Schuylkill Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pottsville, Pennsylvania.
- Location
- 1000 Schuylkill Manor Rd, Pottsville, Pennsylvania 17901
- CMS Provider Number
- 395831
- Inspections on file
- 34
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Schuylkill Center during CMS and state inspections, most recent first.
Surveyors observed extensive unsanitary conditions in the kitchen, including black substances on ceiling tiles and floors, rusted shelves, unmanaged condensation, leaking pipes, contaminated food storage areas, and dirty equipment. The ventilation system failed to control moisture for over a month, and no temporary measures were taken to address these issues.
Meals were not served at the scheduled times on two nursing units, with residents waiting in the dining rooms well past the planned lunch hour. Staff and resident interviews confirmed that late meal service was a recurring issue, and observations showed that lunch service began nearly an hour after the scheduled time on both units.
A resident with respiratory failure and a feeding tube experienced a significant decline, including low oxygen saturation, increased oxygen needs, choking, and fever. Despite these changes, staff did not notify the physician or have the resident assessed until the following day, contrary to facility policy and nursing standards.
Staff did not follow physician orders for insulin administration timing for two residents with diabetes, administering short-acting insulin well before meals were served. Additionally, staff failed to notify a physician when a resident's blood glucose readings exceeded 400 mg/dL, as required by orders. The DON confirmed these lapses in care.
A resident with a history of COPD, stroke, and one-sided weakness, who required total assistance for toileting and hygiene, experienced a fall when staff failed to follow protocol requiring two staff members during use of a sit to stand lift. During incontinent care, only one staff member remained in the room, resulting in the resident sliding out of the lift and falling. The DON confirmed that established safety procedures were not followed.
A resident with hemiparesis and unsteadiness, requiring two-person assistance and a mechanical lift for transfers and toileting, activated the call bell for bathroom help. Despite notifying staff, assistance was not provided for 39 minutes, resulting in a failure to accommodate the resident's needs in a timely manner.
Staff failed to follow physician orders for two residents, including not notifying a physician when a resident's blood glucose exceeded 400 mg/dL and not administering clonidine when another resident's blood pressure was above ordered thresholds. The DON confirmed these lapses in care.
A review of staffing schedules showed that the facility did not meet the required minimum nurse aide-to-resident ratios on multiple day, evening, and night shifts during a 21-day period, resulting in noncompliance with mandated staffing requirements.
A review of nursing schedules revealed that the facility did not meet required LPN-to-resident staffing ratios on multiple occasions, including day, evening, and night shifts. The deficiency was identified through examination of time schedules over a three-week period.
A review of nursing schedules showed that, on multiple days, the facility did not provide the required minimum of 3.2 direct care hours per resident in a 24-hour period. On 12 out of 21 days reviewed, the total direct care hours per resident were below the mandated level, indicating insufficient nursing staff coverage during those times.
Schuylkill Center did not provide an updated all-hazards risk assessment as required, with both the Administrator and Maintenance Director confirming the absence of this documentation during survey review.
The facility did not maintain required documentation for semi-annual fire alarm system inspections and failed to provide evidence that deficiencies with supervisory and tamper flow switches were resolved, as confirmed by facility leadership.
The facility did not maintain required documentation for quarterly inspections of its wet and dry sprinkler systems, failed to correct previously identified issues with sprinkler head orientation, and did not resolve alarm deficiencies related to Supervisory and Tamper Flow Switches. Additionally, several sprinkler heads in the laundry area were found covered with debris, with all findings confirmed by facility leadership.
A door to the Service Hall Food Storage Room was found dragging on the floor and failed to self-close and latch, compromising the smoke resistance required for hazardous area enclosures. This issue was confirmed by facility leadership during the survey.
Surveyors found that the facility's life safety drawings were missing required details such as room capacities, door swings, and fire/smoke wall boundaries. The facility also lacked documentation of annual carbon monoxide alarm testing, confirmation that alarms could be heard by staff, and verification of evacuation and alarm protocols, as required by state law.
Surveyors found that the facility did not have documentation of required owner's quick checks for the kitchen's fixed chemical fire suppression system and could not provide records of semi-annual cleaning for the kitchen exhaust ductwork. These deficiencies were confirmed by the Administrator and Maintenance Director.
Surveyors identified multiple failures in food storage and sanitation, including undated and improperly stored food items, presence of insects in food preparation areas, and a dietary employee serving food with uncovered facial hair and without changing gloves or performing hand hygiene between tasks. These actions were not in accordance with facility policy or food safety standards.
Staff failed to monitor and serve hot beverages at a safe temperature, with coffee being served as high as 181°F and not retested before reaching residents. A resident with cognitive and physical impairments, who required supervision during meals, was left unsupervised and sustained a significant abdominal burn after spilling hot coffee. Staff interviews confirmed that beverage temperatures were not routinely checked, and residents reported that coffee was often too hot to drink.
Surveyors observed that the facility did not maintain a medication error rate below 5%, with four errors out of 26 opportunities. Errors included an LPN failing to instruct a resident to rinse after inhaler use, not cleaning insulin pen tops before use, and another LPN crushing an extended-release acetaminophen tablet before administration, all contrary to orders and manufacturer instructions.
The facility did not deliver meals at scheduled times on three nursing units, with several residents reporting frequent delays that affected their routines and activities. Observations confirmed that meal deliveries were late by up to 49 minutes, and a resident was seen without a meal tray during the delay. The DON confirmed that meal service should have followed the established schedule.
Surveyors observed that trash and refuse, including used gloves, plastic debris, condiment packets, a waffle, animal droppings, and soiled briefs with cloths, were not properly disposed of and were found on the ground and sticking out from under a dumpster.
The facility did not post up-to-date nurse staffing information, as the information displayed in the lobby was outdated and confirmed to be incorrect by the Nursing Home Administrator.
