Harmar Village Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheswick, Pennsylvania.
- Location
- 715 Freeport Road, Cheswick, Pennsylvania 15024
- CMS Provider Number
- 396048
- Inspections on file
- 54
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Harmar Village Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not maintain sufficient nursing staff to consistently provide scheduled showers and basic care, as required by its AM Care Policy. NAs reported that they were often limited to three aides for 39 residents, many requiring two-person Hoyer lifts, while also managing two meals and other ADLs, making it difficult or impossible to complete showers. One resident with anemia, diabetes, and depression, scheduled for twice-weekly showers, had no showers documented over several weeks except for two refusals, and another resident with HTN, BPH, and spinal stenosis, also scheduled for twice-weekly showers, received showers on only a few documented days. The Administrator acknowledged that staffing was insufficient to meet residents’ physical, mental, and psychosocial needs.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment for several residents and in common areas. A resident was observed sitting in a wheelchair with the seat and cushion covered in dried food, sticky residue, and grime, confirmed by a respiratory therapist. In one room, a pipe cover was on the floor under the sink, and in another room, window blinds were damaged with slats missing and one slat on the floor, while thick cobwebs covered the window area behind the blinds, as confirmed by an LPN and the Administrator. Two elevators near the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, which maintenance staff attributed to repeated impact from carts.
A resident with a history of CVA, dementia, and HTN was observed seated in a wheelchair in the main dining room while being fed by the DON, who remained standing throughout the feeding interaction. During surveyor observation and subsequent interview, the DON confirmed they were not seated while feeding the resident, contrary to required practice, resulting in a failure to provide a dignified dining experience.
Surveyors determined that the facility did not follow its psychoactive medication policy for a resident receiving multiple psychotropic drugs, including buspirone, escitalopram, mirtazapine, and quetiapine. The resident’s record, despite diagnoses such as paraplegia, depression, anxiety disorder, and bipolar disorder, lacked specific diagnoses tied to each psychotropic medication, contained no documentation of non-pharmacological interventions, and did not show monitoring of medication effectiveness, behaviors, or side effects. The RNAC, Administrator, and DON acknowledged that the required indications and monitoring for these psychotropic medications were not documented.
Two residents with documented constipation risk and physician-ordered bowel protocols did not receive constipation treatments as ordered, and required notifications to the provider were not made. For one resident, bowel records showed no bowel movement for four days, yet a prescribed Enemeez enema was not administered on the fourth day and the physician was not notified, despite the resident reporting constipation and bleeding when constipated. For the second resident, who had constipation-related diagnoses and orders for Miralax and Senna if no bowel movement by day two, there was no bowel movement for three days, but the ordered PRN Miralax and Senna were not given and the physician was not notified; this resident reported severe soreness, very hard stool, and abdominal pain. Staff, including an LPN, a unit manager LPN, the ADON, and the administrator, acknowledged that the bowel protocol and physician orders were not implemented as required.
Surveyors found that the facility failed to provide timely and appropriate pressure ulcer assessment, treatment, and prevention for two residents. One resident was admitted with a stage 3 buttock ulcer, but the Braden assessment was left incomplete, no pressure-ulcer risk care plan was initiated on admission, and wound consultant recommendations (including Medi-honey and preventive measures) were not promptly entered as physician orders or care-planned; weekly wound measurements were also missing while the ulcer enlarged and was described as stalled. Another resident with a right humerus fracture and sling was initially assessed as not at risk for pressure injuries, with no documentation of limited mobility or sling use, no early orders for a sling or skin checks under it, and a care plan that did not specify monitoring skin under the sling. Skin checks were inconsistently documented, and only after the family raised concerns was a large open elbow pressure injury and additional ankle/heel pressure areas identified, without comprehensive initial wound measurements, repeat Braden scoring, or updated care plans to address the new pressure areas and device-related skin monitoring.
A resident admitted with multiple upper extremity fractures was repeatedly observed wearing a right arm sling without a corresponding physician order or care plan. An LPN confirmed there was no order for the sling, and review of the clinical record verified the absence of any documented order or care plan for its use. The Nursing Home Administrator acknowledged that the facility failed to ensure appropriate medical authorization and documentation for the sling, resulting in noncompliance with state requirements for resident care and nursing services.
A resident with a history of obstructive uropathy and a suprapubic catheter returned from a hospital stay with the catheter still in place, but the facility did not obtain new physician orders for catheter care, catheter size, change frequency, or irrigation after readmission. Previous orders for catheter care and monthly catheter changes using a specified 18 Fr/10 cc catheter had expired prior to the hospital transfer. Despite multiple observations of the resident with a leg bag and confirmation by staff that the catheter remained in use, no corresponding catheter-related orders were in the current physician or readmission orders, and the DON acknowledged that appropriate catheter orders had not been obtained.
A resident with diabetes, hypertension, and dementia had an original diet order for mechanical soft with low concentrated sweets (LCS), which was later changed by physician order and RD recommendation to a regular diet. Although the EMR and dietary tray card system reflected the regular diet, the nutrition care plan continued to direct staff to provide an LCS, mechanical soft diet and was not updated to match the current order. The clinical record also lacked documented rationale from the physician or RD for discontinuing the LCS therapeutic restriction. Facility leadership and clinical staff confirmed that the individualized care plan and documentation did not reflect the resident’s current nutritional needs and discontinued interventions.
A resident with a gastrostomy tube and diagnoses including adult failure to thrive and malnutrition had physician orders for continuous Isosource 1.5 tube feeding and scheduled free water flushes. Surveyors observed that the resident’s tube feeding bottle and water flush bag were not dated on multiple occasions, and both the DON and an LPN confirmed the absence of dates on these supplies. Facility leadership acknowledged that appropriate care and services were not ensured for this resident receiving enteral feeding.
Surveyors found that three residents receiving continuous O2 therapy did not receive care consistent with facility policy and MD orders. One resident with COPD and another with heart failure were observed on concentrators whose humidifier bottles or external filters were dusty and covered with fuzz-like debris, and required weekly cleaning and tubing changes were not evident. A third resident on 2 L O2 had undated oxygen tubing, and the clinical record lacked documentation that tubing was changed as ordered. Staff, including the RT and DON, confirmed that appropriate respiratory care and oxygen equipment maintenance were not provided.
Surveyors observed that an LPN committed three medication errors during 36 administration opportunities, resulting in a medication error rate above 5%. A resident with an order for crushed medications received Ingreeza prepared by softening the capsule in pudding instead of sprinkling the capsule contents as ordered. The same resident did not receive ordered Flonase nasal spray and olopatadine eye drops because the medications were not available. The ADON confirmed the improper Ingreeza administration as a significant medication error, and the NHA acknowledged that the facility exceeded the allowable medication error rate.
