Westminster Woods At Huntingdo
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntingdon, Pennsylvania.
- Location
- 360 Westminster Drive, Huntingdon, Pennsylvania 16652
- CMS Provider Number
- 396015
- Inspections on file
- 29
- Latest survey
- April 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westminster Woods At Huntingdo during CMS and state inspections, most recent first.
The facility was found to have multiple deficiencies in food safety and staff hygiene. An opened box of frozen fish fillets was improperly stored, and a deep fryer was not cleaned after use, violating the facility's policies. Additionally, a staff member with a full beard was observed without a beard restraint during food preparation, contrary to the dress code guidelines.
The facility failed to notify a resident's responsible party about a downgrade in diet consistency after a choking incident and did not inform a urologist about UTI symptoms in another resident. Both residents were cognitively intact, and the deficiencies were confirmed by the DON.
A facility failed to develop a care plan for a resident requiring treatment for an infection using a PICC line for IV antibiotics. The resident was admitted for further care of a left heel wound and had orders to receive Ertapenem daily through the PICC line. However, no care plan was documented for the PICC line, infection, or IV antibiotics, as confirmed by the Nursing Home Administrator.
A facility failed to follow physician's orders for a resident with heart failure and high blood pressure. The resident's care plan required specific administration of Carvedilol and Lisinopril based on apical pulse readings. On several occasions, the facility either administered Carvedilol without checking the pulse or withheld Lisinopril against the orders. The DON confirmed these discrepancies.
A facility failed to provide a privacy cover for a resident's indwelling urinary catheter, as required by policy. The resident, who had a neurogenic bladder, was observed with an uncovered catheter collection bag, and the nurse aide confirmed the absence of a privacy bag. The Director of Nursing acknowledged the catheter tubing should not have been in contact with the fall mat.
A resident's medication, specifically 25 mg of Seroquel, was found on the floor in her bathroom, contrary to the facility's policy that medications should be stored in designated areas. The resident, who was cognitively intact and required assistance for daily care needs, was scheduled to receive the medication in the evening. An LPN confirmed the medication should not have been on the floor, and the DON acknowledged the error, indicating a failure in medication storage practices.
The facility failed to ensure that residents were offered and/or received necessary vaccinations. A resident did not receive the pneumococcal vaccine despite consenting, and two residents did not receive the influenza vaccine, with one not being documented as offered the vaccine. These issues were confirmed through staff interviews and record reviews.
A resident with severe cognitive impairment and vascular dementia was subjected to sexual abuse by a maintenance worker, who was observed by two nurse aides straddling, hugging, and rubbing the resident's flank area under her shirt. The incident was documented by staff and confirmed through interviews, indicating a failure to uphold the facility's abuse prevention policy.
A resident with severe cognitive impairment was recorded on a staff member's personal cell phone without consent during an incident where a maintenance worker was observed hugging and touching the resident under her shirt. The recording was made by a nurse aide who witnessed the event and believed it was necessary to document the situation. Facility policy prohibits the use of personal cell phones and requires protection of resident privacy and rights.
A resident with cognitive impairment and a history of stroke experienced a fall and subsequent changes in condition, but the required nursing assessments were not documented in the clinical record. The Director of Nursing confirmed the assessments were completed but not recorded, violating federal and state regulations for maintaining complete and accurate medical records.
A resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Neurological checks were initiated, and the resident was later admitted to the hospital with a stroke diagnosis. The facility failed to notify the Department of Health about this incident until contacted by Adult Protective Services.
A facility failed to create a comprehensive care plan for a resident with frequent UTIs, despite physician's orders for various medications and treatments. The resident's MDS assessment indicated frequent urinary incontinence, but no care plan was documented to address their condition, as confirmed by the DON.
The facility did not complete monthly pharmacy medication reviews for two residents, as required by their policy. The policy requires timely communication of pharmacist recommendations and a response before the next review. For two residents, there was no evidence that the December and January reviews were addressed by the physician. The DON confirmed the lack of documentation during an interview.
A facility failed to protect a resident's health information during medication administration. An LPN left a computer screen displaying a resident's personal health information unsecured and visible in the hallway. Both the LPN and the DON confirmed that the information should have been covered.
