Haida Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hastings, Pennsylvania.
- Location
- 397 Third Avenue Extension, Hastings, Pennsylvania 16646
- CMS Provider Number
- 395592
- Inspections on file
- 30
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Haida Nursing And Rehab during CMS and state inspections, most recent first.
Two residents with cognitive impairment and psychiatric diagnoses received as-needed psychotropic medications without documented evidence that nonpharmacological interventions were attempted prior to administration. The DON confirmed the lack of documentation for these interventions, contrary to facility policy and regulatory requirements.
The facility did not inform two residents' representatives in advance about the risks, benefits, and alternatives before starting or increasing psychotropic medications, as required by policy. Documentation confirming that this information was provided was missing from the clinical records, despite medication changes for residents with cognitive impairment and behavioral symptoms.
The facility did not meet the required NA-to-resident staffing ratios on several shifts, as the number of NAs scheduled and providing care was below the minimum required for the facility's census. No additional higher-level staff were available to compensate for these shortfalls, as confirmed by the Nursing Home Administrator.
The facility did not provide the required minimum hours of direct resident care on three days, as confirmed by nursing schedules and staff interviews. On these days, the hours of care per resident fell below the regulatory standard.
A facility failed to notify a resident's family member about changes in treatment and physician's orders, despite the resident having an Advanced Directive requiring family notification. The resident, diagnosed with Parkinson's disease and dementia, was prescribed new medications, but there was no documented evidence of family notification, confirmed by the DON.
A resident with Crohn's disease, diabetes, and hemiplegia was not sent to the hospital as ordered by a physician after a family member expressed concern about a possible stroke. Despite the physician's directive, the DON assessed the resident and decided against the transfer, leading to a failure in executing the order and a deficiency in care.
A facility failed to document a resident's medical assessments and physician's orders accurately, leading to a deficiency. The resident, with Crohn's disease, diabetes, and hemiplegia, was suspected of having a stroke by family members. Despite assessments by a nurse and the DON, and a physician's order to send the resident to the hospital, these were not recorded in the clinical record.
The facility failed to provide written notification to residents, their responsible parties, and the LTC ombudsman regarding hospital transfers for seven residents with various medical conditions. This deficiency was confirmed through record reviews and staff interviews, revealing a lack of documentation for the required notifications.
The facility failed to notify residents and their representatives in writing about the bed-hold policy during hospital transfers for five residents with conditions such as CHF, pneumonia, and sepsis. The DON confirmed the oversight, violating state codes.
The facility failed to maintain accurate clinical records for two residents, leading to documentation deficiencies. One resident's Lorazepam medication records showed discrepancies, confirmed by the DON. Another resident's shower preferences were not accurately documented, with only one shower recorded despite multiple opportunities. The DON confirmed issues with the charting system.
A facility did not complete a professional licensure check for an LPN before hiring, contrary to its abuse prevention policy. The check, required to prevent hiring individuals with disciplinary actions, was delayed by two months due to an error by the HR Director, who ran the check on the LPN's graduate license instead of the permanent one.
The facility inaccurately completed MDS assessments for three residents. One resident was incorrectly coded as receiving insulin instead of Victoza, a non-insulin diabetes medication. Another resident's use of a topical antibiotic was not recorded, and a third resident's insulin administration was omitted from the MDS. These errors were confirmed by the RNAC.
The facility failed to develop care plans for two residents, one using smokeless tobacco and another requiring IV antibiotics and PICC line care. The absence of care plans for these specific needs was confirmed by the DON.
A resident with quadriplegia developed a Stage III pressure ulcer on the left heel due to rubbing against a wheelchair footrest. During wound care, an LPN failed to change gloves or perform hand hygiene between tasks, as confirmed by the Infection Preventionist, potentially risking infection.
A resident with hemiplegia/hemiparalysis did not receive the required contracture management intervention of having a rolled towel in her left hand, as per physician's orders and care plan. Observations confirmed the absence of the towel, which was acknowledged by a nurse aide and the DON.