A resident with bipolar disorder, anxiety, and depression had physician orders for 40 mg of Ingreeza daily for drug-induced subacute dyskinesia and for all medications to be crushed, consistent with the care plan directing pills to be finely crushed. During a medication pass, an LPN prepared the Ingreeza capsule softened in pudding and administered it without opening the capsule and sprinkling the contents, thereby not crushing the medication as ordered. In interviews, the LPN and facility leadership confirmed that the medication was not administered according to the physician order and that this constituted a significant medication error.
Surveyors found multiple treatment carts unlocked and unattended in hallways, with nursing staff confirming that the carts had been left unsecured. An East Hall medication cart contained opened but undated ipratropium bromide, albuterol, and fluticasone. In addition, two residents had treatment products, including Vashe wound cleanser, zinc oxide, and triamcinolone cream, left on their bedside stands rather than stored in locked compartments. These findings show that medications and treatment supplies were not consistently secured or labeled according to required standards.
A resident with heart failure, stroke, and diabetes had a lump on the gums reported by family, who provided a photo to the social worker. The social worker notified the care team and contacted the dental vendor, and later believed the dentist had evaluated the resident and determined the lump was an extra piece of bone not requiring surgery, while the family felt it impaired chewing and denture use. Documentation produced on request showed that the resident was not actually seen by the dentist, was not on the dentist’s final list, and that only a discussion with the family about a mandibular torus occurred; the form was unsigned and largely blank. The NHA confirmed the dentist never assessed the resident’s mouth, and the dental visit was not entered into the EHR, contrary to the facility’s dental services policy.
The facility did not hold required Quality Assessment and Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly as mandated by its QAPI policy and state regulations. Policy required the QAA committee to meet at least quarterly to coordinate and evaluate QAPI activities, but review of QAPI sign-in sheets and attendance records showed no documented meetings for two consecutive quarters. In an interview, the Administrator confirmed that the required quarterly QAA meetings were not conducted during those periods.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions policy for a high-risk resident with a feeding tube and did not consistently monitor another resident’s personal refrigerator temperature. An LPN performed a high-contact activity involving a gastrostomy tube while wearing gloves but not a required gown, despite an active EBP order. In a separate finding, a resident’s in-room refrigerator temperature log lacked the month and year and had numerous days left blank, contrary to the facility’s policy requiring documented temperatures within a specified range. The DON and nursing staff confirmed these lapses during interviews.
The facility failed to ensure pneumococcal vaccinations were properly assessed and tracked in the EHR for two residents. One resident with diabetes, stroke, and a seizure disorder had an immunization record showing a pneumococcal vaccine due on a specific date, but there was no documentation that the vaccine status was assessed on that date. Another resident with stroke, hemiplegia, and Parkinson’s disease also had a pneumococcal vaccine due on a specified date, with no corresponding assessment documented. The IP and regional risk staff confirmed that pneumococcal vaccinations were not being tracked in the EHR as required by facility policy.
A resident admitted with multiple wounds, including a Stage 3 pressure injury to a finger, had physician orders for daily wound care with NSS cleansing, medihoney, and a dry dressing. Facility policy required residents with existing pressure injuries to receive necessary treatment and services to promote healing and prevent infection. Review of the MAR over two consecutive months showed that the ordered daily treatment for the finger pressure injury was not documented as completed or refused on multiple dates. The NHA confirmed that the facility failed to ensure proper treatment for the resident’s pressure ulcer, resulting in a cited deficiency under state regulations for licensee responsibility, resident care policies, and nursing services.
The facility failed to obtain and document ordered lab tests for two residents with multiple chronic conditions, including hypertension, dementia, diabetes, hyperlipidemia, and depression. Physician orders directed staff to obtain CBC, CMP, BMP, and UA testing, but clinical record review showed no evidence that these labs were completed as ordered. The NHA confirmed that the ordered laboratory services were not obtained for these residents.
A facility failed to properly document and follow physician orders for crushed medication administration for numerous residents. In one case, a resident with dysphagia and a physician order for crushed medications was given whole pills by an LPN, leading to respiratory distress and death. Staff interviews revealed confusion and lack of awareness regarding which residents required medications to be crushed, and documentation was incomplete for many residents.
A resident with dementia, COPD, and dysphagia, who required medications to be crushed due to swallowing difficulties, was given whole medications by an LPN after a recent diet change. The resident began coughing, experienced respiratory distress, and died after aspiration and unsuccessful resuscitation efforts. Facility leadership confirmed that required policies and procedures to prevent neglect were not followed, resulting in actual harm.
The facility failed to maintain two crash carts in safe operating condition, resulting in a delay in emergency care for a resident experiencing respiratory distress. Staff were unable to access high-flow oxygen due to a missing oxygen key, and crash cart checklists showed repeated lapses in required daily checks and restocking. This deficiency was confirmed by both the administrator and DON.
The facility failed to notify a medical provider of significant changes in condition for two residents, including persistent low oxygen saturation and a substantial weight gain with associated symptoms. In both cases, documentation and staff interviews confirmed that required notifications were not made prior to the residents being sent to the hospital.
The facility did not secure physician orders for crushed medications for the majority of residents who required them, as identified by a speech therapy audit. While some residents had proper orders, most did not, and staff relied on assumptions rather than formal documentation. This was confirmed by the facility's administration.
The facility did not maintain complete and accurate medical records for multiple residents, with staff using inconsistent and unreliable methods to determine medication administration requirements, such as whether medications should be crushed. Inaccuracies were found in both electronic records and paper report sheets, including outdated or missing information about residents' medication needs and code status. Nursing staff and leadership confirmed communication gaps and acknowledged the deficiencies in documentation.
A resident with dysphagia and a physician's order for crushed medications was given whole pills by an LPN, leading to a fatal aspiration event. Staff did not complete an investigation or report the possible neglect to the State Agency, as required by facility policy. The DON and Administrator confirmed the lack of reporting and investigation.
A resident with dementia, COPD, and dysphagia was given whole medications by an LPN despite an order for crushed meds, resulting in a fatal choking event. Staff attempted emergency measures, but the resident died. The facility did not conduct an investigation into the incident as required by policy.
A resident with dysphagia, dementia, and COPD did not have a care plan addressing the need for crushed medications, despite a physician's order and aspiration precautions. An LPN administered whole medications at the resident's request, resulting in a fatal aspiration event. Facility leadership confirmed the lack of a person-centered care plan for this need.