A resident with chronic kidney disease and hypertension had an elevated blood pressure reading of 197/86 mm/Hg, which was not reassessed as required by professional standards. Nursing staff confirmed that such a reading should have prompted further evaluation and documentation, but this did not occur.
A resident, who is cognitively impaired and requires moderate assistance, was transported in a wheelchair without leg rests by an RN. The RN acknowledged knowing the requirement to use leg rests, and the DON confirmed that all staff should use them during transport.
A facility failed to document the rationale for the long-term use of Zyprexa for a resident with severe cognitive impairment and diagnoses of depression and dementia. Despite federal regulations requiring as-needed orders for psychotropic drugs to be limited to 14 days, the resident continued to receive Zyprexa without documented justification. The Director of Nursing confirmed the absence of necessary documentation from the attending physician or psychiatric consultant.
The facility failed to secure a medication cart and properly label medications. An LPN left a medication cart unlocked and unattended, and controlled medications were not stored in a permanently-affixed compartment. Additionally, medications like Tubersol and Insulin Lispro were not labeled with the date they were opened, as confirmed by nursing staff.
The facility failed to prevent the elopement of two residents identified as at risk for elopement. One resident exited through the front door due to a receptionist's unawareness, and another resident exited during a fire alarm when door magnets were deactivated. Both residents were found outside and brought back without injuries.
Deficiencies in Food Safety and Staff Hygiene
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and staff hygiene. During an inspection, it was observed that an opened box of frozen fish fillets was left exposed to the air in the kitchen's walk-in freezer, contrary to the facility's policy requiring bulk freezer items to be properly sealed. This was confirmed by the Dietary Director, who acknowledged that the fish fillets should have been covered. Additionally, the deep fryer in the meal preparation area was found to have a large amount of floating fried debris, indicating it had not been cleaned after use, which is a violation of the facility's policy on sanitizing equipment to prevent food-borne illness. Furthermore, the facility's dress code guidelines were not followed, as observed during a tray line service where a staff member with a full beard and mustache was not wearing a beard restraint while preparing drinks and trays. This was in direct violation of the facility's policy that requires facial hair restraints for staff involved in food production. The Dietary Director confirmed that staff were expected to wear appropriate hair restraints, highlighting a lapse in enforcing hygiene standards during food preparation.
Failure to Notify Responsible Parties and Urologist of Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about changes in diet consistencies and failed to inform a urologist about symptoms of a urinary tract infection (UTI) for two residents. Resident 10, who was cognitively intact and dependent on staff for care needs, experienced a choking incident on water during medication administration. As a result, the resident's diet was downgraded from thin liquids to nectar thick liquids. Despite this significant change, there was no documented evidence that the resident's responsible party was informed about the downgrade in diet consistency after the incident or following a speech therapy assessment. Resident 22, who was also cognitively intact and had an indwelling urinary catheter, was under a urology consult that required notification of the urologist if UTI symptoms developed. The resident exhibited symptoms such as lower back pain and urinary frequency, leading to the reinsertion of the foley catheter. However, there was no documented evidence that the urologist was notified about these symptoms. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure in communication and notification protocols.
Failure to Develop Care Plan for PICC Line and IV Antibiotics
Penalty
Summary
The facility failed to develop a care plan for a resident who required treatment for an infection using a Peripherally Inserted Central Line (PICC) for intravenous antibiotics. The resident was admitted from the hospital for further care of a left heel wound and had physician's orders to receive 1 gram of Ertapenem daily through the PICC line. However, there was no documented evidence in the resident's clinical record indicating that a care plan was developed for the care and treatment of the PICC line, infection, or IV antibiotics. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident with heart failure and high blood pressure, identified as Resident 16. The resident's care plan included specific instructions for administering Carvedilol and Lisinopril based on the resident's apical pulse. On multiple occasions in January, February, and March 2025, the facility did not adhere to these orders. Specifically, on January 6, 2025, Carvedilol was administered without obtaining the required apical pulse, which should have been held if the pulse was below 50 bpm. Additionally, Lisinopril was inappropriately withheld on January 22 and 30, and February 13 and 23, 2025, despite orders to administer it daily. On March 23, 2025, Carvedilol was withheld when the resident's apical pulse was 71 bpm, contrary to the physician's orders. The Director of Nursing confirmed these discrepancies during an interview on April 3, 2025.
