Edison Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 222 West Edison Avenue, New Castle, Pennsylvania 16101
- CMS Provider Number
- 395536
- Inspections on file
- 36
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Edison Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with encephalopathy, stroke, bipolar disorder, epilepsy, and moderately impaired cognition, who was care planned as an elopement risk with a WanderGuard bracelet, was able to leave the unit and exit the building without staff awareness. Staff statements and resident interview showed that the resident accessed an unlocked stairwell door without an alarm, descended the stairs, and exited through another door that also did not alarm, eventually being found in the parking lot. Multiple employees and surveyor observations identified unsecured or malfunctioning doors, including propped-open exterior doors, an often-unlocked elevator lock box, and broken or non-locking doors in housekeeping and laundry areas that created accessible exit routes. Staff also reported that the WanderGuard did not alarm when the resident was last seen on the unit, and the NHA did not initially consider the event an elopement. These actions and inactions led surveyors to cite the facility for failing to prevent elopement and to identify the situation as Immediate Jeopardy.
The facility failed to follow its abuse/neglect investigation policy after a resident eloped from the building by accessing an unlocked, non-alarmed door, descending stairs, and exiting another door without an alarm sounding. Although the policy requires immediate investigation by the NHA and DON, interviews with the resident and all witnesses, and written statements from each witness, not all involved staff were asked to provide handwritten statements, and evidence of a thorough investigation within the required timeframe was lacking.
The facility was cited for a failure by the NHA and DON to effectively manage operations and nursing services to ensure proper supervision and elopement prevention. The NHA’s role includes leading and directing overall operations in compliance with policies and federal and state regulations, while the DON is responsible for organizing and directing the nursing department and collaborating with the Administrator and Medical Director to maintain quality care. Surveyors found that residents were not consistently supervised and that safety interventions designed to prevent elopement were not consistently maintained, indicating that key regulatory requirements for management and nursing services were not met.
Surveyors found that two nursing units lacked sufficient clean linens, with linen carts and storage rooms on both floors missing basic items such as wash cloths, towels, and bed sheets. Multiple rooms on one unit had unmade beds or beds made only with a flat sheet and no fitted sheet. An RN Supervisor reported that beds were left unmade because linens were unavailable until delivered from the laundry. In the laundry area, only one washer was operational, one staff member was handling all laundry tasks, and only a minimal number of clean linens were ready despite a census of 103 residents. The NHA confirmed there were not enough clean linens for all residents at the time.
Two residents experienced multiple missed doses of prescribed medications and supplements due to the facility's failure to obtain medications in a timely manner. Delays in transmitting orders, unclear pharmacy procedures for urgent needs, and lack of access to emergency medication supplies contributed to the deficiency, as confirmed by the Nursing Home Administrator.
The facility did not follow physician orders for daily wound dressing changes for multiple residents. During observations, wound dressings were found to be absent, and a nurse confirmed that dressings were not changed or reapplied as ordered. Clinical records and interviews with cognitively intact residents further confirmed that staff rarely performed the required daily dressing changes.
The facility failed to maintain the sprinkler system, as observed in the main floor laundry room corridor where three sprinkler heads were found to be dust-covered and dirty. This condition, confirmed by the maintenance supervisor, can potentially delay or limit sprinkler activation during emergencies.
The facility failed to provide documentation for the required three-year, four-hour load test of their generator, as discovered during a document review. An interview with the maintenance supervisor confirmed the absence of this documentation, indicating a lapse in maintaining proper records for essential electrical systems.
The facility failed to maintain cooking equipment properly, as kitchen staff were uncertain about the location and operation of the hood fire suppression system's manual activation. This deficiency was confirmed by the maintenance supervisor.
The facility was found to have smoke barrier deficiencies in two rooms. The main floor emergency stock room had loose and missing ceiling tiles, while the third floor roof access room had loose, missing, and unsealed ceiling tiles. These issues were confirmed by the maintenance supervisor during the survey.
The facility failed to maintain electrical system requirements as per NFPA standards. An observation revealed that oxygen cylinder carts were blocking access to electrical panels in the third floor electrical room. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain emergency preparedness guidelines by not conducting a full-scale exercise, test, and evaluation of the emergency preparedness plan within the previous year. This deficiency was confirmed by the maintenance supervisor, who acknowledged the lack of documentation. The facility did not comply with regulations requiring at least two exercises per year to test their emergency plans.
The facility was found to exceed the height requirement for a three-story, Type II (000), unprotected, non-combustible building, as observed during a survey. The maintenance supervisor confirmed the building's height surpassed the allowable limit for its construction type.
The facility failed to maintain proper evacuation diagrams on all building levels. Observations revealed that the diagrams lacked a notation showing the viewer's location, which was confirmed by the maintenance supervisor. This deficiency violates NFPA 170-11.2.4 and 11.4.1 standards.
The facility did not maintain proper exit signage for one of over ten exits. A missing directional exit sign near the second-floor lounge, intended to guide individuals towards the stair towers, was observed. This was confirmed by the maintenance supervisor during the survey.
The facility did not ensure GFCI protection for electrical receptacles in two areas: the main floor employee lounge ice machine and the main floor kitchen dishwashing area. This deficiency was confirmed by the maintenance supervisor.
The facility failed to ensure residents' concerns were documented and addressed during Resident Council meetings. Despite residents expressing issues with call bell response times, snack availability, and housekeeping, these concerns were not followed up or resolved. The Activity Director and Social Services Director were unaware of these issues, indicating a breakdown in communication and documentation.
The facility failed to maintain a clean and sanitary environment, with 14 resident rooms and a dining room found unsanitary. Observations revealed dirty floors, medical waste, and a lack of essential supplies like toilet paper and soap. Residents expressed dissatisfaction with the cleanliness, and staff confirmed the absence of supplies. The Nursing Home Administrator acknowledged the unsanitary conditions.
The facility failed to provide sufficient nursing staff, resulting in delayed response times to call bells. Residents reported waiting up to an hour for assistance, with one resident left on a bedpan for an extended period. Staff were observed ignoring call bell alerts while seated at the nursing station. These issues were consistent across shifts, highlighting a deficiency in nursing services.