A resident with dementia, COPD, and dysphagia, who required strict aspiration precautions and crushed medications, was given whole pills by an LPN, resulting in a fatal choking incident. The DON, designated as the Abuse Coordinator, did not investigate or report the possible neglect to authorities, despite facility policy and job responsibilities requiring such actions.
The NHA and DON failed to ensure that a resident with an order for crushed medications received them as prescribed, resulting in the resident receiving whole medications. This led to the resident experiencing respiratory failure and ceasing to breathe after an aspiration event, creating an Immediate Jeopardy situation. The facility's leadership acknowledged their failure to manage and prevent this significant medication error.
A controlled medication prescribed for anxiety remained in the medication cart after a resident with diabetes, COPD, and panic disorder was discharged home. Despite facility policy requiring prompt removal and destruction of discontinued controlled substances, the medication was still present during a medication cart observation, and staff confirmed the resident was no longer in the facility.
A resident with severe cognitive impairment and a history of dementia, anxiety, and bipolar disorder was not identified as an elopement risk upon admission, despite being disoriented and mobile with assistance. The facility's elopement risk assessment was not fully completed, and no care plan was implemented. Staff did not follow elopement procedures when the resident went missing, and the resident was later found in the basement after being unaccounted for. The facility's admission and assessment processes failed to recognize and address the resident's elopement risk, and staff were not consistently educated or following required protocols.
A resident with dementia, anxiety, and bipolar disorder missed five doses of a prescribed antipsychotic medication, and there was no documentation that the physician was notified about the missed doses. The DON confirmed that the ordered medication was not provided and the physician was not informed, resulting in a failure to provide appropriate treatment and care.
A resident with multiple medical conditions did not receive a controlled substance (oxycodone) as ordered because the medication was not properly signed into the controlled drug log or secured in the medication cart. An agency nurse subtracted the medication from inventory without following protocol, and required destruction forms for additional narcotics were not completed. Facility leadership confirmed that controlled substances were not accurately accounted for or destroyed according to policy.
The facility did not meet the required nurse aide staffing levels on several shifts over a 14-day period, with shortages in NA hours on specific day, evening, and night shifts. These deficiencies were confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels on a day shift, providing only 25.00 LPN hours instead of the required 36.04 hours for 97 residents. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.20 PPD hours of direct care on two days, providing only 3.18 and 3.03 PPD. This was confirmed by the Nursing Home Administrator after reviewing staffing schedules.
The facility did not conduct the required annual fire door assembly inspection, impacting the entire facility. Documentation review and interviews with the Facility Administrator and Maintenance Director confirmed the absence of records for the inspection.
The facility failed to maintain hazardous area enclosures, as the door to the transfer switch room did not latch properly, affecting one of eight smoke compartments. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the kitchen hood fire suppression system, with a wheeled gas-fired deep fryer lacking an approved method to ensure proper placement after maintenance. Additionally, documentation for fire suppression testing in early 2024 was missing, as confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the automatic sprinkler system, with deficiencies affecting four smoke compartments. Items were stored too close to sprinkler heads in the Storage Room and Physical Therapy room, and gaps were found in ceiling tiles in various rooms. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain a portable fire extinguisher as required by NFPA 10 standards. An observation revealed that the pressure gauge on a fire extinguisher in the Physical Therapy area near the kitchen indicated it needed recharging. This issue affected one of the eight smoke compartments, and the Facility Administrator and Maintenance Director confirmed the extinguisher was not ready for use.
The facility was found deficient in maintaining smoke barrier doors, as observed on the first floor near the Receiving Room. The doors had an excessive gap between their meeting edges, compromising their ability to resist smoke passage. This issue was confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct six out of twelve required fire drills over the past year, lacking documentation for specific shifts in the second, third, and fourth quarters. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to meet emergency preparedness requirements by not conducting the annual community-based, full-scale exercise. This deficiency was confirmed during a document review and an interview with the Facility Administrator and Maintenance Director, highlighting a gap in the facility's emergency preparedness efforts.
The facility did not perform the required monthly tests of the emergency lighting system for three months, affecting the entire facility. This was confirmed through document review and interviews with the Facility Administrator and Maintenance Director.
The facility did not conduct monthly exit sign inspections for three months, affecting the entire facility. This was confirmed through document review and interviews with the Facility Administrator and Maintenance Director, revealing a lack of documentation for October, November, and December 2024.
The facility failed to maintain clean equipment in the Main Kitchen, potentially leading to foodborne illness. A fan directed towards clean dishes was found covered in a gray, fuzzy substance, indicating non-compliance with the facility's kitchen sanitation policy.
The facility failed to properly contain and dispose of garbage in one of its outdoor dumpsters, leading to potential rodent and insect infestation. This was confirmed during observations and interviews with the Certified Dietary Manager and the Nursing Home Administrator, who acknowledged that the lid of dumpster one was not closed on multiple occasions.
Insufficient Nursing Staff Leading to Missed Scheduled Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in missed and inconsistent showers for multiple residents. The facility’s AM Care Policy dated 1/6/26 stated that care would be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing, and that showers or baths would be scheduled two times weekly or adjusted per resident preference. Certified nurse aides (NAs) reported that staffing levels were frequently limited to three aides for 39 residents, with many residents requiring Hoyer lifts that needed two staff, and that they were also responsible for serving two meals, getting residents out of and into bed, and providing dressing and bathing care. NAs stated that with only three aides, showers were “out of the question,” residents waited longer than they should, and showers were not always completed, and one NA reported that at times there were only two NAs on the unit. Resident records and schedules showed that this staffing shortage directly affected scheduled bathing care. One resident (R1), with diagnoses including anemia, diabetes, and depression, was scheduled for showers on Tuesdays and Fridays per the third floor shower schedule, but shower documentation from 4/4/26 through 4/22/26 showed no showers provided during that period, with refusals documented only on two dates (4/14/26 and 4/17/26). Another resident (R2), with diagnoses including hypertension, benign prostatic hyperplasia, and spinal stenosis, was scheduled for showers on Mondays and Thursdays and confirmed this schedule during interview, but reported not receiving showers due to insufficient staff. Documentation for this resident from 4/1/26 through 4/22/26 showed showers provided on only four dates, rather than consistently on the scheduled days. The Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the affected residents.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a clean, safe, comfortable, and homelike environment in multiple areas. One resident was observed in the main dining room seated in a wheelchair whose seat and cushion were completely covered in dried food, a sticky substance, and dark grime; this condition was confirmed by a respiratory therapist. In another resident’s room, a white pipe cover was observed lying on the floor under the room sink, and this was confirmed by an LPN. Additional environmental deficiencies were observed in a different resident’s room and in common areas. One resident’s window blinds had three leaves missing and one leaf lying on the floor under the air conditioning unit, as confirmed by an LPN. During a tour with the Administrator, the entire width of this resident’s window was noted to be draped with thick cobwebs behind the blind, which the Administrator confirmed. Two elevators located next to the dietary entrance had lower-wall plastic bumpers with sharp shards of broken plastic exposed, a condition confirmed by the maintenance employee, who stated that carts banging into the bumpers caused the damage. The Administrator confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment in these instances.
