Greene Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 119 Industrial Park Road, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395604
- Inspections on file
- 37
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Greene Health & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Korsakoff’s dementia repeatedly engaged in close physical and sexualized contact with another resident, including hand-holding, kissing, wandering together, attempts to leave the unit, and being found in the other resident’s bed with his pants unbuttoned and exposed. The resident’s daughter, acting as POA and documented decision maker, had clearly and repeatedly instructed staff that she did not want her father around the other resident and that any contact between them should not be permitted or encouraged. Despite these directives, staff continued to allow the two residents to be together, and the POA found them sitting closely together and holding hands after the bed incident, while leadership acknowledged that the two residents were always together and that the other resident was considered too difficult to redirect.
The facility failed to provide individualized, ongoing activities for residents with dementia in a memory-impaired unit. Facility policy and assessment documents required person-centered dementia care and specialized cognitive activities, but activity staffing was insufficient and no dedicated staff had been available to run activities for an extended period. For multiple cognitively impaired residents, care plans either omitted activity preferences or were not individualized to reflect prior lifestyle or specific interests. Observations showed residents sitting or sleeping in common areas without stimulation, wandering aimlessly, yelling out, and one resident repeatedly exposing her breasts without consistent staff response, while an activity aide only played music or passed donuts and drinks without engaging residents or including all of them. A family member and a RN reported that activities had not been occurring for some time, and leadership acknowledged understaffing in the activity department.
Surveyors found that staff failed to follow multiple physician and practitioner orders, including not administering ordered morning medications to a cognitively impaired resident within the established medication pass time, not obtaining ordered orthostatic BPs for a cognitively impaired resident after a fall, and not ensuring that two cognitively impaired residents involved in a sexual exposure incident were evaluated by psychiatric services as had been communicated to their families.
A resident who was cognitively impaired and dependent on staff for daily care received ordered IV Rocephin via a peripheral IV catheter over several days, but the MAR contained no documentation that the IV line was flushed before and after administration as required by the facility’s IV flushing policy. Review of clinical records and the facility’s policy showed that peripheral IV catheters were to be flushed with normal saline or another recommended solution to maintain patency and prevent mixing of incompatible medications, and the DON confirmed the absence of flushing documentation.
The facility failed to provide individualized dementia-focused treatment, activities, and supervision for several cognitively impaired residents on a memory unit. Care plans did not identify residents’ activity preferences or specify meaningful, personalized activities despite documented dementia, behaviors, and need for assistance. Observations showed residents sitting idle, wandering aimlessly, entering cupboards and rooms, yelling out, and one resident repeatedly exposing herself, while an activity aide only played music or passed donuts and drinks without engaging residents in structured activities. Nursing notes documented frequent falls related to self-transfers, physical altercations, feces smearing, and ongoing intimate contact between two residents despite a family member’s explicit request that they be kept apart. Staff interviews revealed that there had been no consistent activities on the unit, residents were largely unsupervised while staff performed care and med passes, and staffing levels were below required ratios, leaving only two aides for about 30 residents. The deficiency was cited under state regulations for resident care planning and nursing services.
The facility failed to follow its grievance policy when a family member of a resident with moderate cognitive impairment and a UTI voiced concerns about the resident being moved from a private room and staff not being nice. A Case Manager documented receiving a voicemail and stated she would discuss the concerns with management and return the call, but no follow-up call occurred, and no grievance investigation or written grievance decision was documented. The grievance log contained no entry for this complaint, and Social Services confirmed the family's unresolved concerns and lack of contact, reflecting a failure to properly process and document the grievance as required.
A resident with multiple chronic conditions and a complex medication regimen was discharged home without being provided a complete written list of current medications and instructions. Although nursing documentation stated the resident was educated on all discharge orders and medications and that all medications were sent home, the discharge paperwork only listed a limited subset of prescribed drugs, omitting several ongoing medications such as anticoagulants, cardiac medications, anticonvulsants, and supplements. The DON later confirmed there was no documentation that a full and accurate medication list with instructions was given to the resident or family at discharge.
The facility did not develop comprehensive, individualized care plans for three residents with dementia. One resident who was cognitively impaired and needed moderate assistance had no care plan addressing dementia-related care and treatment needs. Another severely confused, independently ambulatory resident with Korsakoff's dementia had repeated documented behaviors involving close physical contact and attempts to leave the unit with another resident, yet no behavior- or dementia-specific care plan was created. A third cognitively impaired resident who required staff assistance had no care plan addressing individual activity preferences, likes, or dislikes. The Activity Director and Social Services Director reported they had not been educated on care planning for dementia needs, which they cited as the reason these dementia and activity care plans were not developed.
A resident with cognitive impairment who required staff assistance for daily care reported peri pain when sitting and was found by an LPN during a shower to have a significantly enlarged prolapse compared to prior observations. The LPN notified a supervisor and documented plans to monitor and await further assessment and possible physician orders, but there was no documentation that an RN performed or recorded an assessment of this change in condition, contrary to state nursing practice standards requiring RNs to collect and analyze ongoing data and provide appropriate nursing care.
A resident who was cognitively intact, required maximum assistance with ADLs, and had diabetes with bilateral cataracts was seen by an optometrist for a diabetic eye exam and cataract evaluation, with a recommendation to return in six months for follow-up. The clinical record contained no documentation that this follow-up appointment was scheduled or completed, and there was no indication that the physician disagreed with the optometrist’s plan of care. The NHA confirmed that no documentation existed to show the recommended follow-up occurred, resulting in a failure to assist the resident in accessing needed vision services.
A resident with severe cognitive impairment and dementia had a care plan requiring use of a chair alarm whenever seated, with staff responsible for ensuring the alarm was always working. On observation, the resident was seated in a Broda chair without a visible chair alarm and later stood up from the chair without any alarm sounding and without staff awareness. An RN and the Nursing Home Administrator both confirmed that the chair alarm should have been in place, demonstrating a failure to follow the facility’s fall-prevention policy and the resident’s care plan.
Two residents with colostomies did not receive care in accordance with facility policy and physician/family directives. For one resident, an LPN failed to date the colostomy bag as ordered to be changed and dated every three days. For another resident, an RN prepared and cut an ostomy wafer at the med cart without measuring the stoma, applied a wafer that was visibly too large, and stated she "just eyeballs" the size instead of using a measuring guide, despite facility policy requiring stoma measurement and cutting the wafer to fit.
Surveyors found that the facility repeatedly failed to meet required NA-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census and staffing schedules showed that the number of NAs scheduled and providing care was consistently below the minimum required based on the number of residents, with shortfalls documented on numerous shifts across several weeks. There were no additional higher-level staff available to offset these NA shortages, and the Administrator confirmed that the required staffing ratios were not met on the identified shifts.
Surveyors found that the facility did not maintain required LPN-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census data and nursing schedules showed that the number of LPNs providing care on several day shifts was slightly below the minimum required based on the census, and at least one evening and one night shift were also understaffed. There were no additional higher-level staff available to offset these LPN shortfalls, and the Administrator confirmed that required LPN staffing ratios were not met on the identified shifts.
Surveyors determined that the facility did not consistently provide the required minimum of 3.2 hours of direct nursing care per resident in multiple 24-hour periods. Review of facility staffing schedules over several weeks showed that, on numerous days, the calculated direct care hours per resident fell below the regulatory threshold. The NHA confirmed during interview that the required daily direct care hours were not met on those days.
Two residents who were cognitively intact and dependent on staff for ADLs, including one with MS and another with post-stroke hemiplegia/hemiparesis and diabetes, experienced excessively long call bell response times that did not align with facility policy or expectations. Call bell logs showed repeated delays ranging from many minutes to about an hour, and one resident reported being placed in bed and not checked on for several hours, with unanswered attempts to reach staff by phone. The ADON acknowledged that these call bell wait times were excessive and inconsistent with the expectation that call bells be answered within five minutes.
A resident with dementia and cognitive impairment, who required staff assistance for ADLs and had a care plan specifying twice-weekly showers on set days with bed baths as an alternative if refused, did not receive showers on numerous scheduled days over a two-month period. Facility policy required honoring bathing preferences and documenting refusals and alternatives, but bathing records showed repeated missed showers with no documentation that showers were offered, refused, or replaced with bed baths. The ADON confirmed the absence of documentation and that the resident should have received showers per her preferences and plan of care.
