Buffalo Valley Lutheran Villag
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewisburg, Pennsylvania.
- Location
- 189 East Tressler Boulevard, Lewisburg, Pennsylvania 17837
- CMS Provider Number
- 395261
- Inspections on file
- 24
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Buffalo Valley Lutheran Villag during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A review found that nursing staff, including LPNs and RNs, lacked documented competencies for essential care areas such as enteral tube feeding, use of lifts, catheter care, medication administration, transmission-based precautions, IV therapy, and dressing changes, despite caring for residents with these needs.
Surveyors observed that the facility's kitchen and food storage areas were not maintained in a sanitary manner, with greasy build-up on equipment, food debris and unidentified fluids on floors, expired food items in storage, and inadequate protection of clean pans from environmental contamination. These conditions were confirmed during a walkthrough with the dietary manager and reviewed with facility leadership.
The facility did not provide timely written notification to two residents when their Medicare payment coverage changed. In both cases, required notices about the end of Medicare coverage and the transition to private payment were either not delivered within the mandated timeframe or not properly discussed with the responsible party, as confirmed by record review and staff interviews.
A resident's confidential health information was disclosed when a binder containing survey results, including a complaint deficiency letter with the resident's name and identifier, was placed in a publicly accessible area. This action violated facility policy and HIPAA requirements for PHI confidentiality.
The facility did not develop baseline care plans within 48 hours of admission for two residents, one with anticoagulant and insulin needs and another with a Stage 4 pressure ulcer and PICC line. Key interventions and complications related to their conditions were not addressed in the initial care plans, as confirmed by staff and record review.
A resident with dementia and high risk for skin breakdown developed MASD on the sacrum, but staff failed to routinely or comprehensively reassess the wound after the initial evaluation. Documentation repeatedly noted the skin issue as new and not evaluated over several months, with no evidence of ongoing assessment to monitor improvement or worsening.
A resident with a sacral Stage 2 pressure ulcer was not assessed for three weeks, contrary to facility protocol requiring weekly wound evaluations. During this period, the ulcer progressed to Stage 3, and the DON confirmed that required documentation and assessments were not completed.
A resident with declining mobility and new limitations in range of motion did not receive timely or appropriate therapy interventions. Despite documented decline and recommendations for a restorative ambulation program, there was no evidence that such a program was implemented, and therapy services were delayed. Facility leadership confirmed both the delay and lack of documentation for the required restorative program.
A resident experienced a decline from bowel continence to frequent incontinence, but staff did not review observation records or implement individualized interventions to address this change. The care plan required staff assistance with toileting, yet documentation showed a reduction in scheduled toileting times, and facility leadership confirmed there was no policy for bowel continence.
Two residents were involved in incidents where medications were found unsecured in their rooms, including a resident with dementia found taking unidentified pills and another resident's room where tablets were discovered on the floor and improperly disposed of by an LPN. The medications were not properly secured or disposed of according to facility policy, and in one case, the medication was not ordered for the resident.
Multiple black, winged insects and a large spider were observed in the kitchen, with staff confirming the insects had been present for over a week. Pest control records showed no prior notification to pest management about the issue, and only after the survey was a visit documented that identified flies around drains due to grease and food buildup. The facility did not maintain a pest-free kitchen environment.
During an inspection, discarded medical gloves, debris, paper products, and a washcloth were found around two dumpsters outside the kitchen dock entrance. A plastic apple sauce container and other debris were also observed between the lids of one dumpster. These issues were confirmed with the dietary manager, NHA, and DON.
A resident's family submitted a grievance regarding the unauthorized administration of Morphine and an allegation of abuse by an LPN. The facility did not provide the requested written explanation or documentation, failed to investigate or report the abuse allegation, and staff were unaware of the requirement to issue written grievance decisions. The grievance was not considered resolved by the family, and the issue was only revisited after surveyor intervention.
A resident was allegedly subjected to force-feeding and aggressive behavior by family members, as observed and documented by nursing staff. Despite these observations and concerns, the facility did not complete an incident report, obtain witness statements, remove the family from contact with the resident, or notify regulatory agencies, in violation of its abuse prevention policy.
