Emerald Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Elizabethtown, Pennsylvania.
- Location
- 320 South Market Street, Elizabethtown, Pennsylvania 17022
- CMS Provider Number
- 395469
- Inspections on file
- 33
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Emerald Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide and document catheter care for multiple residents with Foley or suprapubic catheters. A resident with a suprapubic catheter developed drainage, vomiting, and sepsis secondary to CAUTI, while other residents had repeated catheter pain, pus, blockage, hematuria, UTIs, and hospital transfers, including ICU admission for septic shock. The record showed no catheter care orders or task documentation for several residents, and the NHA and DON confirmed the missing documentation.
Dishwasher Sanitization Log Completed Before Required Meal Testing: Surveyors observed the dishwasher running and found that sanitization monitoring was not properly completed or documented. An employee reported no test strips were immediately available, and when strips were found, the water tested greater than 100 PPM. The FSD confirmed staff are to test dishwasher sanitization during each meal and complete the log after testing, but the log had been filled out for the entire day before the meals were finished.
The facility failed to notify the State Ombudsman of emergency transfers for four residents. One resident was sent out after a painful, red incision-line lump and later admitted with cellulitis, another after 911 was called for crushing chest pain and later admitted with CHF exacerbation, a third was admitted with osteomyelitis, and a fourth was transferred for respiratory distress, hypoxia, and cyanosis and later admitted with respiratory failure with hypoxia. Records did not show the required ombudsman notification, and an E5 confirmed the residents were not on the list sent to the ombudsman.
Inaccurate MDS Coding for Insulin: A resident’s quarterly MDS was coded to show insulin use during the lookback period, but review of the physician’s orders and MAR found no evidence the resident received insulin. An LPN confirmed the assessment was coded inaccurately.
Failure to Verify Significant Weight Changes: A resident had multiple significant weight changes recorded without the required reweights for confirmation. The chart showed a large loss, then a gain, then another loss, but staff did not verify the accuracy of the weights as required by facility policy. An E4 confirmed the weights were not being checked for accuracy.
An LPN failed to follow the facility’s infection control protocol during med pass for a resident. While opening pill packets, the meds spilled onto the top of the med cart, and the LPN picked them up from the cart surface, placed them in a med cup, and administered them to the resident.
Failure to Post State Survey Agency Contact Information: The facility did not post the State Survey Agency’s name, address, and telephone number on Station 2 and Station 3. Survey observations found no such posting on either unit, and residents reported they were unaware of any posting. The NHA confirmed the contact information was not posted on the nursing units.
Survey results were posted only in the lobby, and residents on two units were not aware of where to find them. Residents reported they could not access the lobby because the elevator required a code, and the NHA confirmed the results were not posted in a location readily accessible to residents.
Three residents experienced deficiencies in care when staff did not follow physician orders for medications, weight monitoring, and wound care. One resident with chronic diastolic CHF received significantly lower doses of torsemide than ordered and did not have weights monitored as prescribed, despite cardiology instructions for higher dosing and daily weights, and later developed increased edema and weight gain before being sent to the ED for fluid overload. A second resident missed multiple ordered oxycodone doses without documented rationale or provider notification and had bilateral leg cellulitis wounds for which ordered treatments were not properly transcribed into the TAR or consistently applied, with no clear documentation of replacement dressings when the resident removed them. A third resident with a left calf wound and lymphedema had a change from wound vac to dressing and compression therapy, but weekly wound assessments were not documented for several weeks, leaving the wound unassessed during that period.
Surveyors found that a resident’s bathroom was not maintained in a clean and homelike condition. During an observation with an LPN, they noted dried brown substances in and around the toilet, used towels left in the sink, a used drawsheet, a used gown, and a wet washcloth with brown stains on the floor, and a trash can overflowing with used incontinent briefs. The LPN confirmed the bathroom smelled of urine, demonstrating a failure to maintain a safe, clean, and comfortable environment as required by facility management regulations.
A resident with an indwelling urinary catheter, which under facility policy required enhanced barrier precautions (EBP) when contact precautions did not otherwise apply, was observed without any EBP signage on or outside the room and without PPE available as required. The facility’s EBP policy specified that residents with wounds and/or indwelling medical devices require EBP regardless of MDRO status, and that signage and PPE must be placed outside resident rooms. During the survey, an LPN confirmed the absence of the required signage, and the findings were later reported to the NHA and DON.
A resident with moderate cognitive impairment and multiple diagnoses was incorrectly assessed as low risk for elopement. Despite repeated exit-seeking behaviors observed by staff, these were not reported to supervisors. The resident was able to leave the facility unaccompanied and was only discovered missing when a family member called to report the resident's arrival at their home.
A resident with dementia eloped from the facility due to the failure of the NHA and DON to ensure proper completion of elopement assessments and to supervise residents exhibiting elopement behaviors. This resulted in an Immediate Jeopardy situation, as the facility did not maintain effective systems or oversight to safeguard residents at risk.
Multiple residents' rooms and common areas were found with overflowing trash, soiled items, food crumbs, and visible dirt, with residents reporting that housekeeping had not cleaned their rooms for several days. The Nursing Home Administrator confirmed these environmental concerns during walkthroughs, and previous grievances about cleanliness were documented.
Two residents did not receive care according to professional standards: one with diabetes had blood glucose readings above 400 mg/dl without required physician notification or proper documentation, and another with muscle weakness and a fall-related skin tear did not have timely wound care or physician notification, with no treatment orders documented.
Staff failed to provide timely incontinence care and respond to call bells for two residents dependent on assistance, resulting in prolonged periods in soiled briefs and unmet toileting needs. Multiple residents reported excessive wait times, and observations confirmed staff inattentiveness and use of personal devices during shifts, despite care plans requiring regular assistance.
A resident with ESRD who required regular dialysis did not consistently receive care according to physician orders and care plan directives, as blood pressure was documented as being taken from the restricted arm multiple times. Additionally, required dialysis communication forms were missing from the clinical record for several treatment dates, and the DON confirmed these forms were not available as expected.
Annual performance evaluations for nurse aides were not completed as required for four out of five aides reviewed. The DON confirmed that the evaluations were missing from employee files and should have been present.
