Whitestone Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stroudsburg, Pennsylvania.
- Location
- 370 White Stone Corner Road, Stroudsburg, Pennsylvania 18360
- CMS Provider Number
- 396130
- Inspections on file
- 25
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Whitestone Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls, who required total staff assistance and a low bed position, was left unattended in an elevated bed by a nurse aide. The resident fell and later was found to have a comminuted distal femur fracture. The incident was substantiated as neglect due to failure to follow the care plan.
The facility failed to maintain the smoke-tight integrity of an exit stair tower door, affecting both floors. An observation revealed that the first floor's #2 stair tower door did not meet smoke-tight standards. This was confirmed during an exit interview with the Facility Administrator and Facilities Manager.
The facility failed to maintain its automatic sprinkler system, with missing ceiling tiles in the Mechanical and IT Server Rooms, a non-functional attic-level dry sprinkler system, and missing inspection reports. Additionally, the facility was overdue for required maintenance tasks, including internal valve and piping checks and sprinkler gauge recalibration.
The facility failed to maintain the generator set, as the low fuel level lamp was illuminated at the remote annunciator location, affecting both floors. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
A facility failed to ensure the accuracy of the MDS Assessment for a resident, as the Discharge MDS inaccurately indicated the resident was discharged to a hospital, while a nurse's note revealed the resident was discharged home with her son. This discrepancy was confirmed by the DON.
A resident with dementia and chronic kidney disease experienced significant weight loss over several months due to the facility's failure to maintain nutritional status. Despite being on a regular diet with supplements, the resident's weight declined by 23.5% over 195 days. Inconsistent documentation of bowel movements and inadequate interventions contributed to the deficiency.
A resident with dementia and chronic kidney disease experienced a delay in treatment due to the facility's failure to promptly notify the ordering practitioner of lab results indicating dehydration. Despite receiving lab results, the physician was not informed for approximately 24 hours, leading to a delay in initiating necessary interventions such as a midline catheter and supplemental fluids. The Director of Nursing confirmed the delay and acknowledged the facility's responsibility to ensure timely notification of lab results.
A facility failed to provide timely radiology services for a resident who fell and complained of shoulder pain. An x-ray was ordered but not completed promptly, leading to the resident being sent to the emergency room. Upon arrival, the resident refused the initially ordered x-ray and requested imaging of the opposite shoulder, which showed no fracture. The DON confirmed the x-ray was not completed as ordered.
Whitestone Care Center failed to prevent the development of a pressure ulcer in a resident with severe cognitive impairment and multiple health issues. Despite being at risk, the facility did not consistently implement preventative measures such as repositioning and heel elevation. A new unstageable pressure ulcer was discovered on the resident's left heel, highlighting the facility's non-compliance with care standards.
A resident was found unresponsive, and due to a misidentification of their code status by an RN, CPR was delayed by 30 minutes. The RN incorrectly consulted a physical chart instead of the electronic medical record, leading to the error. The delay in initiating CPR may have contributed to the resident's death, highlighting a systemic failure in emergency response protocols.
A resident in a long-term care facility was found unresponsive, but due to a misidentification of their code status, CPR was delayed by 30 minutes. The staff initially believed the resident had a DNR order, leading to a failure to initiate life-saving measures promptly. This delay may have contributed to the resident's death, highlighting a systemic failure in emergency response protocols.
A resident with significant care needs suffered serious injuries, including a fractured thumb and closed head injury, due to neglect in a facility. The resident, requiring maximum assistance and a mechanical lift for transfers, was left unattended by a nurse aide who failed to report the fall. The facility's staff did not conduct a prompt assessment or initiate neurological checks, leading to a delay in addressing the resident's injuries.