A resident at Buffalo Valley Lutheran Village was improperly restrained with a shawl tied to her wheelchair by a nurse, without a physician's order or care plan. Despite being informed of the inappropriate use, the nurse continued the practice, and supervisory staff failed to suspend the nurse immediately, allowing further potential misuse. The facility lacked evidence of staff education on restraint policies following the incident.
A resident with a history of falls experienced multiple incidents where the VST alarm system failed to alert staff, leading to repeated falls. The facility did not thoroughly investigate these discrepancies or implement new interventions to improve the system's reliability. Despite the presence of a plan of care, the facility's investigations were inadequate, contributing to ongoing fall risks.
The facility failed to follow physician orders for two residents with nutrition and hydration needs. A resident on fluid restriction did not receive all requested beverages, and another resident with significant weight loss did not receive prescribed fortified foods and extra gravy. Staff acknowledged these oversights, indicating a lack of adherence to dietary requirements.
The facility failed to develop and implement individualized care plans for three residents diagnosed with dementia, despite assessments indicating the need for such plans. An interview with the DON confirmed the absence of documentation for these care plans, violating nursing service regulations.
A facility failed to reassess a resident's need for Zyrtec, an allergy medication, despite a consultant pharmacist's recommendation and a physician's agreement to do so. The medication was administered daily for three months without reassessment, as confirmed by the DON.
A facility failed to provide written notice of the bed-hold policy to a resident's responsible party during a hospitalization. The resident's sister, who was the responsible party, only received verbal communication about the hospitalization and did not receive the required written notice. The facility claimed the notice was sent with the resident to the hospital, but there was no evidence to confirm receipt by the responsible party.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS incorrectly stated a discharge to a hospital, while records showed a discharge home. Another resident's MDS inaccurately noted antibiotic use, with no evidence of such treatment. These errors were confirmed by facility staff.
A resident with CHF experienced significant weight gain due to fluid retention, which was not properly monitored or reported by the facility staff as per physician orders. Despite orders for daily and weekly weight assessments, the staff failed to notify the physician of a substantial weight increase, leading to respiratory distress and hospitalization. The deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to provide physician-ordered services to maintain range of motion for two residents. One resident did not receive a prescribed palmar roll for contracture prevention, and there was no documentation of required skin checks. Another resident experienced a decline in lower extremity range of motion without appropriate assessment or intervention. The facility did not ensure these residents received necessary treatments to maintain or improve their range of motion.
The facility failed to obtain informed consent and assess bed rail risks for two residents. One resident had enabler bars despite therapy's assessment deeming them unnecessary, with no documented consent or risk education. Another resident had a side rail without informed consent from a responsible party, and the facility could not verify bed suitability due to incomplete documentation.
The facility did not ensure that all nurse aides completed the required 12 hours of annual in-service education. Two nurse aides failed to meet this requirement, with one completing only 7.25 hours and the other 9.0 hours. The training was to include dementia care and abuse prevention, as confirmed by the NHA and DON.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Lack of Documented Nursing Staff Competencies for Specialized Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff, including both LPNs and RNs, possessed the appropriate competencies and skill sets necessary for the care and assessment of residents with specific clinical needs. Documentation and staff interviews revealed that there was no evidence of competency validation for staff responsible for residents requiring enteral tube feeding, use of lifts, catheter care, medication administration, transmission-based precautions, intravenous therapy, and dressing changes. The review identified that the facility had multiple residents with these care needs, including those receiving medications, using lifts, with indwelling urinary catheters, requiring dressing changes, under enhanced barrier precautions, and receiving IV therapy or enteral tube feedings. Despite these needs, the facility was unable to provide documentation confirming that the involved nursing staff had been assessed for competency in these areas.
