Lutheran Home At Hollidaysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Hollidaysburg, Pennsylvania.
- Location
- 916 Hickory Street, Hollidaysburg, Pennsylvania 16648
- CMS Provider Number
- 395427
- Inspections on file
- 30
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Lutheran Home At Hollidaysburg during CMS and state inspections, most recent first.
A resident admitted with a midline surgical incision closed with a VAC dressing and requiring scheduled wound checks and antibiotics did not have a baseline care plan developed to address these immediate needs. The DON confirmed the omission of wound VAC management and antibiotic use from the baseline care plan.
Staff did not follow a physician's order for a resident with dementia to receive Fiberjuice after two days without a bowel movement, as documented records showed no evidence the laxative was offered or refused during multiple periods of constipation. The DON confirmed the facility's bowel policy and physician's orders were not followed.
A resident with a Stage IV pressure ulcer did not receive updated wound care as recommended by a wound consultant. Despite specific instructions to change the treatment to a collagen sheet and Hydrogel, the previous regimen of collagen powder with bacitracin was continued, and the new recommendations were not implemented. The DON confirmed the lapse in following the wound consultant's orders.
The facility did not complete required annual performance evaluations for two nurse aides, as confirmed by a review of employment and evaluation records and an interview with the administrator.
A resident with atrial fibrillation and an arterial aneurysm continued to receive enoxaparin after their INR reached the therapeutic range, contrary to physician orders. Facility records and staff interviews confirmed that the medication should have been discontinued, but it was administered for two additional days, resulting in a significant medication error.
Surveyors observed that raw ground meat was thawing on a tray above a container of cooked ground beef in the walk-in cooler, contrary to the facility's dietary policy requiring separation of raw and cooked foods to prevent cross-contamination. Staff confirmed the improper storage arrangement.
Three direct care staff members, including two nurse aides and an LPN, did not receive required training on effective communication, as confirmed by personnel file reviews and interviews with facility leadership. This failure occurred despite job descriptions and facility policy mandating completion of such training.
Two direct care staff members, a nurse aide and an LPN, did not complete required annual education on resident rights, as confirmed by personnel file reviews and facility leadership. This failure occurred despite job descriptions and facility policy mandating such training.
Two direct care staff members, including a nurse aide and an LPN, did not receive required training on abuse, neglect, and exploitation as mandated by facility policy and state regulations. Personnel file reviews and staff interviews confirmed the absence of this education, despite annual training requirements.
Three direct care staff, including two nurse aides and an LPN, did not receive mandatory Quality Assurance and Performance Improvement (QAPI) training as required by facility policy and state regulations. Personnel files and interviews confirmed the absence of QAPI education for these staff members.
Two direct care staff members, a nursing assistant and an LPN, did not receive required infection control training as mandated by facility policy and regulatory standards. Personnel file reviews and administrative interviews confirmed the absence of documented infection control education for these staff, despite annual training requirements.
Two direct care staff members, a nurse aide and an LPN, did not receive required compliance and ethics training as indicated by their job descriptions and confirmed by personnel file reviews and administrative interviews.
A nurse aide did not complete the required 12 hours of annual training as mandated by facility policy and state regulations. Review of personnel records and staff interviews confirmed the deficiency.
Three direct care staff, including two nurse aides and an LPN, did not receive required behavioral health training as indicated by their job descriptions and personnel files. Facility documents and staff interviews confirmed the absence of this training, which is mandated by state regulations and the facility's own assessment.
The facility failed to provide written notices for hospital transfers for several residents, including those with dementia and diabetes, after incidents such as falls and medical evaluations. The Director of Nursing was unaware of the requirement to issue such notices.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident's care plan included outdated orders for an AFO brace and a hand splint, which were not being used, while another resident's care plan inaccurately included orders for fingerstick blood sugars. Interviews confirmed that these care plans were not revised to reflect current care needs.
A facility failed to provide adequate supervision and maintain a safe environment for residents, leading to repeated unsupervised departures and falls. A resident with cognitive impairment frequently left the second floor unsupervised without proper investigation or analysis. Another resident experienced a fall without documented safety checks, and a third resident had multiple falls without new interventions. The facility's lack of documentation and failure to implement new interventions contributed to the deficiencies.