The facility did not ensure that monthly medication regimen reviews were completed by a pharmacist and that recommendations were addressed by prescribers for several residents with complex medical conditions, including those with heart disease, kidney disease, diabetes, depression, and dementia. Required pharmacy reviews were missing for multiple months, and some pharmacy recommendations were not responded to by staff or prescribers.
Surveyors found that food and beverages were not stored or labeled according to professional standards, with expired items, open and unlabeled food packages, and improper storage of scoops in food containers. The milk refrigerator contained expired milk, personal staff beverages, and was heavily soiled, all in violation of facility policy.
The required members of the Quality Assurance Committee, including the MD or designee, NHA, and DON, did not meet together on a quarterly basis for two consecutive quarters, as confirmed by review of meeting signatory pages and staff interview.
A resident with heart failure and chronic kidney disease, who was assessed as continent, experienced multiple incontinence episodes and embarrassment due to delayed call bell responses and lack of timely assistance to use the bed pan. Staff did not accurately document the resident's continence status, despite frequent requests for help, and concerns about long call bell wait times were noted in Resident Council Meeting Minutes.
The facility did not complete criminal background checks at the time of hire for an LPN and a nurse aide, as required by its abuse prevention policy. This failure was confirmed through personnel file reviews and administrator interview.
A resident with multiple chronic conditions was transferred to the hospital on two occasions without receiving required written notices about bed-hold and transfer policies. Facility policy required these notifications and documentation, but they were not provided due to a misunderstanding by the administrator in training responsible for this task.
A resident with dementia and chronic kidney disease was observed multiple times without hearing aids, despite a physician's order for daily application and removal. The care plan did not address hearing aid use, and the DON confirmed staff were expected to assist with them. This resulted in a failure to provide proper treatment and assistive devices to maintain hearing abilities.
A resident with dementia and severe malnutrition, identified as a fall risk, was observed with two fall mats stacked on one side of the bed instead of having a fall mat on each side as required by the care plan. The DON confirmed that the mats should have been placed on both sides.
A resident with dementia and severe protein-calorie malnutrition experienced significant unmonitored weight loss, with no physician notification or required reweigh completed. Monthly weights were not documented as ordered, and the DON confirmed missing records, indicating non-compliance with facility policy and physician orders.
A resident with heart failure and chronic kidney disease did not receive prescribed Furosemide for several days after admission because agency staff lacked access to the online system needed to obtain the medication, as confirmed by the DON.
A resident reported that coffee was never served hot, and a test tray confirmed the coffee was served at 110°F, below the facility's required 135°F. The Food Service Director indicated coffee was likely poured too early, resulting in it not being palatable or appealing at the time of service.
The facility did not post current daily nurse staffing information as required, with observations showing outdated postings and confirmation from the DON that the assigned staff member failed to update the information on multiple days.
The facility did not meet the required staffing levels for nurse aides during specific shifts from late January to early February 2025. The day shift was understaffed on four days, the evening shift on two days, and the night shift on two days, failing to meet the minimum nurse aide-to-resident ratios. These deficiencies were confirmed through staffing data and an interview with the Nursing Home Administrator.
The facility did not meet the required staffing levels, failing to provide one nurse aide per 10 residents during the day and one per 15 residents overnight. Specific deficiencies were noted on the day shift and night shifts on different days, as confirmed by the Nursing Home Administrator.
A resident with a high fall risk and multiple health issues was left unsupervised by a CNA during a care routine, resulting in a fall and a fracture to the right humerus. The resident's care plan required extensive assistance for bed mobility, but the CNA left the resident on their side without a protective pad to retrieve supplies. This led to the resident becoming unsteady and falling, necessitating hospital transfer and increased pain management.
The facility failed to honor the bathing preferences of three residents who preferred showers but were predominantly given bed baths. Records showed no evidence that the residents refused or were unable to tolerate showers, despite care plans suggesting otherwise. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain a clean and homelike environment on the 2nd floor nursing unit. Multiple rooms had air conditioners with a thin layer of dust, and one resident's bathroom had a clogged toilet with a dried brown substance on the seat, which remained unaddressed for at least two days. The Nursing Home Administrator could not provide evidence of when the air conditioners were last cleaned.
The facility failed to perform criminal background checks for three out of five personnel records reviewed, specifically for Employees E1, E2, and E5, as required by their policy. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. One resident did not receive prescribed medications for constipation, another had missing documentation for fluid intake, and a third did not have bladder scans performed as ordered. These issues were confirmed by the Nursing Home Administrator.
The facility failed to monitor the nutritional status of five residents as per policy and physician orders, resulting in significant weight changes not being properly monitored or confirmed. Interviews with the Nursing Home Administrator confirmed the lapses in monitoring.
A resident was unable to access the bathroom due to the location and size of her wheelchair, forcing her to use a bed pan. The care plan included interventions for an unobstructed path and wheelchair transfers, but these were not effectively implemented.
The facility failed to update the care plan for a resident with Bipolar Disorder, Depression, and Anxiety to reflect her current status. Despite an incident where the resident attempted to harm herself with a call bell, and a subsequent safety contract allowing the call bell, the care plan was not updated. This was confirmed by the Nursing Home Administrator.
The facility failed to report critical lab results to the physician in a timely manner for a resident. A nurse received a call about a critical calcium level and faxed the results to the physician's office, but it took a week before the results were communicated via telephone. The Nursing Home Administrator confirmed the delay and improper faxing of critical values.
The facility failed to maintain accurate medical records for a resident. Initial evaluations showed no pressure ulcers, but subsequent notes documented a Stage 3 pressure ulcer, which was inconsistently recorded in later assessments. The Nursing Home Administrator confirmed the inaccuracies.