Failure to Provide Privacy Cover for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide a privacy cover for a resident with an indwelling urinary catheter, as required by their policy. The policy, dated January 22, 2025, mandates that indwelling urinary catheters must be covered and placed below the bladder for proper drainage. The resident, who was cognitively intact, had an indwelling urinary catheter due to neurogenic bladder, a condition causing loss of bladder control. Observations on March 31, 2025, revealed that the resident's catheter collection bag was uncovered, and urine was visible while being transported by a nurse aide. The nurse aide confirmed the absence of a privacy bag and mentioned searching for one since the morning. The Director of Nursing also confirmed that the catheter tubing should not have been in contact with the fall mat. This deficiency was identified during a review of facility policies, clinical records, observations, and staff interviews, highlighting a failure to adhere to the facility's catheter care policy.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medication appropriately for one of the residents, identified as Resident 23. According to the facility's policy on medication storage, medications for internal use should be stored in medication carts or other designated areas. However, during an observation and interview with Resident 23, a round pink/orange pill was found on the floor in her bathroom. The resident, who was cognitively intact and required assistance for daily care needs, was receiving antipsychotic medication, specifically 25 mg of Seroquel daily for psychosis. The pill on the floor was identified as Seroquel, which the resident was scheduled to receive in the evening. Licensed Practical Nurse 2 confirmed that the medication should not have been on the floor and explained that Resident 23 was the only one using that toilet, and her morning medications were crushed and served with pudding or applesauce. The Director of Nursing also confirmed that medication should not be on the floor, indicating a failure in adhering to the facility's medication storage policy. This incident highlights a deficiency in the facility's handling and storage of medications, as outlined by the relevant state codes.
Failure to Administer Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and/or received necessary vaccinations, specifically the pneumococcal and influenza vaccines. Resident 5, who was cognitively intact, had consented to receive the pneumococcal vaccine as indicated by a signed authorization form dated November 19, 2024. However, the resident did not receive the vaccine, which was confirmed by the Registered Nurse Assessment Coordinator. Similarly, Resident 11, also cognitively intact, had consented to receive the influenza vaccine as per a consent form dated October 2, 2024, but did not receive it, as confirmed by the Director of Nursing. Additionally, Resident 14, who was cognitively intact and dependent on staff for daily care, was not documented as having been offered the influenza vaccine for the 2024-2025 flu season. The Director of Nursing confirmed the absence of documentation indicating that the resident was offered the vaccine. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews, highlighting a failure in the facility's vaccination procedures.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving a maintenance worker and a resident with severe cognitive impairment and vascular dementia. The resident, who was rarely understood and sometimes able to understand others, was observed by two nurse aides to be inappropriately touched by the maintenance worker. Specifically, the maintenance worker was seen straddling the resident while she was seated in her recliner, hugging her, and rubbing her flank area under her shirt. One of the nurse aides recorded a video of the incident on her personal cell phone to document the behavior, as she believed it might not be believed otherwise. Interview statements from the involved staff confirmed the observations, with one aide stating that the maintenance worker's hand was under the resident's shirt and that he was rubbing her side. The maintenance worker admitted to hugging the resident but could not recall if his hand was under her shirt. The incident was witnessed by two nurse aides, who corroborated each other's accounts. The facility's abuse policy required that residents be protected from all forms of abuse, including sexual abuse, but this policy was not upheld in this instance.
Resident Recorded Without Consent During Incident Involving Staff
Penalty
Summary
The facility failed to ensure that residents were protected from being recorded on a personal cell phone without their permission. Facility policy stated that residents should be provided with a safe environment free from abuse, mistreatment, neglect, exploitation, and misappropriation of property. In this incident, a resident with severe cognitive impairment and vascular dementia, who was rarely understood and sometimes able to understand others, was involved. Maintenance staff was observed by two nurse aides to be straddling the resident while she was seated, hugging her, and rubbing her flank area under her shirt. One of the nurse aides, after observing this behavior, used her personal cell phone to record a video of the interaction without the resident's consent. Interview statements revealed that the nurse aide recorded the video because she believed the situation was unusual and wanted evidence of what she witnessed. The resident's face was not visible in the video, and the resident could not be identified. The Nursing Home Administrator confirmed that staff were not permitted to use personal cell phones during working hours and acknowledged that the nurse aide was aware she should not have recorded the video. The incident was determined to be a failure to protect the resident's rights and privacy as outlined in facility policy and state regulations.