The facility failed to maintain complete and accurate clinical records for two residents. One resident's MAR lacked documentation of Humalog insulin administered with meals, while another resident's MAR did not include blood sugar testing results before meals and at bedtime. The DON confirmed these documentation omissions, violating Pennsylvania Code regulations for clinical records and nursing services.
The facility's QAPI committee failed to address recurring deficiencies, including issues with care plan development, timely revisions, resident safety, medication storage, and medical record accuracy. Despite previous corrective plans, these deficiencies persisted, indicating ineffective implementation of corrective actions.
The facility failed to ensure that residents and/or their representatives were informed and assisted in developing advance directives, as required by policy. This deficiency was identified for three residents, including one who was cognitively intact and two who were cognitively impaired. There was no documented evidence in their clinical records of being informed about their rights or offered assistance, as confirmed by interviews with the DON and Social Service Director.
A resident with cognitive impairment and a diagnosis of dementia experienced multiple episodes of nausea and vomiting, yet the facility failed to develop a care plan addressing the risk of dehydration and the use of Zofran. Despite documented instances of emesis, no care plan was created, as confirmed by the DON.
A cognitively impaired resident requiring assistance with ambulation did not consistently receive the prescribed ambulation program. Documentation revealed multiple instances where the program was not completed as planned, which was confirmed by the DON.
A facility failed to follow physician's orders for a diabetic resident, as blood sugar checks were not documented before meals on specific dates, which were necessary for administering sliding scale insulin. The DON confirmed the lack of documentation, highlighting a lapse in adhering to prescribed care.
A resident with cognitive impairment and peripheral vascular disease did not receive physician-ordered treatments for pressure ulcers on multiple occasions. The facility's records showed missed treatments in July and August, and the DON confirmed the lack of documentation for these treatments.
A resident with dementia and obstructive uropathy had an indwelling urinary catheter, which was observed with the drainage tubing and collection bag in contact with the floor, contrary to the care plan. Both a nurse aide and the DON confirmed that the catheter should not be in contact with the floor.
A facility failed to provide a resident with the recommended nutritional interventions, as the resident did not receive enriched pudding during lunch despite significant weight loss and a dietitian's recommendation. This oversight was confirmed by both a nurse aide and the DON.
A nurse aide worked with an expired certification, which the facility failed to monitor and renew as required. The lapse was discovered during a review, revealing a deficiency in the facility's process for ensuring current certifications.
A facility failed to document the administration of controlled medications for a resident receiving opioids for chronic pain. Despite signing out doses of hydrocodone-acetaminophen on multiple occasions, there was no evidence in the resident's clinical records that these medications were administered. The Director of Nursing confirmed the lack of documentation, violating the facility's policy and state regulations.
A medication room on the second floor was found open and unattended, with an unlocked medication cart inside. Facility policy requires all drugs and biologicals to be securely stored and locked when not in use. An LPN confirmed the room should have been locked, and the DON acknowledged the lapse in security.
A facility failed to obtain a PT/INR test for a resident on anticoagulant therapy as ordered by the physician. The resident, who was cognitively impaired and had a history of deep vein thrombosis and pulmonary embolism, was supposed to have the test on a specific date, but it was not conducted. This oversight was confirmed by the DON.
A nurse aide failed to follow proper infection control techniques during incontinent care for a resident with Multiple Sclerosis, who was dependent on staff for toileting hygiene and had an indwelling catheter. The aide did not remove contaminated gloves or wash hands before handling the resident's sling and catheter tubing, contrary to the facility's hand washing policy. This lapse was confirmed by both the aide and the DON.
A resident with cognitive impairment and requiring full assistance suffered a fractured arm due to neglect during a transfer. Staff failed to use a gait belt, opting for a bear hug method, which led to improper handling and injury. The incident was determined to be caused by neglect as proper transfer procedures were not followed.
Failure to Develop Baseline Care Plan for Immediate Post-Surgical Needs
Penalty
Summary
The facility failed to develop a baseline care plan that addressed the immediate care needs of a newly admitted resident within 48 hours of admission. The resident, who was alert and oriented upon arrival, had a midline surgical incision closed with a VAC dressing and required specific wound care and antibiotic therapy as ordered by the physician. The orders included checking the wound VAC settings and connections every four hours and administering two antibiotics, Amoxicillin and Clarithromycin, twice daily for surgical aftercare. Despite these documented care needs, there was no evidence that a baseline care plan was created to address the resident's wound VAC management or antibiotic administration. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan did not include the necessary information for the resident's wound care and antibiotic use.