The facility did not meet the required NA to resident ratios over a 21-day period, with deficiencies noted across day, evening, and night shifts. The day shift was understaffed on seven days, the evening shift on eleven days, and the night shift on two days, as revealed by a review of nursing schedules.
The facility did not meet the required LPN to resident ratios on several occasions. Specifically, the day shift ratio of one LPN per 25 residents was not met on four days, and the evening shift ratio of one LPN per 30 residents was not met on three days, as identified in a review of nursing schedules over a 21-day period.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on 16 out of 21 days. Nursing schedules showed care hours per resident ranging from 2.52 to 3.16, below the regulatory standard.
A resident with cognitive impairment and mobility dependence, who was at risk for pressure sores, was left on a bedpan for several hours without timely assistance. This resulted in the development of a stage 1 pressure sore matching the bedpan's shape, after a staff member failed to follow the care plan for regular repositioning.
The facility did not meet the required NA to resident ratios for 19 out of 21 days reviewed. The deficiency involved failing to maintain the minimum NA to resident ratio during day, evening, and night shifts on multiple days. This was confirmed by the DON.
The facility did not meet the required LPN to resident ratios over a 21-day period, failing to provide adequate staffing during day, evening, and night shifts on multiple occasions. The Director of Nursing confirmed the deficiency.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for 20 out of 21 days reviewed. The nursing schedules showed consistent shortfalls, with the lowest being 2.08 hours per resident. The DON confirmed the deficiency.
The facility failed to provide scheduled showers for five residents who required assistance with ADLs. Despite being scheduled for showers on specific days, there was no documentation of showers being provided, and residents confirmed they had not refused them. The facility's Administrator and DON acknowledged the oversight.
The facility did not provide scheduled showers to two residents, impacting their right to a dignified existence. One resident with anxiety and insomnia missed two out of eight scheduled showers, while another with hemiplegia and diabetes missed five out of nine. Both required staff assistance and preferred showers twice a week.
The facility failed to follow physician's orders for two residents with hypertension and atrial fibrillation. Medications were administered despite specific parameters to withhold them based on systolic blood pressure and heart rate. The DON confirmed the lack of documentation for withholding medications when required.
The facility failed to maintain sanitary conditions in the kitchen, with several food items improperly labeled or stored beyond recommended usage periods. Observations included undated or outdated items in refrigerators, ice buildup on food in the freezer, and missing floor tiles in the kitchen area.
The facility did not follow the pre-approved menus on the C Unit, as identified through observations, documentation, and a test tray audit. Residents had consistently complained about small portion sizes from December 2023 to April 2024. On a specific day, the menu required three ounces of glazed pork and four ounces of vegetables, but only two ounces of pork and three ounces of vegetables were served. The Dietary Manager confirmed the error.
The facility failed to provide dignified dining assistance to two residents, one with Alzheimer's and another with arthritis and vision problems. Both residents were observed eating with their hands without staff intervention, despite care plans indicating the need for assistance. This failure violated residents' rights to dignity and appropriate nursing services.
The facility did not develop comprehensive care plans for two residents. A resident with cognitive impairment and hearing loss lacked interventions for communication issues in their care plan. Another resident with dementia and chronic kidney disease had no interventions for urinary incontinence. The DON confirmed these omissions, violating nursing service regulations.
The facility failed to provide food at appetizing temperatures on the C Unit. Residents reported cold lunches and tough pork, with a pattern of complaints noted from previous months. A test tray audit confirmed that food was served at inadequate temperatures, and observations of residents eating lunch corroborated these findings.
Two residents with specific medical conditions requiring adaptive eating equipment were not provided with the necessary Kennedy cups as per their care plans. Despite recommendations from the dietitian, observations showed that the residents were served drinks in regular cups without lids or straws, which was confirmed by the DON.
Widespread Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean and unsafe food storage, preparation, and serving areas. Surveyors noted a black substance on ceiling tiles above the dish machine and kitchen doorway, rusted shelves storing clean dishes, and condensation accumulating on ceiling bars above food preparation areas. The ventilation system was not adequately managing condensation, resulting in moisture accumulation for over a month without any remedial or temporary measures taken. Ceiling tiles above the steam table were chipped and discolored, and there were holes in ceiling tiles above the beverage station, where open carafes of beverages were stored underneath. Additional issues included a leaking pipe under the sink, wet coffee filters, liquid accumulation on the floor, peeling wall molding with black substance, and stains from dripping moisture. Further observations included a black substance on the floor around the ice machine, dried substances on the outside of a garbage can stored next to clean dish racks, and debris inside the hot top used for meal service. In dry storage, food items and packaging debris were found under shelves, along with open containers of food on storage shelves. The freezer had significant ice accumulation on various surfaces and food items. The food preparation area contained debris, an open bottle of vegetable oil, and an open box of parchment paper contaminated with debris. A black substance surrounded a wall fan, and the slicer cart was dirty and uncovered, with food debris present. Additional food and debris were found behind and under storage surfaces, and there was liquid on the floor in front of hot holding equipment. A piece of drainpipe and dirty floor were also noted under the food preparation counter sink.
