Warren Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Pennsylvania.
- Location
- 682 Pleasant Drive, Warren, Pennsylvania 16365
- CMS Provider Number
- 395650
- Inspections on file
- 25
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Warren Manor during CMS and state inspections, most recent first.
The facility did not maintain its sprinkler system as per NFPA 25 standards. Observations revealed that the kitchen dishwashing area had dust-covered, dirty, and corroded sprinkler heads, and the required sprinkler wrench was not available. These issues were confirmed by the maintenance supervisor.
The facility failed to maintain electrical receptacles in compliance with safety standards in one of over thirty rooms. An observation revealed that the A wing resident laundry room had a washing machine without GFCI protection. This deficiency was confirmed by the maintenance supervisor.
The facility failed to maintain accurate evacuation diagrams, as the diagram in the PT corridor did not display two exit routes from the viewer's location, violating NFPA 170 standards. This deficiency was confirmed by the maintenance supervisor.
Surveyors identified that staff did not follow physician's orders for four residents, including not repositioning a resident with a pressure injury as ordered, allowing weight bearing during transfers for a resident with a non-weight bearing order, failing to provide BiPAP therapy as prescribed, and missing or lacking documentation for wound care treatments. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Three residents with respiratory conditions had oxygen concentrators that were visibly dirty with a white, fluffy substance and dried liquid, and one resident was not receiving oxygen as ordered, with their nasal cannula found on the floor. An LPN confirmed the equipment was not clean and that oxygen therapy was not being provided per physician orders.
A resident with multiple medical conditions did not receive scheduled baths or showers according to their preference over several weeks. Documentation lacked evidence of hygiene care on multiple scheduled dates, and the resident reported and exhibited signs of poor personal hygiene. The DON confirmed the failure to provide bathing as scheduled.
A resident with multiple medical conditions did not receive required quarterly financial statements for their trust fund account, as confirmed by both the resident and the Business Office Manager. Facility policy mandates these statements, but there was no evidence they were provided.
A resident with multiple medical conditions was incorrectly informed by the Business Office Manager that Medicare would cover their stay, but it was later found that Medicare benefits had been exhausted, resulting in a large outstanding balance. The resident and their representative were not given accurate or timely information about financial responsibility, preventing them from making informed decisions about care and payment options.
A resident who transitioned from Medicare covered services to long-term care did not receive the required SNFABN of Non-coverage when Medicare Part A was discontinued, even though benefit days were not exhausted. The Business Office Manager confirmed that neither the resident nor their representative was given advance notice as required.
The facility did not resolve or document grievances related to care and treatment for four residents, including issues with communication about test results, lack of access to a BIPAP machine, and concerns about noise, smoke, hydration, and care routines. Interviews revealed that these concerns were communicated to staff but were not addressed, and the grievance process was found to focus only on missing or broken items rather than care issues.
The facility did not update a resident's care plan to reflect a new non-weight bearing order and failed to provide evidence that two residents or their representatives were invited to or attended care plan conferences, as required by policy and regulations.
A resident was observed keeping and using electronic cigarettes/vaporizers in their room, an unauthorized area, without staff supervision or facility control of smoking materials. Facility leadership confirmed the resident's noncompliance with the smoking policy, resulting in a lack of accountability and increased safety risk.
Surveyors found that leftover potato triangles in a walk-in cooler were stored past the facility's three-day use policy and lacked a discard date. The Dietary Manager confirmed the food item should have been discarded according to facility policy.
An LPN failed to clean and disinfect a blood glucose meter after using it on multiple residents, placing the soiled device on the medication cart between uses and not following manufacturer or facility infection control guidelines. The Infection Preventionist confirmed that the device should have been disinfected after each use.
A resident with Type 2 diabetes and other medical conditions was incorrectly documented as receiving insulin on multiple MDS assessments, when in fact the resident was administered Trulicity, a non-insulin diabetes medication. This error was confirmed by the RN Assessment Coordinator and resulted in inaccurate medical records.