The facility did not follow its infection control policy for Enhanced Barrier Precautions (EBP) in two units. A CRNP failed to wear a gown during a wound assessment for a resident with a chronic pressure ulcer and foley catheter. Additionally, PPE was not available for residents requiring EBP, as confirmed by staff interviews.
A resident was admitted with a stage three pressure ulcer, but the facility inaccurately documented it as a stage two ulcer upon admission. The facility's policy requires comprehensive assessments, but the initial documentation lacked accuracy and detail, as confirmed by the ICLPN.
The facility failed to reorder and store medications properly for two residents, resulting in unavailable medications during administration. A resident with a history of falls and joint replacement therapy was unable to receive Oxycodone due to a lack of reordering, while another resident with multiple diagnoses, including Type 2 Diabetes and heart failure, did not receive Furosemide as it was not reordered. Both nursing staff and management confirmed the oversight.
The facility did not routinely offer nutritious evening snacks as desired by residents. Interviews with several residents revealed their preference for evening snacks, which were not being provided. Observations showed limited snack availability for 54 residents on one floor, with only a few items available. This deficiency was noted under nursing services regulations.
The facility was found deficient for not having a lavatory in the common bathing room on the second floor nursing unit. This was observed and confirmed by the Nursing Home Administrator during a survey.
The facility did not meet the required nurse aide (NA) staffing ratios on specific dates for both the evening and overnight shifts. On the evening shift, the facility failed to maintain the minimum of one NA per 11 residents on two occasions. For the overnight shift, the facility also failed to meet the minimum requirement of one NA per 15 residents on two occasions. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not meet the required LPN staffing levels on a day shift, with only 3.67 LPNs available for 101 residents, falling short of the 4.04 LPNs needed. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide the required 3.2 hours of direct resident care per day for twelve out of fourteen days reviewed. Staffing documents showed care hours per patient per day (PPD) ranged from 2.92 to 3.10, below the mandated minimum. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain a homelike environment due to a shortage of essential supplies, including wash cloths, towels, and toilet paper, on the Second and Third floor nursing care units. Observations and interviews revealed inadequate stock of clean linens and paper products, impacting the care of 91 residents. The DON confirmed the insufficiency of supplies, with residents and family members reporting the use of blankets for drying and purchasing personal wash cloths.
The facility failed to serve meals that were palatable and at a safe temperature, as reported by 17 residents. Meals were often cold due to trays sitting in hallways for long periods, and the food quality was poor. No policy was provided regarding meal service expectations.
The facility failed to honor the bathing preferences of six residents, as outlined in their policy and the RAI manual. Despite the policy requiring a minimum of two baths or showers per week, records and interviews revealed inconsistent bathing schedules for these residents, with some reporting hardly ever receiving a bath or shower. The Interim Nursing Home Administrator confirmed the lack of evidence supporting adherence to resident preferences and facility policy.
The facility failed to ensure residents receive necessary care and services for bathing, with water temperatures in the bathing rooms on the second and third floors being inconsistent and often too low. A resident reported uncomfortable shower experiences due to fluctuating water temperatures, and the Maintenance Director confirmed the ongoing issue.
The facility failed to provide medically related social services, particularly in the grievance process and psychosocial services. A resident's representative exhibited aggressive behavior, and the facility lacked a plan to address this, with no evidence of social, psychological, or emotional consultations provided.
The facility failed to follow physician orders for a resident with multiple diagnoses, including COPD, by not administering the prescribed Anoro Ellipta inhaler on two consecutive days. The LPN erroneously documented that the medication was given and did not inform the physician about its unavailability. The Director of Nursing confirmed the deficiency.
The facility failed to ensure nursing staff had the necessary training to care for residents' needs, as there was no RN Supervisor scheduled for a specific period, and an RN Med Nurse lacked the training to fulfill supervisory duties. This compromised the facility's ability to provide proper care.
A resident with COPD did not receive their prescribed Anoro Ellipta inhaler on two consecutive days due to unavailability. An LPN incorrectly documented that the medication was administered, which was later confirmed as an error by the DON.
Failure to Secure Exits and Supervise At-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to implement sufficient safety interventions and supervision to prevent an elopement for a resident identified as at risk for elopement. The facility had an Elopement Unauthorized Absence Policy that required identification of residents at risk and protection through development and implementation of safety interventions. The resident involved had diagnoses including encephalopathy, stroke, bipolar disorder, and epilepsy, and an elopement assessment identified the resident as at risk for elopement. The resident’s care plan included use of a WanderGuard bracelet, checking its placement and function, monitoring skin integrity, and following facility elopement procedures. A BIMS score of 10 indicated moderately impaired cognition. On the date of the incident, multiple staff statements and interviews established that the resident left the assigned floor and exited the building without staff awareness. One staff member reported seeing the resident walking around the room and did not realize the resident had left the floor, and also noted that the nurse returned from smoking about 45 minutes later and then discovered issues with the elevator lock box and that staff had already been alerted the resident was outside. Another staff member stated they were notified by kitchen staff that a resident wearing a helmet was outside and that the WanderGuard did not alarm when the resident was last observed sitting at the nurse’s station 45 minutes earlier. Staff later reported that when the resident was brought back inside, the WanderGuard system alarmed, and the resident stated they had gone down the stairs. The resident confirmed in interview that they walked to the end of the hall, found the door unlocked with no alarm, went down the stairs, and then outside through another door that also did not alarm. Additional staff interviews and observations revealed multiple unsecured or malfunctioning exit routes that could facilitate elopement. A maintenance employee reported that after the incident, a walkthrough showed the dining room door to the outside propped open with a rock and the third-floor door at the end of the long hall not tightly closed and latched, leading to the stairwell where the resident had exited. Several employees confirmed that the clear plastic lock box over the third-floor elevator button was often found unlocked and open, and that a door leading to the laundry area was sometimes propped open. Observations on a later date showed the laundry room door propped open and a rock lying against the dining room glass door. Another employee confirmed that the locking mechanism and door handle for the door leading from the housekeeping hallway were broken and could not be locked, that the laundry room door from that hallway was left unlocked because the next shift did not have a key, and that the door from the laundry room to the outside had a broken handle and could not be locked from the inside. This created a pathway by which a resident could enter the housekeeping hallway, pass through the unlocked laundry room, and exit the building through an unsecured exterior door. The Nursing Home Administrator did not consider the incident to be an elopement and had no additional documentation to provide at the time of the surveyor’s inquiry. The surveyors determined that these conditions constituted a failure to ensure implementation of all safety measures to prevent elopement for residents in the facility, resulting in an Immediate Jeopardy situation for one of four residents reviewed who were at risk for elopement. The facility’s own documentation showed that elopement assessments for all four residents at risk were only completed on the date of the incident. The combination of an at-risk resident with impaired cognition, unsecured and malfunctioning doors, inconsistent use and monitoring of WanderGuard systems, and lack of timely staff awareness or response to the resident’s departure from the unit led directly to the resident’s unauthorized exit from the building and the identified deficiency.