Staff failed to follow medication storage and supervision requirements when an LPN left a cup containing multiple unlabeled pills on an overbed table for a cognitively intact resident with heart failure, anxiety, and depression, without remaining to observe administration, and when prescription triamcinolone 0.1% cream ordered for dermatitis in another cognitively intact resident with gastroenteritis and colitis was found left unattended on the resident’s bed near the door. The facility’s own policy prohibited leaving medications or chemicals unattended, and leadership confirmed these medications should not have been left unsupervised.
A resident with an unstageable sacral pressure ulcer did not receive Triad cream every shift as ordered by the physician; instead, the treatment was only applied daily over several days, as confirmed by review of records and staff interview.
A resident with hemiplegia and hemiparesis was not provided with physician-ordered adaptive eating equipment, including a divided plate and specialized utensils, during a meal. Despite clear documentation and communication from therapy and dietary staff, the required devices were not supplied, and the resident and family confirmed their ongoing need.
The facility did not serve food and drink at appropriate temperatures, with hot items found to be lukewarm and cold items not sufficiently chilled during a lunch meal observation. A Dietary Technician confirmed that the foods were not served at the required temperatures, resulting in meals that were not palatable.
The facility did not ensure that refrigerated foods were properly labeled and dated, and failed to maintain cleanliness in key kitchen areas and equipment. Required cleaning tasks were not consistently documented as completed, and significant build-up of food debris and dust was observed on kitchen equipment and surfaces. The Dietary Technician confirmed these deficiencies.
A resident experiencing severe, uncontrolled pain was not assessed by an RN after a significant change in condition, despite facility policy and state regulations requiring such assessment. An LPN documented the pain and communicated with the physician, but there was no evidence of RN involvement or assessment during the episode, as confirmed by the DON.
A resident with cognitive impairment, incontinence, and diabetes did not receive scheduled showers as outlined in her care plan, and there was no documentation of showers given or refusals. Facility policy required at least two weekly showers or documentation of refusals, but records showed missing entries and unexplained 'did not occur' notations, as confirmed by the DON.
A resident with cognitive impairment and a physician's order for routine Naproxen did not receive multiple scheduled doses, as confirmed by MAR review and DON interview, despite the medication being available as a stock OTC item.
A resident with a history of DVT and ongoing pain was not provided adequate pain management when scheduled Tylenol failed to relieve her symptoms. Despite documentation of severe, uncontrolled pain and a request for stronger medication or comfort care, there was no evidence that the physician was promptly contacted for additional interventions. The DON confirmed that the resident's acute pain was not properly managed.
A resident with a history of falls and multiple medical conditions experienced several falls, after which the IDT implemented new interventions such as bed and wheelchair alarms. However, the care plan was not updated to reflect these changes, despite the alarms being in use and staff confirming their application.
A resident with dementia, dependent on staff for transfers, was left without access to her call bell and was not assisted out of bed after staff intentionally moved the call bell out of reach. Multiple staff, including an LPN and RN, were aware of the situation but did not report it promptly, resulting in a failure to protect the resident from abuse and neglect.
A resident with paraplegia and a Stage 4 pressure ulcer did not receive prescribed IV antibiotics as ordered, and there was no documentation that an air mattress recommended by a CRNP and requested by the resident was provided. The DON confirmed these omissions.
The facility did not maintain proper documentation for the administration of controlled medications for three residents with significant pain management needs. Although narcotic pain medications were signed out on controlled drug records, there was no evidence in the clinical records or MAR to confirm that these medications were administered as required by policy.
The facility did not maintain complete and accurate documentation for the administration of controlled substances, as required by policy and regulation. Multiple residents with chronic pain and various diagnoses received opioid medications, but staff failed to record these administrations on the controlled medication records, despite documenting them on the MAR. The DON confirmed the absence of required documentation for these medications.
A resident with severe cognitive impairment exhibited ongoing aggressive and combative behaviors, including refusal of care, verbal aggression, and inappropriate sexual comments. Despite these persistent behaviors and changes to the resident's antipsychotic medication regimen, there was no documented evidence that the physician or CRNP was notified on multiple occasions, resulting in a failure to communicate important changes in the resident's condition.
A resident with severe cognitive impairment displayed ongoing behavioral disturbances, including aggression and refusal of care, but did not receive a psychiatric evaluation as indicated in the care plan. The care plan was not updated to address the resident's persistent behaviors, and staff confirmed these omissions during interviews.
A resident with severe cognitive impairment exhibited ongoing verbal, physical, and sexually inappropriate behaviors, including aggression and refusal of care. Despite repeated documentation of these behaviors, staff did not assess or analyze the situation or attempt new interventions, and no psychiatric evaluation was scheduled, as confirmed by the DON.
Three residents with varying cognitive and physical needs did not receive showers according to their documented preferences and care plans, and there was no evidence that showers were offered, refused, or that alternative hygiene care was provided. The DON confirmed the lack of documentation and that showers should have been given as scheduled.
A resident with an unstageable heel pressure injury did not receive a timely change in wound care as recommended by a wound care CRNP. The new treatment order was not implemented until several days after the recommendation, as the LPN responsible was not present during the consultation and only updated the order upon return. The DON confirmed the delay in following the CRNP's recommendations.
A resident with chronic kidney disease did not receive their prescribed metoclopramide before breakfast as ordered. The medication was left unsupervised on the bedside table, and an LPN confirmed it should have been administered before meals. The DON acknowledged the error.
The facility failed to complete comprehensive admission MDS assessments within the required timeframe for seven residents, with delays ranging from 15 to 21 days. Additionally, an annual MDS assessment for a resident was completed 94 days late. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to complete quarterly MDS assessments within the required timeframe for four residents. The assessments were completed beyond the 14-day requirement after the ARD, with one resident's assessment completed 96 days after the ARD. The Nursing Home Administrator confirmed these delays.
The facility failed to accurately complete MDS assessments for several residents, as confirmed by clinical records and staff interviews. Errors included incorrect documentation of medication administration, such as anti-platelet and diuretic medications, and the omission of hospice services and influenza vaccine refusals. These inaccuracies were verified by the RN Assessment Coordinator.
The facility failed to provide adequate activities for residents with dementia on the Memory Impaired Unit. Observations showed residents were mostly inactive, and staff confirmed the lack of scheduled activities due to reduced staffing and increased paperwork. This deficiency affected residents who required cognitive and social stimulation as part of their care plans.
The facility did not honor drink preferences for six residents, who expressed a desire for soda with meals or snacks. Previously available, soda is now only accessible if purchased by residents or brought in by others. The Dietary Manager confirmed limited soda availability, and the NHA stated a preference for drinks with nutritional value, despite residents' requests.
The facility failed to ensure that residents received pneumococcal immunizations, as four residents were identified as not having received the vaccine, nor was there any documented evidence that it was offered. The facility's policy requires documentation of prior vaccinations at admission, but the MDS assessments revealed that these residents' vaccinations were not up to date and were not offered. Interviews confirmed the lack of documentation and offering of the vaccine, violating several Pennsylvania Code regulations.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident, who was alert and oriented, was left with medications unattended, including Carvedilol, Xifaxan, and Lactulose. An LPN confirmed leaving the medications with the resident at his request, and the Nursing Home Administrator acknowledged that no assessment had been conducted to ensure the resident's safety in self-administering medications.
The facility failed to maintain a clean environment for two residents. One resident's wheelchair had a heavy accumulation of dust and debris, while another resident's room had a fan with dust accumulation. Staff interviews confirmed the conditions, and the Director of Environmental Services acknowledged the need for cleaning.
The facility failed to provide timely written notification to residents and their legal guardians regarding the reasons for hospitalization for two residents. One resident was transferred to the ER with a left femur fracture, and another during dialysis due to unresponsiveness and facial droop. The Nursing Home Administrator confirmed the lack of required written notices for these transfers.
A facility failed to complete a significant change MDS for a resident who was enrolled in hospice services for protein-calorie malnutrition. Despite the requirement to conduct a comprehensive assessment within 14 days of a significant change, no MDS was documented. The RNAC confirmed the oversight, highlighting a lapse in protocol adherence.
The facility did not update care plans for two residents, one involving antipsychotic medication use and another regarding infection control measures. The care plan for a resident on Zyprexa was not revised to include medication needs, and another resident's plan was not updated to reflect the discontinuation of Enhanced Barrier Precautions for ESBL.
The facility did not complete a discharge summary, including a recapitulation of the stay, for a resident discharged from the hospital to home. A nursing note confirmed the discharge, but there was no documented evidence of the summary, as verified by the Assistant DON.
