York North Skilled Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in York, Pennsylvania.
- Location
- 1770 Barley Road, York, Pennsylvania 17408
- CMS Provider Number
- 395442
- Inspections on file
- 34
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at York North Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
The facility failed to provide palatable food and beverages at appropriate temperatures, as confirmed by resident interviews and a test tray evaluation. Several residents reported that their meals are always served cold. A test tray taken after a lapse between kitchen preparation and temperature checks showed hot items such as macaroni and cheese and stewed tomatoes below the facility’s hot‑food standard, and cold items such as milk and orange juice above the cold‑food standard, while a cookie was served at room temperature. The Food Service Director acknowledged that the steam table was working and that hot items had recently come from the oven, yet still did not meet expected temperatures, and also stated that the milk should have been colder, with no further explanation provided by the NHA.
Surveyors found that food and beverages were not stored or handled according to professional standards in the kitchen and several nourishment pantries. An open package of cheese in the walk‑in refrigerator was not date‑marked, and a fan, ceiling, and vents above the tray line had visible buildup. Microwaves in multiple nourishment pantries contained dried food and spills, and resident food items in refrigerators lacked required identifiers and dates. Staff food, including a lunch bag and energy drinks, was stored in refrigerators intended for residents. A thawed nutritional shake was not labeled with a use‑by date, and the Food Service Director could not determine when it was thawed. During tray line service, several kitchen staff with facial hair worked without required beard coverings, and leadership acknowledged that food should be stored per standards and that staff food should not be kept in nourishment refrigerators.
A resident with hypertension and depression was started on Zoloft 50 mg daily for depression, but the facility did not follow its Health Care Decision Making policy or its Psychotropic Medication Administration Disclosure process. Review of the clinical record and the psychotropic disclosure form showed that neither the resident nor the representative was informed of the risks and benefits of the antidepressant, and the required disclosure form was not signed. The DON confirmed that the medication and its associated information were not reviewed with the resident at the time it was ordered.
Two residents did not receive accurate MDS assessments when staff coded one resident’s urinary and bowel incontinence as only frequent rather than constant, despite documentation and staff statements that the resident had always been incontinent since admission, and coded another resident with a suprapubic indwelling urinary catheter as having an ostomy instead of correctly identifying the device type, contrary to RAI Manual guidance.
Surveyors found that the facility did not consistently review and revise care plans to match current assessments, MD orders, and resident preferences. One resident with multiple chronic conditions had conflicting care plan entries about smoking and leave-of-absence status that did not align with recent smoking evaluations and LOA orders. Another resident with hypertension and ESRD had a full code order from the physician, while the care plan incorrectly documented DNR status. A third resident with diabetes and GERD had documented discussions about discharge options and changing preferences, but her care plan did not reflect her expressed choice regarding discharge versus remaining in LTC.
A resident with multiple vision-related diagnoses, including macular degeneration, dry eyes, suspected glaucoma, pseudophakia, hyperopia, and presbyopia, had a care plan identifying vision impairment and the need for glasses, yet continued to use severely damaged eyeglasses missing a lens and nose piece, with the remaining lens heavily scratched. The resident reported repeatedly requesting new glasses over the course of a year and described difficulty reading, doing preferred activities, and watching television. An eye consult had recommended new glasses, but the billing for these glasses was mishandled, first being sent to a daughter barred from contact and then not successfully completed by the guardian until much later, resulting in the resident not receiving the prescribed eyewear.
A resident with deforming dorsopathy and gait/mobility abnormalities had a PT discharge recommendation and care plan goal for a restorative ambulation program, including supervised walking with a rolling walker throughout the unit twice daily. Facility policy required patient-specific restorative programs to be implemented per the care plan, but restorative documentation repeatedly showed the ambulation program as "not applicable" over multiple days, and the resident reported being assisted to walk in the hallway only a few times since therapy discharge. The DON later noted that the restorative program was incorrectly titled in the EHR, potentially confusing CNAs, and although the POC task was corrected to specify walking 100–150 ft, staff continued to document the program as "not applicable," indicating the restorative ambulation services were not being provided as planned.
A resident with COPD and muscle wasting, ordered scheduled nebulized bronchodilators and oxygen via nasal cannula, did not receive respiratory care consistent with professional standards and facility policy. Surveyors observed the resident’s nebulizer mask on a bedside table, nebulizer tubing on the floor, and oxygen tubing from the concentrator to the nasal cannula lying across the floor. On subsequent observations, the nebulizer mask and tubing were bagged but not changed despite previously being on the floor, and both the bagged nebulizer tubing and oxygen tubing continued to touch the floor. The DON acknowledged that respiratory equipment should be stored and used to prevent contamination with microorganisms.
A resident with HTN and ESRD who required scheduled hemodialysis did not have complete dialysis communication documentation as required by facility policy. The facility’s dialysis guidelines required use of a Hemodialysis Communication Form to share information such as vital signs, weights, and medications between the center and the dialysis provider. Review of the resident’s records showed that on one treatment date the post-dialysis weight was not recorded, and on another date blood pressure, pre- and post-dialysis weights, pulse, and medications given during hemodialysis were not documented. The DON confirmed that these sections of the forms should have been completed.
Surveyors identified that corridor handrails were not firmly secured in two resident halls, contrary to the facility’s policy for a safe and homelike environment. During observations, a handrail on the left side of one hall and a handrail on the right side of another hall near the therapy gym were found to be loose to the touch, indicating that the corridors were not maintained with securely affixed handrails on both sides as required.
A resident with A-fib and anxiety had an order for Amiodarone 200 mg twice daily that was changed by a heart and vascular provider to once daily, but nursing staff continued to administer the medication twice daily for multiple days after the change. Review of the MAR and clinical record showed the dose was not updated in accordance with the new prescriber order, and nursing documentation later acknowledged that the medication should have been given once daily. The DON confirmed the medication should have been adjusted to once per day per the updated order.
A resident with dementia and anxiety was involuntarily secluded when a nursing assistant held her room door shut while she was inside, yelling to be let out. The staff member admitted to this action due to feeling scared. The incident was not promptly reported to the RN Supervisor, and the initial investigation did not include all relevant staff interviews or an immediate resident assessment. The event was only reported to the RN Unit Manager the next day, who found no injuries upon assessment.
The facility failed to provide proper written notifications for hospital transfers, omitting essential information such as appeal rights and contact details for the Ombudsman. This affected three residents, with missing or incomplete transfer notices, as confirmed by the NHA.
The facility failed to develop comprehensive care plans for three residents, including one with complex medical needs requiring enhanced barrier precautions and two on hospice care. The lack of appropriate care plans was confirmed by the DON, indicating non-compliance with the facility's care planning policy.
Two residents, dependent on staff for personal hygiene, did not receive showers as scheduled due to staffing issues. One resident, with chronic health conditions, missed several scheduled showers despite filing a grievance. Another resident, with heart-related diagnoses, was not given the opportunity to choose her preferred bathing method, missing scheduled showers and receiving bed baths instead. The DON acknowledged the failure to meet residents' preferences and schedules.
The facility failed to follow physician orders and care plans for three residents. A resident on hospice did not have a documented physician order for hospice status. Another resident was not wearing prescribed Geri-leg and Geri-sleeve, and a third resident was given Percocet despite having no documented pain. The DON confirmed these discrepancies against the facility's expectations.
The facility failed to monitor the nutritional status of four residents by not conducting regular weight assessments as ordered. A resident with hypertension and Alzheimer's was not weighed for several months, while another with syncope and cardiomyopathy had missing weight data despite significant weight gain. A resident with diabetes and hypertension was not weighed per orders, and another with diabetes and chronic pain had incomplete weight documentation. The DON confirmed the expected assessments were not completed.
The facility failed to provide adequate dining services staff, resulting in delayed meal and nourishment delivery on multiple occasions. Resident interviews and Food Committee meeting minutes highlighted concerns about late meals, particularly on weekends. Observations on specific dates in February 2025 showed significant delays in meal service, with staff shortages in Dietary contributing to the issue. The Nursing Home Administrator acknowledged staffing challenges, with recent efforts to fill open positions.
