Valley View Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Montoursville, Pennsylvania.
- Location
- 2140 Warrensville Road, Montoursville, Pennsylvania 17754
- CMS Provider Number
- 395895
- Inspections on file
- 26
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Valley View Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident on anticoagulant therapy for atrial fibrillation sustained a head injury and skin tear while being assisted from a wheelchair to the toilet, resulting in a forehead hematoma and initiation of neuro checks. Hours later, a provider evaluated the resident for altered mental status and the head injury, noted the resident was on Eliquis, and ordered transfer to the ER. The resident’s representative was not notified at the time of the incident and was only contacted when the resident was being sent to the hospital, leading to the representative expressing upset about not being informed immediately after the injury.
Three residents did not receive care in accordance with physician orders, care protocols, or integrated care planning. One resident with skin tears received a dressing not specified in the wound care protocol without prior physician contact. Another resident with a cardiac pacemaker lacked a care plan specifying monitoring equipment, and the device was not present until after surveyor inquiry. A third resident on hospice had a care plan that did not document hospice provider details or services.
The facility did not assess the risk of bed rail entrapment in all required zones for several residents using enabler or assist bars, as staff only evaluated zones 1-4 and omitted zone 6, despite residents having beds with headboards and footboards and active orders for these devices. Facility leadership confirmed the omission, and documentation consistently lacked evidence of zone 6 assessment.
Two residents were prescribed Ativan on an as-needed basis for anxiety and agitation without a required 14-day stop date or documented physician rationale for continued use beyond 14 days, as confirmed by the DON.
A resident with bladder cancer and urinary retention had a new order for a Foley catheter, but the care plan was not updated to include this intervention. The omission was identified during a review of clinical records and confirmed in an interview with the DON.
A nurse documented new wound care orders for a resident's skin tears without evidence of contacting the physician or obtaining a proper physician order, as required by facility policy. The LPN involved had not received updated competency training on verbal or telephone physician orders, and the physician later indicated that the correct on-call process was not followed.
Two residents with dementia did not have individualized, person-centered interventions included in their care plans. Despite documented diagnoses and assessments indicating cognitive loss, the care plans developed were generic and did not address the specific needs of each resident.
A resident with natural teeth and documented dental issues did not receive routine dental services as required by facility policy, and there was no evidence that dental care was offered after the resident became Medicaid-eligible, despite multiple care conferences and documented dental concerns.
A resident with a confirmed VRE infection did not have contact precautions implemented promptly after the infection was identified. Although the physician ordered contact precautions, there was a delay over the weekend due to the nurse supervisor not initiating the required measures, as confirmed by the infection preventionist and reviewed with the DON.
The facility failed to store food according to professional standards in the main kitchen and three nursing units. Observations revealed issues such as spills, dust, and debris in the kitchen, and undated food packets in nourishment areas. These deficiencies were discussed with the Nursing Home Administrator.
A facility reported a medication error rate of 17.95%, exceeding the acceptable threshold. An LPN was observed crushing medications that should not be crushed and improperly administering inhaled medications without following the required procedures. These actions were confirmed by the DON.
The facility failed to have a policy and procedure for facility closure or termination of its Medicare/Medicaid Provider Agreement. During an entrance conference, the Nursing Home Administrator and DON could not provide a closure plan. The DON admitted the absence of such a plan, which was previously identified in a past survey. A follow-up interview confirmed the lack of a closure policy.
The facility failed to administer COVID-19 immunization boosters to four residents despite having permission from their responsible parties. The residents, who had previous vaccination histories, did not receive boosters, and subsequently tested positive for COVID-19. The facility did not follow up adequately in one case where permission was not initially received.
A resident was injured during a mechanical lift transfer when a nurse aide operated the lift without a second person, contrary to the care plan. The resident fell and sustained head injuries after the sling attachment came loose. The lift and sling were found to have no defects, and the incident was attributed to neglect.
A resident who required two staff members for bed mobility fell from the bed while being assisted by only one staff member, resulting in injuries. The facility failed to identify the potential for neglect, did not report the incident to appropriate agencies, and did not thoroughly investigate the incident. Staff continued to provide inadequate assistance for bed mobility in subsequent shifts.