Two residents in an LTC facility were not provided with necessary safety devices as per their care plans. A resident at risk for falls was found without a bolster overlay and reacher, while another was transported in a wheelchair without footrests. These deficiencies were confirmed by staff interviews.
Failure to Honor POA Decisions Regarding Resident-to-Resident Physical/Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s legal representative was able to exercise decision-making rights regarding the resident’s physical and sexual contact with another resident. Resident 12, who had Korsakoff’s dementia and was assessed as severely confused but independently ambulatory, had a documented power of attorney (POA) held by his daughter, identified as Family Member 1. Clinical records showed repeated instances of close physical contact between Resident 12 and Resident 11, including hand-holding, kissing, walking together, and attempts to leave the unit together. A quarterly MDS dated March 18, 2026, confirmed Resident 12’s severe cognitive impairment. Nursing notes from December 14 and December 29, 2025, documented that Resident 12 was talking with, holding hands with, kissing, and wandering the unit with Resident 11, and that they were trying to leave the unit together. On March 12, 2026, a nurse’s note documented that Resident 12 was found in Resident 11’s bed next to her with his pants unbuttoned and exposed. When the facility notified his daughter/POA, she was angry because she had previously been told that the residents would be separated. In an interview, Family Member 1 stated that in early December, shortly after admission, staff had informed her that Resident 11 had attached herself to Resident 12 like he was her boyfriend, and she clearly communicated that she did not want her father around Resident 11 due to his age and marital status. She reported that during multiple visits, Resident 11 followed them and told Resident 12 they needed to leave together, and that she had explicitly requested that they be separated and that contact between them not be permitted or encouraged. Despite this, when she arrived at the facility after the March 12 incident, she found Resident 12 sitting with Resident 11 at the nurse’s station, holding hands with her head on his shoulder. The Assistant DON confirmed that Resident 11 believed Resident 12 to be her boyfriend, that they were always together, and that although the daughter did not want them together, staff found Resident 11 too difficult to redirect.
Failure to Provide Individualized Activities for Memory-Impaired Residents
Penalty
Summary
The facility failed to provide adequate, ongoing, person-centered activities for all residents in the Memory Impaired Unit (MIU), despite facility policy and assessment requirements. The dementia care policy required staff to be trained in person-centered dementia care and to use individualized, non-pharmacological, meaningful life enrichment activities. The facility assessment stated that the MIU would offer specialized cognitive activities provided by staff trained in dementia care, with life enrichment staffing of one full-time director and three full-time aides. However, the activity department was reported as understaffed, and there had been no dedicated staff available to provide activities in the MIU for at least two months. Review of clinical records for six cognitively impaired residents with dementia showed that their activity needs and preferences were not properly identified or individualized in their care plans. Multiple quarterly MDS assessments documented that these residents were cognitively impaired, dependent on staff for care needs or ambulatory with dementia diagnoses, and in some cases had verbal behaviors. For several residents, the care plans failed entirely to identify activity preferences, and for others, the plans were not individualized to reflect their prior lifestyle or specific activities they enjoyed, despite documentation that activities resembling prior lifestyle were to be provided. Surveyor observations in the MIU showed residents receiving minimal or no meaningful activities or engagement. At one observation, 14 residents sat around tables while an activity aide only played music without engaging them, and one resident repeatedly exposed her breasts by pulling her shirt over her head without consistent staff intervention. On another observation, an activity aide brought a coffee cart with donuts and drinks, but two residents were not offered any, and no group activity or engagement occurred; residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. A family member reported not seeing any activities in the MIU for several months and stated that she tried to interact with residents herself because they otherwise just sat and slept. A RN confirmed that there had not been activities in the MIU for some time and that nursing staff did not have time to provide them, while the Activities Director and Nursing Home Administrator acknowledged that the activity department was understaffed and that there was currently no one available to provide activities in the MIU.
Failure to Follow Physician and Practitioner Orders for Medications, Monitoring, and Psychiatric Evaluation
Penalty
Summary
The deficiency involves multiple failures to follow physician and practitioner orders for several cognitively impaired residents. One resident with cognitive impairment and dependence on staff for daily care had physician orders for multiple morning medications, including Clonidine, Lasix, Memantine, Metoprolol, and Sertraline, to be administered each morning. Interview with an LPN established that morning medications were to be given between 6:15 a.m. and 10:00 a.m., yet as of 12:44 p.m. on the survey date, this resident had not received the ordered morning medications. The Nursing Home Administrator confirmed that the resident did not receive her morning medications as ordered. Another cognitively impaired resident with dementia had a nurse practitioner order for orthostatic blood pressures to be obtained for three days following a fall, but there was no documentation that these orthostatic blood pressures were obtained. Two additional cognitively impaired residents, both ambulatory and diagnosed with dementia, were involved in an incident in which one resident was found in the other's bed with his pants unbuttoned and exposed. Documentation showed that families of both residents were informed and told that each resident would be seen by psychiatric services the following morning. However, there was no documented evidence that either resident was actually seen by psychiatric services after the incident, and facility leadership confirmed that these ordered or communicated psychiatric evaluations did not occur.
Failure to Flush Peripheral IV Catheter During IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure intravenous (IV) catheters were flushed according to its policy for one resident receiving IV medication. The facility’s IV catheter flushing policy, dated April 20, 2026, required that all peripheral IV catheters be flushed between incompatible medications with normal saline or another manufacturer-recommended solution to maintain catheter patency and prevent mixing of incompatible medications/solutions. A comprehensive MDS for Resident 4, dated March 13, 2026, showed the resident was cognitively impaired and dependent on staff for daily care. Physician’s orders dated April 13, 2026, directed staff to insert a peripheral IV catheter and administer 1 g of Rocephin once daily in the evening from April 14 through April 18, 2026. Review of the April 2026 MARs confirmed the resident received the ordered Rocephin doses on those dates, but there was no documented evidence that staff flushed the peripheral IV catheter before and after the medication administration, which was confirmed by the Director of Nursing during interview.
Failure to Provide Individualized Dementia Care, Activities, and Supervision on Memory Unit
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide appropriate treatment and services for multiple residents with dementia residing on the Memory Impaired Unit (MIU). The facility’s own assessment dated April 6, 2026 stated that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that Life Enrichment staffing should include one full-time director and three full-time aides. However, review of care plans and observations showed that residents with dementia did not have individualized activity preferences identified or implemented. For example, quarterly MDS assessments for four cognitively impaired residents with dementia (Residents 9, 10, 11, and 12) showed needs for staff assistance and, in some cases, independent ambulation and behaviors, yet their care plans either failed to identify activity preferences or contained only vague, non-individualized directions such as providing activities resembling a prior lifestyle without specifying what those activities were. Observations on the MIU over two days showed that residents were not being engaged in meaningful or structured activities despite the unit’s stated purpose. On one day, 14 residents were observed sitting around tables in the common room while an activity aide played music but did not engage them in any activity. One resident repeatedly pulled her shirt over her head, exposing her breasts, and staff were not consistently present in the common room to address this behavior. No further activities were observed that day. On the following day, an activity aide brought a coffee cart with donuts and drinks, but service to residents was delayed, two residents were not offered any items, and no group activity or engagement occurred. During these observations, residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. Clinical record review and nursing notes documented frequent falls and behavioral incidents among the cognitively impaired residents. One resident (Resident 9) was involved in a physical altercation in which he punched his roommate in the face. Another resident (Resident 10) experienced numerous falls over a span of weeks and months, often while attempting to self-transfer from bed, chairs, or to the bathroom, and was also noted to remove her ostomy bag and smear feces in various places. Residents 11 and 12, both with dementia and independent ambulation, were repeatedly documented as engaging in close physical contact, including holding hands, attempting to leave the unit together, and being found in bed together with exposure noted, despite a family member’s clear request that they be separated and that contact not be permitted or encouraged. Staff interviews revealed that there had not been activities in the MIU for some time, that residents wandered the locked unit without redirection while staff were occupied with care and medication administration, and that staffing levels were below the facility’s own requirements, leaving only two nurse aides for 30 residents at times. The Nursing Home Administrator acknowledged that staffing was out of compliance and that the facility was unable to meet necessary nurse aide ratios or daily PPD, contributing to the failure to provide appropriate dementia-specific treatment and services. The deficiency was cited under 28 Pa. Code 211.11(d) Resident care plan and 28 Pa. Code 211.12(d)(5) Nursing services, based on the lack of individualized activity care planning for residents with dementia, the absence of consistent, specialized cognitive activities and engagement on the MIU, the unmanaged wandering and behavioral issues, and the inadequate staffing that left residents largely unsupervised and without appropriate redirection or structured activities.
