Kadima Rehabilitation & Nursing At Greenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Pennsylvania.
- Location
- 110 Fredonia Road, Greenville, Pennsylvania 16125
- CMS Provider Number
- 395158
- Inspections on file
- 26
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Kadima Rehabilitation & Nursing At Greenville during CMS and state inspections, most recent first.
The facility failed to administer insulin according to manufacturer guidelines and appropriate meal timing for three residents with diabetes. In one case, a resident with multiple comorbidities received insulin lispro well before receiving a meal tray and subsequently experienced a hypoglycemic episode requiring Glucagon. In two other cases, residents received Novolin R or insulin lispro based on sliding scale orders tied to meals, but insulin was administered about an hour or more before meals were actually served. An LPN reported routinely giving insulin one hour before meals, and the NHA acknowledged that insulin should be administered within a short time frame before or after meals per manufacturer instructions.
The facility failed to provide sufficient nursing staff and timely call light response, resulting in multiple residents waiting 30 minutes to several hours for assistance despite policies requiring prompt response and frequent checks on those unable to call for help. Resident council minutes and grievance logs documented ongoing concerns about delayed call bell response, especially on afternoon and night shifts. Several residents reported they no longer used their call bells because no one responded, with one resident instead propelling in a wheelchair to the nurses’ station for help. In one case, a resident with a Foley catheter who had activated the call bell for bleeding waited so long that they called 911 and were later found by the DON to have bleeding with large blood clots before being transferred to the hospital.
The facility failed to maintain a functional call bell system on one hall, where the installed system relied on a small digital display at the nurse's station that only briefly beeped, lacked overhead lights, and could show only a limited number of active calls. Staff had to go to the nurse's station and cross-reference a list to determine which room was calling and had no way to know if multiple calls were active without checking the display. Testing showed that one room’s call bell did not register on the digital unit on two separate days. A resident and family member reported that call bells had not been working adequately for months and resorted to using a tap bell and a cow bell so staff could hear them, while another resident’s representative reported that the call bell was not working for that resident.
A resident with paranoid schizophrenia, diabetes, and HTN eloped from the facility and was later identified as being at risk for elopement through an Elopement Risk Assessment. Despite facility policies requiring individualized care plans and specific revisions following any successful elopement, the resident’s comprehensive care plan did not include interventions for elopement risk or the actual elopement, a deficiency confirmed by the RN Assessment Coordinator during surveyor interview.
A resident with paranoid schizophrenia, diabetes, and hypertension eloped from the facility, but the clinical record contained no documentation of the elopement, the resident’s safe return, or notification of the physician or resident representative, contrary to the facility’s documentation policy. Review of the record also showed that elopement risk assessments were not completed on a quarterly basis as required, and interviews with the DON, RNAC, and NHA revealed uncertainty about the required frequency of these assessments and confirmed the absence of timely documentation.
A resident with an indwelling urinary catheter and multiple diagnoses, including bronchitis, hypertension, and diabetes, was receiving antibiotics for a UTI when surveyors observed the resident’s catheter drainage bag lying uncovered on the floor under the bed. Facility policy required catheter bags to be covered, properly positioned, and kept off the floor. An LPN and the Nursing Home Administrator both confirmed that the bag should have been covered and not in contact with an unclean surface, demonstrating a failure to provide essential catheter care and infection prevention measures.
A resident reported that their mail was being opened by facility staff before delivery, which was confirmed by the Nursing Home Administrator. This action violated the resident's right to privacy in written communications as outlined in facility policy.
The facility did not clarify a physician's order for surgical dressing care for a resident, resulting in the dressing remaining in place beyond the ordered removal date. Additionally, a physician's order for a UA C&S for another resident was not carried out in a timely manner, with the urine sample collected several days after the order was given.
A resident with end stage renal disease did not have required dialysis communication forms completed for several treatments, and multiple prescribed medications were not administered on dialysis days as ordered, with no evidence that the physician was notified of these omissions. Facility leadership confirmed these documentation and medication administration failures.
A multi-dose vial of Tirzepatide was found in a medication storage room without labeling to indicate the resident's name, date opened, or use by date. Facility policy requires such labeling for all medications in use. Both a registered nurse and nursing leadership confirmed the vial was in use and not properly labeled.
A resident's personal refrigerator was found without a thermometer and lacked any evidence of temperature monitoring or documentation, despite facility policy requiring regular checks and recording on the EMAR. Interviews with the ADON and an LPN confirmed the monitoring process was not followed, and the administrator acknowledged the deficiency.