Warren Manor did not meet the required NA staffing ratios on a specific day, with insufficient NAs during both the day and overnight shifts for a census of 102 residents. The deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing ratios on both evening and overnight shifts during a review period. On specific days, the evening shift had fewer LPNs than required for the resident census, and the overnight shift also fell short of the minimum LPN requirement. The Nursing Home Administrator confirmed these staffing deficiencies.
A resident with a known fish allergy was mistakenly served a breaded fish patty instead of the specified pork patty, leading to an allergic reaction. The facility's policies for communication and allergen awareness were not effectively implemented, resulting in a lapse in management and communication processes. This incident was confirmed by the Nursing Home Administrator, highlighting a violation of resident care and rights regulations.
The facility failed to review and revise comprehensive care plans for three residents within the required timeframe. Residents with various diagnoses, including diabetes, high blood pressure, chronic kidney disease, dementia, COPD, and GERD, had care plans that were not updated by their target dates. The care plans covered issues such as self-care, skin integrity, falls, and medication use. The Nursing Home Administrator confirmed the oversight, indicating non-compliance with the facility's policy.
The facility failed to update care plans for four residents, leading to discrepancies between documented care preferences and actual care plans. Two residents had care plans indicating Full Code status despite having DNR orders, while two others lacked documentation for necessary wound vacuum treatments. The DON confirmed these care plans were not updated to reflect current medical needs.
The facility failed to properly label and store medications, including expired insulin pens and an undated tuberculin vial. A narcotic storage box was not secured in the refrigerator, and an LPN left medications unattended in a resident's room. These actions violate facility policies and compromise medication management and security.
A resident's Foley catheter and wound vacuum equipment were improperly placed on the floor, contrary to manufacturer's instructions, and an LPN used an ungloved finger to handle medication pills. The DON confirmed the absence of policies addressing these issues.
The facility failed to ensure consistency between physician orders, POLST forms, and paper charts for two residents, leading to discrepancies in their life-sustaining treatment preferences. One resident's records showed a DNR status, but the paper chart indicated Full Code. Another resident's records also showed a DNR status with limited interventions, but the paper chart incorrectly labeled them as Full Code. These inconsistencies were confirmed by facility staff.
A facility failed to develop a comprehensive care plan for a resident with dementia, high blood pressure, and anxiety. Despite a physician's order for a secure care band to prevent elopement, the clinical record lacked a care plan addressing this risk. This deficiency was confirmed by the RN Assessment Coordinator.
A resident with stage four pressure ulcers and MRSA did not receive wound care as per physician orders, with dressings applied incorrectly. The facility also failed to ensure annual staff competencies in wound care, as confirmed by the Nursing Home Administrator and DON.
The facility failed to ensure accurate MDS assessments for four residents. A resident's MDS was incorrectly coded regarding the use of a wander/elopement alarm, while another resident's MDS inaccurately reflected urinary continence status despite having a catheter. Additionally, a resident's MDS did not account for the use of a CPAP device. These errors were confirmed by the RNAC.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, as evidenced by observations and interviews conducted during a survey. Specifically, the kitchen dishwashing area was found to have sprinkler heads that were dust-covered, dirty, and corroded. Additionally, the facility did not have the required sprinkler wrench available at the time of the survey. These deficiencies were confirmed through an interview with the maintenance supervisor.
Plan Of Correction
Sprinkler heads in kitchen area to be replaced. Sprinkler wrench to also be replaced. Cleanliness of sprinkler heads to be monitored by Environmental Services Supervisor or designee weekly for one month. Findings to be discussed at Quality Assurance Performance Improvement meeting.
Electrical Receptacle Deficiency in Laundry Room
Penalty
Summary
The facility failed to maintain electrical receptacles in compliance with safety standards in one of over thirty rooms. During an observation on April 8, 2025, at 10:55 a.m., it was noted that the A wing resident laundry room had a washing machine that was not equipped with ground fault circuit interrupter (GFCI) protection. This deficiency was confirmed through an interview with the maintenance supervisor at the same time, who acknowledged the lack of GFCI protection for the electrical outlet in question.