The facility failed to maintain food safety and hygiene standards, with expired and incorrect test strips for sanitizer, lack of date marking on food items, and unclean prep areas. Staff were unaware of policies regarding facial hair restraints and proper food storage. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to implement enhanced barrier precautions (EBP) for several residents with conditions requiring such measures. Despite having internal devices, chronic wounds, or a history of multi-resistant organisms, there was no PPE or EBP signage for these residents. Interviews with the DON and NHA confirmed the oversight, highlighting a lapse in infection control policy adherence.
A resident experienced a delay in receiving a package suspected to contain pills, which was handed to the DON due to safety concerns. The package was delivered a week later by the NHA. The facility lacked documentation and a policy for handling such packages, contributing to the delay.
A facility failed to ensure a resident was given the opportunity to formulate an Advance Directive, despite having a policy requiring staff to discuss this with capable residents. The resident, with chronic kidney disease and chronic pain syndrome, had an intact cognitive status but no documentation of being offered information on Advance Directives. The Social Services Director confirmed that discussions on Advance Directives were not conducted with residents or their representatives.
A resident with Alzheimer's and hypertension was administered Ativan without proper indication, contrary to the facility's policy against chemical restraints. Despite a care plan focusing on non-pharmacological interventions, Ativan was used for behaviors like restlessness and insomnia, which were not aligned with the resident's documented needs. Staff interviews confirmed the resident was not at risk of falls, yet the medication was used, indicating a failure to adhere to policy.
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their clinical records. One resident's MDS inaccurately documented the number of Stage 4 pressure ulcers, while another resident's MDS incorrectly indicated no hospice care despite prior discharge from hospice services. These errors were identified and confirmed by the Nursing Home Administrator and the Registered Nurse Assessment Coordinator.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident with type two diabetes and chronic pain syndrome. The plan lacked focus areas such as falls, cardiovascular health, dietary needs, and psychotropic medication monitoring. The comprehensive care plan was delayed, and the DON confirmed the omission of expected items.
The facility failed to update care plans for two residents. One resident's care plan still included a focus on an indwelling catheter that had been removed, while another resident's care plan incorrectly listed hospice as responsible for interventions after discharge from hospice services. The DON and NHA acknowledged these oversights.
The facility failed to provide proper respiratory care for two residents with COPD. A resident's nebulizer mask was left uncovered and improperly stored, and the nebulizer machine was left running. Another resident's nebulizer equipment was also left uncovered. The DON confirmed that supplies are distributed weekly, but proper storage and cleaning protocols were not followed.
A facility failed to maintain complete dialysis communication records for a resident with discitis and COPD, missing several pre and post-dialysis weights as required by their care plan. Despite the facility's policy, communication forms were incomplete on multiple occasions, as confirmed by the DON.
A resident with type two diabetes and chronic pain syndrome did not receive their prescribed benazepril medication due to a discrepancy in the number of tablets delivered and administered. The facility ran out of the medication, leading to missed doses. Despite having an alternative pharmacy, the facility did not utilize it, resulting in a delay in medication delivery.
A resident who had right shoulder surgery was not provided with necessary therapy services to improve range of motion, despite physician orders. The resident was advised to perform exercises independently, but no official therapy screen was documented, leading to a deficiency in meeting the resident's rehabilitative needs.
A resident with Diabetes Mellitus Type II and hypercholesterolemia was administered Atorvastatin despite a known allergy, and Metformin was given twice daily instead of once as per hospital discharge instructions. The facility's pharmacy and interdisciplinary team failed to identify these errors, as confirmed by a registered nurse/unit manager.
The facility failed to provide meals at regular times, with significant delays in meal cart arrivals across various stations. A resident experienced a 48-minute delay in receiving their lunch. The Food Services Director acknowledged the issue, noting recent staff hires, and the Nursing Home Administrator was aware of the concerns.
A facility failed to provide sufficient nursing staff, leading to delayed responses to call lights in the Medbridge unit. Observations showed that residents experienced significant delays, with response times ranging from 30 to 46 minutes. Interviews with the Nursing Home Administrator and DON confirmed these delays were inappropriate and did not meet facility expectations.
The facility failed to ensure accurate resident assessments for six residents, including incorrect coding for medications, dental issues, oxygen therapy, open wounds, dialysis, and MDRO diagnoses. These inaccuracies were confirmed by the RNAC and acknowledged by the DON and NHA.
The facility failed to revise and update comprehensive care plans for six residents, including significant weight loss and skin issues, and care plan meetings lacked interdisciplinary team attendance. Staff confirmed these deficiencies and the expectation for accurate care plans and team involvement.
The facility failed to provide evening activities for residents over a seven-month period, despite policy requirements. Interviews and activity calendar reviews confirmed the absence of evening programs, and staff indicated no evening shift coverage in the activities department since 2022.
The facility failed to ensure physician orders for catheter care were followed for a resident with end-stage renal disease and obstructive uropathy. Multiple instances of missing documentation for catheter care were identified across various shifts, indicating non-compliance with the facility's policy and physician orders.
The facility failed to document the color and amount of urine for a resident with a nephrostomy tube during multiple shifts in February and March 2024. The resident had diagnoses including obstructive and reflux uropathy and a history of urinary tract infections. The Director of Nursing confirmed awareness of the staff's failure to document the required care during these shifts.
The facility failed to ensure proper dialysis care and documentation for a resident with end-stage renal disease. The resident's dialysis site monitoring was not documented, and dialysis communication forms were incomplete, as confirmed by staff and the Director of Nursing.
The facility failed to provide food and beverages at safe and appetizing temperatures for one observed meal. A test tray evaluation revealed that several food items did not meet the required temperature standards, and residents expressed concerns about the food quality. The Food Service Director acknowledged the issue, and the Nursing Home Administrator was informed but provided no further information.
The facility failed to store and serve food and beverages in accordance with professional standards for food safety. Observations revealed multiple opened and undated containers of thickened beverages, unlabeled and undated bags of sloppy joes and chili in the freezer, and several opened spices without date marks. The Food Service Director was unaware of the proper dating procedures, and the Nursing Home Administrator was informed of these concerns.
The facility failed to ensure nurse aides received sufficient in-service training, including dementia care and abuse prevention, with none of the reviewed employees meeting the required 12 hours of annual training.
The facility failed to maintain adequate personal hygiene, grooming, transfers, and meal assistance for two residents dependent on staff for ADL. One resident was observed with long, dirty fingernails despite needing assistance, and another resident's ADL care documentation was frequently incomplete or marked as non-applicable.
The facility failed to provide care according to professional standards for two residents. One resident with a skin infection did not receive ongoing assessments and documentation for a toe wound, while another resident with chronic conditions had inadequate documentation and monitoring for a hypodermoclysis order. These deficiencies indicate a failure to follow facility policies and ensure proper care.
The facility failed to conduct thorough investigations and provide adequate assistance to prevent accidents for a resident with dementia, atrial fibrillation, and gait abnormalities. The incident reports for the resident's falls lacked comprehensive investigations and documentation of care provided prior to the falls. Interviews confirmed the investigations were incomplete.
The facility failed to monitor the clinical condition of two residents after significant weight loss was identified. One resident experienced an 11-pound weight loss over six months, and another resident showed a significant weight loss of 14.4% within a short period. Despite recommendations for weekly weight monitoring, the facility did not follow its policy.
A resident with sleep apnea and other conditions had their CPAP nasal mask improperly stored and their physician orders for the CPAP machine were incomplete, lacking necessary pressure settings and hours of use. The resident was unable to manage the mask independently, and the facility's Director of Nursing confirmed the deficiencies.
The facility failed to ensure that the physician addressed significant weight loss in a timely manner for two residents. One resident experienced an 11-pound weight loss over six months, and another resident had a 14.4% weight loss in 20 days. Despite multiple nutrition notes and recommendations for weekly weight monitoring, there was no documentation that the physician was notified.
The facility failed to provide timely dental services for a resident with anxiety, COPD, and epilepsy. Despite a dental consult recommending new dentures and a follow-up x-ray, the resident was not seen as scheduled, and no explanation was provided. The resident was rescheduled for April without a specific date.
