Wesley Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittston, Pennsylvania.
- Location
- 209 Roberts Road, Pittston, Pennsylvania 18640
- CMS Provider Number
- 395602
- Inspections on file
- 35
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Wesley Village during CMS and state inspections, most recent first.
The facility failed to administer medications on time for a resident with Parkinson's disease and did not develop or document appropriate procedures for palliative care for two residents with dementia, including missing care plans, consents, and interdisciplinary documentation.
A resident with severe cognitive impairment was started on an antipsychotic medication without documented notification or informed consent from their designated representative. The facility's records did not show that the representative was informed of the medication, its risks, benefits, or alternative options, despite the resident's inability to provide informed consent.
A resident with a signed DNR preference had a conflicting physician order in the electronic medical record indicating CPR should be performed, despite no documentation of a change in the resident's wishes. The inconsistency was only corrected after surveyor inquiry, and the NHA confirmed that physician orders should have matched the resident's documented code status.
A resident with chronic respiratory failure and a physician's order for oxygen at 2.0 LPM via nasal cannula was found with the oxygen concentrator set at 0.0 LPM. The resident reported no airflow, and an LPN confirmed the oxygen should have been administered as ordered. The facility's policy requiring licensed nurses to follow physician's orders for oxygen therapy was not followed in this case.
A resident with dementia and pulmonary hypertension did not receive a comprehensive pain reassessment after the onset of pain, as required by facility policy. Staff administered PRN narcotic pain medication outside of prescribed parameters, including for lower pain levels and without evidence of shortness of breath, and continued to do so after the physician changed the order. There was no documentation of evaluation or modification of the pain management plan to address the resident's symptoms.
A resident with Alzheimer's disease and dysphagia did not receive lemon ice with meals as ordered by the physician to facilitate swallowing. Observations and staff interviews confirmed that the lemon ice was omitted from the resident's meal trays and was not included on the tray ticket, despite being part of the current physician orders.
The facility did not provide required written notices of facility-initiated hospital transfers to the State Long-Term Care Ombudsman representative for five residents. Although notices were given to residents and their representatives, there was no documentation that the Ombudsman was notified, and this lapse was confirmed by the administrator as an ongoing issue over several months.
The facility did not ensure that its arbitration agreement provided for a mutually convenient venue for both the resident and the facility. The admission agreement only allowed for arbitration at the facility or within a reasonable distance, without guaranteeing convenience for both parties, as confirmed by the NHA.
A facility failed to prevent elopement for two residents, including one with severe cognitive impairment, due to inadequate supervision and reliance on a faulty alarm system. The facility lacked consistent checks on wander alert devices and did not maintain a clear record of residents at risk for elopement, leading to immediate jeopardy.
A resident with dementia and other health issues eloped from the facility, and although staff intervened and implemented safety checks, they failed to document a thorough assessment of the resident's condition upon return. Interviews revealed inconsistencies in staff recollection and issues with alarm audibility, contributing to the deficiency.
A resident with dementia and other health issues managed to exit the facility despite wearing a wander-guard anklet, revealing failures in the facility's monitoring and security systems. The wander-guard system was not functioning effectively, and staff were unaware of which residents were at risk of elopement. Additionally, there was no consistent practice to ensure the functionality of wander-guard devices, leading to a deficiency in resident safety.
A resident received multiple doses of opioid pain medications without attempts at non-pharmacological interventions first. The facility's records showed that staff administered Hydrocodone-Acetaminophen and Oxycodone without trying alternative pain relief methods, as confirmed by the Nursing Home Administrator and Assistant Director of Nursing.
The facility failed to attempt a gradual dose reduction (GDR) for a resident's psychoactive medications and did not justify an increase in another resident's medication. One resident's records lacked evidence of GDR attempts or recent psychiatric evaluations, while another resident's medication was increased without documented clinical necessity, despite no adverse effects from a prior reduction. These deficiencies were confirmed by facility staff during a survey.
The facility failed to maintain proper food storage and sanitation practices, increasing the risk of food-borne illness. Observations included spilled milk in the walk-in refrigerator, pooling water and a splattered ceiling in the dish room, and unlabeled Mighty Shakes in the tray line refrigerator. Additionally, a Speech Pathologist entered the kitchen without a hairnet, and dirty linen cans were coated with substances. The facility's policy required proper labeling of thawed shakes, which was not followed.
