Edenbrook South
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 101 Leader Drive, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395396
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Edenbrook South during CMS and state inspections, most recent first.
A nurse aide, without proper credentials, administered medications and performed medical treatments—including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change—for three residents. These actions were facilitated by an LPN, in violation of professional standards and state regulations requiring specialized training for such tasks.
A resident with schizoaffective disorder did not receive prescribed Ingrezza on multiple occasions because the facility failed to obtain the medication from its pharmacy, instead relying on the resident's family to supply it. Nursing staff documented repeated missed doses and lack of medication availability, with no evidence that the pharmacy was contacted to resolve the issue.
A resident experienced a deficiency in bowel management care due to the facility's failure to adhere to the established protocol. The resident did not have a bowel movement for an extended period, and there was no evidence that prescribed PRN medications were offered. Documentation gaps and a lack of adherence to the protocol led to the resident seeking medical attention independently, resulting in hospital visits for fecal disimpaction and further evaluations.
A resident experienced significant weight loss, but the facility failed to implement necessary interventions or notify the physician. The registered dietitian was aware of the weight loss but did not assess or address the issue, violating the facility's policy on monitoring and intervening in cases of undesirable weight changes.
The facility's main kitchen failed to meet food safety standards, with undated bulk containers, soiled potholders, and dust and debris on equipment and floors. A cooler had rusted shelves, and ceiling vents and tiles were dusty. Food temperatures were not recorded for breakfast meals on two consecutive days. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide consistent ADL care for two residents, one with dementia and another dependent on staff for bathing. Documentation showed infrequent bathing, refusals without re-approach, and lack of hair cleansing. Observations revealed poor grooming, and care plans lacked interventions for refusals. These issues were discussed with the DON.
The facility failed to provide necessary services to maintain or improve ROM and mobility for three residents. A resident had a therapy referral for daily ROM exercises, but the program was delayed and inconsistently documented. Another resident with impairments had a ROM program established but not initiated until a month later, and a splint brace program was also delayed. A third resident's ROM program was never started, as confirmed by the DON. These issues were previously cited, indicating a recurring problem.
The facility failed to document the competencies of four nursing staff members, including RNs and LPNs, in essential care tasks such as enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified through a review of facility documentation and staff interviews, affecting the care of residents with specific medical needs.
The facility failed to maintain and address pharmacy recommendations for three residents. For one resident, a pharmacist's review note indicated a completed medication review, but there was no evidence of the pharmacist's report or physician's response. Similarly, for another resident, a medication review was completed, but no documentation of recommendations or responses was found. These deficiencies were previously cited earlier in the year.
The facility failed to manage psychotropic medications appropriately for two residents. One resident's Cymbalta dosage was not reduced as recommended by a consultant pharmacist, and another resident received multiple PRN orders for Ativan without proper evaluations or documentation. The facility did not ensure non-medicinal interventions were attempted before administering PRN Ativan, leading to deficiencies in medication management.
The facility failed to follow proper infection control practices during medication administration and a dressing change. An LPN handled medications with bare hands, and a nurse did not use enhanced barrier precautions or maintain a clean field during a dressing change for a resident with a pressure ulcer. These actions were confirmed by staff interviews, indicating a breach in infection prevention protocols.
A resident's dignity was compromised when their catheter bag was observed full, uncovered, and on the floor on two occasions while they were sleeping. This issue was previously cited, indicating a recurring problem with maintaining proper care standards.
The facility failed to maintain a clean and safe environment, with observations of unclean enteral feeding pumps for two residents and persistent strong urine odors in several rooms. Additionally, one resident's room had disorganized items and broken furniture, while another had a damaged wall. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with a bruise on the face. The resident was known to be combative during care, but the investigation lacked witness statements and evidence of staff education on managing such behavior. This deficiency was previously cited, indicating a repeated failure to comply with regulations.
A facility failed to ensure accurate assessments for a resident, as a quarterly MDS inaccurately indicated the resident received an anticoagulant medication. Clinical records showed no evidence of such medication being administered during the assessment period. The DON confirmed the MDS was coded in error.
A facility failed to provide the highest practical care for a resident by not implementing a physician's recommendations for hand therapy and warm soaks, despite the resident's complaints of a 'cold hand' and a specialist's advice. The resident had seen a plastic surgeon who noted improvement with exercise and recommended further treatment, which was not documented or implemented until questioned by a surveyor.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy and BiPAP for sleep apnea. The resident's oxygen concentrator was set at 9 LPM without humidification, contrary to the physician's order of 5 LPM. Additionally, the BiPAP mask was improperly stored, increasing infection risk. This deficiency was discussed with the DON.
A facility failed to secure treatments in a resident's room, where open bottles of Dakin's solution and Derma wound cleanser were found on the windowsill. These antiseptics, which should be kept out of reach of children, were improperly stored, as confirmed by the Nursing Home Administrator and DON. This was a repeat deficiency from a previous citation.
The facility failed to follow CDC guidelines for TB screening of newly hired health care personnel. Two newly hired nurse aides did not receive the required pre-employment TB screening, despite providing evidence of prior negative TB tests within 12 months. This deficiency highlights a lapse in the facility's adherence to recommended TB screening procedures.
The facility did not meet the required nurse aide-to-resident ratios during both day and night shifts on multiple occasions. During the day shift, the facility was understaffed on two days, with fewer nurse aides than required for the resident census. Similarly, during the night shift, the facility failed to provide the necessary number of nurse aides on three separate days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day on three occasions. The nursing staff care hours were below the required threshold, with specific deficiencies noted on three days. The Nursing Home Administrator confirmed the shortfall in meeting the regulatory daily hours PPD.