Neglect Resulting in Resident Fall and Femur Fracture
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of falls, and muscle weakness was left unattended in an elevated bed by a nurse aide. The resident required total staff assistance for activities of daily living, including bed mobility and transfers, and the care plan specified that two staff members were needed for these tasks, with the bed to be kept in the lowest position for safety. Despite these requirements, the nurse aide left the resident alone while the bed was raised to retrieve a washcloth from the bathroom, resulting in the resident falling from the bed. Following the fall, the resident was found on the floor on her left side, holding onto the enabler bar, with her legs bent underneath her. Initial assessments by nursing staff did not reveal any visible injuries or signs of pain, and neurological checks were within normal limits. The resident was assisted back into bed using a Hoyer lift, and care was provided by two staff members as per protocol. The nurse aide involved was educated on the importance of following the care plan and not leaving residents unattended in elevated beds. Subsequent follow-up revealed swelling of the resident's right knee, and an x-ray confirmed a displaced and overlapping comminuted distal fracture of the right femur. The incident was investigated and substantiated as neglect, as the nurse aide failed to follow the resident's plan of care, directly resulting in the fall and serious injury.
Stair Tower Door Lacks Smoke-Tight Integrity
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of an exit stair tower door, affecting both floors of the building. During an observation on February 4, 2025, at 11:32 a.m., it was noted that the door of the #2 stair tower on the first floor did not meet the required smoke-tight standards. This deficiency was confirmed during an exit interview with the Facility Administrator and the Facilities Manager later that day.
Plan Of Correction
K-0225 Smoke Enclosures 1. Stair Tower door was adjusted to close and meet smoke tight integrity. 2. Facility audit was completed of all doors. 3. Monthly Audits will be completed X4 months and then quarterly after with results reviewed in QAPI.
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by several deficiencies observed during a survey. On the second floor, ceiling tiles were missing in the Mechanical Room, and similar issues were noted in the first floor IT Server Room. Additionally, the attic-level dry sprinkler system was found to be non-functional at the time of the survey. The facility also lacked an automatic sprinkler system inspection report for the fourth quarter of 2024, and was overdue for the required five-year internal valve, internal piping, and sprinkler gauge recalibration or replacement. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.
Plan Of Correction
K-0353 Sprinkler Systems 1. Ceiling tiles were lacking within the second floor Mechanical Room and ceiling tiles within the first floor IT Server Room were repaired. Attic-level dry sprinkler system was repaired and placed in service. Quarterly Sprinkler inspection was completed 2/2025. Five-year, internal valve, internal piping, and sprinkler gauge recalibration/replacement was also completed. 2. Audit will be competed for areas of missing ceiling tiles weekly x 4 then monthly x2. Sprinkler reports will be monitored for missing inspection pieces. Findings will be reviewed in QAPI.
Generator Set Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the generator set, as evidenced by an observation on February 4, 2025, at 11:50 a.m., which revealed that the low fuel level lamp was illuminated at the remote annunciator location. This deficiency affected both floors of the facility. During an exit interview with the Facility Administrator and the Facilities Manager on the same day, between 12:30 p.m. and 12:40 p.m., the emergency generator set deficiency was confirmed.
Plan Of Correction
K-0919 Generator Low Fuel Light was corrected. Maintenance Director job description reviewed and signed to ensure knowledge of expectation and responsibilities clear. Maintenance Director/designee will perform generator check to ensure no issues on Panel or with Unit weekly X4, then monthly X2 with results reviewed in QAPI.
