William Penn Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jeannette, Pennsylvania.
- Location
- 2020 Ader Road, Jeannette, Pennsylvania 15644
- CMS Provider Number
- 396056
- Inspections on file
- 40
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at William Penn Care Center during CMS and state inspections, most recent first.
The facility failed to conduct a thorough investigation of an elopement-related incident involving a cognitively intact resident with cardiomegaly, hyperlipidemia, and anxiety. Policy required staff to report, investigate, and review all incidents on facility property involving residents. A RN was notified by rehab staff that the resident was outside in a wheelchair; the RN found the resident outdoors with a newspaper and wallet, stating he was trying to go to an appointment, and redirected him back to his room. Facility documentation included only one witness statement from the DON, and the Nursing Home Administrator acknowledged that a complete elopement investigation was not performed as required.
A resident with cardiomegaly, hyperlipidemia, and anxiety, assessed as cognitively intact and not at risk for elopement, was able to leave the building unsupervised after obtaining a newspaper at the front area while the receptionist was briefly distracted by a phone call. The resident was later found outside in a wheelchair with a newspaper and wallet, stating an intent to go to an appointment. Facility records also described a separate prior incident in which another resident was found outside in a power wheelchair after forcing sliding doors off their hinges to exit. The DON acknowledged that the facility failed to provide adequate supervision, resulting in an elopement.
Three residents with complex medical conditions did not have documented monthly medication regimen reviews by a licensed pharmacist, as required by facility policy. Care plans specified monthly pharmacy reviews, but for the month in question, no evidence of these reviews was found in clinical notes or medication records. The DON confirmed the lack of documentation.
Kitchen equipment, specifically the walk-in cooler's cold air condenser unit, was observed to have a build-up of dust, grime, and dark debris around the fan covers and ceiling. The Certified Dietary Manager confirmed the unsanitary condition, which created the potential for cross contamination in the kitchen.
A resident with moderate cognitive impairment and multiple medical conditions was able to exit the facility unsupervised by forcing open a malfunctioning front door in a motorized wheelchair. The door alarm was not functioning, and staff were unaware of the resident's departure until the individual was found outside. The resident was assessed as not at risk for elopement, and staff interviews confirmed no prior history of such behavior.
A resident with traumatic brain injury, aphasia, and heart disease experienced significant weight loss, but the facility did not accurately assess the nutritional status or update the care plan to address this issue. The dietary assessment lacked details on the weight loss, and the care plan did not include specific goals or interventions, as confirmed by staff interviews.
A resident with dementia, anxiety disorder, and Alzheimer's disease was discharged after death, and a law firm requested the resident's medical records. The facility failed to provide access to these records for several months, citing equipment issues, despite policy requirements and available alternatives. This resulted in noncompliance with regulations regarding resident rights to access records.
A facility failed to adhere to physician orders for a resident who was on a Nothing by Mouth (NPO) diet due to their medical condition. Despite the NPO status, the resident was prescribed oral medications, Oxycodone HCl and Claritin, which were not appropriate. The Nursing Home Administrator confirmed the discrepancy, highlighting a failure in following the prescribed care plan.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about hospital transfers for three residents, as required by regulations. The residents, with various medical conditions, were transferred to the hospital and returned without documented evidence of notification. This deficiency was confirmed by the Nursing Home Administrator.
The facility, with a capacity of 145 beds, failed to employ a qualified full-time social worker as required. The previous social worker left, and although a new hire is pending, there is currently no social worker employed, as confirmed by the NHA.
The facility failed to pay bills in a timely manner, leading to service disruptions from Vendor 1. The Kitchen Manager reported that Vendor 1 had cut off services multiple times, requiring reliance on an alternative vendor. The Accounts Payable Ledger showed outstanding balances with both Vendor 1 and Vendor 2. The Nursing Home Administrator confirmed the facility's failure to adhere to state regulations requiring timely payment of bills.
A resident with a history of falls and other medical conditions suffered a tibial fracture due to neglect during a transfer. Despite clear care plans and physician orders requiring a sit-to-stand lift with two staff, aides manually transferred the resident without the lift, leading to injury. The aides admitted to not reviewing the care plan and relying on assumptions, resulting in harm to the resident.
The facility failed to properly store food and verify dish machine temperatures, risking foodborne illness. An employee's lunch was stored with residents' food, and dishwashing temperatures were not checked before use. Incorrect test strips were used, and the machine's temperature was below the required level.
The facility failed to assess the nutritional status of three residents, resulting in incomplete dietary clinical notes and missing nutritional assessments. This deficiency was confirmed by the Dietary Manager, who acknowledged the lack of essential information such as height, weight, and diet orders in the records.