Failure to Serve Meals at Scheduled Times on Two Nursing Units
Penalty
Summary
The facility failed to serve meals at regularly scheduled times in accordance with resident needs and preferences on two of four nursing units, specifically the Homestead and B-wing units. Review of the facility's meal schedule indicated that lunch was scheduled for 12:00 p.m. on both units. However, observations on December 11, 2025, revealed that residents were seated in the dining rooms at the scheduled time, but meals had not been served. On the B-wing unit, residents reported that meals were often late, and the lunch meal did not arrive until 12:52 p.m., with service beginning at 12:58 p.m. On the Homestead unit, an LPN confirmed that lunch typically arrived between 12:00 p.m. and 1:00 p.m., and on this occasion, the meal arrived at 12:57 p.m. with service starting at 1:05 p.m., over an hour after the scheduled time. These findings were based on facility documentation, staff and resident interviews, and direct observation.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition as required by facility policy. The resident in question had multiple diagnoses, including dysphagia, anxiety, respiratory failure, and required a feeding tube. A physician's order specified oxygen administration at two liters per minute via nasal cannula every shift. On one occasion, staff observed the resident with a dangerously low oxygen saturation of 49% while on supplemental oxygen, necessitating the use of a rebreather mask at ten liters per minute. Later, the resident experienced choking on saliva, required suctioning and a breathing treatment, and developed a fever of 101.1°F. The oxygen flow was increased to five liters per minute, exceeding the physician's order, to maintain oxygen saturation at 90%. Despite these significant changes in the resident's condition, there was no evidence that the physician or any practitioner was notified or assessed the resident until the following day. Staff interviews confirmed that the physician should have been notified at the time the change in condition was identified, but documentation and interviews revealed this did not occur. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) for nursing services.
Failure to Follow Physician Orders for Insulin Administration and Blood Glucose Notification
Penalty
Summary
The facility failed to implement physician orders for three residents with diabetes and related conditions. For one resident with diabetes, chronic kidney disease, and heart failure, staff administered a short-acting insulin injection (Admelog) at 12:15 p.m., but the resident did not receive her meal until 1:15 p.m., an hour after the insulin was given, contrary to manufacturer instructions and physician orders that specified insulin should be administered 15 minutes before or immediately after a meal. Another resident with diabetes, diabetic retinopathy, chronic kidney disease, and dementia was administered Humalog insulin at 11:15 a.m., but did not receive her meal until 1:24 p.m., over two hours later, also in violation of the prescribed timing for insulin administration. Staff interviews confirmed that insulin was not administered in accordance with physician orders and manufacturer guidelines. Additionally, for a third resident with hyperglycemia, dementia, diabetes, and chronic kidney disease, staff failed to notify the physician when blood glucose readings exceeded 400 mg/dL, as required by a physician's order. Blood sugar logs showed readings of 424 mg/dL and 416 mg/dL on two separate occasions, with no evidence of physician notification. The Director of Nursing confirmed that there was no documentation of physician notification for these elevated blood glucose levels.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide adequate supervision and follow established safety procedures during the use of a mechanical sit to stand lift for a resident with a history of COPD, stroke, and one-sided weakness. The resident was dependent on staff for toileting and hygiene and was identified as being at risk for falls, with care plans specifying the use of a sit to stand lift with two staff members for all transfers. On the date of the incident, staff were providing incontinent care and used the lift, but one staff member left the room, leaving the resident with only one staff member present. This deviation from protocol resulted in the resident sliding out of the lift and falling. The DON confirmed that staff did not adhere to facility safety procedures by both using the lift during cleaning and by leaving the resident unattended by the required number of staff.
Delayed Response to Call Bell for Resident Requiring Assistance
Penalty
Summary
A deficiency occurred when a resident with hemiparesis and unsteadiness, who required assistance from two staff members and a mechanical lift for transfers and toileting, did not receive timely assistance after activating the call bell for help to use the bathroom. The resident's care plan specified that staff were to provide assistance with toileting as needed and that the resident had been educated to call staff for help. On the day of the incident, the resident activated the call bell at 11:09 a.m. and informed staff of the need for assistance. A staff member acknowledged the request and stated they would return with another staff member, but no one returned promptly. The call bell remained activated for 39 minutes, and the resident continued to wait for assistance, reiterating that no staff had returned during this period. Staff did not return to the resident's room to provide the required assistance until 11:48 a.m. The Director of Nursing later confirmed that staff were expected to respond to call bells in a more timely manner. This delay in response resulted in the facility failing to provide a reasonable accommodation of the resident's needs as required.
Plan Of Correction
The facility will continue to provide a reasonable accommodation of needs. 1. R3, upon notification, was followed up with by the unit manager and has no further concerns. 2. Call bell response time was addressed at resident council on 8/5/2025. Concerns were addressed, and call bell response time audits will be initiated. 3. The Director of Nursing or designee will provide nursing staff education on call bell response times and addressing the needs of residents. 4. A call bell audit will be completed by the Director of Nursing or designee for 20 residents weekly for 4 weeks, with results communicated to the QAPI Committee. 5. Date of compliance is 08/20/2025. The facility will continue to provide a reasonable accommodation of needs. 1. R3, upon notification, was followed up with by the unit manager and has no further concerns. 2. Call bell response time was addressed at resident council on 8/5/2025. Concerns were addressed, and call bell response time audits will be initiated. 3. The Director of Nursing or designee will provide nursing staff education on call bell response times and addressing the needs of residents. 4. A call bell audit will be completed by the Director of Nursing or designee for 20 residents weekly for 4 weeks, with results communicated to the QAPI Committee. 5. Date of compliance is 08/20/2025.
Failure to Follow Physician Orders for Blood Glucose and Blood Pressure Management
Penalty
Summary
The facility failed to implement physician orders for two residents. For one resident with diabetes mellitus, staff were required to obtain glucometer readings and notify the physician if blood glucose levels reached or exceeded 400 mg/dL, as per the physician's order. On one occasion, the resident's blood glucose was recorded at 438 mg/dL, but there was no evidence that the physician was notified of this elevated result, contrary to the order. For another resident with hypertension, physician orders directed staff to check blood pressure twice daily and administer clonidine as needed if the systolic blood pressure exceeded 160 mm Hg or the diastolic exceeded 100 mm Hg. On two separate occasions, the resident's blood pressure readings met or exceeded these thresholds, but there was no evidence that clonidine was administered as ordered. The Director of Nursing confirmed that in both cases, staff did not follow the physician's orders regarding medication administration and notification.