Inaccurate MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment for a resident, which is a federally mandated standardized assessment used to plan resident care. The deficiency was identified during a review of clinical records and the Resident Assessment Instrument (RAI), as well as through staff interviews. Specifically, the Discharge MDS Assessment for a resident who was admitted on October 28, 2024, and discharged on November 15, 2024, inaccurately indicated that the resident was discharged to a short-term general hospital. However, a discharge nurse's note from the same date revealed that the resident was actually discharged home with her son. This discrepancy was confirmed by the director of nursing during an interview on January 30, 2025.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. MDS for resident # 74 was corrected and submitted at the time of survey. To identify like residents that have the potential to be affected, the MDS Nurse/designee will complete a 14-day look back of section A2105, discharge stats to ensure it is coded correctly. To prevent this from happening again, the Regional Reimbursement coordinator/designee will educate the RNAC on appropriate coding for section A2105 on the MDS. To monitor and maintain ongoing compliance, the RNAC will review all discharges weekly x 4 then monthly x 2 to ensure that Section A2105 is coded correctly. Results will be reviewed at QAPI.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by significant weight loss over several months. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, experienced a weight loss of 23.5% over 195 days. Despite being on a regular diet with nutritional supplements and fluids, the resident's weight continued to decline, indicating a failure to maintain nutritional status. The resident's care plan identified increased nutrition and hydration risk, yet interventions such as offering alternate foods and monitoring nutritional needs were insufficient to prevent significant weight loss. The facility's documentation revealed inconsistent recording of the resident's bowel movements, making it difficult to assess the onset and severity of diarrhea, which was reported by the resident and confirmed by staff. The lack of timely and thorough documentation hindered the facility's ability to address the resident's nutritional and hydration needs effectively. Interviews with the Director of Nursing confirmed the facility's failure to document and address the resident's diarrhea and weight loss adequately. The facility did not provide evidence that the resident's weight loss or dehydration was unavoidable, highlighting a deficiency in maintaining the resident's nutritional status and electrolyte balance as required by regulations.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step 1 Resident # 1 loose bowel movements followed up MD/RP on 1/8/2025. Resident #1 weight loss stabilized 2 weeks post loss identification on 1/29/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of progress notes and point of care documentation for last 2 weeks to verify that bowel movements documented accurately with MD/RP follow-up as applicable. In-house audit of residents with weight loss in last 14 days to ensure adequately investigated and followed up timely. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on documentation and follow-up in resident change in condition. DON/designee will educate the C.N.A staff on documentation in point of care changes in the resident continence and consistency of bowel movement and notification of the licensed nurse. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with changes in condition per week for 4 weeks, then monthly for 2 months to ensure timely follow-up. To monitor and maintain compliance, the DON/designee will conduct audits of 5 residents' bowel management point of care documentation to ensure that documentation accurately reflects resident bowel status per week, then monthly for 2 months to ensure compliance. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Delayed Notification of Lab Results Leads to Treatment Delay
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results for a resident, leading to a delay in treatment. The resident, who was admitted with dementia and chronic kidney disease, experienced increased diarrhea and nausea. A physician ordered laboratory tests, including a CBC, CMP, and MAG, which were collected and reported back to the facility. However, there was no documented evidence that the physician received or acted upon these results for approximately 24 hours. The laboratory results indicated significant dehydration, with elevated BUN and creatinine levels, and a decreased potassium level. Despite these findings, the physician's order for a midline catheter insertion and supplemental fluids was not initiated until approximately 30 hours after the laboratory results were reported. The resident received additional fluids and continuous IV treatment, but these interventions were delayed by more than 40 hours after the laboratory report indicated dehydration. The Director of Nursing confirmed the delay in implementing interventions and treatment to address the resident's dehydration. The DON acknowledged that it is the facility's responsibility to ensure the physician is promptly provided with laboratory results. The report highlights the facility's failure to adhere to its policies and procedures for notifying practitioners of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
Step 1 Resident #1 labs were followed up on 1/10/2025. Step 2 To identify like residents that have the potential to be affected, an in-house audit of labs completed for the last 2 weeks to ensure abnormal lab studies were followed up with the physician in a timely manner. Step 3 To prevent this from happening again, DON/designee will educate the licensed staff on following up with abnormal lab studies with physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for labs per week for 4 weeks, then monthly for 2 months to ensure labs followed up with physician in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to ensure the timely provision of radiology services for a resident who was admitted with conditions including unspecified deep vein thrombosis, gout, and anxiety. The resident, who was cognitively intact, experienced a fall and subsequently complained of right shoulder pain. A physician ordered an x-ray of the right shoulder to rule out a fracture. However, the x-ray was not completed in a timely manner, as confirmed by a review of the resident's clinical record during the survey. On the day of the survey, a STAT x-ray was ordered, but the mobile x-ray company had not completed the imaging by 8:30 PM. Consequently, the resident was sent to the emergency room for the x-ray. Upon arrival, the resident refused the right shoulder x-ray and requested imaging of the left shoulder instead. The left shoulder x-ray was completed and showed no acute fracture. The Director of Nursing confirmed that the x-ray was not completed as originally ordered, indicating a failure in the facility's responsibility to provide timely diagnostic services.