Failure to Maintain Palatable and Proper-Temperature Food and Beverages
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures, as required by its own Test Tray Evaluation standards and state regulations. The facility’s form specified that cold foods should be at or below 45°F and hot foods above 140°F. Multiple residents reported that their food was always served cold, including one resident who stated her food is always served cold and another who said the food is cold, as well as a group of residents who collectively expressed concerns that the food is always served cold. During a test tray evaluation, there was a 14‑minute lapse between completion of the food cart in the kitchen and the time temperatures were taken. At 1:14 PM, the Food Service Director recorded the following temperatures: macaroni and cheese at 127°F and stewed tomatoes at 112°F, both noted as not palatable for temperature; coleslaw at 47°F; milk at 50°F and orange juice at 59°F, both noted as not palatable for temperature; a cookie served at room temperature; and coffee at 150°F. The Food Service Director stated that the steam table was functioning, the macaroni and cheese had just come out of the oven not long before, and she believed the hot items should have registered higher temperatures and the milk should have been colder. The Nursing Home Administrator did not provide additional information regarding these test tray results.
Failure to Maintain Safe Food Storage, Sanitation, and Staff Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store and serve food and beverages in accordance with professional standards for food safety in the main kitchen and multiple nourishment pantries. In the walk‑in refrigerator, an open 5‑pound package of American cheese was found without a date mark, and the Food Service Director stated it had been opened that morning. In the dish room, the fan in the window opening on the clean side of the dish machine, as well as the ceiling and ceiling vents above the tray line, contained a light grey fuzzy substance; the Food Service Director reported that maintenance was responsible for cleaning these areas, and the Nursing Home Administrator later stated that the fan and vents were not on a routine cleaning schedule. During tray line service, three kitchen employees with facial hair were working without beard coverings, and the Food Service Director acknowledged that facility policy required beard nets if facial hair was at a particular length, but the requested policy was not provided. In nourishment pantries A, B, Medbridge, and C, surveyors observed additional failures to follow food safety and storage standards. In the A station pantry, the microwave contained dried yellow and red liquid, and the refrigerator held a half submarine sandwich labeled with a resident’s name but not dated, and a stromboli without any resident identifier or date; the Food Service Director stated she did not know who was responsible for cleaning the microwaves and confirmed that resident food items should be labeled with an identifier and date. In the Medbridge pantry, dried food was present in the microwave. In the B station pantry, a lunch bag containing a salad, meal, yogurt, and an energy drink was found, and the Food Service Director confirmed it did not belong to a resident and that staff food should not be stored in the resident refrigerator. In the C station pantry, a thawed vanilla nutritional shake without a pull or use‑by date and an energy drink without an identifier were observed; the Food Service Director could not determine when the shake had been thawed and believed the energy drink belonged to a staff member. The Nursing Home Administrator acknowledged that food should be stored within professional standards, staff food should not be stored in nourishment refrigerators, and resident food should be labeled with an identifier and date.
Failure to Inform Resident of Risks and Benefits of Psychotropic Medication
Penalty
Summary
Surveyors found that the facility failed to ensure a resident was informed in advance of the risks and benefits of a prescribed psychotropic medication. The facility’s Health Care Decision Making policy, reviewed June 12, 2025, states that all patients/residents have the right to participate in their own healthcare, including consent, refusal, or withdrawal of consent for treatments and services. Clinical record review for Resident 3, who had diagnoses including hypertension and depression, showed a physician’s order for Zoloft 50 mg by mouth once daily for depression, initiated on December 5, 2025. Review of the facility’s Psychotropic Medication Administration Disclosure form, which is intended to ensure residents are fully informed about psychotropic medications, revealed that neither the resident nor the resident’s representative was informed of the risks and/or benefits of Zoloft, and the disclosure form was not signed. In an interview, the DON confirmed that the disclosure form was not signed and that the medication was not reviewed with the resident when it was ordered by the physician, resulting in noncompliance with 28 Pa. Code 211.12(d)(5) Nursing services.
Inaccurate MDS Coding for Incontinence and Suprapubic Catheter
Penalty
Summary
The deficiency involves inaccurate completion of the MDS assessments, resulting in resident assessments that did not accurately reflect two residents' bladder and bowel status and use of urinary devices. For one resident with traumatic brain injury, tracheostomy, and severely impaired cognitive skills (BIMS of 0), the admission and quarterly MDS assessments coded urinary incontinence (H0300) as "frequently incontinent" instead of "always incontinent," and bowel incontinence (H0400) as "frequently incontinent" instead of "always incontinent." Clinical record review and staff interview confirmed that this resident had been incontinent of both bowel and bladder since admission, indicating that the MDS coding did not match the resident's actual condition. For another resident with flaccid neuropathic bladder and depression, the clinical record and care plan documented the use of a suprapubic indwelling urinary catheter beginning in early April 2024. However, the quarterly MDS assessment coded Section H0100C as "yes" for an ostomy, indicating the resident had an ostomy rather than correctly identifying the suprapubic catheter as an indwelling catheter per RAI Manual guidance. During interview, the clinical reimbursement coordinator acknowledged that this was incorrect documentation because the resident had a suprapubic catheter and not an ostomy, confirming that the MDS assessment did not accurately reflect the resident's urinary device status.
Failure to Update and Align Care Plans With Current Orders and Resident Preferences
Penalty
Summary
The deficiency involves the facility’s failure to review and revise person-centered care plans to reflect current assessments, physician orders, and resident preferences for three residents. For one resident with diabetes mellitus, protein calorie malnutrition, multiple sclerosis, and end-stage kidney disease, smoking assessments documented that independent smoking was allowed off site on one date, and later that the resident was not allowed to smoke. Physician orders also addressed leave of absence (LOA) privileges, including independent LOA with medications, LOA with a responsible party, and permission to go to the end of the drive independently, with various start, hold, and discontinuation dates. However, the resident’s care plan contained conflicting entries stating both that the resident may not smoke per smoking evaluation and that the resident may smoke independently per smoking evaluation, and it was not updated to reflect the current smoking and LOA status. For another resident with hypertension and end-stage renal disease, physician orders documented a full code status, but the interdisciplinary plan of care listed the resident’s code status as DNR, creating a discrepancy between the care plan and the physician’s orders. A third resident with diabetes and GERD had multiple progress notes documenting discussions about discharge options, including the daughter’s desire for discharge home after renovations, the resident’s resistance to leaving because she felt safe at the facility, and later her agreement to a possible discharge to an independent living facility. Despite these documented discussions and changing preferences, the resident’s care plan did not include her choice for discharge or long-term care placement, which the NHA acknowledged should have been reflected to avoid confusion.
Failure to Ensure Resident Received Functional Eyeglasses
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident had diagnoses including diabetes mellitus, altered mental status, anxiety, depression, anisocoria, macular degeneration, dry eyes, suspected glaucoma, pseudophakia, hyperopia, and presbyopia. Her care plan identified vision impairment and included interventions such as placing glasses within reach, encouraging their use, consulting with a physician for vision evaluation, and administering eye medications as ordered. An eye care consult documented that new glasses were recommended, with follow-up in 3–4 months and instructions to encourage use of glasses for distance and reading. During an interview, the resident reported that the eye doctor had been in about a month earlier and asked how her new glasses were working, but she had not received them. The surveyor observed that her current glasses were missing the right lens and nose piece, and the left lens was severely scratched. The resident stated that she had been in the facility for a year, had been asking for new glasses because they were severely scratched, and that since admission a lens had fallen out and could not be found, followed by the nose piece falling off. She reported that not having functional glasses affected her quality of life because she could not see to read or do activities she enjoyed and had to sit close to the television and could not watch it while lying in bed. The bill for the new glasses was initially sent to the resident’s daughter, who was not allowed contact with the resident due to a history of exploitation, and later to the guardian, but the guardian did not receive or complete the bill until contacted again, resulting in a delay in obtaining the new glasses.
Failure to Implement Restorative Ambulation Program for Resident With Limited Mobility
Penalty
Summary
The facility failed to provide appropriate restorative nursing services to maintain or improve range of motion and mobility for a resident with limited mobility. Facility policy on Restorative Nursing required that restorative programs be patient-specific and implemented according to the care plan to promote the patient’s ability to live as independently and safely as possible. The resident’s diagnoses included deforming dorsopathy and abnormalities of gait and mobility. A physical therapy discharge summary documented that the resident was to be referred to a restorative ambulation program to provide supervision and support for longer-distance ambulation with a rolling walker on the unit to attend activities. The resident’s care plan included a restorative ambulation focus with a goal for the resident to walk throughout the unit at least two times per day. Despite these orders and care plan interventions, restorative nursing documentation for the resident showed the program was repeatedly marked as “not applicable” on numerous dates, indicating that the restorative ambulation program was not being carried out. The resident reported that since discharge from therapy, she had only been assisted to walk in the hallway with her walker two to three times and expressed that it would be nice to walk every day. The DON later stated that the restorative program was titled incorrectly in the electronic system, which could have caused confusion for nurse aides, and that the task had been updated to reflect walking 100–150 feet. However, even after this correction, the restorative program continued to be documented as “not applicable,” and the DON acknowledged he would need to follow up on why the program was still not being implemented as expected.
