Chambersburg Skilled Nursing And Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 1070 Stouffer Avenue, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395348
- Inspections on file
- 30
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Chambersburg Skilled Nursing And Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with vascular dementia, gait difficulty, and muscle weakness experienced falls resulting in hospitalization, yet nursing staff documented multiple neurological assessments on flow sheets during periods when the resident was not in the facility. Facility policy required detailed neurological evaluations and vital sign documentation after such events, and the NHA and DON confirmed that supervisors complete these flow sheets and that entries had been made despite the resident’s absence, contrary to professional standards and expectations for accurate documentation.
A resident with chronic kidney disease, diabetes, and hypertension was treated for hypokalemia with potassium chloride ER 40 mEq three times daily. After the potassium level normalized, the high-dose supplementation continued without an end date and without further lab monitoring for several days, despite ongoing evidence of impaired renal function. When a follow-up potassium lab was ordered, the resident refused twice, and there was no documentation that the resident was informed of the risks of refusing this monitoring. The facility continued administering the same potassium dose without checking levels, and the resident was later transferred to the hospital with altered mental status and was found to have severe hyperkalemia, along with worsened renal function.
Surveyors found that food and beverages, including thickened liquids and items from outside sources, were not consistently labeled with open dates or resident information, and some were kept beyond the allowed time frames. Staff interviews confirmed these items should have been labeled and discarded per facility policy and professional standards.
A resident's bathroom was found to have wallpaper coming away from the wall, rippling under the sink, and torn behind the toilet, with no active maintenance work order in place and the issue persisting for several days despite facility policy requiring a clean and comfortable environment.
Two residents with significant medical histories experienced falls that were not accurately documented in their MDS assessments. Staff interviews confirmed that the assessments failed to reflect these incidents, resulting in inaccurate resident records.
A resident with CHF and atrial fibrillation did not have daily weights consistently documented as ordered, and a significant one-day weight gain was not reported to the practitioner or rechecked. The DON confirmed that daily weights and follow-up were expected but not completed.
The facility failed to maintain and install emergency lighting as required by NFPA 101. There was no documentation of annual maintenance for battery-powered emergency lighting sources, and no battery-powered emergency lighting was installed at the automatic transfer switch, affecting all six smoke compartments. These issues were confirmed by the Assistant DON and Maintenance Director.
The facility was found non-compliant with NFPA 101 smoking regulations due to the absence of a documented smoking policy, lack of no smoking signs in hazardous areas, and failure to provide proper receptacles for cigarette disposal in designated smoking areas. These deficiencies were confirmed through document review, observations, and interviews with facility staff.
The facility did not perform required maintenance and testing of its Essential Electrical System, including missing monthly and annual generator tests. This was confirmed during a review and interview with the Assistant DON and Maintenance Director.
The facility was found non-compliant with GFI protection requirements for power receptacles within six feet of a water source in three smoke zones. Observations revealed non-GFI protected outlets in the D Hall Nurses' Station Nourishment Area, B Hall Beauty Shop, and Main Kitchen Prep Area. This was confirmed by the Assistant DON and Maintenance Director.
The facility failed to maintain smoke-tight doors in a hazardous area, specifically the Boiler Room, where a gap greater than 1/2-inch was observed due to a removed astragal. This was confirmed by the Assistant DON and Maintenance Director.
The facility did not conduct and document the owner's checks of the fixed chemical fire suppression system in one of the smoke compartments. During a review, it was found that the facility lacked documentation for the required quick checks on the kitchen's fire suppression system, which was confirmed by the Assistant DON and Maintenance Director.
The facility did not provide documentation verifying the semi-annual testing and inspection of the fire alarm system within the previous twelve months. This deficiency was confirmed during a document review and an exit conference with the Assistant DON and Maintenance Director.
The facility failed to conduct required fire drills, missing drills for the 2nd shift in the 1st quarter of 2025, and the 1st and 3rd shifts in the 3rd quarter of 2024. This was confirmed by the Assistant DON and Maintenance Director, acknowledging non-compliance with NFPA 101 standards.
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review, and the absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. The lack of documentation indicates non-compliance with NFPA 80 requirements.
