Transitions Healthcare Allens Cove
Inspection history, citations, penalties and survey trends for this long-term care facility in Duncannon, Pennsylvania.
- Location
- 25 Cove Road, Duncannon, Pennsylvania 17020
- CMS Provider Number
- 395915
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Transitions Healthcare Allens Cove during CMS and state inspections, most recent first.
The facility failed to reasonably accommodate resident needs and preferences during meal service by using soft plastic cups for beverages on tray service, despite policy requiring respect, dignity, and a homelike environment. Residents eating in their rooms reported that the soft cups were hard to grasp, caused liquid to spurt or spill, led staff to underfill beverages, and required awkward gripping such as placing a thumb inside the cup, resulting in stained fingers. A dietitian questioned why hard plastic cups, described as easier to grasp and more homelike, were not being used, and the administrator later acknowledged that dining equipment should support resident needs and a dignified dining experience.
Surveyors found that the facility did not provide required written transfer notices to two residents and/or their representatives when the residents were transferred to the hospital multiple times for acute medical changes in condition, despite a facility policy requiring written notification of transfer/discharge and reasons for the move. Record review showed no evidence of transfer notices for four separate hospitalizations involving residents with CHF, CKD, and a stage 4 sacral pressure ulcer, and the NHA could not confirm that any notices had been sent.
Surveyors found that the facility did not provide required annual in‑service education to multiple nurse aides, as personnel and training records for several aides lacked documentation of at least 12 hours of yearly training. Records also did not show that some aides had received dementia management education and that another aide had completed abuse prevention training, despite the administrator’s expectation that annual training include these topics.
A resident with dementia, anxiety, and major depressive disorder received escalating doses of Seroquel for yelling out and agitation without adequate documentation of target behaviors or non-pharmacological interventions, as required by facility policy. Psych consults recommended increasing Lexapro and using PRN Ativan for anxiety, but the Lexapro increase was delayed and Seroquel was increased from twice daily to three times daily without documented clinical justification. Behavior monitoring records over several months lacked entries for the defined target behaviors, and leadership later acknowledged that the resident’s continuous yelling was not being documented by staff.
A resident with dementia, insomnia, and osteoarthritis was found with large bruises on both hands, a large bruise on one forearm, and a skin tear, and reported that a nurse aide had been "too rough" and yelled during care, with the roommate corroborating hearing yelling. Staff statements documented that bruises and a skin tear were noticed on night shift and reported to an RN, and that the resident had stated an employee hurt her, while other staff described the resident as combative during care. The DON conducted an internal investigation, including staff statements and a phone call with the alleged aide, but did not document an unsuccessful attempt to interview the resident, did not record follow-up interviews with LPNs who denied receiving reports of the bruises, and did not notify outside agencies as required by policy and state law, resulting in a failure to thoroughly investigate and report the alleged abuse and injuries of unknown origin.
The facility did not develop and implement baseline person-centered care plans within 48 hours of admission for two residents with conditions including HTN, chronic kidney disease, and heart failure. For one resident, the overall care plan and all focus areas (activities, dietary, nursing, social services, and therapy) were initiated and completed weeks after admission, with only the advance directive care plan started earlier. For the other resident, all care plan focus areas and interventions were initiated several days to weeks after admission. In both cases, neither the residents nor their representatives received a summary of a baseline care plan, and the NHA acknowledged that the baseline care plans were not completed within the required timeframe.
A resident with heart failure and HTN was admitted and had all care plan focus areas and interventions initiated on two documented dates, but the clinical record lacked any evidence that an IDT care plan meeting occurred or that the resident and their representative were invited to participate in the care planning process. The NHA confirmed there was no documentation of such a meeting and acknowledged that the comprehensive care plan development should include the resident and representative, resulting in noncompliance with regulatory requirements for comprehensive care plans.
A resident with colon and bladder cancer and a urostomy was evaluated for excessive blood in the urostomy bag, and the physician received a request from the resident’s urologist for a UA C&S to rule out a UTI. A physician order for the UA C&S was entered and marked as completed, but the clinical record showed no evidence that the specimen was collected or sent to the lab for several days, and a later physician note documented that the UA had not yet been collected. A new order with a later start date was written, and nursing notes indicated the UA C&S was finally collected then, while the NHA acknowledged that the test should have been obtained when it was first ordered.
The facility failed to maintain proper temperature controls for medication storage, as observed in the medication room refrigerator. The thermometer was improperly placed in the freezer section, leading to temperatures recorded at 20°F, below the required range of 36°F to 46°F. The temperature log for April showed inconsistent recordings, with several days missing entries. The NHA and DON acknowledged the expectation for proper storage and daily temperature monitoring, which was not met.
The facility failed to maintain food safety and sanitation standards, with expired and improperly stored food items, a soiled dish machine, and inadequate temperature logs. The Dietary Manager lacked a cleaning schedule, and the facility could not provide temperature logs for six months. The NHA expected proper food storage and equipment maintenance, which were not met.
Transitions Healthcare Allens Cove failed to provide a resident with written notice of the bed-hold policy during hospital transfers, as required by federal regulations. Despite the facility's policy, there was no evidence that the resident or their representative received the necessary information during two hospitalizations. The resident had a history of hypertension and Type 1 Diabetes Mellitus.
The facility failed to ensure accurate resident assessments, leading to discrepancies in documentation for two residents. One resident with a Foley catheter was incorrectly noted as occasionally incontinent, while another resident's fall was not recorded in their MDS. These errors were confirmed by the DON.
A resident with spinal stenosis and muscle weakness did not receive scheduled showers as per her preferred schedule, missing multiple dates over several months. The facility's policy requires maintaining independence in ADLs, but the resident reported not receiving a shower for over two weeks at times. The Nursing Home Administrator mentioned refusals by the resident, but there was no documentation of refusals or reapproach attempts, contrary to expectations stated by the DON.
A facility failed to provide care in line with professional standards for a resident with Alzheimer's and a pacemaker. The resident's clinical record lacked current orders for cardiology consults or pacemaker checks, and the last remote check was months overdue. The DON found that appointment letters were sent to the wrong address, and the facility was not the primary contact, leading to missed appointments and checks.