Incomplete Documentation of Resident Assessments
Penalty
Summary
Westminster Woods at Huntingdon was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. The facility failed to ensure that clinical records were complete and accurately documented for a resident who was cognitively impaired and had a history of stroke. On January 18, 2025, the resident was found on the floor, and although neurological checks were ordered, there was no documented evidence of registered nurse assessments at critical times when the resident's condition changed, such as when the resident complained of a dry mouth, had issues answering questions, and could no longer raise her arm. The facility's policy required documentation of all assessments and interventions following an incident, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the assessments were completed but not documented in the clinical record, which was a requirement. This lack of documentation was a violation of both federal regulations under 42 CFR Part 483 and state regulations under 28 PA Code, which mandate that medical records be complete, accurately documented, and systematically organized.
Plan Of Correction
Resident 1 Electronic Medical Record was updated to reflect nurse assessments in the clinical record. A review of current residents reported change in conditions that occurred in the last 30 days will be completed to ensure there is a documented nurse assessment in the clinical record. Education provided by Director of Nursing to current licensed staff the process to record nurse assessment in medical record after evaluation. Director of Nursing or designee will audit 3 random resident records for change in condition x 4wks, then 3 random records monthly for documentation of nursing assessment when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for serious harm. The resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Following this incident, neurological checks were initiated. Later, the resident's daughter requested that the resident be sent to the emergency room for evaluation, and the resident was subsequently admitted to the hospital with a diagnosis of a stroke. Despite these events, there was no documented evidence that the incident was reported to the Department of Health until after Adult Protective Services contacted the facility, confirming the delay in notification.
Plan Of Correction
Resident 1 has had an incident reported to the Department of Health. A review of the last 30 days incidents were audited to find any resident who were sent for treatment to verify they had been reported to the Department of Health. Education provided to Director of Nursing regarding the process to report resident admissions to the hospital when they are due to an incident that occurred in the facility. Nursing Home Administrator or designee will audit 3 random resident incident reports for transfer to hospital x 4 weeks, then 3 random records monthly for documentation of Event Report submitted to the Department of Health when appropriate. These audits will be forwarded to Quality Assurance for review.
Failure to Develop Comprehensive Care Plan for UTI Management
Penalty
Summary
The facility failed to develop comprehensive care plans for a resident experiencing frequent urinary tract infections (UTIs) and related medication use. The facility's policy, dated March 26, 2024, required that care plans be developed with input from an interdisciplinary team and involve the resident or their representative. However, for one resident, there was no documented evidence of a care plan addressing their frequent UTIs and the use of medications prescribed for prevention and treatment. The resident's quarterly Minimum Data Set (MDS) assessment indicated they were frequently incontinent of urine and occasionally incontinent of bowel. Physician's orders included various medications and treatments for UTI prevention and treatment, such as D-mannose, Estradiol cream, and Macrobid. Despite these orders, the facility did not create a care plan to manage the resident's condition, as confirmed by the Director of Nursing during an interview.
Failure to Complete Monthly Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication reviews were completed for two residents, as required by their policy. The policy, dated March 26, 2024, mandates that comments and recommendations from the consultant pharmacist regarding medication therapy be communicated in a timely manner, allowing for a response before the next review. If the prescriber does not respond within 30 days, the Director of Nursing or the consultant pharmacist should contact the Medical Director. However, for Residents 3 and 14, there was no documented evidence that the monthly medication reviews for December 2023 and January 2024 were addressed by the physician or designee. An interview with the Director of Nursing on May 16, 2024, confirmed the absence of documentation indicating that the medical provider addressed the medication reviews for these months. This deficiency was identified during a review of clinical records and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding pharmacy services.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On May 14, 2024, a Licensed Practical Nurse (LPN) left the medication cart unattended twice without securing the computer screen, which displayed Resident 48's personal health information. The screen was facing the hallway, making the information visible to passersby. The LPN acknowledged the oversight during an interview, confirming that the information should have been covered. The Director of Nursing also confirmed that the computer screen should have been secured when unattended.