Failure to Provide and Document Catheter Care
Penalty
Summary
The facility failed to provide adequate urinary catheter care for four residents with indwelling or suprapubic catheters. The report states that the facility policy required catheter care to be documented in the medical record, including the date and time care was provided, the staff member providing it, and assessment data obtained during care. For Resident 6, who had a suprapubic catheter, the record contained no order for catheter care and no task documentation showing catheter care had been completed since admission. Resident 6 developed suprapubic catheter drainage with serosanguinous fluid, vomiting, and later presented to the hospital with low suprapubic output, blood-tinged leakage, pus around the suprapubic tube, pus and gross hematuria in the tubing, suprapubic abdominal pain, and vomiting. The resident was admitted with sepsis secondary to CAUTI. The Nursing Home Administrator and DON confirmed there was no order or documented evidence that catheter care had been provided per policy. Resident 28’s record also lacked an order for catheter care and lacked task documentation showing catheter care had been completed since admission. The resident had repeated catheter-related complaints and findings, including pain, reports that nurses were not flushing the catheter, pus around the catheter, sediment nearly occluding the Foley, yellow drainage, redness, swelling, hematuria, and multiple transfers to the hospital. The record documents UTIs, positive urinalysis results, antibiotic treatment, and hospital admissions including sepsis. The NHA confirmed there was no documented evidence of catheter care for this resident. Resident 47 had a Foley catheter order, but the record failed to show an order for catheter care or documentation that catheter care had been completed since admission. The resident complained of abdominal and penile discomfort, a Foley flush met resistance, the catheter was changed, the resident remained unable to void, and a bladder scan showed 1211 cc with a hard, distended abdomen. The resident was sent to the hospital and was admitted to ICU with septic shock from ESBL Klebsiella and E. coli bacteremia from complicated UTI/CAUTI present on admission. Resident 8’s record likewise lacked an order for catheter care and lacked task documentation showing catheter care from return from the hospital until discontinuation of the catheter. The NHA and DON confirmed the absence of documented catheter care for Resident 8 as well.
Dishwasher Sanitization Log Completed Before Required Meal Testing
Penalty
Summary
The facility failed to ensure appropriate sanitization monitoring and documentation for the dishwasher used in dietary services. On April 20, 2026, surveyors observed the dishwashing machine running in the kitchen, and Employee E6 stated the dishwasher water temperature was 125 degrees. The dishwasher log was reviewed and found to be completed. During a second kitchen observation on April 22, 2026, the dishwasher was again running, and Employee E6 stated that no test strips were immediately available to test the sanitization of the water coming out of the dishwasher. After test strips were located, the water tested greater than 100 PPM. Review of the dishwasher sanitization log showed the sanitization was tested during the cleaning of breakfast dishes, and Employee E6 stated the log had been completed for the breakfast dishes. The log also showed the entire day was completed at that time. The Food Service Director confirmed employees are to test dishwasher sanitization during each meal and complete the log after testing, and confirmed the log had been completed ahead of the meals on April 22, 2026, so adequate sanitization was not tested during each meal.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the office of the state long term care ombudsman of emergency transfers for four of eight residents reviewed. Resident 2 was seen by the wound NP for a painful, red lump at the incision line, and the NP recommended contacting the wound center and/or surgeon; a surgical group representative later suggested sending the resident to the ED, and the resident was admitted for left above-the-knee amputation cellulitis. Resident 5 had 911 activated for crushing chest pain and was later admitted for CHF exacerbation. Resident 8 was admitted to the hospital with osteomyelitis. Resident 9 developed respiratory distress, hypoxia, a productive cough, abdominal muscle use for breathing, and cyanosis, and was transferred to the hospital; later documentation noted admission for respiratory failure with hypoxia. Facility records did not show evidence that the State Ombudsman's office was notified of the transfers and admissions for Residents 2, 5, 8, and 9. An interview with Employee E5 confirmed that these residents were not on the list provided to the State Ombudsman's office.
Inaccurate MDS Coding for Insulin
Penalty
Summary
Resident 2’s quarterly MDS dated March 22, 2026, was coded to indicate that the resident received insulin on one day in the last seven days in section N0350. However, review of the physician’s orders and the MAR showed no evidence that the resident received insulin during the assessment lookback period. During interview on April 23, 2026, at 1:35 p.m., licensed staff E4 confirmed that the assessment was coded inaccurately.
Failure to Verify Significant Weight Changes
Penalty
Summary
The facility failed to obtain accurate weights and verify weights to maintain acceptable nutritional status for one resident. Facility policy required any weight change of 5% or more since the last weight assessment to be retaken the next day for confirmation. Resident 31 had a weight of 131.0 pounds on December 2, 2025, and then 111.0 pounds on January 8, 2026, a loss of 20 pounds or 15.3%, but no reweight was obtained. The resident was later recorded at 113.0 pounds on January 15, 2026, and 125.0 pounds on January 20, 2026, a gain of 14 pounds or 12.6%, again with no reweight obtained. The next recorded weight was 116.0 pounds on February 3, 2026, a loss of 9 pounds or 7.2%, and no reweight was obtained. An interview with Employee E4 on April 23, 2026, confirmed that the resident's weights were not being verified for accuracy.
Medication Administration Did Not Follow Infection Control Procedures
Penalty
Summary
The facility failed to ensure medications were administered in accordance with its infection prevention protocol for one resident. The facility policy for administering medications required staff to follow established infection control procedures, including handwashing, antiseptic technique, gloves, and isolation precautions as applicable. During observation of medication administration, a licensed employee cut open medication pill packets and spilled the medications onto the top of the medication cart. The licensed employee then picked up the medications from the cart surface, placed them in a medication cup, and administered them to the resident. The issue was reported to another licensed employee and the Nursing Home Administrator.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to post the name, address, and telephone number of the State Survey Agency on two of two units, Station 2 and Station 3. Observations on all days of the survey on both units found no posting of the contact information for the State Survey Agency. During a group interview with residents on April 21, 2026, at 1:00 p.m., residents stated they were not aware of any posting containing the State Survey Agency contact information. The Nursing Home Administrator confirmed on April 23, 2026, at 12:50 p.m. that the State Survey Agency contact information was not posted on the nursing units.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to post the results of the most recent Department of Health survey in a place readily accessible to residents for two of two units, Stations 2 and 3. Observations during all days of the survey showed only a posting in the lobby stating that the state survey results were available there. During a resident group meeting, residents stated they were not aware of the location of the state survey results and reported that they do not have access to the lobby because the elevator to the lobby requires a code. The Nursing Home Administrator confirmed that the survey results were only located in the lobby, which was not readily accessible to residents.
