William Penn Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Pennsylvania.
- Location
- 163 Summit Drive, Lewistown, Pennsylvania 17044
- CMS Provider Number
- 395335
- Inspections on file
- 21
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at William Penn Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors identified that several MDS assessments contained inaccurate information, including incorrect documentation of anticoagulant use, limb and trunk restraint use, and lower extremity impairments for multiple residents. Staff interviews confirmed these were coding errors, and the DON was notified of the discrepancies.
Six residents were not assisted in obtaining routine dental care, with clinical records and staff interviews confirming that they were not offered or provided dental services every six months as required. Some had not seen a dentist in years, and others had no documentation of dental care since admission, despite having natural teeth, broken teeth, or dentures.
The facility did not track or document staff COVID-19 vaccination status as required. Instead of offering the vaccine individually, signs were posted instructing staff to seek vaccination elsewhere, and no records were maintained to show staff vaccination status or that the vaccine was offered.
A resident with a Foley catheter for urinary retention was repeatedly observed with their catheter bag uncovered and visible from the hallway, either hanging on the bed or lying on the floor. The DON confirmed these findings, indicating a failure to uphold resident dignity as required.
Two residents reported extended delays in call bell response for toileting assistance, with one experiencing waits of up to an hour and another frequently waiting over 30 minutes. Both residents attributed these delays to insufficient staffing, resulting in episodes of incontinence and unresolved grievances. Interviews and record reviews confirmed the lack of timely response and inadequate staffing levels.
A medication cart used by an LPN was found to contain significant debris and hair, along with several unsecured and unidentified medication tablets mixed in with medication punch cards. These issues were confirmed by the DON.
The facility did not post current daily nurse staffing information at the beginning of each shift for two nursing units. Observations and staff interviews confirmed that the posted information was outdated and not displayed in prominent locations at or near the nurse stations.
William Penn Nursing and Rehab failed to meet the required nurse aide-to-resident ratios as per Pennsylvania regulations. Over a 21-day period, the facility did not maintain the necessary staffing levels during the day, evening, and night shifts, as confirmed by staffing records and interviews with the administration.
The facility did not meet the required LPN to resident ratios, with deficiencies noted on both day and night shifts. On two occasions, the day shift was understaffed, and on six occasions, the night shift did not meet the required LPN per resident ratio. These staffing shortfalls were confirmed by the Nursing Home Administrator and DON.
The facility failed to accurately assess residents' status, with errors in MDS coding for restraints and anticoagulant use. Several residents were incorrectly documented as having bed rails used as restraints, despite evidence showing they were for mobility. Additionally, two residents were inaccurately noted as receiving anticoagulants, which was not supported by clinical records. These errors were confirmed by facility staff.
The facility failed to maintain a clean and safe environment in two shower rooms on Nursing Unit 1. Observations revealed dislodged tiles, debris in ceiling lights, grime on floors, peeling paint, and sharp metal tabs in the larger shower room. The second shower room had debris, wall damage, stained curtains, and spiders. A chair at Nurse Station 1 was also worn and damaged. These issues were discussed with the Nursing Home Administrator and DON.
The facility did not complete a significant change MDS assessment within the required timeframe after a resident elected hospice care. The MDS, which should have been completed within 14 days, was not documented until identified by a surveyor. This deficiency was confirmed during an interview with the Nursing Home Administrator and DON.
The facility failed to create comprehensive care plans for two residents, one with vision loss due to macular degeneration and another needing extensive dental work. The absence of these care plans was identified during a survey, and plans were only developed after the surveyor's inquiry.
A resident with a PICC line for intravenous antibiotics due to osteomyelitis did not receive proper care as per physician orders. The facility failed to change the midline dressing every seven days and did not perform required assessments of the catheter site. Observations confirmed the dressing was unchanged for 17 days, and there was no emergency kit or arm restriction signs in the resident's room. The facility lacked a policy outlining staff competencies for midline catheter care.
A facility failed to implement recommended interventions for a resident with sensorineural hearing loss. Despite an audiology assessment recommending a pocket talker to aid communication, the resident's care plan did not include this device. The deficiency was identified during an interview with the resident, who reported difficulty hearing and relied on a dry erase board for communication.