Two residents experienced significant unplanned weight loss due to the facility's failure to monitor nutritional status adequately. One resident, with muscle wasting and depressive disorder, lost 8.6 pounds without proper monthly weight checks or a timely nutrition assessment. Another resident, with dementia and intellectual disabilities, lost 16 pounds, and despite a dietician's recommendation, weekly weights were not recorded. The DON acknowledged the lapses in monitoring.
The facility failed to ensure accurate assessments for three residents, leading to deficiencies in care documentation. A resident with Alzheimer's and diabetes had unreported dental issues in their MDS due to off-site staff errors. Another resident developed a pressure injury post-admission, with incorrect MDS coding regarding the injury and weight loss. A third resident receiving hospice care was not accurately documented in MDS assessments. These issues were confirmed by facility staff during interviews.
The facility failed to document necessary wound care treatments for three residents with pressure ulcers, leading to potential lapses in care. A resident with dementia and muscle weakness had missing documentation for sacrum wound care, while another with dementia and intellectual disabilities had incomplete records for heel and ankle treatments. A third resident with peripheral vascular disease also had undocumented treatments for heel and buttocks wounds. The DON acknowledged the missing documentation and emphasized the expectation for proper record-keeping.
A facility failed to provide proper respiratory care for a resident with chronic lung conditions. The resident's nebulizer mask was left uncovered, and the tubing was not changed weekly as required. Staff interviews revealed that nebulizer equipment should be cleaned and changed regularly, but this was not consistently done. The resident reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so.
A resident with neurogenic bladder and spina bifida did not have complete clinical records maintained, as staff failed to document the administration of prescribed treatments, including zinc paste and Ketoconazole cream, on several occasions. The DON confirmed that all treatments should be signed off on the TAR.
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Observations included black substances on air vents, debris in heating/cooling units, and missing plastic grates. The Nursing Home Administrator and DON acknowledged the concerns during a tour.
Inaccurate Neurological Assessment Documentation for Hospitalized Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that care and services were provided in accordance with professional standards of quality, specifically related to neurological evaluations after falls. Facility policy and procedure required that neurological evaluations include documentation of level of consciousness, orientation, ability to follow commands, response to sensation and/or pain, pupil reaction, motor function, and vital signs on a Neurological Assessment Flow Sheet. Resident 4, who had diagnoses including vascular dementia with mood disturbances, difficulty walking, and muscle weakness, experienced a fall on January 11, 2026, with complaints of left leg pain and a hematoma to the left side of the forehead. She was transferred to the hospital shortly after the fall and remained hospitalized until January 17, 2026. Despite Resident 4’s absence from the facility during this hospitalization, her neurological evaluation flow sheet contained multiple entries indicating that neurological assessments were completed at numerous times on January 11, 12, 13, and 14, 2026. Similarly, after another fall on March 25, 2026, Resident 4 was transferred to the hospital on March 26, 2026, and remained hospitalized until March 28, 2026, yet her neurological evaluation flow sheet documented an assessment on March 26, 2026, during the 3–11 shift when she was not present in the facility. During interviews, the NHA and DON explained that neurological flow sheets are placed on a clipboard for nursing supervisors to complete and confirmed that neurological evaluations had been documented as completed even though the resident was not in the facility, acknowledging that documentation was expected to be accurate.
Failure to Adjust Potassium Supplementation and Ensure Informed Refusal of Lab Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to discontinue or adjust potassium chloride ER dosing and to ensure a resident was informed of the risks of refusing laboratory monitoring, resulting in unmonitored treatment for hypokalemia in a resident with chronic kidney disease. The resident had diagnoses including chronic kidney disease, diabetes, and hypertension, and was cognitively intact per an admission BIMS score of 13. Laboratory results showed hypokalemia with a potassium level of 2.8, along with elevated BUN and creatinine and a reduced eGFR, indicating impaired renal function. In response, the physician ordered potassium chloride ER 20 mEq tablets, 40 mEq three times daily, without an end date. A repeat lab two days later showed a normal potassium level of 4.5, but BUN and creatinine remained elevated and eGFR remained low. No labs were ordered for the next two days. A lab was ordered for a subsequent date to recheck potassium, but the resident refused two attempts to obtain the specimen, and there was no documentation that the resident was made aware of the risks of declining the lab test. When the physician was notified of the refusal, the lab was simply reordered for a later date, and the facility continued administering potassium chloride ER 40 mEq three times daily over several days without any potassium level monitoring. The resident was later sent to the hospital for altered mental status, where admission labs revealed hyperkalemia with a potassium level of 7.1, along with further elevated BUN and creatinine and a lower eGFR. The hyperkalemia was treated in the emergency department, and the resident was admitted for continued monitoring and evaluation of altered mental status and possible infection. The deficiency was cited under 28 Pa. Code 211.2(d)(3)(9) Medical Director, 28 Pa. Code 211.10(c) Resident Care Policies, and 28 Pa. Code 211.12(c) Nursing Services.