Failure to Follow Medication, Weight Monitoring, and Wound Care Orders for Three Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for medications, diagnostic monitoring, and wound care for three residents. For the first resident, who was cognitively intact, dependent for ADLs, and diagnosed with chronic diastolic CHF, the physician ordered torsemide 120 mg PO BID and later ordered weights three times weekly with specific parameters to notify the provider and the resident’s daughter of significant weight changes or refusals. After a hospitalization for CHF and discharge with instructions to continue torsemide 120 mg BID, the facility’s MAR showed an order for only 20 mg BID. A subsequent cardiology consult documented that the resident “should be on 120 mg of torsemide but since [they have] only been getting 20 BID, increase to 60 mg BID” and requested daily weights. The TAR documented only two weights over several days, and there were gaps in weight documentation despite orders for more frequent monitoring. Further documentation for the first resident showed ongoing weight fluctuations and edema consistent with fluid retention. Dietary notes identified significant weight changes and referenced increased torsemide per progress notes, while nursing notes described refusal of an outside IV diuresis appointment, abnormal BMP and magnesium results, and provider orders to encourage fluids and increase torsemide to 80 mg BID with BP monitoring. Cardiology later ordered torsemide 80 mg BID, daily pre-breakfast weights, and instructions to call for specified weight gains or worsening symptoms. Subsequent weights showed increases, and nursing notes documented weeping edema of the bilateral lower extremities, a 5‑pound weight gain, and 3+ pitting edema. The provider was notified and ordered BLE ultrasound and blood work, and the family arranged a cardiology appointment. The cardiology office later reported the resident was being sent to the ED for fluid volume overload, and hospital records confirmed admission for acute on chronic CHF. The surveyors concluded the facility failed to implement medication orders and failed to monitor the resident’s weight as ordered, resulting in increased CHF symptoms and actual harm. For the second resident, a physician ordered oxycodone 5 mg PO every eight hours for three days. The MAR showed missed doses on three occasions, with only one progress note indicating a dose was held because the resident was hard to arouse with low SpO2; there was no documentation explaining the other missed doses. The record also lacked evidence that the physician was notified of the resident’s change in condition or of the missed oxycodone doses. Wound consult documentation for this resident described bilateral lower leg cellulitis with detailed treatment orders, including Betadine to the left leg and acetic acid with Xeroform and bordered dressing to the right leg, and later an order for hydrogel with foam dressings and compression wraps to both legs. However, the right leg wound care order was not present in the physician orders, the Betadine order for the left leg was not transcribed to the TAR, and the hydrogel treatment ordered on March 20 was not completed as ordered from March 20 until March 26 because it was not transcribed into the TAR. Nursing notes recorded that the resident was removing leg dressings but did not document what replacement treatments or dressings were applied. The DON confirmed the wound orders were not followed as ordered, and a corporate nurse reported EMR changes with order transcription contributed to the issue. For the third resident, who had a history of a left lower leg wound with hematomas requiring incision and drainage, cellulitis, and lymphedema, a wound consult documented an unstageable left calf wound with tunneling and ordered NPWT (wound vac) at 125 mmHg continuous three times per week and as needed. A later nursing note indicated the wound vac was discontinued after a wound center appointment, and a new physician order directed cleansing the left lower leg with soap and water, applying Prisma and calcium alginate twice weekly, and applying Profore compression from toes to knees. Weekly skin assessments documented that the resident’s skin was not intact but did not include an assessment of the left calf wound on specified dates, and there was no documentation of weekly wound assessments on additional dates. The DON confirmed that the left calf wound was not assessed from December 31 until January 21. Overall, the surveyors determined the facility failed to ensure physician orders were followed and that ordered monitoring and treatments were completed for all three residents, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, clean, and homelike environment in one resident’s bathroom. During an observation of Resident 2’s bathroom conducted in the presence of a licensed nurse (Employee E3), surveyors noted dried brown substances in front of the toilet bowl, brown substances in the toilet bowl, two used towels left in the sink, and a used drawsheet, a used gown, and a wet washcloth with brown stains on the bathroom floor. Additionally, the garbage can in the bathroom was overflowing with used incontinent briefs, and Employee E3 confirmed that the bathroom smelled of urine. These observed conditions demonstrated that the facility did not ensure Resident 2’s bathroom was maintained in a clean and sanitary state, as required by 28 Pa. Code 201.18(b)(1)(3)(e)(1) regarding management responsibilities for providing a safe, clean, and comfortable environment.
Failure to Provide PPE and Enhanced Barrier Precaution Signage for Resident With Indwelling Catheter
Penalty
Summary
The facility failed to implement its infection prevention and control program by not providing required personal protective equipment (PPE) and signage for a resident who met criteria for enhanced barrier precautions (EBP). The facility’s March 2024 policy on Enhanced Barrier Precautions states that EBP are indicated, when contact precautions do not otherwise apply, for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organism (MDRO) colonization status, and that signs must be posted on the door or wall outside the resident room indicating the type of precautions and PPE required, with PPE available outside resident rooms. During an observation on February 4, 2026, at approximately 12:05 p.m., a resident identified as having an indwelling urinary catheter was observed without any EBP signage on or outside the room and with no PPE available in the room. Two LPNs confirmed the lack of required signage later that afternoon, and these findings were reported to the Nursing Home Administrator and Director of Nursing the same day. The deficiency was cited under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services. The resident involved had an indwelling urinary catheter, defined in the report as a flexible tube inserted into the bladder to continuously drain urine into an external bag, which under facility policy required EBP when contact precautions did not otherwise apply. Despite this condition and the clear policy requirements, there was no posted indication of EBP or required PPE and no PPE available as specified by the policy at the time of the surveyor’s observation.
Failure to Supervise and Accurately Assess Elopement Risk Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident who was inaccurately assessed as low risk for elopement, despite having diagnoses including Parkinson's disease with dyskinesia, neurocognitive disorder with Lewy bodies, muscle weakness, and difficulty walking. The resident's admission assessment incorrectly indicated no dementia, resulting in a low-risk classification for wandering, even though the Minimum Data Set (MDS) showed moderate cognitive impairment. Multiple staff members observed the resident exhibiting exit-seeking behaviors, such as attempting to use the elevator, but none reported these behaviors to their supervisors. On the day of the incident, the resident was seen several times by different staff members attempting to access the elevator and was redirected to their room each time. However, these repeated exit-seeking behaviors were not communicated to supervisory staff. Later, the resident was observed by a staff member leaving the facility but was mistakenly believed to be on a leave of absence. The staff member did not report this observation, and the resident subsequently exited the building and walked out of the facility. The facility only became aware that the resident was missing when the resident's daughter called to report that the resident had arrived at her home after crossing multiple busy streets. The facility's failure to accurately assess the resident's elopement risk and to provide appropriate supervision for a resident actively exhibiting exit-seeking behaviors resulted in the resident leaving the facility without staff knowledge.