The facility failed to follow enhanced barrier precautions for two residents and did not implement proper transmission-based precautions for a resident with COVID-19. A resident with a Stage 4 pressure ulcer received care without the required gown, and another resident with a wound vacuum lacked a physician order for EBP. Additionally, there was no signage for a COVID-19 positive resident, and staff were uncertain about isolation protocols. These deficiencies were confirmed by the Director of Nursing.
The facility did not have a designated Infection Preventionist (IP) with specialized training for six months. The Director of Nursing was covering the IP role since the previous IP left in February 2024, as confirmed by the Nursing Home Administrator. This was a violation of management and nursing services regulations.
The facility failed to maintain an effective training program for staff, as five employee files lacked documentation of required annual in-service training in critical areas such as resident rights, abuse, QAPI, and fire safety. This deficiency was confirmed by a Human Resource employee, indicating non-compliance with regulatory requirements.
The facility failed to maintain respiratory equipment for two residents. A resident's CPAP mask was not stored properly, risking contamination, while another resident's nasal cannula lacked a required date label. These deficiencies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to provide trauma-informed care for two residents with PTSD, as their care plans did not identify or address specific triggers. Despite the facility's policy requiring staff training on trauma assessment and trigger identification, the care plans lacked necessary details, which was confirmed by a social worker.
The facility failed to properly date medications after opening, as required by its policy, in two of three medication carts in the East Hall. Observations revealed that several residents' medications, including albuterol inhalers and Trelegy, were opened without a date. Staff interviews confirmed these deficiencies, and the DON acknowledged the failure to store medications properly and securely.
A resident's funds totaling $5,251.83 were misappropriated by a former Business Officer Manager (BOM) at the facility. The resident's daughter reported the issue when the funds were not reflected in the trust account, despite a receipt being issued. The facility's investigation failed to locate the money or the employee, leading to a police report.
A facility failed to implement its policies to prevent abuse and misappropriation of property when a nurse aide, under police investigation for theft from a resident, was not suspended. The resident, with medical conditions including high blood pressure and renal insufficiency, was allegedly stolen from, but the aide continued working without separation from residents, violating the facility's policy.
A facility failed to report an alleged misappropriation of property involving a resident, who was under investigation for possible theft by a nurse aide. Despite being contacted by local police, the facility did not report the incident to the Department of Health or law enforcement within the required timeframe, violating their policy and state regulations.
A facility failed to investigate an allegation of misappropriation of property involving a resident with high blood pressure, renal insufficiency, and atrial fibrillation. Despite being informed by local police about a possible theft by a nurse aide, the facility did not initiate an investigation, contrary to its policy requiring thorough investigation of all abuse or neglect allegations.
The facility failed to maintain proper admission documentation for two cognitively impaired residents. Despite severe cognitive impairments indicated by BIMS scores, both residents signed their admission packets. An admission coordinator confirmed that these residents should not have signed the paperwork, highlighting a deficiency in adhering to the facility's admissions policy.
The facility failed to communicate necessary information during transfers for two residents, including care plan goals and advanced directives. This deficiency was confirmed by the DON, highlighting a lapse in following the facility's emergency transfer policy.
A facility failed to follow physician orders and conduct weekly assessments for a resident with a surgical wound. The resident had a history of falling, a fracture, hypertension, and an infection requiring a wound vacuum. The facility did not perform weekly wound assessments and lacked a contingency plan for wound vacuum malfunction. Observations showed the wound vacuum machine was off, and staff confirmed the oversight.
The facility failed to ensure that two residents with severe cognitive impairment had a representative sign their binding arbitration agreements. Both residents, with BIMS scores indicating severe impairment, signed the agreements themselves, which was confirmed as inappropriate by the Admission Coordinator.
A facility failed to update and implement a comprehensive person-centered care plan for a resident with dementia, diabetes, and bipolar disorder. Despite a wandering risk assessment indicating moderate risk, the care plan was not updated to reflect this. The Nursing Home Administrator confirmed the oversight.
A resident with dementia, diabetes, and bipolar disorder was found outside after the facility's door was locked for the evening. The resident, assessed as low risk for wandering, was assisted back inside without injury. The facility failed to provide adequate supervision, as confirmed by the Nursing Home Administrator.