Failure to Properly Store and Label Food and Beverages
Penalty
Summary
The facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and three of four nourishment areas. Observations revealed multiple instances where thickened beverages and food items were either not labeled with an open date or were kept beyond the allowable time frames specified by both facility policy and product labeling. Specifically, containers of thickened lemon water and apple juice were found open and either undated or dated beyond the seven-day limit for use after opening. Additionally, food items brought in from outside sources were not consistently labeled with the resident's name and the date the food was brought in, nor were they always discarded after the three-day holding period as required by facility policy. Interviews with the Food Service Director confirmed that these items should have been properly labeled and discarded according to the established time frames. The Nursing Home Administrator also stated that it was the facility's expectation for expired items to be discarded and for all food and beverages to be labeled and stored per policy and professional standards. These findings indicate a failure to adhere to both internal policies and professional standards regarding the safe storage and handling of food and beverages.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in one of the resident rooms reviewed. Facility policy requires that residents have a right to a safe, clean, and comfortable environment, and that housekeeping and maintenance services are provided to maintain a sanitary and orderly interior. A resident reported disappointment with the condition of the wallpaper in his bathroom, which had been in poor condition since his admission to the room. Observations confirmed that the wallpaper was coming away from the wall in several areas, was rippling under the sink, and was torn behind the toilet. A review of the facility's maintenance work order report did not show any active work order for the bathroom in question, despite the issue being present for several days. The Nursing Home Administrator stated that staff are responsible for identifying and reporting environmental concerns in resident rooms daily, but there was no evidence that this process was followed for this resident's bathroom. Follow-up observations showed that the wallpaper remained in poor condition several days after the initial report and observation.
Inaccurate MDS Coding for Resident Falls
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents. For one resident with diagnoses including COPD, end stage renal disease, and difficulty walking, clinical records showed a fall with no injuries occurred. However, the resident's Minimum Data Set (MDS) assessment did not document this fall, indicating inaccurately that no falls had occurred since the prior assessment. This discrepancy was confirmed during staff interviews. Another resident, with a history of muscle weakness, difficulty walking, and traumatic brain injury, experienced a fall with injury and was sent to the emergency room. Despite this, the resident's MDS assessment also failed to document the fall, incorrectly stating that no falls had occurred since the previous assessment. Staff interviews confirmed the inaccuracy in the MDS coding for this resident as well.
Failure to Document and Respond to Significant Weight Changes in Resident with CHF
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for a resident diagnosed with congestive heart failure and atrial fibrillation. Physician orders required daily weights and notification of the practitioner if the resident gained 2 pounds or more in a day or 5 pounds in a week. Documentation showed that daily weights, or refusals, were not recorded for multiple days across three months. Additionally, a significant weight gain of 11.7 pounds in one day was documented, but there was no evidence that the practitioner was notified or that a reweigh was performed. The Director of Nursing confirmed that daily weights should have been recorded and appropriate follow-up should have occurred when the weight gain was identified.
Deficiency in Emergency Lighting Maintenance and Installation
Penalty
Summary
The facility was found to be deficient in maintaining and installing emergency lighting as required by NFPA 101. During a document review and observation, it was discovered that the facility lacked documentation verifying the annual maintenance of battery-powered emergency lighting sources. Additionally, it was observed that there was no installed battery-powered emergency lighting at the automatic transfer switch, affecting all six smoke compartments within the component. These findings were confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1. and 2. Maintenance Director has completed annual maintenance of battery-powered emergency lighting and installed battery-powered emergency lighting at the automatic transfer switch. 3. Maintenance department will be educated on the standards of ensuring the facility has completed the annual maintenance of battery-powered emergency lighting and ensuring there is a battery back-up emergency lighting at the automatic transfer switch. 4. Maintenance or facility designee will audit the facilities battery-powered emergency lighting weekly x2 for 2 months, then every 60 days throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with Smoking Regulations
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 smoking regulations due to several deficiencies. During a document review, it was discovered that the facility did not have a documented smoking policy available for review. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director. Additionally, the facility failed to post no smoking signs in areas where flammable liquids, combustible gases, or oxygen are used or stored, which was also confirmed during the exit conference interview. Furthermore, observations revealed that the facility did not provide metal containers with self-closing cover devices for ashtrays, nor did it have fire-resistant ashtrays in the designated smoking area behind the facility at the picnic table. This area was found to have an abundance of cigarette butts discarded on the ground, indicating a lack of proper receptacles. The absence of these required receptacles was confirmed during the exit conference interview with the Assistant Director of Nursing and the Maintenance Director.