Failure to Provide a Dignified Dining Experience During Assisted Feeding
Penalty
Summary
The facility failed to provide a dignified dining experience for one of three observed residents when the Director of Nursing (DON) fed the resident while standing. The resident, identified as R81, had been admitted earlier in the month and had documented diagnoses including stroke, dementia, and high blood pressure, as recorded on the MDS dated 2/28/26. On 3/30/26 at 12:05 p.m., surveyors observed Resident R81 seated in a wheelchair in the main dining room being fed by the DON, who remained standing during the feeding interaction. During an interview at 12:06 p.m. on the same day, the DON confirmed that they were not in a seated position while feeding the resident, as required, thereby acknowledging that the facility did not provide a dignified dining experience for this resident. This conduct was cited as noncompliance with 28 Pa. Code 211.10(a)(c)(d) regarding resident care policies and 28 Pa. Code 211.12(d)(1)(2)(5) regarding nursing services.
Failure to Document Indications and Monitoring for Psychotropic Medications
Penalty
Summary
Surveyors found that the facility failed to ensure a resident’s psychotropic medication regimen was free from potentially unnecessary medications and lacked adequate indications for use. Facility policy dated 8/15/25 required that all residents receiving psychoactive medications have their behaviors, the effectiveness of pharmacological and non-pharmacological interventions, and the potential for gradual dose reduction monitored and documented. One resident, admitted on 3/27/2026 with diagnoses including paraplegia, depression, anxiety disorder, and bipolar disorder, had physician orders for multiple psychotropic medications: buspirone 10 mg (2 tablets three times daily), escitalopram 20 mg once daily, mirtazapine 15 mg at bedtime, and quetiapine 100 mg at bedtime plus quetiapine 25 mg once daily. The clinical record did not contain specific diagnoses linked to the use of each of these medications. Review of the resident’s clinical record also showed no documented non-pharmacological interventions, no documentation of the effectiveness of the prescribed psychotropic medications, and no evidence of monitoring for side effects or behaviors related to psychotropic use. During interviews, the RN Assessment Coordinator confirmed that the psychotropic medication orders lacked diagnoses for usage and that the record did not include documentation of interventions, medication effectiveness, or monitoring of side effects and behaviors. The Administrator and DON likewise confirmed that the facility failed to ensure the resident’s medication regimen was free from potentially unnecessary psychotropic medications without adequate indications for use, as required by state regulations and facility policy.
Failure to Follow Bowel Protocol and Physician Orders for Constipation Management
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care for constipation in accordance with physician orders, the facility’s bowel protocol policy, and professional standards of practice for two residents. The facility’s Bowel Tracking Protocol required bowel activity to be recorded each shift, issues such as constipation to be reported to a licensed nurse, and a daily audit by the DON to identify residents without a bowel movement (BM) in 48 hours, followed by a stepwise laxative/enema protocol. For one resident, the care plan identified risk for constipation with interventions to administer medications, enemas, and suppositories as ordered, document bowel movement frequency and character, and check for fecal impaction as needed. For this resident, a physician order directed administration of an Enemeez (docusate sodium) micro enema if there was no BM by the morning of day 4, with instructions to contact the provider if no BM occurred within one hour after administration. Bowel documentation showed no BM for four consecutive days, yet the March MAR showed the ordered PRN enema was not given on the fourth day, and there was no documentation that the physician was notified of the absence of a BM after four days. The resident subsequently had a large BM the following day and reported concerns related to constipation, stating that when constipated it caused bleeding. Staff interviews indicated that nurses were expected to review daily bowel lists, administer PRN medications for constipation, and notify supervisors and physicians if residents did not defecate by mid-shift, and that unit managers ran reports to identify residents without BMs and ensured bowel protocols were implemented. The second resident had documented diagnoses including constipation and an MDS confirming current conditions, with a care plan noting increased nutrition/hydration risk related to constipation; however, the facility did not implement specific constipation interventions in the care plan. Physician orders directed administration of Miralax if no BM by day 2 in the morning, Miralax twice daily PRN for constipation, and Senna twice daily PRN if no BM by day 2 in the morning. Bowel documentation showed no BM for three days, but the March MAR revealed that neither Miralax nor Senna was administered as ordered on the third day, and there was no evidence the physician was notified of the continued absence of a BM. The resident reported constipation-related discomfort, including severe soreness, inability to defecate, very hard stool, and significant abdominal pain. The ADON and the Nursing Home Administrator confirmed that the ordered bowel protocol was not implemented for these two residents.