Unsanitary Food Storage and Kitchen Conditions Identified
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and did not maintain the kitchen environment in a clean condition. During an observation of the main kitchen with the dietary manager, surveyors found a black, greasy build-up on the splash guard and surrounding hoses near the dishwasher. Cooking pans identified as clean were stored on a rack with significant debris, crumbs, and dirt, and were not protected from the ambient environment. The walk-in cooler floor had food debris and dirt, especially under storage racks, and there were two red-colored puddles of fluid on the floor. A box of chicken breasts with rib meat was stored on a bottom shelf next to a puddle of unidentified fluid. In the walk-in freezer, a package of ravioli and waffles were found with use-by dates that had already passed. Additional unsanitary conditions included two black-colored, wheeled carts with extensive grease and dirt build-up, and a stainless-steel table with a coffee machine that had debris in the shelving area underneath and brown dried stains on the adjacent wall. In a storage area, a shelving rack holding cooking pans on the bottom shelf had an extensive build-up of cobwebs between the pans and the wall, and there was no splash guard to protect these items from mop splash. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Timely Notification of Medicare Coverage Changes
Penalty
Summary
The facility failed to provide timely written notification to residents regarding changes in their Medicare payment coverage, as required by federal regulations. For one resident, services were primarily paid for by Medicare Part A, but the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare coverage. Documentation showed that the resident was scheduled for discharge and no longer required skilled therapy, but the required notice was not provided within the mandated timeframe. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the resident did not leave against medical advice and that the notice was not issued as required. For another resident, Medicare A coverage ended and the resident transitioned to private payment. Although the responsible party signed the NOMNC and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), the facility did not document that staff discussed the change in payment and the estimated cost per day with the responsible party as soon as reasonably possible when the change in coverage was anticipated. The required notification and discussion regarding financial responsibility were not completed in a timely manner, as confirmed by review of the clinical record and interviews with facility leadership.
Resident Health Information Disclosed in Public Area
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal and medical information by placing a binder labeled 'Department of Health Surveys' in the main lobby, which was accessible to the public. The binder contained the full health survey and complaint survey results, including a complaint deficiency letter and the associated Statement of Deficiencies (Form CMS-2567) for a complaint investigation. The letter specifically identified a resident by name and included their specific resident identifier, thereby disclosing protected health information (PHI) in violation of the facility's confidentiality policy and HIPAA requirements. This lapse was confirmed through policy review, direct observation, and staff interviews.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for two residents. For one resident admitted after hospitalization for left lower extremity cellulitis and a venous stasis ulcer, the clinical record showed that his medication regimen included daily Warfarin, and he was later started on insulin for prediabetes. However, the baseline care plan did not address the use or complications of anticoagulant therapy, nor did it include the use of insulin for elevated blood sugars. The care plan for anticoagulant therapy was not initiated until one week after admission, and there was no evidence that insulin use was included in the care plan during the initial period after admission. Another resident was admitted with a Stage 4 sacral pressure ulcer and a PICC line for intravenous antibiotics due to sacral osteomyelitis. The baseline care plan did not address interventions for the resident's skin integrity impairment or the care and potential complications of the PICC line. A care plan for the pressure ulcer was not initiated until more than two weeks after admission, and no care plan was developed for the PICC line. These omissions were confirmed by staff interviews and clinical record review.
Failure to Routinely Assess and Document Wound Status
Penalty
Summary
Facility staff failed to provide the highest practicable care regarding wound assessment for a resident with dementia and high risk for skin breakdown. The resident was identified as having a Braden Score of 12, indicating high risk for pressure ulcers, and was noted to be incontinent of bowel and bladder. Initial documentation on June 6, 2025, identified the development of moisture-associated skin damage (MASD) on the sacrum, with measurements recorded and a fax sent to the medical provider. The care plan included the use of a moisture barrier and noted the resident's risk for altered skin integrity. Despite the initial assessment, subsequent clinical documentation repeatedly indicated that the skin issue had not been evaluated, and staff continued to document the wound as new over several months. There was no evidence that the MASD was routinely or comprehensively reassessed after the initial evaluation to determine if the wound was improving or worsening. An interview with the Director of Nursing confirmed that no further evidence of ongoing assessment could be provided.
Failure to Assess and Monitor Pressure Ulcer Progression
Penalty
Summary
The facility failed to assess and implement appropriate treatment and services to promote the healing of a pressure ulcer for one resident. According to the facility's Pressure Injury Treatment Protocol, all pressure injuries are to be assessed weekly and as needed, with specific actions required if the wound does not improve within 14 days. Clinical records show that a resident was admitted with a Stage 2 sacral pressure ulcer, which was initially measured and assessed by a wound care specialist on two occasions within the first nine days of admission. However, after April 24, there was a gap of three weeks without any documented assessment of the wound. During this period without assessment, the resident's pressure ulcer progressed from Stage 2 to Stage 3, indicating a deterioration in the wound. The Director of Nursing confirmed that the pressure ulcer was not assessed at least weekly as required, and that documentation of the wound's date observed, location, staging, and size was missing for the three-week period. This failure to follow the facility's protocol resulted in a lack of timely evaluation and intervention for the resident's pressure ulcer.