The facility failed to ensure a resident received necessary cardiology follow-ups and did not provide prescribed restorative nursing care for another resident with mobility issues. The oversight in coordinating medical appointments and incomplete range of motion exercises were identified as deficiencies.
The facility failed to maintain effective infection control during medication administration for three residents. An employee did not follow hand hygiene protocols, improperly cleaned a glucometer, and neglected Enhanced Barrier Precautions for a resident with a central line. These actions were confirmed by the NHA and DON, who acknowledged the expectation for staff to adhere to infection control guidelines.
The facility did not follow its policy for TB screening of new employees, as one employee did not receive the required screening before starting their duties. The Nursing Home Administrator acknowledged the issue is being addressed.
Multiple stained ceiling tiles and a wall with a brown liquid stain were observed in common areas and a resident's room, indicating a failure to maintain a clean and homelike environment as required by facility policy. Maintenance staff and the administrator confirmed that these soiled surfaces should have been identified and addressed during regular environmental rounds.
Annual performance evaluations for three nurse aides were not completed or available for review, as required by facility policy and state regulations. The issue was attributed to a recent change in the facility's electronic evaluation system, which resulted in the loss of some records, and was confirmed by both staff interviews and documentation review.
The facility was found to have multiple violations of food service safety standards. Employees were observed working without hairnets, and an open bottle of stir fry sauce was improperly stored without an open date. Additionally, clean utensils were stored in a drawer with dried food particles, and the drawer itself was not clean. These issues were confirmed by the NHA and Food Service Director.
The facility failed to notify the State Long-Term Care Ombudsman of the transfer of four residents to the hospital, as required by regulations. The residents, who had various medical conditions, were transferred between January and April 2024. Interviews with the Nursing Home Administrator confirmed the lack of notification.
A facility failed to provide necessary care and services for a resident's hygiene and bathing needs, as part of their ADLs. The resident, with chronic respiratory failure and hypoxemia, was on a restorative nursing program requiring staff assistance for washing and grooming. However, multiple instances were recorded where these tasks were not completed, and the Director of Nursing could not explain the omissions. The Nursing Home Administrator expected these tasks to be completed, indicating a deficiency in maintaining the resident's ADL capabilities.
The facility failed to provide an ongoing activities program to meet residents' needs, with only one activity staff member working weekdays, resulting in no weekend activities. Residents expressed dissatisfaction, noting canceled activities and the need for additional support for the activity director. Facility documents confirmed the absence of scheduled activities on weekends.
The facility failed to provide physician-ordered therapeutic diets for residents on renal/low potassium and consistent carbohydrate diets. The dietary extension sheets did not document these diets, and staff confirmed that the facility did not offer them, leading to a deficiency in dietary management.
The facility failed to provide proper respiratory care for four residents. A resident's nebulizer was not stored correctly, another's equipment was outdated and not covered, a third used oxygen without a documented order, and a fourth had undated distilled water in their room. Staff confirmed these were against facility policies.
The facility failed to meet food safety standards, with issues in food storage and labeling in the kitchen and nourishment pantry. Observations included open and unlabeled food items, such as pasta, hard-boiled eggs, meat, ice cream, nutritional shakes, and soup. Interviews with the Food Service Director and Nursing Home Administrator confirmed these deficiencies.
The facility failed to provide a dignified meal service by not serving meals simultaneously to residents at the same table, as required by their policy. Observations revealed that meals were served at staggered times, and all residents were served on trays, contrary to the facility's policy. The NHA acknowledged the discrepancy during an interview.
The facility failed to provide three residents with the required bed-hold policy notice upon their transfer to a hospital, as per their policy. Despite the policy's requirement for notification at admission and transfer, residents with chronic conditions and pressure ulcers were transferred without receiving this notice. Interviews with the NHA confirmed the oversight, leading to a deficiency in compliance with regulatory requirements.
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their clinical records. One resident on hospice services was not documented as such in the MDS due to an oversight in physician orders. Another resident using oxygen was incorrectly marked as not using it in the MDS, despite progress notes indicating otherwise. These errors were acknowledged by the DON and Nursing Home Administrator.
A facility failed to include hemodialysis in a baseline care plan for a resident admitted after hospitalization. The resident, with a history of hemodialysis, protein calorie malnutrition, and diabetes mellitus, lacked documented orders for hemodialysis and related care needs. The Nursing Home Administrator confirmed that these should have been included in the care plan.
A resident with COPD and sleep apnea did not receive a prescribed nicotine patch for several days due to a delay in completing an OTC authorization form. The facility's pharmacy policy required this form for non-stock medications, leading to a delay in the medication's delivery and administration.
The facility failed to provide food and beverages at safe temperatures during a meal service on the South unit. A test tray revealed unsatisfactory temperatures for coffee and milk, and staff interviews highlighted the absence of a policy for checking food temperatures at the point of service. Resident concerns about cold food were documented in previous council meetings.
Failure to Provide Appropriate, Dignified Drinking Vessels During Meals
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences regarding dining equipment, specifically the use of soft plastic cups during meal service. Facility policy on Resident Rights, last revised February 6, 2025, states that each resident must be treated with respect and dignity in a manner that promotes quality of life and a homelike environment, including the right to reside and receive services with reasonable accommodation of needs and preferences. During lunch meal service, surveyors observed a beverage cart stocked with soft plastic cups for tray service down the south hall, and residents eating in their rooms, including two identified residents, were served beverages in these soft plastic cups on their meal trays. Multiple residents and staff reported problems with the soft plastic cups. One resident stated that when beverages are served in the soft plastic cups, the liquid spurts out, leading staff to underfill the cups so the resident receives less to drink, and that the cups are more difficult to hold. Another resident reported difficulty grasping the soft plastic cups, stating that when he picks them up, the cups squeeze in and the liquid spills on him. A third resident showed a thumb stained red from cranberry juice and explained that she must place her thumb inside the soft plastic cup to pick it up. The Registered Dietitian stated she was also wondering why the facility was not using hard plastic cups, which she said are easier to grasp and more homelike. The Nursing Home Administrator acknowledged the concern and stated he would expect dining equipment to accommodate residents’ needs and preferences and promote a dignified and homelike dining experience.