A facility failed to provide physician-ordered ROM services for a resident, as staff did not document the completion of a restorative program aimed at preventing contractures. The program included passive stretching of the left lower extremity, which was not consistently documented over several months, suggesting non-compliance with the physician's orders.
A facility failed to implement supplemental oxygen per physician orders for a resident with hypoxia. The resident's oxygen concentrator was set at one and one-half liters per minute instead of the ordered 0.5 liters per minute, despite a 99% oxygen saturation. The treatment administration record contained erroneous documentation, and the plan of care did not reflect the correct oxygen flow. Additionally, nebulizer equipment was not stored properly, violating infection control policy.
A facility failed to ensure a resident's medication regimen was free from unnecessary drugs. A pharmacist recommended dose reductions for Escitalopram and Ativan, but the physician disagreed without explanation. There was no documentation of behaviors justifying the continued use of these medications. The Nursing Home Administrator and DON were informed of these concerns.
The facility's medication error rate was 6.67%, exceeding the acceptable threshold. Errors included administering Omeprazole after breakfast instead of before meals, and a resident self-administering Fluticasone Propionate nasal spray incorrectly without intervention or assessment for self-administration capability.
A facility failed to implement enhanced barrier precautions for a resident with an open foot wound and a midline for IV antibiotics. Despite a sign indicating the need for gown and gloves, a nurse performed wound care without wearing an isolation gown, contrary to the facility's infection control policy.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the actual status of six residents, as identified through clinical record reviews and staff interviews. For one resident, the Minimum Data Set (MDS) assessment incorrectly indicated the use of an anticoagulant, despite no evidence in the clinical record that the medication was prescribed or administered during the assessment period. Staff confirmed this was a coding error. In another case, a resident was marked as having used a limb restraint, but staff interviews revealed that the resident had never utilized such a restraint, indicating another MDS coding error. Additional inaccuracies were found in the assessments of other residents, including two residents who were incorrectly documented as having impairments of their lower extremities, and two residents who were marked as having used trunk restraints, though staff confirmed these restraints were never used. These errors were confirmed by registered nurse assessment coordinators during interviews, and the Director of Nursing was made aware of the discrepancies. The deficiencies were cited under federal and state regulations regarding the accuracy of resident assessments and nursing services.
Failure to Provide Routine Dental Services to Residents
Penalty
Summary
The facility failed to assist six out of eight reviewed residents in obtaining routine dental care as required. Observations and clinical record reviews revealed that several residents with natural teeth, broken teeth, or dentures had not been offered or provided with routine dental services every six months, as covered under the state Medicaid plan. For example, one resident with natural teeth had not seen a dentist since 2020, and another with broken teeth had no evidence of ever being seen by a dentist since admission. Interviews with staff confirmed the lack of documentation or evidence that these residents were offered or received routine dental care. Additional record reviews showed that residents with dentures or some natural teeth also lacked documentation of being offered or provided with routine dental services. Staff interviews further confirmed these findings, and the Director of Nursing acknowledged that there was no further evidence of routine dental care being provided to the affected residents. The deficiency was cited under state regulations for nursing and dental services.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain and document the COVID-19 vaccination status of its staff as required. During an interview, the Infection Preventionist (a registered nurse) acknowledged that she was not tracking staff vaccination status and had no evidence of offering the COVID-19 vaccine to staff members. Instead of individually offering the vaccine, the facility posted signs near the time clock and in the employee breakroom instructing interested staff to seek vaccination from their primary care physician or local pharmacy. This lack of individualized tracking and documentation was confirmed when the surveyor requested vaccination information and none could be provided for the staff reviewed.
Failure to Maintain Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to maintain resident dignity by not covering the urinary catheter bag of a resident with a physician's order for a Foley catheter to straight bag drainage for urinary retention. Multiple observations over several days showed the resident in bed with the catheter bag uncovered and in full view from the hallway, either hanging on the side of the bed or lying on the floor, making it visible to anyone passing by. These findings were confirmed during an interview with the Director of Nursing. The deficiency was cited under regulations related to management and resident rights.