A resident with heart failure and a cardiac pacemaker experienced a significant weight gain over two days, totaling 14 pounds. Despite a physician's order to notify them of such changes, the facility failed to inform the physician of the resident's weight gain, as confirmed by the Nursing Home Administrator.
A facility failed to maintain a clean and sanitary environment for a resident with chronic pressure ulcers and dysphagia, requiring a feeding tube. Observations revealed a pungent odor, debris, and dried tube feeding formula splattered on the feeding pole and sticky carpeting. The Nursing Home Administrator confirmed the unsanitary conditions.
A resident with an implantable loop recorder, used to monitor heartbeats, was not included in their care plan. Despite the device being placed, the care plan did not address its presence or care, as confirmed by the DON.
A resident with anxiety exhibited increased behaviors such as constant yelling and arguing with a roommate, which were not addressed in their care plan. Despite a psychiatric consult, no new interventions were developed to manage these behaviors, and facility staff could not provide evidence of meeting the resident's behavioral health needs.
A facility failed to accurately account for controlled medications for a resident. Nursing staff signed out doses of Hydrocodone-Acetaminophen and Oxycodone, but the administration was not recorded on the MAR. This discrepancy was confirmed by the Nursing Home Administrator, indicating a deficiency in the facility's pharmaceutical services and record-keeping.
A resident with a nephrostomy tube was unnecessarily administered Cefdinir after reporting mild urinary symptoms, despite no further UTI symptoms. The antibiotic was discontinued after four doses when it was found to be ineffective against the colonized bacteria. The Infection Preventionist confirmed the administration was unjustified.
A facility failed to provide a resident and their representative with written notice of a facility-initiated transfer to the hospital. The absence of documentation for the transfer notice was confirmed by the Nursing Home Administrator and Assistant Director of Nursing.
A facility failed to follow the prescribed bowel protocol for a resident with a history of severe constipation, leading to a severe fecal impaction and hospital transfer. The facility did not administer the ordered bisacodyl suppository and skipped steps in the protocol without justification. Additionally, there was no documented pain or abdominal assessment prior to the resident's transfer.
Failure to Administer Medications Timely and Lack of Palliative Care Procedures
Penalty
Summary
The facility failed to provide quality care by not administering medication according to physician orders and not developing appropriate procedures for palliative care. For one resident with Parkinson's disease, there were multiple documented instances where Carbidopa-Levodopa was administered significantly later than the prescribed times, ranging from over one hour to more than three hours late, despite facility policy requiring administration within one hour of the scheduled time. The Nursing Home Administrator confirmed that medications should be administered timely in accordance with physician orders and professional standards of practice. Additionally, the facility did not establish or follow proper procedures for implementing palliative care for two residents with dementia. In one case, after a resident's representative requested a transition to palliative care, there was no documented palliative care plan, no signed consent, and no supporting notes from a physician or social worker. In another case, a resident's representative requested palliative care with specific directives, but the clinical record lacked documentation of a clinical diagnosis or rationale for palliative care, as well as a comprehensive care plan, signed consent, and interdisciplinary progress notes. Interviews with facility leadership confirmed the absence of documentation outlining the clinical rationale or medical necessity for palliative care orders and the lack of a facility policy or established criteria for determining eligibility for palliative care services. These deficiencies were cited under relevant state codes for resident care policies and nursing services.
Failure to Inform Resident Representative of Psychotropic Medication Initiation
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of the initiation of a psychotropic medication, including the associated risks, benefits, and alternative treatment options. The resident in question was admitted with diagnoses of dementia and encephalopathy and was assessed as being severely cognitively impaired, with a BIMS score of 05. Despite having a designated power of attorney as a resident representative, the clinical record showed that consent for the antipsychotic medication Seroquel was documented as verbal consent from the resident, with no evidence that the representative was informed or involved in the decision-making process. Further review of the resident's records revealed no documentation that the responsible party was notified about the new medication, nor that the risks, benefits, or alternative treatments were discussed. The resident received Seroquel for an extended period before the representative inquired about the medication and expressed opposition to its use. The facility was unable to provide documentation of the pre-hospital medication list supplied by the representative, and the Nursing Home Administrator confirmed the absence of documentation regarding notification or informed consent from the resident's representative.