Improper Storage and Handling of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards, the resident’s care plan, and facility policy for one resident requiring respiratory support. Facility policy required that respiratory equipment be cleaned and disinfected by qualified staff on a scheduled basis, between patients, and upon discontinuation from service, with the purpose of removing microorganisms from equipment surfaces. The resident had diagnoses including COPD and muscle wasting/atrophy, and physician orders for scheduled nebulized Ipratropium-Albuterol every six hours for shortness of breath/wheezing and oxygen via nasal cannula titrated to maintain oxygen saturation above 90%. The comprehensive care plan identified the resident as at risk for respiratory complications related to COPD, shortness of breath, and wheezing, with interventions to administer aerosol treatments and oxygen as ordered. On multiple observations over two days, the resident’s respiratory equipment was found stored and maintained in a manner that did not prevent contamination. The resident, who reported feeling sick and wanting to see a doctor and exhibited a wet cough, had a nebulizer machine at the bedside with the nebulizer mask lying on a bedside table on top of a tissue box, nebulizer tubing on the floor dated the previous day, and oxygen tubing from the concentrator to the nasal cannula lying across the floor. Later observations showed the nebulizer mask and tubing bagged but with the same date, indicating the tubing had not been changed after being on the floor, and both the oxygen tubing and the storage bag were touching the floor. On the following day, the nebulizer tubing remained in a bag touching the floor with the same date, and the oxygen tubing continued to lie on the floor between the concentrator and the resident’s nose. The DON stated an expectation that respiratory equipment be stored and used in a way that prevents contamination with microorganisms.
Incomplete Dialysis Communication Documentation for Resident Requiring Hemodialysis
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received services consistent with professional standards and its own dialysis communication policy. The facility’s Dialysis Guidelines policy required shared communication between the center and the dialysis facility using a Hemodialysis Communication Form, including timely documentation of medications, physician/treatment orders, laboratory values, vital signs, and weights. The clinical record for Resident 45, who had hypertension and end-stage renal disease and required renal dialysis on Monday, Wednesday, and as needed, showed incomplete Hemodialysis Communication Record Forms. On one date, the dialysis center did not document the resident’s post-dialysis weight, and on another date, the dialysis center did not document blood pressure, pre-dialysis weight, post-dialysis weight, medications given during hemodialysis, or pulse. In an interview, the Director of Nursing confirmed that the missing documentation on the communication forms should have been completed. These findings were cited under 28 Pa. Code 211.12 (d) (1) (2) (5) related to nursing services.
Loose Corridor Handrails in Two Resident Halls
Penalty
Summary
The facility failed to ensure that its corridors were equipped with firmly secured handrails on both sides in two of the seven resident halls observed (400 and 500 halls). The facility’s policy titled “Safe and Homelike Environment,” revised November 14, 2025, states that the resident has the right to a safe, clean, comfortable, and homelike environment. During an observation of the 500 hall on March 25, 2026, at approximately 12:00 PM, the handrail affixed on the left side of the hall was found to be loose to the touch. A subsequent observation of the 400 hall on the same day at 1:25 PM revealed that the handrail affixed on the right side of the hall, near the therapy gym, was also loose to the touch. These observations demonstrated that the facility did not maintain securely affixed handrails in these corridors as required, resulting in noncompliance with its own policy and with 28 Pa. Code 201.18(b)(1) regarding management responsibilities for providing a safe environment.
Failure to Adjust Amiodarone Dosing After Order Change
Penalty
Summary
The facility failed to ensure that a resident received medication in accordance with current prescriber orders and the person-centered plan of care. Facility policy on Medication Administration requires that medications be administered according to written prescriber orders. The resident had diagnoses including atrial fibrillation and anxiety and was ordered Amiodarone HCL 200 mg by mouth twice daily for atrial fibrillation starting on December 24, 2025. On January 6, 2026, a heart and vascular provider consultation documented a recommendation changing the Amiodarone dose to 200 mg once daily. Despite this updated order, review of the Medication Administration Record for January 1–31, 2026, showed nursing staff continued to administer Amiodarone 200 mg twice daily after the January 6 change. Nursing communication to the resident’s provider on January 16, 2026, documented that Amiodarone should only be given once a day and requested an update, confirming that the order had changed but the MAR and administration practices had not been adjusted between January 6 and January 16. The Director of Nursing confirmed that the medication should have been changed to once per day beginning January 6, 2026, in accordance with the physician’s order.
Failure to Prevent Involuntary Seclusion and Incomplete Incident Investigation
Penalty
Summary
The facility failed to protect a resident's right to be free from involuntary seclusion, as required by its own Abuse Prohibition policy. During the night shift, a nursing assistant was found holding a resident's room door shut while the resident was inside, yelling to be let out and banging on the door. The nursing assistant admitted to holding the door closed because the resident was upset and the staff member felt scared. The resident, who had diagnoses including dementia, anxiety, and a recent fracture, was care planned for being resistive to care and at risk for behavioral issues, with interventions to redirect and allow time for composure. Despite these interventions, the staff member confined the resident to her room against her will. The incident was not immediately reported to the appropriate supervisor, and the initial investigation failed to include an interview with the RN Supervisor who was on duty at the time. The RN Supervisor did not initiate an investigation or assess the resident after the incident. The event was only reported to the RN Unit Manager during the following day shift, at which point a full body assessment was completed and no injuries were found. Staff interviews revealed confusion about which door was held shut, and the resident expressed feeling like she was being held hostage. The facility's investigation lacked timely and complete documentation, including omission of key staff interviews and immediate assessment.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide proper written notification to residents, their representatives, and the Office of the State Long-Term Care Ombudsman regarding hospital transfers. Specifically, the transfer notices for three residents did not include essential information such as the reason for transfer, date, location, statement of appeal rights, and contact details for the Ombudsman. For Resident 37, the transfer notices for hospitalizations on two occasions lacked a statement of appeal rights and necessary contact information. Resident 66's transfer notice was not provided at all, and for Resident 121, there was no evidence of any written notice for two hospital transfers. Interviews with the Nursing Home Administrator (NHA) revealed that the facility had changed its transfer forms, which resulted in the omission of required information. The NHA confirmed that it was the facility's expectation to provide a written notice of transfer, but the current forms did not meet regulatory requirements. The facility's written transfer notice template was reviewed and found to be missing several required elements, including appeal rights information and contact details for relevant advocacy agencies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident 10, who had multiple complex medical conditions including neurogenic bladder, diabetes mellitus, pneumonia, and three Stage 4 chronic pressure ulcers, required enhanced barrier precautions (EBP) due to internal devices and chronic wounds. However, there was no care plan indicating EBP for this resident, as confirmed by the Director of Nursing (DON). Similarly, Resident 14, who was on hospice status with chronic diastolic congestive heart failure, did not have a hospice care plan developed when hospice services were initiated. Additionally, Resident 57, diagnosed with chronic kidney disease and chronic pain syndrome, had an order for hospice services but lacked an interdisciplinary plan of care for hospice services. The DON confirmed these omissions, indicating a failure to adhere to the facility's policy on person-centered care planning.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming for residents dependent on staff assistance for activities of daily living. Resident 112, diagnosed with chronic obstructive pulmonary disease and chronic heart failure, reported not receiving showers on scheduled days due to staff shortages. Her shower days were set for Wednesdays and Saturdays, but she missed showers on several occasions, including January 18, 22, and February 8, 2025. Despite filing a grievance in January 2025, which was confirmed and resolved with staff education, the issue persisted. Similarly, Resident 117, with diagnoses of syncope and cardiomyopathy, did not receive showers on her scheduled days, preferring showers over other forms of bathing. Her care plan emphasized the importance of allowing her to choose her bathing method, but she missed showers on February 3, 6, and 10, 2025, receiving bed baths instead. The Director of Nursing acknowledged that both residents should have received showers according to their preferences and schedules.