Removal Plan
- Nursing Administration reviewed all residents' electronic health records for accurate elopement/wandering evaluations.
- Elopement books at the reception desk and every unit were reviewed to ensure all residents identified as elopement risks were current and resident identifiers were available.
- Sign posted at reception notifying visitors of the Leave of Absence (LOA) process.
- Staff educated on routine resident checks, the wandering and elopement policy, and the wander management and elopement prevention policy.
- RN Supervisors/Unit managers educated on the completion of headcounts of all residents compared to the midnight census and the immediate reporting of any discrepancy to the Director of Nursing (DON).
- Staff educated on the LOA process.
- Reception staff educated on the facility visitor badge protocol, visitor badge process, resident leaves of absence, and signing residents out.
- Staff educated on the elopement/missing person policy and procedure including the elopement code announcement to notify staff in the center, search on the premises and the surrounding areas, and notification processes.
- Staff educated on elopement drills including the frequency of drills and expected responses.
- Training regarding elopement added to the general orientation schedule for new employees.
- Elopement drill completed.
- Elevator and keypads assessed. Elevator keypad code changed. Additional training provided to staff related to not providing keypad codes to visitors and/or residents.
- Elopement/wandering evaluation updated as needed.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia by not effectively managing elopement risks. Specifically, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not establish or maintain systems to ensure that elopement assessments were completed correctly, nor did they prevent residents exhibiting elopement behaviors from leaving the facility without proper supervision. This lapse in management and oversight resulted in a resident eloping from the facility, creating an Immediate Jeopardy situation. Review of job descriptions and facility policies indicated that both the NHA and DON were responsible for developing and implementing operational policies and procedures to meet residents' needs and ensure their safety. However, documentation and staff interviews revealed that these responsibilities were not fulfilled, as evidenced by the failure to complete elopement assessments and to supervise residents at risk for elopement. The resident involved had a diagnosis of dementia, which increased their vulnerability, and the lack of appropriate interventions directly led to the elopement incident.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on one of its nursing units, as evidenced by multiple observations and resident interviews. Several rooms were found to have overflowing trash, food crumbs, soiled items, and visible dirt or stains on various surfaces, including nightstands, baseboards, privacy curtains, and bathroom fixtures. Residents reported that housekeeping had not cleaned their rooms for several days, and nursing staff had not emptied trash cans. These environmental concerns were confirmed by the Nursing Home Administrator during walkthroughs, who acknowledged that the rooms required cleaning. Additional observations included soiled clothing and briefs left on the floor, strong urine odors, lifted floor tiles, and non-operational air conditioning units in common areas. The chapel and surrounding hallways were noted to have black wheelchair marks, dried patches, and food crumbs, with no evidence of recent cleaning. The presence of a dead vine growing into the building through a window was also documented. The facility's grievance log had previously recorded complaints about cleanliness and overflowing trash, further substantiating the ongoing environmental deficiencies.
Failure to Follow Professional Standards in Medication Administration and Wound Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. For one resident with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, and congestive heart failure, clinical records showed that blood glucose levels exceeded 400 mg/dl on two occasions. On one occasion, 14 units of aspart insulin were administered and the supervisor was notified, but there was no documentation that the physician was notified as required by the sliding scale insulin order. On the second occasion, there was no documentation that insulin was administered or that the physician was notified. Progress notes did not reflect any physician notification for either event, despite the physician order specifying this action. For another resident with muscle weakness and gait abnormalities, after sustaining a fall and a skin tear on the left lower arm, there was no documentation that the physician was notified or that treatment orders were obtained. The resident reported that the wound was not cleaned for three days and only rebandaged upon her request. Clinical records did not include any physician orders for treatment of the wound, and the DON confirmed that a standard order for dressing and treatment should have been in place.
Failure to Provide Timely Incontinence Care and Call Bell Response
Penalty
Summary
Facility staff failed to provide timely and adequate assistance with activities of daily living, specifically incontinence care, for residents dependent on staff. Multiple residents reported excessive wait times for call bell responses, with some waiting over an hour or even up to two hours for assistance. Residents described instances where staff turned off call bells without providing help or stated they would return but did not. Observations confirmed that staff, including nursing assistants, were seen using personal cell phones at the nursing station instead of attending to resident needs. Resident council meeting minutes documented ongoing concerns about delayed call bell responses, staff inattentiveness, and the use of personal devices during shifts, particularly on the second and third shifts. Clinical record reviews for two residents revealed care plans requiring regular toileting assistance and incontinence care due to conditions such as dementia, urge incontinence, impaired mobility, and a history of falls. Despite these documented needs, observations and interviews showed that residents were left in soiled briefs for extended periods, sometimes overnight, and were not assisted in a timely manner. One resident reported being left in a soiled brief for three hours overnight, while another had to wait for over 20 minutes for help and sometimes attempted to manage toileting independently despite mobility challenges. These failures were observed and corroborated by both residents and facility leadership, with the expectation for call bells to be answered within 10 to 20 minutes not being met.
Failure to Provide Safe Dialysis Care and Maintain Required Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident with end stage renal disease (ESRD) who was dependent on renal dialysis. Despite having a physician order specifying dialysis three times per week at an outside facility and a clear directive for dialysis precautions—specifically, no blood draws, injections, or blood pressure measurements from the resident's left arm—documentation showed that blood pressure was recorded as being taken from the left arm on nine occasions. The resident's care plan also included instructions to avoid the left arm for these procedures and to coordinate care with the dialysis center. Additionally, the facility did not maintain complete records of dialysis communication forms, which are used to facilitate the exchange of assessment data between the dialysis center and the nursing facility. Multiple dates were identified where the resident attended dialysis, but no corresponding communication forms were available in the clinical record. The Director of Nursing confirmed the absence of these forms and acknowledged that they should have been completed and available for review.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for nurse aides as required. A review of facility documentation identified five nurse aides who had been employed for over a year, and the last annual performance evaluations for these employees were examined. It was found that four of the five nurse aides did not have documented performance evaluations completed within the past 12 months. During an interview, the Director of Nursing confirmed that she was unable to locate the required evaluations for these staff members and acknowledged that they should have been available in the employee files.