Failure to Follow Physician's Orders for Bowel Protocol
Penalty
Summary
Facility staff failed to follow physician's orders regarding a bowel protocol for a resident with dementia who was always incontinent of bowel and required assistance with daily care needs. The resident had a physician's order to receive 5 ounces of Fiberjuice as needed for constipation if no bowel movement occurred by the second day. Bowel movement records showed that the resident did not have a bowel movement for several consecutive days on two separate occasions. There was no documented evidence that Fiberjuice was offered to or refused by the resident after the second day without a bowel movement, as required by the physician's order. An interview with the Director of Nursing confirmed that staff did not adhere to the facility's bowel policy or the physician's orders for the resident on the specified dates. The deficiency was identified through a review of facility policy, clinical records, and staff interviews, and was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Implement Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards of practice for a resident with a Stage IV pressure ulcer. The resident, who was cognitively intact, had a documented history of a pressure ulcer on the left lateral malleolus, with wound clinic notes specifying changes in wound care treatment. On two separate occasions, the wound clinic recommended discontinuing the previous treatment of collagen powder mixed with bacitracin and instead applying a collagen sheet and Hydrogel to the wound base, including areas of undermining, every other day and as needed. Despite these recommendations, a review of the resident's Treatment Administration Record for the relevant month showed that the resident continued to receive the previous treatment and did not receive the Hydrogel as advised by the wound clinic. The DON confirmed that the updated wound care recommendations from the wound consultant were not followed. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for failing to ensure that wound consultant recommendations were reviewed with the attending physician and implemented as directed.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two of three nurse aides reviewed. Specifically, one nurse aide hired in May 2000 and another hired in June 2022 did not have documented evidence of annual performance evaluations being completed as required by facility policy. This was confirmed through a review of the nurse aides' hire dates and performance review records, as well as an interview with the Nursing Home Administrator, who acknowledged that the required evaluations had not been conducted for these staff members.
Failure to Discontinue Anticoagulant as Ordered After INR Reached Therapeutic Range
Penalty
Summary
A review of facility policy, clinical records, and staff interviews revealed that the facility failed to administer medication as ordered by the physician, resulting in a significant medication error for one resident. The facility's policy required medications to be administered according to prescriber orders, including any specified time frames. A resident with diagnoses of atrial fibrillation and an arterial aneurysm was discharged from the hospital with an order to receive 50 mg of enoxaparin daily until the resident's INR reached a therapeutic range. Laboratory results showed that the resident's INR was within the therapeutic range on September 17, 2025. Despite the INR being in the therapeutic range, the Medication Administration Record indicated that enoxaparin was still administered on September 18 and 19, contrary to the physician's order. The DON confirmed that the medication should have been discontinued once the INR was therapeutic, but it was not, resulting in the resident receiving unnecessary doses. This failure to discontinue the medication as ordered constituted a significant medication error.
