Caring Heights Community Care & Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Coraopolis, Pennsylvania.
- Location
- 234 Coraopolis Road, Coraopolis, Pennsylvania 15108
- CMS Provider Number
- 395603
- Inspections on file
- 28
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Caring Heights Community Care & Rehab Ctr during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not have physician-ordered CBC and CMP laboratory tests obtained as required. Review of clinical records and staff interviews confirmed the absence of documentation that the bloodwork was completed, resulting in a failure to follow physician orders.
The facility did not maintain accurate care plans or conduct ongoing assessments for bedrail use for several residents with complex medical conditions, despite the presence of enabler bars on their beds. Clinical records lacked documentation of assessments, and care plans did not include goals or interventions related to bedrail usage, as confirmed by the DON.
A resident with an indwelling urinary catheter, admitted with diagnoses including hypertension, heart failure, and obstructive uropathy, was observed with a catheter drainage bag lying on the floor and lacking a privacy cover. An LPN confirmed the absence of the privacy cover, which did not uphold the resident's dignity as required by facility policy.
A medication cart was left unattended with its computer screen open, exposing resident personal and medical information to anyone passing by. A registered nurse confirmed that this lapse resulted in a failure to protect the confidentiality of residents' records as required.
The facility did not ensure that grievance forms were available or that residents could file anonymous grievances, as required by policy. Observations revealed no grievance forms in designated areas, and the only available form was for staff recognition, not grievances. The NHA confirmed that residents could not file grievances anonymously due to the lack of appropriate forms.
Two residents with significant medical conditions were provided with bed bolsters without proper assessment or documentation to determine if these devices functioned as physical restraints. Although care plans and, in one case, a physician order referenced the use of bolsters for fall prevention, there was no evidence that the facility evaluated whether the bolsters restricted the residents' freedom of movement, as required by policy. The DON confirmed the lack of assessment and identification of bolsters as possible restraints.
A resident with heart failure, anxiety, and respiratory failure was prescribed Hydroxyzine PRN for anxiety without a 14-day stop date or documented physician rationale for continued use. The medication was administered multiple times without documentation of behaviors or non-pharmacological interventions prior to use, as confirmed by the DON.
A resident with multiple chronic conditions was admitted to hospice care, but the facility did not complete a required significant change MDS assessment within 14 days of hospice enrollment, as confirmed by the RNAC and review of clinical records.
Two residents' MDS assessments were inaccurately coded to indicate anticoagulant use, despite only receiving aspirin, an antiplatelet medication. Staff interviews confirmed that aspirin was incorrectly counted as an anticoagulant in the assessments, leading to inaccurate documentation of medication use.
A resident with multiple medical conditions, including anxiety treated with buspirone, did not have a care plan addressing anxiety as required by facility policy. The omission was confirmed by the RN Assessment Coordinator after review of the clinical record and MDS.
A resident with diabetes experienced a critically low blood glucose level, but staff did not document the episode, assess the situation, notify the physician, or implement the facility's hypoglycemia protocol as required by policy and physician orders.
Two residents with limited mobility who required assistive equipment, such as an ankle brace and bilateral hand splints, did not have comprehensive, individualized care plans addressing the use of these devices. Staff interviews revealed confusion over which department was responsible for care planning, leading to the omission of necessary goals and interventions for maintaining or improving mobility.
A resident with heart failure and respiratory failure received oxygen and nebulizer treatments using tubing that had not been changed according to facility policy. An LPN and the DON confirmed the equipment was overdue for replacement, resulting in a failure to provide appropriate respiratory care.
A resident with PTSD, depression, and high blood pressure did not have their trauma triggers identified or addressed in their care plan, despite facility policy requiring individualized interventions. Staff interviews confirmed the absence of ongoing PTSD assessment and trigger identification, resulting in a lack of measures to prevent re-traumatization.
A resident with severe cognitive impairment and a diagnosis of dementia did not have an individualized, person-centered care plan addressing their dementia or cognitive loss. Staff interviews revealed confusion over responsibility for developing such care plans, and both nursing and social services staff confirmed that no appropriate plan had been created or implemented.
During a review of the East Wing Medication Room, five expired 21-gauge needles were found, indicating a failure to comply with the facility's policy on proper storage and expiration dating of medical supplies. Both an LPN and the DON confirmed the improper storage during interviews.
A resident with orders for honey-consistency thickened liquids due to medical conditions including dementia and diabetes was observed with a cup of clear thin liquid at bedside. An LPN confirmed the thickener was not properly mixed, and the DON acknowledged the failure to provide the drink in the required form.
The facility did not ensure proper coordination of hospice services for two residents receiving end-of-life care. One resident with multiple diagnoses did not have ongoing documentation of hospice nurse visits, and another resident admitted to hospice lacked required physician certification documentation. In both cases, the facility failed to meet policy and regulatory requirements for hospice care coordination.
A resident with an indwelling urinary catheter had their drainage bag placed directly on the floor without a privacy cover, and a nursing assistant emptied the catheter without wearing required PPE under Enhanced Barrier Precautions, despite facility policies and available signage. The DON confirmed these lapses in infection control.
A direct care staff member did not receive required training on effective communication, as confirmed by review of facility education records and staff interviews. The DON acknowledged that communication training was not provided to this staff member, despite it being a requirement in the job description and facility policy.
Two direct care staff members did not receive required Resident Rights training, as confirmed by review of facility education records and staff interviews with the DON.
One direct care staff member did not receive mandatory training on abuse, neglect, and exploitation, as confirmed by review of facility education records and interviews with the DON.
Two direct care staff members did not receive required QAPI training as mandated by facility policy and regulations. Review of education records and staff interviews confirmed the omission, with the DON acknowledging the failure to provide this training.
A nurse aide did not receive mandatory Infection Control training as required by facility policy and state regulations. Review of education records and staff interviews confirmed the omission, resulting in a deficiency related to staff development and infection prevention standards.