Failure to Thoroughly Investigate Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough and timely investigation of an elopement involving one resident (R1). The facility’s Pennsylvania Resident Abuse Policy, dated 9/02/25, requires that all allegations of neglect be investigated immediately, with the NHA and DON initiating an investigation upon notification, interviewing the resident and all witnesses, obtaining written statements from each witness and the resident if possible, and documenting evidence of the investigation. A final report is to be submitted to the applicable state agency no later than five working days after the alleged occurrence. Neglect is defined in the policy as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or coercion. Facility documents showed that R1 eloped from the facility on 4/14/26 at approximately 5:30 a.m. During an interview on 4/16/26 at 7:25 a.m., R1 stated that they walked to the end of the hall, found an unlocked door with no alarm, went down the stairs, and exited another door that also had no alarm sounding, then encountered several people outside. Review of witness statements dated 4/14/25 revealed that handwritten statements were not obtained from all staff involved in the incident. Staff interviews on 4/16/26 confirmed that not all witnesses were required to submit handwritten statements at the time of the elopement and that R1 had eloped on the stated date and time. There was no evidence that the facility completed a thorough investigation of R1’s elopement within the required timeframe following the incident, which occurred two days before the on-site survey.
Failure of NHA and DON to Ensure Effective Elopement Prevention and Supervision
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage and supervise facility operations to ensure proper elopement prevention and resident safety. The NHA’s job description states that the NHA is responsible for leading, directing, and managing overall operations in accordance with facility policies and applicable federal, state, and local regulations, and for organizing and directing resources so that the highest degree of quality care is maintained for each resident at all times. The DON’s job description specifies responsibility for organizing, developing, managing, and directing the overall operations of the nursing department in compliance with the same regulatory requirements, and for working directly with the Administrator and Medical Director to ensure the highest quality of care for each resident. Survey findings determined that the facility failed to consistently supervise residents and maintain all safety interventions intended to prevent elopement. As a result, the NHA and DON did not fulfill their essential job duties to ensure that federal and state guidelines and regulations related to supervision, management, and nursing services were followed, as cited under F689 and multiple sections of 28 Pa. Code, including 201.14(a), 201.18(a), 201.18(b)(1)(3), 201.18(e)(1), 211.12(c), and 211.12(d)(1)(5).
Inadequate Linen Supply Resulting in Unmade and Improperly Made Beds
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment on two nursing care units due to inadequate availability of clean linens. On the second floor, observations showed that the clean linen stock had no wash cloths, no bed sheets, and no towels, and the clean storage room on that floor had no bedding supplies available. On the third floor, one clean linen cart contained only one sheet, three pillowcases, and no towels or wash cloths, and the third floor clean storage room also had no additional linens. Room observations on the third floor showed multiple beds that were not made, with some having no sheets at all and others having only a flat sheet and no fitted sheet. During an interview, the RN Supervisor stated that beds were not made because there were no linens available until they arrived from the laundry room. Observation of the laundry room revealed that only one washing machine was functioning, with a single employee responsible for sorting, washing, drying, folding, and redistributing all linens. At that time, there were only two wash cloths, three towels, four sheets, and four fitted sheets cleaned and ready for use, with one load in the washer and three to four bags of soiled laundry waiting to be processed. Observation of the clean linen cart at approximately the same time confirmed that there were not enough clean wash cloths, towels, fitted sheets, and flat sheets for the facility’s census of 103 residents. In an interview, the Nursing Home Administrator confirmed that there was not enough clean linen available for all residents at the time of observation.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to obtain ordered medications in a timely manner for two residents, resulting in multiple missed doses of prescribed drugs and supplements. For one resident with diagnoses including Type 2 Diabetes, lumbago with sciatica, depression, and difficulty walking, the electronic medication administration record (eMAR) showed missed doses of bupropion, CoQ-10, prednisone, Tresiba, adult multivitamin gummies, and baclofen, all due to the medications not being available. For another resident with respiratory failure, persistent vegetative state, tracheostomy, paranoid schizophrenia, and gastrostomy, the eMAR documented missed doses of atropine sulfate, ciprofloxacin, cefepime, and diazepam, also due to drug unavailability. The deficiency was attributed to delays in transmitting medication orders to the pharmacy, lack of clear instructions in the pharmacy policy for obtaining non-controlled medications before routine delivery times, and staff not requesting access to the emergency medication supply for controlled substances. Additionally, there was no alternate pharmacy listed for urgent medication needs. These issues were confirmed by the Nursing Home Administrator during interviews, who acknowledged the delays and gaps in the facility's processes for ensuring timely medication delivery.
Failure to Follow Physician Orders for Daily Wound Dressing Changes
Penalty
Summary
The facility failed to follow physician's orders for daily wound dressing changes for eight out of thirteen residents reviewed. During wound dressing observations, it was noted that daily wound dressings were absent for several residents, and a licensed nurse confirmed that the dressings were not changed or reapplied as ordered. Clinical record reviews showed that each affected resident had physician's orders for daily wound dressing changes, and interviews with cognitively intact residents further verified that staff rarely performed the dressing changes as required. One resident, who was cognitively intact, also confirmed that staff did not complete the daily wound dressing changes as ordered by the physician. These findings were based on direct observation, clinical record review, and resident interviews, all of which consistently indicated that the facility did not provide wound care in accordance with physician's orders and resident care plans.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the sprinkler system as required, which was evidenced by an observation and interview during a survey. On January 15, 2025, at 10:23 a.m., it was observed that the main floor laundry room corridor had three sprinkler heads that were dust-covered and dirty. This condition can potentially delay or limit the activation of the sprinklers during an emergency. The maintenance supervisor confirmed the existence of these deficiencies during an interview conducted on January 14, 2025, at 10:23 a.m.