Failure to Investigate and Document Family Grievance Regarding Room Change and Staff Behavior
Penalty
Summary
The facility failed to follow its grievance policy by not documenting or investigating a family member's concerns regarding a resident's room change and staff behavior. The written grievance policy, dated April 20, 2026, required the Grievance Official to investigate all oral, written, or anonymous grievances, take immediate action if needed, and complete a written grievance decision that included the date received, a summary of the grievance, steps taken to investigate, pertinent findings or conclusions, whether the grievance was confirmed, and any corrective actions. Resident 6 had an admission MDS indicating moderate cognitive impairment, ability to make needs known, and a urinary tract infection. A nursing note documented that the Case Manager received a voicemail from the resident's family member, who was upset about the resident being moved from a private room and other issues on the 400 wing, and that the Case Manager planned to speak with management and return the call. Despite this, there was no documented evidence that the family member's concerns were followed up on or that any grievance investigation was initiated. The April grievance log contained no entry related to the family member's complaint. The Case Manager later confirmed that she did not make a follow-up call to the family member regarding these concerns. Social Services also confirmed that the family member had concerns about the move from a private room and that staff were not being nice to the resident, and that no call had been made to the family, who were very angry. This lack of investigation and documentation constituted a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by facility policy and 28 Pa. Code 201.29(i) on resident rights.
Incomplete Medication Information Provided at Discharge
Penalty
Summary
The facility failed to provide a complete and accurate list of medications and instructions to a resident and her responsible party at the time of discharge to home. The resident’s admission MDS from November 2025 showed she was cognitively intact, incontinent of bowel and bladder, and at risk for pressure ulcers without any current ulcers. A subsequent MDS from March 2026 documented that she was moderately cognitively impaired but able to make her needs known and had a urinary tract infection. Physician orders dated in March and April 2026 included multiple medications: acetaminophen, allopurinol, Eliquis, famotidine, folic acid, Lantus, levetiracetam, levothyroxine, a multivitamin, nadolol, Novolog on a sliding scale, pregabalin, polyethylene glycol, thiamine, tramadol, and Xifaxan. On the day of discharge, a nursing note documented that a family member came to take the resident home and that the resident was educated on all discharge orders and medications, with all belongings and medications, including narcotics, sent home. However, the written discharge instructions provided to the resident only listed Novolog, Lantus, acetaminophen, and polyethylene glycol as current medications with instructions. There was no documented evidence that the resident or her family received a complete list of all current medications and instructions corresponding to the full set of physician orders. In an interview, the Director of Nursing confirmed the absence of documentation showing that a complete medication list and instructions were provided, constituting a failure to meet the requirements of 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.
Failure to Develop Comprehensive Dementia and Activity Care Plans
Penalty
Summary
The facility failed to develop comprehensive, individualized care plans addressing dementia-related care needs for multiple residents. For one resident with dementia who was cognitively impaired and required moderate assistance with daily care needs, a quarterly MDS assessment documented these conditions, but there was no corresponding care plan to address her individual care and treatment needs related to dementia. Another resident, assessed as severely confused, independently ambulatory, and diagnosed with Korsakoff's dementia, also had no documented care plan addressing his dementia or behaviors despite multiple nursing notes describing ongoing behavioral issues. For this severely confused resident, clinical documentation showed repeated episodes of close physical contact and boundary issues with another resident, including holding hands, kissing, walking together while attempting to leave the unit, and being found in the other resident's bed with his pants unbuttoned and exposed. Despite these documented behaviors and the family’s prior concern about separation, no individualized behavioral or dementia-specific care plan was developed. Additionally, a third resident with dementia, who was cognitively impaired and required staff assistance for daily care needs, had no documented care plan addressing individual activity preferences, likes, or dislikes. The Activity Director and Social Services Director stated they had not been educated regarding care planning for residents’ dementia needs, which they identified as the reason dementia-specific and activity care plans were not in place for these residents.
Failure to Obtain RN Assessment After Resident’s Change in Condition
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not obtaining a timely assessment by a registered nurse (RN) when a resident experienced a change in condition. According to the Pennsylvania Nursing Practice Act, an RN is required to collect complete and ongoing data, analyze health status, compare data with norms, and carry out nursing actions to promote, maintain, and restore well-being. Resident 8 had a quarterly MDS assessment indicating cognitive impairment and a need for staff assistance with daily care. On the evening of March 29, 2026, the resident reported pain in the peri area when sitting in a chair in the dining area, though she denied pain when lying in bed or walking. During a shower, an LPN was called to observe the resident’s peri area, where a previously observed prolapse was now noted to be very enlarged, more than three times its prior size. The LPN reported the prolapse and the resident’s pain with sitting to a supervisor and documented that they would monitor and await the supervisor’s assessment and any changes made by the physician. However, there was no documented evidence that an RN assessed the resident’s change in condition or that such an assessment was recorded in the medical record. In an interview, the Clinical Consultant confirmed that the resident should have been assessed by an RN and that this assessment should have been documented.
Failure to Arrange Recommended Optometry Follow-Up for a Resident
Penalty
Summary
The facility failed to follow an optometrist’s recommendation for a follow-up eye examination for one of 14 residents reviewed. A quarterly MDS assessment dated December 31, 2025, documented that Resident 5 was cognitively intact and required maximum assistance for daily care needs. An optometry consult dated March 21, 2025, showed that the resident, who had diabetes and bilateral cataracts, was seen for a diabetic eye exam and cataract evaluation, and the optometrist recommended a return visit in six months for a follow-up examination. There was no documented evidence in the clinical record that this six-month follow-up appointment was scheduled or completed, nor was there documentation that the resident’s physician disagreed with or altered the optometrist’s plan of care. In an interview on April 22, 2026, at 3:10 p.m., the Nursing Home Administrator confirmed that there was no documentation that the recommended follow-up appointment had been completed, constituting a failure to assist the resident in gaining access to necessary vision services, in violation of 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Implement Care-Planned Chair Alarm for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a fall-prevention device was in place as care planned for one resident. Facility policy on fall prevention and management, dated April 20, 2026, stated that when risks are identified, preventive measures are to be implemented as care planned. A comprehensive MDS assessment for Resident 10, dated January 29, 2026, documented severe cognitive impairment, limited ability to be understood, and diagnoses including dementia. The resident’s care plan, dated March 5, 2026, specified that she was to utilize a chair alarm while in her chair and that staff were to ensure the alarm was always working. On April 21, 2026, at 11:56 a.m., Resident 10 was observed sitting in a Broda chair with no chair alarm visible. A subsequent observation at 12:27 p.m. showed the resident standing up from the chair without any alarm sounding and without staff awareness of her standing. In an interview at 12:34 p.m., RN 2 confirmed that the resident’s chair alarm was not in place and that it should have been. In a later interview at 3:50 p.m., the Nursing Home Administrator also confirmed that the chair alarm should have been in place, indicating noncompliance with the resident’s care plan and the facility’s fall-prevention policy.
Failure to Follow Colostomy Care Policy for Two Residents
Penalty
Summary
The facility failed to provide proper colostomy care for two residents who were cognitively impaired and dependent on staff for daily care. For one resident, a quarterly MDS assessment documented the presence of an ostomy and a physician’s order directed that the colostomy bag and setup be changed every three days and that the bag be dated when changed per family request. During an observation with an LPN, the resident’s colostomy bag was found with no date marked anywhere on it. The LPN confirmed during interview that the colostomy bag was not dated and acknowledged that it should have been. For the second resident, a quarterly MDS assessment also documented cognitive impairment, dependence on staff for all daily care needs, and the presence of a colostomy. During an observation, an RN was seen preparing and changing the resident’s colostomy appliance. The RN cut the ostomy wafer at the medication cart without measuring the stoma, then cleaned the skin, applied skin prep, and placed the wafer and bag. The wafer was visibly large compared to the stoma, and the RN did not measure the stoma or apply the wafer close to it, instead stating she “just eyeballs it.” Review of the facility’s colostomy care policy showed that staff were required to measure the stoma using a measuring guide and trace and cut the wafer opening to the correct size, and the DON confirmed that staff should measure the stoma to cut the wafer to size.