A facility failed to assess the safety of an air mattress for a resident with cognitive impairment and a Stage 3 pressure ulcer. The resident was receiving hospice services and required assistance for care needs. The DON confirmed that no safety assessment was conducted before the air mattress was used, and hospice staff placed it without informing the facility.
A facility failed to ensure proper IV therapy administration and monitoring for a resident. The resident's PICC line was not flushed as required, and arm circumference was not measured on specified dates, despite physician's orders and facility policy. This was confirmed by the DON.
A facility failed to ensure that a physician wrote progress notes for a resident's visits. The resident, who was cognitively intact and required maximum assistance, was seen by a physician on multiple occasions due to increased behaviors and family concerns. However, no progress notes were documented in the clinical record. The DON confirmed the absence of notes and stated that the physician was behind in documentation.
A resident with quadriplegia was prescribed hydrocodone-acetaminophen for pain, but the medication label was improperly altered with pen without the required change sticker. Interviews confirmed that the label should not have been modified, violating facility policy and state regulations.
The facility's QAPI committee failed to address repeated deficiencies in MDS accuracy, individualized care plans, and medication management. Despite previous corrective plans, a recent survey found ongoing issues with inaccurate MDS assessments, inadequate care plans, and improper medication storage and labeling.
A resident with a documented diagnosis of diabetes and orders for insulin and blood sugar checks was admitted to a facility. However, these orders were not identified or clarified with the physician, leading to the resident's hospitalization due to hyperglycemia. Staff interviews confirmed the oversight in reviewing and incorporating the necessary medical information into the resident's chart.
The facility failed to follow infection control guidelines during a COVID-19 outbreak and for residents requiring Enhanced Barrier Precautions. Staff did not consistently wear required PPE, such as N95 masks and eye shields, when caring for COVID-positive residents. Additionally, residents on Enhanced Barrier Precautions did not have accessible PPE in their rooms, and staff were observed handling medical devices without gloves or gowns. The Assistant Director of Nursing confirmed these lapses in protocol.
The facility failed to ensure that a resident received adequate supervision and care as per her care plan. Despite requiring extensive assistance, a nurse aide provided incontinence care alone, leading to the resident falling out of bed and sustaining a right hip fracture. The resident was hospitalized for surgery due to the injury.
Failure to Document Nonpharmacological Interventions Before Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. Facility policy required that psychotropic medications only be used when nonpharmacological interventions were clinically contraindicated, and that such medications should not be used for staff convenience or as a chemical restraint. For one resident with severe cognitive impairment, dementia, and anxiety, clinical records showed repeated administration of Alprazolam as needed for anxiety, but there was no documented evidence that nonpharmacological interventions were attempted prior to each administration. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation for attempted nonpharmacological approaches before giving the medication. Similarly, another resident with cognitive impairment, dementia, depression, and anxiety received Lorazepam as needed for anxiety on multiple occasions. Review of the clinical record revealed no documentation that nonpharmacological interventions were attempted before administering the medication. The Director of Nursing also confirmed the absence of such documentation for this resident. These findings indicate that the facility did not follow its own policy or regulatory requirements regarding the use of psychotropic medications and the documentation of nonpharmacological interventions.