The facility failed to provide adequate assistance with activities of daily living for three residents. A resident requiring supervision for personal hygiene did not receive shaving assistance as scheduled. Another resident with urinary incontinence had lapses in documented oral care and toileting assistance. A third resident, needing help with bathing and oral care, was observed with overgrown fingernails and missed scheduled care. These deficiencies were discussed with the DON and Nursing Home Administrator.
The facility failed to consistently implement restorative programs for two residents with mobility deficits. One resident expressed concerns about walking and was discharged from physical therapy without a restorative program, while another required assistance due to poor balance. Documentation revealed frequent failures to provide and document the required restorative ambulation programs, as confirmed by staff interviews.
A resident reported dissatisfaction with meals, receiving food she is allergic to and dislikes, despite communicating preferences. Staff failed to address meal discrepancies, and the food service director acknowledged mismatched menu tickets, indicating systemic issues in meal planning.
The facility was found to have multiple deficiencies in maintaining a clean and homelike environment across four nursing units. Observations included moisture-related spots on vents, dust accumulation, slimy substances on drip trays, and dead insects in various areas. These issues were noted in dining rooms, nurse stations, hallways, and resident areas, indicating a widespread problem with cleanliness and maintenance.
A resident was prescribed Temozolomide, a cancer medication, without a proper diagnosis or indication for its use. Despite not having a history of cancer or radiation treatments, the medication was ordered and administered for the duration of radiation therapy. The oversight was confirmed by interviews with the facility's administration and medical staff.
The facility failed to investigate and report an allegation of mental abuse involving a resident. Employee 1 was reported to have used her phone inappropriately, potentially taking and sharing photos or videos of residents. Despite a witness statement supporting this claim, the facility did not obtain further statements or notify relevant agencies, violating policy and regulatory requirements.
A facility failed to provide necessary bathing assistance to a dependent resident, as documented in the April 2024 report. The resident, assessed as dependent on staff for bathing, did not receive documented bed baths on three occasions. This deficiency was reviewed with the Nursing Home Administrator.
A resident was administered Temozolomide, a cancer medication, without an appropriate diagnosis. Despite multiple reviews by CRNPs, the medication was not flagged as inappropriate. The facility failed to provide evidence of a medical evaluation before ordering the medication.
A resident was prescribed Temozolomide without a cancer diagnosis or radiation therapy, and the consultant pharmacist failed to report this irregularity to the physician or DON. This oversight was confirmed by the facility's administration.
A resident experienced neglect resulting in harm due to a failure in communication and response by staff. The resident showed signs of a stroke, which were not reported by an LPN to the RN on duty. The resident's condition was only addressed after a shift change, leading to emergency medical intervention.
Unlicensed Staff Administered Medications and Treatments
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three residents. On a specific date, a nurse aide (NA) administered prescribed medications and performed medical treatments, including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change, for three residents. These actions were performed on behalf of a licensed practical nurse (LPN), who was aware of and facilitated the NA's involvement in medication administration and treatment procedures. The NA's actions included administering oral medications and subcutaneous insulin to one resident, administering medications via PEG tube and subcutaneous insulin to another, and completing a dressing change on a surgical site for a third resident. Pennsylvania regulations require specialized training and credentialing for medication administration, which the NA did not possess. Resident interviews and facility documentation confirmed that the NA performed these tasks, and the LPN acknowledged facilitating the NA's actions. The incident was discovered and reported to the Director of Nursing (DON) several days later. The facility's failure to ensure that only appropriately licensed and credentialed staff administered medications and performed medical treatments resulted in a breach of professional standards of quality for the affected residents.
Failure to Provide Prescribed Medication Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to obtain and provide a prescribed medication, Ingrezza, for a resident with a history of schizoaffective disorder. Upon admission, the resident's hospital discharge records indicated the need to continue Ingrezza 40 mg nightly. However, nursing documentation showed that the pharmacy did not supply the medication, and instead, the resident's sister was expected to bring it in. There was no documentation explaining why the pharmacy was not contacted or able to provide the medication, and the Ingrezza was the only medication not obtained through the facility's pharmacy. Review of the Medication Administration Record (MAR) revealed that nursing staff did not administer the resident's nightly Ingrezza on multiple occasions, documenting that the medication was not available from the pharmacy or not found in the medication cart. Further nursing notes indicated ongoing communication with the resident's sister regarding the medication, but no evidence was found that the pharmacy was contacted to resolve the issue. These findings were confirmed by a registered nurse during an interview.