Failure to Provide Appropriate ROM and Mobility Services
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve range of motion. The resident, who was previously able to walk 150 feet with supervision or minimal assistance and had no documented limitations, began experiencing an unsteady gait, shuffling, and difficulty lifting his right foot. Despite a request from the resident's wife for a physical therapy screen due to these mobility concerns, the initial therapy referral indicated no skilled therapy needs and no change in function. Subsequent assessments documented a decline in the resident's ability to perform activities of daily living, including increased assistance required for ambulation, toileting hygiene, and dressing. A therapy referral was eventually made for the resident's significant decline, and occupational therapy evaluated the resident, noting no further needs but referring to physical therapy for ambulation training. Physical therapy did not assess the resident until over a month later, after which a restorative ambulation program was recommended. However, the facility was unable to provide any documentation that such a restorative nursing program was implemented for the resident, despite physical therapy's recommendation and the resident's ongoing decline. Interviews with facility leadership confirmed both the delay in therapy services and the absence of evidence for the restorative program.
Failure to Assess and Implement Individualized Bowel Continence Interventions
Penalty
Summary
The facility failed to assess and implement individualized interventions to promote bowel continence for a resident whose continence status declined over time. Clinical record review showed that the resident was initially assessed as continent of bowel, but subsequent Minimum Data Set (MDS) assessments documented a decline to occasional and then frequent bowel incontinence. Despite this change, there was no evidence that staff reviewed the resident's bowel and bladder observation records to develop or implement specific interventions tailored to the resident's needs. Additionally, the resident's care plan indicated a need for staff assistance with toileting, but documentation revealed inconsistencies in the frequency of toileting assistance offered. Initially, staff were to assist the resident at multiple times throughout the day, but later documentation showed a reduction in these scheduled toileting times. Interviews with facility leadership confirmed the absence of a policy addressing bowel continence, and the findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Ensure Medication Security and Proper Disposal
Penalty
Summary
The facility failed to ensure proper medication security for two residents. In one instance, a resident with dementia and cognitive deficits was found in her room taking two unidentified pills, with no documentation indicating where the medication originated or how many pills had been ingested. The nurse on duty was unaware of the source or type of medication, and there was no record of the resident's morning medications being administered. The incident was not documented at the time it occurred, and the medications were removed and disposed of by a unit LPN without clear adherence to established procedures. In another case, a privately paid caregiver discovered a medication tablet on the floor of a resident's room and reported it to the unit nurse, who disposed of it in the room's garbage receptacle. Further observation revealed another tablet on the floor near the trash, which was identified as Omeprazole 20 mg, a medication not ordered for the resident. These events demonstrate lapses in medication storage and security, as medications were found unattended and accessible in resident areas, and disposal did not follow the facility's outlined protocols.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen area, as evidenced by direct observation and staff interview. During an inspection of the kitchen, multiple black, winged insects were observed on the wall of the dishwashing area, and additional insects were seen on the ceiling near a vent, which also had unidentified splash stains. A large spider was also observed moving across the floor and entering a floor drain. The dietary manager confirmed that the insects had been present for at least one and a half weeks, and that traps had been placed in an attempt to address the issue. Review of pest control documentation showed that while the facility had received general pest control and exterior treatments in previous months, there was no evidence that the pest control service had been notified about the presence of winged insects in the kitchen. Only after the survey was a pest management visit documented, which identified phorid flies and fruit flies around the drains due to grease and food buildup. The facility did not maintain a pest-free environment in the main kitchen, as required by regulations.
Improper Containment and Disposal of Garbage at Facility Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage at both observed dumpsters located outside the kitchen dock entrance. During an observation with the dietary manager, discarded medical gloves, debris, paper products, and a washcloth were found around the dumpsters. Additionally, a discarded plastic apple sauce container and unidentified debris were observed between the lids on top of one dumpster. These findings were confirmed during a meeting with the Nursing Home Administrator and Director of Nursing.