Failure to Inform Resident Representatives of Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to inform resident representatives in advance about the risks, benefits, and treatment alternatives prior to initiating or increasing psychotropic medications for two residents. Facility policy requires that before starting or increasing psychotropic medications, the resident, family, or representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotics, and that this communication must be documented. For one resident with severe cognitive impairment and diagnoses of dementia and anxiety, Buspar was initiated for agitation without documented evidence that the representative was informed in advance of the medication's risks, benefits, or alternatives. The Director of Nursing confirmed the absence of such documentation in the clinical record. For another resident with cognitive impairment and diagnoses of dementia, depression, and anxiety, Seroquel was increased and later further adjusted due to behavioral escalation and agitation. Although nursing notes indicated that the representative was notified of dosage changes, there was no documented evidence that the representative was informed in advance of the risks, benefits, or treatment alternatives prior to the medication changes. The Director of Nursing confirmed that the required documentation was not present in the clinical record for these medication adjustments.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, on four separate shifts, the number of NAs scheduled and providing care was below the minimum required based on the facility's census. On the night shift of July 19, 2025, with a census of 75 residents, only 4.73 NAs were present when 5 were required. On the day shift of July 20, 2025, 7.47 NAs were present instead of the required 7.5 for 75 residents. On the evening shift of July 25, 2025, 6.97 NAs were present when 7.18 were required for 79 residents. On the day shift of July 27, 2025, 7.5 NAs were present instead of the required 8 for 80 residents. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed that the facility did not meet the required NA-to-resident staffing ratios for the days listed.
Plan Of Correction
1.) The facility is unable to correct the cited two of 21 days on the day shift, one of 21 days on the evening shift, and one of 21 days on the night shift for minimum nurse aides. There were no concerns noted due to staffing. 2.) Education will be provided to the Scheduler and Registered Nurse staff on the nurse aide ratios per shift. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the ratio. 3.) Director of Nursing or designee will audit the nurse aide staffing ratio daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting. P 5520
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to provide the required minimum hours of direct resident care per day as mandated by regulation. Specifically, a review of nursing schedules for the period between July 14 and August 3, 2025, showed that on three separate days, the facility provided less than the required 3.20 hours of direct care per resident. The actual hours provided were 3.19, 3.16, and 3.13 on the respective days. This deficiency was confirmed through staff interviews, including with the Nursing Home Administrator, who acknowledged that the facility did not meet the required daily hours of direct resident care on the identified dates.
Plan Of Correction
1.) The facility is unable to correct the cited three of 21 days that it failed to provide 3.20 hours of direct resident care for each resident. There were no concerns noted due to the direct care hours. 2.) Education will be provided to the Scheduler and Registered Nurse staff on providing 3.20 hours of direct care per resident. The facility has a labor management meeting to discuss staffing levels and needs. The facility can utilize agency and nursing management to assist with maintaining the 3.20 staffing hours per resident. 3.) Director of Nursing or designee will audit the daily hours of direct resident care for each resident daily times 5 days, weekly times 3 weeks, and monthly times 2 months. 4.) Results of the audit will be reviewed at the Quality Assurance Performance Improvement meeting.
Failure to Notify Family of Treatment Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative regarding changes in treatment and physician's orders. Specifically, for one resident, there was no documented evidence that the resident's power of attorney and interested family member was informed about new physician's orders for medications prescribed on two separate occasions. The resident, who had a diagnosis of Parkinson's disease and dementia, was moderately impaired and had an Advanced Directive in place, which required staff to keep the family informed of changes in condition. Despite the facility's policy requiring documentation of family notifications, there was no record of communication with the resident's family member about the new orders for Paxil and Anafranil. The Director of Nursing confirmed that the family member was not notified about these changes. This oversight was identified during a review of policies, clinical records, and staff interviews, highlighting a deficiency in the facility's adherence to its own documentation and notification procedures.