A resident with dementia and age-related disability was found to have an acute hip fracture of unknown origin. The facility did not report this serious injury to the State Survey Agency within the required timeframe, as confirmed by the DON, despite regulations mandating immediate reporting of such incidents.
The facility did not meet the required NA staffing ratios on multiple occasions, failing to provide adequate care for its residents. The deficiency was confirmed through a review of staffing documents and staff interviews, revealing consistent shortages in NA coverage across day, evening, and overnight shifts.
The facility did not meet the required LPN staffing ratios on four occasions, failing to provide the mandated number of LPNs per resident during the day shift. The Nursing Home Administrator confirmed these staffing shortages.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. A review of staffing documents revealed that the care hours were below the mandated minimum on several days, with the lowest being 2.72 hours per patient per day. This deficiency was confirmed by the Nursing Home Administrator.
Failure to Administer Insulin in Accordance With Manufacturer Guidelines and Meal Timing
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin in accordance with manufacturer guidelines and good nursing principles for three residents with diabetes. Facility policy required medications to be administered as prescribed and in accordance with good nursing practices. Manufacturer instructions for Humalog (insulin lispro) specified administration within 15 minutes before or immediately after a meal, and for Novolin Regular within 30 minutes before or immediately after a meal. For one resident with diabetes, CHF, and COPD, the record showed a blood sugar of 336 at 5:00 p.m. on 2/26/26, and 10 units of insulin lispro were administered per sliding scale by an LPN. At approximately 5:45 p.m., the resident had not yet received a meal tray and subsequently experienced a hypoglycemic episode requiring administration of Glucagon at 5:50 p.m. and again at 6:10 p.m. Another resident with diabetes, altered mental status, hypertension, and coronary artery disease had an order for Novolin R sliding scale with meals. On 3/05/26, the blood sugar at 11:30 a.m. was 315, and 5 units of Novolin R were administered by an LPN, but the lunch meal was not delivered until 1:25 p.m. That same day, the resident’s evening blood sugar at 4:00 p.m. was 276, and 4 units of Novolin R were given, while dinner was not served until 6:50 p.m. A third resident with diabetes, COPD, gastrointestinal hemorrhage, and hypovolemic shock had an order for insulin lispro sliding scale with meals; on 3/05/26, a blood sugar of 236 at 4:00 p.m. led to administration of 3 units of insulin lispro, while dinner was not served until 6:49 p.m. During interview, the LPN who administered the insulin to the latter two residents stated that insulin was typically given one hour before meals, and the Nursing Home Administrator confirmed insulin should be administered within a short time span before or after meals per manufacturer guidelines.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff and timely call light response to meet residents’ needs, as required by facility policy and job descriptions. The facility’s call light policy and CNA/RN job descriptions state that staff must respond to call lights and resident needs promptly, check frequently on residents unable to call for help, and that all employees must answer call lights regardless of department. Resident Council minutes over a three‑month period documented repeated concerns that call bells were not answered as timely as residents preferred, particularly on afternoon and midnight shifts. Grievance logs from the same period showed multiple complaints of residents waiting from 30 minutes up to two to three hours for assistance after activating their call bells. Interviews conducted with multiple residents and a resident representative confirmed ongoing delays of 30 minutes or more in call bell response, with some residents reporting they had stopped using their call bells because staff did not respond. One resident reported waiting two hours for assistance on a specific evening. Another resident stated they had to self‑propel in a wheelchair to the nurses’ station to obtain help. During an observation, a resident with a Foley catheter was found in bed, upset and calling out for a nurse, and reported having activated the call bell approximately 1 hour and 45 minutes earlier due to bleeding; this resident ultimately called 911 and was found by the DON to have bleeding with large blood clots before being transferred to the hospital. The DON acknowledged that all residents should have their call bells answered in a timely manner and that waiting 30 minutes or more for staff response was unacceptable.