Plan Of Correction
1 and 2. Maintenance Director will print smoking policy for life safety binder, will post non-smoking signs in rooms, wards, or compartments where flammable liquids, combustible gases or oxygen is used or stored and will provide metal receptacles to be available where smoking is permitted. 3. Maintenance department will be educated on the standards of the facilities smoking policy, need for non-smoking signs, and providing metal receptacles where smoking is permitted. 4. Maintenance or facility designee will audit facilities smoking policy, metal receptacles, and non-smoking signs to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Maintain Essential Electrical System
Penalty
Summary
The facility failed to perform the required maintenance and testing of its Essential Electrical System (EES), which is crucial for ensuring the safety and functionality of the power supply in emergency situations. Specifically, the facility did not conduct the necessary weekly, monthly, and annual inspections and testing of the generator and associated equipment. This includes the failure to perform a monthly 30-minute load test using the transfer switches and an annual 90-minute load bank test. During a document review and interview conducted on April 16, 2025, it was confirmed by the Assistant Director of Nursing and the Maintenance Director that these essential maintenance activities were not carried out as required. The lack of adherence to the maintenance schedule outlined in NFPA 101 and related standards indicates a significant oversight in the facility's operational procedures, potentially compromising the reliability of the emergency power system.
Plan Of Correction
1 and 2. 4 hour building load test performed 3/8/2024 by GenServ. Maintenance Director has performed the monthly 30 min. test and will complete the annual 90 minute load bank inspection and testing of the facilities generator. 3. Maintenance department will be educated on the standards of completing weekly, monthly and annual inspections and testing of generator. 4. Maintenance or facility designee will audit facilities generator weekly for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Non-Compliance with GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in three of six smoke zones. During an observation on April 16, 2025, between 12:30 PM and 12:45 PM, it was noted that various outlets were not GFI protected. Specifically, at 12:30 PM, one outlet in the D Hall Nurses' Station Nourishment Area was found to be non-compliant. At 12:40 PM, three outlets in the B Hall Beauty Shop, located by sinks, were also not GFI protected. Additionally, at 12:45 PM, two outlets in the Main Kitchen Prep Area, near the coffee machine and ice machine, were identified as lacking GFI protection. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the time of the exit conference on the same day.
Plan Of Correction
1 and 2. Maintenance Director has updated GFI's in D hall nurses station nourishment room (1 outlet), B hall beauty shop (3 outlets), and main kitchen prep area (2 outlets). 3. Maintenance department will be educated on the standards of maintaining power receptacles to be GFI within six feet of a water source. 4. Maintenance or facility designee will audit facilities GFI receptacles weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Deficiency in Smoke-Tight Integrity of Boiler Room Doors
Penalty
Summary
The facility failed to maintain the smoke-tight integrity of hazardous area doors in one of six smoke compartments. During an observation on April 16, 2025, at 11:55 AM, it was noted that there was a gap greater than 1/2-inch between the double doors of the Boiler Room due to a removed astragal. This deficiency was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM.
Plan Of Correction
1 and 2. Maintenance Director installed astragal between the double doors in the boiler room. 3. Maintenance department will be educated on the standards of ensuring the facility's corridor doors do not have a gap greater than 1/2in. and to not remove astragal. 4. Maintenance or facility designee will audit the facilities corridor doors weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Suppression System Checks
Penalty
Summary
The facility failed to conduct and document the owner's checks of the fixed chemical fire suppression system in one of the six smoke compartments within the component. During a document review and interview conducted on April 16, 2025, it was revealed that the facility could not provide documentation of the owner's quick check for the fixed chemical fire suppression system installed in the kitchen. This deficiency was confirmed during an exit conference with the Assistant Director of Nursing and the Maintenance Director, who acknowledged the lack of documentation for the required quick checks on the kitchen's fire suppression system.