Failure to Provide Required Written Transfer Notices for Hospitalizations
Penalty
Summary
The facility failed to provide required written transfer/discharge notices to residents and/or their representatives for multiple hospitalizations. Facility policy titled "Resident Discharge/Transfer from Facility," effective January 21, 2025, required that upon a transfer or discharge, the facility notify the resident and resident representative in writing, in a language and manner they understand, and send a copy of the notice to the resident/resident representative. Surveyors reviewed clinical records and available documentation and found no evidence that such written notices were provided for two residents who experienced a total of four hospital transfers for acute medical changes in condition. One resident with diagnoses including congestive heart failure and chronic kidney disease was transferred to the hospital twice for acute medical changes in condition and later returned to the facility after each hospitalization; no written transfer notices were found in the record for either hospitalization. Another resident with diagnoses including congestive heart failure and a stage 4 sacral pressure ulcer was also transferred to the hospital twice for acute medical changes in condition and subsequently returned after each stay; again, no documentation of written transfer notices was identified for either hospitalization. In an interview, the Nursing Home Administrator stated he was unable to determine if transfer notices were sent for these four hospitalizations and acknowledged that he would expect the facility to provide written transfer notices to residents/representatives in the event of a hospitalization.
Failure to Provide Required Annual In‑Service, Dementia, and Abuse Prevention Training for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received the required minimum of 12 hours of annual in‑service training, including dementia management and resident abuse prevention, for four of five nurse aide personnel files reviewed. Personnel records showed that Employees 1, 2, 3, and 5 had hire dates ranging from November 13, 2023, to March 3, 2025. Review of facility training records did not show evidence that these employees had completed 12 hours of required annual training in the previous 12 months. Further review showed no documentation that Employees 1, 2, and 5 had received dementia management training within the past 12 months, and no documentation that Employee 3 had received abuse prevention training within the past 12 months. In an interview, the Nursing Home Administrator stated he would expect nurse aide annual training to be completed every 12 months and to include abuse and dementia content. No specific residents or clinical events were identified in the report; the deficiency was based on personnel record review and staff interview related to required staff development and in‑service education.
Failure to Justify and Document Psychotropic Dose Escalation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s medication regimen was free from unnecessary psychotropic medications, specifically related to the use and dose escalation of Seroquel. Facility policy on psychotropic medications required assessment of the necessity of such medications, attempts to meet needs through the care plan and behavior modification, use of calm redirection and reassurance, and documentation of behaviors, interventions tried, and their effectiveness before offering PRN medications. The resident involved had diagnoses including stroke, dementia with behavioral disturbance, anxiety, and major depressive disorder with psychotic symptoms, and had been admitted to hospice. Psych consult notes documented staff reports of increased anxiety and yelling out, and recommended increasing Lexapro to 10 mg to address mood and anxiety, as well as encouraging use of PRN Ativan for anxiety that was not redirectable. Despite these recommendations, the increase in Lexapro to 10 mg was not implemented when first recommended and was not ordered until several weeks later. A physician progress note documented that the resident was in bed calling out for help, expressing a desire to see her husband and go shopping, and noted agitation and episodes of calling out. At that time, the resident was on Seroquel 25 mg twice daily, and the physician ordered an increase to 50 mg twice daily, citing repetitive calling out episodes as the reason. Subsequent physician orders further increased Seroquel to 50 mg three times daily, but the clinical record contained no indication or documented justification for this additional increase from twice daily to three times daily. The resident’s antipsychotic target behaviors were defined as yelling/calling out, continuously ringing the call bell, expressing multiple complaints such as stating she could not breathe despite normal oxygen saturation, repeatedly asking for bed covers to be adjusted, and disrobing. Staff were required to document observed behaviors and interventions every shift. However, behavior documentation for multiple months showed no recorded target behaviors, and the clinical record contained no behavior documentation other than the two psych consult notes and one physician note describing yelling out. There was also no documentation that non-pharmacological interventions were attempted prior to increasing the Seroquel dose. During interviews, the NHA acknowledged that the resident did have a behavior of continuous yelling out but that staff were not documenting it, and the DON confirmed that the Seroquel was increased due to repetitive yelling out with delusional thoughts, while also confirming the absence of documentation of the continuous behaviors around the time of the dose increase.
Failure to Thoroughly Investigate and Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an allegation of abuse involving Resident 9 in accordance with facility policy and state requirements. Facility policy on Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property requires staff to report all allegations and injuries of unknown etiology, and for administration to notify appropriate agencies and conduct a thorough investigation within required timeframes. Resident 9’s clinical record showed diagnoses including dementia, insomnia, and osteoarthritis. A nursing progress note documented that a nurse aide reported the resident had large bruises on both hands, a large bruise on the left forearm, and a skin tear with a border dressing, and that the resident stated a nurse aide was “too rough” and yelled at her while providing care on the night shift, with a roommate witness indicating the incident occurred the prior evening. The DON stated he investigated the allegation on the day it was reported, collected statements, and determined the allegation was unsubstantiated, but he did not notify any outside agencies and did not suspend the alleged perpetrator. He also attempted to interview Resident 9 but was unable to obtain information and did not document this in the investigation details. Staff statements collected on January 17, 2026, indicated that one nurse aide noticed new bruises and reported them to a registered nurse, and that the resident had stated an employee hurt her, with the roommate reporting hearing yelling at night while a nurse aide provided care. Other staff statements described the resident as combative and aggressive with care, including hitting, kicking, and threatening staff, and one statement from the DON documented that the roommate believed the incident involved a specific nurse aide, although the roommate could not see due to the privacy curtain. Additional staff documentation indicated that bruises and a skin tear were first noticed during night shift rounds and that a nurse aide reported these bruises to an LPN, who allegedly stated they were already aware and would handle it. However, the DON later reported that when he spoke with the two LPNs who had worked that shift, both denied the bruises were reported to them, and he did not record these follow-up interviews in the investigation file and could not recall which LPNs were involved. The facility lacked evidence that the allegation of abuse and injuries of unknown origin were reported to required external agencies within five working days, and the investigation documentation was incomplete, omitting key attempted interviews and follow-up staff contacts, resulting in noncompliance with state regulations and the facility’s own abuse policy.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline, person-centered care plan within 48 hours of admission for two residents, and also failed to provide the residents or their representatives with a summary of that baseline care plan. For one resident with diagnoses including hypertension and chronic kidney disease, the clinical record showed that the resident was admitted on an unspecified date, but the overall care plan was not initiated until February 17, 2026, and was not completed until March 16, 2026. Further review showed that the activities, dietary, nursing, social services, and therapy focus areas and interventions were all initiated and completed on March 16, 2026, well beyond the required 48-hour timeframe. The only timely care plan focus area for this resident was the advance directive care plan, which was initiated on February 17, 2026. For another resident with diagnoses including heart failure and hypertension, the clinical record showed that the resident was admitted on an unspecified date, but all care plan focus areas and interventions were initiated only on December 17, 2025, or December 30, 2025, rather than within 48 hours of admission. Neither of these residents had a timely baseline care plan developed and implemented, and neither the residents nor their representatives were provided with a summary of the baseline care plan. In an interview on March 19, 2026, at 11:00 AM, the Nursing Home Administrator confirmed that the baseline care plans for these residents were not completed within 48 hours of admission and stated that he would have expected them to be completed within that timeframe.