Plan Of Correction
Laundry room receptacle replaced with ground fault circuit interrupter protection. Whole house audit to be completed by Environmental Services Supervisor or designee to ensure all outlets are in compliance by 4/30. Findings to be discussed at Quality Assurance Performance Improvement meeting.
Evacuation Diagram Deficiency in PT Corridor
Penalty
Summary
The facility failed to maintain accurate evacuation diagrams, as observed on April 8, 2025. Specifically, the evacuation diagram located in the PT corridor did not display two exit routes from the viewer's location, which is a requirement under NFPA 170 - 11.2.4 and 11.3.2. This deficiency was confirmed during an interview with the maintenance supervisor conducted at the same time as the observation.
Plan Of Correction
Physical Therapy hallway evacuation plan was updated. All other evacuation diagrams reviewed to verify two exit routes on each one. Findings will be reported at Quality Assurance Performance Improvement meeting.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to follow physician's orders for four residents, as evidenced by clinical record reviews, staff interviews, and direct observations. One resident with a history of a Stage Three pressure injury to the coccyx had a physician's order to be repositioned every two hours to offload the coccyx. However, observations showed the resident remained in a wheelchair for approximately four hours without repositioning, and staff interviews confirmed the order was not followed during this period. Another resident with a broken left hip and a physician's order for no weight bearing on the left leg was observed being transferred in a manner that allowed weight bearing on the affected leg. Staff interviews confirmed that the resident was assisted to stand and hold onto a grab bar, permitting weight bearing contrary to the physician's order. The Director of Nursing also confirmed that the current order required non-weight bearing status, which was not maintained. A third resident with a physician's order for BiPAP therapy at hours of sleep was found to be without the BiPAP machine for several months, as confirmed by both the resident and staff. Additionally, a fourth resident with an order for Active Critical Care 30 ml twice daily for wound healing had multiple missed or undocumented administrations of the treatment, as shown in the Medication Administration Record and confirmed by the Director of Nursing. No facility policy regarding following physician's orders was provided.
Failure to Maintain Clean Respiratory Equipment and Administer Oxygen as Ordered
Penalty
Summary
The facility failed to maintain cleanliness and proper infection control regarding respiratory care equipment for three residents, as well as failed to provide oxygen therapy according to physician's orders for one resident. Observations revealed that oxygen concentrators for all three residents had a significant accumulation of a white, fluffy substance and dried liquid on their surfaces, which persisted over multiple days. Additionally, one resident's nasal cannula was found on the floor, and the resident was not receiving oxygen as ordered by the physician. The clinical records for these residents included diagnoses such as hypertension, anxiety, hypothyroidism, COPD, hyperlipidemia, and respiratory failure, with physician orders specifying weekly maintenance and cleaning of oxygen equipment. Staff interviews confirmed that the oxygen concentrators should have been kept clean and that oxygen therapy should have been administered as prescribed. The LPN interviewed acknowledged the presence of the white substance and dried liquid on the equipment, as well as the failure to ensure the resident was receiving oxygen and that the nasal cannula was not on the floor. These findings indicate lapses in following physician orders and facility policies related to respiratory care and infection control.
Failure to Provide Scheduled Bathing According to Resident Preference
Penalty
Summary
The facility failed to provide a resident with baths or showers according to their scheduled days and personal preference. Documentation for the resident showed that several scheduled bath/shower dates were marked as 'not applicable,' and there was no evidence that the resident received the necessary hygiene care during the specified period. The facility's policy requires that each resident receive care and services to maintain the highest practicable physical, mental, and psychosocial well-being, including assistance with activities of daily living such as grooming and personal hygiene. The resident, who has diagnoses including morbid obesity, urinary tract infection, hypokalemia, and hypothyroidism, reported not receiving scheduled showers for several weeks. During an interview, the resident expressed concern about greasy and knotted hair, which was also observed by surveyors. The DON confirmed that the resident did not receive baths or showers as scheduled and preferred during the review period.