Failure to Maintain Functional Call Bell System on 500 Hall
Penalty
Summary
The facility failed to ensure that the call bell system was adequately working on one of six halls (500 hall/Unit 1), as required by its policy that mandates a call bell or alternative device be within reach of each resident in their room, toilet, or bathing area, with staff alerted by visual and audible signals. The installed call system used an oblong digital unit at the nurse's station that displayed two-digit numbers corresponding to room and bathroom call bells and emitted three beeps when the first call was activated. However, the system did not provide ongoing audible alerts, did not illuminate overhead lights down the hall or outside resident rooms, and could only display up to eight active calls at a time. When more than one call bell was activated, subsequent calls displaced earlier numbers on the display without additional sound or visual alerts, and any calls beyond eight were not displayed until earlier calls were cleared. Staff reported that to identify which resident was calling, they had to go to the nurse's station, view the two-digit number on the unit, and then cross-reference a separate list to match the number to a resident room. On the 500 hall, testing and observation revealed that call bell number 47, associated with a specific room, did not display on the digital unit when activated on two consecutive days, a problem confirmed by a CNA and the DON. A resident and family member reported that call bells had not been working adequately for several months, and that the resident had been provided a tap bell by the facility while the daughter purchased a cow bell so staff could hear it. Another resident representative reported that the call bell was not working for that resident. Staff interviews confirmed they had no way to know if more than one call bell was activated unless they physically went to the nurse's station to look at the digital unit, and that the system’s limited display and lack of continuous audible or visible alerts impeded their awareness of active calls. These observations and interviews demonstrated that the call system on the 500 hall was not reliably functioning as intended by facility policy.
Failure to Care Plan for Resident Elopement Risk After Actual Elopement
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, individualized plan of care addressing elopement risk for one resident. Facility policies on MDS/RAI/care planning, Resident Elopement, and Resident Elopement Follow-Up Procedure required that each resident have a written, individualized care plan and that any resident with a successful elopement be reassessed, with additional interventions identified and incorporated into the plan of care, including modifications for increased elopement risk and monitoring as needed. Review of the resident’s clinical record showed that an Elopement Risk Assessment was completed on 2/26/26 and identified the resident as being at risk for elopement. The resident, admitted on 11/7/14, had diagnoses including paranoid schizophrenia, diabetes, and high blood pressure. Information submitted by the facility showed that the resident eloped from the facility on 2/26/26. Despite this event and the completed Elopement Risk Assessment, review of the comprehensive plan of care did not reveal any care plan addressing the resident’s risk for elopement or the actual elopement. During an interview on 3/6/26, the RN Assessment Coordinator confirmed that the resident’s comprehensive plan of care did not include a care plan for elopement risk or the actual elopement, in contrast to the facility’s stated policies.
Failure to Document Elopement Incident and Complete Quarterly Elopement Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and timely documentation related to an elopement incident and to follow its own policies for elopement risk assessment. Facility policy on documentation required nursing documentation to be concise, clear, pertinent, accurate, and to communicate the resident’s status and provide an accurate accounting of care and monitoring. A separate policy on resident elopement required that residents be reassessed at least quarterly for elopement risk. One resident, admitted with diagnoses including paranoid schizophrenia, diabetes, and hypertension, eloped from the facility on 2/26/26. However, the clinical record progress notes contained no documentation of the elopement event, the resident’s safe return, or notification of the physician and/or resident representative. Review of the resident’s elopement risk assessments showed they were completed on 1/14/25, 4/17/25, and 2/26/26, with no evidence that these assessments were performed on a quarterly basis as required by policy. During interviews, the DON confirmed that the clinical record lacked documentation of the elopement, the resident’s return, and required notifications, and stated that a risk management entry and/or progress note should have been completed. The DON and RNAC reported they were unsure how often elopement risk assessments were to be completed, and the NHA was also unable to verify the required frequency at the time of interview. The NHA confirmed that the resident’s record lacked evidence of quarterly elopement risk assessments, resulting in noncompliance with state regulations governing medical records and nursing services.
Failure to Maintain Indwelling Catheter Bag Off Floor and Covered
Penalty
Summary
The facility failed to follow its own catheter care policy for a resident with an indwelling urinary catheter. The policy dated 11/2024 required that residents with indwelling catheters receive appropriate care, including maintaining catheter drainage bags off the floor, ensuring the catheter is anchored, and keeping the drainage bag covered and properly positioned. Resident R1, admitted on 12/24/25 with diagnoses including bronchitis, hypertension, and diabetes, was identified in the clinical record as currently receiving a seven-day course of antibiotics for a urinary tract infection. During an observation on 1/27/26 at 11:44 a.m., Resident R1’s urinary catheter drainage bag was seen lying uncovered on the floor under the bed, without any covering over the bag. In an interview at 11:50 a.m., an LPN (Employee E3) confirmed that the catheter bag was on the floor and acknowledged that the bag should be covered and maintained off the floor for infection control. In a separate interview at 12:40 p.m., the Nursing Home Administrator also confirmed that the catheter bag should be covered and not touch an unclean surface due to the risk of infection. These observations and interviews established that the facility did not ensure essential catheter care and infection prevention measures for this resident.