Plan Of Correction
1. Nursing home administrator/designee cleaned the sprinkler heads in the main floor laundry room. 2. Nursing home administrator and/or designee will audit sprinkler heads weekly times 4 weeks and monthly times 2 months for cleanliness and debris.
Failure to Document Generator Load Test
Penalty
Summary
The facility failed to meet the electrical system requirements as outlined in NFPA 101 and related standards. During a document review on January 15, 2025, it was found that the facility could not provide documentation for the mandatory three-year, four-hour load test of their generator. This test is crucial to ensure that the generator can supply power within the required 10 seconds in case of an emergency. The absence of this documentation indicates a lapse in the facility's maintenance and testing protocols for their essential electrical systems. An interview with the maintenance supervisor on the same day confirmed that the documentation for the three-year load test was unavailable at the time of the survey. This deficiency highlights a failure in maintaining proper records of maintenance and testing, which are necessary to verify compliance with NFPA 110 and NFPA 111 standards. The lack of documentation raises concerns about the facility's ability to ensure the reliability of their emergency power systems, which are critical for the safety and well-being of the residents.
Plan Of Correction
1. Facility had third party Generator Specialist Inc. complete the 4 hour load test of the generator on 2/3/2025. 2. Facility contracts with Generator Specialist Inc to ensure that the 4 hour load test is completed every three years as required.
Deficiency in Kitchen Fire Safety Procedures
Penalty
Summary
The facility failed to maintain cooking equipment in the kitchen, as evidenced by observations and interviews conducted on January 15, 2025. During the inspection, kitchen staff members were found to be uncertain about the location and operation of the hood fire suppression system's manual activation. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the issue with the cooking equipment.
Plan Of Correction
1. Nursing home administrator and/or designee will educate dietary staff on the location of the hood fire suppression system's manual activation pull station. 2. Nursing home administrator and/or designee will educate all new dietary staff during orientation on the location of the hood fire suppression system's manual activation pull station. 3. Nursing home administrator and/or designee will audit 2 dietary staff weekly to ensure they are aware of the location of the hood fire suppression system's manual activation pull station.
Smoke Barrier Deficiencies in Facility
Penalty
Summary
The facility failed to maintain smoke barrier requirements in two of over ten rooms, as observed during a survey on January 15, 2025. Specifically, deficiencies were noted in the main floor emergency stock room, where ceiling tiles were found to be loose and missing. Additionally, the third floor roof access room had loose, missing, and unsealed ceiling tiles. These observations were confirmed through an interview with the maintenance supervisor conducted at the time of the survey.
Plan Of Correction
1. Missing ceiling tiles were replaced in the emergency stock room. 2. Third floor roof access room loose and ensealed ceiling tiles were replaced and repaired. 3. Facility maintenance/NHA will audit ceiling tiles weekly times 4 weeks then monthly times 2 months.
Electrical System Deficiency Due to Blocked Access
Penalty
Summary
The facility failed to maintain and inspect electrical system requirements as per NFPA 70 and NFPA 99 standards. During an observation on January 15, 2025, at 12:04 p.m., it was noted that the third floor electrical room had several oxygen cylinder carts obstructing access to the electrical panels. This deficiency was confirmed through an interview with the maintenance supervisor conducted at the same time.
Plan Of Correction
1. Oxygen cylinder carts have been removed from blocking the access to the electrical panels. 2. Nursing home administrator and/or designee will educate all facility staff on maintaining a clear pathway to the electrical panels. 3. Maintenance/nursing home administrator will audit access to the electrical panels is maintained daily times 5 days, weekly times 3 weeks, and monthly times 2 months.
Failure to Conduct Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to maintain proper emergency preparedness guidelines as required by regulations. During a document review conducted on January 15, 2025, it was discovered that the facility did not have records indicating that a full-scale exercise, test, and evaluation of the emergency preparedness plan had been performed within the previous year. This lack of documentation suggests that the facility did not conduct the necessary exercises to test their emergency plan, which is a critical component of ensuring readiness for potential emergencies. The deficiency was confirmed during an interview with the maintenance supervisor on the same day. The supervisor acknowledged the absence of documentation, which further substantiates the facility's failure to comply with the regulatory requirements for emergency preparedness. This oversight indicates a lapse in the facility's adherence to mandated protocols designed to ensure the safety and well-being of its residents and staff in the event of an emergency. The regulations require that long-term care facilities conduct at least two exercises per year to test their emergency plans, including a full-scale community-based exercise or an individual facility-based functional exercise. The facility's inability to provide evidence of such exercises being conducted within the specified timeframe highlights a significant gap in their emergency preparedness efforts.
Plan Of Correction
1. Nursing home administrator/designee immediately scheduled full scale exercise with outside community resources to be completed. 2. Regional Vice President of operations educated nursing home administrator on E0039 and the importance of yearly exercises to test the emergency plans. 3. Nursing Home Administrator will verify continued compliance with the EPP/tabletop exercises.
Building Height Exceeds Construction Type Limits
Penalty
Summary
The facility failed to maintain compliance with building construction type requirements as outlined in NFPA 101. During an observation on January 15, 2025, it was noted that the facility exceeded the height requirement for a three-story, Type II (000), unprotected, non-combustible building. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged that the building's height surpassed the allowable limit for its construction type. The report does not mention any specific patients or their conditions in relation to this deficiency.
Plan Of Correction
No adverse effects occurred from the facility exceeding the height requirement for this construction type. Life Safety Consultant Peters Rice Associates conducted an FSES on 3/20/2017, which is on file with the Department of Health. Edison Manor has been working with various vendors on a construction proposal that will minimize disturbance to the residents of the facility. Once a viable proposal has been acquired, the facility will submit architectural plans and determine the time frame to have the work completed to stay in compliance. TLW was submitted to the local department of health field office to be sent for approval. FSES is being requested to be updated.