Failure to Provide Timely Pressure Ulcer Assessment, Treatment, and Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive services consistent with professional standards for two residents, and failure to prevent the development of new pressure ulcers for one of them. For one resident admitted with malnutrition, stroke, hypertension, and a stage 3 pressure ulcer on the left buttock, the Braden Scale assessment dated on admission was left blank and incomplete, and no pressure ulcer risk care plan was initiated upon admission. Although a wound consultant later documented a stage 3 left buttock ulcer with specific treatment recommendations, including cleansing, application of medical-grade honey, and preventive measures such as turning/repositioning and moisture management, these recommendations were not incorporated into the physician orders from the date of the consultant’s assessment through the following week. The clinical record also lacked evidence that the recommended preventive measures were care planned, and weekly wound measurements were missing for at least one week, despite documentation that the wound was larger and stalled during that period. The same resident’s care plan for pressure injuries was not initiated until 21 days after admission, even though the resident had an existing stage 3 pressure ulcer and was at risk due to comorbidities, immobility, and incontinence. Wound assessments over time showed that the left buttock ulcer increased in size and was described as stalled before later being documented as stable and improving. The wound consultant confirmed that there were no measurements documented for the week in early January and that the medi-honey treatment recommended in mid-December was not implemented. The Nursing Home Administrator and other administrative staff acknowledged that the facility failed to timely implement wound care treatment recommendations, failed to document weekly assessments for the stage 3 ulcer during the identified week, and failed to ensure Braden assessments were accurately completed and a pressure ulcer risk care plan was initiated in a timely manner. For a second resident, admitted with a right humerus fracture and other diagnoses including prior fractures, lung mass, muscle weakness, and hypertension, the admission nursing assessment documented no wound concerns and a Braden score of 19 (not at risk), and did not note the right humerus fracture, sling use, or limited mobility. Occupational therapy notes shortly after admission documented that the resident was non-weight bearing to the right arm and had impaired safety awareness, and the resident was observed with a sling, but there were no physician orders for a sling or for skin checks under and around the sling until later. The initial care plan identified risk for pressure ulcers due to decreased mobility and called for skin inspections every shift, but did not specify checking the skin under and around the sling. Skin check records showed intermittent documentation of “skin clear” and redness, with several days missing and no evidence of skin inspection every shift or specific checks under the sling. Subsequently, the resident’s son reported concerns about an open wound and the state of the sling, and staff then identified a large open pressure injury to the right elbow with reddened skin. Nursing notes from that time did not include a comprehensive assessment or wound measurements, and there was no additional Braden scale completed to reassess risk after the wounds were found. Within days, new deep tissue injuries and pressure areas were documented on the right ankle and heel, and later wound assessments by a consultant identified an unstageable right elbow pressure injury and additional pressure injuries on the right lateral heel and malleolus. Physician and PA documentation did not initially include wound measurements, and subsequent care plans after these pressure areas developed did not include the new pressure areas, a plan to check skin under and around the sling, or interventions related to healing the new pressure areas. Interviews with therapy, nursing, and wound care staff confirmed that the resident had a sling on admission, that expectations included checking skin under the sling, and that there were no early sling or skin-check orders, supporting the finding that the facility failed to prevent the development of pressure ulcers and to provide necessary treatment and services in accordance with professional standards. The surveyors concluded that the facility failed to ensure residents were provided necessary treatment and services to prevent and treat pressure ulcers, failed to complete accurate Braden assessments, failed to initiate timely care plans for pressure ulcer risk and existing wounds, failed to implement wound consultant treatment recommendations in a timely manner, and failed to conduct and document appropriate and consistent skin assessments, including under medical devices such as slings. These failures were cited under 28 Pa. Code: 201.29(a) Resident Rights, 28 Pa. Code 211.10(c)(d) Resident Care Policies, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Lack of Physician Order and Care Plan for Resident Sling Use
Penalty
Summary
Surveyors found that the facility failed to obtain a physician order for the use of a right arm sling for a resident with limited mobility. The resident was admitted with diagnoses including a displaced fracture of the surgical neck of the right humerus, a closed fracture, and a fracture of the lower end of the left radius. On two separate observations, the resident was seen wearing a right arm sling. During an interview, an LPN confirmed that there was no physician order for the sling, and review of the clinical record showed no physician order or care plan addressing the resident’s sling use. The Nursing Home Administrator acknowledged that the facility failed to ensure a resident with limited mobility had a physician order for the sling, in violation of applicable Pennsylvania regulatory requirements for licensee responsibility, resident care policies, and nursing services.
Failure to Obtain Physician Orders for Indwelling Urinary Catheter After Readmission
Penalty
Summary
The deficiency involves the facility’s failure to obtain appropriate physician orders for an indwelling urinary catheter for a resident following hospital readmission. The facility’s policy on indwelling urinary catheter care, dated 8/15/25, stated that clinical staff may provide catheter care to help prevent catheter-associated urinary tract infections and prolong the life of the catheter system. The resident, who had diagnoses including repeated falls, anxiety disorder, benign prostatic hyperplasia with lower urinary tract involvement, and a history of lung cancer, had a care plan dated 1/5/26 indicating a history of obstructive uropathy, the need to remain free from catheter trauma, provision of catheter care per routine, and catheter changes per physician order and as needed. Prior physician orders dated 10/27/25 directed staff to provide catheter care, change the suprapubic catheter monthly and as needed, and use an 18 French/10 cc catheter, with documentation of the catheter size inserted; this order ended on 3/25/26. After the resident was sent to the hospital on 3/25/26 due to respiratory concerns and copious mucus and saliva, he returned to the facility on 3/29/26. Review of physician orders and readmission orders dated 3/30/26 showed there were no active orders for catheter care, catheter sizing, catheter change schedule, or catheter irrigation for this resident, despite the continued presence of the catheter. Observations on multiple occasions on 3/30/26 and 3/31/26 documented the resident in bed with a catheter in place connected to a leg bag, and a nurse aide confirmed the presence of the leg bag. During an interview, the DON confirmed that the facility failed to obtain appropriate physician orders for the resident’s urinary catheter as required by facility policy and state regulations.
Failure to Update Care Plan and Document Rationale for Diet Change
Penalty
Summary
Surveyors identified that the facility failed to update an individualized care plan to reflect a resident’s current diet order and failed to address discontinued resident-specific nutritional interventions. Facility policies required that diet orders be provided as ordered by the healthcare provider, that the tray card system match the medical record, and that comprehensive care plans be updated on an ongoing basis to reflect resident needs, wishes, or changes in condition. The resident involved had diagnoses including diabetes mellitus, hypertension, and dementia. A Medical Nutritional Therapy assessment documented a diet order of mechanical soft with low concentrated sweets (LCS). A clinical progress note later recommended advancement to regular solids and thin liquids, and the physician order for LCS, mechanical soft was discontinued and replaced with a regular diet order. The facility’s EMR diet order report and the dietary tray card system both showed a regular diet for the resident. Despite these changes, the resident’s nutrition status care plan, last updated several days before the diet change, continued to list an intervention to provide an LCS, mechanical soft texture diet and was not revised to reflect the current regular diet order. The RN Assessment Coordinator confirmed that the care plan did not match the current diet order. A subsequent RD progress note also indicated the resident was on a regular diet, but the clinical record did not contain documentation from the RD or physician providing a rationale for discontinuing the LCS therapeutic diet restriction. The Regional Risk staff member confirmed the absence of this rationale in the record, and the Administrator and DON acknowledged that the facility failed to update the individualized care plan to address the resident’s specific nutritional concerns and preferences and failed to address the discontinued resident-specific interventions.