Plan Of Correction
Step 1 Resident # 64 x-ray was obtained on 1/29/2025 with no negative findings. Step 2 To identify like residents that have the potential to be affected, an in-house audit of radiology/diagnostics studies was completed for the last 2 weeks to ensure that diagnostics were completed and followed up in a timely manner. Step 3 To prevent this from happening again, the DON/designee will educate the licensed staff on following up with radiology/diagnostics studies with the physician in a timely manner. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will conduct an audit of 5 residents with orders for radiology/diagnostics studies per week for 4 weeks, then monthly for 2 months to ensure diagnostic tests are followed up in a timely manner. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Prevent Pressure Ulcers
Penalty
Summary
Whitestone Care Center was found to be non-compliant with federal and state regulations regarding the prevention and treatment of pressure ulcers. The facility failed to develop and implement adequate care and services to prevent the development of pressure ulcers for a resident. This resident, who was admitted with severe cognitive impairment and multiple health issues including Fournier gangrene, Type 2 diabetes, and cerebral infarction, was identified as being at risk for pressure ulcers. Despite this, the facility did not take sufficient preventative measures. The resident's care plan included interventions such as providing a pressure-reducing mattress and wheelchair cushion, incontinence care, and repositioning every two hours. However, there was no documented evidence that these measures were consistently implemented. Specifically, the facility did not document turning and repositioning the resident every two hours or elevating the resident's heels off the bed, which are critical actions to prevent pressure ulcer development. A new unstageable pressure ulcer was discovered on the resident's left heel, which was not identified in the facility's weekly skin assessment but was noted by an outside wound consultant. The facility's failure to document and implement preventative measures, such as pressure relief for the resident's heels, contributed to the development of this pressure ulcer. The Nursing Home Administrator confirmed the lack of documented evidence for the timely and consistent implementation of these preventative measures.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Step One Resident #1 no longer resides at the community. Resident #1 wound consultant recommendations implemented on November 14, 2024. Step Two To identify like residents that have the potential to be affected, the DON/designee conducted a whole house review of physician/nursing ordered pressure reduction interventions and validated proper placement, cross-referencing the device list. The DON/designee will conduct an in-house review of wound consultant reports to ensure timely follow-up of recommendations. Step Three To prevent this from happening again, the DON/designee will educate the licensed nursing staff and CNA staff on the utilization and review of the device list ordered interventions and the importance of ensuring they are in place. To prevent this from happening again, the DON/designee will educate the licensed nursing staff on timely follow-up of wound care consultant recommendations. To prevent this from happening again, the DON/designee will educate the Department Head staff on the use of the device list which lists ordered interventions and ensuring during concierge rounds the importance of ensuring they are in place. Step Four To monitor and maintain ongoing compliance, the DON/designee will conduct an audit of 5 residents per week for 4 weeks, then monthly for 2 months to ensure all ordered interventions are in place. The DON/designee will conduct an audit of 5 residents with orders for wound consults per week, then monthly for 2 months to ensure timely follow-up to recommendations. Results of audits will be submitted to the QAPI committee for further review and recommendation.