Failure to Promptly Resolve and Communicate Grievance Decision
Penalty
Summary
The facility failed to promptly resolve a grievance submitted by the family of a resident who was determined to lack capacity to understand her rights and responsibilities. The grievance, submitted by the resident's son and daughter, alleged unauthorized administration of a narcotic pain medication (Morphine) and included an accusation by a staff member that the family was abusing the resident by force-feeding and withholding pain medication. The family requested a detailed written explanation of the events, including vital signs, medication administration records, and hospital discharge documents. Although the facility's grievance policy required prompt investigation and communication of resolution, it did not specify the right to a written decision, and the family did not receive the requested written documentation or a thorough investigation into their concerns. Interviews with the family confirmed that they did not consider the grievance resolved, as they had not received the information they requested or a written response. The Grievance Officer and clinical manager were unaware of the regulatory requirement to provide written grievance decisions, and the facility did not investigate or report the abuse allegation to the appropriate authorities. The grievance was only reopened after the surveyor's inquiry, indicating that the facility did not follow its own policy or regulatory requirements regarding grievance resolution and communication.
Failure to Investigate and Report Alleged Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an incident of potential resident abuse involving a resident and her family members. Nursing documentation indicated that a family member was observed force-feeding the resident, aggressively forcing her head forward, shaking her shoulder, and yelling at her, despite the resident expressing discomfort and refusing food. Staff documented concerns about mistreatment and reported the situation to a supervisor, but no incident report was completed, and no witness statements were obtained from those present during the incident. The facility did not remove the family members from contact with the resident to ensure her safety during the investigation, as required by policy. Additionally, the facility did not notify the appropriate regulatory agencies, such as the Department of Health or Area Agency on Aging, about the alleged abuse. The facility's abuse prevention policy referenced state-specific guidelines for Illinois and Missouri but did not include Pennsylvania's regulatory requirements. Interviews with staff and family confirmed the incident and the lack of a formal investigation or reporting. The Director of Nursing acknowledged that no incident report was filed and that the required steps to protect the resident and investigate the allegation were not taken.
Improper Use of Physical Restraints
Penalty
Summary
Buffalo Valley Lutheran Village was found to be non-compliant with federal and state regulations regarding the use of physical restraints. The facility failed to ensure that a physical restraint was used for the treatment of medical symptoms for one resident. The incident involved a nurse who tied a resident to her wheelchair with a shawl, despite the absence of a physician's order or a plan of care authorizing such a restraint. The resident had a history of noncompliance with transfer status and behaviors of frequently placing herself on the floor. The facility's policies on abuse prevention and restraint use were not adhered to, as evidenced by the actions of Employee 1, who tied the resident to her wheelchair multiple times. Despite being informed by other staff members that the use of the shawl as a restraint was inappropriate, Employee 1 continued to use it. The supervisory staff, including Employee 2, failed to immediately suspend Employee 1 after the initial report of inappropriate restraint use, allowing the nurse to continue working and potentially restrain other residents. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that there was no evidence of counseling for Employee 2 regarding the failure to suspend Employee 1. Additionally, there was no evidence of staff education following the incident to reinforce the facility's policies on restraint use and resident protection during abuse investigations. This lack of immediate action and education contributed to the facility's non-compliance with the regulations.
Plan Of Correction
Please accept the following Plan of Correction as the facility's credible allegation of compliance with F604. This Plan of Correction is being submitted in response to the regulatory requirement and should not be considered an admission of guilt or liability by the facility. Resident #1 assessed by RN supervisor on 2/12/2025 after removal of shawl. No injuries or change in demeanor/level of alertness noted. Employee 1 was suspended pending investigation on 2/11/2025 and was terminated from employment on 2/13/2025. Residents residing in the facility have the potential to be affected. Resident #1 and all residents will be free from restraints. All residents residing in facility on 2/28/2025 will be audited for restraints. Facility staff educated on policy and procedure that residents should be free from restraints. Education included: - Reporting of improper use of restraint - Proper consent, order, and managing of restraint if a restraint is needed - RN supervisors/managers were re-educated on steps to take when abuse is witnessed or reported to them. - New Hire orientation education reviewed and revised to include education that residents will be free from restraint. The Director of Nursing or designee will audit 20 random residents weekly x 4 weeks, then 10 residents monthly x 2 months for improper restraint use. Results will be reported to the Executive Director. Any variance noted will be corrected immediately. The Executive Director or designee will report results of the audits monthly in the Quality Improvement meeting. Trends and analysis will be evaluated. If there are any negative trends or analysis the community will adjust the plan to assure that residents remain free from restraints.