Failure to Involve Resident and Representative in Comprehensive Care Planning
Penalty
Summary
The facility failed to involve a resident and the resident’s representative in the development of the comprehensive care plan. Clinical record review for Resident 68, who had diagnoses including heart failure and hypertension and was admitted on a specified date, showed that all care plan focus areas and interventions were initiated on either December 17 or 30, 2025. The record did not contain evidence that a care plan meeting was held with an interdisciplinary team, nor any documentation that the resident or the resident’s representative was invited to participate in the care planning process. In an interview, the Nursing Home Administrator confirmed there was no evidence of a care plan meeting with the resident or their representative and acknowledged that the comprehensive care plan development should include them. These findings demonstrate noncompliance with 28 Pa. Code 211.11(d) regarding the resident care plan and 42 CFR 483.21(b) concerning comprehensive care plans, specifically related to resident and representative participation in care planning.
Delay in Implementing Ordered UA C&S for Resident With Urostomy
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards and physician orders for a resident with colon and bladder cancer and a urostomy. The resident’s physician progress note documented that the resident was being seen for excessive blood draining into the urostomy bag, and that the responsible party intended to contact the resident’s urologist. Later that same day, the facility nurse informed the physician that the urologist had called and requested a urinalysis with culture and sensitivity (UA C&S) to rule out a UTI, and a corresponding physician order for a UA C&S was entered and marked as completed. Despite this, review of the clinical record showed no evidence that the UA C&S was actually collected and sent to the lab on the date it was first ordered or over the next two days. A subsequent physician progress note specifically stated that the UA had not yet been collected. A new order for a UA C&S was then written with a later start date, and nursing documentation indicated that the specimen was finally collected on that later date. The Nursing Home Administrator acknowledged in an interview that the UA C&S should have been collected and sent to the lab when it was initially ordered, confirming that the facility did not timely implement the physician’s order for diagnostic testing related to the resident’s urostomy concerns.
Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to store medications under proper temperature controls in the medication room, as required by federal regulations. The facility's policy, last revised in August 2020, mandates that medications be stored within temperature ranges specified by the United States Pharmacopeia (USP) and the Centers for Disease Control (CDC). Specifically, refrigerated medications should be kept between 36°F and 46°F. However, an observation on April 22, 2025, revealed that the thermometer in the medication room refrigerator was placed inside the freezer section, which had significant ice build-up, and the temperature was recorded at 20°F, well below the required range. A review of the facility's medication room refrigerator temperature log for April 2025 showed inconsistent temperature recordings, with several days missing entries. Temperatures recorded on various days were either below the required range or not recorded at all, indicating a failure to maintain and monitor appropriate storage conditions. During an interview, the Nursing Home Administrator and Director of Nursing acknowledged the expectation for medications to be stored at appropriate temperatures and for daily temperature recordings to be maintained, which was not adhered to in this instance.
Plan Of Correction
1. A new thermometer was purchased for the medication room refrigerator. 2. Medication room refrigerator was cleaned and defrosted. 3. DON or designee will provide education to nursing staff in regard to routine checking of temperatures and that all medication should be stored between 36-46 degrees. 4. An audit will be conducted by NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure that all medications are stored between 36-46 degrees. 5. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. In the dry storage area, expired food items, including bags of white bread and undated English muffins, were found. The dish machine in the main kitchen was heavily soiled with a brown substance, and the exhaust vent above it was covered with a fuzzy black substance. The dish machine's temperature logs revealed that the final rinse temperature was below the minimum safe level on multiple occasions, with no corrective actions documented. Additionally, a tub of hard-boiled eggs in the walk-in refrigerator was dirty, improperly sealed, and past its use-by date. Interviews with the Dietary Manager revealed a lack of awareness regarding the source of the substances on the dish machine and the last cleaning of the exhaust hood. The manager also admitted to not having a routine cleaning schedule checklist. Furthermore, the facility was unable to provide dish machine temperature logs for a six-month period. The Nursing Home Administrator expressed expectations for proper food storage, labeling, and equipment maintenance, which were not met according to the observations and findings.
Plan Of Correction
1. All food not stored properly was discarded. 2. Dietary manager will provide education to dietary staff on proper storage of food, proper dishwasher temperatures and cleaning of kitchen equipment. 3. Facility has signed a lease for a new dishwasher on 5/1/25, looking to have installed in the next month. 4. Exhaust vent over top of dish machine was cleaned as well as dishwasher. 5. An audit will be performed on the exhaust vent two times weekly x 4 weeks, then monthly x 2 months. 6. An audit will be performed on the dish machine temperature log weekly x 4 weeks, then monthly x 2 months to ensure final rinse temperatures are above 180 degrees. 7. An audit will be performed to make sure all food is being stored and dated properly in the pantry, walk in refrigerator, dry storage area and freezer three times weekly x 4 weeks, then two times monthly x 2 months. 8. Dietary Manager going forward will have dietary aides perform a checklist for both AM and PM to ensure that the dish machine is cleaned inside and out as well as the vent above dish machine daily. 9. Results will be taken to QAPI for review of findings and further interventions if warranted.