Undated Enteral Feeding and Water Flush Supplies for Tube-Fed Resident
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via gastrostomy tube did not receive appropriate care and services related to the management of tube feeding and water flush supplies. The resident, admitted with diagnoses including encounter for attention to gastrostomy, adult failure to thrive, and malnutrition, had care plan and physician orders directing provision of tube feeding with Isosource 1.5 at 60 ml/hr for 22 hours daily and free water flushes of 150 ml every four hours, six times a day. During observations on two separate days, surveyors noted that the resident’s Isosource 1.5 bottle and 1000 ml water flush bag were not dated, and on a subsequent observation the water flush bag remained undated. The DON and an LPN confirmed that the tube feed and water flush bag lacked required dating, and facility leadership acknowledged that the facility failed to ensure appropriate care and services for this resident receiving enteral feeding.
Failure to Maintain Oxygen Equipment and Provide Ordered Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory care and maintain oxygen equipment in accordance with its own policy and physician orders for three residents receiving oxygen therapy. Facility policy dated 8/15/25 required that all residents on oxygen have tubing, masks, and cannulas changed weekly and concentrator external filters cleaned weekly. For one resident with COPD, muscle wasting, and abnormal lung findings, a physician order dated 1/12/26 directed weekly cleaning of the oxygen concentrator and filter and weekly tubing changes. On observation, this resident was in the main dining room on oxygen via nasal cannula with an oxygen concentrator whose humidifier bottle was empty and still labeled with a date from earlier in the month, and the concentrator and external filter were dusty with a layer of fuzz-like debris. The respiratory therapist confirmed these observations. Another resident, admitted with constipation, hypertension, and pneumonia, had a care plan directing oxygen at 2 L with oxygen precautions and a physician order for continuous 2 L oxygen and tubing changes every seven days. During observation, this resident’s oxygen tubing was not dated, and review of the clinical record showed no evidence that the tubing was changed as ordered. A third resident with heart failure, hypertension, and depression had a physician order identical to the first resident’s, requiring weekly cleaning of the concentrator and filter and weekly tubing changes. Observation showed this resident sitting in a wheelchair connected to a concentrator by nasal cannula with undated tubing and a concentrator and external filter that were dusty with a layer of fuzz-like debris. The respiratory therapist and the DON confirmed that appropriate respiratory care and oxygen equipment maintenance were not provided for these three residents.
Medication Error Rate Exceeded Due to Omitted and Improperly Administered Medications
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, identifying three errors out of 36 medication administration opportunities, resulting in an 8.33% error rate. During a medication pass observation on 4/1/26 at 8:56 a.m., an LPN prepared a 40 mg Ingreeza capsule for a resident with an order for medications to be crushed, by softening the capsule in pudding rather than sprinkling the capsule contents in pudding as ordered. The LPN later confirmed that she did not prepare and administer the Ingreeza in accordance with the ordered method. In the same observation period, the LPN failed to administer the resident’s ordered 50 mcg/actuation fluticasone propionate (Flonase) nasal spray and 1 mg/mL olopatadine ophthalmic solution because these medications were not available. The LPN acknowledged that these medications were not given due to unavailability. The Assistant DON confirmed that the Ingreeza administration constituted a significant medication error, and the Nursing Home Administrator confirmed that the facility did not meet the requirement to remain free of a medication error rate of 5% or greater, based on the three identified errors out of 36 opportunities.
Failure to Properly Administer Ordered Crushed Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Ingreeza. Facility policy on Medication Shortages/Unavailable Medications required staff to obtain medications from the pharmacy or alternate sources and to obtain alternate prescriber orders if medications were unavailable, and the resident’s care plan directed that pills be finely crushed. The resident, admitted with bipolar disorder, anxiety, and depression, had a physician’s order for 40 mg of Ingreeza once daily for drug-induced subacute dyskinesia and a separate order that medications be crushed. During a medication pass observation, an LPN prepared to administer the resident’s 40 mg Ingreeza capsule softened in pudding and failed to ensure that all medications were finely crushed, contrary to the resident’s care plan and physician order. The LPN did not open the capsule and sprinkle the contents into the pudding, and instead administered the capsule softened in pudding. In subsequent interviews, the LPN confirmed she failed to administer the Ingreeza as ordered, and the Assistant Director of Nursing confirmed that this was an inappropriate administration of the medication and constituted a significant medication error. The Nursing Home Administrator also confirmed that the facility failed to ensure residents were free of significant medication errors for this resident.
Failure to Secure and Properly Manage Medications and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to properly secure and label medications and treatment supplies. Surveyors observed multiple treatment carts unlocked and unattended in hallways on several occasions. One treatment cart was found unlocked and unattended outside a resident room in the morning and again at midday, and a second-floor treatment cart was also left unlocked and unattended in the South hallway. Staff, including an RN and LPNs, confirmed that these carts were left unlocked and unattended at the times observed. In addition, the East Hall medication cart contained opened ipratropium bromide, albuterol, and fluticasone that were not dated as required, which was confirmed by an LPN. The deficiency also includes treatment medications left at residents’ bedsides instead of being properly stored. For one resident, surveyors observed a container of Vashe (hypochlorous acid wound cleanser) and a tube of zinc oxide on the nightstand while the resident was out of bed in a wheelchair; an LPN confirmed these items were present on the nightstand. For another resident, a tube of triamcinolone cream was observed on the bedside stand while the resident was sitting out of bed in a chair, and this was also confirmed by an LPN. These observations demonstrate that medications and treatment products were not consistently stored in locked compartments or otherwise secured in accordance with professional standards and facility policy.
Failure to Ensure Dental Assessment for Resident With Oral Lump
Penalty
Summary
The facility failed to ensure that a resident received an appropriate dental assessment in accordance with its Dental Services Policy, which states that the facility will assist residents in obtaining routine and 24-hour emergency dental care and that all dental services will be recorded or scanned into the medical record. The resident, identified as R14, was admitted to the facility and had documented diagnoses including heart failure, stroke, and diabetes. A progress note indicated that the social worker spoke with the resident’s family, who showed a picture of a lump on the resident’s gum. The social worker discussed this concern with the care team and contacted the dental vendor to schedule a dentist visit. The social worker later reported that the resident had been seen by the dentist and that the dentist considered the lump to be an extra piece of bone not requiring surgical intervention, while the family believed the lump affected the resident’s ability to chew and wear dentures. When the surveyor requested the dental exam, the facility produced a form not scanned into the electronic health record, which documented a date of service but stated that the resident was not seen and was not on the dentist’s final list. The form indicated that the dentist only spoke with the family about a mandibular torus and that the resident would need an oral surgeon for removal, but it was not signed by the dentist and was left otherwise blank. The Nursing Home Administrator confirmed that the dentist never actually saw or assessed the resident’s mouth, demonstrating that the resident did not receive the dental assessment required by facility policy and state nursing services regulations.