The facility failed to implement comprehensive care plans for three residents, omitting critical care needs such as a pessary for a resident with a prolapsed vaginal vault and contact precautions for two residents with infections (ESBL and VRE). These omissions were confirmed during a survey, highlighting deficiencies in maintaining the highest practicable care.
The facility did not identify or assess a decline in ADL for two residents, specifically in bed mobility. One resident's need for assistance increased from supervision to extensive assistance, while another went from independent to requiring limited assistance. There was no documentation of these declines being assessed, as confirmed by the RN assessment coordinator.
The facility failed to follow physician orders for daily weights and notify the physician of significant weight changes for a resident with CHF. Additionally, recommendations from a swallowing study for another resident with mild dysphagia were not implemented, increasing the risk of choking. The DON acknowledged these deficiencies during interviews.
A resident's medication regimen was not free from adverse reactions due to a failure to address a drug-drug interaction between Omeprazole and Clopidogrel. Despite a pharmacy note suggesting a switch to Pantoprazole, the new order was discontinued without explanation, and Omeprazole was reordered. There was no evidence of further action by the physician or pharmacist to address the interaction.
A facility failed to ensure a resident's medication regimen was free from potentially unnecessary medications. A review showed that a gradual dose reduction was due for anxiety and depression medications. The physician noted benefits without adverse effects but did not specify the benefits versus risks. No medication changes were made, and the facility lacked documentation of previous dose reduction attempts or justification for continued use, as confirmed by the DON.
An LPN failed to follow infection control procedures during the administration of Systane eye drops to a resident. The LPN did not wear gloves and used the same tissue for both eyes, contrary to facility policy. The Director of Nursing confirmed the breach in protocol.
The facility failed to investigate and report potential misappropriation of Morphine for two residents. Discrepancies in medication counts and discoloration of Morphine were noted, but no thorough investigation or notification to authorities was conducted. The DON confirmed the lack of investigation into these discrepancies.
Failure to Immediately Notify Resident Representative After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative of a significant change in condition following an accident that resulted in injury. The resident had atrial fibrillation and was receiving Apixaban (Eliquis) 5 mg orally every 12 hours as an anticoagulant, with this therapy reflected in both physician orders and the care plan. In the early morning, nursing documentation recorded that while staff were assisting the resident from a wheelchair to the toilet, the resident bent forward, hit her head on the wall, and sustained a 3 cm by 3 cm hematoma on the forehead and a skin tear to the right upper shin. Neuro checks were initiated, but the resident was uncooperative with certain components of the assessment, including pupil checks and hand grasps. Later that morning, a medical provider documented that the resident had fallen, hit her head, was on Eliquis, and had a hematoma to the right upper forehead, and recommended transfer to the ER for further evaluation and treatment. Nursing documentation shortly thereafter noted the hematoma, the resident’s use of Eliquis, receipt of an order to send the resident to the ER, and that staff spoke with the resident’s family, who agreed to the transfer. Subsequent documentation indicated that the resident’s representative was upset because they were not called when the resident initially hit her head and believed the resident should have been sent to the hospital as soon as possible. There was no evidence that the responsible party was notified of the incident and resulting injury at the time it occurred, and notification did not occur until approximately seven hours later when the resident was being transferred to the hospital, constituting a failure to immediately notify the resident’s representative of an accident involving injury that had the potential to require physician intervention.
Failure to Ensure Physician Orders, Care Planning, and Hospice Coordination
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with two skin tears on the left leg, staff applied a Tegaderm dressing instead of the Aquacel foam dressing specified in the facility's wound care protocol. Documentation did not show that a physician was contacted prior to implementing this treatment, and the physician later clarified that proper procedures for obtaining orders were not followed, as there was an on-call provider available and no direct communication occurred before the treatment was initiated. Another resident, admitted with a cardiac pacemaker, had a baseline care plan that included instructions for pacemaker checks but did not specify the method or equipment to be used. The resident reported having a home monitoring machine prior to admission but did not have it in the facility until after the surveyor's inquiry. There was no evidence that the need for a pacemaker monitoring device was identified or addressed in the care plan upon admission, and the device was only brought to the facility after staff were prompted by the surveyor. A third resident, admitted with hospice services for terminal dementia, had a care plan that did not integrate hospice services or specify the hospice provider, disciplines involved, or frequency of services. The care plan lacked documentation of the full range of hospice services to be provided for the management of the resident's terminal illness, and there was no evidence of coordination between the facility and the hospice provider.