Plan Of Correction
NotSpecified The facility will continue to implement physicians' orders. 1. R1 no longer resides at the facility. R2's MD and RP were notified of elevated BP on 7/11/2025 and 7/26/2025, and PRN not administered. No negative outcome to R2 noted. 2. Facility audit completed for like residents with sliding scale and blood pressure orders with parameters. 3. The Director of Nursing or designee will provide licensed nurses education on ensuring orders with parameters are being followed and have proper prompts, and notifying MD and RP. 4. The Director of Nursing/designee will audit cardiac medications and sliding scale orders weekly for 4 weeks. Results of audits will be reported to the QAPI Committee. 5. Date of compliance is 08/20/2025.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
A review of nursing schedules for a 21-day period revealed that the facility did not meet the required minimum nurse aide (NA) to resident ratios on several occasions. Specifically, the facility failed to provide at least one NA for every ten residents during the day shift on two days, one NA for every eleven residents during the evening shift on six days, and one NA for every fifteen residents during the night shift on one day. These findings were based on direct examination of the facility's staffing schedules and reflect noncompliance with the mandated staffing levels for nurse aides during the specified shifts and dates. No information regarding the medical history or condition of individual residents was provided in the report.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 08/20/2025. P 5520
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to comply with state regulations requiring minimum LPN-to-resident staffing ratios during specific shifts. A review of nursing schedules from July 14, 2025, through August 3, 2025, showed that the facility did not meet the required ratio of one LPN per 25 residents during the day shift on four separate days, and did not meet the ratio of one LPN per 30 residents during the evening shift on one day. Additionally, the facility failed to meet the minimum ratio of one LPN per 40 residents during the night shift on one day. These deficiencies were identified through a review of the facility's nursing time schedules for the specified period. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
P 5530 1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has scheduled recruitment appearances at LPN schools to recruit new staff, and introduced employee referral program. Recruitment outreach via social media and messaging to area LPNs encourage joining our facility staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 08/20/2025.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that on 12 separate days, the total direct care hours per resident fell below the mandated threshold. Specific days were identified where the care hours ranged from 2.72 to 3.16 per resident, indicating that the facility did not consistently staff enough nursing personnel to meet the required standard during the reviewed timeframe. No information regarding the medical history or condition of individual residents at the time of the deficiency was provided in the report.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility recently completed nurse aide training classes to fill vacant nurse aide positions. LPN school recruitment efforts continue with presentation scheduled this fall to graduating LPNs. Continue with collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 08/20/2025.
Failure to Maintain Updated All-Hazards Risk Assessment
Penalty
Summary
Schuylkill Center was found to be noncompliant with federal emergency preparedness requirements following an Emergency Preparedness Survey. The facility failed to provide an updated all-hazards risk assessment, which is required to be reviewed and updated at least annually. During document review, surveyors were unable to obtain documentation of a current all-hazards risk assessment for the facility. At the time of the exit conference, both the Administrator and Maintenance Director confirmed that they could not provide an updated all-hazards risk assessment. This deficiency affected the entire facility component and was based solely on the lack of required documentation. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Plan Of Correction
The facility will continue to provide an updated all hazards risk assessment for the facility. 1. The facility utilizes the Kaiser Permanente Hazard Vulnerability Assessment Tool, which was last updated at the time of annual manual approvals on 1/17/2025. This tool will be updated at least quarterly, or as needed, and used to identify and update the facility's Emergency Preparedness plan. The Hazards Risk Assessment will be filed in all copies of the Emergency Preparedness plan. 2. The Maintenance Director or designee will audit the Hazard Vulnerability Assessment tool at least semi-annually to confirm that updates are filed in all copies of the Emergency Preparedness plan. Results of the audits will be reviewed at least semi-annually with the QAPI Committee, including any revisions required to the Facility Emergency Preparedness plan as a result of the assessment. Date of Correction is 7/30/2025.
Failure to Maintain and Document Fire Alarm System Testing
Penalty
Summary
The facility failed to provide required testing and maintenance for its fire alarm system on a semi-annual basis. Documentation review revealed that there was no evidence of semi-annual visual inspections or testing of the fire alarm system within the previous twelve months. Additionally, the facility lacked documentation for the semi-annual inspection and testing of both wet and dry system valve supervisory switches and pressure switch waterflow alarms. These deficiencies were confirmed during interviews with the Administrator and Maintenance Director. Further review of service call reports indicated that certain supervisory and tamper flow switches on the wet system failed to register as a priority fire alarm. There was no documentation provided to show that this issue had been resolved. The absence of records verifying the correction of these alarm deficiencies was also confirmed by facility leadership during the exit conference.
Plan Of Correction
The facility will provide testing and maintenance to the fire alarm system on a semi-annual basis as required. A copy of the January 2025 inspection report was acquired and placed in the facility life safety book. Documentation of repairs will also be placed in the life safety book. At least semi-annually, the Maintenance Director or NHA will audit the life safety book to confirm that all reports have been filed in the book. Results of the audits will be reported to the QAPI Committee. Date of correction is 7/30/2025.