Evacuation Diagram Deficiency
Penalty
Summary
The facility was found to be deficient in maintaining proper evacuation diagrams across all three building levels. During an observation conducted on January 15, 2025, between 11:20 a.m. and 12:10 p.m., it was noted that the evacuation diagrams lacked a critical notation indicating the location of the viewer on the diagram. This deficiency was confirmed in an interview with the maintenance supervisor, who acknowledged that the diagrams did not show the viewer's location or the exit paths, as required by NFPA 170-11.2.4 and 11.4.1.
Plan Of Correction
1. Evacuation Diagrams have been updated to contain the notation showing the location of the viewer on the diagram.
Missing Exit Signage Near Second-Floor Lounge
Penalty
Summary
The facility failed to maintain proper exit signage for one of over ten exits. During an observation on January 15, 2025, at 12:06 p.m., it was noted that a directional exit sign was missing near the second-floor lounge, which was supposed to direct individuals towards the stair towers. This deficiency was confirmed through an interview with the maintenance supervisor at the time of the survey.
Plan Of Correction
1. Nursing home administrator and/or designee immediately changed the lightbulb in the exit sign to ensure the directional arrow was on. 2. Nursing home administrator and/or designee will audit facility exit signs to ensure all directional arrows are engaged weekly x 4 weeks and monthly times 2 months.
Failure to Maintain GFCI Protection in Electrical Receptacles
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with NFPA 101 standards in two specific areas. During an observation on January 15, 2025, it was noted that the ground fault circuit interrupter (GFCI) protection was not ensured for the receptacle used by the ice machine in the main floor employee lounge and the receptacle in the main floor kitchen dishwashing area. This deficiency was confirmed through an interview with the maintenance supervisor conducted on the same day.
Plan Of Correction
1. Facility immediately contacted a third-party contractor to evaluate outlets with need for GFCI and replace the outlets identified with GFCI outlets to include the employee lounge for the ice machine and the main floor dishwashing receptacle area. 2. GFCI receptacles have been replaced.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that residents could effectively voice their concerns during Resident Council meetings and that these concerns were documented and addressed in a timely manner. The facility's policy stated that the Life Enrichment Director or designee may attend the Resident Council Meeting to act as a liaison between the group and the facility if requested by the Council. However, the policy was not effectively implemented, as evidenced by the lack of documentation of resident concerns and follow-up actions in the meeting minutes from October, November, and December 2024. During a Resident Council meeting on January 7, 2025, seven residents expressed that their concerns were not being followed up by each department, and they never received feedback or saw resolutions to their issues. These concerns included call bell response times, snack availability, food quality, linen and care supplies availability, and housekeeping frequency. Despite these issues being raised, the Activity Director and Social Services Director were unaware of any concerns other than dietary issues, indicating a breakdown in communication and documentation. The review of the Resident Council meeting notes from the previous months revealed a lack of evidence of resident participation and facility responses to concerns. This deficiency highlights the facility's failure to adhere to its policy and ensure that resident concerns are properly documented, communicated, and addressed, leading to unresolved issues and dissatisfaction among the residents.
Plan Of Correction
a. Emergency Resident Council meeting held on January 21st to address all concerns. b. Nursing Home Administrator/designee educated Activity Director on resident council process and concern forms to be completed with each concern. c. Resident Council Concern form template updated and given to Activity Director to use with resident council concerns. d. Nursing Home Administrator/designee will meet with Resident Council president within 3 days of resident council meeting monthly (starting Jan 2025) times 3 months to verify completion of new concern forms are completed from the meeting and to discuss resolutions. Concerns will be reviewed in the old business of the next meeting. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Inadequate Housekeeping Services Lead to Unsanitary Conditions
Penalty
Summary
The facility failed to provide adequate housekeeping services, resulting in unsanitary conditions in 14 of 94 resident rooms and one of two dining rooms. Observations revealed dirty floors with dried stains, debris, trash, and food particles in several rooms. Additionally, some rooms lacked essential supplies such as toilet paper, soap, and paper towels. Interviews with residents indicated dissatisfaction with the cleanliness and frequency of cleaning in their rooms. The facility's policy on environmental cleaning and disinfection was not adhered to, as evidenced by the presence of medical waste and dried liquids in some rooms. Further observations on different dates confirmed that hand sanitizer dispensers in the hallways were empty, and several restrooms lacked necessary supplies. Interviews with staff members, including a Licensed Practical Nurse and a Registered Nurse, confirmed the absence of supplies in the restrooms and hallways. The Nursing Home Administrator acknowledged the unsanitary conditions and the failure to maintain a clean and sanitary environment as per the facility's policy.
Plan Of Correction
Facility immediately addressed rooms 207, 209, 210, 217, 220, 223, 224, 226, 303, 307, 310, 319, 321, and 325 and cleaned all rooms to include the bathrooms and replenishing the toilet paper. Facility immediately implemented a cleaning schedule to include common areas/dining rooms and thorough cleans for each floor and patient rooms to protect residents in similar situations. Administrator/designee will educate all staff on F584, facility cleanliness and supplies. Administrator/designee will re-educate housekeeping staff on daily checklist which include replenishing supplies and cleaning compliance. Administrator/designee will begin daily audits of 2 rooms per floor verifying compliance/thorough cleans and replenishing supplies were completed using the housekeeping checklists for 5 days and then audit 2 rooms/areas 3x/week for 2 weeks and then audit 10 rooms/areas monthly x 2 months. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Delayed Response to Call Bells Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed response times to call bells. Residents expressed concerns about having to wait nearly an hour for assistance after activating their call bells. Specific instances included Resident R226, who was left on a bedpan for an extended period, causing discomfort, while staff were observed seated at the nursing station with the call bell system audibly and visually alerting them. During a Resident Council meeting, several residents reported similar issues with delayed responses to call bells, with wait times ranging from 30 to 45 minutes. These delays were consistent across different shifts, with some residents noting longer wait times during shift changes. The deficiency was identified under 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.12(d)(4)(5) Nursing services, indicating a failure to provide adequate nursing services to ensure the well-being of residents.