Failure to Provide Bed-Hold Policy Notice
Penalty
Summary
Transitions Healthcare Allens Cove was found to be non-compliant with the federal requirement 42 CFR Part 483 Subpart B, specifically regarding the notice of bed-hold policy. The facility failed to provide written notice of the bed-hold policy to a resident and/or their representative at the time of transfer to a hospital. This deficiency was identified during a review of the facility's policy, clinical records, and staff interviews. The facility's policy mandates that residents be informed of the bed-hold policy upon admission and again at the time of transfer, with the second notice detailing the duration of the bed-hold policy. However, there was no evidence that such notice was provided to Resident 45 during her hospitalizations on two separate occasions. Resident 45, who has a medical history including hypertension and Type 1 Diabetes Mellitus, was transferred to the hospital on two occasions. Despite the facility's policy requiring written notification of the bed-hold policy at the time of transfer, the Nursing Home Administrator confirmed that there was no documentation indicating that Resident 45 or her representative received this notice during her hospitalizations. This oversight was identified during an interview conducted on April 23, 2025.
Plan Of Correction
1. An audit will be conducted on past discharged residents to identify past deficient practice. 2. Any current residents moving forward will have a bed hold policy signed by resident or documentation on bed hold policy that the policy was explained to resident. 3. A copy of the bed hold policy as well as the bed hold agreement will be placed in a binder at the nurse's station. If a resident must be transferred, the facility form will be completed in person or via phone if required, with the original provided to patient or responsible party and a copy to remain in the chart. 4. DON or designee will provide education to nursing staff on the proper procedure for issuing the bed hold notice. 5. DON or designee will audit all transfers three times weekly x 4 weeks, then two times monthly x 2 months to ensure that the proper bed hold policy is initiated and executed. Results will be taken to the QAPI committee for review of findings and further interventions if warranted.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for two residents, leading to discrepancies in their documented status. Resident 9, diagnosed with Multiple Sclerosis and neurogenic bladder, had a physician's order for a Foley catheter. However, the Quarterly MDS inaccurately indicated that the resident was occasionally incontinent of urine, which was confirmed as an error by the Director of Nursing during an interview. This misrepresentation of the resident's continence status was due to incorrect coding on the MDS. Similarly, Resident 32, who had diagnoses of heart failure and chronic kidney disease, experienced an unwitnessed fall resulting in an abrasion on the left thigh. Despite this incident, the Significant Change MDS inaccurately recorded that the resident had not experienced any falls since admission or prior assessment. This error was also confirmed by the Director of Nursing, indicating a failure to accurately document the resident's fall history in the assessment.
Plan Of Correction
1. R9 and R32 MDS were corrected with accurate coding and resubmitted with modifications. 2. The regional care manager will complete education with the Licensed Practical Nurse Assessment Coordinator on accurate coding of identified sections of MDS per RAI guidelines and appropriate coding with emphasis on accurate coding. 3. An initial audit of MDS's will be completed for the past 30 days on identified residents. The Licensed Practical Nurse Assessment Coordinator will complete all assessments. 4. Licensed Practical Nurse Assessment Coordinator / Designee will complete an audit of 5 resident MDS submissions weekly x 4 weeks, then 5 resident MDS submissions two times monthly x 2 months. 5. When MDS is ready for submission, the Licensed Practical Nurse Assessment Coordinator will coordinate with the RN to verify accuracy of MDS prior to submission. 6. The results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Provide Scheduled ADL Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This deficiency was identified for one of two residents reviewed for ADLs, specifically Resident 23. The facility's policy on ADLs emphasizes maintaining as much independence as possible in daily activities, including hygiene. However, Resident 23, who has diagnoses of spinal stenosis, repeated falls, and muscle weakness, reported not receiving a shower for over two weeks at times, and specifically not for eight days recently. Resident 23's clinical record indicated a preferred shower schedule of Wednesdays and Saturdays during the 2-10 shift, but records showed missed showers on multiple dates in January, February, March, and April 2025. The Nursing Home Administrator noted that Resident 23 sometimes refused to get out of bed for showers, but there was no documentation of such refusals or any reapproach attempts in the clinical record. The Director of Nursing stated that staff are expected to document refusals and reapproach residents later, which was not done in this case.
Plan Of Correction
1. Facility cannot edit old documentation errors. 2. Facility will audit ADL care for dependent residents with regards to hygiene and bathing to identify any baseline opportunities for missed documentation or incorrect documentation. 3. DON or designee will provide education to the nursing staff on reviewing the ADL coding report prior to end of shift to ensure completion and accuracy of hygiene and bathing (showers) and address concerns prior to end of shift. 4. DON or designee will provide education to nursing staff regarding ADL coding and accuracy of coding in regard to hygiene and bathing. 5. Nursing staff will run an ADL coding report prior to end of all shifts with regards to bathing and hygiene (showers) to ensure showers are given and if resident is refusing what other alternatives were offered (bed bath). 6. An audit will be conducted by DON or designee three times weekly x 4 weeks, then two times monthly x 2 months for ADL coding for dependent residents with regards to hygiene and bathing. 7. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Ensure Timely Cardiology and Pacemaker Checks
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for a resident with Alzheimer's disease, atrioventricular heart block, and a cardiac pacemaker. The resident's clinical record did not contain current physician orders for a cardiology consult or pacemaker checks, despite the presence of a remote telephonic pacemaker check device at the resident's bedside. The last documented pacemaker remote check was completed several months prior, and the care plan for the pacemaker had not been revised since July 2022. The Director of Nursing (DON) acknowledged the oversight after being informed of the issue. The DON discovered that the cardiology office had sent appointment letters to an incorrect address and had not listed the facility as the primary contact for the resident. Consequently, the resident missed the scheduled yearly cardiology appointment and the three-month remote pacemaker checks. The cardiology office confirmed that the pacemaker was still transmitting data but had not alerted the facility to any issues due to the contact information error.