Failure to Conduct Thorough Investigation of Elopement-Related Incident
Penalty
Summary
The facility failed to initiate a thorough investigation of an elopement-related incident involving one resident. Facility policy dated 1/28/25 required staff to report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve a resident. The resident, admitted on 10/18/24, had diagnoses including cardiomegaly, hyperlipidemia, and anxiety, and an MDS dated 1/18/26 showed a BIMS score of 13, indicating cognitive intactness. A progress note dated 2/17/26 at 11:36 a.m. documented that a RN was informed by rehab staff that the resident was outside in a wheelchair; upon assessment, the nurse found the resident outside with a newspaper and wallet in hand, stating he was trying to go to an appointment, and the resident was redirected back inside. Facility-provided documents contained only one witness statement from the DON, and during an interview on 3/20/26, the Nursing Home Administrator confirmed that the facility did not conduct a thorough elopement investigation for this incident as required by policy. This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1)(3) Management, 28 Pa. Code: 211.10(d) Resident care policies, and 28 Pa. Code: 211.12(d)(3) Nursing services, based on the lack of a complete investigation into the resident’s elopement-related event despite policy requirements.
Failure to Adequately Supervise Resident Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident. Facility policy on Elopements and Wandering Residents requires a systemic approach to identifying and managing residents at risk for elopement, including assessment of risk, implementation of interventions, and vigilant staff response to alarms, with the understanding that alarms are not a substitute for necessary supervision. The resident involved was admitted in October 2024 and had diagnoses including cardiomegaly, hyperlipidemia, and anxiety. A BIMS score of 13 on the MDS indicated the resident was cognitively intact, and an elopement/wandering risk assessment completed in January 2025 documented that the resident was not at risk for elopement and not at safety risk for wandering, or wandered but was easily redirected. On the date of the incident, a progress note documented that a nurse was informed by rehab staff that the resident was outside in a wheelchair. When the nurse went outside, the resident was found sitting in the wheelchair with a newspaper and wallet in hand, stating he was trying to go to an appointment, and had exited the building without staff knowledge. Facility documentation indicated that the receptionist saw the resident get his newspaper, then turned away to take a phone call and obtain a phone number, and when she turned back, the resident had left through the front door. The record also included a prior employee statement describing a different resident found outside in a power wheelchair in the back parking lot after having pushed sliding doors off their hinges to exit the building. During interview, the DON confirmed that the facility failed to provide adequate supervision resulting in an elopement for one resident.
Lack of Documented Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to provide documentation of monthly medication regimen reviews (MRR) by a licensed pharmacist for three sampled residents. According to the facility's policy, a licensed pharmacist is required to conduct a thorough monthly review of each resident's medication regimen, including a review of the medical chart. For each of the three residents reviewed, their care plans indicated that pharmacy reviews were to occur monthly as per protocol. However, for the month of April 2025, there was no documentation in the clinical progress notes or medication regimen review records to show that these reviews had been completed. The residents involved had complex medical histories, including diagnoses such as dementia, heart disease, diabetes, chronic kidney disease, hyperlipidemia, emphysema, hypertension, and cirrhosis of the liver. Despite these conditions and the facility's stated policy, there was no evidence that a licensed pharmacist had performed or documented the required monthly medication reviews for these residents during the specified period. The Director of Nursing confirmed the absence of this documentation during an interview.
Failure to Maintain Sanitary Conditions in Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, specifically in the main kitchen's walk-in cooler. During an observation conducted with the Certified Dietary Manager, the cold air condenser unit was found to have a build-up of dust, grime, and dark colored debris around the fan covers and on the ceiling immediately forward of the fans. The Certified Dietary Manager confirmed the unsanitary condition of the equipment and acknowledged that this failure to maintain cleanliness created the potential for cross contamination in the kitchen. The facility's policy required adherence to all local, state, and federal standards to ensure a safe and sanitary food and nutrition department, which was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with moderate cognitive impairment. The resident, who had diagnoses including heart disease, chronic kidney disease, and diabetes, was assessed as not being at risk for elopement or unsafe wandering on multiple occasions. Despite these assessments, the resident was able to exit the facility unsupervised by using a motorized wheelchair to force open the front lobby doors, which were found to be off their tracks and not properly alarmed at the time of the incident. Staff discovered the resident outside in the parking lot after a staff member returning from a break noticed the individual in their wheelchair. The resident was confused, had a pile of belongings in their lap, and required assistance to return to their room. Upon investigation, it was determined that the door alarm was not functioning, and no alarm had sounded during the event. The resident had no recollection of leaving the building and did not sustain any injuries. Interviews with staff confirmed that the behavior was new for the resident and that there were no prior indications of elopement risk. The facility's policy required vigilant supervision and timely response to alarms, as well as a systemic approach to monitoring residents at risk for elopement. However, the failure of the door alarm and lack of adequate supervision directly contributed to the resident's unsupervised exit from the facility.