Failure to Align Physician Orders with Resident's Documented Code Status
Penalty
Summary
The facility failed to ensure that physician orders were consistent with a resident's documented code status preference. A review of the clinical record for a resident with diagnoses including hypertension and epilepsy showed that the resident had completed and signed a CPR Status form indicating a preference not to receive cardiopulmonary resuscitation (CPR) if their heart or breathing stopped. Despite this, the electronic medical record contained a physician order listing the resident's code status as CPR, which was not in accordance with the resident's documented wishes. There was no evidence in the record that the resident had changed their decision or participated in any discussion to update their previously signed CPR Status form. The inconsistency between the physician order and the resident's expressed wishes was only corrected after it was identified by surveyors. The Nursing Home Administrator confirmed that physician orders are expected to match the resident's signed CPR Status form and acknowledged that the discrepancy should have been addressed prior to surveyor identification.
Failure to Administer Oxygen Therapy per Physician's Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician's orders for one resident. The resident, who had a diagnosis of chronic respiratory failure with hypoxia, had a physician's order for oxygen to be delivered via nasal cannula at 2.0 liters per minute. However, during an observation, the oxygen concentrator was found set at 0.0 liters per minute, and the resident reported not feeling any airflow from the nasal cannula. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician's orders, but this was not followed in this instance. A review of the clinical record and interviews confirmed that the resident should have been receiving continuous oxygen at the prescribed rate. The discrepancy was identified during a staff interview, and it was acknowledged that the oxygen was not being administered as ordered. The resident's blood-oxygen saturation was measured at 93% at the time of the incident, and the resident denied experiencing shortness of breath or distress. The Nursing Home Administrator confirmed the facility's responsibility to ensure that care is provided in accordance with physician's orders and the resident's plan of care.
Failure to Reassess and Appropriately Manage Resident Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not conducting a comprehensive reassessment of the resident's pain status and prescribed PRN medications, as required by facility policy. The resident, who had diagnoses including dementia and pulmonary hypertension, was admitted with no reported pain and was not on scheduled pain medication. However, after the onset of pain, there was no documented evidence that a comprehensive pain assessment was completed to identify the cause of pain or to develop an individualized pain management plan. Despite having a care plan that included monitoring and evaluating pain interventions, staff administered narcotic pain medication outside of the prescribed parameters. Specifically, Morphine Sulfate, which was ordered for pain levels 6-10 or for shortness of breath, was given multiple times for pain levels of 4-5 and without evidence of shortness of breath. Additionally, after the physician changed the order to indicate use only for shortness of breath, staff continued to administer the medication without documentation of this symptom. There was no evidence in the clinical record that the facility evaluated the cause of the resident's pain, reassessed the appropriateness of PRN medications, or modified the care plan in response to the resident's emerging symptoms. The Director of Nursing confirmed that a comprehensive pain assessment was not completed as per policy, and that narcotic medication was administered without proper indication or reassessment. This resulted in a failure to ensure that pain management was based on comprehensive reassessment and the individual needs of the resident.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A resident with diagnoses including Alzheimer's disease and oral phase dysphagia had a physician order for a pureed no added salt (NAS) diet with lemon ice at meals, following a speech therapy recommendation to use lemon ice to facilitate oral movement and swallowing. Despite this order, observations during two separate lunch meals revealed that the resident did not receive lemon ice on her meal tray, and the meal tray ticket did not include the lemon ice order. Interviews with facility staff, including an LPN and the Certified Dietary Manager (CDM), confirmed that the lemon ice was not provided as ordered and was not listed on the tray ticket, despite being part of the current physician orders. This failure resulted in the resident not receiving the prescribed therapeutic diet as required by the physician's order.
Failure to Notify Ombudsman of Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide copies of written notices regarding facility-initiated hospital transfers to the representative of the Office of the State Long-Term Care Ombudsman for five residents. Clinical record reviews showed that these residents were transferred to the hospital on various dates and subsequently readmitted to the facility. While written notices of the transfers were given to the residents and their representatives, there was no documented evidence that the required notifications were sent to the Ombudsman representative as mandated. An interview with the nursing home administrator confirmed that there was no documentation showing that copies of the transfer notices were sent to the Ombudsman for the identified residents. Furthermore, the administrator acknowledged that this failure to notify the Ombudsman representative was not limited to these cases but was a consistent issue for resident transfers from July 2024 through May 2025.