Failure to Ensure Resident Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened, as required by facility policy and resident rights regulations. Review of the facility's policies confirmed that residents have the right to privacy in written communications, including the right to send and promptly receive unopened mail. During an interview, a cognitively intact resident reported that the facility was opening their mail prior to delivery, which the resident identified as an invasion of privacy. The Nursing Home Administrator confirmed that some of the resident's mail was being opened before being given to the resident.
Failure to Clarify and Follow Physician Orders for Wound Care and Urine Testing
Penalty
Summary
The facility failed to clarify a physician's order regarding surgical dressing care for one resident. The resident was admitted with an order stating that an Aquacel dressing should have been removed on a specific date and the incision left open to air. However, upon arrival at the facility several days later, the Aquacel dressing was still intact, indicating that the order was not followed or clarified as required by facility policy. The Director of Nursing confirmed that the conflicting orders should have been clarified with the physician. Additionally, the facility did not follow a physician's order to obtain a urinalysis and culture & sensitivity (UA C&S) in a timely manner for another resident. The order was written for the test to be performed due to symptoms of dysuria and frequency, but the urine sample was not collected until several days after the order was given. The clinical record lacked evidence that the test was collected promptly, as required by the physician's instructions.
Failure to Document Dialysis Communication and Administer Medications as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate records of dialysis communication and did not ensure that medications were administered according to physician's orders for a resident receiving dialysis. A review of the Memorandum of Agreement between the facility and the dialysis provider required the exchange of relevant information regarding the resident's condition and treatment, and facility policy mandated documentation of dialysis care in the medical record. However, the clinical record for a resident with diagnoses including diabetes, end stage renal disease, and respiratory failure lacked evidence of completed dialysis communication forms for multiple scheduled dialysis treatments. Additionally, the resident's care plan included an intervention to ensure medication administration times did not conflict with the dialysis schedule. Despite this, the Medication Administration Records showed that several prescribed medications were not administered on dialysis days, with the reason documented as Leave of Absence. There was no documentation that the physician was notified about the missed or altered medication administration times on these days. Interviews with facility leadership confirmed the absence of required dialysis communication documentation and the failure to administer medications as ordered, as well as the lack of physician notification regarding these omissions. These findings were cited under multiple state regulations related to licensee responsibility, management, medical records, and nursing services.
Unlabeled Multi-Dose Tirzepatide Vial Found in Medication Room
Penalty
Summary
Surveyors found that a multi-dose vial of Tirzepatide, a prescription medication used for type 2 diabetes and weight loss, was stored in the Unit One medication room without being labeled with the resident's name, the date it was opened, or the date it should be used by. Facility policy requires that all medications be stored in a safe, secure, and orderly manner, and that drug containers must have complete and legible labels, including the resident's name and relevant dates. During the observation, a registered nurse confirmed that the vial was opened and in use but lacked the required labeling. The Director of Nursing and Assistant Director of Nursing also confirmed that the vial was missing this information and acknowledged that it should have been properly labeled.
Failure to Monitor Personal Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperature of a resident's personal refrigerator as required by facility policy. The policy stated that personal refrigerators must include a thermometer and be subject to the same regular temperature monitoring as other facility refrigerators, with documentation of temperatures. Observation revealed that a resident had a personal refrigerator in their room without a thermometer and without any visible temperature log sheet. Further inspection of the refrigerator confirmed the absence of a thermometer. Interviews with the Assistant Director of Nursing and an LPN confirmed that temperatures for personal refrigerators were supposed to be documented on the resident's electronic medication administration record (EMAR) every shift. However, review of the resident's EMAR showed no evidence that temperatures had been monitored or recorded. The Nursing Home Administrator also confirmed that the refrigerator lacked a thermometer and that there was no evidence of temperature monitoring for the resident's personal refrigerator.