Plan Of Correction
1. R24's yearly pacemaker appointment has been scheduled. 2. Facility will audit pacemaker orders and appointments on other residents to identify any baseline opportunities for missed pacemaker checks and/or annual appointments. 3. A Binder will be kept at the nurse's station with all residents that have pacemakers to ensure yearly appointments and regular checks are not missed going forward. 4. DON or designee will provide education to nursing staff on reviewing all pacemaker orders to ensure they are entered correctly, and appointments are made accordingly. 5. An audit will be conducted by DON or designee monthly x 3 months on all cardiac pacemakers to ensure remote checks are taking place and that yearly appointments are made. 6. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Deficiency in Resident Care Coordination and Restorative Nursing
Penalty
Summary
The facility failed to ensure that Resident 24 received her annual cardiology appointment and remote pacemaker checks. The Director of Nursing (DON) confirmed that the facility staff should have followed up with the cardiology office when they did not follow up with the facility. This oversight indicates a lapse in the facility's responsibility to coordinate and ensure necessary medical appointments and checks for their residents. Additionally, the facility did not provide the required restorative nursing care for Resident 29, who was diagnosed with peripheral vascular disease and hypertension, and had a condition of flaccid hemiplegia on the right side. The clinical records showed that the restorative nursing program tasks for both passive and active range of motion exercises were not completed as prescribed. Specifically, there were multiple days in April 2025 where the exercises were either not completed twice daily or marked as "not applicable," contrary to the expectations of the Nursing Home Administrator.
Plan Of Correction
1. The facility cannot address past missed RNP programs. 2. Therapy department will do a baseline assessment for any adverse reactions from not receiving the RNP for resident 29. 3. Facility will audit residents on a restorative nursing program to identify any baseline opportunities for missed RNP on residents. 4. DON or designee will provide education to nursing staff on providing restorative care as documented in the restorative nursing program. 5. An audit will be conducted by DON or designee on 5 random residents with RNP's weekly x 4 weeks, then 5 random residents with RNP's monthly x 2 months to ensure that all restorative nursing programs are documented as completed. 6. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection control program during the preparation and administration of medications for three residents. The facility's policy on medication administration requires staff to adhere to good hand hygiene, including washing hands before beginning a medication pass, prior to handling any medication, and after coming into direct contact with a resident. However, during a medication pass observation, Employee 2 did not follow these guidelines. After administering an insulin injection to Resident 9, Employee 2 did not cleanse her hands before preparing medications for Resident 27. Employee 2 also failed to follow proper infection control procedures when performing a blood glucose test for Resident 27. She used her gloved hand to close a window and then proceeded with the test without changing gloves. Additionally, she did not properly clean the glucometer according to the facility's policy, which requires cleaning and disinfecting the device after each use. Employee 2 was unsure of the correct cleaning procedure and used an alcohol pad instead of the required germicidal disposable wipe. Furthermore, Employee 2 did not adhere to Enhanced Barrier Precautions (EBP) when attending to Resident 155, who had a central line. Despite the EBP sign indicating the need for hand cleansing and wearing gloves and gowns, Employee 2 entered the room without cleansing her hands and did not wear a gown while flushing the central line. These actions were confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for staff to follow personal protective equipment guidance and hand hygiene protocols.
Plan Of Correction
1. DON will provide education to Employee 2 on infection control practices during medication administration to ensure all infection control procedures are being followed. 2. DON will provide education to Employee 2 on Enhanced Barrier precautions for gown and gloves when giving care to an individual on these precautions. 3. DON will provide education to Employee 2 on proper cleaning and disinfecting of glucometers after each use. 4. DON will provide education to nursing staff on infection control practices during medication passes, Enhanced Barrier Precautions, and proper glucometer disinfecting. 5. Resident's 9, 27 and 155 were all assessed for any adverse effects regarding nonadherence to infection control practices and enhanced barrier precautions. 6. All other residents on Employee 2's medication pass were assessed for any adverse reactions related to not following infection control practices and enhanced barrier precautions. 7. DON/ designee will conduct an audit 2 times a week x 4 weeks on via direct observation of a medication pass, then monthly x 2 months. 8. All findings will be taken to QAPI for review.
Failure to Conduct TB Screening for New Employee
Penalty
Summary
The facility failed to adhere to its policy regarding tuberculosis (TB) screening for newly hired employees. According to the facility's policy, IM-162 Tuberculosis-Employee Screening, revised on June 14, 2023, each newly hired employee must be screened for TB infection and disease after an employment offer has been made but before the employee begins their duties. However, a review of the personnel records revealed that one of the five employees reviewed, referred to as Employee 1, did not receive the required tuberculin screening within the specified timeframe. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the process is currently being worked on.
Plan Of Correction
1. Facility policy has been reviewed and revised in accordance with state regulations. 2. Employee 1 has had a TB questionnaire completed and signs/symptoms were all negative. 3. Employee 1 had a T-Spot done. 4. NHA will provide education to HR Coordinator regarding TB testing completion before a candidate starts on their job duty assignment. 5. Baseline audit will be completed on employee files to determine compliance with TB screening. 6. NHA or designee will conduct an audit monthly x 2 months on all new hires to ensure all have proper TB documentation before the start date of employment. 7. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.
Failure to Maintain Clean and Homelike Environment in Common Areas and Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several common areas and in one resident room. Observations revealed multiple ceiling tiles with brown ring stains in the South and East Hallways, as well as at the Nurse's Station. Additionally, a brown liquid stain was observed dripping down the side of a wall in the East Hallway. In one resident's room, there were stained ceiling tiles at the entrance and in the middle of the room, all with visible brown liquid marks. These findings were inconsistent with the facility's policy, which requires regular cleaning and disinfection of environmental surfaces, especially when visibly soiled. Interviews with the Maintenance Director confirmed that maintenance staff are responsible for conducting regular environmental rounds and room checks to identify issues requiring repair or replacement. The Maintenance Director acknowledged ongoing issues with roof leaks during heavy rain and stated that staff should have identified and replaced the soiled ceiling tiles and cleaned the stained wall. The Nursing Home Administrator also stated that he would expect soiled ceiling tiles to be identified and replaced, and environmental surfaces to be cleaned when soiled.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five nurse aides reviewed, as required by its own Employee Handbook and state regulations. Documentation showed that these nurse aides had been employed for over a year, but their most recent annual evaluations could not be located. The Nursing Home Administrator confirmed that the facility had recently switched electronic systems for employee evaluations, resulting in the loss of some records if they had not been printed prior to the transition. Additionally, one nurse aide confirmed she had not received an annual evaluation. The administrator acknowledged that annual evaluations were expected to be completed and available for review.