Two direct care staff members did not receive required Compliance and Ethics training, as confirmed by review of facility education records and staff interviews with the DON.
A nurse aide did not receive the minimum 12 hours of annual training as required, with records showing only 0.21 hours completed. The DON confirmed the deficiency during interviews and review of facility documentation.
A direct care staff member did not receive required Behavioral Health training as outlined in the facility's staff development policies and job descriptions. Review of education records and staff interviews confirmed the omission, resulting in a deficiency under state regulations.
The facility did not display complete and required contact information for Adult Protective Services, the State Agency, and the State Long-Term Care Ombudsman program in areas accessible to all residents, as confirmed by observation and staff interview.
The facility did not display written information on how to apply for Medicare and Medicaid benefits or how to receive refunds for previous payments covered by these programs on either the West Wing or East Wing. This was confirmed by observation and staff interview.
The facility failed to notify the Office of the LTC Ombudsman Division about the hospital transfers of four residents with various medical conditions, including heart failure and hypertension. Despite transfers occurring between April and September, no notifications were documented, with the last known notification made in March. The DON confirmed this lapse, violating resident rights under 28 Pa. Code 201.29(a)(c.3)(2).
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, affecting four residents with various medical conditions. The deficiency was confirmed by the DON, who acknowledged the lack of documentation for the required notifications.
The facility failed to ensure accurate MDS assessments for two residents, with errors in documenting pneumococcal vaccination status. Despite records indicating vaccination status, the MDS sections were incorrectly dashed out, as confirmed by the RNAC.
A facility failed to uphold a resident's dignity by not adhering to a physician's dietary order. The resident, with a history of cerebrovascular issues, was observed with a sign indicating 'Nectar Thick' on their headboard, which was confirmed by a registered nurse. This was identified as a deficiency in promoting and protecting the resident's dignity.
The facility did not provide quarterly personal fund statements to several residents, leaving them unaware of their account balances. A resident confirmed not receiving statements and having no financial assistance. The Business Office Manager acknowledged the issue, and the NHA admitted the statements were managed by their corporate office without proof of distribution.
A resident with Friedreich ataxia, heart failure, and atrial fibrillation experienced symptoms like pain, difficulty breathing, and elevated heart rates. Despite these changes, the facility failed to notify a physician, as documented in the resident's records. The resident was eventually sent to the hospital, where they were treated for atrial fibrillation, atrial flutter, high blood pressure, and a non-ST elevation myocardial infarction.
The facility failed to ensure residents were properly informed about Medicare coverage. A resident with severe cognitive impairment signed a NOMNC form without proper explanation, and another resident received the form late, after services ended. The DON confirmed these deficiencies.
The facility failed to maintain a clean, safe, and homelike environment for several residents. Observations revealed deep gouges in walls, sticky debris, and grime on floors, and a corroded tube feeding pole. These issues were confirmed by the Maintenance Director, indicating non-compliance with federal regulations for a sanitary and comfortable interior.
Two residents experienced neglect and abuse in the facility. One resident, dependent on assistance for transfers, was improperly transferred by an agency NA, resulting in increased pain. Another resident reported an NA took unauthorized photos of her while soiled, violating her rights. The facility confirmed these incidents, highlighting a failure to protect residents.
A resident with multiple health conditions was transferred by a single agency NA, against the care plan requiring two staff and a Hoyer lift, resulting in injury. The incident was reported to the DON but was not reported to authorities, violating state regulations.
A resident with multiple health conditions was transferred by a single agency Nurse Aide, against the care plan requiring two staff and a Hoyer lift, resulting in pain. The resident reported the incident, but the facility failed to investigate the allegation of neglect, lacking a witness statement and not adhering to its investigation policy.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred and expected to return. One resident had heart failure, obesity, and dysphagia, while the other had chronic obstructive pulmonary disease, obstructive sleep apnea, and hypertension. The Director of Nursing confirmed the lack of communication, violating resident rights.
A resident with cerebral infarction and hemiplegia was admitted with unstageable pressure ulcers, but the LTC facility failed to implement a timely care plan or obtain necessary physician orders for wound care. Despite policies requiring immediate assessment and treatment, the resident's care plan lacked interventions, and wound care orders were delayed, leading to inadequate care and potential infection risk.
A resident with dementia and a fractured ankle required two-person assistance for transfers, but only one nurse aide was present during a transfer, resulting in a 17-cm laceration on the resident's right calf. The incident was not documented in the facility's report for October, and staff interviews confirmed the lapse in following transfer protocols.
A facility failed to update a resident's care plan to reflect current dietary orders. The resident, with conditions such as cerebral palsy and aspiration pneumonia, had a physician-ordered diet of Regular, Nectar thick, Mech Soft, but the care plan still indicated a Puree, Nectar thick diet. This discrepancy was confirmed by an RNAC.
A facility failed to maintain consistent communication with a dialysis provider and did not accurately update a care plan for a resident with an AV fistula. The resident's care plan incorrectly included management for a peritoneal access site, which the resident did not have. Incomplete communication forms were noted, and the Director of Nursing confirmed these deficiencies.
A facility failed to provide appropriate treatment for a resident with mental health issues and medication misuse. The resident, with a history of depression and bipolar disorder, was found misusing medications like Xanax and oxycodone. Despite staff awareness, the care plan lacked interventions to address these behaviors, violating state regulations.
A facility failed to address pharmacy recommendations for a resident's medication regimen review. The resident, with conditions like heart and respiratory failure, had a lorazepam order without a stop date for over 14 days. Despite pharmacy recommendations to review and potentially discontinue the medication, no action was taken, and the reviews were unsigned by the physician. The DON and Administrator confirmed the oversight.
The facility failed to limit PRN orders for psychotropic drugs to 14 days for a resident with multiple diagnoses, and did not monitor the effectiveness or adverse consequences of antipsychotic medication for another resident. The oversight in PRN orders was confirmed by the DON and Nursing Home Administrator, while the lack of monitoring was confirmed by the RNAC.