Failure in Bowel Management Protocol
Penalty
Summary
The facility failed to provide the highest practical care related to bowel management for a resident, as evidenced by the lack of adherence to the established bowel management protocol. The protocol required the administration of Milk of Magnesia, Dulcolax suppository, and Fleet's enema in a sequential manner if the resident did not have a bowel movement over several days. However, documentation revealed that the resident did not have a bowel movement for an extended period, and there was no evidence that the prescribed PRN medications were offered or refused by the resident. Additionally, there was a gap in documentation from February 1 to 5, 2025, due to a transition in facility ownership, which contributed to the oversight in the resident's care. The resident experienced significant discomfort and sought medical attention independently, resulting in a hospital visit where fecal disimpaction was performed. The resident's condition was further complicated by rectal bleeding and abdominal pain, leading to additional hospital evaluations. The facility's failure to follow the bowel management protocol and adequately document the resident's bowel movements resulted in a deficiency in providing the highest practical care, as confirmed by interviews with facility staff and a review of the resident's clinical records.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for a resident, identified as Resident 1, who experienced significant weight loss. According to the facility's policy, a significant weight change is defined as a 5 percent change over 30 days, 7.5 percent over 90 days, or 10 percent over 180 days. Resident 1 was admitted on June 21, 2024, and experienced a severe weight loss of 8.04 percent in 30 days and 12.71 percent in less than 90 days. Despite these significant changes, there was no evidence that the staff obtained a re-weight or notified the resident's physician, nor were there any assessments or interventions documented to address the severe weight loss. The registered dietitian, identified as Employee 1, confirmed awareness of the resident's weight loss but admitted to waiting for weight verifications and did not assess or implement interventions to address the issue. The facility's policy requires cooperation between nursing staff and the dietitian to monitor and intervene in cases of undesirable weight variances, but this protocol was not followed. The lack of action and communication regarding the resident's significant weight loss constitutes a deficiency in the facility's care practices.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, as observed during a survey. Two large bulk containers labeled as 'flour' and 'sugar' lacked dates indicating when the products were placed or needed to be used by. Additionally, several white potholders were found on top of the convection oven, soiled with dried foods and significantly stained. The bottom shelf of the steamer and prep table, as well as the lower shelf of the production table, contained dust and dried food debris. The flooring under and behind the steamer and the table beside it had dried food and debris buildup, with a pipe area caked with dried food and debris. Further observations revealed that a two-door cooler had multiple shelves with exposed rust-colored metal due to worn-off protective coating. Ceiling vents and tiles over the coolers and serving line were covered in dust, with one tile significantly stained and drooping. The plate warming unit had dried food splatter and debris. The food serving temperature log for January 21 and 20, 2025, showed no recorded temperatures for breakfast meals, indicating a failure to check food temperatures. A follow-up observation on January 23, 2025, found potholders on the convection oven blackened and covered in dried food. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Bulk containers and soiled potholders were removed from service, with the contents of the containers discarded. Shelves in the steamer and prep areas were immediately cleaned, along with the floor and pipes in the steamer area. Cooler shelves were replaced, ceiling tiles were changed, and vents were thoroughly cleaned. Additionally, the plate warmer underwent a deep cleaning. Although the temperature logs for the food on the trayline for the cited dates could not be completed, the cook received proper education, and logs for future meals were successfully recorded. Like: Potholders and cooler shelves will be inspected to ensure they remain in good condition. Items that are worn or soiled will be replaced proactively. The structured cleaning schedule was revised for the steamer area, prep areas, floors (including pipe), vents, and plate warmer. Staff will be assigned specific cleaning tasks with checklists. The food service director/designee will review the checklists to verify compliance. Cooks and staff will receive ongoing training on the importance of maintaining accurate temperature logs. The food service director/designee will review logs daily to ensure they are completed correctly. Educations: Food Safety and Sanitation training will be completed with all kitchen staff including the importance of maintaining cleanliness in food preparation areas with focus on proper cleaning and sanitizing procedures for kitchen equipment, shelves, and floors. Additionally, staff will be educated on the importance of maintaining accurate temperature logs for food safety compliance, proper techniques for measuring and recording food temperatures, and how to troubleshoot and respond to temperature irregularities. Audits: Food Service Director/designee will complete a daily audit to ensure temperatures, bulk container labeling and dating, and cleaning tasks for floors (including pipe area) and shelves are completed. The daily audit will also include visual inspection for the cleanliness of potholders, ceiling tiles, and vents. Daily audits will be completed x 21 days, and will then be completed weekly.
Failure to Provide Consistent ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, as evidenced by clinical record reviews and staff interviews. Resident 65, who was dependent on staff for bathing, had a significant change MDS assessment indicating the importance of choosing between different types of baths. However, task documentation showed inconsistent bathing schedules and instances where the resident refused or was not documented as having received a bath. There was no evidence that staff re-approached or offered bathing opportunities on subsequent shifts or days. Additionally, there were multiple instances where hair cleansing was either not documented or refused, with no follow-up actions taken by the staff. Observations of Resident 65 revealed disheveled hair, indicating a lack of proper grooming. Resident 89, admitted with dementia and adult failure to thrive, required assistance with bathing and personal hygiene. Task documentation indicated that showers were scheduled twice a week, but records showed infrequent bathing and numerous refusals without documentation of re-approach or alternative bathing opportunities. The care plan for Resident 89 lacked interventions for addressing bathing refusals. These deficiencies were discussed with the Director of Nursing during the survey, highlighting the facility's failure to ensure consistent and adequate ADL care for dependent residents.
Plan Of Correction
Cited: Resident 65 and resident 89 bathing preferences were collected and honored. • Like: Facility wide sweep will be completed to ensure residents bathing preferences are honored. • Education: NHA/designee will educate staff on resident bathing preferences. • Audits: NHA/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure resident bathing preferences are being honored. Results will be taken through QAPI.
Failure to Implement ROM Programs for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) and mobility for three residents. Resident 65 had a therapy restorative referral indicating the need for active and active assisted range of motion exercises to be performed one to two times daily. However, the nursing staff did not implement the restorative nursing program until several days after the referral, and there were multiple dates where the program was not documented as completed. Resident 42 had impairments in her upper and lower extremities, and although a restorative ROM program was established, it was not initiated until nearly a month later, after the surveyor's intervention. Additionally, Resident 42 was supposed to have a splint brace program, which was also not implemented in a timely manner. Resident 70 had a limited ROM on one side of his body, and a ROM program was established for him as well. However, there was no evidence that the program was ever initiated. The Director of Nursing confirmed that the ROM program for Resident 70 was never started. These deficiencies were previously cited in earlier surveys, indicating a recurring issue with the facility's ability to provide adequate nursing services to maintain or improve residents' ROM and mobility.