Food Service Safety Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the main kitchen area, as observed during a survey. Employees working in the kitchen were found without hairnets, which is a violation of the facility's policy on food preparation and handling. Additionally, an open bottle of stir fry sauce was found in the dry storage area without an open date, despite instructions on the bottle to refrigerate after opening. This indicates a failure to properly label and store food items as per the facility's food storage policy. Further observations revealed unsanitary conditions in the kitchen, with clean utensils stored in a drawer containing dried food particles. The drawer and its surrounding areas also had dried food stuck on them, which is contrary to the facility's policy that requires kitchen surfaces and equipment to be cleaned and sanitized. These deficiencies were confirmed by the Nursing Home Administrator and the Food Service Director during interviews conducted immediately after the observations.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide the required notification to the Office of the State Long-Term Care Ombudsman regarding the transfer of four residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. The residents involved had various medical conditions, including chronic kidney disease, hypertension, chronic obstructive pulmonary disease, multiple sclerosis, stage 4 pressure ulcer, dementia, and ileus. Each resident was transferred to the hospital due to their medical conditions, but the facility did not notify the Ombudsman as required. Interviews with the Nursing Home Administrator confirmed that the notifications were not made for any of the four residents. The transfers occurred between January and April 2024, and the lack of notification was acknowledged during interviews conducted in May 2024. This failure to notify the Ombudsman is a violation of the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa Code 201.18(b)(3).
Failure to Provide Necessary ADL Assistance to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was provided with the necessary care and services related to hygiene and bathing, which are part of the activities of daily living (ADLs). Resident 32 has a medical history that includes chronic respiratory failure and hypoxemia. Despite having a restorative nursing program in place that required staff to assist the resident with washing and drying her face, hands, and upper body, and performing grooming tasks, there were multiple instances where these tasks were not completed. The resident reported not receiving a wash-up on a specific morning, and the clinical record review showed several dates where the ADL tasks were marked as 'Not Applicable,' indicating they were not performed. During an interview, the Director of Nursing was unable to provide an explanation for why the ADL tasks were not completed on the specified dates. The Nursing Home Administrator expressed an expectation that the resident's ADL tasks should have been completed. This deficiency was identified during a survey, and it highlights a failure in the facility's responsibility to maintain the resident's ability to perform ADLs unless there is a medical reason for the decline, as per the regulatory requirement under 28 Pa code 211.12(d)(1)(5) Nursing services.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing activities program designed to meet the physical, mental, and psychosocial well-being of residents. This deficiency was identified through resident and staff interviews, as well as a review of facility documents. It was revealed that the facility employs only one activity staff member who works Monday through Friday, resulting in no scheduled activities for residents on weekends. Residents expressed dissatisfaction during interviews, noting that scheduled activities are sometimes canceled, and the activity director appears to be overwhelmed and in need of assistance. Further review of the facility's Resident Council Meeting Minutes from March and April 2024 highlighted ongoing concerns about the lack of activities. Residents reported that activities have deteriorated, with the activities director often absent, leaving residents alone in the dayroom with only movies to watch. The minutes also indicated a desire for a volunteer program and more outdoor activities. The facility's activity calendar for March, April, and May 2024 confirmed the absence of scheduled activities on weekends. The Nursing Home Administrator acknowledged the lack of weekend activities and confirmed the activity director's Monday through Friday schedule.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to provide therapeutic diets as per physician's orders for residents requiring specific dietary management. Specifically, four residents on a renal/low potassium diet and eighteen residents on a consistent carbohydrate diet did not receive the appropriate dietary modifications. The facility's dietary extension sheets, which guide meal preparation based on diet orders, did not document these therapeutic diets. Instead, they only included regular, dysphagia advanced, and puree diets. This oversight was identified during a review of the facility's diet type report and extension sheets, which revealed discrepancies between physician orders and the diets provided. Interviews with facility staff, including the Food Service Director and the Nursing Home Administrator, confirmed that the facility did not offer renal or consistent carbohydrate diets, and these were not documented on the extension sheets. The Food Service Director acknowledged that dietary restrictions for these diets were communicated verbally to staff, but there was no formal documentation or adherence to the prescribed therapeutic diets. This lack of documentation and adherence to physician orders led to the deficiency, as the facility did not ensure that residents received the necessary dietary management to maintain their health.
Deficiencies in Respiratory Care and Oxygen Services
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards for four residents. Resident 14, diagnosed with COPD and MS, had nebulizer equipment left on the bedside table instead of being stored in a labeled plastic bag as per facility policy. This was observed on two consecutive days, and staff confirmed the equipment should have been bagged. Resident 31, with chronic respiratory failure and other conditions, had nebulizer equipment that was not covered or removed despite not needing the medication since January. The equipment was dated from January, and the nightstand was observed to have a white powdery residue. Staff acknowledged the equipment should have been bagged or removed, and the nightstand cleaned. Resident 32, with chronic respiratory failure and hypoxemia, was using oxygen without a physician's order documented until May. The care plan did not initially include oxygen use as an intervention, and there were gaps in the treatment administration record for changing oxygen equipment. Resident 111, with COPD and obstructive sleep apnea, had an undated, opened container of distilled water in their room, contrary to facility policy. Staff confirmed the water should have been dated.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety in both the kitchen area and the nourishment pantry. Observations revealed multiple instances of improper food storage and labeling. In the dry store room, a half package of pasta was found open and not securely closed. In the walk-in refrigerator, a container of thirty hard-boiled eggs and a 25-pound container of hard-boiled eggs were not securely closed or date marked. Additionally, in the walk-in freezer, several bags of meat, including beef hamburgers, chicken breasts, and pork sausage, were not date marked. Further issues were identified in the nourishment pantry. The freezer contained containers of vanilla ice cream and boxes of chocolate-coated vanilla ice cream cones that were not labeled with a resident identifier or date marked. In the refrigerator, open containers of fortified nutritional shakes and a plastic thermal bowl of tomato soup were not date marked. The soup was improperly stored and should have been discarded after meal service. These deficiencies were confirmed through interviews with the Food Service Director and the Nursing Home Administrator, who acknowledged the concerns but provided no further information.