Improper Food Storage Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for food service safety. During an observation in the kitchen, a roll of frozen raw ground meat was found thawing on a tray in the walk-in cooler, and directly below it was a container labeled as cooked ground beef for chili. According to the facility's dietary policy, raw meat should be stored separately from ready-to-eat and prepared foods to prevent cross-contamination. Staff interviews confirmed that the raw meat should have been placed on the bottom shelf, below the cooked food, and that the current arrangement did not comply with the facility's policy.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on effective communication to direct care staff members, as evidenced by a review of job descriptions, facility documents, and staff interviews. The Nursing Assistant and Licensed Practical Nurse job descriptions both specify the need to complete all assigned training and education as required by law and regulation. However, personnel file reviews for three staff members—a nurse aide hired in 2014, a nurse aide hired in 2000, and an LPN hired in 2020—showed no record of education or training related to effective communication. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary education on effective communication, despite the facility's requirement for annual training. This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Resident Rights training to two of five direct care staff reviewed. Review of the Nursing Assistant and Licensed Practical Nurse job descriptions indicated that staff are required to complete all assigned training, including that mandated by law and regulation. Personnel file reviews showed that a nurse aide hired in 2000 and an LPN hired in 2020 did not have any documented education regarding resident rights for the current year. The Human Resources Director confirmed that annual training is required, and the Nursing Home Administrator verified that these two staff members had not completed the necessary education on resident rights as required by facility policy and state regulations.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation to two of five direct care staff reviewed. Review of the Nursing Assistant and Licensed Practical Nurse job descriptions indicated that staff are required to complete all assigned training and education as mandated by law and regulation. However, personnel file reviews revealed that a nurse aide hired in 2000 and an LPN hired in 2020 did not have any documented education or training on abuse, neglect, and exploitation in their continuing education transcripts. Interviews with the Human Resources Director confirmed that annual training is required for staff, and the Nursing Home Administrator verified that the two staff members had not completed the necessary education on abuse, neglect, and exploitation. This deficiency was identified through review of facility documents, job descriptions, and staff interviews, and is a violation of 28 Pa. Code: 201.14(a) and 201.20(a) regarding staff development and licensee responsibility.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to three of five direct care staff reviewed. Review of job descriptions for nursing assistants and licensed practical nurses indicated that staff are required to complete all assigned training and education as required by law and regulation. However, personnel files and continuing education transcripts for two nurse aides and one LPN showed no evidence of QAPI training since their hire dates. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary QAPI education. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development, as the facility did not ensure that all direct care staff received required QAPI training.
Failure to Provide Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to two of five direct care staff reviewed, as required by its infection prevention and control program. Review of the job descriptions for both nursing assistants and LPNs indicated that staff are required to complete all assigned training, including that mandated by law or regulation. Personnel file reviews revealed that a nursing assistant hired in 2000 and an LPN hired in 2020 did not have any documented education or training regarding infection control. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary infection control education, despite annual training requirements.
Failure to Provide Compliance and Ethics Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required compliance and ethics training to two of five direct care staff reviewed. Review of the job descriptions for both Nursing Assistants and Licensed Practical Nurses indicated that staff are required to complete all assigned training and education as mandated by law and regulation. Personnel file reviews revealed that a nurse aide hired in 2000 and an LPN hired in 2020 did not have any documented education regarding compliance and ethics. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary compliance and ethics education, as required by facility policy and state regulations.
Failure to Provide Required Annual Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that one of five direct care staff reviewed, a nurse aide, completed the required minimum of 12 hours of annual training. Review of the nurse aide's personnel file and continuing education transcript showed that she did not meet the annual training requirement. The facility's job descriptions for both nursing assistants and LPNs specify the obligation to complete all assigned and legally required training. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that staff are required to complete annual training and that the nurse aide in question did not fulfill this requirement.
Failure to Provide Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required behavioral health training to three of five direct care staff reviewed. Review of job descriptions for nursing assistants and LPNs indicated that staff are expected to complete all training and education as assigned and as required by law and regulations. Personnel files and continuing education transcripts for two nurse aides and one LPN showed no evidence of behavioral health education. Interviews with the Human Resources Director confirmed that annual training is required for staff, and the Nursing Home Administrator confirmed that the identified staff members had not completed the necessary behavioral health education. This deficiency was identified through review of facility documents, job descriptions, personnel files, and staff interviews. The lack of behavioral health training was found to be inconsistent with the requirements outlined in the facility assessment and state regulations. No information was provided regarding the impact on residents or specific incidents resulting from this deficiency.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide clearly documented reasons for facility-initiated transfers to the hospital to the resident and resident's representative in a language and manner that could be easily understood. This deficiency was identified for five residents during the review. For Resident 8, who was cognitively intact and had a diagnosis of dementia, there was no documented evidence of a written notice of transfer to the hospital after a fall and complaint of hip pain. Similarly, Resident 18 was transferred to the hospital without a Notice of Transfer letter being issued. Resident 35, who was cognitively impaired and dependent for care needs, was transferred for intravenous antibiotics without a written notice provided to the resident's representative. Resident 42, who was cognitively intact and had diabetes, was transferred to the emergency room due to dizziness and nausea without documented evidence of a written notice to the resident or representative. Lastly, Resident 47, who had dementia, was transferred after a fall and laceration without a written notice. An interview with the Director of Nursing revealed a lack of awareness regarding the requirement to send a written notice upon transfer, resulting in the deficiency.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to deficiencies in their care. For Resident 15, the care plan, dated July 29, 2019, indicated the use of an AFO brace and a resting hand splint due to right-sided hemiparesis and hemiplegia. However, there was no documented evidence that these devices were being used. Interviews revealed that the resident had refused the hand splint, and the order was discontinued, but the care plan was not updated to reflect this change. Additionally, the physical therapist was unaware of any need for an AFO brace, indicating a lack of communication and documentation updates. For Resident 29, the care plan dated June 23, 2023, included orders for fingerstick blood sugars, but there was no evidence in the clinical record of such orders being in place. An interview with the Director of Nursing confirmed that the care plan was not revised to reflect the discontinuation of fingerstick blood sugars. These oversights demonstrate a failure to maintain accurate and current care plans, which are essential for providing appropriate care to residents.