Plan Of Correction
Cited: Residents 42, 65, and 70 range of motion programs were reviewed with IDT team and were reevaluated by therapy. - Like: The facility will complete a two-week look back on residents who were discharged from therapy to review if resident is appropriate for ROM program and ensure it is initiated. - Educations: DON/designee will educate nursing staff and ensuring ROM program recommendations from therapy are followed appropriately. - Audits: DON/designee will audit 5 residents weekly x 4 weeks then monthly x 2 months to ensure residents who are discharged from therapy have appropriate ROM programs initiated if appropriate. Results will be taken through QAPI.
Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for specific care tasks, including enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified during a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses (RNs) and two licensed practical nurses (LPNs). These employees were responsible for the care of residents with various medical needs, such as enteral tube feedings, tracheostomies, indwelling catheters, and pressure ulcers. The facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters, five residents with pressure ulcers, five residents with enteral tube feedings, and one resident with a tracheostomy. Despite these care requirements, the facility was unable to provide documentation confirming that Employees 4, 5, 6, and 7 had the specific competencies and skill sets necessary to meet these residents' needs. This lack of documentation was confirmed during an interview with the Director of Nursing, indicating a failure to ensure that nursing staff were adequately prepared to provide the required care.
Plan Of Correction
Cited: Employees 4, 5, 6, and 7 completed the following competencies: enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. • Like: HR/designee will complete audit of current employees to ensure appropriate competencies are completed. • Education: NHA/designee will educate the staff educator to ensure plan of current staff to obtain appropriate competencies. • Audits: Staff educator/designee will audit 5 employees including new hires weekly x 4 weeks then monthly x 2 months to ensure staff have appropriate competencies completed. Results will be taken through QAPI.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain and address pharmacy recommendations for three residents, as required by §483.45(c) Drug Regimen Review. For Resident 23, a pharmacist's monthly medication review note dated June 10, 2024, indicated that a medication review was completed, but there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations. The Nursing Home Administrator and Director of Nursing confirmed that the pharmacy recommendation for this date could not be located. Similarly, for Resident 49, a medication review was completed by the consultant pharmacist on November 10, 2024, but there was no documentation of the pharmacist's recommendations or any response from the physician or facility. For Resident 42, a pharmacist's review note also dated June 10, 2024, indicated a completed medication review with a directive to "see report for recommendation," yet no evidence of the pharmacist's report or physician's response was found. The Nursing Home Administrator and Director of Nursing confirmed the absence of the pharmacy recommendation for this date. These deficiencies were previously cited on February 16, 2024, and May 22, 2024.
Plan Of Correction
Cited: Residents 23, 42, and 49 pharmacy recommendations were reviewed by the physician with a response. • Like: The facility will complete a two-week look back to review pharmacy recommendations to ensure there is a physician response. • Education: DON/designee will educate the licensed staff to ensure responses are provided to pharmacy recommendations. • Audits: DON/designee will audit 5 resident pharmacy recommendations weekly x 4 weeks then monthly x 2 months to ensure physician response is provided. Results will be taken through QAPI.
Failure to Manage Psychotropic Medications Appropriately
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications for two residents. Resident 9 was admitted on January 16, 2023, and was receiving Buspar and Cymbalta. A consultant pharmacist recommended a dose reduction of Cymbalta from 90 mg to 60 mg on July 13, 2024, which the physician agreed to on July 24, 2024. However, the facility did not implement this change until January 17, 2025, as confirmed by the Nursing Home Administrator and Director of Nursing. Resident 65 had multiple PRN orders for Ativan, a psychotropic medication, without appropriate stop dates or evaluations by a physician to justify the extensions beyond 14 days. The facility's documentation lacked evidence of non-medicinal interventions before administering the PRN Ativan. The consultant pharmacist recommended evaluating the necessity of the PRN Ativan, but the facility's physician and contracted physician's assistant opted to continue the medication with a 90-day stop date due to ongoing anxiety, without proper documentation of behaviors or provider evaluations to justify this decision. The facility's failure to adhere to regulatory requirements for psychotropic medications resulted in deficiencies related to unnecessary drug use. The surveyor confirmed these findings with the Nursing Home Administrator and Director of Nursing, highlighting the lack of compliance with medication management protocols and the absence of necessary documentation to support the continued use of psychotropic medications for Resident 65.
Plan Of Correction
• Cited: Resident 9 and resident 65 medication regime was reviewed and properly addressed by the physician. • Like: The facility will complete a medication regime review for current residents to ensure they are free for unnecessary medications directly related to physician recommendation to decrease Cymbalta and review of PRN antianxiety medication without supporting documentation. • Education: DON/designee will educate nursing staff to ensure the pharmacist and resident 39's recommendations are followed to avoid unnecessary medications as well as recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. • Audits: DON/designee will audit 5 random residents weekly x 4 weeks then monthly x 2 months to ensure the pharmacist resident 39's recommendations are followed to avoid unnecessary medications. Audit will also include recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. Results will be taken through QAPI.
Infection Control Deficiencies During Medication Administration and Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for two residents. An LPN was observed preparing medications for two residents using her bare hands, which is against standard infection control procedures. She handled various medications, including Famotidine, Mucinex, and Clopidogrel, without wearing gloves, and placed them into medication cups. This practice was confirmed during an interview with the LPN, indicating a breach in infection prevention protocols. Additionally, during a dressing change for a resident with a left lateral heel pressure ulcer, the facility's infection preventionist and wound nurse did not follow proper infection control measures. The nurse failed to clean the overbed table before placing supplies on it, did not change gloves after removing the old dressing, and did not use enhanced barrier precautions, such as wearing a gown. The absence of a sign indicating the need for enhanced barrier precautions on the resident's door further highlighted the lapse in infection control practices. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies, which included improper medication handling and inadequate infection control during a dressing change. These observations demonstrate a failure to maintain a safe and sanitary environment, as required by the facility's infection prevention and control program.