Failure to Provide Resident with Required Quarterly Financial Statements
Penalty
Summary
The facility failed to provide quarterly financial statements to a resident whose personal funds were managed by the facility. According to facility policy, residents are entitled to receive a quarterly accounting of deposits, interest earned, and withdrawals from their trust fund accounts. Documentation showed that the facility was responsible for handling the resident's finances, and the resident's account had a balance of $1.74. However, during an interview, the resident reported not receiving any financial statements regarding their funds or a monthly allowance. Further investigation revealed that the Business Office Manager confirmed quarterly financial statements were not provided at the end of the quarter or within 30 days of the quarter's end. The facility lacked evidence that the resident was given statements detailing deposits, interest, or withdrawals. The resident's clinical record included diagnoses of morbid obesity, urinary tract infection, hypokalemia, and hypothyroidism at the time of the deficiency.
Failure to Provide Accurate Insurance Coverage Information to Resident
Penalty
Summary
The facility failed to provide accurate and timely communication regarding insurance coverage for a resident's stay and services. The resident, who had diagnoses including osteomyelitis of the left ankle and foot, anemia, metabolic encephalopathy, and chronic atrial fibrillation, was admitted and later discharged after a period of care. During the stay, the Business Office Manager informed the resident's representative that Medicare would cover the stay and that there would be no private pay responsibility. However, it was later discovered that the resident had exhausted Medicare benefits, resulting in a significant outstanding balance for the period of care. The Business Office Manager acknowledged that the information about insurance coverage was confusing and that the resident's representative was not made aware of the financial responsibility until after the services had been provided. This lack of accurate and timely communication prevented the resident and their representative from making an informed decision about continuing the stay or considering alternative care and financial options.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) of Non-coverage to a resident or the resident's representative when Medicare Part A coverage was discontinued, even though the resident's benefit days were not exhausted. The resident had returned from a qualifying hospital stay and began receiving Medicare covered services, but when the facility initiated discharge from Medicare coverage, there was no documentation that the SNFABN was given in advance as required. This was confirmed by the Business Office Manager, who acknowledged that the notice was not provided at the time Medicare services ended, despite the resident remaining in the facility for long-term care.
Failure to Address and Resolve Resident Grievances Related to Care and Treatment
Penalty
Summary
The facility failed to resolve grievances related to care and treatment for four residents, as required by its own grievance policy. The policy states that all complaints or grievances will be resolved promptly and fairly, and that residents, their representatives, or other interested parties are encouraged to bring concerns to the attention of the Administrator, who serves as the Grievance Officer. However, a review of the facility's grievance records from January through April 2025 showed no documentation of grievances from the four residents or their family member regarding care and treatment concerns, despite multiple interviews indicating that such concerns had been raised. Specifically, one resident reported repeated requests for lab and test results without resolution, while another expressed ongoing issues with noise and smoke from a resident smoking area outside their window, affecting their ability to open the window and sleep. A third resident stated they had been without their BIPAP machine for several days despite asking multiple staff members for assistance. Additionally, a family member of another resident reported multiple unresolved care concerns, including the location of the smoking area, resident hydration, and the timing of morning care. The Nursing Home Administrator confirmed that the facility's grievance process typically only addressed missing or broken items and acknowledged the lack of evidence that these care and treatment concerns were addressed in a timely manner.