Failure to Provide Sufficient Nursing Staff for Timely Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically regarding timely response to call bells for assistance with toileting. One resident, who was cognitively intact and occasionally incontinent, reported waiting up to an hour for help to use the bathroom, resulting in incontinence and embarrassment. The resident also noted that an LPN would turn off the call bell and state they would notify a nurse aide, but no one would return to assist. A grievance was filed by this resident regarding the incident, but there was no documented resolution, and call bell audits were not conducted until nearly two weeks later. Another resident, who was frequently incontinent of bladder, expressed ongoing concerns about insufficient staffing, stating that delays in call bell response occurred on all shifts and often resulted in waiting over 30 minutes for assistance. Both residents' concerns were confirmed through interviews and clinical record reviews. These findings were discussed with facility leadership, and the lack of timely response was attributed to inadequate staffing levels.
Improper Storage and Labeling of Medications in Medication Cart
Penalty
Summary
During a medication pass on the Station Two Nursing Unit (Honey Creek Hall), a medication cart in use by an LPN was observed to have a significant accumulation of debris and dirt, including hair, in the bottom of its drawers. Additionally, several unsecured and unidentified medication tablets were found in the drawer containing medication punch cards, including two white round pills, two orange round pills, a multi-colored capsule, and a large brown pill. These findings were confirmed during a meeting with the Director of Nursing. No information was provided regarding the involvement of specific residents or their medical conditions at the time of the deficiency.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information at the beginning of each shift for both Nursing Unit One and Nursing Unit Two. Observations on two separate occasions revealed that the nurse staffing sheet displayed near the main lobby was outdated, showing the previous day's date. Additionally, there was no nurse staffing information posted in a prominent place at or near the nurse stations for either nursing unit. Staff interviews confirmed the absence of the required postings at the nurse stations, and it was noted that the information near the main lobby was not updated until later in the day.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
William Penn Nursing and Rehab was found to be non-compliant with the Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to maintain the required nurse aide-to-resident ratios during various shifts over a 21-day review period. On one day, the day shift did not meet the required ratio of one nurse aide per 10 residents. The evening shift failed to meet the required ratio of one nurse aide per 11 residents on three separate days. Additionally, the night shift did not meet the required ratio of one nurse aide per 15 residents on seven different days. The deficiency was identified through a review of nursing staffing hours and confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The facility's staffing records for specific weeks in December 2024 and January 2025 showed that the number of nurse aides scheduled was insufficient to meet the regulatory requirements based on the resident census. This failure to comply with staffing regulations was acknowledged by the facility's administration during the survey process.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by regulations effective July 1, 2023. Specifically, during the day shift, the facility did not provide the minimum of one LPN per 25 residents on two occasions within the 21 days reviewed. On December 27, 2024, there were 4.5 LPNs for a census of 113 residents, requiring 4.52 LPNs, and on December 29, 2024, there were 4 LPNs for a census of 111 residents, requiring 4.44 LPNs. Additionally, the night shift was understaffed on six occasions, failing to provide the required one LPN per 40 residents. For instance, on December 4, 2024, there were 2.19 LPNs for a census of 116 residents, requiring 2.90 LPNs, and similar shortfalls were noted on December 7, 18, 21, 26, and 30, 2024. These deficiencies were confirmed through an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025.