Failure to Ensure Fair Arbitration Venue Selection
Penalty
Summary
The facility failed to ensure a neutral and fair arbitration process by not providing clear language in its admission agreement that guarantees both the resident or resident representative and the facility mutually agree on a convenient venue for arbitration. The reviewed admission agreement specified that arbitration would occur either at the facility or at a site within a reasonable distance of the facility, subject to mutual agreement, but did not explicitly state that the location must be convenient for both parties. During an interview, the Nursing Home Administrator confirmed that the agreement only offers these two options and does not address the convenience for both the resident and the facility.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and effective safety measures to prevent elopement for two residents, leading to immediate jeopardy. Resident CR1, who was admitted with diagnoses including dementia and severe cognitive impairment, was identified as an elopement risk. Despite having a wander alert device, the resident was able to exit the facility unsupervised. The facility's reliance on the alarm system was insufficient, as the system failed to prevent the resident from leaving the premises. The incident occurred when a visitor reported seeing the resident outside, prompting staff to intervene and redirect the resident back inside. The facility's policies and procedures for managing elopement risks were inadequate. Staff interviews revealed a lack of consistent checks on the functionality of wander alert devices and insufficient training on identifying and managing elopement risks. The facility did not have a comprehensive system to monitor residents at risk of elopement, and there was no documentation of regular checks on the wander alert devices or the doors' functionality. This oversight contributed to the residents' ability to leave the facility unsupervised. Additionally, the facility's failure to maintain a clear and updated record of residents at risk for elopement further exacerbated the issue. Staff members were unaware of which residents were at risk, and there was no centralized system to communicate this information across different units. The lack of a coordinated approach to monitoring and preventing elopement placed residents in immediate jeopardy, as evidenced by the incidents involving Resident CR1 and another resident with similar risks.
Failure to Document Post-Elopement Assessment
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not thoroughly conducting and documenting a professional nursing assessment of a resident's clinical status following an elopement. The incident involved a resident with dementia, syncope, unsteadiness, weakness, and gait abnormalities, who was admitted to the facility. On the evening of the incident, the resident, identified by a wander-guard anklet, attempted to leave the facility and was found outside by a visitor who notified the staff. The staff, including two registered nurses, responded to the situation. The resident was redirected back to her room, and immediate interventions such as 15-minute safety checks were implemented. However, the facility's documentation did not include a comprehensive assessment of the resident for injury after she was returned to the facility. Interviews with the nursing staff revealed inconsistencies in their recollection of the event, and it was confirmed that the alarms were not audible in certain areas of the facility, which may have contributed to the delay in response. The facility's failure to document a thorough assessment of the resident's condition post-elopement was confirmed by the Assistant Director of Nursing. Despite the implementation of safety checks and communication with the resident's family, the lack of documented evidence of a full assessment highlights a deficiency in the facility's adherence to professional nursing standards and documentation practices.
Failure to Prevent Resident Elopement Due to Inadequate Monitoring
Penalty
Summary
The facility's administration failed to effectively use its resources to ensure resident safety, specifically in monitoring resident whereabouts and preventing elopement. This deficiency was identified through a series of observations, clinical record reviews, and staff interviews. A resident with dementia and other health issues, who was identified as an elopement risk, managed to exit the facility. The resident was found outside the building, having asked a visitor for a ride, which prompted the visitor to notify the facility. Despite having a wander-guard anklet, the resident was able to leave the premises, indicating a failure in the facility's monitoring and security systems. The incident revealed several lapses in the facility's procedures and staff actions. The wander-guard system, which was supposed to prevent such incidents, was not functioning effectively. During a test conducted by the state surveyor, it was found that the facility's doors could be opened with minimal pressure, even when the wander-guard was active. Additionally, there was a lack of clear communication and documentation regarding residents at risk of elopement, as staff members were unaware of which residents were at risk and how to ensure the functionality of the wander-guard system. Interviews with staff members highlighted further issues, such as the absence of a comprehensive system to track and monitor residents at risk of elopement across different units. Staff members were not equipped with tools to check the functionality of wander-guard bracelets, and there was no consistent practice in place to ensure these devices were working. The facility's failure to implement effective safety measures and supervision placed residents at risk, leading to the cited deficiency under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering opioid pain medications. The clinical record review revealed that the resident had physician's orders for Hydrocodone-Acetaminophen and Oxycodone HCL to be given as needed for pain levels 6-10. However, the Medication Administration Records (MAR) for June and July 2024 showed that the staff administered these medications multiple times without attempting non-pharmacological methods to alleviate the resident's pain first. Specifically, in June 2024, the resident received 14 doses of Hydrocodone-Acetaminophen, all without prior non-pharmacological interventions. In July 2024, the resident received 5 doses of Hydrocodone-Acetaminophen and 26 doses of Oxycodone, with only a few instances where non-pharmacological interventions were attempted. An interview with the Nursing Home Administrator and the Assistant Director of Nursing confirmed the lack of consistent attempts to use non-pharmacological methods before administering as-needed pain medications.