Failure to Timely Report Serious Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an incident involving a resident who sustained a serious bodily injury of unknown origin. According to facility documentation and staff interviews, a resident with dementia and age-related disability was found to have an acute fracture of the left proximal femur, as confirmed by x-ray. The injury was determined to be of unknown origin, and there was no documentation of any recent falls. The facility's policy and federal regulations require that such incidents, especially those involving serious bodily injury of unknown source, be reported immediately, but not later than two hours after discovery. Despite these requirements, the incident was not reported to the State Survey Agency until several days after the resident's injury was identified. The Director of Nursing confirmed during an interview that the reporting did not occur within the required timeframe. The delay in reporting was in direct violation of both facility policy and federal regulations regarding the timely notification of authorities in cases of suspected abuse, neglect, or injuries of unknown source.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios across multiple shifts over several weeks. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day, one NA per 11 residents during the evening, and one NA per 15 residents overnight. This deficiency was observed on numerous dates between November 2024 and January 2025, as evidenced by a review of the facility's nursing staffing documents and confirmed through staff interviews. The staffing shortages were significant, with the facility often having fewer NAs than required for the number of residents present. For instance, on several occasions, the facility had a census of over 100 residents but failed to provide the necessary number of NAs to meet the regulatory requirements. The Nursing Home Administrator acknowledged these staffing deficiencies during an interview, confirming the facility's failure to comply with the mandated NA ratios on the specified dates and shifts.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Nursing Aide ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Nurses aides, call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing(DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Nursing Aid Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews NA ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement(QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet NA needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on the day shift on four specific dates. The regulation mandates a minimum of one LPN per 25 residents during the day. However, on 11/22/24, with a census of 105 residents, only 4.00 LPNs worked when 4.20 were required. On 12/10/24, with 103 residents, 4.00 LPNs worked instead of the required 4.12. On 1/06/25, with 101 residents, 4.00 LPNs worked when 4.04 were needed, and on the same day with 102 residents, 4.00 LPNs worked when 4.06 were required. The Nursing Home Administrator confirmed these staffing shortages during an interview on 1/15/25.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in Licensed Practical Nurse (LPN) ratios not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on staffing ratios for Licensed Professional Nurses (LPN), call off policies for all staff members of the facility, and attendance expectations for all staff members of the facility to be completed by Director of nursing (DON)/designee and human resources. Key staff educated are Nurse Aides, Licenses Professional Nurses, and Registered Nurses. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. LPN Hours will be monitored Monday through Friday by DON/Designee as well as NHA/designee at end of stand up meeting. On weekends Charge Nurse, scheduler, and Manager on Duty reviews LPN ratios. If there are staff needs charge nurse and manager on duty contacts facility and agency staffing for available shifts. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/Director of nursing. Weekends this is completed by charge nurse & manager on duty. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Monthly Staffing audits to be completed at monthly Quality Assurance performance improvement (QAPI) meeting. Audits will consist of totals of ratios and deployment zones. This will include unit, days of any missed ratios if any, and corrective actions pursued or utilized. Audits consist of results of daily activity of deployment sheet and working hours compared to what is within regulation. Daily audits completed at end of stand up meeting utilizing DON/designee and NHA/designee with immediate action taken place in order fill open position. Action steps being noted including any redeployment of staffing to meet LPN needs. Contacts to be noted by facility for open positions. Daily x4 weeks, weekly x2 weeks, monthly thereafter. QAPI plan has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on twelve out of fourteen days reviewed. The deficiency was identified through a review of the facility's nursing staffing documents and confirmed during an interview with the Nursing Home Administrator. Specific dates were noted where the hours of direct resident care fell below the required minimum, with the lowest being 2.72 hours per patient per day. This shortfall in staffing levels was acknowledged by the Nursing Home Administrator, indicating a consistent failure to meet the mandated care hours over the specified periods.
Plan Of Correction
Facility will continue to discourage unexpected call offs which may result in PPD not being met. This will be done through in-services and staffing outreach conducted by Director of Nursing/Designee and Human Resources. Educations completed on Staffing ratios and PPD, call off policies, and attendance expectations to be completed by DON/designee and human resources. Facility will utilize agency personnel when the facility has available nursing hours if in house staff do not fill available hours. Staffing will be monitored daily by DON/Designee as well as NHA at end of stand up meeting. Appropriate staffing for open positions to be contacted on an as need basis to fill any holes in the schedule by nursing scheduler/nursing supervisor/DON. Nursing Schedule posts all nursing staff regular schedules on a continual basis with a working schedule at least 1 weeks notice if there are any changes. Program has been developed with nursing for staff to opt to switch shifts with one another in order in the event that a staff member needs time off on short notice, allowing the facility to be more adjustable to staff needs. Nursing scheduler educating nursing staff on shift switch program. Staffing audits to be completed at monthly QAPI meeting. Audits will consist of PPD and deployment zones for the day which may indicate patterns for intervention. This will include unit, days of any missed PPD if any, and corrective actions pursued or utilized at the time of the event. QAPI has active performance improvement plan for staff retention and recruitment which includes effective measures to hire and retain staff members entering the facility. Facility continues to investigate local education centers and community events for recruitment opportunities.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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