Failure to Follow Physician Orders and Care Plans
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards for three residents. Resident 14, who was on hospice status due to chronic diastolic congestive heart failure, did not have a physician order for hospice status documented in their clinical record. The Director of Nursing (DON) confirmed that the hospice orders should have been entered when hospice status was effective, but the facility did not receive a copy of the order from the attending physician until a month later. Resident 90, diagnosed with hypertension and Alzheimer's disease, was observed not wearing prescribed Geri-leg and Geri-sleeve as per their care plan, which was intended to prevent skin integrity issues. The DON acknowledged that these items should have been worn as care planned. Additionally, Resident 252, with type two diabetes mellitus and chronic pain syndrome, was administered Percocet despite having a documented pain level of 0, with no rationale provided for the administration. The DON stated that it was the facility's expectation that medications be administered according to physician orders and indications.
Failure to Monitor Resident Nutritional Status
Penalty
Summary
The facility failed to monitor the nutritional status of four residents, as evidenced by the lack of regular weight assessments. Resident 90, diagnosed with hypertension and Alzheimer's disease, was not weighed for several months despite orders for monthly weight checks. The Medication Administration Record (MAR) inconsistently marked weight orders as completed or refused, yet no weights were recorded. Similarly, Resident 117, with syncope and cardiomyopathy, had orders for monthly and weekly weight checks that were not followed, resulting in a lack of weight data for several months. A dietitian noted a significant weight gain for Resident 117, but no recent weight comparisons were available. Resident 131, with hypertension and type 2 diabetes, was not weighed according to the physician's orders, and the MAR indicated refusals and missing weights. The resident's care plan highlighted nutritional risk, yet the required weight monitoring was not conducted. Resident 252, admitted with type 2 diabetes and chronic pain syndrome, had orders for weekly weight checks that were not documented in the MAR. Interviews with the Director of Nursing confirmed that the expected weight assessments were not completed for these residents, indicating a failure to adhere to physician orders and facility policy.
Insufficient Dining Services Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient dining services staff to ensure timely meal and nourishment delivery to residents during two of the three meals observed on February 11 and 12, 2025. The facility's policy on snacks, nourishments, supplements, and pantry stock, effective May 1, 2023, states that Food and Nutrition Services should deliver snacks to nursing stations at specified times. However, resident interviews revealed concerns about meals being served late, and Food Committee meeting minutes from October and November 2024 highlighted issues with meal delays, particularly on weekends, and snacks not being offered. Documented meal service times were not adhered to, with significant delays observed, such as a 45-minute delay in lunch service on February 11, 2025, and late delivery of snacks on February 12, 2025. The report indicates that on February 11, 2025, three employees called off for the day shift in Dietary, contributing to the delays. The facility's records showed multiple instances of meal carts being delivered late by 55 minutes or more on several dates in February 2025. Interviews with staff, including Employee 5 and Employee 7, confirmed the delays and the need for assistance from nursing staff to pass trays. The Nursing Home Administrator acknowledged that staffing levels in Dietary depend on available staff and that there were multiple open positions in previous months, although many had been filled recently. The surveyor informed the NHA about the late delivery of snacks on February 12, 2025.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in several areas, as observed during a survey. The test strips used for checking the sanitizer solution at the three-compartment sink were expired and of the incorrect type, resulting in a sanitizer solution that registered 0. Additionally, there was no log maintained for the three-compartment sink, and the temperature log only documented dish machine temperatures without pH levels for the sanitizer. In the dry storeroom, bulk containers of cereal were not date marked, and nutritional shakes in the refrigerator were not labeled with thaw or pulled dates, despite being required to be used within 14 days of thawing. Furthermore, the ceiling, vent, and fan in the prep area were observed to have a black fuzzy substance, indicating a lack of cleanliness. In the prep area, bulk containers of sugar and flour were not date marked, and their lids were not securely closed. A scoop was improperly stored inside the sugar bin. Additionally, three male employees working on the tray line did not wear facial hair restraints, contrary to the facility's policy. Interviews with staff revealed a lack of awareness regarding the facial hair restraint policy and the requirement for date marking and proper storage of food items. The Nursing Home Administrator acknowledged these deficiencies, confirming that the items should be date marked, the scoop should not be stored in the sugar container, a log for the three-compartment sink is necessary, staff should wear appropriate hair restraints, and the ceiling and vents should be clean.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain a safe environment that supports infection prevention and control for five residents. The facility's infection control policy requires enhanced barrier precautions (EBP) for residents colonized or infected with multi-resistant drug organisms, those with chronic wounds, or internal devices. However, observations revealed that there was no personal protective equipment (PPE) cart or signage indicating the need for EBP for Residents 10, 37, 108, 113, and 119, despite their medical conditions necessitating such precautions. Resident 10 had multiple diagnoses, including neurogenic bladder, diabetes mellitus, pneumonia, and three Stage 4 chronic pressure ulcers, along with internal devices such as an ostomy and a supra pubic catheter. Despite these conditions, there was no PPE cart or EBP signage in place. Similarly, Resident 37, who had a supra pubic catheter, also lacked appropriate EBP signage and PPE availability. Resident 108, with a non-healing pressure ulcer, a PICC line, and an indwelling urinary catheter, was also not provided with the necessary EBP signage or PPE. Resident 113, with a history of VRE in urine, had a care plan indicating the need for EBP, but no signage was observed. Resident 119, with a suprapubic urinary catheter and multiple wounds, also lacked EBP signage and PPE. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that EBP signage and PPE should have been in place for these residents, indicating a failure in implementing the facility's infection control policy.
Delayed Delivery of Resident's Package
Penalty
Summary
The facility failed to ensure a resident's right to receive mail, including packages, in a timely manner. This deficiency was identified through interviews, policy review, and clinical record examination. A resident, diagnosed with anxiety disorder and congestive heart failure, reported a delay in receiving a package she expected. The package, which was suspected to contain pills, was handed over to the Director of Nursing (DON) by an employee due to concerns about its contents. The package was eventually delivered to the resident by the Nursing Home Administrator (NHA) after a delay of approximately one week. The facility's policy on resident rights under federal law states that residents have the right to receive unopened mail promptly. However, there was no documentation in the resident's clinical record regarding the package or the education provided about the safety concerns of receiving medications by mail. Additionally, the facility lacked a policy or procedure for handling packages that might contain items posing safety concerns. The DON's absence due to illness contributed to the delay, and the NHA confirmed the delay and lack of documentation.
Failure to Ensure Resident's Right to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 57, was given the opportunity to formulate an Advance Directive. An Advance Directive is a written statement of a person's wishes regarding medical treatment, which is crucial for ensuring that these wishes are respected if the person becomes unable to communicate them. The facility's policy, revised in January 2024, mandates that capable residents without an Advance Directive should be approached by the Social Worker or designated staff upon admission, quarterly, and with any change in condition to discuss the possibility of developing an Advance Directive. However, a review of Resident 57's clinical record showed no documentation that the facility offered information regarding the right to formulate an Advance Directive. Resident 57, who has diagnoses including chronic kidney disease and chronic pain syndrome, was assessed with a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognitive status. Despite this, the interdisciplinary progress notes from a care meeting held in January 2025 indicated that Advance Directives were not reviewed. Furthermore, an interview with the Social Services Director revealed that he does not discuss Advance Directives with any residents or their representatives, highlighting a systemic failure to adhere to the facility's policy and ensure residents' rights to participate in their own health care decision-making.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from chemical restraints, as evidenced by the administration of unnecessary psychotropic medication to a resident. The facility's policy stated that patients have the right to be free from chemical restraints imposed for discipline or convenience, and not required to treat medical symptoms. However, the review of Resident 143's clinical records revealed that Ativan, a psychotropic medication, was administered multiple times without proper indication or for reasons not associated with the resident's documented behaviors. Resident 143, diagnosed with Alzheimer's disease and hypertension, had a care plan that included non-pharmacological interventions for behaviors such as physical aggression and resistance to care. Despite this, the resident's medication administration record showed that Ativan was given for reasons like restlessness, insomnia, and attempts to get out of bed, which were not aligned with the care plan's interventions. The medication was often noted as ineffective, indicating it was not addressing the intended symptoms. Interviews with staff, including the Director of Nursing and the Rehabilitation Director, revealed that the resident was not at risk of falls and could ambulate with assistance. Despite this, Ativan was used to manage behaviors that did not pose a physical risk, suggesting its use as a chemical restraint. The facility did not provide further information to justify the administration of Ativan outside the indicated behaviors, highlighting a deficiency in adhering to the policy of avoiding unnecessary chemical restraints.