Failure to Maintain and Document Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to provide documentation verifying that quarterly inspections of both wet and dry automatic sprinkler systems were conducted for the second and third quarters of 2024. During document review, it was found that records confirming these inspections were missing, and this was confirmed by the Administrator and Maintenance Director. Additionally, two sprinkler heads located behind the dryers in the laundry area were found to be incorrectly oriented above the ceiling tile, an issue previously identified in a quarterly report but not corrected. The facility also lacked documentation showing that deficiencies related to the wet system's Supervisory Flow Switches and Tamper Flow Switches, which failed to register as a priority on the fire alarm panel, had been resolved. Further observations revealed that multiple sprinkler heads in the laundry room were covered with debris, specifically four in the clean area, two in the soiled area, and two in the personal area. These findings were confirmed by the Administrator and Maintenance Director during the exit conference. The report does not mention any residents or specific patient involvement, nor does it provide information about their medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility will ensure the wet/dry sprinkler systems are subject to inspection and/or testing at least quarterly. The two sprinkler heads noted during the survey behind the dryers in Laundry will be modified for correct orientation. The 1 and 2 Wet System Supervisory Flow Switches will be repaired to resolve the issue. The sprinkler head identified as covered with debris will be cleaned. The sprinkler inspection reports will be maintained in the facility Life Safety book, including repair reports. 2. The Maintenance Director or designee will perform at least quarterly audits of the facility Life Safety book to confirm that the sprinkler system has been inspected and tested, and that deficiencies have been repaired. Audit results will be reported to the QAPI Committee. Date of compliance is 7/30/2025.
Failure of Hazardous Area Door to Self-Close and Latch
Penalty
Summary
Surveyors observed that the door to the Service Hall Food Storage Room did not self-close and latch within the door frame as required for hazardous area enclosures. The door was found dragging on the floor, which prevented it from closing and latching properly. This deficiency was confirmed during an interview with the Administrator and Maintenance Director, who acknowledged that the door failed to self-close and positively latch, thereby compromising the smoke resistance of the hazardous area enclosure in one of seven smoke compartments.
Plan Of Correction
1. The door to the Service Hall food storage room will be modified and/or replaced to allow self-closure and latching within the door frame, and repair the drag on the floor. A time-limited waiver will be requested if door replacement is required. 2. A time-limited waiver will be requested until 1/5/2026 for the door replacement in the Service Hall food storage room. Maintenance will complete monthly door checks to verify ongoing compliance with regulatory requirements, and report any negative findings to the QAPI Committee monthly. Date of compliance is 7/30/2025.
Deficiencies in Life Safety Documentation and Carbon Monoxide Alarm Compliance
Penalty
Summary
Surveyors identified several deficiencies related to the facility's compliance with Life Safety Code (LSC) and state regulations. During document review and interviews, it was found that the facility's life safety drawings were incomplete, lacking critical information such as resident room capacities, door swings, fire wall and smoke wall boundaries, hazardous areas, and compartment designations. This was confirmed by the Administrator and Maintenance Director during the exit conference. Additionally, the facility did not have documentation of annual testing and inspection of installed carbon monoxide alarms as required by the manufacturer's instructions and the 2016 Act 48 Care Facility Carbon Monoxide Alarms Act. There was also no documentation confirming that the carbon monoxide alarms could be heard by on-duty staff or verifying evacuation and alarm protocols related to these alarms. These deficiencies were acknowledged by facility leadership during interviews.
Plan Of Correction
1. The facility Life Safety drawings will be revised to include the items noted lacking in the survey process. Documentation of annual testing and inspection of installed Carbon Monoxide alarms, per manufacturer's instructions, will also be maintained. The Carbon Monoxide alarms will be modified to ensure they can be heard by on-duty staff as required. Evacuation and alarm protocols will be updated and reviewed at least annually, with annual in-service education for facility staff. 2. The Life Safety drawings will be reviewed for compliance with the required components by the Maintenance Director and NHA. The documentation of annual testing and inspection of Carbon Monoxide alarms will also be reviewed monthly by the Maintenance Director, and documentation of the Carbon Monoxide alarms being able to be heard by on-duty staff will occur monthly. Evacuation and alarm protocols will be reviewed and updated as required, and staff in-services will be held with facility staff to educate on same. Each of these items will be reported monthly to the QAPI Committee for three months, and at least quarterly thereafter until compliance is achieved. Date of correction is 7/30/2025.
Failure to Document Fire Suppression System Checks and Hood Cleaning
Penalty
Summary
The facility failed to provide documentation of the required owner's quick checks for the fixed chemical fire suppression system installed in the kitchen. During a review of facility records, surveyors were unable to locate evidence that these quick checks had been performed as required. This was confirmed in an interview with the Administrator and Maintenance Director, who acknowledged the absence of documentation for the quick checks on the kitchen's fire suppression system. Additionally, the facility could not provide documentation verifying that the kitchen exhaust ductwork had been cleaned on a semi-annual basis. The last available documentation showed that the most recent cleaning cycle was completed several months prior, with no records of subsequent cleanings. This lack of documentation was also confirmed by the Administrator and Maintenance Director during the exit conference.
Plan Of Correction
1. Kitchen suppression system inspections and hood cleaning certificates will be placed in the facility's life safety book. The owner's quick checks of the fixed chemical fire suppression system will continue to be displayed in the kitchen. The semi-annual hood cleaning has been scheduled for July 2025, and documentation will be maintained when completed. 2. The Maintenance Director will audit, at least semi-annually, the facility's life safety book to verify the existence of the required kitchen suppression inspections and hood cleaning certificates, and report to the QAPI Committee with results of these audits. Date of correction is 7/30/2025.
Food Storage and Sanitation Deficiencies in Dietary Department
Penalty
Summary
The facility failed to store and serve food in a sanitary manner in both the dietary department and on one nursing unit. During a kitchen tour, surveyors observed multiple violations of facility policy and food safety standards. In several coolers, opened food items such as tea, sliced turkey lunch meat, ham, and shredded cheese were either undated or stored past their use-by dates. Juices from an opened bag of turkey lunch meat were dripping onto a box of pork below, forming a puddle on the cooler floor, and opened bags of ham and cheese were stored inappropriately. Milk crates were stored directly on the floor, and a juice lid was found on the floor near the milk. The trayline refrigerator had visible dried food substances on the door and shelves, and utensil drawers had dried food debris. Flying insects were present in both the food preparation and dish room areas, and dry storage had a fly, an open window, and bug and dust debris on the windowsill. During meal service on one unit, a dietary employee with uncovered facial hair was observed serving food. The employee wore gloves but failed to change them or perform hand hygiene after touching the phone and then handling resident plates and utensils. The same gloved hands were used to serve food, and the employee did not change gloves or perform hand hygiene between tasks, contrary to facility policy. The administrator confirmed that utensils, not gloved hands, should have been used to serve meat. These findings demonstrate multiple failures to follow food safety and sanitation protocols as required by facility policy and federal regulations.