Failure to Complete and Respond to Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were completed by a consultant pharmacist and that recommendations were responded to in a timely manner by the attending physician or prescriber for four out of five residents reviewed for unnecessary medications. Specifically, for one resident with hypertensive heart disease and chronic kidney disease, there were no pharmacy reviews documented for August and November 2024. Another resident with type 2 diabetes, end stage renal disease, and dependence on dialysis did not have pharmacy reviews documented for July, August, and April, and pharmacy recommendations from September and December 2024 were not responded to by facility staff or a prescriber. Additionally, a resident with major depressive disorder, hypertension, and anxiety disorder did not have pharmacy reviews completed for July and August 2024. Another resident with dementia and severe protein-calorie malnutrition also lacked pharmacy reviews for July and August 2024. Interviews with the DON confirmed the expectation that pharmacy reviews should be completed monthly and responded to appropriately, but these expectations were not met for the residents identified.
Failure to Store and Handle Food According to Professional Standards
Penalty
Summary
The facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Observations in the dry storage area revealed a bottle of honey thick orange juice with a past best by date, and in the reach-in freezer, multiple packs of waffles and fish patties were found open, unlabeled, and not dated as required by facility policy. Additionally, scoops were stored inside containers of flour and sugar, contrary to policy which requires scoops to be stored separately and cleaned regularly. Further inspection of the milk reach-in refrigerator showed two containers of milk with expired sell by dates, as well as personal water and soda bottles belonging to kitchen staff. The bottom of the refrigerator was heavily soiled with liquid and dried milk. An interview with the Nursing Home Administrator confirmed that the facility's expectation is for expired items to be discarded, food items to be labeled and dated, and for food and kitchen equipment to be stored, cleaned, and used according to professional standards.
Failure of Required QA Committee Members to Meet Quarterly
Penalty
Summary
The required members of the facility's Quality Assurance Committee, specifically the Medical Director (MD) or designee, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), failed to meet together on a quarterly basis for two consecutive quarters. Review of the committee meeting signatory pages showed that there was no meeting attended by all required members during the last quarter of 2024 and the first quarter of 2025. This was confirmed during an interview with the NHA, who acknowledged that the facility's expectation was for the required members to meet at least once every quarter.
Failure to Ensure Dignity and Timely Assistance for Resident Needing Restroom Support
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure and chronic kidney disease, who was documented as being continent of bladder upon admission, experienced several episodes of incontinence due to long call bell wait times. The resident reported feeling embarrassed after not receiving timely assistance to use the bed pan, particularly when she first arrived at the facility. This was corroborated by the facility's Resident Council Meeting Minutes, which documented concerns about long call bell response times. Further review of the resident's clinical record showed that she was marked as incontinent for three consecutive days, despite her admission assessment indicating continence. The DON confirmed that staff reported the resident frequently rang the call bell for restroom assistance, but this was not accurately reflected in the clinical documentation. The DON also stated that staff are expected to document each episode of continence or incontinence, which was not done in this case.
Failure to Conduct Required Criminal Background Checks for New Hires
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the prevention of abuse, neglect, and misappropriation of resident property by not conducting criminal background checks upon hire for two employees. Review of the facility's policy indicated that background checks are required to ensure that no individual found guilty of abuse, neglect, exploitation, or misappropriation is employed. Personnel file reviews revealed that a Licensed Practical Nurse and a Nurse Aide, both hired in March 2025, did not have criminal background checks completed at the time of hire. An interview with the Nursing Home Administrator confirmed that these checks were not conducted as required by facility policy.
Failure to Provide Bed-Hold and Transfer Notices at Hospitalization
Penalty
Summary
The facility failed to provide required written notifications regarding transfer and bed-hold policies to a resident and/or their representative at the time of hospitalization. Facility policy mandates that before a resident is transferred to the hospital, written information about the facility's bed-hold and return policy must be given to the resident or their representative, and documentation of this notification must be included in the medical record. However, review of the clinical record for a resident with diagnoses including heart failure, anxiety disorder, and chronic kidney disease showed no evidence that bed-hold or transfer notices were provided during two separate hospitalizations. An interview with the Nursing Home Administrator confirmed that the responsibility for sending these notices was assigned to an administrator in training, who did not send them due to a misunderstanding. This resulted in the absence of required documentation and notification for the resident's transfers, as required by facility policy and state regulation.
Failure to Provide Hearing Aid Assistance as Ordered
Penalty
Summary
A deficiency was identified when a resident with dementia and chronic kidney disease did not receive proper assistance with hearing aids as ordered by the physician. Observations over several days showed the resident lying in bed without hearing aids, despite a physician's order to apply them each morning and remove them each evening. The resident's care plan did not address the use of hearing aids, and the Director of Nursing confirmed that the hearing aids were brought in by the family and that staff were expected to apply them daily. The lack of implementation of the physician's order and absence of a care plan for hearing aids led to the deficiency.
Failure to Properly Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for a resident identified as being at risk for falls. Review of the resident's care plan indicated that fall mats were to be placed on each side of the bed as an intervention, but observations on multiple dates revealed that two fall mats were stacked on one side of the bed instead. The resident had diagnoses including dementia and severe protein-calorie malnutrition. During an interview, the Director of Nursing confirmed that the expectation was for fall mats to be on each side of the bed, in accordance with the care plan.
Failure to Monitor and Document Resident Weight and Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to properly monitor and document the nutritional status of a resident diagnosed with dementia and severe protein-calorie malnutrition. According to facility policy, residents' weights are to be measured on admission, weekly for two weeks, and then monthly if no concerns are noted, with any significant weight change (5% or more) requiring a reweigh for confirmation and physician notification. For this resident, there was a significant weight loss of 8.7% over a short period, but the clinical record did not show that the physician was notified of this change. Additionally, there was no documentation of a reweigh to confirm the significant weight loss as required by policy. Further review revealed that monthly weights were not obtained or recorded for the resident in the months following the significant weight loss, despite a standing physician order for monthly weights. The Registered Dietitian reported a change in the process for notifying physicians of significant weight losses but was unable to provide evidence of notification for this resident. The DON confirmed that the treatment administration records for the relevant months were blank for the resident's weight order, indicating non-compliance with both physician orders and facility policy.