Failure to Assess Bed Rail Entrapment Risk in All Required Zones
Penalty
Summary
The facility failed to properly assess the risk of bed rail entrapment for six out of seven residents reviewed for accident hazards. Facility policy required maintenance staff to conduct bed inspections for entrapment points using a measurement device, following the manufacturer's test methods, but the policy did not specify all entrapment zones. Specifically, staff consistently assessed only zones 1-4 and omitted assessment of zone 6, which is the space between the end of the rail and the side edge of the headboard or footboard, as outlined in FDA guidance. This omission was confirmed through staff interviews and review of facility documentation. Multiple residents were observed with enabler or assist bars attached to their beds, and clinical records showed active physician orders for these devices. For each resident reviewed, documentation indicated that only zones 1-4 were assessed for entrapment risk, with no evidence that zone 6 was evaluated. Residents reported using the bars to assist with mobility and transfers, and their beds were equipped with headboards and footboards, making the unassessed zone 6 relevant for potential entrapment risk. The lack of assessment for this zone was consistent across all reviewed cases. During interviews, facility leadership and maintenance staff acknowledged that zone 6 was not included in their standard assessment process. Additionally, the facility was unable to provide the manufacturer's identification information for the beds and assist bars when requested by surveyors. The deficiency was cited under 28 Pa. Code 211.12 (d)(5) for nursing services.
Failure to Ensure Timely Review and Justification for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents' medication regimens were free from potentially unnecessary psychotropic medications. For one resident, a consultant pharmacist recommended the use of Ativan as needed for anxiety, with a re-evaluation after 30 days. However, the physician's order for Ativan did not include a 14-day stop date, nor was there a physician's progress note providing a rationale for continuing the medication beyond 14 days. This omission was confirmed by the Director of Nursing. Similarly, another resident had a physician's order for Ativan as needed for anxiety and agitation, but the order also lacked a 14-day stop date and did not have a physician's progress note justifying the ongoing use of the medication past 14 days. The Director of Nursing confirmed these findings as well. These actions did not comply with regulatory requirements for the use of psychotropic medications and pharmacy services.
Failure to Update Care Plan for Indwelling Foley Catheter
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident following the initiation of a new physician's order for a Foley catheter due to urinary retention related to bladder cancer. Observation revealed the resident had a urinary collection bag in use, and clinical records confirmed an active order for the indwelling catheter. However, review of the resident's care plans showed that the intervention of an indwelling Foley catheter was not included, despite existing care plans addressing urinary retention, incontinence, chronic kidney disease, and urinary tract infection. This omission was confirmed during an interview with the Director of Nursing.
Failure to Ensure Nursing Staff Competency in Obtaining and Documenting Physician Orders
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LPN, possessed and demonstrated the necessary competencies related to obtaining and documenting verbal or telephone physician orders. Review of facility policies, staff competency records, and clinical documentation revealed that a nurse documented new treatment orders for a resident's skin tears without evidence of contacting the resident's physician or obtaining a proper physician order. The nurse's documentation implied that a physician had provided the order, but there was no supporting evidence that such communication occurred. Additionally, the physician later noted that messages were left on an incorrect phone line and that an on-call provider was available, but not contacted. Further review showed that the LPN in question had not received updated education or competency evaluation on obtaining and documenting verbal or telephone physician orders since 2018, despite the facility's assessment identifying this as a necessary competency for staff. The facility's own policy required that verbal or telephone orders be given to and recorded by a licensed nurse, but there was no documentation to confirm that this process was followed in the case of the resident's wound care.