Plan Of Correction
a. Facility completed a random audit of 15 residents to for call bell response times and to verify needs are being met with no adverse affects to any residents. b. Emergency Resident council meeting held on January 21st to address all concerns and nursing home administrator/designee will follow up with resident council president to ensure concerns are addressed and resolved. c. Nursing home Administrator/designee will educate facility staff of F725. d. Facility management team/designee will complete 6 random call bell audits over all 3 shifts for timeliness and resident satisfaction with needs being met daily times 5 days, weekly x 3 weeks, and monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its own infection control practices regarding Enhanced Barrier Precautions (EBP) for residents in two units. The facility's policy, dated September 2024, specifies that EBP are necessary to prevent the transmission of multi-drug resistant organisms (MDROs) through contaminated hands and clothing of healthcare workers. These precautions are particularly important for residents with chronic wounds, indwelling devices, or those colonized or infected with MDROs. However, observations revealed that a Certified Registered Nurse Practitioner (CRNP) did not don a gown while performing a wound assessment on a resident with a chronic stage four coccyx pressure ulcer and a foley catheter, who was under EBP. Additionally, it was observed that there was no Personal Protective Equipment (PPE) available at the doorways or in the hallways for several rooms housing residents requiring EBP. Interviews with staff, including a Nursing Assistant and the Director of Nursing, confirmed the absence of readily available PPE and acknowledged that staff should have been wearing appropriate PPE, such as gloves and gowns, when providing care to these residents. This lack of adherence to the facility's infection control policy was confirmed by the Director of Nursing.
Plan Of Correction
Resident 42 no longer resides in the facility. b. Director of nursing/designee completed a whole house audit to verify any resident requiring enhanced barrier precautions has personal protective equipment readily available outside of room. c. Nursing home administrator/designee educated all facility staff and wound nurse practitioner on personal protective equipment, enhanced barrier precautions and F880. d. Nursing home administrator/designee will audit personal protective equipment availability and use for 3 enhanced barrier precautions residents per floor daily x 5 days; weekly x 3 weeks; monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Inaccurate Pressure Ulcer Assessment on Admission
Penalty
Summary
The facility failed to comprehensively assess and document a pressure ulcer for a resident, identified as Resident R42, upon admission. The facility's policy requires that pressure injuries be assessed initially and at least weekly, including detailed documentation of the wound's characteristics. However, upon admission, Resident R42's pressure ulcer was inaccurately documented as a stage two ulcer, despite hospital records indicating it was a stage three ulcer with macerated, weeping skin and macules and papules around the edges. This discrepancy in documentation and assessment was confirmed by the Infection Control Licensed Practical Nurse (ICLPN). Resident R42 was admitted with a stage three pressure injury to the coccyx, as documented in hospital records, which included specific details about the wound's size, depth, and condition. However, the facility's initial assessment on the day of admission incorrectly documented the wound as a stage two ulcer, with different measurements and lacking a comprehensive assessment. This failure to accurately assess and document the pressure ulcer upon admission was identified during a review of the clinical records and confirmed through staff interviews.
Plan Of Correction
a. Resident 42 no longer resides in the facility. b. Director of Nursing/Designee will audit all residents with pressure ulcers to verify the last assessment and MDS are consistent for accuracy in a 90-day look back period. c. Director of Nursing/designee will educate nursing staff on pressure ulcer documentation, staging, and F686. d. Director of Nursing/designee will audit 5 random pressure ulcers to ensure documentation in assessments and MDS are consistent with the documentation from the wound nurse practitioner and accurate weekly times 4 weeks and monthly times 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Medication Reordering and Storage Deficiency
Penalty
Summary
The facility failed to properly reorder and store medications for two residents, leading to a deficiency in medication management. Resident R72, who had a history of falls, a fracture of the left femur, and was undergoing aftercare for joint replacement therapy, had a physician's order for Oxycodone 5 mg every 6 hours as needed for pain. However, during a medication pass observation, it was discovered that there was no medication card available in the cart to fulfill this order. The last administration of the medication was recorded on 11/04/24, and the order was not resubmitted to the pharmacy, resulting in the medication being unavailable when requested by the resident. Similarly, Resident R73, who had diagnoses including Type 2 Diabetes, depression, heart failure, and a history of cerebral infarction, had a physician's order for Furosemide 20 mg daily. During a medication pass, it was observed that the medication cart did not contain Furosemide, and the medication had not been reordered from the pharmacy after the last dose was administered. Both the LPN and RN involved confirmed the absence of the medications and the failure to reorder them. The Director of Nursing and Nurse Supervisor also acknowledged that the medications were not reordered as required, leading to their unavailability in the medication carts for the residents.
Plan Of Correction
a. R72 was assessed for adverse effects with no concerns and scripts were obtained for reorder of medication immediately. Facility completed an initial audit of all med carts to ensure that all medications were available as ordered which includes Furosemide with no issues or concerns. b. Director of Nursing/Designee completed a whole house audit to verify all ordered meds in facility are present for like residents-any medications not present will be addressed and resident will be assessed for adverse effects and physician/resident representative will be notified. c. Director of Nursing/designee will educate licensed nursing staff on F761 and obtaining new scripts and reordering of medications when needed. d. Director of Nursing/designee will audit 2 of 4 medication carts each week to verify medications ordered by the physician were not missed on the MAR and are readily available for each resident on the unit weekly x 4 weeks and monthly x 2 months. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Failure to Provide Routine Nutritious Evening Snacks
Penalty
Summary
The facility failed to routinely offer nutritious snacks as desired by residents, as evidenced by interviews with six alert and oriented residents who expressed that snacks were not routinely offered in the evening, despite their preference for an evening nutritious snack. The facility's policy, dated September 2024, states that there should be no more than 14 hours between dinner and breakfast unless a nourishing snack is provided at bedtime, allowing up to 16 hours between meals if agreed upon by a resident group. However, observations revealed limited snack availability, with only one fruit bar, five oatmeal cookies, one single-serve applesauce container, and one can of chicken soup available for 54 residents on the third floor, as confirmed by a nursing assistant. This deficiency was noted under 28 Pa. Code 211.12 (d)(1) Nursing services.