A survey found that a medication cart in the facility's East Wing Front Hall contained several inhalers, including Symbicort, Albuterol, and Fluticasone Propionate, that were not dated when opened, as required by facility policy. This deficiency was confirmed by an RN and the DON during interviews.
A resident experienced a delay in receiving dental services due to the facility's failure to obtain timely consent for dental procedures. The resident, who had been waiting over a month for dentures, was evaluated for upper complete dentures and required root extractions. The Activities Director had not contacted the resident's daughter for consent, resulting in a delay in dental care, violating Pennsylvania Code regulations.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
Facility staff failed to obtain laboratory studies as ordered by the physician for one of three residents reviewed. Specifically, a resident with diagnoses including malignant neoplasm of the brain, diabetes mellitus, and hypothyroidism had physician orders for a CBC and CMP on two separate occasions. The clinical record did not contain documented evidence that the required bloodwork was obtained on either occasion as ordered. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that there was no documentation showing the laboratory tests were completed for the resident. The deficiency was identified through clinical record reviews and staff interviews, which verified that the facility did not follow physician orders regarding laboratory testing for the resident.
Failure to Assess and Care Plan for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for four residents. Observations revealed that each of these residents had enabler bars (bedrails) present on their beds, but their clinical records did not include ongoing assessments for the use of these devices. Additionally, the care plans for these residents did not contain goals or interventions related to bedrail usage, despite the presence of physician orders in some cases. The residents involved had various medical conditions, including hyponatremia, cancer, malnutrition, high blood pressure, Friedreich ataxia, hyperkalemia, anxiety, and bipolar disorder. The lack of documentation and assessment was confirmed by the Director of Nursing, who acknowledged that the facility did not ensure bedrails were used to meet residents' needs or address the associated risks as required by regulation.
Failure to Maintain Dignity in Catheter Care
Penalty
Summary
The facility failed to maintain resident dignity in the care of a resident with an indwelling urinary catheter. According to facility policy, catheter drainage bags must be kept off the floor and covered with a privacy/dignity bag. Review of the clinical record showed the resident had diagnoses including high blood pressure, heart failure, and obstructive uropathy, and had an indwelling urinary catheter as part of their care plan. During an observation, the resident's catheter drainage bag was found lying on the floor beside the bed without a privacy cover. In a subsequent interview, an LPN confirmed that the drainage bag was not covered and that this did not maintain the resident's dignity.
Failure to Maintain Confidentiality of Resident Medical Information
Penalty
Summary
During an observation, a medication cart located in the West Wing was found unattended outside a resident's room with the computer screen left open, displaying identifiable resident personal and confidential medical information. This allowed any passerby to view sensitive information. A registered nurse confirmed the incident and acknowledged that the facility failed to maintain the confidentiality of residents' medical records as required by state regulations. The deficiency was identified based on direct observation and staff interview.
Failure to Provide Accessible and Anonymous Grievance Forms
Penalty
Summary
The facility failed to ensure that grievance forms were available and that residents could file anonymous grievances on both the West Wing and East Wing units. A review of the facility's posted Concern Resolution and Grievance Procedure indicated that residents have the right to file grievances orally, in writing, and anonymously, with instructions to use forms located near the front desk and submit them in a suggestion box. However, during an observation, no Concern/Grievance forms were found in the Front Lobby or at the Front Desk, and the facility's Grievance Log showed no grievances filed during July and August 2025. During an interview, the Nursing Home Administrator (NHA) stated that residents could request a grievance form from staff or use a blank piece of paper, but acknowledged this did not facilitate anonymous reporting. The only available form at the suggestion box was an "Impact" card intended for staff recognition, which did not include information about filing grievances. The NHA confirmed that grievance forms were not readily available and that the current process did not allow residents to file anonymous grievances as required by facility policy.
Failure to Assess Bed Bolsters as Potential Restraints
Penalty
Summary
The facility failed to properly identify and assess the use of bed bolsters as potential physical restraints for two residents. According to facility policy, any device that restricts a resident's freedom of movement and cannot be easily removed by the resident should be evaluated as a possible restraint. For one resident with diagnoses including high blood pressure, Friedreich ataxia, and malnutrition, bolsters were observed on both sides of the bed, but there was no physician order for their use and no assessment or ongoing evaluation documented in the clinical record. The care plan noted a history of falls and included bolsters as an intervention, but did not address their use as a restraint. For another resident with high blood pressure, dementia, and arthritis, bolsters were also observed on both sides of the bed. While there was a physician order and care plan intervention for bolsters due to fall risk, the clinical record lacked any assessment or ongoing evaluation regarding their use as a restraint. During staff interviews, the DON confirmed that the facility did not identify bolsters as possible restraints and did not assess the residents' functional status to determine if the bolsters restricted their freedom of movement.