Plan Of Correction
1 and 2. Maintenance Director completed the monthly check of the chemical fire suppression system. 3. Maintenance department will be educated on the standards to ensure we are checking the chemical fire suppression system monthly. 4. Maintenance or facility designee will audit facilities chemical fire suppression system to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide documentation verifying that the semi-annual testing and inspection of the fire alarm system had occurred within the previous twelve months. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of this documentation affects the entire component of the fire alarm system. During an exit conference on the same day at 1:45 PM, the Assistant Director of Nursing and the Maintenance Director confirmed the lack of documentation for the required semi-annual testing and inspection of the fire alarm system.
Plan Of Correction
1 and 2. Maintenance Director contracted Eastern Time, Inc. to revisit facility to complete semi-annual fire alarm system testing. 3. Maintenance department will be educated on the standards of the facilities fire alarm system inspection. 4. Maintenance or facility designee will audit facilities fire alarm system inspection located in the life safety book weekly x2 for 2 months then quarterly throughout the year to confirm fire alarm reports are still available for review and results of the audit will be reported to the QA Committee.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct and perform fire drills as required, with deficiencies noted in the documentation review. Specifically, the facility did not perform fire drills for the 2nd shift in the 1st quarter of 2025, the 1st shift in the 3rd quarter of 2024, and the 3rd shift in the 3rd quarter of 2024. This was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director, who acknowledged that the fire drills were not conducted as mandated by the NFPA 101 standards, which require fire drills to be held at least quarterly on each shift under varying conditions.
Plan Of Correction
1 and 2. Maintenance Director will complete monthly fire drills, one per shift, per quarter. 3. Maintenance department will be educated on the standards of the facilities monthly fire drill policy ensuring they are being conducted one per shift, per quarter. 4. Maintenance or facility designee will audit facilities fire drills to ensure it is checked off weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation of the annual fire-rated door inspection for six smoke compartments. This deficiency was identified during a document review conducted on April 16, 2025, between 9:00 AM and 11:15 AM. The absence of documentation was confirmed during an interview with the Assistant Director of Nursing and the Maintenance Director at the exit conference on the same day at 1:45 PM. The lack of documentation indicates that the required annual inspections of fire door assemblies, as mandated by NFPA 80, were not properly recorded or possibly not conducted, leading to non-compliance with the Life Safety Code requirements.
Plan Of Correction
1 and 2. Maintenance Director has completed the annual fire door inspection in six of six smoke compartments. 3. Maintenance department will be educated on the standards of the facility's annual fire door inspection. 4. Maintenance or facility designee will audit facilities annual fire door inspection in life safety binder weekly x2 for 2 months then quarterly throughout the year and results of the audit will be reported to the QA Committee.
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status for two residents, leading to significant unplanned weight loss. Resident 60, diagnosed with muscle wasting, atrophy, muscle weakness, and major depressive disorder, experienced an unplanned weight loss of 8.6 pounds (4.9%) between March and April 2024. The facility did not obtain monthly weight measures for November 2023 and January 2024, nor did they conduct a re-weigh for the weight change in April 2024. Additionally, there was no nutrition assessment conducted between March 22, 2024, and April 26, 2024, despite the resident's weight loss. Resident 72, diagnosed with dementia and moderate intellectual disabilities, experienced an unplanned significant weight loss of 16 pounds (approximately 10%) between March and April 2024. Although a dietician noted the weight loss and recommended weekly weight monitoring, the facility failed to obtain or record these weekly weights between April and May 2024. The Director of Nursing acknowledged the expectation for weekly weights following the significant weight loss, which was not met.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in care documentation. Resident 12, diagnosed with Alzheimer's disease and type II diabetes mellitus, reported tooth pain due to poor dentition, which was confirmed by dental consults and a speech therapy evaluation. However, the comprehensive annual MDS for Resident 12 did not reflect the presence of obvious or likely cavities or broken teeth. This discrepancy arose because the MDS was completed by an off-site staff member who relied on an admission evaluation that inaccurately indicated the resident had dentures without other dental concerns. Resident 52, with diagnoses of dementia and type 2 diabetes, developed a pressure injury on the right heel after admission, which progressed to include necrotic tissue. The Discharge Return Anticipated MDS and Quarterly MDS for Resident 52 were incorrectly coded, indicating the pressure injury was present upon admission and misreporting weight loss. The Director of Nursing confirmed these coding errors during a staff interview. Resident 80, diagnosed with epileptic seizures and Alzheimer's disease, was admitted to hospice services, but the facility failed to indicate hospice care in two quarterly and one annual MDS assessments. This oversight was acknowledged by the Nursing Home Administrator and Director of Nursing during interviews with the surveyor, who highlighted the expectation for accurate MDS assessments.