Failure to Develop Individualized Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents diagnosed with dementia. For one resident admitted with a diagnosis of vascular dementia, the clinical record and MDS assessment confirmed the presence of cognitive loss, and the facility determined that a care plan addressing dementia would be developed. However, the care plan initiated did not include individualized interventions tailored to the resident's specific needs related to dementia and cognitive impairment. Similarly, another resident admitted with a diagnosis of dementia, as documented in the clinical record and MDS assessment, had a care plan that also lacked individualized, person-centered interventions to address their cognitive loss. Both care plans were generic and did not specify strategies or supports based on the unique presentation and needs of each resident. These findings were confirmed through clinical record review and staff interviews, and were discussed with facility leadership.
Failure to Obtain Routine Dental Services for Resident with Dental Concerns
Penalty
Summary
The facility failed to obtain routine dental services for a resident with natural teeth who was identified as having obvious or likely cavities or broken teeth on two consecutive annual MDS assessments. Although the facility's policy required at least an annual oral examination and the offering of dental services every six months, the resident's daughter initially declined dental care upon admission when the resident was not yet Medicaid-eligible. However, after the resident's payment source changed to Medicaid, the facility did not provide evidence that the daughter was offered dental services under the Medicaid benefit during the following year. Clinical records showed no care plan was developed to address the resident's dental issues, despite documentation of dental concerns in the MDS and care area assessment. Multiple care conferences occurred with the resident's daughter present or updated, but there was no documentation that dental services were discussed or offered after the resident became Medicaid-eligible. The deficiency was identified through review of facility policies, clinical records, and interviews with the resident's family and staff.
Delay in Implementing Contact Precautions for VRE Infection
Penalty
Summary
The facility failed to ensure timely implementation of transmission-based precautions for a resident with a confirmed infection. A review of the facility's policies indicated that standard and transmission-based precautions, including contact precautions for infections such as Vancomycin Resistant Enterococcus (VRE), are to be implemented as soon as a resident is known or suspected to be infected. Resident 83 was admitted on February 21, 2025, and a urine culture collected on April 23, 2025, showed the presence of enterococcus faecium VRE. The physician documented the positive result and initiated antibiotic treatment, with an order for contact precautions placed on April 27, 2025. Despite the order, there was a delay in starting the required contact precautions for the resident. The infection preventionist confirmed during an interview that the nurse supervisor did not implement the transmission-based precautions over the weekend, resulting in a lapse in infection control practices. This delay was identified during a review of the resident's clinical record and staff interviews, and the issue was discussed with the Director of Nursing.
Failure to Maintain Food Storage Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety and sanitation in its main kitchen and three nursing units. Observations in the main kitchen revealed several issues, including dried brown liquid spills, dust, and debris on the coffee beverage station's lower shelf, and a stained white blanket. The tubing on juice dispensers was sticky and dusty, and the flooring under various kitchen equipment contained dried food and debris. Additionally, the wall area beside the plate warmers was covered in dried food splatter, and the lower shelves of production tables and dry storage had a buildup of dust. In the nourishment areas of the 100, 300, and 800 halls, storage cabinets contained various food packets and condiments without any identification of when they were placed there or their expiration dates. Items such as hot chocolate packets, peanut butter packs, jelly packs, and more were found in these areas, with no dates indicating their placement or expiration. These findings were reviewed with the Nursing Home Administrator, highlighting the facility's failure to adhere to food storage standards.
Medication Administration Errors and Policy Violations
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 17.95 percent based on 37 medication opportunities and 7 errors. During a medication administration pass, an LPN was observed crushing medications that were on the facility's 'Do Not Crush or Chew' list, including Metoprolol Tartrate, Potassium Chloride ER, and Paroxetine, and attempting to administer them to a resident who refused. On another occasion, the same LPN crushed and administered these medications in pudding to another resident. Additionally, the LPN did not follow proper procedures for administering inhaled medications. She administered two puffs of Albuterol Sulfate Inhaler without waiting the required 1-2 minutes between puffs and immediately followed with a different inhaler, Fluticasone-Salmeterol, without waiting. Furthermore, the LPN failed to instruct the resident to rinse and spit after using the steroid inhaler, as per facility policy. These observations were confirmed by the Director of Nursing, who acknowledged the errors in medication administration.