Failure to Ensure Psychotropic Medication Regimen Was Free from Unnecessary Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. Specifically, a resident with diagnoses of heart failure, anxiety, and respiratory failure was prescribed Hydroxyzine, a psychotropic medication, to be administered orally twice a day as needed for anxiety. The physician's order for Hydroxyzine did not include a required 14-day stop date, nor was there any documented rationale from the physician to justify the continuation of the medication beyond 14 days. Additionally, the resident's Medication Administration Record showed that Hydroxyzine was administered on four occasions, but there was no documentation in the progress notes indicating the resident's behaviors or any non-pharmacological interventions attempted prior to administering the medication. The Director of Nursing confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by facility policy and regulatory guidelines.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a comprehensive assessment following a significant change in condition for a resident who began receiving hospice services. According to the Minimum Data Set (MDS) User's Manual, a significant change in status assessment is required when a terminally ill resident enrolls in hospice and remains in the facility, with the Assessment Reference Date (ARD) to be set within 14 days of the hospice election. In this case, the resident, who had diagnoses of hypothyroidism, congestive heart failure, and high blood pressure, was admitted to hospice care, but the clinical record did not show evidence that a significant change MDS assessment was completed within the required timeframe. Review of the resident's clinical record showed a physician's order to consult hospice services, followed by an order to admit to hospice. The care plan was updated to reflect hospice services for congestive heart failure. However, there was no documentation of a significant change MDS assessment being completed within 14 days of hospice admission, as required. This was confirmed by the Registered Nurse Assessment Coordinator during an interview, acknowledging the facility's failure to meet the assessment requirement.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. According to the RAI User's Manual, only anticoagulant medications such as warfarin or heparin should be coded under Section N0415E1, and antiplatelet medications like aspirin should not be included. However, for two residents, the MDS assessments incorrectly indicated that they had received anticoagulant medications during the 7-day look-back period. Review of the clinical records for both residents showed physician orders for aspirin, an antiplatelet medication, but no orders for anticoagulant medications. Staff interviews confirmed that the MDS assessments were incorrectly coded, as staff had been instructed to count aspirin as an anticoagulant when used for DVT prophylaxis. This resulted in inaccurate documentation of the residents' medication use in their assessments.
Failure to Develop Comprehensive Care Plan for Anxiety
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing anxiety for one resident, despite a physician's order for buspirone to treat anxiety. Review of the resident's clinical record and Minimum Data Set (MDS) indicated multiple diagnoses, including high blood pressure, atrial fibrillation, and COPD. Although the facility's policy requires a person-centered care plan with measurable goals and timetables for all identified needs, the resident's care plan did not include any interventions or planning for anxiety. This deficiency was confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Implement Hypoglycemia Protocol and Notify Physician
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with diabetes by not implementing its hypoglycemia protocol and not notifying the physician in a timely manner following a significant change in the resident's condition. Specifically, the resident, who had diagnoses including diabetes, high blood pressure, and cerebral infarction, was found to have a blood glucose level of 45 mg/dL, which is below the threshold requiring intervention according to facility policy. The resident was also under physician orders to notify the provider if blood glucose was less than 60 mg/dL and was NPO (nothing by mouth). Despite these findings, there was no documentation in the resident's clinical record regarding the hypoglycemic episode, no assessment of the event, no evidence of physician notification, and no record of interventions taken to address the low blood glucose. Staff interviews confirmed the absence of documentation and the failure to follow the hypoglycemia protocol as required by facility policy and physician orders.
Failure to Develop Comprehensive Care Plans for Residents Using Mobility Equipment
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-specific care plans for two residents with limited mobility who required the use of assistive equipment. One resident, diagnosed with COPD, dementia, and malnutrition, had a physician's order to wear a right ankle brace when out of bed, but the care plan did not include goals or interventions related to the use of the ankle brace. Another resident, with diagnoses including high blood pressure, anxiety, and bipolar disorder, had a physician's order for bilateral resting hand splints, but the care plan similarly lacked goals and interventions for the use of these splints. Interviews with facility staff revealed confusion regarding responsibility for care planning related to braces and splints. The Registered Nurse Assessment Coordinator believed therapy staff entered care plans for splints, while the Rehabilitation Director clarified that the therapy department does not develop care plans for braces or splints. This lack of clarity contributed to the omission of necessary care plan components for both residents, resulting in a failure to meet regulatory requirements for comprehensive, individualized care planning.
Failure to Provide Timely Respiratory Equipment Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with diagnoses including heart failure, anxiety, and respiratory failure. According to the facility's policy, oxygen tubing, masks, and cannulas are to be changed weekly and documented. Review of the resident's clinical record showed active physician orders for oxygen therapy via nasal cannula and administration of ipratropium-albuterol solution for respiratory symptoms. During observation, the resident was found receiving oxygen through tubing and using a nebulizer, both of which were dated more than two weeks prior, indicating they had not been changed as required by policy. Staff interviews confirmed the oversight, with an LPN acknowledging that the tubing should have been changed and the DON confirming the failure to provide appropriate respiratory care. The deficiency was identified for one of four residents reviewed, based on direct observation, record review, and staff interviews.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, depression, and high blood pressure. The facility's policy required individualized care plans that address trauma and PTSD, including identifying and mitigating triggers. However, review of the resident's care plan showed that while PTSD was noted, there was no identification of specific triggers or strategies to avoid them. Interviews with the Social Service Director and the Director of Nursing confirmed that there was no documented ongoing assessment for PTSD and no identification of triggers in the care plan, resulting in a lack of interventions to eliminate or mitigate potential re-traumatization for the resident.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with dementia and severe cognitive impairment. Clinical record review showed that the resident had a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment. Despite facility policy requiring appropriate treatment and services for residents with dementia, the care plan for this resident did not address their dementia or cognitive loss. Interviews with facility staff revealed confusion regarding responsibility for developing dementia care plans. The Registered Nurse Assessment Coordinator stated that Social Services was responsible, while the Social Worker was unaware of this responsibility and believed it was the RNAC's duty. Both confirmed that no individualized care plan addressing dementia and cognitive loss had been developed or implemented for the resident.
Expired Medical Supplies Found in Medication Room
Penalty
Summary
The facility failed to properly store medical supplies in the East Wing Medication Room, as evidenced by the presence of five 21-gauge needles with an expiration date of 4/30/25 found during a medication storage room review. The facility's policy requires regular inspection of nursing station storage areas for compliance with storage and expiration dating of medications, biologicals, syringes, and needles. Both an LPN and the Director of Nursing confirmed the improper storage of these expired medical supplies during interviews. No information about specific residents or their conditions was provided in the report.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
A deficiency occurred when the facility failed to provide drinks in a form that met the individual needs of a resident. The facility's policy required that all physician or provider orders, including those related to diet and nutritional supplements, be transcribed and reviewed by the charge nurse. The resident in question had diagnoses of high blood pressure, diabetes, and dementia, and was assessed as requiring a mechanically altered diet with thickened liquids at honey consistency, as documented in both the Minimum Data Set and the care plan. Physician orders specifically indicated the need for thickened liquids. During an observation, the resident was found in bed with a cup of clear thin liquid within reach, rather than the prescribed thickened liquid. An LPN confirmed that while thickener appeared to have been added, staff failed to mix it properly and ensure it reached the correct consistency. The DON also confirmed that the facility did not provide the drink in the required form for this resident.