Failure to Investigate and Address Fall Prevention System Deficiencies
Penalty
Summary
The facility failed to thoroughly investigate and implement individualized interventions to prevent falls for a resident identified as having fall concerns. The resident, who had a history of falls, experienced multiple incidents where the fall prevention system, VST, did not function as intended. Despite the presence of a plan of care that included the use of VST and other alarms, the facility did not adequately ensure the reliability of these systems, leading to repeated falls. The resident's clinical records revealed numerous falls over a period of ten weeks, with several incidents where the VST alarm failed to alert staff. Interviews and documentation indicated that the facility did not investigate the discrepancies in the alarm system's functioning or provide evidence of new interventions to improve its reliability. The facility's interdisciplinary team often noted that the plan of care was followed, despite evidence suggesting that the VST system was not functioning properly. The facility's investigations into the falls were inadequate, as they did not determine the duration of the VST alerts or whether staff received them. Additionally, there was no evidence that skilled therapy evaluated the resident after certain falls, and the facility did not report the failure of the plan of care intervention in the required notifications. The lack of thorough investigation and failure to address the alarm system's deficiencies contributed to the ongoing risk of falls for the resident.
Failure to Implement Nutrition and Hydration Interventions
Penalty
Summary
The facility failed to implement interventions consistent with physician orders and resident preferences for two residents with nutrition and hydration concerns. Resident 43, who was on a physician-ordered fluid restriction of 1800 ml per day, did not receive the milk he requested during a lunch meal, despite it being listed on his meal tray ticket. The nurse aide confirmed the oversight, acknowledging that Resident 43 should have received his requested beverages, including milk. Resident 66 experienced a significant weight loss of 9.88% over one month. Despite physician orders for extra gravy with meat and fortified food during lunch, these interventions were not consistently provided. During a lunch meal observation, Resident 66 did not receive the extra gravy or fortified mashed potatoes as indicated on her meal ticket. The dietary aide admitted to not providing these items, revealing a lack of understanding of the fortified diet requirements. These deficiencies were reviewed with the Nursing Home Administrator and the Director of Nursing.
Failure to Implement Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for three residents diagnosed with dementia. Resident 52 was admitted on February 24, 2021, and diagnosed with dementia on November 8, 2022. Despite the facility's assessment on July 3, 2024, indicating the need for a care plan, no such plan was developed or implemented. Similarly, Resident 60, admitted on August 12, 2021, was diagnosed with dementia with agitation on May 30, 2023. The facility's assessment confirmed the need for a care plan, but none was created or executed. Resident 79, admitted on December 11, 2023, with a diagnosis of dementia with anxiety, also lacked a person-centered care plan despite the facility's assessment indicating its necessity. An interview with the Director of Nursing on September 29, 2024, confirmed the absence of documentation for individualized care plans for these residents. This deficiency is a violation of 28 Pa Code 211.12 (d)(1)(3)(5) regarding nursing services.
Failure to Reassess Unnecessary Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medication. A clinical record review for a resident revealed a physician order for Zyrtec, an allergy medication, to be administered daily for a cold and runny nose. A consultant pharmacist recommended that the physician reassess the need for the continued use of Zyrtec, which the physician agreed to do in two weeks. However, there was no evidence in the clinical record that staff reassessed the resident's need for Zyrtec after the two-week period. The medication order remained active and was administered daily until it was discontinued several months later. An interview with the Director of Nursing confirmed that the staff did not complete the reassessment of the resident's use of Zyrtec, resulting in the medication being administered for three months beyond the recommended reassessment period.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice to a resident's responsible party regarding the duration of the bed-hold policy during a hospitalization. This deficiency was identified during a clinical record review and interviews with staff and family members. Specifically, the sister of the resident, who is the responsible party, reported that all communication from the facility about the hospitalization was verbal, and she did not receive any written notices. The resident had been sent to the hospital after being found on the floor with swelling on her forehead, and the responsible party had verbally requested a bed hold. The facility claimed that a copy of the bed-hold notice was sent with the resident to the hospital, where her sister was supposed to receive it. However, there was no evidence to confirm that the responsible party actually received the written information. This oversight was a violation of the federal regulation 483.15(d)(1)(2) regarding the notice of bed-hold policy before or upon transfer, and it was a repeat deficiency from a previous citation on September 1, 2023.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. For Resident 88, the MDS assessment dated May 29, 2024, incorrectly indicated that the resident was discharged to a hospital setting, while nursing documentation on the same date showed that the resident was discharged home with her husband. This error was confirmed during an interview with the Administrator and Director of Nursing on August 29, 2024. For Resident 2, the MDS assessment inaccurately recorded that the resident was on an antibiotic, despite there being no evidence in the clinical record of antibiotic administration during the assessment period. This discrepancy was confirmed in an interview with the Nursing Home Administrator on August 29, 2024.