Plan Of Correction
1. Facility will continue to take measures to adequately provide staff to ensure the needs of residents are met. 2. The Director of Nursing or designee will provide re-education on minimum staffing ratios to RN Supervisors, Human Resources, and Scheduling Coordinator who are responsible to maintain adequate staffing and staffing ratios. 3. The Director of Nursing or designee will audit the daily schedules to ensure the minimum number of staff to resident ratios have been scheduled and will audit that protocols were followed if a call off occurred. 4. Audits will be completed weekly, and results of these audits will be reviewed at Quality Assurance and Process Improvement Meetings until substantial compliance is achieved. 5. Compliance Date: 1/27/2025
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status, affecting 10 out of 24 residents reviewed. For several residents, the Minimum Data Set (MDS) assessments inaccurately documented the use of physical restraints, specifically bed rails, which were not used as restraints according to the CMS RAI Manual. Residents 60, 41, 97, 109, 32, 55, 63, and 85 were all incorrectly assessed as having bed rails used as restraints, despite evidence showing that these rails were used for bed mobility and not as restraints. Interviews with residents and their family members confirmed that no restraints were used, and the facility's own assessments supported this finding. Additionally, the facility inaccurately documented the use of anticoagulant medications for Residents 19 and 9. The MDS for Resident 19 noted the use of an anticoagulant, but clinical records showed no evidence of such medication being administered during the assessment period. Similarly, Resident 9's MDS indicated anticoagulant use, but a review of medication administration records for March and April 2024 revealed no anticoagulant was given. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these errors in MDS coding. The errors in the MDS assessments were confirmed through interviews with the Director of Nursing, the Nursing Home Administrator, and the Registered Nurse Assessment Coordinator. These inaccuracies in the MDS coding were acknowledged as errors, with the staff confirming that the residents did not have restraints or receive anticoagulants as documented. The facility's failure to accurately assess and document the residents' status led to these deficiencies being identified during the survey.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in two shower rooms located on Nursing Unit 1, Windmill Hill. During an observation, a dislodged piece of tile was found on the floor around the drain area in the larger shower room. The ceiling lights in this room contained debris, including dead insects, and the tiled floor had a build-up of grime and stains. Additionally, the paint on the ceiling above the shower was peeling, and a ceiling light above the commode also had debris and a dead insect. A metal hand hygiene product dispenser base near the sink had sharp metal tabs, posing a potential hazard, and a heater vent had an extensive build-up of dust. In the second shower room, a ceiling light above the commode had debris, and there was a damaged section of the wall behind the commode. The shower curtain was stained, and multiple spiders were observed in and around the shower stall. There was also a build-up of debris on the base of the wheelchair scale. Additionally, a maroon chair at Nurse Station 1 had extensive wear, with peeling and cracked cushions. These observations were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Timely Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner following the election of hospice care for a resident. According to the Resident Assessment Instrument 3.0 User's Manual, a significant change MDS must be completed no later than 14 days after the effective date of the election of hospice care. For Resident 103, hospice care was ordered by their physician on June 6, 2024. However, there was no documentation indicating that the facility completed the required significant change MDS assessment until it was identified by the surveyor. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on June 24, 2024. The failure to complete the MDS assessment as required was a violation of 28 Pa. Code 211.5 (f) regarding clinical records.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, resulting in deficiencies in maintaining the highest practicable care. Resident 41, who is legally blind due to macular degeneration, did not have a care plan addressing her vision loss. Although a care plan was initially created in September 2020, it was resolved shortly after and not updated until the surveyor's inquiry in June 2024. This oversight was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. Similarly, Resident 81, who required extensive dental work due to receding gums and the need for several teeth extractions, did not have a care plan addressing her dental issues. The absence of a care plan was noted during a surveyor's review and confirmed in discussions with facility leadership. A care plan was only developed after the surveyor highlighted the deficiency. These failures indicate a lack of comprehensive care planning for the residents' specific needs.
Deficiency in Midline Catheter Care
Penalty
Summary
The facility failed to provide the highest practicable care related to intravenous access for a resident, identified as Resident 80, who was reviewed for intravenous access concerns. The facility's policy on midline dressing changes did not include necessary interventions to prevent infection or complications from the use of a midline catheter. The policy also lacked routine assessments needed to monitor the resident during the presence of a midline catheter. Resident 80 was admitted with a PICC line in the right upper arm and had physician orders for intravenous antibiotics due to acute osteomyelitis of the right ankle and foot. Upon review of Resident 80's clinical records, it was found that the facility did not adhere to the physician's orders regarding the care and maintenance of the midline catheter. The orders included changing the midline dressing and caps every seven days and monitoring the site every shift. However, staff failed to measure the circumference of the resident's arm and the length of the external midline tubing as required. Observations confirmed that the midline dressing had not been changed for 17 days, despite orders to change it every seven days. Additionally, there was no emergency kit or signs indicating restrictions for the resident's right arm in the room. Interviews and observations with the resident and staff revealed discrepancies in the documentation and actual care provided. The treatment administration record indicated a dressing change was completed, but observations showed the dressing remained unchanged. The facility did not provide a policy or procedure outlining staff competencies or expectations for planning care for residents with a midline catheter. These findings were discussed with the Director of Nursing and the Nursing Home Administrator.