Plan Of Correction
Cited: Employee's #8 was required to complete a medication administration pass competency with the DON. Employee #9 was required to complete a treatment completion competency and was provided education relating to adherence to Enhanced Barrier Precautions. Like: Licensed staff will complete a medication administrator competency directly related to infection prevention with medication preparation as well as following enhanced barrier precautions, and general infection control practices with dressing changes. Education: DON/designee will educate nursing staff to ensure medication administration follows infection control procedures as well as following enhanced barrier precautions, and general infection prevention practices with dressing changes. Audits: Infection Preventionist/designee will audit 4 residents weekly then monthly x2 months to ensure medication administration follows infection control guidelines. Results will be taken through QAPI.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of the residents sampled. Specifically, Resident 61 was observed on two separate occasions with their catheter bag full of urine, uncovered, and laying on the floor. These observations were made from the hallway while the resident was sleeping in bed, indicating a lack of privacy and dignity in the care provided. The observations were made on January 21 and January 22, 2025, and were discussed with the Director of Nursing on January 24, 2025. This deficiency was previously cited on February 16, 2024, indicating a recurring issue with maintaining resident dignity and proper care standards. The facility's failure to address this issue demonstrates a lack of adherence to the resident's rights to a dignified existence and quality care.
Plan Of Correction
Cited: Resident 61's Catheter bag was placed in a cover and moved to the non-hallway side of the bed. • Like: Residents requiring the use of a urinary catheter were audited to ensure the catheter bags were covered and placed on the non-hallway side of the bed. • Education: DON/designee will educate nursing staff catheter bags being in covers and on non-hallway side of the beds. • Audits: DON/designee will audit residents with catheter bags to ensure they are in covers and placed on non-hallway sides of the bed. Audits will be completed weekly x4 weeks then monthly x 2 months. Results will be taken through QAPI.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across all four nursing units, as evidenced by multiple observations of unclean conditions and strong odors. Resident 85 was observed with an enteral feeding pump that had dried brown liquid splatters on its exterior, indicating a lack of proper cleaning. Similarly, Resident 56's feeding pump, pole, and bagged supplies were also found with dried brown liquid splatters. These observations were reviewed with the Director of Nursing and the Nursing Home Administrator. Additionally, the West Nursing Unit was noted to have a persistent strong odor of urine in the rooms and bathrooms of Residents 68 and 14 over several days. Resident 39's room was found to have a strong urine smell, a dirty floor, and disorganized items on nightstands with broken handles. The walls were marred and peeling. Resident 50's room had a cove base coming off the wall with crumbled pieces on the floor. These issues were brought to the attention of the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Resident 85 and resident 56 feeding pump pole was cleaned. Resident 68 and resident 14's rooms and bathroom were cleaned to ensure free of urine odor. Resident 39's night stand handles were repaired by maintenance director. Items in resident 39's room were organized. Resident 50's cove base was repaired in his room behind the head of the bed. • Like: Feeding pumps and poles facility wide were cleaned. Resident rooms and bathrooms facility wide were cleaned to ensure free of urine odor. Resident room floors were cleaned and resident room cove basing and walls were cleaned and repaired as needed. • Education: NHA/designee will educate the environmental staff on ensuring feeding poles and pumps and resident rooms and bathrooms are properly cleaned. NHA/designee will educate maintenance department on ensuring handles of night stands and wall and cove basing are repaired appropriately. • Audits: Environmental Director/designee will audit 5 random resident rooms and bathrooms to ensure cleanliness as well as odor weekly x 4 weeks and monthly x 2 months. Maintenance director/designee will audit 5 night stands and 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure night stands are appropriate as well as cove basing and walls. Results will be taken through QAPI.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident 42, who was reviewed for abuse. A clinical record review revealed that on December 30, 2024, a nurse noted a bruise on the right side of Resident 42's face, measuring 3 cm x 2 cm, with a dark bluish and purplish color. The bruise was located outside the right eye. The resident was known to be combative during care, and staff were instructed to walk away if the resident became combative to prevent self-inflicted injuries. However, there were no follow-up progress notes related to the event until January 22, 2025, after a surveyor inquired about the incident. The facility's investigation into the event was inadequate, as it did not include witness statements from staff regarding how the injury may have occurred, nor was there evidence of staff education on interventions for managing the resident's combative behavior. An interview with the Director of Nursing confirmed the lack of witness statements and staff education documentation. This deficiency was previously cited on May 22, 2024, indicating a repeated failure to comply with regulations prohibiting and preventing abuse, neglect, and exploitation of residents.
Plan Of Correction
Cited: Per follow up investigation, abuse and neglect was ruled out for resident 42. Like: Facility will do a two week look back of injuries of unknown origin to ensure a full investigation was completed. Education: DON/designee will educate nursing staff on the facility Abuse Policy and Procedure, Incident and Accident Investigations to ensure residents with injuries of unknown origins are fully investigated to rule out potential abuse/neglect. Audits: Residents with injuries of unknown origins will be audited weekly x4 then monthly x2 to ensure injuries are fully investigated. Results will be taken through QAPI.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident. A clinical record review for this resident revealed a discrepancy in the quarterly Minimum Data Set (MDS) dated November 6, 2024. The facility staff had assessed the resident as receiving an anticoagulant medication during the last seven days of the assessment period. However, further review of the clinical records showed no evidence that the resident had received such medication during that time. An interview with the Director of Nursing confirmed that the MDS was coded in error regarding the administration of the anticoagulant medication.