Failure to Assess and Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to accurately assess the nutritional status of a resident and did not update the individualized care plan to address specific nutritional concerns. The facility's policy requires a comprehensive nutritional assessment, including current status and risk factors, to be conducted upon admission and as indicated by changes in condition. For one resident with diagnoses of traumatic brain injury, aphasia, and heart disease, the Minimum Data Set (MDS) indicated significant weight loss. However, the clinical dietary assessment note did not identify the parameters of this weight loss, such as prior weights or specific time frames. Additionally, the resident's nutritional plan of care was not updated to reflect a focus on the significant weight loss, nor did it include goals or interventions to address the issue. Staff interviews confirmed that the assessment and care plan failed to address the resident's nutritional concerns as identified in the MDS. This deficiency was found during a review of four resident records.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for one resident, as required by both facility policy and state and federal regulations. According to the facility's policy, medical records should be released upon a valid request, with proper legal documentation and notification of associated costs. In this case, a law firm submitted a request for a resident's medical records, and the facility acknowledged receipt of the request several months prior to the survey. Despite this, the records were not provided due to issues with the facility's copier and the volume of the records. The Nursing Home Administrator confirmed that the facility had not fulfilled the request and that alternative means, such as using an off-site scanner, were available but not utilized. The resident in question had diagnoses of dementia, anxiety disorder, and Alzheimer's disease, and had been discharged from the facility after passing away. The deficiency was identified through staff interviews and review of facility documentation, which confirmed that the facility did not provide access to the requested medical records for this resident, in violation of resident rights under 28 Pa. Code 201.29(a).
Failure to Follow NPO Orders for a Resident
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with diagnoses including malignant neoplasm of the upper lobe, right bronchus or lung, cyst of kidney, and ischemic cardiomyopathy. The resident was ordered to be on a Nothing by Mouth (NPO) diet with enteral feeding every shift by j-port. However, the resident's physician orders for January included two medications, Oxycodone HCl and Claritin, to be administered orally, which contradicted the NPO status. During an interview, the Nursing Home Administrator confirmed that the resident should not receive medication by mouth, indicating that the orders were inappropriate for an NPO resident.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three residents. Resident R2, who was admitted with diagnoses including diabetes, anxiety disorder, and fibromyalgia, was transferred to the hospital and returned to the facility without documented evidence of a written transportation notification to the Ombudsman. Similarly, Resident R1, with diagnoses of protein-calorie malnutrition, chronic kidney disease, and cardiomegaly, was transferred to the hospital and returned without the required notification. Resident R3, admitted with anemia, respiratory disorders, and spinal stenosis, was also transferred to the hospital on two occasions without the necessary notification to the Ombudsman. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to provide the required transfer notices for these residents. The report highlights that the facility did not comply with the regulation requiring timely notification to the Ombudsman, as outlined in 28 Pa. Code 201.29(a)(c.3)(2) regarding resident rights. This oversight affected three out of nine residents reviewed, indicating a lapse in the facility's adherence to regulatory requirements for resident transfers.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker, which is required for facilities with more than 120 beds. The facility assessment indicated the need for a full-time Social Services Director, and the facility has a capacity of 145 beds, necessitating a full-time social worker. An interview with the Nursing Home Administrator revealed that the previous social worker left on September 6, 2024, and although a new social worker has been hired, they have not yet started. As of September 17, 2024, the Nursing Home Administrator confirmed that there is currently no social worker employed at the facility, which is a requirement.
Failure to Pay Bills Timely
Penalty
Summary
The facility failed to pay bills in a timely manner, as evidenced by a review of financial documents and interviews with staff and vendors. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, a facility owner is required to pay bills incurred in the operation of a facility in a timely manner, especially those that are not in dispute and are essential for the residents' health and safety. The Nursing Home Administrator's job description emphasizes the importance of adhering to federal, state, and local standards to ensure quality care for residents. During an interview, the Kitchen Manager revealed that Vendor 1 had cut off services multiple times due to unpaid bills, forcing the facility to rely on an alternative vendor. The Accounts Payable Ledger showed an outstanding balance with Vendor 1 and Vendor 2, with Vendor 1's credit manager confirming a significant overdue amount. The Nursing Home Administrator acknowledged the facility's failure to pay bills promptly, which is a violation of the management's responsibilities as outlined in the state code.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R27, was free from neglect, resulting in actual harm evidenced by fractures to her right tibia. The deficiency occurred when two nurse aides, despite being trained on the proper use of mechanical lifts, transferred Resident R27 without using the required sit-to-stand lift. The aides, unable to locate the lift, decided to perform a manual two-person assist transfer, contrary to the resident's care plan and physician orders, which specified the use of a sit-to-stand lift with the assistance of two staff members. Resident R27 had a medical history that included a history of falling, chronic kidney disease, spinal stenosis, an artificial hip joint, and a history of other fractures. Her care plan and physician orders clearly indicated the need for a sit-to-stand lift with two staff members for transfers. On the day of the incident, the aides lifted Resident R27 manually, which led to her experiencing discomfort and subsequently being found with a significant bruise on her right shin. An X-ray confirmed an acute to sub-acute proximal right tibial fracture, and further hospital evaluation revealed a non-displaced comminuted proximal tibial fracture. Interviews with the staff involved revealed that they were aware of the requirement to use a sit-to-stand lift but proceeded with a manual transfer due to the unavailability of the lift. The aides admitted to not reviewing the resident's transfer status in the care plan or Kardex before the transfer, relying instead on assumptions and verbal communication. This neglect in following established protocols and care plans directly led to the resident's injury, highlighting a significant lapse in ensuring resident safety and adherence to care procedures.