Plan Of Correction
1. Resident 7 remains in the facility; residents medical record was reviewed by the physician and medications remain appropriate. Family member is aware of all medication's orders. 2. The Director of Nursing/Designee will review progress notes and 24-hour report daily to ensure notification to resident's representatives are informed of any medication changes and document the notification in the medical record. 3. The Director of Nursing/Designee will educate the Registered nurses on the importance of notifying Resident's representative on any medication changes, and documenting in the medical record of any medication changes. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure notification to Resident's representative on medication changes and documentation was completed on any medication changes. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Failure to Follow Physician's Orders for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice by not following a physician's order to send the resident to the hospital. The resident, who had Crohn's disease, diabetes, and hemiplegia, was assessed by a registered nurse after a family member expressed concern that the resident might be having a stroke. Although the resident was awake, alert, and oriented, the physician was contacted and gave an order to send the resident to the hospital. However, the order was not documented in the electronic medical record, and the resident was not sent to the hospital as instructed. Interviews with staff revealed a breakdown in communication and decision-making. The Director of Nursing assessed the resident and decided not to send her to the hospital, contrary to the physician's order. The registered nurse, who was new to the facility, did not document the order because the Director of Nursing instructed otherwise. This led to a failure in executing the physician's directive, as the resident's family was informed that the resident would be sent to the hospital, but this did not occur. The incident highlights a lapse in following professional standards and physician orders, resulting in a deficiency in the care provided to the resident.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. Residents that have a change in condition will have a full assessment completed by the Registered Nurse with documentation in the medical record. The Registered Nurse will immediately call the physician informing him of the assessment and the change in condition. The Registered Nurse will then implement orders received and update the resident's representative of orders. 3. The Director of Nursing and the Registered Nurses will be educated by the facility Consultant/Designee on assessing residents with change of conditions and following the physician's orders, along with implementing physician's orders, updating resident's representatives, and completing documentation in the medical record. 4. An audit will be completed by the facility consultant/Designee on any resident with a change of condition to ensure a complete assessment was performed, with physician notification, orders implemented, complete documentation in the medical record, and resident representative updated. This audit will be completed daily 5 times a week for two weeks, then three times a week for two weeks, then weekly for two weeks, then monthly for two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Incomplete Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, leading to a deficiency. The facility's policy required documentation to be objective, complete, and accurate. However, for one resident with Crohn's disease, diabetes, and hemiplegia, there was no documented evidence of assessments conducted by a registered nurse and the Director of Nursing, nor the physician's orders to send the resident to the hospital. The resident's family expressed concerns about the resident's condition, suspecting a stroke, but the assessments and subsequent physician's orders were not recorded in the clinical record. The registered nurse involved admitted to forgetting to update the electronic medical record with her assessments and the physician's orders. The Director of Nursing also confirmed the lack of documentation. The physician indicated that he was not aware of why the resident was not sent to the hospital as ordered. The Regional Director of Clinical Services confirmed the absence of documentation and noted that the nurse had been asked to write a statement after a family grievance was raised. This lack of documentation violated the facility's policy and state regulations, resulting in a deficiency.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. DON/Designee will review progress notes and 24-hour report daily to ensure complete documentation of resident's assessments, Physician notification, and Resident representative is completed in the medical record. 3. The Director of Nursing/Designee will educate Registered nurses on the importance of documenting complete assessments, Physician notification, orders received by the Physician, and updating of resident's representatives in the medical record. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure complete assessments, Physician notification, orders received by the Physician, and resident Representatives notification is documented in the medical record. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their responsible parties, and the long-term care ombudsman regarding the reasons for hospital transfers. This deficiency was identified for seven residents who were transferred to the hospital for various medical conditions, including congestive heart failure, urinary tract infection, possible pneumonia, hypoosmolarity hyperglycemic state, lethargy and disorientation, sepsis, aspiration pneumonia, and a change in mental condition. In each case, there was no documented evidence that the required written notices were provided to the relevant parties. The deficiency was confirmed through clinical record reviews and staff interviews, specifically with the Director of Nursing, who acknowledged the lack of written notifications. The failure to provide these notifications is a violation of the residents' rights as outlined in the facility's discharge policy and resident rights regulations. The absence of documentation for these notifications indicates a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to a hospital for five residents. This deficiency was identified through a review of policies, clinical records, and staff interviews. Specifically, the nursing notes for Residents 1, 22, 27, 29, and 53 revealed that each was transferred to a hospital for various medical conditions, including congestive heart failure, hypoosmolarity hyperglycemic state, pneumonia, sepsis, and aspiration pneumonia. However, there was no documented evidence that these residents or their responsible parties were notified about the facility's bed-hold policy at the time of their transfer. The Director of Nursing confirmed during an interview that the facility did not provide the required bed-hold notice to the affected residents or their responsible parties. This oversight is a violation of the facility's responsibility to inform residents and their representatives about the duration for which their bed would be held during hospital transfers or therapeutic leaves, as required by the relevant state codes.