Failure to Maintain Required NA-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to meet state-mandated NA-to-resident staffing ratios on multiple dates across day, evening, and night shifts. Review of census and staffing data for March 8–14, March 22–28, and April 5–11, 2026, showed that the number of NA hours actually worked fell below the minimum required based on the resident census. For example, on March 8, 2026, with a census of 105 residents requiring 10.50 NAs on the day shift, only 8.10 NAs were scheduled and provided care. On March 9, 2026, the same census of 105 residents required 10.30 NAs on the day shift, but only 6.88 NAs were provided. Similar shortfalls occurred on numerous other day shifts. On March 12, 2026, a census of 105 residents required 10.50 NAs, but 7.03 NAs were provided; on March 13, 2026, 10.50 NAs were required and 6.89 were provided; on March 14, 2026, 10.50 NAs were required and 8.16 were provided. On March 22, 2026, a census of 101 residents required 10.10 NAs, but 8.15 were provided; on March 24, 2026, a census of 102 residents required 10.20 NAs, but 9.07 were provided; on March 25, 2026, a census of 103 residents required 10.30 NAs, but 8.60 were provided; on March 27, 2026, a census of 106 residents required 10.60 NAs, but 8.65 were provided. In April, on April 5, 2026, a census of 108 residents required 10.80 NAs, but 9.81 were provided; on April 6, 2026, the same census required 10.80 NAs, but 7.04 were provided; on April 7, 2026, 10.80 NAs were required and 9.05 were provided; and on April 9, 2026, a census of 109 residents required 10.90 NAs, but 8.70 were provided. The facility also failed to meet required NA staffing ratios on several evening and night shifts. On the evening shift, with a census of 105 residents on March 8, 13, and 14, 2026, 9.55 NAs were required each evening, but only 8.81, 8.21, and 8.62 NAs, respectively, were provided. On March 28, 2026, with a census of 107 residents requiring 9.73 NAs on the evening shift, only 9.31 NAs were provided. On the night shift, on March 11, 2026, a census of 104 residents required 6.93 NAs, but 6.13 were provided; on March 14, 2026, a census of 105 residents required 7.00 NAs, but 6.09 were provided; on March 22, 2026, a census of 101 residents required 6.73 NAs, but 6.68 were provided; and on March 27, 2026, a census of 106 residents required 7.07 NAs, but 6.42 were provided. The surveyors also determined there were no additional excess higher-level staff available to compensate for these NA staffing deficiencies, and the Administrator confirmed on interview that the required NA-to-resident ratios were not met on the identified dates.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held two times daily to review the scheduled staffing hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Maintain Required LPN-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts over specified dates. Review of census data and nursing time schedules showed that on several day shifts, the number of LPNs scheduled and providing care was below the minimum requirement based on the facility’s census. On March 8, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, only 1.80 LPNs provided care. On March 9 and March 12, 2026, with a census of 103 residents requiring 4.12 LPNs on each day shift, only 4.00 LPNs provided care on each of those days. On March 14, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, 4.03 LPNs provided care. On April 6, 2026, with a census of 108 residents requiring 4.32 LPNs on the day shift, 4.00 LPNs provided care, and on April 9, 2026, with a census of 108 residents requiring 4.36 LPNs on the day shift, 4.06 LPNs provided care. The facility also failed to meet minimum LPN staffing ratios on at least one evening and one night shift. On an evening shift on March 8, 2026, with a census of 105 residents requiring 3.50 LPNs, only 3.44 LPNs provided care. On a night shift on March 13, 2026, with a census of 105 residents requiring 2.63 LPNs, only 2.06 LPNs provided care. The review further determined that there were no additional excess higher-level staff available to compensate for these LPN staffing shortfalls. In an interview on April 20, 2026, the Administrator confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the identified days and shifts.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the scheduled hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Meet Minimum Daily Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.2 hours of direct nursing care per resident per 24-hour period on 12 of 21 reviewed days. Review of nursing time schedules for March 8 through 14, March 22 through 28, and April 5 through 11, 2026, showed that on multiple specific dates the total direct care hours per resident fell below 3.2, with documented levels of 2.58, 3.00, 2.98, 2.80, 2.74, 3.01, 2.91, 3.15, 3.08, 2.89, 3.15, and 3.02 hours depending on the day. These figures were derived from staffing information furnished by the facility and reflected the total general nursing care hours provided across the entire facility for each 24-hour period reviewed. In an interview on April 20, 2026, at 8:52 a.m., the Nursing Home Administrator confirmed that the facility did not meet the required daily direct resident care hours on the identified days.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing direct care hours to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required hours per patient day requirements with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the staffing hour per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff direct care hours to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. From that point forward, ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 05/11/2026
Failure to Maintain Resident Dignity Through Timely Call Bell Response
Penalty
Summary
The facility failed to maintain resident dignity by not responding promptly to call bells for two residents who were cognitively intact and dependent on staff for assistance with toileting, hygiene, and transfers. For one resident with multiple sclerosis, a quarterly MDS dated January 9, 2025, showed he was alert, oriented, and able to make his needs known, but required staff assistance for daily care. Interview with this resident on February 28, 2023, revealed he had to wait an extended period for staff to respond to his call bell. Review of his call bell logs for January and February 2026 showed multiple instances of prolonged response times, including waits of 19, 21, 27, 19, 60, 41, and 18 minutes on various January dates, and 16 and 46 minutes on February 1, 2026. These delays occurred despite a facility policy dated October 28, 2025, stating that staff alerted to an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. Another resident, with an annual MDS dated January 6, 2026, was cognitively intact and required staff assistance for daily care needs due to hemiplegia and hemiparesis following a stroke, as well as diabetes. A grievance form dated December 15, 2025, documented that this resident reported being put to bed around 10:00 p.m. and not being checked on until about 4:00 a.m., during which time he attempted to call the nurses’ station with his cellphone but received no answer until staff eventually came and told him they were short staffed. Review of his call bell log from December 14–16, 2025, showed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time was one hour and 47 seconds. In a February 3, 2026, interview, the resident stated that it took staff a long time to get him into bed after his request and that he sometimes called the front desk to get a faster response, but that night no one answered the phone. The Assistant DON acknowledged in a February 3, 2026, interview that the documented call bell wait times were excessive and not acceptable, and stated that she expects call bells to be answered within five minutes, noting that anyone can answer a call bell.
Failure to Provide Showers per Resident Preference and Care Plan
Penalty
Summary
Surveyors identified a failure to provide bathing care according to a resident’s preferences and care plan. Facility policy dated October 28, 2025, required that residents be bathed or showered according to their preferences to maintain hygiene and skin condition, and that the charge nurse speak with any resident who refused, attempt alternative arrangements, and document refusals in the medical record. Resident 5 had a quarterly MDS dated December 4, 2025, showing cognitive impairment, dementia, and a need for staff assistance with daily care needs including bathing. The resident’s care plan dated July 29, 2024, specified a preference for showers twice weekly on Wednesdays and Saturdays, with the option to refuse and receive a bed bath instead. Review of the bathing detail report for Resident 5 from December 1, 2025, through January 31, 2026, showed multiple missed showers on scheduled Wednesdays and Saturdays, including but not limited to December 6, 10, 13, 17, 20, 24, 27, 29, 2025, and January 3, 7, 10, 17, 21, 24, and 31, 2026. There was no documentation that showers were offered on these dates, that the resident refused, or that alternative bathing such as a bed bath was provided. In an interview on February 3, 2026, at 1:06 a.m., the Assistant DON confirmed there was no documented evidence that staff offered showers and that the resident should have received showers per her stated preferences and plan of care, resulting in noncompliance with 28 Pa. Code 211.12(d)(5) Nursing services.