Inadequate Supervision and Safety Checks in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for three residents. Resident 40, who was moderately cognitively impaired with a history of wandering, repeatedly left the second floor unsupervised. Despite the facility's policy requiring analysis of elopements, no investigation or analysis was conducted for Resident 40's repeated unsupervised departures. The Director of Nursing confirmed that these incidents were not viewed as elopements, as the resident remained within the facility due to locked outside doors, although there was potential for the resident to be unsafe. Resident 4, who was cognitively impaired and dependent for transfers, experienced a fall while attempting to transfer himself to the bathroom. Although hourly safety checks were initiated following the fall, there was no documented evidence that these checks were completed at specific times on August 27, 2024. The Director of Nursing confirmed the lapse in safety checks. Similarly, Resident 29, who was cognitively impaired and had a history of falls, experienced multiple falls without new interventions being developed. There was also a lack of documentation for hourly safety checks on several occasions following her falls. The facility's failure to conduct thorough investigations and analyses of incidents, as well as lapses in completing safety checks, contributed to the deficiencies identified. The lack of documentation and failure to implement new interventions after repeated falls and elopements indicate a systemic issue in ensuring resident safety and compliance with facility policies.
Incomplete Clinical Records for Insulin Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, which was identified during a review of policies, clinical records, and staff interviews. For one resident, the facility's medication administration policy required that medications be documented by the licensed team member responsible for the medication cart. However, the Medication Administration Record (MAR) for this resident did not document the amount of Humalog insulin administered with meals according to the sliding scale, despite physician's orders specifying this requirement. The Director of Nursing confirmed the absence of documentation for the insulin administered. For another resident, the clinical record review revealed a lack of documentation for blood sugar testing results before meals and at bedtime, as required by physician's orders. The MAR did not include blood sugar results before supper on one day and before breakfast, lunch, and supper on subsequent days. The Director of Nursing confirmed that these results were not documented in the clinical record, although they should have been. These deficiencies were noted under the Pennsylvania Code regulations for clinical records and nursing services.
Repeated Deficiencies in Care Planning and Safety
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in the current survey ending September 13, 2024. These deficiencies included the failure to develop and implement comprehensive care plans, revise care plans timely, protect residents from accidents and hazards, securely store medications, and maintain complete and accurate medical records. These issues were also noted in the previous survey ending October 12, 2023, indicating a lack of successful implementation of corrective actions by the QAPI committee. The facility had previously developed plans of correction that involved completing audits and reporting the results to the QAPI committee for review. However, the current survey findings revealed that these plans were not successfully implemented, as evidenced by repeated citations under F656, F657, F689, F761, and F842. The deficiencies highlight the facility's ongoing struggle to maintain compliance with nursing home regulations, as the same issues persisted despite the proposed corrective measures.
Failure to Ensure Residents' Rights to Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives, as required by their policy. This deficiency was identified for three residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated January 11, 2024, mandates that upon admission, residents should be provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive. If a resident has not established an advance directive, the staff is required to offer assistance in doing so and document the offer and the resident's decision in the medical record. For Residents 22, 27, and 35, there was no documented evidence in their clinical records that they were informed of their rights to develop advance directives or that they were provided the opportunity and assistance to formulate one. Resident 22 was cognitively intact, while Residents 27 and 35 were cognitively impaired, with Resident 35 rarely able to understand or be understood. Interviews with the Director of Nursing and the Social Service Director confirmed the lack of documentation and indicated that if residents chose not to formulate an advance directive, the facility did not pursue it further or document the decision.