Plan Of Correction
Step 1: Re-education on coding accuracy. Please obtain signatures of all applicable MDS coordinators from the facility (See attached Section N of the RAI Manual): Immediate Remedy and Re-education/MDS modification submitted by Regional. Step 2: Audit most recently completed OBRA MDS Assessment 100% of current residents, any coding errors identified to be fixed. **See Audit tool. **Tip** You can pull an MDS item response specific for MDSs and how this question N0415E was coded- then review the MAR for that time frame. To be completed by Facility MDS. Completed Audit to be reviewed by Regional MDS. Step 3: Continued Audit needs: 10 completed MDSs to be reviewed by 2nd MDS coordinator and/or regional. To be completed weekly x 4 weeks:
Failure to Implement Consultant Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure the highest practical care for a resident, identified as Resident 93, by not implementing consultant recommendations. Resident 93, who had a history of pain and stiffness in his right hand, was observed on January 21, 2025, complaining of a 'cold hand' with no grasp and partially contracted fingers. He mentioned that he sits on his hand to warm it and straighten his fingers. A review of his clinical record showed that he had seen a plastic surgeon on January 13, 2025, who noted improvement in his range of motion with some exercise. The physician recommended warm soaks twice a day and resuming hand therapy. However, there was no documentation that the facility implemented these recommendations. The Director of Nursing confirmed these findings during an interview on January 24, 2025, acknowledging that the recommendations were only implemented after the surveyor's inquiry.
Plan Of Correction
Cited: Resident 93 has orders regarding soaking hands and orders reflecting therapy to assist with hand therapy. • Like: The facility will do a two-week look back to ensure residents who attend appointments and return with follow up recommendations, that recommendations are timely addressed. • Education: DON/designee will educate nursing staff on ensuring appointment follow up recommendations are addressed timely. • Audits: DON/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure recommendations from resident appointments are followed up timely. Results will be taken through QAPI.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident who required oxygen therapy and BiPAP for sleep apnea. The clinical record for the resident indicated a physician's order for oxygen to be administered at 5 liters per minute (LPM) via nasal cannula continuously during the day and evening, and 6 to 7 LPM at bedtime with BiPAP. However, observations revealed that the resident's oxygen concentrator was set at 9 LPM without humidification, which deviated from the prescribed order. Additionally, the resident's BiPAP mask was found unbagged and improperly stored, lying on the floor behind the oxygen concentrator and on the bedside stand during different observations. This improper handling and storage of respiratory equipment could increase the risk of infection, as noted by the American Association for Respiratory Care, which emphasizes the importance of proper cleaning and storage of nebulizer equipment to reduce infection risk. The deficiency was discussed with the Director of Nursing during the survey.
Plan Of Correction
Cited: Resident 43's oxygen order was clarified. Resident 43's Bipap mask was placed in an appropriate bag. • Like: Facility-wide sweep was completed to ensure residents who have active oxygen orders are correctly being followed. Facility-wide sweep also completed to ensure appropriate respiratory supplies are stored in bags appropriately. • Education: DON/designee will educate nursing staff on ensuring oxygen orders are followed and respiratory equipment is stored appropriately. • Audits: DON/designee will audit 5 residents per week x 4 weeks then monthly x 2 months to ensure oxygen orders are appropriately followed and that respiratory equipment is stored appropriately. Results will be taken through QAPI.
Failure to Secure Treatments in Resident's Room
Penalty
Summary
The facility failed to secure treatments on one of its nursing hallways, specifically the North Hall, involving a resident identified as Resident 56. During observations conducted on three separate occasions, open bottles of Dakin's solution and a bottle of Derma wound cleanser were found on the windowsill in Resident 56's room. These items are antiseptics used for treating and preventing infections in wounds, and their labels indicated that they should be kept out of reach of children and that medical help should be sought if swallowed. The deficiency was confirmed during a meeting with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the items should not have been stored on the windowsill. This incident was a repeat deficiency, as a similar issue had been cited previously on February 16, 2024. The facility's failure to properly store these drugs and biologicals violated both federal regulations and state codes related to pharmacy and nursing services.
Plan Of Correction
Cited: All solutions and cleansers were removed from the window sill of resident 56. • Like: Facility-wide sweep will be completed to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Educations: DON/designee will educate staff to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Audits: DON/designee will audit 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. Results will be taken through QAPI.
Failure to Implement TB Screening for New Hires
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) recommendations for tuberculosis (TB) screening and testing for newly hired health care personnel. Specifically, the facility did not implement the required pre-employment TB screening procedures for two of the five newly hired employees reviewed. According to the CDC guidelines, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. Additionally, if a previous documented negative TB result is provided within 12 months before new employment, only a single test is required. However, the facility did not follow these guidelines for Employees 2 and 3. Employee 2, a nurse aide, was hired on November 14, 2024, and provided evidence of a negative TB skin test dated March 4, 2024, which was within 12 months of being hired. Despite this, there was no evidence of any further testing, such as a one-step, blood test, or chest x-ray, upon their employment at the facility. Similarly, Employee 3, also a nurse aide, was hired on December 10, 2024, and provided evidence of a prior negative TB blood test dated August 5, 2024, within 12 months of hire. Again, there was no evidence that Employee 3 received any further testing prior to employment with the facility. This lack of adherence to the CDC's TB screening guidelines constitutes a deficiency in the facility's pre-employment screening procedures.