Failure to Implement GDR and Justify Medication Increase
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) of psychoactive medications for one resident and failed to clinically justify the increase of psychoactive medication for another resident. Resident 44, who was admitted with schizoaffective disorder and Parkinson's disease, was prescribed Invega Trinza, Sertraline, and Abilify. A pharmacist recommended a GDR for these medications, but the physician deferred to psychiatry without providing a clinical rationale. No evidence of a GDR attempt or recent psychiatric evaluation was found in the resident's records, which was confirmed by the Nursing Home Administrator and Director of Nursing. Resident 69, diagnosed with major depressive disorder, stroke, and aphasia, had their Zyprexa dosage reduced following a pharmacy review. Despite no adverse effects or behavioral changes noted after the reduction, the dosage was increased again without documented clinical justification. The pharmacist requested documentation to support the increase, but none was provided, as confirmed by the Director of Nursing. These deficiencies were identified during a survey, highlighting the facility's failure to adhere to regulatory requirements for psychoactive medication management.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the kitchen, it was observed that there was milk spilled underneath the shelves in the walk-in refrigerator. In the dish room area, a significant amount of water was pooling on the floor, and a ceiling tile was bowed with gaps near the vent, along with a red/brown substance splattered on ceiling tiles above the dish machine. Additionally, during the lunch tray line meal service, a Speech Pathologist entered the kitchen area without wearing a hairnet. Further observations revealed that inside the tray line reach-in refrigerator, a tray of approximately forty 4-ounce cartons of Mighty Shakes was not dated with a thaw date, contrary to the manufacturer's instructions. In the resident's main dining room, two white plastic cans used for dirty linens were coated with splattered substances. In the East Unit Medication Room, several Mighty Shakes and nutritional juice drinks were not labeled or dated. The facility's policy indicated that frozen shakes should be labeled with a use-by date of fourteen days once thawed, and the day of preparation or opening is considered Day 1. The Nursing Home Administrator confirmed that sanitary practices should be maintained to prevent foodborne illness.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to timely consult with the physician regarding a significant weight gain experienced by a resident diagnosed with heart failure and equipped with a cardiac pacemaker. The resident was admitted with a physician's order to monitor daily weight due to heart failure, with instructions to notify the physician if a 3-pound weight gain in 24 hours or a 5-pound weight gain in one week was observed. On June 30, 2024, the resident's weight increased by 9.2 pounds in one day, a 5.08% weight gain, yet there was no documented evidence that the physician was notified of this significant change. The resident's weight continued to increase, reaching 195.2 pounds on July 1, 2024, marking an additional 4.8-pound gain in 24 hours and a total of 14 pounds over 48 hours. Despite this continued weight gain, there was still no documented evidence of timely physician notification. An interview with the Nursing Home Administrator confirmed the facility's failure to notify the physician of the resident's significant weight gain on both June 30 and July 1, 2024.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident, identified as Resident 111, who was admitted with chronic pressure ulcers and dysphagia, requiring a feeding tube for nutrition and hydration. During an observation, a pungent odor was detected in the resident's room. Additionally, a plastic spoon and debris were found underneath the resident's tube feeding pole. Dried tube feeding formula was observed splattered on the tube feeding pole and the carpeting below, which was sticky to walk on. An interview with the Nursing Home Administrator confirmed that the room was not maintained in a clean and sanitary condition.
Failure to Include Cardiac Device in Care Plan
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for a resident with an implantable cardiac recording device. Resident 69, who was admitted with diagnoses of anxiety, seizures, and stroke, had an implantable loop recorder placed on October 1, 2023. This device records the heartbeat continuously and requires a transmitter at the bedside to send information to the healthcare provider. However, a review of the resident's care plan, initially dated the same day as the device placement, revealed that it did not address the presence or care of the implantable loop recorder. The Director of Nursing confirmed during an interview that the device was not included in the resident's care plan.