Failure to Monitor Hot Beverage Temperatures and Supervise Leads to Resident Burn
Penalty
Summary
The facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units, resulting in residents being placed at risk for burn injuries. Observations and interviews revealed that staff did not routinely test the temperature of hot beverages before serving them to residents, and coffee was served at temperatures as high as 181 degrees Fahrenheit. The facility's policy allowed hot beverages to be served at temperatures above 155 degrees Fahrenheit, which is contrary to safety recommendations from the American Burn Association, and there was no evidence that beverages were retested at the point of service before being given to residents. A resident with significant medical conditions, including Parkinson's disease, Lewy body dementia, apraxia, and cognitive impairment, required assistance with meals and supervision during self-feeding. Despite these needs, the resident was observed unsupervised in the dining room on multiple occasions, drinking coffee without a lid. The resident sustained a burn injury to the abdomen after spilling hot coffee, which was measured at 15 cm by 2 cm. The incident was discovered when the resident was heard screaming, and staff noted the spill and resulting burn. Further interviews with dietary and nursing staff confirmed that they did not typically test the temperature of coffee before serving it to residents. Residents also reported that the coffee was too hot to drink and needed to sit before it could be consumed. The lack of temperature monitoring, failure to provide required supervision, and absence of adaptive equipment contributed to the incident, resulting in actual harm to a resident and the identification of an Immediate Jeopardy situation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during observed medication administration on two of four nursing units. Over the course of two observation periods, there were 26 medication administration opportunities, with four errors identified, resulting in a medication error rate of 15.38%. These errors were confirmed by the Director of Nursing. Specific deficiencies included a nurse not instructing a resident with chronic obstructive pulmonary disease and diabetes to rinse their mouth after using a tiotropium bromide inhaler, and failing to clean the tops of two insulin pens with alcohol before attaching needles, contrary to physician orders and manufacturer instructions. Additionally, another nurse crushed an extended-release acetaminophen tablet before administering it to a resident with chronic pain and dementia, despite drug information stating that these tablets should not be crushed.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs and preferences on three of four nursing units. Multiple residents reported that meal delivery was frequently late, with one resident stating she had to wait a long time for a meal and another indicating that late meals interfered with participation in scheduled activities. Additional residents confirmed that the delivery of meal trucks and steam tables was often delayed. Review of the facility's meal schedule showed specific delivery times for each unit, with a 15-minute grace period allowed. However, observations revealed that meal deliveries were significantly late on several units, with delays ranging from 33 to 49 minutes past the scheduled times. One resident was observed without a meal tray during the delay and confirmed that late meals were a typical occurrence. The DON acknowledged that meal service should have adhered to the scheduled delivery times.
Improper Disposal of Trash and Refuse
Penalty
Summary
During an observation of the dumpster area, various items were found improperly disposed of on the ground next to the garbage dumpsters. These items included multiple used gloves, plastic debris, condiment packets, a waffle, and a pile of animal droppings behind the dumpster. Additionally, one of the dumpsters had four soiled briefs and cloths sticking out from underneath it. These findings indicate that the facility failed to dispose of trash and refuse properly as required.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information as required. During facility tours on June 8 and June 9, 2025, it was observed that the staffing information displayed in the lobby was outdated, showing the date of June 6, 2025. In a subsequent interview, the Nursing Home Administrator confirmed that the posted staffing information was incorrect. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Inadequate Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to comply with the required nurse aide (NA) to resident ratios over a 21-day period from March 14 to April 3, 2025. Specifically, the facility did not meet the minimum staffing requirements on multiple occasions across different shifts. During the day shift, the facility was short of the required one NA per ten residents on seven days. The evening shift was understaffed on eleven days, failing to maintain the required one NA per eleven residents. Additionally, the night shift did not meet the minimum requirement of one NA per fifteen residents on two days. These deficiencies were identified through a review of the nursing schedules, indicating a consistent pattern of inadequate staffing levels.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility continues to attend job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. Nurse Aide classes will resume at the facility on 4/28/25. Facility continues with an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.
Non-Compliance with LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on March 15, 16, 29, and 30, 2025. Additionally, the facility did not meet the required ratio of one LPN per 30 residents during the evening shift on March 16, 29, and 30, 2025. These deficiencies were identified based on a review of nursing time schedules over a 21-day period from March 14 through April 3, 2025, indicating non-compliance on four of those days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Presentation to local LPN school graduates scheduled for 4/28/25, and they graduate in May. Entered collaboration with local Penn State campus to introduce graduating nurses to our facility onsite. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to QAPI committee. 5. Date of correction is 06/11/2025.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of nursing schedules from March 14 through April 3, 2025, revealed that on 16 out of 21 days, the facility did not meet this minimum standard. Specific days with deficiencies included March 14, 15, 16, 17, 18, 22, 23, 24, 26, 28, 29, 30, 31, and April 1, 2, and 3, 2025. On these days, the care hours per resident ranged from 2.52 to 3.16, falling short of the required 3.2 hours.
Plan Of Correction
Nursing hours noted in the survey cannot be corrected as this is a past event. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. The facility has developed internal incentives to retain and attract new staff. Two nurse aide classes have been already scheduled and are being recruited with the first class starting 4/28/25. LPN school recruitment efforts continue with a presentation scheduled on 4/24/25 for nurses that graduate in May. Developed collaboration with local Penn State campus to introduce graduating nurses to long term care in our facility. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. PPD hours will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. Date of compliance is 06/11/2025.