Failure to Provide Timely CPR Due to Code Status Misidentification
Penalty
Summary
The facility failed to provide prompt cardiopulmonary resuscitation (CPR) intervention consistent with a resident's advanced directives, resulting in a deficiency. A resident, identified as CR1, was found unresponsive in their room by a nurse aide. The nurse aide called for assistance, and a registered nurse (RN) responded but incorrectly identified the resident's code status as 'do not resuscitate' (DNR) by consulting a physical chart instead of the electronic medical record. This error led to a delay in initiating CPR for the resident, who was actually designated as 'full code' and should have received immediate resuscitative efforts. The RN Supervisor, Employee 2, failed to verify the resident's identity and correct code status, resulting in a 30-minute delay in providing life-sustaining measures. During this time, the RN incorrectly notified another resident's family of their loved one's death, further compounding the error. It was only after the oncoming RN Supervisor, Employee 3, arrived and observed the error that CPR was initiated, but by then, significant time had elapsed since the resident was found unresponsive. The delay in initiating CPR may have contributed to the resident's subsequent death, as CPR was not started until 30 minutes after the resident was found unresponsive. The facility's failure to follow proper emergency response protocols and accurately verify the resident's code status placed the resident in immediate jeopardy, representing a systemic failure to ensure the health and safety of residents requiring emergency care.
Failure to Initiate Timely CPR Due to Misidentification of Resident's Code Status
Penalty
Summary
The facility's administration failed to effectively use its resources to promote resident safety by not implementing established procedures for timely cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, as per a resident's advanced directive. This deficiency was identified for one out of five sampled residents, referred to as Resident CR1. The facility's policy required licensed nurses, respiratory therapists, and van drivers to hold active CPR certificates from an American Heart Association (AHA) approved provider, with in-person skills verification. However, during an emergency, the staff failed to follow these procedures. On the day of the incident, a nurse aide found Resident CR1 unresponsive and called for help. An RN responded but incorrectly identified the resident as having a do-not-resuscitate (DNR) order, based on a physical chart that was misidentified. This error led to a delay in initiating CPR. The RN left the room to consult with another RN Supervisor, who upon arrival, realized the mistake and initiated CPR approximately 30 minutes after the resident was found unresponsive. Emergency Medical Services (EMS) were called, but the delay in CPR initiation may have contributed to the resident's death. The facility's investigation revealed that the RN Supervisor failed to verify the resident's identity and code status before deciding not to initiate CPR. This oversight resulted in a 30-minute delay in providing life-sustaining measures, placing the resident in immediate jeopardy. The Nursing Home Administrator confirmed the failure to identify the resident's code status and perform necessary emergency procedures, leading to the termination of the RN involved. The deficiency was cited under the Code of Federal Regulatory Groups for Long Term Care, indicating a systemic failure to ensure the health and safety of residents requiring emergency care.
Neglect Leads to Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in serious injuries, including a fractured thumb and a closed head injury. The resident, who was admitted with diagnoses of cerebral infarction, dysphagia requiring enteral feeding, and diabetes, required maximum assistance with personal care and the use of a mechanical lift for transfers. Despite these needs, the resident was left unattended by a nurse aide, Employee 1, who was providing care alone when the resident rolled out of bed. Employee 1 did not report the fall and instead sought the assistance of another nurse aide to return the resident to bed without using the mechanical lift. The facility's investigation revealed inconsistencies in staff accounts and a lack of immediate and thorough assessment following the incident. Employee 1 and another nurse aide failed to report the fall, and the licensed nursing staff did not conduct a prompt assessment or initiate neurological checks despite the resident's visible injuries. Surveillance footage and witness statements indicated that the resident was not properly attended to, and the necessary protocols for handling such incidents were not followed. The facility's administrative staff confirmed that the nursing staff neglected to provide the necessary care to prevent physical harm to the resident. The failure to adhere to the resident's care plan, which required two staff members and a mechanical lift for transfers, and the lack of timely reporting and assessment of the resident's condition, contributed to the severity of the injuries sustained.
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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