Failure to Implement Hearing Loss Interventions
Penalty
Summary
The facility failed to implement interventions to treat hearing loss for a resident who was reviewed for hearing concerns. The resident, identified as having sensorineural hearing loss bilaterally, was assessed by the facility's contracted audiology professional. The assessment recommended the use of a pocket talker, a personal sound amplifier, to aid in communication. However, the resident's plan of care did not include this recommendation, and there was no evidence that the facility implemented the audiology provider's recommendation. The deficiency was identified during an interview with the resident, who reported difficulty hearing and required a dry erase board for communication, and was confirmed through interviews with the Director of Nursing and the Nursing Home Administrator.
Failure to Provide Physician-Ordered ROM Services
Penalty
Summary
The facility failed to provide physician-ordered services to maintain a resident's range of motion (ROM) for one of the two residents reviewed. Resident 55 had a current physician's order for a restorative program to prevent contractures, which included passive stretching of the left lower extremity into knee extension, to be performed five times and held for 30 seconds during morning and evening care. However, a review of task documentation for April, May, and June 2024 revealed that staff did not document the completion of this restorative task on multiple dates across both day and evening shifts. This lack of documentation indicates that the ordered ROM exercises may not have been consistently performed as required.
Failure to Implement Physician-Ordered Supplemental Oxygen
Penalty
Summary
The facility failed to implement supplemental oxygen per physician orders for a resident diagnosed with hypoxia. The resident, who was diagnosed with rhinovirus, was observed using a room concentrator set at one and one-half liters per minute, contrary to the physician's order of 0.5 liters per minute at hour of sleep. Despite the resident's oxygen saturation being assessed at 99 percent, the oxygen flow was not adjusted according to the physician's order, and the resident did not exhibit signs of dyspnea. Additionally, the treatment administration record contained erroneous documentation of oxygen liter flow, with entries ranging from 93 to 99 liters per minute, which was not feasible with the available equipment. The facility's plan of care for the resident did not reflect the physician's ordered oxygen liter flow, and there was no policy or procedure provided regarding the use of supplemental oxygen. Furthermore, the nebulizer equipment used for the resident's medication administration was not stored in a protective bag as required by the facility's infection control policy. Interviews with staff confirmed these discrepancies, highlighting a lack of adherence to physician orders and infection control protocols.
Failure to Ensure Medication Regimen Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications. A review of the clinical record for a resident revealed that a pharmacist had recommended a gradual dose reduction of Escitalopram, a medication used to treat depression, but the attending physician disagreed without providing an explanation. Additionally, there was no documentation of behaviors related to the resident's depression that would justify the continued use of Escitalopram. Similarly, a pharmacist recommended a trial dose reduction of Ativan, a medication used to treat anxiety, but the physician again disagreed without explanation. The clinical record also lacked documentation of behaviors related to the resident's anxiety that would necessitate the use of Ativan. The Nursing Home Administrator and Director of Nursing were informed of these concerns, highlighting the facility's failure to ensure the resident's medication regimen was free from potentially unnecessary drugs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.67 percent, exceeding the acceptable threshold of less than five percent. This was based on 30 medication opportunities with two errors identified. One error involved the administration of Omeprazole to a resident after breakfast, contrary to the recommended practice of taking it one hour before meals to ensure optimal absorption. The registered nurse confirmed the error during an interview, acknowledging that the medication was given after the resident had eaten. Another error involved the administration of Fluticasone Propionate nasal spray to a different resident. The resident was observed administering two sprays in each nostril instead of the prescribed one spray per nostril. The nurse did not intervene to correct the resident after the first incorrect administration. Furthermore, there was no documentation indicating that the resident had been assessed for the capability to self-administer medications. The nurse confirmed the error and acknowledged the lack of assessment for self-administration capability.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBPs) for a resident with infection control concerns. The facility's policy on EBPs, last reviewed in March 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the spread of multi-drug resistant organisms. This includes activities such as wound care and device care. Despite a sign indicating the need for EBPs on the resident's door, a registered nurse did not wear an isolation gown while performing wound care on the resident's open foot wound. The resident, identified as having osteomyelitis of the right foot and receiving intravenous antibiotics through a midline, had a culture that identified pseudomonas bacteria. During an observation, the nurse conducted wound care procedures without donning an isolation gown, despite the presence of a sign indicating the requirement for enhanced barrier precautions. The nurse confirmed the oversight during an interview, acknowledging the failure to adhere to the facility's infection control policy.
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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