Lack of Facility Closure Plan
Penalty
Summary
The facility was found to be deficient in having a policy and procedure in place for facility closure or termination of its Medicare and/or Medicaid Provider Agreement. During the entrance conference, the Nursing Home Administrator and the Director of Nursing were unable to provide a closure plan when requested. The Director of Nursing admitted that the facility lacked such a plan and acknowledged that this issue had been identified during the previous full health survey. A follow-up interview with the Nursing Home Administrator confirmed the absence of a policy or procedure addressing facility closure.
Failure to Administer COVID-19 Boosters
Penalty
Summary
The facility failed to ensure the administration of COVID-19 immunization boosters for four residents, despite having received permission from their responsible parties. Resident 119, admitted in July 2023, had a history of receiving COVID-19 vaccinations in 2021 but did not receive a booster after permission was granted in December 2023. Similarly, Resident 11, admitted in 2017, had received vaccinations up to March 2023, but there was no record of a booster being administered after permission was given in December 2023. Both residents later tested positive for COVID-19 in February 2024. Resident 109, admitted in April 2023, had received vaccinations in March 2023 but did not receive a booster after permission was granted in May 2023. Resident 118, admitted in July 2023, had a history of vaccinations in 2021, and although the facility sought permission for a booster in December 2023, they did not follow up after receiving no response. Both residents also tested positive for COVID-19 in February 2024. These findings were confirmed by the infection preventionist during an interview in June 2024.
Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in injury. A clinical record review revealed that a resident was being transferred using a mechanical lift when the top of the sling came loose, causing the resident to fall to the floor and sustain head injuries. The injuries included a 2.5 cm x 0.3 cm laceration to the mid back of the head and a smaller laceration measuring 0.5 cm x 0.5 cm. The facility's investigation included statements from staff members, which indicated that the lift slipped, and the resident slipped out of the sling. A nurse checked the mechanical lift sling after the fall and found no defects, and maintenance confirmed no concerns with the lift. The investigation further revealed that the nurse aide responsible for the transfer was operating the mechanical lift without a second person present, contrary to the resident's care plan, which required the assistance of two staff members. The nurse aide admitted to possibly bumping the sling attachment while moving the lift, which had sticking wheels, leading to the sling coming loose. This action was identified as neglect, as the resident's care plan was not followed, resulting in the fall and subsequent injuries.
Failure to Implement Abuse Prohibition Policy and Investigate Potential Neglect
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy to ensure a complete and thorough investigation of an incident involving potential neglect for a resident. The facility's policy, last reviewed without changes, mandates that all allegations of mistreatment, neglect, or abuse, as well as injuries of unknown source, are reported timely. However, the facility did not adhere to this policy when a resident, who required two staff members for bed mobility, fell from the bed while being assisted by only one staff member. The incident resulted in the resident sustaining a skin tear, an abrasion, and redness on their body. The incident report confirmed the nursing documentation but failed to identify the resident's need for two staff members during bed mobility or the potential for neglect due to the absence of a second staff member. The facility's intervention was limited to a physical therapy screen, and there was no second staff statement provided. Furthermore, documentation showed that staff continued to provide only one staff assistance for bed mobility for numerous shifts following the incident. The facility did not report the fall to the appropriate agencies, did not thoroughly investigate the incident for neglect, and failed to complete an abuse report or re-educate staff on the correct number of staff required for bed mobility.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in maintaining the highest practicable care. Resident 116 was admitted with a diagnosis of a prolapsed vaginal vault and required a pessary, but her care plan did not initially include this critical aspect of her care. It was only after the surveyor's intervention that the facility updated her care plan to reflect the use of the pessary. Additionally, the facility did not address the need for contact precautions in the care plans of two other residents. Resident 11 had a positive urine culture for ESBL, and Resident 119 had VRE in their urine, both requiring contact precautions. However, their care plans lacked any mention of these conditions or the necessary precautions, as confirmed by the infection preventionist during the survey.
Failure to Assess Decline in ADL for Residents
Penalty
Summary
The facility failed to identify and assess a decline in the activities of daily living (ADL) for two residents, specifically in their ability to perform bed mobility. Resident 10 was initially assessed as requiring supervision for bed mobility, but later assessments indicated a need for extensive assistance. However, there was no documented evidence that the facility identified or assessed this decline. Similarly, Resident 118 was initially assessed as independent with bed mobility, but later required limited assistance. Again, there was no documentation indicating that the facility identified or assessed this decline. These findings were confirmed during an interview with the registered nurse assessment coordinator, who was unable to provide further documentation regarding the assessment of these declines.