Failure to Update Care Plans and Involve Residents in Care Plan Conferences
Penalty
Summary
The facility failed to provide evidence of conducting resident care plan conference meetings or inviting residents and/or their representatives to such meetings, as well as failed to revise comprehensive care plans to reflect current care needs for two residents. For one resident with a history of a broken left hip, spinal stenosis with disc degeneration, and difficulty walking, the clinical record showed a physician's order for no weight bearing on the left leg. However, the care plan was not updated to reflect this non-weight bearing status, and the Director of Nursing confirmed this omission during an interview. For another resident with diagnoses including chronic obstructive pulmonary disease, anxiety, and hyperlipidemia, the clinical record lacked evidence that the resident or their representative had been invited to or attended a care plan conference meeting following the most recent assessment. The resident confirmed not being invited or attending such a meeting, and the Social Service Manager also confirmed the absence of documentation regarding care plan conference invitations or attendance. These findings were in violation of facility policy and state regulations regarding care planning and resident involvement.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for one of two residents reviewed who smoke at the facility. According to the facility's Smoking Policy, residents are only permitted to smoke in designated areas and must be accompanied by staff, family, or properly trained volunteers. Smoking materials, including electronic cigarettes and vaporizers, are to be kept in a designated area accessible only by staff, and residents are not allowed to keep these items in their possession. Smoking in bed or in unauthorized areas is strictly prohibited. During the survey, observations revealed that a resident had several electronic cigarettes/vaporizers on their bedside table and was seen smoking an electronic cigarette/vaporizer in their room, which is not a designated smoking area. Interviews with the NHA and DON confirmed that the resident smokes in their room and keeps their own electronic cigarettes/vaporizers, contrary to facility policy. The facility had no accountability for these items, and the resident refused to follow the smoking policy, placing others at risk.
Improper Storage of Leftover Food in Walk-In Cooler
Penalty
Summary
The facility failed to store food in accordance with its own policy and professional food safety standards. During a kitchen tour, surveyors observed a clear plastic container in the walk-in cooler containing five leftover potato triangles (hashbrowns) that were labeled with a prepared date but lacked a discard date. The prepared date indicated that the food item was beyond the facility's policy of using or discarding prepared or leftover foods within three days. The Dietary Manager confirmed during the observation that the potato triangles were past their use-by date and should have been discarded.
Failure to Disinfect Blood Glucose Meter Between Resident Uses
Penalty
Summary
Facility staff failed to properly clean and disinfect a blood glucose meter (BGM) after use on multiple residents during medication administration. Manufacturer's guidelines and facility policy both require that the BGM be cleaned and disinfected after each use. Observations revealed that an LPN used the BGM to obtain blood specimens from three residents, placing the soiled device on top of the medication cart after each use without cleaning it according to the required procedures. It could not be determined if the BGM was cleaned before or after use for one of the residents. During interviews, the LPN confirmed not cleaning the BGM prior to obtaining blood specimens from two residents. The facility's Infection Preventionist also confirmed that the BGM should have been cleaned and disinfected after each use. These actions were in direct violation of both the manufacturer's instructions and the facility's own protocols for infection prevention and control.
Inaccurate MDS Assessment Coding for Diabetes Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for one resident, resulting in incorrect documentation of the resident's medication administration. Specifically, the MDS for this resident repeatedly indicated that insulin was administered one time during the seven-day look-back period for multiple quarterly and annual assessments. However, a review of the Medication Administration Records (MARs) showed that the resident was actually receiving Trulicity, a non-insulin injectable diabetes medication, and not insulin during those periods. The error was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS coding for insulin administration was incorrect and should have been recorded as zero days. The resident involved had a medical history including a bacterial bone infection, Type 2 diabetes, and an irregular heartbeat. The deficiency was cited under 28 Pa. Code 211.5(f)(x) for inaccurate medical records.