Unsupervised and Unsecured Medications Left at Bedside
Penalty
Summary
Facility staff failed to ensure medications were properly stored and labeled, resulting in drugs being left unattended at the bedside for two residents. For one resident who was cognitively intact, required assistance with daily care, and had diagnoses including heart failure, anxiety, and depression, surveyors observed an unsupervised medicine cup containing twelve unlabeled pills on the overbed table while the resident was lying in bed. The resident reported that she was aware the pills were there and that nurses frequently left her pills sitting on the table. The LPN responsible acknowledged that he had left the medications in the room because he believed the resident would take them after eating breakfast and confirmed he did not remain in the room to observe medication administration, contrary to the facility’s medication administration policy that staff should not leave medications or chemicals unattended. For another cognitively intact resident who required assistance with daily care and had diagnoses including noninfective gastroenteritis and colitis, physician orders directed the use of triamcinolone 0.1% cream to the back and hips twice daily for dermatitis. During observation, surveyors found a box of triamcinolone 0.1% cream left on the bottom left side of the resident’s bed near the door, unsupervised by staff. The Assistant DON confirmed in both cases that medications and topical prescription products should not have been left unsupervised in the residents’ rooms, indicating noncompliance with the facility’s policy and state requirements for pharmacy and nursing services regarding proper labeling and secure storage of drugs and biologicals.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to follow wound care recommendations for a resident with an unstageable pressure ulcer to the sacral area. The resident, who was cognitively intact and required assistance with daily care, was identified as being at risk for pressure ulcers. A wound consultation and physician's orders specified that Triad cream should be applied to the sacral wound every shift. However, review of the Treatment Administration Record showed that the cream was only applied daily over a four-day period, rather than every shift as ordered. This was confirmed by the Assistant Director of Nursing, who acknowledged that the treatment was not administered according to the physician's instructions.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
A deficiency occurred when staff failed to provide a resident with the assistive eating devices as ordered by the physician. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, required set-up assistance with eating and was specifically ordered to use a divided plate with dycem underneath and left angled black ridged non-weighted utensils for all meals. Occupational therapy and physician documentation confirmed the ongoing need for these adaptive devices, and a dietary slip was completed to communicate these requirements. During a lunch meal observation, the resident was found without the required divided plate and utensils. Both the resident and his sister confirmed that these items were necessary for him to eat independently, as he used the edge of the divided plate to assist with getting food onto his utensils. The Dietary Manager initially indicated that the adaptive equipment had been discontinued and the resident was not listed as needing them, but later confirmed that current dietary communication sheets still indicated the need for these devices. The resident did not receive the ordered adaptive equipment during the observed meal.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food and drink at palatable and safe temperatures, as required by its own policy. According to the policy, hot foods should be plated at 135°F and cold foods at 41°F or below. During a lunch meal observation, a test tray revealed that hot items such as potato encrusted fish and sliced carrots were served at 121.1°F and 120.4°F, respectively, while cold items like creamy coleslaw, fruit cup, and milk were served at 67.7°F, 62.0°F, and 59.8°F, respectively. These temperatures were confirmed by tasting to be neither hot nor cold enough to be palatable. The Dietary Technician acknowledged that the foods were not served at the proper temperatures.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions as required by policy and professional standards. Review of the facility's policy indicated that refrigerated foods should be marked with the date for consumption or disposal, but observations in the main kitchen revealed multiple cartons and containers of prepared salads in the walk-in refrigerator that were not labeled or dated. Additionally, the deep cleaning calendar showed that required cleaning tasks, such as cleaning the outside of the dish machine and wiping walls, were not consistently documented as completed, with only two days signed off for the entire month. Further inspection found significant build-up of food debris and dust on kitchen equipment, including the convection oven, grease trap, ceiling vent, and ice machine filter, as well as dirty flooring around the stove and ice machine. The Dietary Technician confirmed that the food should have been labeled and that the areas identified were dirty and needed cleaning.
Failure to Ensure RN Assessment After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a registered nurse (RN) assessed a resident following a significant change in condition. According to the Pennsylvania Nursing Practice Act and the facility's own policies, an RN is required to assess residents after a change in condition, particularly when there is new or worsening pain. In this case, a resident who was cognitively intact and required assistance with daily care experienced severe, uncontrolled pain that was not relieved by scheduled Tylenol. The resident cried out in pain when moved, expressed distress, and verbalized a desire to die due to the pain. Documentation showed that an LPN noted the resident's pain and communicated with the physician regarding comfort care, stronger pain medication, or hospice, but there was no evidence that an RN assessed the resident during this episode. The Director of Nursing confirmed that there was no documented RN assessment at the time of the resident's pain episode, despite facility policy and state regulations requiring such an assessment. The lack of RN assessment and documentation following the resident's significant change in condition constituted a failure to meet professional standards of quality and the facility's own protocols for pain management and change in condition.
Failure to Provide Scheduled Showers and Document Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled according to her care plan and preferences. Facility policy required that residents be bathed or showered at least twice weekly, or as per their preference, and that refusals be reported to the charge nurse, who would then document the refusal and attempt to make alternative arrangements. For the resident in question, the care plan specified a preference for showers twice weekly on the day shift, with a prompt bed bath and skin checks if a shower was refused. A review of the resident's records, including the bathing detail report and weekly skin sheets over a six-week period, showed no documented evidence that the resident received showers as scheduled or that she refused them, which would have triggered a bed bath. The DON confirmed the lack of documentation and was unable to explain why some days were marked as 'did not occur.' The resident was cognitively impaired, required moderate assistance with bathing, was occasionally incontinent, and had diabetes, all of which were relevant to her care needs at the time of the deficiency.
Failure to Administer Ordered Pain Medication
Penalty
Summary
A cognitively impaired resident who required partial to moderate assistance and received routine pain medication was admitted with a physician's order for 500 mg of Naproxen to be administered twice daily with meals. Review of the resident's Medication Administration Record (MAR) for August 2025 showed that the Naproxen was not documented as given on several specified dates and times. The Director of Nursing confirmed that the resident did not receive the ordered Naproxen doses on those occasions, despite the medication being available as a stock item in the emergency box and as an over-the-counter medication.
Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing acute pain. According to the facility's pain management policy, a pain evaluation should occur with any new onset of pain, and the physician should be notified of new or significantly increased pain. The resident, who was cognitively intact and required assistance with daily care, had a physician order for scheduled Tylenol. On one occasion, the resident was found to have a deep vein thrombosis (DVT) in the left lower extremity and was started on anticoagulant therapy. Despite this, nursing documentation indicated that the resident continued to experience significant pain that was not relieved by the scheduled Tylenol, including crying out in pain during care and expressing distress about her pain. A note was placed in the physician's communication book requesting comfort care, stronger pain medication, or hospice, but there was no documented evidence that the physician was contacted at that time for additional interventions or treatment to relieve the resident's pain. The Director of Nursing confirmed that the resident's acute pain was not controlled as it should have been. This lack of timely physician notification and intervention for uncontrolled pain constituted a failure to follow the facility's pain management policy and provide adequate nursing services.
Failure to Update Care Plan After Falls and New Interventions
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect changes in care needs following multiple falls and the implementation of new safety interventions. The resident, who had a history of falls, left shoulder injury, left hip fracture, and conditions such as deconditioning, limited mobility, vertigo, orthostatic hypotension, and weakness, experienced several falls over a period of time. After each fall, the interdisciplinary team met and decided on new interventions, including the addition of bed and wheelchair alarms to help prevent further incidents. Despite these interventions being implemented, there was no documented evidence that the resident's care plan was revised to include the use of bed and wheelchair alarms. Observations confirmed the presence of these alarms in use, and staff interviews verified their application, but the care plan did not reflect these updates. This failure to update the care plan was confirmed by the Director of Nursing and was not in accordance with the facility's policy or regulatory requirements.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident with dementia, who was dependent on staff for transfers and had no behavioral issues, from abuse and neglect. The incident involved a nurse aide removing the resident's call bell, making it inaccessible, and refusing to assist the resident out of bed over a weekend. Documentation and witness statements confirmed that the resident repeatedly requested to get out of bed and that her call bell was intentionally moved out of reach. The resident verbally reported not having access to her call bell, and staff observed the call bell draped over the nightstand. Multiple staff members, including two nurse aides and an RN, were aware of the situation. One nurse aide admitted to removing the call bell, while another was aware of the action and did not intervene. The RN was informed by the aides that the call bell was moved to prevent the resident from bothering them due to their workload. The incident was not reported in a timely manner as required by the facility's abuse policy, and the investigation determined that the resident was not allowed out of bed and was left without access to her call bell.