Inaccurate Clinical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, leading to deficiencies in documentation. For one resident, a quarterly Minimum Data Set (MDS) assessment indicated cognitive impairment and dependency on staff for daily care, with a diagnosis of depression. Physician's orders prescribed Lorazepam for anxiety, but discrepancies were found in the medication administration records. The controlled drug accountability sheet showed an incorrect remaining amount of Lorazepam, which was confirmed by the Director of Nursing upon observation. Another resident, who was cognitively intact, had a preference for showers documented in their Kardex. However, the shower log for two months showed only one documented shower out of 18 opportunities. An interview with the resident revealed they received showers twice a week, but the Director of Nursing confirmed that the shower record was not correctly entered into the charting system, preventing accurate documentation.
Failure to Timely Verify LPN Licensure
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a professional licensure check prior to hiring a licensed practical nurse. The policy, dated August 27, 2024, mandates that the facility should not employ individuals with disciplinary actions against their professional license due to findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. However, the personnel file review revealed that the licensure check for the nurse, hired on September 3, 2024, was not conducted until November 4, 2024, two months post-hire. An interview with the Director of Human Resources confirmed the delay, attributing it to an error where the check was mistakenly run on the nurse's graduate license instead of her permanent license.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as identified during a review of clinical records and staff interviews. For one resident, the MDS assessment incorrectly indicated that the resident received insulin, when in fact, the resident was administered Victoza, a non-insulin medication for diabetes. This error was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. Another resident's MDS assessment failed to record the administration of a topical antibiotic, Silvadene, which was applied twice daily during the assessment period. Additionally, a third resident's MDS assessment did not reflect the administration of insulin, despite physician orders and medication records indicating daily insulin administration. These inaccuracies were also confirmed by the RNAC, highlighting a pattern of incorrect MDS coding for these residents.
Failure to Develop Care Plans for Specific Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were developed to reflect the specific care needs of two residents. For one resident, who was cognitively intact and diagnosed with quadriplegia, the facility did not create a care plan addressing the resident's use of smokeless tobacco, despite the resident being observed with tobacco products and confirming their use. This oversight was confirmed by the Director of Nursing during an interview. Another resident, who had physician's orders for intravenous antibiotics and a PICC line, did not have a care plan developed to address the care of the PICC line and the need for antibiotics. The resident's Medication Administration Record indicated that the resident received the prescribed IV antibiotics and had the PICC line flushed and monitored as ordered. However, there was no documented evidence of a care plan for these medical needs, which was also confirmed by the Director of Nursing.
Failure in Pressure Ulcer Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper pressure ulcer care for one resident, identified as Resident 19, who had a facility-acquired Stage III pressure ulcer on the left inner heel. The resident, who was cognitively intact and diagnosed with quadriplegia, reported that his heels were rubbing against the back of his wheelchair footrest, which contributed to the development of the ulcer. Physician's orders were in place for wound care, including cleansing the wound, applying bacitracin antibiotic, collagen, and securing with a border dressing twice a day. During an observation of wound care, an LPN did not adhere to proper hand hygiene protocols. After removing the soiled dressing and cleaning the wound, the LPN failed to change gloves or perform hand hygiene before applying new dressings. This was confirmed by the LPN and the Infection Preventionist, who stated that staff are expected to change gloves and perform hand hygiene between dirty and clean tasks. This failure to follow hand hygiene protocols during wound care could potentially lead to infection, compromising the resident's health.
Failure to Implement Contracture Management for a Resident
Penalty
Summary
The facility failed to provide physician-ordered contracture management interventions for a resident, identified as Resident 65, who was cognitively impaired and diagnosed with hemiplegia/hemiparalysis. According to the resident's care plan and physician's orders, a rolled towel was to be placed in the resident's left hand at all times, except during morning and evening care, and checked every shift for placement and integrity. However, observations on November 4, 2024, revealed that the resident did not have the rolled towel in her left hand as required. This was confirmed by an interview with Nurse Aide 3, who acknowledged the absence of the towel, and the Director of Nursing, who confirmed the requirement for the towel's presence.