Plan Of Correction
a. Nursing home administrator/designee immediately audit nursing units to ensure nutritious snacks were available on the units for residents and there were no adverse effects to residents related to snacks. b. Nursing home administrator/designee educated dietary and nursing department staff on F809 and nutritious snack availability on the units and daily during the evening. c. Nursing home administrator/designee will randomly audit 3 residents on each unit daily x 5 days; weekly x3 weeks; monthly x2 months to ensure snacks are available/offered and that enough snacks are available on the unit. e. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Missing Lavatory in Second Floor Bathing Room
Penalty
Summary
The facility failed to meet the regulatory requirement of including a lavatory in each bathing room. During an observation on January 6, 2025, at 11:00 a.m., it was noted that the common bathing room on the second floor nursing unit did not have a lavatory. This deficiency was confirmed during an interview and further observation with the Nursing Home Administrator on January 8, 2025, at approximately 1:45 p.m., who acknowledged the absence of a lavatory in the specified bathing room.
Plan Of Correction
1. Facility is unable to retroactively correct not having a sink in the shower room. 2. Full house audit completed and all other shower rooms were assessed and are equipped with a sink and needed equipment. 3. Facility hired a contractor to come and evaluate the shower room for the installation of the sink. 4. Facility will install the sink in the second-floor shower room. 5. Sanitizer station placed directly outside of the shower room for use while waiting on installation. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on specific dates for both the evening and overnight shifts. On the evening shift, the facility did not maintain the minimum of one NA per 11 residents on two occasions: November 30, 2024, and January 6, 2025. Specifically, on November 30, 2024, with a census of 100 residents, only 8.63 NAs were available when 9.09 were required. Similarly, on January 3, 2025, with a census of 101 residents, 8.63 NAs were present when 9.18 were needed. For the overnight shift, the facility also failed to meet the minimum requirement of one NA per 15 residents on two occasions: November 26, 2024, and January 3, 2025. On November 26, 2024, with a census of 100 residents, 6.43 NAs were available when 6.73 were required. On January 6, 2025, with a census of 102 residents, 6.43 NAs were present when 6.80 were needed. The Nursing Home Administrator confirmed these staffing shortages during an interview on January 9, 2025.
Plan Of Correction
1. The facility is unable to retroactively correct the CNA staffing ratio for 11/26/24, 11/30/24, 1/3/25 and 1/6/25. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing of nurse aides. 3. Nursing home administrator/designee will schedule CNA's to meet state ratio. Call outs will be monitored by nursing home administrator/Director of Nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonus' to increase applicants as well as pick up bonus' to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of CNAs. 5. Nursing home administrator and/or designee will monitor staffing ratio weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
LPN Staffing Shortfall on Day Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on the day shift for one of the days reviewed. Specifically, on November 28, 2024, the facility had a census of 101 residents, which required 4.04 LPNs to meet the regulatory staffing ratio of one LPN per 25 residents. However, only 3.67 LPNs were on duty that day, resulting in a staffing shortfall. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 9, 2025, who acknowledged the failure to meet the minimum LPN ratio requirements for the specified shift and date.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing ratio for days: 11/28/2024. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing of LPN. 3. Nursing home administrator/designee will schedule LPNs to state ratio of 1 to 25 for day shift, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. Call outs will be monitored by nursing home administrator/Director of Nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonus' to increase applicants as well as pick up bonus' to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of LPN ratios of 1 to 25 for day shift, 1 to 30 for afternoon shifts and 1 to 40 for midnight shifts. 5. Nursing home administrator and/or designee will monitor staffing ratio weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
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 resident in a 24-hour period for twelve out of fourteen days reviewed. The deficiency was identified through a review of nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. On specific dates, the facility's direct resident care hours per patient per day (PPD) fell below the required minimum, with recorded PPDs ranging from 2.92 to 3.10. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified period.
Plan Of Correction
1. The facility is unable to retroactively correct the staffing PPD of 3.2 for 11/24/24, 11/25/24, 11/26/24, 11/27/24, 11/29/24, 11/30/24, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/6/25 and 1/7/25. 2. Nursing home administrator immediately audited future schedules for compliance with regulatory guidance for staffing to PPD. 3. Nursing home administrator/designee will schedule staff to meet state PPD of 3.2. Call outs will be monitored by nursing home administrator/Director of nursing and/or designee daily. Facility staff and staffing agencies will be utilized to facilitate replacement/procurement of staff. Facility has put into place sign on bonuses to increase applicants as well as pick up bonuses to increase retention. 4. Nursing home administrator/designee will educate the scheduling coordinator, director of nursing, assistant director of nursing, and human resources on the requirements of the minimum PPD of 3.2. 5. Nursing home administrator and/or designee will monitor staffing PPD weekly x4 weeks. 6. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring and changes needed.
Deficiency in Providing Homelike Environment Due to Insufficient Supplies
Penalty
Summary
The facility failed to provide a homelike environment for residents on the Second and Third floor nursing care units. Observations revealed a significant shortage of clean linens, including wash cloths and towels, on both floors. The soiled linen rooms contained bagged linens that had not been sent to the laundry room for washing. The laundry room had clean linens ready for distribution, but the stock was insufficient to meet the needs of the 91 residents. Interviews with the Director of Laundry and Housekeeping Services and the Director of Nursing confirmed that the nursing staff had not sent the soiled linens for washing, and the available clean linens were inadequate for resident care. Residents and their family members reported a lack of wash cloths, towels, and toilet paper, with some residents using blankets to dry off after bathing. Observations of resident restrooms showed no backup rolls of toilet paper, and the kitchen area lacked paper towels. A housekeeping employee and the Central Supply Manager confirmed the absence of paper towels and toilet paper, with supplies ordered but not yet arrived. The DON acknowledged the insufficient stock of essential items, impacting the residents' care needs.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable food at a safe and appetizing temperature, as determined through resident interviews. During a survey, 17 out of 18 alert and oriented residents expressed dissatisfaction with their meals, citing that the food was often cold upon delivery. This issue was attributed to meal trays being left in the hallways for extended periods before being served to residents. Additionally, residents reported that the overall quality and taste of the food were poor. The facility did not provide a policy outlining the expectations or requirements for meal service timeliness and food palatability, contributing to the deficiency.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for bathing and showering, as outlined in their policy and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Six residents (R1, R2, R4, R5, R6, and R7) did not receive baths or showers according to their preferences. The facility's policy mandates that residents be bathed or showered according to their preferences to maintain hygiene and skin condition, with a minimum of two baths or showers per week unless otherwise preferred by the resident. However, the records and interviews revealed that this was not consistently followed for the six residents reviewed. For instance, Resident R1, who was alert and oriented with a BIMS score of 13/15, reported hardly ever receiving a bath or shower, despite the records indicating only a few bed baths over a two-month period. Similarly, Resident R2, with a BIMS score of 15/15, indicated not receiving showers as often as preferred, with records showing sporadic shower dates. Resident R4, also alert and oriented with a BIMS score of 15/15, mentioned receiving showers only when all staff were present, which was infrequent. Resident R5, with a BIMS score of 13/15, had inconsistent bathing records, including bed baths and showers. Resident R6, with severely impaired cognition, had a few recorded showers and a refusal of a bed bath. Resident R7, with a BIMS score of 15/15, had only one recorded bed bath over the review period. The Interim Nursing Home Administrator confirmed the lack of evidence indicating that these residents received baths or showers twice a week as per their preferences and facility policy. This deficiency highlights the facility's failure to promote and facilitate resident self-determination and choice in their care routines, specifically regarding bathing and showering preferences. The facility's policy and the RAI manual's guidelines were not adhered to, resulting in residents not receiving the care they preferred and were entitled to.