Failure to Follow Physician Orders for Medication and Pressure Ulcer Equipment
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including paraplegia, wound infection, and a Stage 4 pressure ulcer. Physician's orders specified that the resident was to receive 4.5 grams of Piperacillin-tazobactam intravenously every eight hours. However, the Medication Administration Record showed no documented evidence that the resident received the antibiotic as ordered on three occasions within a specified day. Additionally, the resident requested bed rails and an air mattress for repositioning and pressure ulcer management. A wound consult by a CRNP recommended an air mattress for the resident's pressure ulcers. Despite these recommendations and requests, there was no documented evidence in the clinical record that the resident received an air mattress. The Director of Nursing confirmed that the resident did not receive the IV antibiotic as ordered and that there was no documentation of the air mattress being provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three out of five residents reviewed. Facility policy required documentation of controlled substance administration in accordance with applicable law, including recording when medications are given on appropriate forms. For three residents, controlled drug records showed that doses of narcotic pain medications were signed out on specific dates and times. However, there was no corresponding documentation in the residents' clinical records or Medication Administration Records (MAR) to confirm that these medications were actually administered at those times. The residents involved were cognitively intact and had significant pain management needs, with diagnoses such as fractures, osteoarthritis, chronic pain syndrome, fibromyalgia, and polyneuropathy. Each had physician orders for opioid or narcotic pain medications, either scheduled or as needed. Despite these orders and the signing out of medications on controlled drug records, the lack of documentation in the MAR or clinical records was confirmed by the Director of Nursing, indicating a failure to ensure proper tracking and accountability for controlled substances as required by facility policy and state regulations.
Failure to Document Controlled Substance Administration in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding the documentation of controlled substance administration. According to the facility's medication administration policy, staff are required to document the administration of controlled substances in accordance with applicable law, including recording each dose on the appropriate controlled medication record. However, for all five residents reviewed, there were multiple instances where narcotic pain medications such as Tramadol, oxycodone-acetaminophen, oxycodone, and hydrocodone-acetaminophen were administered as documented on the Medication Administration Record (MAR), but there was no corresponding documentation on the controlled medication record for those administrations. The residents involved were all cognitively intact and required assistance with care needs. Each had significant pain management needs and diagnoses such as multiple sclerosis, chronic pain, polyneuropathy, spinal stenosis, osteoarthritis, fibromyalgia, and fractures. Physician orders for these residents included scheduled and as-needed administration of opioid medications for pain control. Despite these orders and the administration of the medications as recorded on the MAR, the required documentation on the controlled medication record was missing for several dates and times for each resident. The Director of Nursing confirmed during an interview that there was no documented evidence on the controlled medication sheets for the administration of the specified medications to the five residents on the identified dates and times. This lack of documentation was found to be inconsistent with both facility policy and regulatory requirements for clinical records and nursing services.
Failure to Notify Provider of Ongoing Resident Behaviors During Medication Changes
Penalty
Summary
The facility failed to notify the physician or provider regarding ongoing behavioral issues for one resident who was severely cognitively impaired and required staff assistance for daily care. The resident exhibited repeated episodes of combative and aggressive behavior, including refusing care and medications, verbal aggression, yelling, wandering into other residents' rooms, making inappropriate sexual comments, and being physically combative with staff. Despite these ongoing behaviors, there was no documented evidence that the physician or Certified Registered Nurse Practitioner (CRNP) was notified on multiple occasions when these incidents occurred. The resident's care plan included a Gradual Dose Reduction (GDR) of antipsychotic medication unless clinically contraindicated. However, nursing notes indicated that the resident's behaviors persisted or increased during the period when the GDR was implemented and after the antipsychotic medication was discontinued. The lack of communication with the physician or CRNP regarding these ongoing and escalating behaviors meant that the provider was not informed in a timely manner to potentially prevent the GDR or address the resident's needs. The Director of Nursing confirmed that the provider was not notified about the ongoing behaviors or the inappropriateness of the GDR for this resident.
Failure to Update Care Plan and Refer for Psychiatric Evaluation
Penalty
Summary
A resident with severe cognitive impairment was admitted from the hospital and exhibited ongoing behavioral issues, including combativeness, verbal aggression, refusal of care and medications, inappropriate sexual comments, and physical aggression towards staff. Despite these persistent behaviors, there was no documented evidence that the resident was referred for a psychiatric evaluation as indicated in the care plan. Additionally, the care plan was not updated to reflect new interventions to address the resident's escalating behaviors, even as the resident's antipsychotic medication was discontinued and later restarted by physician order. Clinical record reviews and staff interviews confirmed that the care plan was not reviewed or revised in response to the resident's changing condition and ongoing behavioral challenges. The Director of Nursing acknowledged that the care plan was not updated and that the psychiatric evaluation was not completed, resulting in a failure to meet regulatory requirements for timely and appropriate care planning and intervention.
Failure to Assess and Intervene for Escalating Resident Behaviors
Penalty
Summary
The facility failed to monitor, assess, and analyze a resident's escalating behavioral issues, including verbal and physical aggression as well as inappropriate sexual behaviors. The resident, who was severely cognitively impaired and required staff assistance for daily care, exhibited a pattern of combative and aggressive actions, such as refusing care and medications, yelling at staff, threatening to hit staff, wandering into other residents' rooms, and making inappropriate sexual comments. These behaviors were documented repeatedly in nursing notes over a two-month period. Despite the ongoing and increasing nature of these behaviors, there was no documented evidence that the facility assessed or analyzed the resident's behaviors or attempted new interventions to address them. Additionally, although the resident's antipsychotic medication was discontinued and later restarted, no psychiatric evaluation or treatment was scheduled. The Director of Nursing confirmed that the resident was in need of psychiatric evaluation, but none had been arranged as of the time of the survey.
Failure to Provide Showers per Resident Preferences and Care Plans
Penalty
Summary
The facility failed to provide showers to three residents according to their documented preferences and care plans. Facility policy required that residents be bathed or showered per their preferences, and if a resident refused, the charge nurse was to ascertain the reason, offer alternatives, and document the refusal in the medical record. For one resident with cognitive impairment and a history of stroke, the care plan indicated a preference for weekly showers, with bed baths as an alternative if refused. However, records showed inconsistent showering and no documentation of refusals or bed baths provided. Another resident, cognitively intact with incontinence, a deep tissue injury, and multiple diagnoses, preferred three showers weekly, but there was no evidence of showers given or refusals documented. A third resident with Alzheimer's dementia, requiring assistance with daily care, preferred twice-weekly showers, but records indicated missed showers and no documentation of refusals or alternative care. Review of bathing detail reports for all three residents over a nearly three-month period revealed that showers were not provided as per their preferences, and there was no documentation that showers were offered and refused, nor that bed baths were given as alternatives. An interview with the DON confirmed the lack of documentation and that the residents should have received showers according to their preferences. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
A deficiency was identified when the facility failed to implement a wound care recommendation for a resident with an unstageable pressure injury on the right heel. The resident, who was cognitively intact and required substantial assistance with care, had significant medical conditions including peripheral vascular disease and diabetes. A wound care CRNP recommended a change in the wound care regimen, specifying the use of 0.125% Dakin's Solution, Santyl, calcium alginate, abdominal dressing, and kerlix. However, review of the resident's Medication Administration Record showed no evidence that this new treatment was initiated as recommended. The wound nurse, an LPN, was not present during the CRNP's visit and only became aware of the recommended change after returning to the facility. Upon review, the LPN found that the order had not been updated to reflect the new wound care protocol. The order was not changed until several days after the recommendation, resulting in a delay in implementing the prescribed wound care for the resident. The DON confirmed that the CRNP's recommendations were not followed in a timely manner.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to follow physician's orders for a resident diagnosed with chronic kidney disease. The resident, who was cognitively intact and independent with personal care needs, was prescribed 10 mg of metoclopramide to be taken before meals three times a day. On the morning of December 17, 2024, the resident was observed lying in bed with a medicine cup containing two white pills left unsupervised on the bedside table, and no breakfast was present. An interview with an LPN confirmed that these were the resident's morning medications, which should have been administered before breakfast. The Director of Nursing confirmed that the medication should not have been left unsupervised and should have been administered as ordered.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for seven residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 48, 70, 98, 203, 204, 205, and 206 were completed between 15 to 21 days after admission, exceeding the mandated timeframe. This delay in completing the assessments was confirmed during an interview with the Nursing Home Administrator. Additionally, the facility did not complete an annual MDS assessment within the required timeframe for one resident. The RAI User's Manual specifies that an annual comprehensive MDS assessment should be completed no later than 14 days after the assessment reference date (ARD). For Resident 36, the annual MDS assessment was due on May 19, 2024, but was not completed until August 7, 2024, resulting in a delay of 94 days. This deficiency was also confirmed by the Nursing Home Administrator during the interview.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the facility did not adhere to these guidelines for Residents 27, 45, 55, and 63. Resident 27's quarterly MDS assessment, with an ARD of May 4, 2024, was completed 96 days after the ARD, which was beyond the required timeframe. Similarly, the assessments for Residents 45, 55, and 63 were completed 16 days after their respective ARDs, exceeding the 14-day completion requirement. The Nursing Home Administrator confirmed these delays during an interview, acknowledging that the assessments were completed late.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as determined through a review of clinical records and staff interviews. The deficiencies were identified in the coding of specific sections of the MDS assessments, which are crucial for evaluating residents' abilities and care needs. For instance, Resident 20's assessment inaccurately indicated that they did not receive anti-platelet or diuretic medications, despite physician orders and medication administration records showing otherwise. Additionally, the assessment failed to document a physician's note on the contraindication of a gradual dose reduction for an antipsychotic medication. Similar inaccuracies were found in the assessments of other residents. Resident 22's assessment incorrectly noted the administration of intravenous medication and failed to record the receipt of an antiplatelet medication. Resident 34's assessment also omitted the administration of an antiplatelet medication. Resident 38's assessment did not reflect the administration of a diuretic medication, and Resident 49's assessment failed to document the receipt of an anti-platelet medication. These errors were confirmed through a review of physician orders and medication administration records. Further discrepancies were noted in the assessments of Residents 87 and 92. Resident 87's assessment inaccurately stated that the influenza vaccine was not offered, despite documentation of the resident's refusal. Resident 92's assessment failed to indicate the receipt of hospice services, contrary to physician orders. These coding errors were confirmed by the Registered Nurse Assessment Coordinator, highlighting a pattern of inaccuracies in the facility's MDS assessments.