Failure to Prevent Neglect Resulting in Pressure Sore
Penalty
Summary
A facility failed to protect a resident from neglect when staff did not provide timely assistance with toileting. The resident, who was cognitively impaired, had difficulty communicating needs, was dependent on staff for mobility, and was unable to use a toilet independently, was identified as being at risk for pressure sores and required turning and repositioning every two hours per care plan. On one occasion, the resident was placed on a bedpan at approximately 2:30 p.m. and was not assisted off until about 7:00 p.m. Subsequently, a nurse assessed the resident and found a ring-shaped stage 1 pressure sore, matching the size and shape of the bedpan, on the resident's buttocks. The evening shift aide acknowledged being aware of the resident's care needs but failed to provide timely assistance, a fact confirmed by the Director of Nursing.
Failure to Meet Nurse Aide to Resident Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios for 19 out of 21 days reviewed, as evidenced by a review of nursing schedules from December 9 through 29, 2024. Specifically, the facility did not maintain the minimum NA to resident ratio of one NA for ten residents during the day shift on 15 days, one NA for 11 residents during the evening shift on 18 days, and one NA for 15 residents during the night shift on 11 days. This deficiency was confirmed by the Director of Nursing during an interview on December 30, 2024.
Plan Of Correction
1. C.N.A. ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift C.N.A. ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. The facility has attended job fairs and nursing schools to recruit direct care staff, in addition to other ongoing recruiting initiatives. We are using recruitment lists to call area CNAs to consider joining our facility. We have reached out to Nurse Aide training institutions to determine their ability to staff ongoing Nurse Aide Training classes. The facility has introduced an employee referral program to recruit staff also. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate C.N.A. ratios as needed. 4. C.N.A. ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.
Failure to Meet LPN to Resident Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on multiple occasions over a 21-day period in December 2024. Specifically, the facility did not maintain the minimum ratio of one LPN per 25 residents during the day shift on six days, one LPN per 30 residents during the evening shift on three days, and one LPN per 40 residents during the night shift on eight days. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the facility's inability to meet the staffing requirements on the identified days.
Plan Of Correction
1. LPN ratios for the dates noted in the survey cannot be corrected as this is a past event. 2. Calculation of shift LPN ratios will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Facility has attended LPN schools to recruit new staff, and introduced an employee referral program, as well as calling area LPNs to consider joining facility staff. Agency staff are being utilized in an effort to reach daily shift ratios. The scheduler will look ahead for a minimum of 1 week at projected staffing patterns to enable more time to achieve appropriate LPN ratios as needed. 4. LPN ratios will be audited by the scheduler and DON daily for 4 weeks, then 3 days per week x 2 months or until substantial compliance is achieved. Results will be reported to the QAPI committee. 5. Date of correction is 03/05/2025.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for 20 out of 21 days reviewed. The review of nursing schedules from December 9 through December 29, 2024, revealed that the facility consistently fell short of the required care hours, with the lowest being 2.08 hours per resident on December 25, 2024. The Director of Nursing confirmed during an interview that the facility did not meet the minimum required nursing care hours on the identified days.
Plan Of Correction
1. Nursing hours noted in the survey cannot be corrected as this is a past event. 2. Calculation of daily PPD will be completed and reviewed daily for accuracy by the scheduler. 3. The facility has developed internal incentives to retain and attract new staff. Re-introduction of a Nurse Aide Training program is scheduled with classes to train new nurse aides. Agency contracts are in place in an effort to reach daily PPD requirements. The scheduler will look ahead for a minimum of 1 week to determine projected PPD to allow more time to achieve PPD hours requirements. 4. PPD hours will be audited by scheduler and DON daily for 4 weeks, then 3 days per week x 2 months, or until substantial compliance is achieved. Results will be reviewed at QAPI meeting. 5. Date of compliance is 03/05/2025.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for five residents who required assistance with activities of daily living (ADLs). These residents were scheduled for showers on specific days, but there was a lack of documentation indicating that showers were provided on several occasions. Interviews with the residents confirmed that they had not refused showers on the dates in question. Resident 1, admitted with diagnoses including diabetes mellitus with diabetic neuropathy and an acquired absence of the right leg above the knee, was not documented as having received showers on three scheduled dates. Resident 4, with a history of ischemic attack and diabetes mellitus, missed showers on two scheduled dates. Resident 5, diagnosed with acute chronic diastolic heart failure and difficulty walking, was not documented as having received showers on three scheduled dates. Resident 6, with hemiplegia following cerebral infarction, missed showers on five scheduled dates. Resident 8, with hypertensive heart disease and mobility issues, was not documented as having received a shower on one scheduled date. The facility's Administrator and Director of Nursing acknowledged that the residents should have been offered showers on their scheduled dates.
Plan Of Correction
1. Resident 1 has been discharged. Resident 4 received a shower on 12/3/24. Resident 5 received a bed bath and care planned as a preference. Resident 6 received a shower on 12/4/2024. Resident 8 received a bed bath and care planned as a preference. Resident 5 and 8 interviewed again for shower preference. 2. Facility will complete a 7 day look back audit of resident showers. Any resident documented as not receiving a shower on their designated day will be offered a shower. 3. The Director of Nursing/Designee will re-educate nursing staff on providing resident showers on designated shower days and/or PRN. Current residents to be interviewed to determine bathing preference. The education will include providing shower per bathing preference. If shower unable to be given, shower to be offered on the next day/shift and documented. 4. The Director of Nursing/designee will complete bathing audits weekly x 4. The results of the audits will be presented at the monthly QA meeting. 5. Date of compliance will be 1/15/2025.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination by not providing scheduled showers to two residents. Resident 3, diagnosed with anxiety and insomnia, was oriented and required staff assistance for bathing. Despite preferring and being scheduled for showers twice a week, the resident was not offered a shower on two out of eight scheduled occasions in the past 30 days. Similarly, Resident 4, who had hemiplegia and diabetes mellitus, was also oriented and required staff assistance for bathing. This resident preferred and was scheduled for showers twice a week but was not offered a shower on five out of nine scheduled occasions in the past 30 days. These failures were identified through clinical record reviews and resident interviews.