Inconsistent Water Temperatures in Bathing Rooms
Penalty
Summary
The facility failed to ensure residents receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, specifically in relation to bathing. During an interview, a resident indicated that the water temperature during showers fluctuated from hot to cold, making the experience uncomfortable and leading the resident to request a bed bath instead. Observations with the Maintenance Director confirmed that water temperatures in the bathing rooms on the second and third floors were inconsistent and often too low, with the second floor reaching a maximum of 73 degrees and the third floor reaching a maximum of 94 degrees before dropping again. The Maintenance Director acknowledged that fluctuating water temperatures have been a consistent problem, resulting in residents often receiving cold showers. The Nursing Home Administrator confirmed that the water temperatures were too low for comfortable bathing experiences and acknowledged the facility's failure to ensure residents receive the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being related to bathing. The facility did not provide a water temperature policy for bathing, further highlighting the deficiency in maintaining appropriate water temperatures for resident showers.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide residents with medically related social services, specifically in relation to the grievance process and psychosocial services. The facility's documentation and policy review revealed that the Social Worker position, which is responsible for addressing residents' emotional and social needs, was vacant. The responsibilities were being handled by Registered Nurse Assessment Coordinators (RNACs), who were not consistently involved in the grievance process. Out of 36 grievances, only nine had involvement from the RNAC-Social Services designee, indicating a lack of consistent social services for residents. Resident R1's case highlighted the deficiency further. The resident had multiple chronic conditions, including Chronic Congestive Heart Failure and Type 2 Diabetes Mellitus. The resident's representative exhibited very aggressive behaviors, which were known to the facility. Despite this, there was no evidence of social, psychological, or emotional consultations to address the representative's aggressive behavior. The facility also lacked a plan to protect other residents and staff from this aggressive behavior. Interviews with the Nursing Home Administrator (NHA) and the Interim NHA confirmed the absence of a licensed Social Worker and the failure to provide necessary social services. The NHA attempted to fill the void but acknowledged the inconsistency in service provision. The facility did not provide evidence of medically related social services to Resident R1 and their representative, failing to meet the psychosocial needs and address the aggressive behavior pattern effectively.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to follow physician orders for Resident R3, who had multiple diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, diabetes mellitus, and chronic obstructive pulmonary disease (COPD). The Medication Administration Record (MAR) for Resident R3 indicated a physician order for Anoro Ellipta inhaler to be administered once daily for wheezing, starting on 5/18/23. However, during an observation on 1/09/24, it was found that the medication was not available in the medication cart, and Resident R3 did not receive the inhaler on 1/08/24 and 1/09/24 as prescribed. LPN Employee E1 confirmed the medication was not administered and had erroneously documented that it was given on 1/08/24. The LPN also failed to communicate to the physician that the medication was unavailable. The Director of Nursing confirmed that the Anoro Ellipta inhaler was not administered to Resident R3 on the specified dates as per the physician's order. This failure to follow physician orders and ensure the availability of prescribed medication constitutes a deficiency in nursing services as per 28 Pa. Code 211.12(d)(1) and 28 Pa. Code 211.12(d)(5). The incident highlights a lapse in medication management and communication within the facility, directly impacting the care provided to Resident R3.
Lack of RN Supervisor and Insufficient Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary training to properly care for residents' needs on 12/29/23. Specifically, the facility did not have an RN Supervisor scheduled from 7:00 p.m. on 12/29/23 to 7:30 a.m. on 12/30/23. The daily deployment sheet and employee punch reports confirmed the absence of an RN Supervisor during this period. Additionally, RN Med Nurse Employee E2, who was expected to fulfill the RN Supervisor responsibilities, confirmed that they had not received the specific training required for the RN Supervisor role and did not feel comfortable or safe performing those duties. The Interim Director of Nursing also confirmed the lack of an RN Supervisor and the insufficient training provided to the RN Med Nurse expected to take on those responsibilities. Observations on 1/09/24 and 1/10/24 revealed that the RN Supervisor was responsible for multiple critical tasks, including communicating with physicians, completing admissions, transferring residents to the hospital, reconciling narcotic medications, and supervising other nursing staff. The RN Med Nurses were observed administering medications and completing treatments for their assigned residents. The lack of an RN Supervisor and the insufficient training for the RN Med Nurse to perform supervisory duties compromised the facility's ability to ensure that nursing staff possessed the competencies required to maximize residents' well-being.
Failure to Administer and Document Medication Correctly
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for Resident R3. Resident R3, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, diabetes mellitus, and chronic obstructive pulmonary disease (COPD), had a physician order for Anoro Ellipta inhaler to be administered once daily for wheezing. However, during an observation of the medication cart, it was found that the inhaler was not available, and Resident R3 did not receive the medication on two consecutive days as prescribed. This was confirmed by LPN Employee E1, who admitted to documenting in error that the inhaler was administered when it was not. Further interviews revealed that the Director of Nursing confirmed the medication was not administered per the physician's order and that the documentation was incorrect. This deficiency highlights a failure in the facility's medication administration and documentation process, leading to Resident R3 not receiving the necessary treatment for COPD as prescribed by the physician.
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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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