Failure to Develop Care Plan for Resident's Nausea and Vomiting
Penalty
Summary
The facility failed to develop a care plan that addressed a resident's specific care needs, particularly concerning the risk of dehydration due to episodes of nausea and vomiting. The facility's policy mandates that care plans be individualized and revised as necessary when significant changes occur. However, despite multiple documented instances of the resident experiencing emesis, there was no evidence of a care plan being developed to manage the resident's risk for dehydration or to incorporate the treatment with Zofran, a medication prescribed for nausea and vomiting. The resident in question was cognitively impaired, with a diagnosis of dementia, and required assistance with some care needs. The resident had a physician's order for Zofran to be administered as needed for nausea and vomiting. Despite several nurse's notes documenting episodes of emesis, the facility did not create a care plan to address these issues. The Director of Nursing confirmed that a care plan should have been developed to address the resident's risk for dehydration related to these episodes.
Failure to Consistently Implement Ambulation Program
Penalty
Summary
The facility failed to ensure that ambulation programs to maintain or improve physical abilities were provided as ordered and/or care planned for a resident. The resident, who was cognitively impaired but usually understood and able to understand others, required partial/moderate assistance to walk various distances. An annual Minimum Data Set (MDS) assessment indicated the resident's need for an ambulation program, which was initiated with the potential for decline in abilities. The care plan specified that staff should offer assistance with the program and incorporate it into daily activities to improve participation. However, a review of the resident's clinical records and daily charting documentation revealed that the ambulation program was not consistently completed as planned. There was no documented evidence of the program being completed on several specific dates in both the morning and evening sessions. This lack of documentation was confirmed by the Director of Nursing during an interview, indicating a failure to adhere to the prescribed ambulation program for the resident.
Failure to Follow Physician's Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that physician's orders were followed for a resident with diabetes. The resident was admitted with a diagnosis that included diabetes, and the physician's orders required blood sugar checks before meals and at bedtime, with sliding scale insulin administration based on the blood sugar levels. However, the Medication Administration Record (MAR) for September 2024 showed no documented evidence of blood sugar checks before breakfast on September 9 and 10, and before supper on September 10. An interview with the Director of Nursing confirmed the absence of documentation for these required checks, indicating a failure to adhere to the physician's orders.
Failure to Administer Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to provide pressure ulcer treatments as ordered by the physician for a resident, leading to a deficiency in care. The resident, who was cognitively impaired and dependent on assistance for transfers, had two unstageable pressure ulcers on their heels and a diagnosis of peripheral vascular disease. The care plan required specific treatments for these ulcers, including cleansing, applying skin prep, xeroform, and other dressings. However, the Treatment Administration Record (TAR) for July 2024 showed that the resident did not receive the prescribed treatment on July 19, 2024. Further deficiencies were noted in August 2024, where the resident's TAR indicated missed treatments on August 2, 5, and 14, 2024, despite physician orders for specific wound care involving cleansing and applying silver alginate. An interview with the Director of Nursing confirmed the absence of documented evidence that these treatments were administered on the specified dates, highlighting a failure in adhering to the prescribed care plan.
Failure to Prevent UTI in Resident with Catheter
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had diagnoses including dementia and obstructive uropathy, was observed on two occasions with her catheter drainage tubing and collection bag in direct contact with the floor. This was contrary to the care plan, which specified that the catheter tubing and collection bag should be kept off the floor. Both a nurse aide and the Director of Nursing confirmed that the catheter tubing and bag should not be in contact with the floor.
Failure to Provide Recommended Nutritional Interventions
Penalty
Summary
The facility failed to provide the necessary nutritional interventions for a resident, as recommended by the dietitian. Resident 13, who was cognitively intact and required supervision with eating, experienced significant weight loss. The dietitian recommended adding four ounces of magic cup daily with dinner and four ounces of enriched pudding daily with lunch. However, during an observation of the resident's lunch meal, it was noted that the resident did not receive the enriched pudding, despite it being indicated on her meal ticket. This was confirmed by a nurse aide and the Director of Nursing, who acknowledged that the resident should have received the enriched pudding as per the meal ticket instructions.