Plan Of Correction
Cited: Employees 2 and 3 will have a full TB screen completed. • Like: HRD/designee will complete a sweep of current staff members to ensure all staff have completed a TB screen. • Educations: NHA/designee will educate the HRD to ensure all staff have completed a TB screen upon hire. • Audits: HRD/designee will audit 5 staff members' files weekly x4 weeks and monthly x 2 months to ensure all staff have completed a TB screen upon hire. Results will be taken through QAPI.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, during the day shift, the facility did not provide the minimum of one nurse aide per 10 residents on two occasions. On December 29, 2024, with a census of 97 residents, only 9.55 nurse aides were available, falling short of the required 9.70. Similarly, on January 18, 2025, with a census of 101 residents, only 8.50 nurse aides were present, whereas 10.10 were needed. Additionally, during the night shift, the facility failed to maintain the required one nurse aide per 15 residents on three occasions. On January 1, 2025, with a census of 96 residents, only 4.85 nurse aides were available, while 6.10 were required. On January 19, 2025, with a census of 103 residents, 6.10 nurse aides were present, but 6.87 were needed. Lastly, on January 21, 2025, with a census of 102 residents, only 4.47 nurse aides were available, whereas 6.80 were required. These deficiencies were confirmed through an interview with the Nursing Home Administrator on January 23, 2025.
Plan Of Correction
Cited: Unable to correct staffing ratios for CNA's on the five days selected during the review. • Like: Staffing coordinator/designee will review the last two weeks to ensure staffing ratios are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. • Educations: NHA/designee will educate the staffing coordinator to ensure staffing ratios are met. • Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing ratios are met.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for three specific days. This deficiency was identified during a review of nursing staff care hours for the periods of November 23, 2024, through November 29, 2024, December 26, 2024, through January 1, 2025, and January 17, 2025, through January 23, 2025. On January 1, 2025, the facility provided 3.05 hours PPD, on January 18, 2025, 3.07 hours PPD, and on January 19, 2025, 3.14 hours PPD. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required daily hours PPD on these dates.
Plan Of Correction
Cited: Unable to correct the staffing PPD for the three days reviewed. Like: Staffing coordinator/designee will review the last two weeks to ensure staffing PPD are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. Educations: NHA/designee will educate the staffing coordinator to ensure staffing PPD are met. Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing PPD is met.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for three residents, as observed and documented by surveyors. Resident 2, who requires supervision and cueing for personal hygiene, was observed with several days of beard growth and reported not receiving shaving assistance during his shower, which was provided on an unscheduled day. Resident 3, with a history of urinary incontinence and recurrent urinary tract infections, did not receive documented oral care on multiple occasions across three months, and there were significant lapses in documented toileting assistance, particularly during the night shift. Resident 4, who requires assistance with bathing and oral care, was observed with overgrown fingernails and reported that staff should trim them. Documentation revealed missed shower and oral care assistance on several occasions over three months. The surveyor discussed these deficiencies with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to adhere to the care plans developed for these residents. The facility had previously been cited for similar deficiencies, indicating ongoing issues with providing necessary nursing services as required by regulations. The lack of documentation and observed lapses in care suggest a systemic issue in ensuring that residents receive the assistance they need for daily living activities.
Inconsistent Implementation of Restorative Programs for Mobility Deficits
Penalty
Summary
The facility failed to provide adequate services for mobility deficits for two residents. Resident 2 expressed concerns about walking and requested an evaluation, which led to physical therapy services being initiated. However, after being discharged from skilled physical therapy, there was no restorative program implemented. The plan of care for Resident 2 included encouraging participation in restorative programs, but documentation revealed inconsistent assistance with the restorative ambulation program. Interviews confirmed that the program was not consistently completed as required. Similarly, Resident 4 required restorative programs due to poor balance and an unsteady gait. The plan of care included instructions for staff to encourage participation in restorative programs. However, task list documentation showed that staff frequently failed to document assistance with the restorative ambulation program. The surveyor's review highlighted these deficiencies in the care provided to both residents, indicating a lack of consistent implementation of restorative programs as outlined in their care plans.
Failure to Accommodate Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of a resident, identified as Resident 5. During an interview, Resident 5 expressed dissatisfaction with the meals, rating them a seven out of ten, and reported receiving food she is allergic to, such as strawberries, and food she dislikes, such as rice. Despite having communicated her preferences during care conferences, these were not reflected in her meal tray tickets. On one occasion, her meal included peaches, which were listed as a disliked food, and rice, which was not listed as disliked, while the tray ticket indicated she should receive noodles and green beans, which were not provided. The issue was further compounded by the inaction of staff members. Employee 2, an activities staff member, confirmed the meal provided did not match the tray ticket but did not know how to address the concern and failed to report it. Employee 1, the food service director, acknowledged that the menu tickets did not match the planned meal items, indicating a systemic issue in meal planning and delivery. The concerns were reviewed with the Nursing Home Administrator and the Director of Nursing, highlighting a failure in dietary services as per 28 Pa. Code 211.6 (a).