Inaccurate Resident Assessments in Clinical Records
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their clinical records. For one resident with diabetes mellitus, pneumonia, and three Stage 4 pressure ulcers, the Quarterly MDS inaccurately documented only two Stage 4 pressure ulcers instead of three. This error was identified during a review of the resident's clinical record and was later confirmed by the Nursing Home Administrator. The discrepancy was corrected by the Registered Nurse Assessment Coordinator, who provided a modified MDS reflecting the accurate number of pressure ulcers. Another resident, diagnosed with chronic kidney disease, had an inaccurate discharge-return anticipated MDS. The MDS incorrectly documented that the resident was not receiving hospice care, despite the resident being discharged from hospice services earlier. This error was acknowledged during an interview with the Nursing Home Administrator and the Registered Nurse Assessment Coordinator, who confirmed that the MDS should have indicated hospice services were received while the resident was in the facility.
Failure to Implement Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, as required by their policy. The baseline care plan, initiated on January 31, 2025, only included two focus areas: the resident's code status and needs for completing activities of daily living. However, it did not address other critical areas such as falls, cardiovascular health, dietary needs including insulin use, incontinence, and the use and monitoring of psychotropic medications, which were identified in the physician orders upon admission. The resident, who was admitted with diagnoses including type two diabetes mellitus and chronic pain syndrome, did not have a comprehensive plan of care until February 3, 2025, which was beyond the 48-hour requirement. The Director of Nursing confirmed that the baseline care plan did not include items that the facility would expect to be included, indicating a lapse in meeting the professional standards of quality care as outlined in the facility's policy.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure the care plans for two residents were reviewed and revised appropriately. Resident 59, who had diagnoses including malignant neoplasm of the colon and congestive heart failure, had a care plan that included a focus area for an indwelling catheter due to terminal illness/comfort measures. However, upon observation, it was noted that the resident did not have a catheter, and the clinical admission assessment indicated that the catheter had been removed during a hospital stay. The Director of Nursing acknowledged that the catheter focus area should have been removed from the care plan. Resident 118, diagnosed with chronic kidney disease, was discharged from hospice services, yet the care plan still listed hospice as responsible for several interventions, including pain management and assistance with activities of daily living. During interviews, it was revealed that the care plan had not been updated to reflect the discharge from hospice services. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents. Resident 48, diagnosed with congestive heart failure and COPD, had physician orders for Ipratropium-Albuterol inhalation. Observations revealed that the nebulizer mask was left uncovered on the wheelchair seat and later found on the mattress, with the medication canister on the trash can. The nebulizer machine was left running, and the mask was not securely stored. An LPN admitted to forgetting to check on the resident before going on break, and the mask was rinsed with tap water instead of sterile water as per facility policy. Resident 77, with diagnoses including hemiplegia, dementia, congestive heart failure, and COPD, had orders for Ipratropium-Albuterol inhalation. Observations showed the nebulizer mask and medication canister were left uncovered on the nightstand without a plastic bag. The Director of Nursing confirmed that central supply distributes necessary supplies weekly and that distilled water should be used for cleaning equipment. However, the mask was not stored properly, and no further information was provided by the DON.
Incomplete Dialysis Communication Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident requiring such services. The facility's policy, titled Dialysis Guidelines, mandates the use of collaborative communication forms to document nutritional and fluid management, including pre and post-dialysis weights. However, for one resident, these forms were not completed on several occasions between January 2, 2025, and February 6, 2025. Specifically, there were no communication forms completed on five specific dates, and on several other dates, either pre-dialysis or post-dialysis weights were missing. The resident in question had diagnoses including discitis and chronic obstructive pulmonary disease and was at risk for impaired renal function and complications related to hemodialysis. The comprehensive care plan for this resident included an intervention to request pre and post weights from the dialysis center, initiated on August 13, 2024. Despite this, the Hemodialysis Communication Record forms were incomplete, as confirmed by the Director of Nursing, who acknowledged the expectation for these records to be fully completed with the necessary weight information.
Medication Administration and Reordering Failure
Penalty
Summary
The facility failed to ensure the accurate acquiring and administration of medications for a resident diagnosed with type two diabetes mellitus and chronic pain syndrome. The resident had an admission medication order for benazepril 20 mg to be administered once daily, starting on January 31, 2025. The pharmacy delivered only five tablets of benazepril on January 31, 2025, but the Medication Administration Record (MAR) showed that the medication was administered six times between January 31 and February 5, 2025. This discrepancy led to the facility running out of the medication by February 6, 2025, resulting in a missed dose for the resident. The facility staff notified the physician about the unavailability of the medication on February 6, 2025, and reordered it from the pharmacy. However, the pharmacy did not fill the order until February 7, 2025, leading to a delay of approximately 31 and a half hours and causing the resident to miss a second dose. The Director of Nursing confirmed that the facility was expected to have medications ready for administration, but could not explain why the medication was not reordered in time. The facility had an alternative pharmacy available for such situations, but it was not utilized in this instance.
Failure to Provide Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to Resident 23, who had undergone right shoulder surgery and was released from using a sling. Despite physician orders for physical therapy to increase the range of motion and prevent muscle atrophy, Resident 23 was not placed on the therapy caseload. The resident expressed uncertainty about appropriate stretching exercises and a desire to receive therapy services, but no therapy or restorative nursing program was initiated. An interview with the Occupational Therapist revealed that Resident 23 was advised to perform gentle stretching independently, as it was believed she could achieve sufficient range of motion for daily activities. However, the therapist did not document an official therapy screen. The Nursing Home Administrator was informed of the lack of therapy services or a restorative nursing program for Resident 23, highlighting a deficiency in ensuring the resident's rehabilitative needs were met.
Medication Administration Errors and Allergy Oversight
Penalty
Summary
The facility failed to ensure that all residents received treatment and care in accordance with professional standards of practice, as evidenced by the case of a resident with documented allergies and specific medication orders. The resident, who had a history of Diabetes Mellitus Type II and hypercholesterolemia, was discharged from the hospital with specific instructions regarding medication, including an allergy to Atorvastatin, which was known to cause a rash. Despite this, the resident was prescribed and administered Atorvastatin at the facility, indicating a failure to adhere to the allergy information provided in the hospital discharge summary. Additionally, the resident was prescribed Metformin to be taken once daily according to the hospital discharge summary, but the facility administered it twice daily. This discrepancy in medication administration was not identified by the facility's pharmacy representative or the interdisciplinary team, highlighting a lapse in the medication regimen review process. The errors were confirmed through an interview with a registered nurse/unit manager, who acknowledged the oversight in medication administration and the failure to catch these errors during the resident's stay.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to provide meals at regular times and in accordance with resident needs, preferences, and requests. This deficiency was observed in five of ten resident areas reviewed for mealtimes and specifically for one resident. The facility's documentation indicated significant delays in meal cart arrivals across various stations. For instance, the dinner meal cart for Medbridge #2 was scheduled to arrive at 5:20 PM but left the kitchen at 6:05 PM. Similar delays were noted for other stations, with carts arriving significantly later than the posted times. An interview with a resident revealed that their lunch meal was served approximately 48 minutes late, as the meal cart arrived at 1:20 PM instead of the scheduled 12:35 PM. The Food Services Director acknowledged the issue, noting that the facility had recently hired seven new staff members and was aware of the delays in meal service. The Nursing Home Administrator also expressed understanding of the concerns regarding the delays in meal delivery to residents.