Failure to Coordinate Hospice Services for Residents Receiving End-of-Life Care
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for two residents requiring end-of-life care. For one resident with diagnoses including aphasia, anemia, and CVA, hospice services were documented as being provided, but the last recorded visit from a hospice nurse was several months prior, and there was no evidence of ongoing coordination or service provision after that date. The facility's policy required timely hospice services and coordination, including maintaining up-to-date hospice plans of care and documentation, but these requirements were not met for this resident. For another resident with congestive heart failure, palliative care, and atherosclerotic heart disease, there was a physician's order for hospice admission and confirmation of hospice service initiation. However, the clinical record did not contain documentation of a Physician Certification of Terminal Illness, which is necessary for hospice care coordination. In both cases, the facility's social worker confirmed the lack of required documentation and coordination, indicating a failure to meet the residents' end-of-life care needs as outlined in facility policy and regulatory requirements.
Failure to Maintain Infection Control Practices for Catheter Care and PPE Use
Penalty
Summary
The facility failed to maintain proper infection control practices in the care of an indwelling urinary catheter for one resident. Specifically, the resident had a diagnosis of high blood pressure, heart failure, and obstructive uropathy, and required an indwelling urinary catheter. During an observation, the resident's catheter drainage bag was found lying directly on the floor beside the bed without a privacy cover, contrary to facility policy which requires the drainage bag to be kept below bladder level but not on the floor and covered for privacy and dignity. Additionally, staff failed to use Personal Protective Equipment (PPE) as required under Enhanced Barrier Precautions (EBP) when providing care to the resident. A nursing assistant emptied the resident's catheter without wearing gloves or a gown, despite EBP signage and PPE being available outside the room. The nursing assistant acknowledged awareness of the EBP requirements and confirmed the failure to use PPE and the improper placement of the drainage bag. The Director of Nursing also confirmed these lapses in infection control practices.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required communication training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are expected to complete all assigned training and education as required by law and regulation. Review of facility education records for the year 2024 showed that one nurse aide did not receive training on effective communication. This was confirmed by the Director of Nursing during staff interviews, who acknowledged that the communication training was not provided to the identified staff member.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Resident Rights training to two of five direct care staff members reviewed. Review of the Nursing Assistant job description indicated that staff are expected to complete all assigned training as required by law and regulation. Examination of facility education records for the year 2024 showed that two nurse aides did not receive training on Resident Rights. This was confirmed by the Director of Nursing during staff interviews, who acknowledged that the training had not been provided to these staff members as required by facility policy and state regulations.
Failure to Provide Abuse, Neglect, and Exploitation Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required training on abuse, neglect, and exploitation to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are required to complete all assigned training and education as mandated by law and regulations. Review of facility education records for the year 2024 showed that one nurse aide did not receive this mandatory training. The Director of Nursing confirmed during interviews that the staff member had not been provided with the necessary education on abuse, neglect, and exploitation, as required by facility policy and state regulations.
Failure to Provide QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to two of five direct care staff members reviewed. According to the facility's Nursing Assistant job description, staff are required to complete all assigned training and education as mandated by law and regulation. Review of facility education records for the year 2024 showed that two nurse aides did not receive QAPI training. This was confirmed by the Director of Nursing during staff interviews, who acknowledged that the required QAPI training was not provided to these employees.
Failure to Provide Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory Infection Control training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are required to complete all assigned training and education as mandated by law and regulation. Review of facility education records for the calendar year 2024 showed that one nurse aide did not receive Infection Control training. This was confirmed by the Director of Nursing during staff interviews and review of documentation. The deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(a) for failure to ensure required staff development and training.
Failure to Provide Compliance and Ethics Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to two of five direct care staff members reviewed. Review of the Nursing Assistant job description indicated that staff are required to complete all assigned training and education as mandated by law and regulation. Examination of facility education records for the year 2024 showed that two nurse aides did not receive training on Compliance and Ethics. During interviews, the Director of Nursing confirmed that these two staff members had not been provided with the necessary training, as required by facility policy and regulatory standards.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide the required minimum of 12 hours of annual training to a nurse aide, as mandated by regulations. Review of the nurse aide's job description indicated that completion of all assigned and legally required training is a primary responsibility. Facility education records for the calendar year showed that one nurse aide received only 0.21 hours of training, significantly less than the required amount. During interviews, the Director of Nursing confirmed that the facility did not meet the minimum training requirement for this staff member. This deficiency was identified through review of facility documents and staff interviews.
Failure to Provide Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to one of five direct care staff members reviewed. According to the Nursing Assistant job description, staff are expected to complete all assigned training as required by law and regulation. Review of facility education records for the year 2024 showed that one nurse aide did not receive Behavioral Health training. This was confirmed by the Director of Nursing during staff interviews and review of documentation. The deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(a) for failure to ensure staff development and compliance with training requirements.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post required information in areas accessible to all residents, specifically omitting contact details for Adult Protective Services, the State Agency, and the State Long-Term Care Ombudsman program. During an observation in the main entrance hallway, it was noted that while various information was available, it did not include Adult Protective Services information or the full address and email contact for the State Agency and Ombudsman as required. The Nursing Home Administrator confirmed during an interview that these postings were incomplete and not in compliance with regulatory requirements.