Improper Food Storage and Dish Machine Temperature Verification
Penalty
Summary
The facility failed to properly store food products and verify the washing temperature of the dish machine in the Main Kitchen, which created the potential for foodborne illness. During an observation, an employee's lunch was found stored among the residents' food supply in the walk-in refrigerator, and it remained there for at least two days. The Dietary Manager confirmed the improper storage of food products. Additionally, the facility utilized a high-temperature dishwashing machine, but the staff did not verify the machine's operating temperature before washing dishes. Instead, they attempted to use test strips after the dishes were washed, which would not identify any issues beforehand. The test strips used were not appropriate for measuring the temperature of the dish machine. The first strip was intended for the three-compartment sink, and the second strip was for measuring chemical concentration, not temperature. The Temperature and Sanitizer Log indicated consistent entries of 160 degrees for the wash temperature, but an observation showed the gauge at 145 degrees, below the required minimum of 150 degrees. The Dietary Manager confirmed the failure to verify the washing temperature, which posed a risk of foodborne illness.
Failure to Assess Nutritional Status of Residents
Penalty
Summary
The facility failed to adequately assess the nutritional status of three residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. For Resident R3, the facility's dietary clinical note did not include essential information such as height, weight, and diet order, which were documented in the Minimum Data Set (MDS). This omission was confirmed by the Dietary Manager, who stated that she was instructed to provide only a brief note. Similarly, Resident R67's dietary clinical note also lacked the necessary details captured in the MDS, including height, weight, and diet order. Additionally, Resident R35 did not receive a nutritional assessment during significant change and quarterly assessments, as required. The Certified Dietary Manager confirmed the absence of these assessments. These failures indicate a lack of adherence to the facility's policy and state regulations, which require comprehensive nutritional assessments to ensure residents' dietary needs are met.
Deficiencies in Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for two residents, as well as proper signage and staff knowledge for a resident with a positive COVID-19 diagnosis. Resident R33, who had a Stage 4 pressure ulcer, was observed receiving incontinence care from a nurse aide who did not wear a gown as required by EBP. This was confirmed by a registered nurse who acknowledged the failure to follow the necessary precautions during high-contact care activities. Additionally, Resident R74, who had a wound vacuum and a PICC line, did not have a physician order for EBP, and there was no signage indicating the need for such precautions. A nurse aide providing care to Resident R74 was unaware of the requirement to wear a gown, and the resident's clinical record lacked the necessary documentation for EBP. The facility also failed to implement proper transmission-based precautions for Resident R180, who was in isolation for COVID-19. There was no signage at the facility entrance or on the resident's door to indicate the presence of an active COVID-19 infection. A registered nurse was uncertain about the resident's isolation status, and the Director of Nursing confirmed that the appropriate precautions were not in place. The facility's failure to follow EBP and transmission-based precautions was acknowledged by the Director of Nursing, highlighting deficiencies in infection prevention and control practices.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) with specialized training in infection prevention and control for six months, from February 2024 to July 2024. During the annual survey on July 15, 2024, it was found that the Director of Nursing was also serving as the current Infection Preventionist. The Nursing Home Administrator confirmed in interviews on July 15 and July 19, 2024, that the Director of Nursing had been covering the IP role since the previous IP's last day of work on February 5, 2024. This lack of a qualified IP was a violation of the facility's management and nursing services regulations as outlined in 28 Pa. Code 201.18(b)(3), 28 Pa. Code 201.14(a), and 28 Pa. Code 211.12(d)(1)(3).