Insufficient Nursing Staff and Delayed Call Light Response
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents in one of its nursing units, Medbridge. Observations and interviews revealed that staff failed to respond promptly to call lights, which is a requirement according to the facility's policy. On April 23, 2024, multiple residents experienced significant delays in response times to their call lights, ranging from approximately 30 to 46 minutes. These delays were observed for several residents, including Resident 1, who needed assistance with toileting, and Resident 3, who required help to use the restroom but was often wet by the time staff arrived. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the response times were not appropriate and did not meet the facility's expectations. The facility's policy, last reviewed on February 1, 2023, mandates that staff respond to call lights and communication devices promptly, which was not adhered to in these instances. The deficiency was noted under the Pennsylvania Code sections related to nursing services and management, indicating a failure to provide adequate nursing and related services to ensure the well-being of residents.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' statuses for six of the 33 residents reviewed. For Resident 3, the Quarterly MDS was inaccurately coded as not receiving opioid medication, despite records showing opioid administration on specific dates. Similarly, Resident 10's Annual and Quarterly MDS were incorrectly coded as not receiving antiplatelet medication, although the medication was administered daily during the assessment periods. These inaccuracies were confirmed by the Registered Nurse Assessment Coordinator (RNAC) and acknowledged by the Director of Nursing (DON) and Nursing Home Administrator (NHA). Resident 67's quarterly MDS did not document a loose upper denture, despite a dental consult recommending replacement and fitting for new dentures. The resident confirmed the loose denture during an interview, and the observation corroborated this. The RNAC admitted that the dental assessment portion of the MDS was completed via clinical record review without a visual dental assessment. Resident 111's quarterly MDS failed to reflect the use of supplemental oxygen therapy, even though the Treatment Administration Record indicated daily oxygen therapy during the relevant period. The RNAC confirmed this coding error. Resident 118's quarterly MDS was inaccurately coded as not having an open wound, despite continuous treatment for an open wound on the left lower extremity since admission. Resident 127's quarterly MDS was incorrectly coded as not receiving dialysis and not having a multidrug-resistant organism (MDRO) diagnosis, despite physician orders and clinical records indicating otherwise. These errors were confirmed by the RNAC and acknowledged by the DON and NHA. The facility's expectation was that MDS assessments be completed accurately, which was not met in these cases.
Failure to Revise and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for six residents, as required by their policy. For Resident 10, despite significant weight loss documented in dietician progress notes, the care plan was not updated to reflect this change. Additionally, care plan meetings for Resident 10 were inadequately attended, with only the resident and a social services representative present, lacking interdisciplinary team involvement. The DON and other staff members confirmed that the care plan should have been updated and that care plan meetings should include the entire interdisciplinary team. Resident 11 had a documented skin issue on their left great toe, which was not included in their care plan. Observations confirmed the presence of the skin issue, and interviews with staff revealed that the area should have been care planned when initially identified. Care plan meetings for Resident 11 also lacked interdisciplinary team attendance, with only the resident and a social services representative present. The DON acknowledged that the care plan should have been revised to include the skin issue and that care plan meetings should involve the entire interdisciplinary team. Other residents, including Residents 73, 93, 118, and 129, also had deficiencies in their care plans. Resident 73's care plan did not include an intervention for CPAP use despite physician orders. Resident 93's care plan failed to document significant weight loss, and care plan meetings lacked dietary representation. Resident 118's care plan incorrectly resolved a focus area for VRE, and Resident 129's care plan was not updated to reflect significant weight loss. Interviews with staff confirmed these deficiencies and the expectation that care plans should be accurate and involve the interdisciplinary team.
Failure to Provide Evening Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs, interests, and functional abilities of residents for seven months (September 2023-March 2024). Interviews with five residents during a resident council meeting revealed that no evening activities were provided, despite the facility's policy requiring structured programs at least twice weekly during evening hours. Review of activity calendars confirmed the absence of evening programs. An interview with a staff member indicated that no activities department staff worked the evening shift since an employee left in 2022. The Nursing Home Administrator acknowledged the expectation for evening activities to be offered.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure physician orders were followed for catheter care for one resident. The facility's policy required catheter care to be performed twice a day and as needed, with documentation of the care provided. However, a review of the resident's Treatment Administration Record (TAR) revealed multiple instances where catheter care was not documented as completed across various shifts in January, February, and March 2024. The resident had diagnoses including end-stage renal disease and obstructive and reflux uropathy, necessitating the use of an indwelling urinary catheter. The comprehensive plan of care and physician orders specified catheter care every shift, which was not consistently documented as performed. During an interview, the Director of Nursing (DON) confirmed that it was the facility's expectation for physician orders to be followed and documented. The lack of documentation indicated non-compliance with the facility's policy and physician orders, leading to the identified deficiency. The report highlights the specific dates and shifts where documentation was missing, underscoring the facility's failure to adhere to established protocols for catheter care.
Failure to Document Nephrostomy Care
Penalty
Summary
The facility failed to ensure that a resident requiring urostomy services received care consistent with professional standards of practice and based on the comprehensive person-centered plan of care. Specifically, the facility did not document the color and amount of urine for a resident with a nephrostomy tube during multiple shifts in February and March 2024. The resident had diagnoses including obstructive and reflux uropathy and a history of urinary tract infections. The physician's orders required monitoring for signs and symptoms of complications and emptying the nephrostomy tube every shift, with documentation of the urine's color and amount. However, the Treatment Administration Record (TAR) showed multiple instances where this documentation was missing across various shifts in both months. The Director of Nursing confirmed awareness of the staff's failure to document the required care during these shifts. This lack of documentation indicates a failure to adhere to the prescribed care plan and professional standards of practice for nephrostomy care. The specific dates where documentation was missing include several shifts in February and March 2024. In February, the evening shift on the 3rd, the night shifts on the 6th, 8th, and 15th, the day and night shifts on the 22nd, the day shift on the 23rd, and the day and night shifts on the 26th were not documented. In March, the night shift on the 1st, the evening shift on the 11th, the day shift on the 17th, the night shift on the 20th, and the day shift on the 26th were also not documented. This pattern of missing documentation highlights a significant lapse in the facility's adherence to the resident's care plan and professional standards of practice for nephrostomy care.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice. Specifically, for Resident 127, who has end-stage renal disease and is dependent on renal dialysis, the facility did not have an active order for dialysis site monitoring. The resident's treatment administration record and medication administration record for January, February, and March 2024 did not document dialysis site monitoring. Additionally, the dialysis communication forms in the resident's hard chart only had pre-dialysis vital signs documented, with no post-dialysis information completed. Interviews with staff revealed that the night shift nursing staff were responsible for completing the pre-dialysis section of the form, but this was not being done. The post-dialysis section was also not being completed because the dialysis center sent their summary post-dialysis. The Director of Nursing confirmed that physician orders had been entered to monitor the dialysis catheter site, but nursing staff had not been completing the dialysis communication forms as expected. This failure to document and monitor dialysis care was confirmed by the Nursing Home Administrator and Director of Nursing during the surveyor's investigation.
Failure to Provide Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food and beverages at a safe and appetizing temperature for one observed meal on the Heritage Nursing Unit. A review of the Food and Nutrition Services Test Tray Evaluation form indicated that hot entrees, starches, and vegetables should be greater than 140 degrees Fahrenheit, and cold food and beverages should be less than 55 degrees Fahrenheit. Interviews with several residents revealed concerns about the temperature and quality of the food. A test tray evaluation conducted on March 26, 2024, showed that the roast pork was 127 degrees F, green peas were 136 degrees F, mashed potatoes were 146 degrees F, vanilla ice cream was 27 degrees F, apple juice was 59 degrees F, milk was 49 degrees F, and coffee was 152 degrees F. The Food Service Director acknowledged that the hot food should have been warmer and the cold food cooler. The Nursing Home Administrator was informed of these concerns but provided no further information.
Failure to Store and Serve Food in Accordance with Professional Standards
Penalty
Summary
The facility failed to store and serve food and beverages in accordance with professional standards for food safety in the kitchen area. Observations in the reach-in refrigerator revealed multiple containers of thickened apple juice, cranberry juice, and milk that were opened but not date marked with an open or use by date. The Food Service Director was unaware that these items should be dated once opened and did not know the appropriate use-by period for the thickened beverages. Additionally, the walk-in freezer contained unlabeled and undated bags of sloppy joes and a container of chili. The preparation area also had several opened spices that were not date marked. During interviews, the Food Service Director confirmed that leftovers and spices should be labeled and date marked once opened. The Nursing Home Administrator was informed of these concerns but no further information was provided. The facility's policy on use-by dating guidelines was not followed, leading to the deficiency in food safety practices.