Failure to Display Required Medicare and Medicaid Information
Penalty
Summary
The facility failed to display written information regarding the application process for Medicare and Medicaid benefits, as well as information on receiving refunds for previous payments covered by these programs. During an observation in the Main Entrance Hallway, it was noted that although various information was posted for residents, there was no information available about applying for Medicare and Medicaid benefits or about obtaining refunds for payments previously covered by these programs. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required information was not displayed on either the West Wing or East Wing nursing floors.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of four residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. The residents involved were diagnosed with various conditions, including adult failure to thrive, high blood pressure, atrial fibrillation, heart failure, obesity, dysphagia, chronic obstructive pulmonary disease, obstructive sleep apnea, and hypertension. Despite these transfers occurring between April and September 2024, there was no documented evidence that the required notifications were sent to the Ombudsman Division. The facility's records indicated that the last notification to the Ombudsman Division was made in March 2024, suggesting a lapse in compliance with the notification requirements. The Director of Nursing confirmed during an interview that the facility did not provide the necessary transfer notices for the four residents. This failure to notify the Ombudsman Division is a violation of resident rights as outlined in 28 Pa. Code 201.29(a)(c.3)(2).
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. Specifically, the facility did not provide written information about the bed-hold policy to four residents or their representatives at the time of their hospital transfers. These residents included individuals with diagnoses such as adult failure to thrive, high blood pressure, atrial fibrillation, heart failure, obesity, dysphagia, chronic obstructive pulmonary disease, obstructive sleep apnea, and hypertension. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the failure to notify the residents or their representatives about the bed-hold policy. The report highlights that the facility did not have documented evidence of providing the required notifications for the hospital transfers of these residents. Additionally, the facility failed to provide a written transportation notification to the Office of the Long-Term Care Ombudsman for one resident who ceased to breathe at the hospital.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, as identified through a review of the Resident Assessment Instrument (RAI), clinical records, and staff interviews. Specifically, the Minimum Data Set (MDS) assessments for these residents contained inaccuracies in Section O, which pertains to pneumococcal vaccination status. For Resident R68, the MDS dated 9/1/24 did not accurately reflect the resident's vaccination status, as the section was incorrectly dashed out despite documentation indicating the resident had received the vaccine in 2020. Similarly, for Resident R114, the MDS also had Section O dashed out, even though the resident's vaccine consent form indicated they had not received the vaccine and had given permission for it to be administered if ordered by a physician. The Registered Nurse Assessment Coordinator (RNAC) confirmed the inaccuracies during an interview, acknowledging that the facility failed to ensure the accuracy of the assessments for these residents. This deficiency was noted under the Pennsylvania Code regulations concerning the responsibility of the licensee, resident care policies, and nursing services. The failure to accurately complete the MDS assessments for these residents highlights a lapse in the facility's adherence to required assessment protocols.
Failure to Uphold Resident Dignity
Penalty
Summary
The facility failed to promote and protect the dignity of a resident, identified as Resident R38, as observed during a survey. Resident R38 was admitted with diagnoses including transient cerebral ischemic attack, muscle weakness, and cerebrovascular disease. A physician's order dated 11/11/23 indicated that Resident R38 was to be on a regular puree diet with nectar thick liquids. However, during an observation on 10/21/24, a sign was noted on the resident's headboard stating 'Nectar Thick,' which was confirmed by a registered nurse on 10/22/24. This oversight was identified as a failure to uphold the resident's dignity, as required by resident rights and nursing services regulations.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements of personal fund accounts to five out of eight residents reviewed for personal funds concerns. During a resident group interview, it was revealed that residents were unaware of their account balances and did not receive financial statements. Specifically, Resident R2 confirmed not receiving any financial statements and mentioned having no family or individuals to assist with financial management. The Business Office Manager acknowledged the issue with the statements, and the Nursing Home Administrator admitted that the statements were managed by their corporate office in Ohio, with no evidence of distribution to residents. This deficiency violates several Pennsylvania codes related to the responsibility of the licensee, resident rights, and nursing services.
Failure to Notify Physician of Change in Resident Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for Resident R14, who was admitted with diagnoses including Friedreich ataxia, heart failure, and atrial fibrillation. On multiple occasions, the resident exhibited symptoms such as pain, difficulty breathing, and elevated heart rates, yet there was no documentation that a physician was notified. On one occasion, the resident's heart rate was recorded at 130, and later at 116, with complaints of trouble breathing. Despite these symptoms, the physician was not contacted, and the resident was only given Tylenol for pain relief. Further observations noted that the resident continued to feel unwell, with a heart rate of 139 and later 135, but again, the physician was not notified. Eventually, the resident's condition worsened, with a blood pressure reading of 62/42 and a heart rate of 87, prompting the facility to send the resident to the hospital. The hospital discharge summary indicated the resident was treated for atrial fibrillation, atrial flutter, high blood pressure, and a non-ST elevation myocardial infarction. Interviews with facility staff confirmed the failure to notify a physician in a timely manner for the resident's change in condition.