Staffing Ratio Deficiency at Warren Manor
Penalty
Summary
Warren Manor failed to meet the required nurse aide (NA) staffing ratios as per the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations. On December 15, 2024, the facility did not have the mandated minimum of one NA per 10 residents during the day shift, with only 9.06 NAs working when 10.20 were required for a census of 102 residents. Additionally, the overnight shift on the same day did not meet the requirement of one NA per 15 residents, with 6.35 NAs working when 6.80 were needed. This deficiency was confirmed by the Nursing Home Administrator during an interview on December 23, 2024.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Warren Manor will be protected from future staff ratios below the 1:10 nurse aide for days, 1:11 nurse aide for evenings, and 1:15 nurse aide for nights by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing/Designee. The Director of Nursing/designee will review the monthly schedule prior to its start date to review for adequate staffing and fill in missing shifts before giving to the staff. The nursing scheduler/designee will review projected staffing levels with the Director of Nursing/designee daily to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Charge Nurses will be educated on appropriate staffing ratios by Director of Nursing/designee by 1/31/25 to immediately contact Director of Nursing for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution. Warren Manor will continue to aggressively advertise externally for the recruitment of nursing/nurse aide applicants to enhance current staffing levels. The facility will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Warren Manor is an approved provider of the Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. The facility offers extra incentives to current staff to cover extra shifts. A weekly recruiting meeting is held to address open positions. Open walk-in interview sessions will be held weekly. Nurse aide ratios will be reviewed by Director of Nursing/nursing designee 3x's a week for a month, then weekly x3 weeks, then monthly x2 months. Results will be reported at the monthly Quality Assurance and Process Improvement committee meeting.
LPN Staffing Shortages on Evening and Overnight Shifts
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) on both the evening and overnight shifts during the review period from December 15, 2024, to December 21, 2024. Specifically, on December 19 and 20, 2024, the evening shift did not meet the minimum requirement of one LPN per 30 residents, with only 3.28 and 3.21 LPNs working against the required 3.43 and 3.50, respectively, for a census of 103 and 106 residents. Additionally, the overnight shift on December 19, 20, and 21, 2024, did not meet the minimum requirement of one LPN per 40 residents, with staffing levels of 3.28, 3.21, and 2.08 LPNs against the required 3.43, 3.50, and 2.60 for a census of 103, 105, and 104 residents, respectively. The Nursing Home Administrator confirmed these staffing shortages during an interview on December 23, 2024.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Warren Manor will be protected from future staff ratios below the 1:25 daylight Licensed Practical Nurse, 1:30 evening Licensed Practical Nurse, and 1:40 night Licensed Practical Nurse by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by Director of Nursing/Designee. The Director of Nursing/designee will review the monthly schedule prior to its start date to review for adequate staffing and fill in missing shifts before giving to the staff. The nursing scheduler/designee will review projected staffing levels with the Director of Nursing/designee daily to ensure that any foreseeable staffing levels below Licensed Practical Nurse ratios are adequately covered. Charge Nurses will be educated by Director of Nursing/designee by 1/31/25 on appropriate staffing ratios and to immediately contact Director of Nursing for any day that ratios unexpectedly drop below the nurse ratio minimum for immediate resolution. Warren Manor will continue to aggressively advertise externally for the recruitment of nursing applicants to enhance current staffing levels. The facility will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Administrative registered nurses are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. The facility offers extra incentives to current staff to cover extra shifts. A weekly recruiting meeting is held to address open positions. Open walk-in interview sessions will be held weekly. Licensed Practical Nurse ratios will be reviewed by Director of Nursing/nursing designee 3x's a week for a month, then weekly x3 weeks, then monthly x2 months. Results will be reported at the monthly Quality Assurance and Process Improvement committee meeting.
Failure to Prevent Allergen Exposure
Penalty
Summary
The facility failed to prevent exposure to a food allergen for a resident with a known allergy, resulting in an allergic reaction. The facility's policies, including the Nutrition Services Communication Form and Food Allergen Awareness, were not effectively implemented. These policies were designed to ensure communication between nursing and dietary staff and to prevent allergic reactions by identifying food allergens. However, on 11/11/2024, a resident with a documented fish allergy was mistakenly served a breaded fish patty instead of the specified breaded pork patty. This error occurred despite the meal tray ticket indicating the correct item, and the mistake was only realized after the resident began to develop a rash following consumption of the meal. The incident was confirmed by the Nursing Home Administrator during an interview on 12/23/2024, acknowledging that the facility did not adhere to the physician's orders to avoid serving the resident a food allergen. The deficiency was identified through a review of facility policies, clinical records, and staff interviews, highlighting a lapse in the facility's management and communication processes. The failure to provide the correct meal as per the resident's dietary restrictions led to an adverse health event, violating several Pennsylvania Code regulations related to resident care and rights.