Failure to Provide Required Nurse Aide Training
Penalty
Summary
The facility failed to ensure that nurse aides received sufficient in-service training and continuing education competencies, including dementia care and abuse prevention training. The review of five nurse aide training documents revealed that none of the employees had completed the required annual dementia or abuse prevention training. Additionally, the total annual training hours for these employees were significantly below the mandated 12 hours per year. Specifically, Employee 16 had only 4.5 hours, Employee 17 had 10:44 hours, Employee 18 had 1:26 hours, Employee 19 had 0 hours, and Employee 20 had 4:58 hours of training. An interview with the Director of Nursing confirmed that the facility could not access the nurse aide training documentation. The Director also mentioned that a new Registered Nurse Educator would be addressing the lack of nurse aide training requirements going forward. This deficiency was identified during a document review and staff interview, highlighting the facility's failure to comply with the required training standards for nurse aides.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to maintain adequate personal hygiene and grooming, transfers, and meal assistance for residents dependent on staff for assistance with activities of daily living (ADL). Resident 33, who has diagnoses including polyneuropathy, congestive heart failure, cognitive loss, and chronic obstructive pulmonary disease, was observed on multiple occasions with long fingernails containing a brown substance underneath. Despite the care plan indicating a need for one-person physical assistance with bathing and grooming, these needs were not met as evidenced by the observations and the Director of Nursing's acknowledgment that the resident's fingernails needed trimming. Resident 241, who had diagnoses including chronic diastolic congestive heart failure, chronic kidney disease stage 4, and diabetes mellitus, also did not receive adequate ADL care. The care plan required two-person physical assistance for daily hygiene, grooming, dressing, oral care, eating, and transfers. However, documentation for ADL and transfers was frequently left blank or marked as non-applicable on several dates. Interviews with the Nursing Home Administrator, Director of Nursing, and a Registered Nurse Unit Manager confirmed issues with documentation and a lack of additional information regarding the provision of ADL care for Resident 241.
Failure to Adhere to Professional Standards of Practice
Penalty
Summary
The facility failed to ensure care and services were provided in accordance with professional standards of practice for two residents. For Resident 11, who had diagnoses including cerebral infarction, dementia, and a localized skin infection, there was a lack of ongoing assessment and documentation of a dark-colored area on the left great toe. Despite initial treatment orders and a podiatrist visit, no further evaluations or documentation were found after February 1, 2024, until the issue was raised during a surveyor's observation on March 27, 2024. The Director of Nursing confirmed the expectation for ongoing evaluations and assessments, which were not met in this case. For Resident 241, who had chronic diastolic congestive heart failure, chronic kidney disease, and diabetes mellitus, there was a failure to document the rationale, administration, and monitoring of a hypodermoclysis order for hydration. The order was not properly entered into the electronic medication administration record (MAR), leading to a lack of documentation regarding the administration, site monitoring, and patient response. The Director of Nursing acknowledged the error in order entry and the absence of proper documentation for the hypodermoclysis administration. These deficiencies indicate a failure to adhere to the facility's policies on skin integrity and wound management, as well as the administration and documentation of hypodermoclysis. The lack of proper assessments, documentation, and adherence to professional standards of practice resulted in inadequate care for the residents involved.
Failure to Conduct Thorough Investigation and Provide Adequate Assistance
Penalty
Summary
The facility failed to ensure a thorough investigation was conducted following resident falls and did not provide adequate assistance to prevent accidents for one of the residents reviewed for falls. The facility's policy required that all accidents/incidents be reported, reviewed, and investigated thoroughly, including witness interviews and documentation of the root cause. However, the investigation into Resident 3's falls on two separate occasions was incomplete. The incident reports lacked sufficient witness statements and did not document the care provided to the resident prior to the falls. Additionally, there was no follow-up on the witness statements that indicated inadequate care and supervision at the time of the incidents. Resident 3, who had diagnoses including dementia, atrial fibrillation, vertebral disc degeneration, and gait abnormalities, experienced falls on two occasions. The first fall occurred when the resident was found on the floor at the foot end of their bed, and the second fall happened when the resident attempted to toilet themselves. The incident reports for both falls did not contain comprehensive investigations, and there was a significant gap in the documentation of care provided to the resident before the falls. Interviews with the Nursing Home Administrator, Director of Nursing, and a Registered Nurse Unit Manager confirmed that the investigations were incomplete and lacked necessary details about the resident's care and supervision.
Failure to Monitor Significant Weight Loss
Penalty
Summary
The facility failed to monitor the clinical condition of two residents after significant weight loss was identified. Resident 93 experienced an 11-pound weight loss over six months, which was greater than 10%. Despite the nutrition progress notes documenting significant weight loss and recommending weekly weight monitoring, the medical practitioner notes failed to acknowledge the weight loss. The Director of Nursing confirmed that the weight should have been monitored per policy. Resident 129, who had diagnoses including a stage 4 pressure injury and paraplegia, was not weighed weekly upon admission as required. The resident's weight was only documented 24 days after admission, showing a significant weight loss of 14.4% within a short period. Despite a registered dietician's note to monitor weekly weights, no documented weights were found after February 23, 2024. The Director of Nursing confirmed that the weight should have been monitored per policy.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one resident. Resident 73, who had diagnoses including diabetes mellitus, sleep apnea, and Parkinson's disease, was observed on multiple occasions with their CPAP nasal mask improperly stored on the nightstand on top of the machine and not covered. The resident was unable to remove and store the nasal mask independently, and the mask should have been stored in a plastic bag behind the machine as per facility policy. The Director of Nursing (DON) confirmed that the nasal mask should be stored properly and that the resident could not manage this task independently. Additionally, Resident 73's physician orders for the CPAP machine were incomplete. The initial order did not include necessary pressure settings or specify hours of use, which are required for proper CPAP therapy. This omission was confirmed by both the DON and a Registered Nurse Supervisor, who stated that the physician orders should contain information on pressure and time, and the care plan should include an intervention for the CPAP. A new order with the correct settings was documented later, but the initial deficiency in the physician orders was a significant lapse in care.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the physician addressed significant weight loss in a timely manner for two residents. Resident 93 experienced an 11-pound weight loss between August 2023 and March 2024, which equated to greater than 10% in six months. Despite multiple nutrition notes documenting significant weight loss and recommendations for weekly weight monitoring, there was no documentation that the physician was notified of Resident 93's weight loss. The Director of Nursing confirmed that the Registered Dietitian works remotely and acknowledged the lack of physician notification during interviews on March 27 and March 28, 2024. Resident 129, who had diagnoses including a stage 4 pressure injury and paraplegia, also experienced significant weight loss. Upon admission, Resident 129 weighed 220 pounds, but weekly weights were not performed. The next documented weight was 24 days later, showing a weight of 218 pounds, and subsequently, a significant weight loss of 14.4% was recorded between February 3 and February 23, 2024. Despite the Registered Dietitian's progress note on February 28, 2024, indicating significant weight loss, there was no documentation that the attending physician was notified. A routine medical follow-up visit on March 20, 2024, also failed to address the weight loss. As of March 28, 2024, the facility could not provide documentation that the physician was informed of Resident 129's significant weight loss.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide routine and/or emergency dental services for Resident 67, who had diagnoses including anxiety, COPD, and epilepsy. The resident had seen a dentist several months prior, who recommended replacing her full upper denture and fitting her for a partial lower denture. However, the dentist did not return, and the resident had not received any follow-up. The resident's upper denture was observed to be loose, although it did not hinder her ability to eat. The resident's clinical record indicated that Medicaid was her payor source, and a dental consult dated January 18, 2024, recommended a full mouth x-ray and follow-up for new dentures and a six-month dental cleaning. Despite being scheduled for a dental hygienist visit on March 25, 2024, the resident was not seen on that date, and no explanation was provided by the contracted dental group. The resident was rescheduled to be seen in April 2024, but no specific date was given. Interviews with the Director of Social Work and the Director of Nursing confirmed that the resident should have been seen on March 25, 2024, and that the x-ray for denture fitting was the first step in the process. The interdisciplinary team decided that completing the x-ray in April 2024 would be acceptable since the resident had not experienced any ill effects. The facility's failure to ensure timely dental services for Resident 67 resulted in a deficiency under 28 Pa Code 211.15 Dental services.
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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.
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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