Failure to Monitor Weight and Notify Physician
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with congestive heart failure by not adhering to physician-ordered weight assessments. The resident, who was on a fluid restriction and prescribed Lasix, experienced significant weight fluctuations that were not properly monitored or reported to the physician as required. The physician's orders specified daily weight assessments initially, followed by weekly assessments, but these were not consistently implemented. The resident's weight increased significantly over several weeks, leading to symptoms of respiratory distress and eventual hospitalization. Despite a physician's order to notify them if the resident's weight increased by more than five pounds in one week, the staff did not report a 5.8-pound increase in one week or a 9.8-pound increase over two weeks. It was only after the resident exhibited wheezing and a 10-pound weight gain over two weeks that the physician was notified, resulting in an adjustment of the resident's medication. The Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a lapse in following the care plan and physician's orders.
Failure to Provide Physician-Ordered ROM Services
Penalty
Summary
The facility failed to provide physician-ordered services to maintain a resident's range of motion for two residents. For Resident 23, a clinical record review revealed a physician's order dated October 15, 2023, for the use of a palmar roll on her right hand every evening at bedtime to prevent contracture. The order also required staff to perform skin checks each shift while the palmar roll was worn. However, there was no documentation indicating that the palmar roll was placed nightly or that skin checks were completed. An observation and interview with Resident 23 on August 27, 2024, showed her right hand was contracted, and she reported doing her own physical therapy program. No palmar roll was found in her room. For Resident 40, a clinical record review showed an MDS assessment dated June 4, 2024, indicating no lower extremity impairments. However, a subsequent quarterly MDS assessment revealed bilateral lower extremity impairment. An interview with the Director of Nursing confirmed there was no evidence that the facility assessed Resident 40's decline in lower extremity range of motion. The facility failed to ensure Resident 40 received appropriate treatment and services to maintain or improve her range of motion.
Failure to Obtain Informed Consent and Assess Bed Rail Risks
Penalty
Summary
The facility failed to obtain informed consent and assess the risk of side rail entrapment for two residents, leading to deficiencies in accident hazard prevention. For Resident 12, observations revealed the presence of bilateral one-quarter enabler bars on the bed, despite therapy's assessment indicating they were unnecessary. Maintenance staff evaluated the bars for potential entrapment, but there was no documentation of consent from Resident 12 or their responsible party, nor evidence of education provided regarding the risks. Additionally, the nursing staff did not assess the need for enabler bars concerning entrapment zones. A facility note later confirmed that Resident 12 should not have had enabler bars, and the resident's request for them was not communicated to nursing or therapy. For Resident 66, a side rail was observed on the left side of her bed. Although nursing documentation indicated consent was obtained from Resident 66, a physician's order noted her incapacity to understand her rights and responsibilities. The facility could not provide evidence of informed consent from Resident 66's responsible party or a side rail entrapment risk assessment. The Bed System Measurement Device Test Results Worksheets lacked specific resident information, making it unclear if the bed's dimensions were appropriate for Resident 66. The facility confirmed that these worksheets do not become part of the residents' medical records, and no informed consent was provided for the use of the side rail.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that all nurse aide staff completed the required minimum of 12 hours of in-service education training annually. This deficiency was identified during a review of facility staff education records and staff interviews. Specifically, two nurse aides, Employee 1 and Employee 2, did not meet the training requirements. Employee 1, who was hired on January 10, 2017, completed only 7.25 hours, and Employee 2, hired on June 5, 2023, completed only 9.0 hours of the required training. The training was supposed to include dementia care, abuse prevention, and address any areas of weakness or special care needs of residents. This was confirmed during interviews with the Nursing Home Administrator and the Director of Nursing.
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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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