Plan Of Correction
R1 was immediately sent to the hospital for assessment after the incident. All other food allergies in the facility were reviewed, and residents were interviewed to verify no allergic foods have been provided to them. An updated allergy list will be available to dietary staff and nursing staff to review. The Nutrition Services Supervisor or designee will highlight food allergies on meal tickets for every meal. The Nutrition Services Supervisor or designee will educate dietary and nursing staff on how to read meal tickets and how to cross-reference the tray with the ticket before serving by 1/23/25. The Nutrition Services Supervisor or designee will audit all trays with food allergies for accurate meal items during one meal per day daily for one week, weekly for one month, and monthly thereafter. Findings will be discussed at the Quality Assurance Performance Improvement meeting.
Failure to Update Resident Care Plans Timely
Penalty
Summary
The facility failed to review and revise comprehensive care plans for three residents within the required timeframe, as mandated by their policy. The policy requires that a comprehensive care plan be developed within seven days after the completion of a comprehensive assessment and periodically reviewed and revised by a team of qualified persons. However, for Residents R8, R11, and R14, the care plans were not updated by the target dates specified. Resident R8, with diagnoses including diabetes, high blood pressure, and chronic kidney disease, had 16 care plans with an outstanding target date of 8/13/24. Similarly, Resident R11, diagnosed with a left hip fracture, diabetes, and high blood pressure, had 14 care plans with an outstanding target date of 8/12/24. Resident R14, who has dementia, COPD, and GERD, had 17 care plans with an outstanding target date of 8/10/24. The care plans for these residents covered various problem categories such as self-care, skin integrity, falls, nutrition, and medication use, among others. The Nursing Home Administrator confirmed during a telephone interview that the care plans for these residents were not reviewed or revised within the required timeframe, indicating a lapse in adherence to the facility's policy and regulatory requirements.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current care and services for four residents. Resident R99's care plan inaccurately indicated Full Code status despite having a POLST and physician orders for Do Not Resuscitate (DNR) and Comfort Measures Only. Similarly, Resident R106's care plan also incorrectly listed Full Code, conflicting with the resident's POLST and physician orders for DNR with limited interventions. The Director of Nursing confirmed that the care plans for these residents were not updated to reflect their current care preferences. Additionally, the care plans for Residents R31 and R85 did not include necessary interventions for their medical conditions. Resident R31, who had stage four pressure ulcers and a physician's order for a wound vacuum application, lacked documentation in the care plan for this treatment. Similarly, Resident R85, with a stage four pressure ulcer and a physician's order for a wound vacuum, also had no evidence of this intervention in the care plan. The Director of Nursing confirmed the absence of these critical updates in the care plans, indicating a failure to align the care plans with the residents' current medical needs.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to adhere to proper labeling and storage protocols for medications, as evidenced by several observations and staff interviews. In one instance, a multi-dose insulin pen in the C Hall medication cart was found to be expired, and another insulin pen was not labeled with the date it was opened. Additionally, a multi-dose vial of tuberculin solution in the medication storage room was not labeled with the date it was opened, making it impossible to determine its expiration date. These lapses in labeling violate the facility's policy, which requires that the date opened be recorded on multi-dose vials and that they expire 28 days after initial use unless otherwise specified by the manufacturer. Furthermore, the facility failed to ensure the security of controlled substances. A secured narcotic storage box inside the medication refrigerator was not permanently affixed, potentially allowing unauthorized access to resident-specific medications. This was confirmed by the Director of Nursing during an interview. Additionally, an LPN left a medication cup with multiple unknown medications unattended in a resident's room while the resident was asleep, which was acknowledged as inappropriate by the LPN. These deficiencies highlight significant lapses in medication management and security protocols within the facility.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care and urinary catheter care for a resident, as well as during medication administration. The manufacturer's instructions for the Nisus pump wound vacuum specified that the pump should be kept in a clean environment and in its black carrying case. However, observations revealed that the resident's Foley catheter bag and tubing, along with the wound vacuum collection canister and tubing, were lying on the bedroom floor. This was confirmed by Registered Nurse Employee E2 and LPN Employee E3, who acknowledged that these items should not be on the floor. The resident involved had a flaccid neuropathic bladder, kidney failure, a stage four pressure ulcer, and malnutrition, with specific physician orders for catheter maintenance and wound care. Additionally, during medication administration, LPN Employee E5 was observed transferring pills into a medication cup and using an ungloved finger to hold the pills while pouring them into envelopes for crushing. LPN Employee E5 confirmed that touching the pills with bare hands was inappropriate. The Director of Nursing (DON) confirmed the lack of policies regarding these practices and acknowledged that the urine collection bag, tubing, and vacuum canister should not be on the floor, and that pills should not be touched with ungloved hands.