Failure to Properly Inform Residents of Medicare Coverage
Penalty
Summary
The facility failed to ensure that residents were properly informed about their Medicare coverage and potential liabilities for services not covered. Specifically, the facility did not ensure that the Notice of Medicare Non-Coverage (NOMNC) form was understood by Resident R105, who had a severe cognitive impairment with a BIMS score of 3. Despite this impairment, the NOMNC form was signed by Resident R105, indicating a lack of proper explanation to the resident or their representative, who was listed as the spouse and primary financial contact. Additionally, the facility did not provide the NOMNC form in a timely manner to Resident R321. The resident was admitted with diagnoses including high blood pressure, alcohol abuse, and sciatica. The NOMNC form indicated that services would end on June 20, 2024, but the form was not signed until June 21, 2024, a day after the services were supposed to end. This delay in providing the NOMNC form was confirmed by the Director of Nursing during an interview, highlighting the facility's failure to adhere to the required timelines for informing residents about their coverage status.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for five residents. During a facility tour with the Maintenance Director, it was observed that five resident rooms had deep gouges behind the head of the bed. Additionally, two resident rooms had sticky debris and grime on the floor under the bedside table and between the door and window beds. The base of one resident's tube feeding pole was corroded with dried tube feed formula. These observations were confirmed by the Maintenance Director, indicating a failure to maintain a sanitary, orderly, and comfortable interior as required by federal regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. Resident R57, who has multiple sclerosis, peripheral vascular disease, and coronary artery disease, was dependent on assistance for transfers. Despite care plan instructions requiring two staff members and a Hoyer lift for transfers, an agency Nurse Aide (NA) transferred Resident R57 alone, resulting in the resident being twisted in bed and experiencing increased pain in the left lower extremity. The facility was unable to produce a witness statement from the NA involved in the incident. In another incident, Resident R84, diagnosed with cirrhosis of the liver, chronic kidney disease, and autoimmune hepatitis, reported that an NA took unauthorized photographs of her while she was soiled with diarrhea. The NA admitted to taking the pictures and sending them to another NA from the previous shift, violating the resident's rights. The facility's investigation substantiated the claim, leading to the termination of the NA involved. These incidents demonstrate the facility's failure to ensure residents were free from abuse and neglect.
Failure to Report Alleged Neglect Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident, identified as Resident R57, who was admitted with diagnoses including multiple sclerosis, peripheral vascular disease, and coronary artery disease. The resident's care plan required assistance from two staff members and the use of a Hoyer lift for transfers. However, an agency Nurse Aide, identified as Employee E10, transferred the resident alone, contrary to the care plan instructions. During the transfer, the resident was twisted in the bed, resulting in pain to the left lower leg. The resident reported the incident to the Director of Nursing the following morning. Despite being informed, the facility did not report the allegation of neglect to the appropriate authorities as required by their policy. This failure to report was confirmed during an interview with the Director of Nursing. The deficiency was identified as a violation of specific Pennsylvania Code regulations related to the responsibility of the licensee, resident care policies, and management.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident, identified as Resident R57, who was admitted with diagnoses including multiple sclerosis, peripheral vascular disease, and coronary artery disease. The resident's care plan required assistance from two staff members and the use of a Hoyer lift for transfers. However, an agency Nurse Aide, identified as Employee E10, transferred the resident alone, contrary to the care plan, resulting in the resident being twisted in bed and experiencing pain in the left lower leg. The resident reported the incident to the Director of Nursing the following morning, but the facility did not conduct an investigation into the allegation of neglect. A witness statement from the involved Nurse Aide could not be produced, and the facility did not follow its policy to investigate and complete the investigation within five days of the alleged occurrence. This failure to investigate the incident was identified as a deficiency by the surveyors.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred and expected to return. Resident R59, who was admitted with diagnoses including heart failure, obesity, and dysphagia, was transferred to the hospital and returned to the facility. However, there was no documented evidence that the facility communicated essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information to the receiving health care provider. Similarly, Resident R49, who had diagnoses of chronic obstructive pulmonary disease, obstructive sleep apnea, and hypertension, was transferred to the hospital and returned to the facility. The clinical record for Resident R49 also lacked documented evidence of communication of necessary information to the receiving health care provider. The Director of Nursing confirmed that the facility failed to provide the necessary information for both residents, which is a violation of resident rights as per 28 Pa. Code 201.29(a)(c.3)(2).
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent infection for a resident admitted with existing pressure injuries. The resident, who had a history of cerebral infarction and hemiplegia, was admitted with two unstageable pressure ulcers on the left hip. Despite the facility's policy requiring immediate and ongoing assessment and treatment of pressure injuries, the resident's baseline care plan did not include a pressure ulcer care plan, and there were no physician orders for wound care from the time of admission until several weeks later. The resident's progress notes and skin observations indicated the presence of unstageable pressure ulcers with heavy seropurulent drainage, suggesting infection. However, the facility did not obtain physician orders to cleanse or dress the wounds until weeks after admission. The Braden Scale assessment identified the resident as at mild risk for pressure ulcer development, but the interventions section was left blank, and the care plan was not updated to reflect necessary wound care interventions. Interviews with facility staff, including the Wound Care LPN and the Registered Nurse Assessment Coordinator, confirmed the lack of timely implementation of a pressure ulcer care plan and the absence of necessary physician orders for wound care. The Director of Nursing and Nursing Home Administrator acknowledged the facility's failure to provide services consistent with professional standards to promote healing and prevent infection for the resident.
Inadequate Transfer Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate assistance during a transfer for a resident, resulting in a laceration that required 15 sutures. The resident, who had diagnoses of dementia, depression, and a displaced ankle fracture, was supposed to be transferred with the assistance of two persons as per physician orders and care plan. However, during the transfer from a wheelchair to a bed, the resident's right leg was injured, leading to a 17-centimeter laceration on the right calf. The incident was unwitnessed, and it was later discovered that only one nurse aide was present during the transfer, contrary to the requirement for two-person assistance. The resident's leg got caught on the bottom of the side rail, causing the injury. The facility's incident/accident report for October 2024 did not include this incident, indicating a lapse in documentation and reporting. Interviews with staff confirmed that the resident required two-person assistance for transfers, and the nurse aides were expected to refer to assignment sheets or clinical records for transfer status. However, the nurse aide involved in the incident did not follow this protocol, leading to the deficiency. The facility's management acknowledged the failure to provide adequate assistance during the transfer, which resulted in the resident's injury.
Failure to Update Nutritional Care Plan
Penalty
Summary
The facility failed to update an individualized care plan to address a resident's specific nutritional concerns and preferences. The resident, identified as R82, was admitted with diagnoses including cerebral palsy, aspiration pneumonia, and gall bladder stones. The Minimum Data Set (MDS) assessment dated 9/5/24 indicated these conditions. The current physician orders, dated 9/10/24, prescribed a Regular, Nectar thick, Mech Soft diet. However, the care plan initiated on 9/2/24 still reflected a Puree, Nectar thick diet, which was not updated to match the physician's orders. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC) Employee E1 on 10/23/24.