Failure to Provide Prescribed Medication Due to Staff Access Issues
Penalty
Summary
The facility failed to ensure the availability and administration of prescribed medication for one resident. Clinical record review showed that a resident with diagnoses of heart failure and chronic kidney disease was admitted to the facility and had a physician's order for Furosemide 40 mg daily starting on May 15, 2025. However, the Medication Administration Record indicated that the resident did not receive the medication from May 15 to May 18, 2025. During an interview, the Director of Nursing confirmed the missed doses and explained that agency staff working at the time of admission did not have access to the online system required to obtain the medication as ordered.
Failure to Serve Coffee at Palatable Temperature
Penalty
Summary
The facility failed to provide coffee at a palatable and appealing temperature, as required by its Food and Nutrition Services Meal Assessment policy, which specifies that coffee should be served at 135°F or above. During an interview, a resident reported that the coffee is never served hot. A test tray conducted after lunch service confirmed that the coffee temperature was 110°F, which was not considered palatable or appealing. The Food Service Director acknowledged that coffee should be poured and lidded shortly before meal service to maintain the required temperature, but indicated that the coffee was likely poured too early on the day in question. The Nursing Home Administrator stated that she expects coffee to be served at a palatable and appealing temperature.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the facility name, date, census, and total hours of nursing staff directly responsible for resident care per shift, on multiple dates. Observations during entrance to the facility revealed that the posted staffing information was outdated, with the most recent posting dated May 16, 2025, when reviewed on May 19, 2025, and again on May 21, 2025, when the posting was still not current. During an interview, the Director of Nursing confirmed that the staff member responsible for posting the daily staffing, the Nursing Scheduler, did not complete this task on the specified dates, and acknowledged that daily posting is expected per federal regulation.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during specific shifts over a period from January 28, 2025, to February 6, 2025. On the day shift, the facility did not maintain the minimum requirement of one nurse aide per 10 residents on four separate days. Similarly, the evening shift was understaffed on two days, lacking the required one nurse aide per 11 residents. Additionally, the night shift did not meet the standard of one nurse aide per 15 residents on two occasions. These deficiencies were confirmed through a review of facility staffing data and a telephone interview with the Nursing Home Administrator on February 11, 2025.
Plan Of Correction
Nursing Home Administrator/Designee will continue to audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing Home Administrator/Designee will utilize the Staffing Calculator Tool Spreadsheet to calculate these staff ratios to ensure compliance. Nursing Home Administrator, Director of Nursing, and Scheduler/HR will continue to hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Facility will hold bi-weekly meetings with cooperate recruiting team to improve hiring process and discuss opportunities to contract with additional Staffing Agencies to ensure the facility remains in continued compliance with nurse staff ratios and PPD. Nursing Home Administrator will continue to have daily staffing meetings with Director of Nursing and Facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it effects facility ratios. Nursing Home Administrator will continue to audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months utilizing the Staffing Calculator Tool Spreadsheet. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels as per the regulation effective July 1, 2024, which mandates a minimum of one nurse aide per 10 residents during the day and one nurse aide per 15 residents overnight. A review of the facility's staffing data from December 2 through December 11, 2024, revealed deficiencies on specific dates. On December 5, 2024, the day shift did not have the required number of nurse aides, and the night shift was understaffed on both December 5 and December 7, 2024. These findings were confirmed with the Nursing Home Administrator during a telephone interview on December 16, 2024.
Plan Of Correction
Nursing Home Administrator/designee will audit nursing staffing schedules for the next two weeks to ensure schedules reflect at a minimum 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight. Nursing home administrator, Director of Nursing, and Scheduler/HR will hold weekly meetings to discuss new opportunities to utilize local community resources for staffing including vocational schools that offer aide training programs. Discussion to also include facility holding open interview times weekly for any walk-ins for immediate interviews. Nursing Home Administrator will have a daily staffing meeting with Director of Nursing and facility Nursing Scheduler to review daily staffing schedules to ensure compliance with staffing regulations, discuss potential barriers to meeting required staffing ratios and identify strategies to meet staffing ratios including but not limited to recruitment efforts, bonus structure, use of agency and overtime hours. Scheduler/HR will discuss with staffing agencies any issues with their staff involving absenteeism and/or tardiness as it affects facility ratios. Nursing Home Administrator will audit daily nursing staffing ratios to ensure nurse aide ratios are in compliance with mandated state laws regarding minimum staffing ratios. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in actual harm to a resident who sustained a fall and a fracture. The resident, who had a history of multiple health issues including renal cell cancer, muscle weakness, and a high risk for falls, was left unsupervised by a CNA during a care routine. The CNA left the resident on their side without a protective pad to retrieve supplies, during which time the resident became unsteady and fell, hitting their right elbow and sustaining a skin tear. The resident's care plan indicated a need for extensive assistance with bed mobility and required one staff member to assist with turning and repositioning in bed. Despite these requirements, the resident was left alone, leading to the fall. The resident's fall risk assessment had previously identified them as being at high risk for falls, and their MDS assessment confirmed they were cognitively intact, requiring significant assistance for mobility. Following the fall, the resident was diagnosed with a fracture to the neck of the right humerus, necessitating hospital transfer and subsequent orthopedic consultation. The incident led to increased pain management needs, as evidenced by the increased administration of Oxycodone for pain relief. Interviews with the resident and the Nursing Home Administrator confirmed that the staff's action of leaving the resident unsupervised was inappropriate and contributed to the incident.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the residents' preferences for their method of bathing, specifically for three residents who preferred showers but were predominantly given bed baths. During a Resident Council Meeting, it was revealed that these residents were not receiving showers as per their preferences. Resident 8's records indicated a strong preference for choosing between different bathing methods, yet the resident received only one shower in a 30-day period, with no documentation to support the need for bed baths. Similarly, Resident 29 and Resident 59 had care plans that included provisions for sponge baths when showers could not be tolerated, but their records showed no evidence that they were unable to tolerate showers during the review period. The clinical records for Residents 8, 29, and 59 lacked documentation indicating that they had refused showers or were unable to tolerate them, despite the care plans suggesting otherwise. The Nursing Home Administrator confirmed these findings during an interview. This failure to incorporate the residents' bathing preferences into their personal care routines constitutes a violation of their rights to self-determination and choice, as outlined in the relevant state codes.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment on the 2nd floor nursing unit. During an environmental tour, it was observed that multiple rooms had air conditioners with a thin layer of dust covering the units. This issue persisted over several days, as confirmed by observations on April 16, 17, 18, and 19, 2024. Interviews with residents revealed that they could not recall the last time their air conditioners were cleaned. Additionally, one resident's bathroom had a clogged toilet with a dried brown substance on the toilet seat, which remained unaddressed for at least two days. The Nursing Home Administrator was unable to provide evidence of when the air conditioners were last cleaned and confirmed the observations made by the surveyors. Housekeeping staff reported the clogged toilet to the maintenance director, but it was not resolved until April 18, 2024. The facility's failure to maintain a clean environment violates the residents' right to a safe, clean, comfortable, and homelike environment as required by regulations.
