lemonade. The resident, who was also alert and oriented, confirmed that he frequently received lemonade despite his stated preference. The dietary department was expected to follow the residents' preferences as identified on the meal tickets, but this was not adhered to in these cases.
Plan Of Correction
Facility provided re-education to the dietary staff on following food preferences listed for residents. NHA/Food Service Director will review job functions of the dietary tray line with the tray line staff. Re-education will include having last person on the tray line double checking items on tray against items listed on preferences. NHA/Designee will conduct audits 3 times a week for 2 weeks, then weekly for 4 weeks to ensure residents are being served items according to their listed preferences. All results will be reported to the QAPI Committee.
Failure to Post Menus Two Weeks in Advance
Penalty
Summary
The facility failed to comply with the regulation requiring menus to be planned and posted at least two weeks in advance. During a tour of the facility, it was observed that the menus posted on the nursing units only included lunch and dinner meals for January 3 and 4, 2025, rather than the required two-week advance posting. In an interview, the Registered Dietician admitted that menus were neither given to residents nor posted two weeks in advance. The Nursing Home Administrator confirmed this deficiency, acknowledging that the facility did not meet the regulatory requirement for menu posting and distribution.
Plan Of Correction
Dietary Director was posting menus in a common area daily; the NHA re-educated the director on posting menus two weeks in advance. Dietary Director will distribute two weeks' worth of menus at least weekly to residents and have them posted as well. NHA/Designee will conduct audits to ensure two weeks' worth of menus are posted and available for residents. Audit will be conducted weekly at 4 weeks, then monthly x 2. All results will be reported to the QAPI Committee.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to comply with the mandated nurse aide (NA) to resident ratios as specified in the regulation effective July 1, 2024. During a review of nursing time schedules from December 2 through 22, 2024, it was found that the facility did not meet the required staffing levels on several occasions. Specifically, the facility did not maintain the minimum ratio of one NA per 10 residents during the day shift on December 8, 9, 14, 15, 20, and 21, 2024. Additionally, the facility failed to meet the minimum ratio of one NA per 15 residents during the night shift on December 8, 9, 10, 14, and 15, 2024. These deficiencies were identified over a period of seven out of the 21 days reviewed.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor staffing ratio compliance. The NHA or designee will educate the DON/ADON and Nursing Supervisors on state ratio staffing regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly for 4 weeks, bi-weekly for 2 weeks, and monthly for 1 month. The results will be reviewed at the QAPI meeting.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing time schedules from December 2 through 22, 2024, revealed that on six specific days, the facility did not meet this requirement. On December 8, 9, 10, 13, 14, and 15, 2024, the care hours per resident were 2.70, 2.92, 2.93, 3.07, 2.97, and 2.81, respectively. This deficiency was identified based on the analysis of the nursing time schedules, indicating a shortfall in the required nursing care hours for the residents on these days.
Plan Of Correction
The facility staffs the facility to at least meet the required staffing ratios of NAs, including the use of agency staff if necessary. When there are staff call outs, the facility attempts to call other staff in and notify agency staff as well. The facility continues to focus on recruitment and retention activities. Valley Manor will hold staffing meetings throughout the week to monitor state staffing ppd compliance. The NHA or designee will educate DON/ADON and Nursing Supervisors on state staffing ppd regulation. To monitor the corrective action and ensure that it does not recur, the DON will audit nursing staff to resident ratios weekly X4; bi-weekly X2 and monthly X1. The results will be reviewed at the QAPI meeting.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide necessary supervision to prevent an elopement incident involving a resident at high risk for elopement. The resident, who had been identified as cognitively impaired and at risk for elopement since admission, was last seen wandering the facility at approximately 5:00 a.m. on the day of the incident. The resident managed to push open the front door of the facility and leave unattended, despite the presence of an alarm system. Staff failed to respond to the alarm, allowing the resident to leave the premises. The resident was found over three hours later, approximately 5.5 miles away from the facility, having crossed a four-lane highway and walked on unlit rural roads. The incident was identified as an Immediate Jeopardy situation due to the lack of adequate supervision and monitoring of the resident's whereabouts, which was a direct violation of the facility's elopement policy. The deficiency was noted as past non-compliance, and the facility was required to implement a corrective action plan.
Pest Control Deficiency in North Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in one of its three nursing units, specifically the North unit. On July 25, 2024, at 10:42 a.m., flies were observed in the hallway and in rooms 304, 308, 405, and 407. A subsequent observation on the same day at 11:38 a.m. confirmed the presence of flies in the hallway and in rooms 303, 304, 308, 405, and 407. During an interview conducted on July 25, 2024, at 12:40 p.m., the Administrator confirmed the presence of flies on the North unit, indicating a lapse in the facility's pest control measures.
Failure to Prevent and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse and did not report the incidents to the State Licensing Agency. Resident 1, who had a history of behavioral disturbances including yelling, screaming, cursing, and pushing others, was involved in two incidents of physical abuse. On March 8, 2024, Resident 1 was documented pushing Resident 6 against a soda machine and attempting to hit them. This incident was not reported by the shift supervisor or investigated by the Administrator, Director of Nursing, or Risk Manager until March 19, 2024. On March 14, 2024, Resident 1 was involved in another incident where he pushed Resident 2, causing them to fall to the ground after a verbal altercation. This incident was also not reported to the State Licensing Agency. The facility's policy on abuse prevention and reporting was not followed, as confirmed by the Administrator and Director of Nursing during an interview on March 19, 2024. The facility's failure to report and investigate these incidents in a timely manner constitutes a deficiency in ensuring resident safety and compliance with state regulations.
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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