Failure to Hold Required Quarterly QAA/QAPI Committee Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly as required by its own Quality Assurance and Performance Improvement (QAPI) Program policy and state regulation. The written QAPI policy dated 8/15/25 stated that the QAA Committee, responsible for both QA and PI activities, would meet on a regular basis at least quarterly to coordinate and evaluate QAPI activities. Review of QAPI sign-in sheets and attendance records showed no documentation that QAA/QAPI meetings were held for the second and third quarters of 2025. During an interview, the Administrator confirmed that the facility did not conduct the required quarterly QAA meetings for those two quarters. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the facility’s failure to hold and document the mandated QAA Committee meetings in accordance with its policy and 28 Pa Code 201.18(e)(1)-(4).
Failure to Follow Enhanced Barrier Precautions and Refrigerator Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to properly implement its Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling device and to consistently monitor a resident’s personal refrigerator temperature. The facility’s EBP policy dated 8/15/25 required staff to don both gloves and a gown before initiating high-contact activities with high-risk residents, such as those with indwelling devices, and to remove personal protective equipment before exiting the room. Resident R12, admitted on an unspecified date, had diagnoses including diabetes, stroke, and seizure disorder, and the MDS dated 2/9/26 documented the presence of a feeding tube. A physician’s order dated 1/11/26 indicated that EBP were required for this resident. On 3/30/26 at 10:00 a.m., an LPN (Employee E1) was observed wearing gloves while hanging a new bag of tube feeding supplement via pump to the resident’s gastrostomy tube, a high-contact activity, but failed to wear a gown as required by the EBP policy. In a subsequent interview, the LPN confirmed not wearing a gown during this high-contact activity. The deficiency also includes failure to follow the facility’s Freezers and Refrigerators Policy dated 8/15/25, which required monthly tracking sheets for all refrigerators and freezers to record temperatures between 35 and 41 degrees. Resident R44, admitted on an unspecified date, had a personal refrigerator in the room with a temperature log posted on the outside. On 3/30/26 at 9:16 a.m., observation revealed that the log had the month and year fields left blank and that fifteen of thirty days on the log were not completed. In an interview at 9:30 a.m., an RN (Employee E2) confirmed the missing month and year and the fifteen blank days on the temperature log. Later that day, the Director of Nursing confirmed that the facility failed to ensure EBP were properly managed for Resident R12 and failed to properly monitor the personal refrigerator temperature for Resident R44, in violation of 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Track Pneumococcal Vaccinations in the EHR
Penalty
Summary
The facility failed to ensure pneumococcal vaccinations were properly assessed and tracked in the electronic health record for two residents, as required by its Infection Prevention and Control Plan. The policy dated 8/15/25 states that the Infection Preventionist (IP) is responsible for oversight of infection prevention strategies, including vaccinations. For one resident with diagnoses of diabetes, stroke, and seizure disorder, the face sheet showed admission to the facility and the MDS dated 2/9/26 documented these conditions. The resident’s immunization record indicated that a pneumococcal vaccine was not due until 3/26/25, but the facility could not provide documentation in the medical record that the immunization was assessed on that due date. For another resident admitted to the facility with diagnoses of stroke, hemiplegia, and Parkinson’s disease, the MDS documented these conditions, and the immunization record indicated that a pneumococcal vaccine was not due until 4/28/25. As with the first resident, the facility could not provide documentation in the medical record that the pneumococcal immunization was assessed on the identified due date. During interviews, the IP confirmed that there was no documentation of assessment for either resident on their respective due dates, and the Regional Risk staff member confirmed that the facility failed to ensure pneumococcal vaccinations were tracked in the electronic health record for these residents.
Failure to Provide Ordered Daily Treatment for Stage 3 Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident with a Stage 3 pressure injury received ordered wound care treatment in accordance with facility policy and professional standards of practice. Facility policy on Pressure Injury Prevention and Management dated January 2026 stated that residents admitted with existing pressure injuries would receive necessary treatment and services to promote healing and prevent infection. The resident was admitted with multiple wounds, including a Stage 3 pressure injury to the left first finger, surgical wounds to the left leg (BKA) and left thumb (amputation), and vascular wounds to the right knee, right lateral shin, and right dorsal foot. A nursing progress note documented that the wound team assessed the resident shortly after admission, that the resident was alert, cooperative, and in no acute distress, and that new treatment orders were obtained for the various wounds, including medihoney and dry dressing for the Stage 3 pressure injury to the left first finger. A physician order dated 9/29/25 directed that the left first finger wound be cleansed with normal sterile saline, patted dry, treated with a thick layer of medihoney, and covered with a dry dressing daily. Review of the October 2025 MAR showed that this ordered treatment was not signed off as completed or refused on multiple dates (10/4, 10/7, 10/12, 10/17, 10/18, and 10/29). Review of the November 2025 MAR showed additional missed documentation of completion or refusal on 11/3 and 11/4. During an interview, the Nursing Home Administrator confirmed that the facility failed to ensure that the resident received proper treatment for the pressure ulcer, resulting in a deficiency under applicable Pennsylvania regulations regarding licensee responsibility, resident care policies, and nursing services.
Failure to Obtain Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to obtain ordered laboratory tests for two residents, resulting in missed CBC, CMP, BMP, and UA testing as prescribed by their physicians. For one resident with diagnoses including hypertension, dementia, and diabetes mellitus, physician orders dated 11/4/25 directed staff to obtain a CBC, CMP, and complete urinalysis. Review of this resident’s clinical record did not show any documentation that these laboratory tests were obtained or completed as ordered. For another resident with diagnoses including hypertension, hyperlipidemia, and depression, physician orders dated 12/31/25 directed staff to obtain a BMP and CMP, and an additional order dated 1/2/26 directed staff to obtain a complete urinalysis. Review of this resident’s clinical record likewise failed to show documentation that the BMP, CMP, and UA were obtained and completed as ordered. During an interview, the Nursing Home Administrator confirmed that the facility did not obtain the ordered laboratory services for these two residents.