Failure to Assess Safety of Air Mattress for Resident
Penalty
Summary
The facility failed to complete safety assessments for a resident who used an air mattress, which is a deficiency in ensuring a safe environment free from accident hazards. The facility's policy on support surface guidelines, dated August 27, 2024, required assessments for appropriate pressure-reducing and relieving devices for residents at risk for skin breakdown. The resident in question, identified as Resident 47, was cognitively impaired, required assistance for care needs, had a Stage 3 pressure ulcer on admission, and was receiving hospice services. Observations on November 7, 2024, revealed that the resident was lying on an air mattress without documented evidence of an assessment for potential safety hazards prior to its use. The Director of Nursing confirmed that no such assessment was conducted, and the hospice staff placed the mattress without informing the facility.
Failure to Properly Administer and Monitor IV Therapy
Penalty
Summary
The facility failed to ensure the proper administration and monitoring of intravenous (IV) therapy for a resident, specifically regarding the flushing of a peripherally-inserted central catheter (PICC line) and the measurement of arm circumference. According to the facility's policy, a 10 milliliter saline flush was required before each medication infusion. Physician's orders for the resident specified that the PICC line should be flushed with 10 cubic centimeters of 0.9 percent sodium chloride every shift, before and after medication administration, and that the circumference of the upper arm at the PICC insertion site should be measured every shift and as needed. However, the Medication Administration Record (MAR) for the resident indicated that while the resident received IV meropenem from November 3 through 7, 2024, there was no documented evidence that the PICC line was flushed as required or that the arm circumference was measured on November 2, 3, and 7, 2024. An interview with the Director of Nursing confirmed the lack of documentation for these required procedures, indicating a failure to adhere to the physician's orders and facility policy.
Physician Documentation Deficiency
Penalty
Summary
The facility failed to ensure that the physician wrote a progress note for each visit for a resident, identified as Resident 15. The resident was cognitively intact and required maximum assistance from staff for care. On three separate occasions, the resident was seen by a physician due to increased behaviors and concerns from family members. However, there was no documented evidence of a provider's progress note in the clinical record for these visits. The Director of Nursing confirmed the absence of the physician's notes and mentioned that the physician was behind in his documentation, requiring the facility to contact the office for the notes.
Improper Medication Labeling for Resident
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated, as evidenced by the case of a resident who was cognitively intact and required assistance with care needs due to quadriplegia. The resident was prescribed hydrocodone-acetaminophen for pain management, with specific instructions to take the medication at bedtime and every six hours as needed for moderate pain. However, during an observation of the medication cart, it was found that the medication label had been altered with pen to include additional instructions, without the required sticker indicating a change in order. Interviews with staff, including a Licensed Practical Nurse and the Nursing Home Administrator, confirmed that the medication label should not have been altered. The facility's policy clearly stated that medication labels should not be modified by nursing personnel, and any changes in physician's directions should be indicated with a sticker, not by writing directly on the label. This failure to adhere to labeling protocols resulted in a deficiency as per the facility's policies and state regulations.
Repeated Deficiencies in MDS Accuracy, Care Plans, and Medication Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a survey ending November 7, 2024. These deficiencies included inaccuracies in Minimum Data Sets (MDS) assessments, failure to develop individualized care plans, and improper storage and labeling of medications. The facility had previously developed plans of correction for these issues following a survey ending December 7, 2023, which included implementing quality assurance systems and conducting audits. However, the current survey revealed that these measures were ineffective in addressing the recurring deficiencies. Specifically, the QAPI committee was unable to correct deficient practices related to accurate MDS assessments, as cited under F641. Additionally, the committee failed to address issues in developing comprehensive person-centered care plans, as cited under F656. Furthermore, the committee was ineffective in ensuring proper storage and labeling of medications, as cited under F761. These findings indicate that the facility's efforts to implement corrective actions and maintain compliance with regulations were insufficient, leading to repeated deficiencies in critical areas of care and service delivery.