Inadequate Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to ensure consistent communication between the dialysis provider and facility staff for a resident requiring dialysis services. The facility's Hemodialysis Care Policy mandates communication before and after each hemodialysis treatment, but a review of the clinical record revealed incomplete communication forms since the resident's admission. Specifically, there were only four incomplete communication sheets, with missing dialysis portions and facility medications, for specific dates, and one sheet was undated. The Director of Nursing confirmed the lack of complete communication forms as required. Additionally, the facility did not maintain an accurate care plan for the resident's dialysis access site. The resident, who was admitted with diagnoses including renal failure with dialysis, had an AV fistula in the right upper arm. However, the care plan incorrectly indicated management for a peritoneal access site, which the resident did not have. A Registered Nurse confirmed that the care plan did not reflect the resident's current needs. The facility's Comprehensive Care Planning Policy requires an interdisciplinary plan of care to be established and updated as needed, which was not adhered to in this case.
Failure to Address Resident's Mental Health and Medication Misuse
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with mental or psychosocial adjustment difficulties, as evidenced by the lack of a relevant policy and inadequate care planning. The facility's administrator admitted that there was no policy in place for addressing mental or psychosocial concerns. The resident, who had a history of depression, bipolar disorder, and a below-the-knee amputation, was observed to have behavioral symptoms such as attention-seeking and manipulative behaviors. Despite these observations, the care plan did not adequately address the resident's potential drug addiction and manipulation issues. The resident was prescribed medications including Xanax for anxiety and oxycodone for pain management. However, there were multiple instances where the resident was found to be misusing these medications, such as crushing Xanax and snorting oxycodone. Staff interviews revealed that the resident was caught in the act of crushing pills and was known to manipulate her medication intake. Despite these incidents, the facility's care plan did not reflect interventions to prevent future occurrences of medication misuse. The facility's failure to address the resident's drug manipulation and potential addiction was highlighted by the lack of documentation in the clinical record regarding these issues. Interviews with staff, including the Director of Nursing, confirmed that the resident's behavior was known, yet no effective measures were implemented to manage the situation. This deficiency was noted as a violation of several Pennsylvania Code regulations related to resident care policies and nursing services.
Failure to Act on Pharmacy Recommendations for Medication Review
Penalty
Summary
The facility failed to ensure that irregularities identified in the medication regimen reviews (MRR) by the pharmacy were addressed for one resident. Resident R12, who was admitted with diagnoses including heart failure, respiratory failure, and rhabdomyolysis, had an active physician order for lorazepam to be administered as needed for anxiety. The pharmacy's MRR on two occasions noted that the lorazepam order had been in place for more than 14 days without a stop date and recommended reviewing the order to add a potential stop date or document the intended duration and rationale for extended use. However, these recommendations were not acted upon, and the pharmacy reviews were not signed by the physician. The clinical record review from February through October failed to provide a rationale for the continued order of lorazepam without a stop date. During an interview, the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not ensure that the recommendations and orders from the pharmacy and physician were acted upon as required. This deficiency was identified for Resident R12, highlighting a lapse in the facility's medication management and review process.
Failure to Limit PRN Orders and Monitor Psychotropic Medication
Penalty
Summary
The facility failed to adhere to its policy regarding the limitation of PRN orders for psychotropic drugs to 14 days, as evidenced by the case of a resident who was prescribed lorazepam without a stop date. The resident, who had been diagnosed with heart failure, respiratory failure, and rhabdomyolysis, had an active physician order for lorazepam as needed for anxiety, which was not reviewed or discontinued after 14 days. This oversight was confirmed by the Director of Nursing and the Nursing Home Administrator during an interview. Additionally, the facility did not identify a specific diagnosed condition for the use of antipsychotic medication in another resident, nor did it monitor the effectiveness or adverse consequences of the medication. This resident, diagnosed with cerebral palsy, aspiration pneumonia, and gall bladder stones, was prescribed Quetiapine without a documented rationale for its use. The care plan for this resident included monitoring for adverse drug reactions, but the clinical record lacked evidence of such monitoring. This deficiency was confirmed by the Registered Nurse Assessment Coordinator.
Failure to Date and Store Medications Properly
Penalty
Summary
The facility failed to adhere to its policy regarding the dating and storage of medications, as observed during a survey. Specifically, the East Wing Front Hall medication cart contained several inhalers, including Symbicort, Albuterol, and three Fluticasone Propionate inhalers, that were not labeled with the date and time they were opened. This is a requirement when medications have a shortened expiration date once opened. The issue was confirmed by a Registered Nurse (RN) and the Director of Nursing during interviews conducted on the same day as the observation.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident, identified as Resident 11, who was reviewed for dental concerns. According to the facility's Dental Services Policy, dated 7/1/24, the facility is responsible for assisting residents in obtaining routine and emergency dental care. Resident 11 was admitted and readmitted to the facility on unspecified dates and had a diagnosis of depression and orthostatic hypotension as per the MDS assessment dated 6/18/24. The resident was evaluated by a dentist on 8/6/24 for upper complete dentures, and it was noted that two roots needed extraction. However, the Activities Director, Employee E6, was required to contact the resident's daughter for consent for the extraction, which had not been done by the time of the interview on 10/22/24. During an interview on 10/21/24, Resident 11 expressed concern about the delay in receiving dentures, stating that he had been waiting for over a month. The Activities Director confirmed the delay in contacting the resident's daughter for consent, acknowledging the facility's failure to provide timely dental services. This deficiency was identified as a violation of the Pennsylvania Code 211.12(d)(1)(3)(5) regarding nursing services and 211.15 concerning dental services.
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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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