Deficient Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the review of personnel records and staff interviews. Specifically, five out of ten employee files reviewed showed deficiencies in annual in-service training. These employees included Nurse Aides (NA) and a Licensed Practical Nurse (LPN). The personnel records of these employees lacked documentation of required training in areas such as resident rights, abuse, quality assurance performance improvement (QAPI), behavioral health, dementia care, infection control, communication, falls/incident accident, restorative care, emergency preparedness, and fire safety. The deficiencies were confirmed during an interview with Human Resource Employee E10, who acknowledged the facility's failure to provide the necessary training. The lack of training was noted across various critical areas, which are essential for ensuring the safety and well-being of residents. The report highlights the facility's non-compliance with the regulatory requirements set forth by 28 Pa. Code 201.18(b)(3) Management and 28 Pa. Code: 201.14(a) Responsibility of licensee.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate care of respiratory equipment for two residents, R70 and R71. Resident R70, who has diagnoses including high blood pressure, obstructive sleep apnea, and insomnia, was observed with a CPAP mask not stored in its designated storage bag, which is necessary to prevent contamination. This observation was confirmed by a registered nurse, indicating a lapse in following the facility's policy for storing respiratory equipment. Resident R71, diagnosed with hypertension, obstructive sleep apnea, and depression, was found to have a nasal cannula without a label indicating the date issued, contrary to the facility's policy requiring such labeling every two weeks. This was confirmed by an LPN, and the Director of Nursing acknowledged the facility's failure to adhere to the respiratory equipment care policy for both residents.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD), identified as Resident R1 and Resident R67. The facility's policy on Trauma Informed Care, dated January 30, 2024, mandates that nursing staff be trained on screening tools, trauma assessment, and identifying triggers associated with re-traumatization. However, the care plans for both residents did not identify specific PTSD triggers or strategies to avoid them, which is a critical component of trauma-informed care. Resident R1 was admitted with diagnoses including PTSD, high blood pressure, and dysphagia, while Resident R67 had PTSD, a cerebral vascular accident, and dysphagia. Despite these diagnoses, their care plans lacked the necessary details to address their PTSD triggers. This oversight was confirmed during an interview with Social Worker Employee E2, who acknowledged the facility's failure to identify and mitigate potential triggers for these residents, potentially leading to re-traumatization.
Medication Storage Deficiency in East Hall
Penalty
Summary
The facility failed to adhere to its medication storage policy, which requires that when the original seal of a manufacturer's container or vial is broken, the container or vial must be dated. During an observation of the East Hall medication carts A and B, it was found that several medications did not have a date opened as required. Specifically, Resident R10's albuterol inhaler and Resident R21's ipratropium albuterol were opened without a date on medication cart B. Similarly, on medication cart A, Resident R11's Trelegy and ipratropium albuterol, as well as Resident R23's fluticasone, were also opened without a date. Interviews with staff confirmed these deficiencies. LPN E18 confirmed the lack of date on the medications in cart B, while RN E20 confirmed the same issue for cart A. The Director of Nursing later confirmed that the facility failed to store medications properly and securely in two of the three medication carts. This failure to comply with the facility's medication storage policy was a violation of the relevant pharmacy and nursing services regulations.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, specifically $5,251.83, which was entrusted to the previous Business Officer Manager (BOM), Employee E8. The incident involved Resident R5, who was admitted to the facility with diagnoses including high blood pressure, renal insufficiency, and heart failure. The resident's daughter reported that the cash given to Employee E8 was not reflected in the resident's trust account, despite a receipt being issued. The money was also not found in the facility's safe. The facility conducted a lengthy investigation and made multiple attempts to contact Employee E8, but was unable to locate either the money or the employee. Consequently, the findings were reported to the police. The Nursing Home Administrator confirmed the facility's failure to ensure residents were free from misappropriation of funds, as evidenced by the incident involving Resident R5.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of property for a resident. The policy, dated January 30, 2024, stated that the facility would take all reasonable measures to protect residents during an abuse investigation, including suspending any employee alleged to be involved. However, this policy was not followed in the case of a resident who was allegedly a victim of theft by a nurse aide. The resident, who had been diagnosed with high blood pressure, renal insufficiency, and atrial fibrillation, was allegedly the victim of theft by Nurse Aide Employee E9, who was under investigation by local police for stealing between $18,000 and $20,000. Despite the ongoing investigation, the nurse aide continued to work at the facility and was not suspended or separated from residents, as confirmed by the Human Resource Employee E10 and the Nursing Home Administrator. This failure to act according to the facility's policy resulted in a deficiency related to the protection of residents' rights and property.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of property involving a resident, identified as Resident CR1, who was admitted with diagnoses including high blood pressure, renal insufficiency, and atrial fibrillation. The incident came to light when local police contacted the facility on June 18, 2024, regarding an investigation into Nurse Aide Employee E9 for the possible theft of $18,000 to $20,000 from Resident CR1. Despite this notification, the facility did not report the allegation to the Department of Health or any law enforcement entity within the required 24-hour timeframe, as stipulated by their policy. The facility's records of state reportable abuse allegations from August 27, 2023, to July 11, 2024, did not include any report related to the misappropriation allegations concerning Resident CR1. An interview with the Nursing Home Administrator on July 17, 2024, confirmed that the facility failed to report the alleged misappropriation to the local State field office. This oversight is a violation of the facility's responsibility and management regulations, as well as resident rights under the specified Pennsylvania codes.