Inadequate Activities for Memory Impaired Residents
Penalty
Summary
The facility failed to provide adequate ongoing activities designed to meet the needs of residents with wandering behaviors and/or dementia residing on the Memory Impaired Unit (MIU). Specifically, five residents were identified as not receiving the scheduled activities that were supposed to be provided according to their care plans and the MIU activity calendar. These residents were severely cognitively impaired, with some requiring a secure, locked unit for safety due to their conditions, such as dementia and behavioral disturbances. The care plans for these residents indicated the need for participation in individual and group activities to maintain cognitive and social stimulation. Observations during the survey revealed that the majority of the time, residents were either sitting or walking around the tables in the activity room, with only minimal activities being provided. Interviews with staff, including a registered nurse, a nurse aide, and the Activities Director, confirmed the lack of activities on the MIU. The Activities Director acknowledged that due to increased paperwork and reduced staffing, the residents had not been receiving the activities listed on the calendar. This deficiency was noted under 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Honor Resident Drink Preferences
Penalty
Summary
The facility failed to honor drink preferences for six residents, as determined through clinical record reviews, observations, and interviews with residents and staff. Residents expressed a desire to have soda as a drink choice with meals or snacks, a preference that was previously accommodated but is no longer available. Instead, residents were informed they could purchase soda from the activity room or snack wagon, or have someone bring it in for them. The Dietary Manager confirmed that only ginger ale is available for residents who are ill, and no other sodas are ordered regularly. The Activities Manager acknowledged that residents miss having soda and occasionally incorporates it into activities. The Nursing Home Administrator stated the facility prefers to provide drinks with nutritional value and is aware of the residents' continued requests for soda, but maintains that residents must purchase it themselves.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that each resident received pneumococcal immunizations, as evidenced by the review of clinical records and staff interviews. Specifically, four residents were identified as not having received the pneumococcal vaccine, nor was there any documented evidence that the vaccine was offered to them. The facility's vaccination policy, dated September 26, 2024, requires that residents and/or their responsible party be asked about prior vaccinations at admission, with documentation in the electronic health record. However, for Residents 20, 42, 49, and 55, the Minimum Data Set (MDS) assessments revealed that their pneumococcal vaccinations were not up to date and were not offered. Interviews with the Nursing Home Administrator confirmed the lack of documentation and offering of the pneumococcal vaccine to these residents at the time of their admissions or afterward. This deficiency is in violation of several Pennsylvania Code regulations, including the responsibility of the licensee, management, and nursing services. The absence of documented evidence and the failure to offer the vaccine highlight a significant lapse in the facility's adherence to its own vaccination policy and regulatory requirements.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess whether a resident was safe to self-administer medications, as required by their policy. The policy, dated September 26, 2024, mandates that the interdisciplinary team must evaluate each resident's ability to self-administer medications based on their functionality and health condition. However, for Resident 107, who was alert and oriented upon admission, no such assessment was conducted. Despite having physician's orders for Carvedilol, Xifaxan, and Lactulose, the resident was left with these medications unattended. An LPN confirmed that she left the medications with the resident because he preferred to take them himself without her presence. The Nursing Home Administrator also confirmed that no assessment had been performed to determine the resident's capability to self-administer medications safely.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by the condition of a resident's wheelchair and another resident's room. One resident, who was severely cognitively impaired and required assistance with most daily care needs, was observed with a wheelchair that had a heavy accumulation of removable dust and debris on the wheels and metal supports, as well as a large amount of crumbs and dirt beside the seat cushion. Staff interviews confirmed the condition of the wheelchair and indicated that environmental services were responsible for cleaning it. The Director of Environmental Services acknowledged that the wheelchair should have been cleaned and mentioned a recently implemented process for cleaning facility wheelchairs. Another resident's room was observed to have a fan with an accumulation of dust on the fan guard over several days. The Director of Environmental Services confirmed the dust accumulation and stated that staff should notify them if a resident's equipment needs cleaning sooner. These observations and interviews highlight the facility's failure to ensure a clean and homelike environment, as required by their policy and resident rights regulations.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the residents and their legal guardians regarding the reasons for hospitalization for two residents. Resident 22, who was cognitively impaired and required assistance with daily care, was transferred to the emergency room after being found on the floor with severe pain in her left hip. She was later admitted to the hospital with a left femur fracture. There was no documented evidence that a written notice of her transfer was provided to her responsible party. Similarly, Resident 32, who was undergoing dialysis, became unresponsive and exhibited a left facial droop, prompting a transfer to the emergency room. She was subsequently admitted to the hospital with diagnoses including anemia, syncope, and end-stage renal disease. Again, there was no documented evidence that a written notice of her transfer was provided to her responsible party. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant change in condition. According to the Resident Assessment Instrument (RAI) User's Manual, a comprehensive assessment must be conducted within 14 days after a significant change in a resident's physical or mental condition is determined. This includes when a resident enrolls in a hospice program. The resident in question was cognitively impaired, required assistance with daily care needs, and had a diagnosis of atherosclerosis. The resident was admitted to hospice services for protein-calorie malnutrition, and the care plan indicated hospice services began on August 14, 2024. Despite the resident's enrollment in hospice services, there was no documented evidence that a significant change MDS was completed. A nurse's note indicated that the resident's family requested a transfer to a different hospice provider, but the necessary MDS assessment was not conducted. An interview with the Registered Nurse Assessment Coordinator confirmed that the significant change MDS should have been completed when the resident was enrolled in hospice services, indicating a lapse in following the required assessment protocol.
Failure to Update Care Plans for Medication and Infection Control
Penalty
Summary
The facility failed to review and revise care plans to reflect changes in residents' care needs for two residents. For one resident, the care plan was not updated to include the care and treatment needs for antipsychotic medication use, despite the resident being administered Zyprexa nightly. This oversight was confirmed by the Director of Nursing, who acknowledged that the care plan should have been revised to include this information. Another resident's care plan was not updated to reflect the discontinuation of Enhanced Barrier Precautions (EBP) for ESBL in the urine. Observations revealed that there were no signs indicating the resident was on contact precautions, and the Director of Nursing confirmed that the resident no longer required EBP, indicating the care plan should have been revised accordingly.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for a discharged resident. A nursing note indicated that the resident was discharged from the hospital directly to home. However, as of a later date, there was no documented evidence of a completed discharge summary for this resident. An interview with the Assistant Director of Nursing confirmed the absence of this documentation.
Failure to Implement Safety Devices for Residents
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for two residents. Resident 22, who was cognitively impaired and at risk for falling, was observed without a bolster overlay on her air mattress and without a reacher within reach, despite these interventions being part of her care plan. This was confirmed by both a Licensed Practical Nurse and the Director of Nursing during interviews. Resident 74, also cognitively impaired and at risk for falls due to dementia, was observed being transported in a wheelchair without footrests, causing her to elevate her feet off the floor. This was confirmed by the Nurse Aide transporting her and the Assistant Director of Nursing. These observations indicate a failure to adhere to the care plans designed to prevent accidents for these residents.
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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