Expired Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide maintained an active certification on the nurse aide registry, which is a requirement for performing the functions of the position. The personnel file for Nurse Aide 3 revealed that her certification had expired, and the facility was unaware of this lapse until it was discovered during a review. Nurse Aide 3 continued to work in the facility with an expired certification for a period of time. The Nursing Home Administrator confirmed that Nurse Aide 3's certification had expired and should have been renewed before she continued working. This oversight indicates a lapse in the facility's process for monitoring and ensuring that all nurse aides maintain current certifications as required by their job descriptions.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for one resident, identified as Resident 3. The deficiency was identified through a review of policies, clinical records, and staff interviews. The facility's medication administration policy, dated January 11, 2024, required that medications be poured, administered, and documented by the licensed team member responsible for the specific medication cart. However, discrepancies were found in the controlled drug record for Resident 3, who was cognitively impaired and received an opioid for chronic arm pain. The controlled drug record showed that doses of hydrocodone-acetaminophen were signed out for administration on several dates in June, July, and August 2024, but there was no documented evidence in the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, that these doses were actually administered. An interview with the Director of Nursing on September 12, 2024, confirmed the lack of documentation for the administration of the signed-out doses of hydrocodone-acetaminophen to Resident 3. This failure to document the administration of controlled medications is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 211.9(a)(1) Pharmacy Services and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. The absence of proper documentation raises concerns about the accountability and management of controlled substances within the facility.
Medication Storage Security Lapse
Penalty
Summary
The facility failed to properly secure and store medications in one of its medication rooms, specifically the front hall on the second floor. The facility's policy, dated January 11, 2024, mandates that all drugs and biologicals be stored securely and locked when not in use. On September 9, 2024, at 10:25 a.m., it was observed that the door to the medication room was left open and unattended, with the medication cart inside the room also unlocked. This was confirmed by an interview with a Licensed Practical Nurse who acknowledged that the room should have been locked. Additionally, the Director of Nursing confirmed that both the medication cart and room should have been secured when not attended by staff.
Failure to Obtain Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to ensure that laboratory specimens were obtained as ordered by the physician for one resident. The resident, who was cognitively impaired and receiving an anticoagulant, had a care plan indicating a history of deep vein thrombosis and pulmonary embolism. The physician's orders required the resident to receive 6.5 mg of Coumadin daily and to have a PT/INR test on a specific date. However, the clinical record review revealed that the staff did not obtain the PT/INR test as ordered. This was confirmed by an interview with the Director of Nursing, who acknowledged that the test was not conducted as required.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection control techniques during incontinent care for a resident. The facility's policy on hand washing, dated January 11, 2024, emphasizes that hand washing is crucial in preventing infections and should be performed after resident care and any potentially contaminating contact. Gloves are to be used when in contact with bodily fluids, but they are not a substitute for hand washing. The resident involved was cognitively intact, dependent on staff for toileting hygiene, had an indwelling catheter, and was frequently incontinent of bowel. Diagnoses included Multiple Sclerosis, which affects muscle coordination and bladder control. On August 11, 2024, observations revealed that a nurse aide, while providing incontinent care to the resident, failed to remove contaminated gloves and wash her hands before handling the resident's sling, catheter drainage bag tubing, and disposable wipes. This was confirmed during an interview with the nurse aide, who acknowledged the lapse in protocol. The Director of Nursing also confirmed that the nurse aide should have performed hand hygiene immediately after providing care and before touching the resident's personal belongings and catheter tubing.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure that residents were free from neglect, resulting in a fractured arm for a resident. The resident, who was cognitively impaired and required assistance for all care, was involved in an incident where staff did not properly transfer her, leading to her injury. The resident was sometimes understood and could sometimes understand, with diagnoses including dementia, and required assistance for all care. On the day of the incident, two nurse aides attempted to transfer the resident onto the toilet. During the process, they did not use a gait belt and instead used a bear hug method to assist the resident. When attempting to use a sit-to-stand lift to help the resident off the toilet, she complained of pain in her right arm and was unable to use it. The resident was noted to have a hematoma and complained of pain, which led to further assessment and the discovery of a fracture. The investigation revealed that the nurse aides involved did not follow proper transfer procedures, as they failed to use a gait belt. The resident's injury was determined to be caused by neglect due to improper handling during the transfer process. The facility's investigation concluded that the cause of the injury was neglect, as the staff did not adhere to the established protocols for safe resident handling.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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