Failure to Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to investigate a potential allegation of abuse/neglect related to the misappropriation of property for one resident. The facility's policy, dated 1/30/24, mandates that all allegations of abuse, neglect, exploitation, or mistreatment of residents be thoroughly investigated by the administrator and support staff. Resident CR1, who had diagnoses of high blood pressure, renal insufficiency, and atrial fibrillation, was admitted to the facility and resided there until 3/6/24. On 6/18/24, the facility was contacted by local police regarding an investigation into Nurse Aide Employee E9 for the possible theft of $18,000 - $20,000 from Resident CR1. Despite this notification, the Nursing Home Administrator confirmed on 7/17/24 that the facility did not initiate an investigation into the allegation, thus failing to adhere to their policy and potentially neglecting the resident's rights.
Failure to Maintain Proper Admission Documentation for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain proper admission documentation for two residents, both of whom were cognitively impaired. The facility's admissions policy, last reviewed on January 30, 2024, mandates fair and impartial admission practices. However, the review of resident records revealed that Resident R60, diagnosed with dementia, cardiomegaly, and chronic kidney disease, was admitted with a BIMS score of 7, indicating severe cognitive impairment. Despite this, the admission packet dated April 6, 2022, contained a signature from Resident R60. Similarly, Resident R2, diagnosed with chronic kidney disease and hypertensive heart disease, was admitted with a BIMS score of 2, also indicating severe cognitive impairment. The admission packet dated November 16, 2023, included a signature from Resident R2. During an interview, Admission Coordinator Employee E25 confirmed that both residents were cognitively impaired and should not have signed the facility paperwork. This failure to adhere to the admissions policy and ensure appropriate documentation was noted as a deficiency.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. According to the facility's policy on emergency transfers or discharges, a transfer form should be prepared and sent with the resident. However, for Resident R67, who was admitted with diagnoses including PTSD, cerebral vascular accident, and dysphagia, there was no documented evidence that specific information such as care plan goals, advanced directive information, and instructions for ongoing care were communicated to the hospital upon transfer. Similarly, Resident R72, who had diagnoses of high blood pressure, Alzheimer's disease, and hearing loss, was transferred to the hospital without documented evidence of communication of necessary information to the receiving health care provider. This included the resident's care plan goals, advanced directive information, and other essential details needed to meet the resident's specific needs. The Director of Nursing confirmed the lack of evidence for communication of necessary information for both residents during an interview.
Failure to Follow Physician Orders and Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to provide care according to physician orders and did not conduct weekly assessments for a resident with a surgical area. The resident, identified as R74, had a history of falling, a displaced trimalleolar fracture, hypertension, a dislocation to the left tarsometatarsal joint, an insertion of a left artificial ankle joint, and an infection. The hospital records indicated that the resident was hospitalized due to an infection in the left ankle surgical area, and a wound vacuum was ordered. The physician's orders specified the application of a wound vacuum and dressing changes every Monday, Wednesday, and Friday, with no need for a wound vac on the medial incision. However, the facility did not include actions to take if the wound vacuum was inoperable or unavailable. Observations and interviews revealed that the facility did not perform weekly assessments of the resident's surgical wound area from 7/4/24 to 7/16/24. During an interview, a registered nurse confirmed that there was no order for a wet-to-dry dressing change in case of wound vacuum malfunction. Additionally, the wound vacuum machine was found off during an observation, and the Assistant Director of Nursing stated it might have been shut off during therapy. The Director of Nursing confirmed the facility's failure to provide care as per physician's orders and to conduct the required weekly assessments.