Failure to Clarify Diabetes Diagnosis and Orders
Penalty
Summary
The facility failed to clarify a physician's orders and a diagnosis of diabetes for a resident, resulting in the resident's hospitalization. The resident, who was admitted from a hospital and was cognitively impaired and dependent on staff for care, had a documented diagnosis of diabetes mellitus and orders for insulin and blood sugar checks. However, there was no evidence in the clinical record that these orders were identified and clarified with the physician. As a result, the resident's blood glucose level reached 923 mg/dL, leading to their transfer to a local hospital with hyperglycemia and altered mental status. Interviews with various staff members, including a Licensed Practical Nurse, Registered Dietician, Medical Director, Registered Nurse Assessment Coordinator, and Registered Nurse, confirmed that the diagnosis and orders were missed. The Registered Dietician noted that the resident's diet was initially controlled for carbohydrates but was changed due to the absence of a diabetes diagnosis. The Registered Nurse Assessment Coordinator and other nursing staff acknowledged that the paperwork from the resident's Primary Care Provider, which included the diabetes diagnosis and treatment orders, should have been reviewed and incorporated into the resident's medical chart but was overlooked.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and the CDC during a COVID-19 outbreak, as well as for residents requiring Enhanced Barrier Precautions (EBP). The facility's policy, dated August 27, 2024, stated that it would follow current guidelines for managing COVID-19, including ensuring the availability of necessary supplies such as PPE. However, observations and staff interviews revealed that the facility did not consistently implement these guidelines. For instance, during a facility tour, it was observed that staff caring for residents with COVID-19 did not wear the required PPE, including N95 masks and eye shields, despite these being mandated by physician orders and facility protocols. Several residents were affected by the facility's failure to implement proper infection control measures. Resident 1, who was COVID-positive, was observed in a room with the door open, and staff were seen exiting the room without wearing the full PPE required for droplet precautions. Similarly, Resident 2, also COVID-positive, was cared for by staff who did not wear N95 masks or eye shields, even though these were available in the isolation station outside the resident's room. The Assistant Director of Nursing/Infection Preventionist confirmed that staff should have been wearing full PPE, including protective eye shields, N95 masks, gowns, and gloves, as per the facility protocol and physician's orders. The facility also failed to implement Enhanced Barrier Precautions for residents with indwelling catheters or other medical devices. For example, Resident 3, who had an indwelling catheter, was transferred by staff without gloves or gowns, and the isolation station in the resident's room was empty. Similar deficiencies were noted for Residents 5, 6, and 7, who were on EBP but did not have accessible PPE in their rooms. The Assistant Director of Nursing/Infection Preventionist acknowledged that isolation stations should be stocked with appropriate PPE and accessible for staff when caring for residents on EBP.
Failure to Provide Adequate Supervision and Care
Penalty
Summary
The facility failed to ensure that Resident 2 received adequate supervision and care as per her care plan. The quarterly Minimum Data Set (MDS) assessment indicated that Resident 2 was cognitively intact and required extensive assistance from staff for daily care. Despite this, Nurse Aide 1 provided incontinence care to Resident 2 alone, contrary to the care plan that required an extensive assist of two. Later, Resident 2 was found with a bruise on her forehead and complained of severe pain, which led to the discovery of a right hip fracture. The resident was subsequently sent to the emergency room and admitted to the hospital for surgery. Interviews with staff and the Director of Nursing confirmed that the care plan was not followed, and Resident 2 did not receive the required assistance. The resident's inability to get back into bed on her own after falling out of bed further highlighted the lack of adequate supervision. The facility's failure to adhere to the care-planned interventions resulted in significant harm to Resident 2, as evidenced by the hip fracture and subsequent hospitalization.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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