Failure to Implement Physician's Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to implement physician's orders for two residents with diagnoses of hypertension and atrial fibrillation. For Resident 2, a physician ordered metoprolol to be administered twice daily, with instructions to withhold the medication if the systolic blood pressure was less than 100 mm/Hg. However, the medication was administered 15 times when the resident's systolic blood pressure was below this parameter. Similarly, for Resident 4, a physician ordered carvedilol to be administered once daily, with instructions to withhold the medication if the systolic blood pressure was less than 110 mm/Hg or the heart rate was less than 60 bpm. The medication was administered eight times when the resident's vital signs were below these parameters. During an interview, the Director of Nursing confirmed the absence of documented evidence that the medications were withheld when the residents' systolic blood pressure or heart rate were below the established parameters.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen, as observed during a survey. The Director of Dietary Services stated that refrigerated foods should be labeled, dated when opened, and used within three days. However, during a kitchen tour, several items in the walk-in refrigerator were found to be improperly labeled or stored. These included a container of pumpkin puree, raspberry glaze, pureed peaches, cottage cheese, salad, and spaghetti with sauce, all of which were either undated or past the three-day usage guideline. Additionally, in the reach-in refrigerators, there were items such as chopped lettuce, ham luncheon meat, turkey luncheon meat, and chicken that were either undated or past the recommended usage period. The walk-in freezer had a large accumulation of ice buildup on food items, including a container of ground beef with ice directly on it. In the food preparation area, there were undated opened containers of cereal, and in the dry storage area, an opened, undated bag of noodles was found. Furthermore, there were chunks of tile missing on the floor in several areas of the kitchen.
Failure to Follow Pre-Approved Menus on C Unit
Penalty
Summary
The facility failed to adhere to the pre-approved menus on one of its nursing units, specifically the C Unit. This deficiency was identified through a combination of observations, facility documentation, a test tray audit, and staff interviews. A review of the monthly Resident Council and Food Committee meeting minutes from December 2023 to April 2024 revealed consistent complaints from residents regarding the portion sizes of food served at mealtimes. On May 8, 2024, during a confidential group meeting, residents reiterated that the portion sizes were often too small. The facility's menu for lunch on May 8, 2024, specified that residents should receive three ounces of glazed pork medallions and four ounces of California blend vegetables. However, a test tray audit conducted on the same day showed that staff served only two ounces of glazed pork and three ounces of vegetables. The Dietary Manager confirmed in an interview that the incorrect portion sizes were provided for the lunch cart delivered to the C Unit, thus failing to meet the nutritional needs as outlined in the pre-approved menu.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide dining assistance in a manner that promoted and maintained dignity for two residents on two different nursing units. Resident 42, who has Alzheimer's disease and cognitive impairment, was observed eating spaghetti with her fingers in the dining room without any staff intervention or assistance, despite her care plan indicating she required supervision with eating and was on a restorative nursing program for dining. Similarly, Resident 74, who has arthritis and vision problems, was observed eating cake with her hands, resulting in her hands being covered in cake and icing. Despite her care plan indicating she required meal set-up and as-needed assistance due to her compromised functional ability and impaired vision, no staff offered assistance or redirection during the meal. These observations indicate a failure to uphold the residents' rights to dignity and appropriate nursing services as outlined in the relevant state codes.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as identified during a clinical record review and staff interview. Resident 141, who has cognitive impairment, hearing loss, and dementia, was noted to have communication issues that were supposed to be addressed in the care plan according to the Care Area Assessment (CAA) summary. However, there was no evidence of interventions for communication problems in the current care plan. Similarly, Resident 168, diagnosed with dementia and chronic kidney disease, was occasionally incontinent of urine. The CAA summary indicated that urinary incontinence should be addressed in the care plan, but no interventions were included. The Director of Nursing confirmed that the care plans for these residents did not address the identified care areas, which is a violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable and at appetizing temperatures on one of its nursing units, specifically the C Unit. On May 7, 2024, residents reported that their lunch was cold, and a review of meeting minutes from December 2023 through April 2024 revealed a pattern of complaints about food temperatures. During a confidential group interview on May 8, 2024, residents reiterated that food was often not served at the right temperature and that the pork was too tough. A test tray audit conducted on the same day showed that the glazed pork was served at 120.7 degrees Fahrenheit, scalloped potatoes at 111 degrees Fahrenheit, and California blend vegetables at 116 degrees Fahrenheit, all of which were cool to taste. Observations of residents eating lunch in the C unit dining room confirmed that the pork was tough and not hot, with residents expressing difficulty in cutting and chewing it.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to two residents, both of whom had specific medical conditions necessitating such equipment. Resident 29, diagnosed with Parkinson's disease, dementia, arthritis, and a lack of coordination, required assistance for all meals and was supposed to use Kennedy cups as per their care plan. However, observations on May 8 and 9, 2024, revealed that Resident 29 was served drinks in regular cups without lids or straws, contrary to the care plan and dietitian's recommendations. Similarly, Resident 76, who had paralysis on one side and vision problems, was also supposed to use a Kennedy cup with a straw for all meals due to their cognitive impairment and nutritional needs related to diabetes and impaired skin integrity. Despite this, observations on May 7 and 8, 2024, showed that Resident 76 was using regular cups without lids or straws. The Director of Nursing confirmed that both residents were supposed to have their drinks served in Kennedy cups, indicating a failure in adhering to the prescribed care plans.
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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