Failure to Address Resident's Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that a resident received timely and necessary behavioral health care to maintain their highest practicable mental and psychosocial well-being. The resident, who was admitted with a diagnosis of anxiety, exhibited behaviors such as constant yelling for help and arguing with their roommate. These behaviors increased in frequency starting in June 2024, as documented in the resident's progress notes. Despite these documented changes, the resident's most recent psychiatric consult did not address the increased anxiety and behaviors, nor was there any indication that a potential room change was considered to alleviate the resident's discomfort with their roommate's preference for keeping the privacy curtain closed. During the survey ending in July 2024, it was found that no new or revised behavioral interventions were added to the resident's care plan to manage or modify the resident's behaviors. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that they could not provide evidence that the resident's behavioral health needs were met or that services were provided to promote the resident's highest practicable physical, mental, and psychosocial well-being.
Inaccurate Accounting of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications for a resident. The clinical records and controlled drug records review revealed discrepancies in the administration of Hydrocodone-Acetaminophen and Oxycodone for a resident. On multiple occasions, nursing staff signed out doses of these medications, but the administration was not recorded on the resident's Medication Administration Record (MAR). Specifically, doses were signed out on June 28, July 3, July 5, July 6, and July 11, 2024, but were not documented as administered on the MAR. The resident had physician orders for Hydrocodone-Acetaminophen and Oxycodone to be administered as needed for pain levels 6-10. Despite these orders, the lack of documentation on the MAR indicates a failure in the facility's procedures for tracking the administration of controlled substances. The Nursing Home Administrator confirmed these inconsistencies during an interview, highlighting a deficiency in the facility's pharmaceutical services and record-keeping practices.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic drugs. Resident 19, who was admitted with chronic kidney disease, kidney stones, and heart disease, had a nephrostomy tube in place. After an emergency room visit for a dislodged nephrostomy tube, antibiotic therapy was stopped as the resident's urine culture showed colonized bacteria that were not causing harm. Later, the resident reported irritation and slight burning during urination, prompting a physician to order a urinalysis and subsequently prescribe Cefdinir, an antibiotic, without further symptoms of a urinary tract infection being documented. The resident received four doses of Cefdinir before the attending physician discontinued the antibiotic, opting to wait for the final urine culture and sensitivity results. The urine culture later revealed that the organisms were resistant to Cefdinir. An interview with the Infection Preventionist confirmed that the administration of Cefdinir was not clinically justified, indicating a failure in the facility's pharmacy and nursing services to prevent unnecessary drug use.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide written notices of a facility-initiated transfer to a resident and the resident's representative. Specifically, Resident 69 was transferred to the hospital on May 29, 2024, and subsequently readmitted to the facility. However, there was no documented evidence that the resident and the resident's representative received written notice of this transfer. This deficiency was confirmed during an interview with the Nursing Home Administrator and Assistant Director of Nursing on July 18, 2024, who acknowledged the lack of documentation for the transfer notice.
Failure to Follow Bowel Protocol and Conduct Assessments
Penalty
Summary
The facility failed to provide prescribed treatment necessary to manage constipation for a resident with a history of severe constipation and fecal impaction. The resident was admitted with a bowel regimen that included multiple laxatives and a protocol to follow if no bowel movement occurred. Despite this, the resident did not have a bowel movement for several days, and the facility did not follow the prescribed steps in the bowel protocol. Specifically, the resident received Milk of Magnesia (MOM) but did not receive the subsequent bisacodyl suppository as ordered, and an enema was administered without documented justification for skipping the intermediate steps. The resident's daughter reported that her mother was in excruciating pain, prompting a transfer to the hospital. However, there was no documented pain or abdominal assessment in the resident's clinical record prior to the transfer. The hospital confirmed a severe fecal impaction, which was not adequately addressed by the facility's staff. Upon the resident's return to the facility, there was no evidence that the hospital's recommendation for daily MOM was initiated. The Director of Nursing confirmed that the facility failed to administer the physician-ordered bowel protocol and did not conduct thorough assessments of the resident's abdomen and pain. This lack of adherence to the prescribed treatment and failure to document assessments led to the resident experiencing severe constipation and pain, ultimately resulting in a hospital transfer.
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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