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across four nursing units, as observed on August 6, 2024. In the main dining room of the [NAME] Nursing Unit, there were three ceiling vents with dark moisture-related spots and a smaller vent with a significant dust-like substance. A nourishment ice cart at the South/West nurse station had a drip tray with a slimy, black substance. Additionally, a brown moisture stain was noted on a ceiling tile near an exit sign, and a vent in the hallway had significant moisture accumulation. The nourishment room behind the South/West nurse's station also had a vent with a dust-like substance. Further observations on the South Nursing Unit revealed wall heating/air conditioning units with black substance accumulation and dead insects. Ceiling lights in the lounge and resident hallway contained debris and dead insects. The North Nursing Unit had a large water-stained ceiling tile and a refrigerator with dust, debris, and an unsmoked cigarette on top. Resident 1's bathroom vent had a significant dust accumulation, and the physical therapy area had dusty vents and ceiling tiles. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Unnecessary Medication Prescribed Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. A closed clinical record review and staff interviews revealed that a resident, who did not have a history of cancer or radiation treatments, was prescribed Temozolomide, a medication used to treat certain types of brain cancer. The initial verbal physician order for Temozolomide was dated April 10, 2024, and was signed electronically by a certified registered nurse practitioner on April 15, 2024. The order instructed staff to administer the medication daily for the duration of radiation therapy, despite the resident not being prescribed radiation therapy. The nursing staff discontinued the initial order on April 22, 2024, but a new verbal order with the same administration parameters was entered on the same day and electronically signed by a doctor on April 24, 2024. The practitioner did not identify that Temozolomide was included in the resident's medication profile without an appropriate diagnosis or indication for its use. Interviews with the Nursing Home Administrator, the Director of Nursing, and a medical records employee confirmed these findings. The facility implemented Temozolomide in the resident's medication regimen without adequate indications for its use, violating several Pennsylvania Code regulations related to pharmacy, medical director, and nursing services.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of mental abuse involving a resident. The CMS State Operations Manual defines mental abuse as conduct causing humiliation, intimidation, fear, shame, agitation, or degradation, including abuse facilitated by technology. The facility's policy, however, did not include the inappropriate use of technology, such as taking resident pictures or videos, as examples of mental abuse. This oversight contributed to the facility's failure to address the situation appropriately. The incident involved Employee 1, a nurse aide, who was reported to have used her electronic device inappropriately. An Employee Education/Counseling Form noted that Employee 1 was educated on the facility's policy prohibiting the use of recording devices. However, there was no detailed information on how Employee 1 used her phone, and her statement denied taking any photos or videos of residents. Despite this, a witness statement from another employee indicated that Employee 1 was allegedly taking pictures and videos of residents and sending them to others, including her boyfriend. The Nursing Home Administrator confirmed that the facility did not attempt to obtain statements from Employee 1's boyfriend or other involved staff members. Additionally, the facility failed to notify the Department or other agencies about the allegation of inappropriate photo or video taking. This lack of thorough investigation and reporting violated the facility's policy and regulatory requirements, leading to the deficiency.
Failure to Provide Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary bathing assistance to a dependent resident, identified as Resident CR1, during her stay from an unspecified date to May 10, 2024. According to the admission MDS dated April 3, 2024, Resident CR1 was assessed as being dependent on staff for bathing. The Documentation Survey Report for April 2024 indicated that nurse aides were responsible for providing a bed bath to Resident CR1 on Tuesdays and Saturdays. However, the report showed that staff did not document the completion of a bed bath on three specific dates: April 13, April 16, and April 27, 2024. This deficiency was discussed with the Nursing Home Administrator on May 23, 2024.
Medication Administered Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a physician supervised the care of a resident, identified as Resident CR1, who was administered a medication without an appropriate diagnosis. Resident CR1 was given Temozolomide, a medication used to treat certain types of brain cancer, despite not having a history of cancer or undergoing radiation treatments. A verbal physician order for Temozolomide was issued on April 10, 2024, and signed by a certified registered nurse practitioner (CRNP) on April 15, 2024, without identifying the lack of an appropriate diagnosis. Throughout multiple visits, another CRNP reviewed Resident CR1's medication list but failed to identify the inappropriate inclusion of Temozolomide. Although the initial order was discontinued on April 22, 2024, a new verbal order with the same parameters was entered and signed by a doctor on April 24, 2024, again without recognizing the absence of a valid diagnosis. Interviews with the Nursing Home Administrator, Director of Nursing, and medical records staff confirmed these findings, and the facility could not provide evidence of a medical evaluation conducted before ordering the medication.
Failure in Drug Regimen Review for Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review for a resident, identified as Resident CR1, who was prescribed Temozolomide, a medication typically used for treating certain types of brain cancer. Resident CR1 did not have a cancer diagnosis nor was she undergoing radiation therapy, which was a parameter for the medication's administration. Despite this discrepancy, the consultant pharmacist did not report the potential medication irregularity to the attending physician or the Director of Nursing. This oversight was confirmed during an interview with the Nursing Home Administrator, the Director of Nursing, and a medical records employee. The deficiency was noted under 483.45(c)(4) Drug Regimen Review and had been previously cited on February 16, 2024.
Neglect of Resident Leading to Harm
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm. The deficiency involved a resident on the East Hall Nursing Unit who experienced a significant change in condition that went unreported and unaddressed by the staff. On April 14, 2024, a licensed practical nurse (LPN) noted a concern with the facility's bladder scanner and documented the resident's urine output as below the physician's order threshold. Despite this, the LPN held the resident's insulin without documented parameters to do so and recorded multiple medication refusals by the resident throughout the day. The resident's condition deteriorated, showing signs of altered mental status, right-sided facial droop, and other symptoms indicative of a stroke. However, these changes were not communicated to the registered nurse (RN) on duty during the shift. The LPN failed to report the resident's condition to the RN, citing personal reasons for not speaking to the RN. The resident's condition was only addressed after the shift change when another RN assessed the resident and initiated emergency medical services for a suspected stroke. Witness statements from other staff members, including nurse aides, indicated that the resident appeared unwell throughout the day, with symptoms such as slurred speech and a request to go to the hospital. Despite these observations, the LPN did not take appropriate action to ensure the resident received timely medical attention. The facility's failure to ensure proper communication and response to the resident's condition resulted in neglect and harm to the resident.
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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