Failure to Reassess Elevated Blood Pressure
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not further assessing an elevated blood pressure for one resident. The resident, who was moderately cognitively impaired and had diagnoses including chronic kidney disease and primary hypertension, was on medication for high blood pressure. On a specific day, the resident's blood pressure was recorded at 197/86 mm/Hg, which is significantly higher than the normal range of 120/80 mm/Hg as determined by the American College of Cardiology and the American Heart Association. Despite the elevated reading, there was no documented evidence that the blood pressure was reassessed. Interviews with nursing staff confirmed that such an elevated reading would typically warrant a recheck, evaluation, and documentation, which did not occur. The Director of Nursing also confirmed that the elevated blood pressure warranted further assessment, which was not performed.
Failure to Use Leg Rests During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment for residents by not using leg rests while transporting a resident in a wheelchair. Resident 47, who is cognitively impaired and requires moderate assistance for all care, was observed being pushed in a wheelchair without leg or foot rests by Registered Nurse 4. This occurred as the resident was moved from her room to the dining room, with her feet elevated due to the absence of leg rests. Registered Nurse 4 acknowledged awareness of the requirement to use leg rests during transport. The Director of Nursing confirmed that all staff, including agency and hospice staff, are expected to use leg/footrests when transporting residents in wheelchairs.
Failure to Document Rationale for Long-term Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of psychotropic drugs. The facility policy and federal regulations require that as-needed orders for psychotropic medications be limited to 14 days unless a documented rationale is provided for extending the order. In the case of Resident 14, who was severely cognitively impaired with diagnoses of depression and dementia, there was an order for a 5 mg injection of Zyprexa to be administered daily as needed for combativeness. However, there was no documented evidence that this order was discontinued after 14 days, nor was there any documented rationale for its long-term use. The clinical records, including physician progress notes and consultant pharmacist recommendations, lacked any justification for the continued as-needed use of Zyprexa for Resident 14. The Director of Nursing confirmed that there was no documented rationale provided by the attending physician or a psychiatric consultant for the long-term use of this medication. This oversight indicates a failure to adhere to both facility policy and federal regulations, resulting in the resident receiving potentially unnecessary medication without proper documentation or justification.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper security and labeling of medications, as observed during a survey. A medication cart was found unlocked and unattended by an LPN while administering medications to a resident, which was confirmed by both the LPN and the Director of Nursing. Additionally, controlled medications were not stored in a separately locked, permanently-affixed compartment within the medication refrigerator, as required. This was confirmed by both a registered nurse and the Assistant Director of Nursing. Furthermore, the facility did not label medications with the date they were opened, as required by their policy. An opened vial of Tubersol in the main medication room refrigerator and an Insulin Lispro pen in a medication cart were not properly labeled with the date they were opened. These deficiencies were confirmed by interviews with nursing staff, including a registered nurse and the Assistant Director of Nursing.
Failure to Prevent Elopement of At-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent elopement for two residents identified as at risk for elopement. Resident 1, who had a diagnosis of altered mental status and was new to the facility, was identified as an elopement risk upon admission. Despite being equipped with a Wanderguard device, Resident 1 managed to exit the facility through the front door, which was opened by a receptionist who was unaware of the resident's status. The receptionist did not hear any alarms, and the resident was later found outside and brought back into the facility without injuries. Resident 2, who had a diagnosis of dementia and was also identified as an elopement risk, managed to exit the facility during a fire alarm. The fire alarm system deactivated the door magnets, allowing the resident to walk out. The resident was found outside knocking on the door to be let back in. The Wanderguard system did not function properly during the fire alarm, and the resident was promptly assisted back inside without injuries. Interviews with staff revealed that the receptionist was not familiar with Resident 1 and did not receive a photo of him in time. Additionally, the fire alarm system's deactivation of door magnets during emergencies allowed Resident 2 to exit the building. Both incidents highlighted lapses in the facility's supervision and intervention measures to prevent elopement, despite the presence of Wanderguard devices and other security measures.
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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