Failure to Ensure Proper Representation for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that a representative signed a binding arbitration agreement on behalf of two residents who lacked the capacity to understand the agreement terms. This deficiency was identified for two residents, referred to as Resident R2 and Resident R60, both of whom were assessed with severe cognitive impairment. Resident R60, admitted with diagnoses including dementia, cardiomegaly, and chronic kidney disease, had a BIMS score of 7, indicating severe cognitive impairment. Despite this, the arbitration agreement dated 4/1/22 was signed by Resident R60. Similarly, Resident R2, admitted with chronic kidney disease and hypertensive heart disease, was assessed with a BIMS score of 2, also indicating severe cognitive impairment. The arbitration agreement for Resident R2, dated 11/4/23, was signed by the resident. During an interview, the Admission Coordinator confirmed that both residents were cognitively impaired and should not have signed the facility paperwork. This failure to ensure proper representation in signing the arbitration agreements constitutes a deficiency in the facility's admission policy and responsibility of the licensee.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as R1. According to the facility's policy dated 1/31/23, each resident should have a care plan that includes measurable objectives and timetables to meet their physical, psychosocial, and functional needs. Resident R1 was admitted with diagnoses of dementia, diabetes mellitus, and bipolar disorder. A Minimum Data Set (MDS) assessment dated 4/10/24 confirmed these diagnoses were current. Additionally, a wandering risk assessment indicated that Resident R1 was at moderate risk for wandering. However, the resident's care plan was not updated to reflect this risk. During an interview, the Nursing Home Administrator confirmed the facility's failure to update and develop a comprehensive care plan for Resident R1.
Failure to Provide Adequate Supervision for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident R1, who was identified as having a low risk for wandering. Resident R1, who has diagnoses including dementia, diabetes mellitus, and bipolar disorder, was found outside the facility after the receptionist locked the door for the evening. The resident was knocking on the door and was assisted back into the building by staff. A nurse assessed Resident R1 and found no injuries, and notifications were made to the resident's son, physician, and the Director of Nursing. However, no new orders were issued following the incident. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility failed to provide adequate supervision to prevent a potential accident for Resident R1. The facility's policy on incident/accident reporting emphasizes maintaining resident safety in the least restrictive manner, yet the lack of adequate supervision and a comprehensive care plan for Resident R1 led to this oversight. The incident highlights a lapse in ensuring the safety and supervision of residents, particularly those with cognitive impairments.
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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.
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.
Facility staff failed to follow dialysis care policies and the care plan for a resident with diabetes mellitus, chronic kidney disease, and an upper extremity hemodialysis fistula. Despite clear directions to avoid using the arm with the dialysis access for any treatment, including blood pressure measurement, staff repeatedly documented taking blood pressure on that arm over multiple months. The DON later confirmed that the resident’s blood pressure had been measured on the arm containing the dialysis access.
A resident admitted with PTSD, depression, polyneuropathy, and insomnia, and assessed as having no cognitive impairment but needing substantial assistance with ADLs, was not evaluated for PTSD-related symptoms or triggers. The care plan did not address the resident’s trauma history, identify triggers, or include specific interventions to minimize triggers or re-traumatization. The DON confirmed that no PTSD assessment or related care planning had been completed, resulting in a deficiency in required nursing services.
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.
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.
Improper Blood Pressure Measurement on Dialysis Access Arm
Penalty
Summary
Facility staff failed to provide appropriate dialysis-related care by not adhering to policy and the resident’s care plan regarding protection of a hemodialysis access site. The facility’s policy on hemodialysis external catheter evaluation and maintenance, last reviewed February 24, 2026, directed staff to avoid taking blood pressure from an arm with a dialysis access device. The resident, who had diabetes mellitus with chronic kidney disease and required ongoing hemodialysis, had a care plan initiated November 11, 2021 and last reviewed December 17, 2025 that instructed staff to monitor the left upper extremity fistula for bleeding and to avoid using that arm for any treatment to prevent complications related to dialysis access. Despite these directives, clinical record review showed that staff documented taking the resident’s blood pressure on the left arm 10 times in January 2026, 10 times in February 2026, 14 times in March 2026, and four times in April 2026. In an interview on April 17, 2026, the Director of Nursing confirmed that the documentation showed the resident’s blood pressure had been measured on the left arm containing the dialysis access. These findings were cited under 28 Pa. Code 211.10(d) Resident care policies and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
Surveyors identified that the facility failed to provide trauma-informed, person-centered care for a resident with a documented diagnosis of post-traumatic stress disorder (PTSD). The resident was admitted with PTSD, depression, polyneuropathy, and insomnia, and a Minimum Data Set assessment showed no cognitive impairment, a need for substantial assistance with activities of daily living, and a confirmed PTSD diagnosis. Despite this, the clinical record contained no documentation that the resident had been assessed for PTSD-related symptoms or triggers, and the resident’s care plan lacked any measures addressing the history of trauma, identifying triggers, or specifying interventions to minimize triggers or re-traumatization. In an interview, the Director of Nursing confirmed that the resident had not been assessed or care planned for PTSD, in violation of 28 Pa. Code 211.12(d)(3)(5) regarding nursing services.
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