Failure to Perform Criminal Background Checks for Employees
Penalty
Summary
The facility failed to perform criminal background checks for three out of five personnel records reviewed, specifically for Employees E1, E2, and E5. According to the facility's policy titled 'Residents Right to Freedom from Abuse, Neglect, and Exploitation Policy and Procedure' dated 2022, the facility is required not to employ individuals found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. However, a review of the personnel records revealed that the facility did not obtain criminal background checks for these employees prior to their hire. This was confirmed during an interview with the Nursing Home Administrator on April 19, 2024, at 11:30 a.m. The deficiency was cited under 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(b)(1)(3)(e)(1), and 28 Pa. Code 201.29(a)(d).
Failure to Follow Physician Orders for Three Residents
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. Resident 17, diagnosed with Irritable Bowel Syndrome and Diverticulitis, had physician orders for Milk of Magnesia, Dulcolax suppository, and a fleet enema if no bowel movement occurred. However, from January 24, 2024, to February 8, 2024, there was no documented evidence that these medications were administered despite the resident not having any bowel movements during this period. This was confirmed by the Nursing Home Administrator on April 18, 2024. Resident 30, diagnosed with Chronic Kidney Disease and Congestive Heart Failure, had a physician order for a 1500 ml fluid restriction, with specific amounts to be documented by nursing staff each shift. A review of the clinical record revealed multiple instances of missing documentation for fluid intake across various shifts from March 20, 2024, to April 17, 2024. Additionally, Resident 42, diagnosed with Benign Prostate Hyperplasia, had orders for bladder scans and straight catheterization if urine retention was detected. However, there was no documented evidence of bladder scans being performed on several shifts where no voiding was recorded. These deficiencies were confirmed with the Nursing Home Administrator on April 19, 2024.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to monitor the nutritional status of five residents as per their policy and physician orders. Resident 16 experienced an 11.48% increase in weight without a reweight for confirmation. Resident 17's weight was not obtained as ordered, delaying the assessment by the dietitian. Resident 35 did not have weights taken on the second day after admission or weekly for two weeks as required. Resident 42 experienced an 8.02% weight loss without a reweight for confirmation, and the facility failed to obtain weekly weights as ordered. Resident 47 had a 13.53% increase in weight without a reweight for confirmation. Interviews with the Nursing Home Administrator confirmed that the weights for Residents 16, 17, 35, 42, and 47 were not monitored according to the facility's policy or physician orders. The facility's failure to adhere to its weight assessment and intervention policy resulted in significant weight changes not being properly monitored or confirmed, potentially impacting the residents' nutritional status and overall health.
Bathroom Accessibility Issue for Resident
Penalty
Summary
The facility failed to ensure that a bathroom was accessible to Resident 56, who was unable to access the bathroom due to the location of the bathroom and the size of her wheelchair. The resident's wheelchair could not fit through the space between her roommate's bed and dresser, forcing her to use a bed pan instead. This issue was confirmed through an interview with the resident and her nurse aide, as well as an observation that measured the width of the wheelchair and the space available. The resident's care plan included interventions to ensure an unobstructed path to the bathroom and to use a wheelchair for bathroom transfers due to weakness. However, these interventions were not effectively implemented, as evidenced by the resident's continued inability to access the bathroom. The findings were confirmed with the Nursing Home Administrator, highlighting a failure to reasonably accommodate the resident's needs and preferences.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to update the care plan for a resident with Bipolar Disorder, Depression, and Anxiety to accurately reflect the resident's current status. A nurse's note from August 27, 2023, documented an incident where the resident attempted to use a call bell to harm herself. Consequently, the care plan was updated on August 28, 2023, to remove the call bell and provide a hand bell instead. However, an observation on April 17, 2024, revealed that the resident had a call bell in place on her bed. The resident had signed a safety contract in September 2023, allowing her to have a call bell again, but the care plan had not been updated to reflect this change. The Nursing Home Administrator confirmed on April 18, 2024, that the care plan was not updated accordingly.
Failure to Timely Report Critical Lab Results
Penalty
Summary
The facility failed to report critical laboratory results to the physician in a timely manner for one resident. Specifically, a nurse received a call from the laboratory on December 21, 2023, at 11:50 a.m. regarding a critical calcium level of 12.9 for Resident 56 and was instructed to fax the results to the unit. The results were faxed to the physician's office at 4:12 p.m. the same day. However, it was not until December 28, 2023, that the critical lab results were refaxed to the physician's office and a telephone call was made to communicate the results. The Nursing Home Administrator confirmed that critical lab values should not be faxed and acknowledged the week-long delay in relaying the lab results to the physician.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for one of the 24 residents reviewed. Resident 14's Admission Skin Evaluation indicated no pressure ulcers on April 1, 2024. However, the Wound Care Notes on April 2, 2024, documented a Stage 3 pressure ulcer on the sacrum. Subsequent Weekly Skin/Body Checks on April 3, 2024, again showed no pressure ulcers. The Admission Minimum Data Set (MDS) on April 6, 2024, inaccurately coded the resident as having a Stage 3 pressure ulcer on admission. By April 9, 2024, the Wound Care Notes only mentioned an area of Moisture Associated Skin Dermatitis (MASD) that had resolved, with no further documentation of the Stage 3 pressure ulcer. The Nursing Home Administrator confirmed the inaccurate documentation and coding during an interview on April 19, 2024.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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