Inconsistencies in Life-Sustaining Treatment Documentation
Penalty
Summary
The facility failed to ensure consistency between physician orders, POLST forms, and paper charts for two residents, leading to a deficiency in honoring residents' rights to make decisions about their life-sustaining treatments. For one resident, identified as R99, there was a discrepancy between the physician's order, which indicated a Do Not Resuscitate (DNR) status, and the paper chart, which incorrectly labeled the resident as Full Code, meaning resuscitation should be performed. This inconsistency was confirmed by the Director of Nursing during an interview. Similarly, for another resident, identified as R106, the physician's order and POLST indicated a DNR status with limited interventions, including antibiotics as needed and no artificial feeding. However, the paper chart incorrectly labeled the resident as Full Code. This inconsistency was confirmed by the Registered Nurse Assessment Coordinator. These discrepancies highlight a failure to align critical documents that guide life-sustaining treatment decisions, potentially impacting the residents' rights and care.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident identified as R71. The facility's policy, dated 12/19/23, mandates the creation of a person-centered care plan with measurable objectives and timetables for each resident, addressing their medical, nursing, and psychosocial needs as identified in a comprehensive assessment. Resident R71, admitted with diagnoses including dementia, high blood pressure, and anxiety, had a physician's order dated 10/27/23 for a secure care band to be worn, with its placement verified every shift and function verified daily. However, the clinical record lacked evidence of a care plan addressing the resident's risk for elopement and the use of the secure care band. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator on 5/22/24.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to provide wound care consistent with physician orders for a resident with stage four pressure ulcers and other serious conditions. The resident, identified as R31, had been admitted with diagnoses including stage four pressure ulcers on the left and right buttocks, a bacterial infection of the bone, and MRSA. Physician orders specified the application of a wound vacuum to the left buttock and right hip pressure ulcers three times per week, and the use of Vashe moistened gauze on the left hip wound. However, during an observation of wound care, it was noted that the dressings were applied incorrectly, with the left hip dressing and the left buttock dressings reversed, contrary to the physician's orders. Additionally, the facility did not ensure that staff competencies related to wound care were performed annually. This was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the failure to complete wound care as ordered and the lack of annual competency assessments for wound care provision. These deficiencies were identified through a review of facility documents, clinical records, observations, and staff interviews.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of four residents. For Resident R12, the MDS was inaccurately coded as not using a wander/elopement alarm, despite having a secure care band in place during the entire look-back period. Similarly, Resident R71's MDS was also incorrectly coded as not using a wander/elopement alarm, although the resident had a secure care band in place. These inaccuracies were confirmed by the Registered Nurse Assessment Coordinator (RNAC) during interviews. Resident R21's MDS assessments were incorrectly coded as always incontinent for urinary continence, despite the resident having an indwelling suprapubic catheter throughout the look-back period. Additionally, Resident R86's MDS assessments failed to reflect the use of a CPAP device, which was used nightly as per the physician's order. These coding errors were also confirmed by the RNAC. The deficiencies were identified through a review of clinical records, MDS assessments, and staff interviews.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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