Failure to Implement Physician Orders and Swallowing Study Recommendations
Penalty
Summary
The facility failed to provide the highest practicable care for two residents by not adhering to physician orders and recommendations. For one resident with Congestive Heart Failure, the facility did not document daily weights as ordered and failed to notify the physician of significant weight changes on specified dates. This oversight occurred despite clear physician orders to monitor weight changes closely and report any significant increases, which are critical for managing the resident's condition. Another resident, who had a swallowing function study indicating mild dysphagia and a mildly unsafe swallow, did not have the recommended interventions implemented. The study recommended that the resident sit fully upright during and after meals to reduce choking risks. However, these recommendations were not followed, as the Director of Nursing indicated that the resident remained on speech therapy services, and staff were feeding her meals without implementing the necessary precautions.
Failure to Address Drug-Drug Interaction in Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from adverse medication reactions. A clinical record review for a resident revealed a pharmacy note to the physician indicating a potential drug-drug interaction (DDI) between Omeprazole, a proton-pump inhibitor, and Clopidogrel, a platelet inhibitor. The pharmacist suggested switching from Omeprazole to Pantoprazole to avoid reducing the efficacy of Clopidogrel. The physician agreed to the change, but the new medication order for Pantoprazole was discontinued the next day without documentation explaining the reason, and Omeprazole was reordered. The facility's pharmacy communication indicated that the Pantoprazole order was flagged for a DDI, but the pharmacy approved it, and the facility subsequently canceled it. There was no evidence that the physician addressed the DDI between Omeprazole and Clopidogrel after the medication was reordered, nor was there documentation of the pharmacist addressing the DDI in subsequent reviews. The deficiency was discussed with the Director of Nursing, highlighting a failure to manage the resident's medication regimen appropriately.
Failure to Ensure Medication Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. A clinical record review for Resident 89 revealed that a gradual dose reduction review was due for Buspirone and Citalopram, medications used to treat anxiety and depression, respectively. The attending physician indicated that the resident was benefiting from the therapy without adverse effects and that the benefits outweighed the risks, but did not specify what benefits outweighed what risks. There were no changes made to the medications, and the facility could not provide documentation of a previous dose reduction attempt or justification for the continued use of the medications. An interview with the Director of Nursing confirmed the lack of documentation.
Infection Control Breach During Eye Drop Administration
Penalty
Summary
The facility failed to prevent the potential spread of infection during medication administration on one of its nursing units. Specifically, during a medication pass observation, an LPN administered Systane eye drops to a resident without wearing gloves and used the same tissue to wipe both eyes. This action was contrary to the facility's policy, which requires gloves to be worn and a separate tissue to be used for each eye. The incident was confirmed by the Director of Nursing, who acknowledged that the proper procedures were not followed.
Failure to Investigate Medication Discrepancies
Penalty
Summary
The facility failed to thoroughly investigate and notify the appropriate agencies regarding potential misappropriation of medication for two residents. Discrepancies were identified in the controlled substance counts for liquid Morphine Sulfate for two residents. The medication for one resident was noted to have changed color, indicating possible contamination or diversion, yet no comprehensive investigation was conducted to address these issues. For Resident 5, a discrepancy was noted when the liquid Morphine appeared a different color than usual, and the controlled substance count did not match the documented administration records. The medication administration records showed the last dose was given in April, but the controlled medication log indicated a discrepancy in the remaining amount. Similarly, for Resident 4, the controlled medication record showed a discrepancy in the Morphine count, with no doses documented as administered between the last known dose and the identified discrepancy. Despite these discrepancies, the facility did not conduct a thorough investigation or report the potential misappropriation to the Department of Health. The Director of Nursing confirmed that no additional staff interviews or investigation documentation was available to justify the discrepancies or rule out misappropriation or diversion. The facility also failed to follow the pharmacist's recommendations for investigating the discoloration of the medication.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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