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services to promote healing and prevent infection of pressure ulcers, as evidenced by missing documentation of wound care treatments for three residents. Resident 11, diagnosed with dementia and muscle weakness, had a stage III pressure injury on the sacrum. The treatment orders included cleansing with saline, applying skin prep, hydrogel, and a dry dressing. However, documentation was missing for several dates in March and May 2024, indicating that the treatments may not have been completed as ordered. Resident 72, with dementia and moderate intellectual disabilities, had stage III pressure injuries on the left heel, right heel, and right ankle. The treatment orders involved cleansing with wound cleanser, applying skin prep, hydrogel, and optifoam dressing. Documentation was missing for multiple dates in April 2024, suggesting a lack of adherence to the prescribed treatment schedule. The Director of Nursing acknowledged the missing documentation and expressed the expectation that treatments should be documented. Resident 110, diagnosed with a pressure ulcer of the left heel, peripheral vascular disease, and muscle weakness, also had missing documentation for wound care treatments. The treatment orders included cleansing with saline, applying wet gauze, and covering with ABD and kerlex. Documentation was absent for several dates from November 2023 to May 2024. The Director of Nursing was unable to provide additional information regarding the missing documentation and reiterated the expectation for wound treatments to be documented.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for a resident with a history of pulmonary embolism, acute pulmonale, and chronic obstructive pulmonary disease. The resident had physician orders for Ipratropium-Albuterol Solution to be administered four times daily and as needed. Observations revealed that the nebulizer mask was left uncovered on the resident's nightstand with the medication reservoir still attached, and the tubing was not changed weekly as required. The resident reported that staff no longer cleaned or changed the mask frequently. Interviews with staff, including a registered nurse and a respiratory therapist, confirmed that nebulizer tubing should be changed weekly and masks should be cleaned after each treatment. However, the respiratory therapist, who had recently started working at the facility, was unaware of the current status of nebulizer equipment and was waiting for a list of nebulizers in the building. The resident also reported having to remove the nebulizer mask herself after treatment, as staff did not return to do so, and the mask was not cleaned afterward. The facility's nursing home administrator and director of nursing were informed of these observations and the resident's statements.
Incomplete Clinical Records for Resident Treatments
Penalty
Summary
The facility failed to maintain complete clinical records for a resident, identified as Resident 107, who has diagnoses including neurogenic bladder and spina bifida. The resident was cognitively intact and required specific treatments for moisture-associated skin damage (MASD) on his buttock and scrotum, which included the application of zinc paste every shift. Additionally, the resident was receiving Ketoconazole cream 2% for a skin condition on his head, face, and neck every shift. However, the Treatment Administration Record (TAR) for Resident 107 showed that staff did not initial and check the block confirming the administration of the Ketoconazole cream on three specific dates and shifts in April 2024. Similarly, the TAR also revealed that staff failed to document the administration of the zinc paste on three different dates and shifts in April 2024. During an interview, the Director of Nursing (DON) confirmed that all treatments should be signed off as completed on the TAR. This deficiency was identified through a review of clinical records and staff interviews, indicating a lapse in maintaining complete and accurate medical records in accordance with accepted professional standards.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in three of the four nursing units observed. Specific observations included the presence of a black, speckled substance on air vents in the dining room outside the main kitchen, black substance accumulations along the corners of walls beside heating vents/units in multiple residents' rooms, and debris in heating/cooling units. Additionally, some heating/cooling units had missing plastic grates, dried spill/splash spots, and crumbling walls with debris noted in and on the units. During a tour with the Nursing Home Administrator and Director of Nursing, they acknowledged the concerns. The Director of Nursing later revealed that work orders had been submitted for the required repairs, and staff were in the process of auditing rooms for cleanliness.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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