Failure to Ensure Dignified Meal Service
Penalty
Summary
The facility failed to ensure each resident's right to a dignified existence during meal service, as observed in one dining room. According to the facility's policy on Resident Rights, meals should be provided to all residents at each table simultaneously. However, during lunch on May 6, 2024, it was observed that Resident 50 was eating her lunch while Residents 6, 10, 17, and 30, who were seated at the same table, had not yet been served. The meals for these residents were served at staggered times, with Resident 30 receiving her meal at 1:04 PM, Resident 6 at 1:08 PM, Resident 17 at 1:12 PM, and Resident 10 at 1:25 PM. Further observations on May 6 and May 8, 2024, revealed that all residents in the dining room were served their meals on trays, contrary to the facility's policy. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 8, 2024, the NHA acknowledged that residents should be provided meals at the same time and should not be served meals on trays. This inconsistency with the facility's policy led to the determination of a deficiency in honoring the residents' rights to a dignified existence.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide residents with a copy of the bed-hold policy upon their transfer to a hospital, as required by their own policy. The policy, titled 'Bed Holds and Returns and Therapeutic Leave of Absence,' mandates that residents receive information on bed hold requirements upon admission and again at the time of transfer. However, for three residents reviewed for hospitalization, this policy was not followed. Resident 10, who had chronic kidney disease and hypertension, was transferred to the hospital without receiving the bed hold notice. Similarly, Resident 14, with chronic obstructive pulmonary disease and multiple sclerosis, was also transferred without receiving the notice, despite being an automatic 15-day bed hold under Medicaid. Resident 26, suffering from a stage 4 pressure ulcer and hypertension, was transferred without the notice as well. Interviews with the Nursing Home Administrator (NHA) confirmed the oversight in providing the bed hold notices. The NHA acknowledged that Resident 10 and Resident 26 did not receive the bed hold notice upon their transfer to the hospital. In the case of Resident 14, the NHA stated that the notice was not provided due to the automatic Medicaid bed hold, which was a misinterpretation of the policy requirements. This failure to adhere to the facility's policy resulted in a deficiency as it did not comply with the regulatory requirements to inform residents or their representatives about the duration of the bed hold policy during transfers.
Inaccurate Resident Assessments in Clinical Records
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to deficiencies in their clinical records. Resident 21, diagnosed with dementia, Parkinson's disease, moderate protein-calorie malnutrition, and psychosis, was on hospice services since November 15, 2023. However, the quarterly Minimum Data Set (MDS) dated February 7, 2024, did not document the hospice services. This oversight occurred because the physician's order for hospice services had an end date of November 19, 2023, causing it to fall off the physician orders. The Director of Nursing confirmed this during an interview, and the facility later provided an amended MDS to include hospice services. Resident 32, diagnosed with chronic respiratory failure and hypoxemia, was observed using oxygen at 2 liters on multiple occasions. Despite this, the quarterly MDS indicated that the resident had not used oxygen during the lookback period. Progress notes from February 26 and February 28, 2024, documented the resident's continued use of oxygen. During an interview, the Director of Nursing and the Nursing Home Administrator acknowledged that the MDS should have indicated oxygen use, and a modification MDS was completed to correct this error.
Failure to Include Hemodialysis in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who had been admitted to skilled nursing care following hospitalization. The resident, who had a history of hemodialysis, protein calorie malnutrition, and diabetes mellitus, did not have an order for hemodialysis or related care needs documented in their physician orders. Additionally, the baseline care plan did not include hemodialysis and the necessary care surrounding it. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that hemodialysis and related care should have been included in the baseline care plan.
Failure to Provide Timely Medication Due to Administrative Oversight
Penalty
Summary
The facility failed to provide routine drugs to its residents, specifically failing to ensure the timely acquisition and administration of a nicotine patch for a resident with chronic obstructive pulmonary disease and obstructive sleep apnea. The resident had an order for a nicotine patch starting on May 1, 2024, for smoking cessation, but the medication was not administered from May 1 to May 6, 2024. The medication administration record indicated that the nicotine patch was not available, and nursing notes confirmed that the medication was on order and pending delivery from the pharmacy. The delay in providing the nicotine patch was attributed to the requirement for an over-the-counter (OTC) authorization form, which was not completed in a timely manner by the nursing staff. The Director of Nursing confirmed that nicotine patches are not stocked in-house and require an OTC authorization form for the pharmacy to send them. This oversight resulted in a delay in the resident receiving the prescribed medication until May 7, 2024, when the patch was finally applied by a Licensed Practical Nurse.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The facility failed to provide food and beverages at a safe and appetizing temperature during a meal service on the South unit. This deficiency was identified through observation, review of facility policy, and interviews with residents and staff. The facility's policy on Hazard Analysis Critical Control Points and Food Safety, dated 2021, requires staff to handle potentially hazardous foods carefully, with specific temperature guidelines for cold and hot foods. However, during a test tray conducted on May 6, 2024, the temperatures of coffee and milk were found to be unsatisfactory, measuring 134 degrees Fahrenheit and 51 degrees Fahrenheit, respectively. These temperatures did not meet the standards set by the facility's policy or the United States Department of Health and Human Services Food Code. Interviews with staff revealed a lack of a test tray form or policy for checking food temperatures at the point of service. Employee 6, a Dietary Aide, confirmed the expected temperatures for coffee and milk, while Employee 5, the Food Service Director, acknowledged the absence of a formal procedure for monitoring these temperatures. The Nursing Home Administrator noted that the meal service on May 6th was the first day the main dining room was closed for renovations, resulting in all residents being served on meal trays. Resident council meeting minutes from February and March 2024 also documented concerns about cold food, indicating ongoing issues with food temperature management.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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