Failure to Document and Administer Crushed Medications Results in Significant Medication Error
Penalty
Summary
The facility failed to accurately document and follow physician orders regarding the administration of crushed medications for a significant number of residents. Specifically, 29 out of 33 residents who required their medications to be crushed did not have this need properly documented in their care plans or physician orders. This lack of documentation and communication led to staff uncertainty about which residents required crushed medications, as confirmed by interviews with staff members who assumed others would know or relied on incomplete information. One resident with a diagnosis of dementia, chronic obstructive pulmonary disease (COPD), and dysphagia had a physician's order for medications to be given crushed in pudding or applesauce. However, the resident's care plan did not include specific interventions for dysphagia or the need for crushed medications. On the day of the incident, the resident requested to take medications whole, and an LPN provided the medications uncrushed, contrary to the physician's order. Shortly after, the resident began coughing, experienced respiratory distress, and ultimately became unresponsive. Staff attempted various emergency interventions, including the Heimlich maneuver, suctioning, and oxygen administration, but were delayed in providing high-flow oxygen due to the unavailability of an oxygen key. A finger sweep revealed whole pills in the resident's mouth/throat, and the resident was pronounced deceased after these efforts were unsuccessful. Interviews with staff confirmed that the need for crushed medications was not consistently communicated or documented, and that staff were not always aware of the correct medication administration method for each resident. The facility's failure to ensure accurate documentation and adherence to physician orders for medication administration resulted in a significant medication error and an immediate jeopardy situation for one resident, with widespread deficiencies identified for many others.
Removal Plan
- Facility had speech therapist complete a whole house audit to validate medication delivery method (crushed vs whole). All discrepancies were immediately addressed.
- An order will be obtained by physician for all current residents requiring crushed meds and all care plans will be updated to reflect the orders.
- Education will be provided to all licensed staff on proper medication administration, following physician orders and the steps to take for resident refusals.
- For agency staff a binder will be created containing the education on proper medication administration, following physician orders and the steps to take for resident refusals. Agency staff will be educated prior to the start of their shift.
- LPN identified with deficient practice will receive 1:1 education and disciplinary process will be followed.
- Director of Nursing, or designee, will audit 10 residents a day, 5 days a week for 4 weeks. The audit is to validate the nurse followed physician orders for medication administration.
- An ad hoc QAPI will be held to discuss deficient practice and immediate Plan of Correction with the Interdisciplinary Team.
Failure to Follow Medication Administration Orders Results in Resident Death
Penalty
Summary
The facility failed to implement its policies and procedures to protect a resident from neglect, resulting in actual harm. A resident with diagnoses of dementia, COPD, and dysphagia had a physician's order requiring all medications to be crushed and administered in pudding or applesauce due to swallowing difficulties. The resident's care plan included strict aspiration precautions but did not contain specific goals or interventions for dysphagia or the need for crushed medications. Despite these orders and precautions, an LPN provided the resident with whole medications after the resident requested them, following a recent diet order change. The LPN confirmed administering the medications uncrushed, after which the resident began coughing and experienced respiratory distress. Additional staff responded, and a finger sweep was performed, removing food matter and whole pills from the resident's mouth and throat. The resident, who was a DNR, subsequently ceased to breathe and was pronounced dead after resuscitation efforts were unsuccessful. Facility leadership confirmed that policies and procedures were not properly implemented to protect the resident from neglect, which led to aspiration, respiratory failure, and death.
Failure to Maintain Emergency Equipment Causes Delay in Care
Penalty
Summary
The facility failed to ensure that emergency equipment, specifically two crash carts, was maintained in safe operating condition, resulting in a delay in emergency care for a resident. According to the facility's Emergency Equipment Check Policy, crash carts are to be checked daily, with outdated or opened items replaced and missing items restocked promptly. However, review of the crash cart checklists for multiple months revealed frequent lack of documentation of checks and repeated notations that no items were available on the carts. Additionally, there were missing checklists for entire months, indicating a systemic failure to follow the established policy for emergency equipment maintenance. A resident with diagnoses including dementia, COPD, and dysphagia experienced respiratory distress and required emergency intervention. During the event, staff were unable to access high-flow oxygen from the crash cart because the necessary oxygen key was missing. Staff had to search for several minutes before a key was located, during which time only a low-flow oxygen concentrator was available. The resident's oxygen saturation was critically low, and the delay in accessing high-flow oxygen contributed to the inability to provide timely emergency care. Whole pills were found in the resident's mouth and throat, indicating a possible aspiration event. Interviews with staff confirmed the absence of the oxygen key on the crash cart and the lack of proper documentation and checks of emergency equipment. Both the Nursing Home Administrator and the Director of Nursing acknowledged the failure to maintain the crash carts in safe operating condition, which directly resulted in a delay in emergency care for the resident. The deficiency was cited under 28 Pa Code: 201.14(a) Responsibility of licensee.
Failure to Notify Provider of Change in Condition for Two Residents
Penalty
Summary
The facility failed to notify a medical provider of a change in condition for two of seven residents, as required by facility policy and state regulations. For one resident with diagnoses of high blood pressure and heart failure, clinical records showed that the resident's oxygen saturation remained below 77% throughout a shift, despite being on continuous oxygen therapy. The nurse on the previous shift did not notify the physician of the resident's persistently low oxygen levels. The issue was only addressed during the following shift, when the physician was informed and the resident was subsequently sent to the hospital for further care. For another resident with chronic obstructive pulmonary disease (COPD) and heart failure, the facility failed to notify the provider of a significant weight gain of approximately fifteen pounds over four weeks, as well as other symptoms such as increased abdominal distention, shortness of breath, and +3 lower leg edema. Although a one-time order for Lasix was received, there was no documentation of provider notification regarding the weight gain or the change in the resident's condition prior to the resident being transported to the hospital for COPD exacerbation and right-sided heart failure. Interviews with facility staff, including the Medical Records employee, confirmed that there was no documentation of provider notification for these changes in condition. The Nursing Home Administrator and Director of Nursing also acknowledged the failure to notify the medical provider as required. These findings were based on a review of facility policies, clinical records, and staff interviews.
Failure to Obtain Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to obtain physician's orders for the administration of crushed medications for 29 out of 33 residents who required this modification. According to the facility assessment, speech therapy services are provided, and the speech therapist confirmed that while they adjust diet consistency orders, they do not address the need for physician's orders for crushed medications. During interviews, it was revealed that nursing staff relied on assumptions rather than formal orders to determine which residents needed their medications crushed. A review of clinical records showed that only four residents had proper physician orders for crushed medications, while a speech therapy audit identified 29 additional residents needing this intervention without corresponding physician orders. The Nursing Home Administrator and Director of Nursing confirmed this oversight.
Incomplete and Inaccurate Medical Records and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that medical records for residents were complete and accurately documented, as evidenced by discrepancies and omissions in both electronic and paper records for 14 out of 104 residents. Staff interviews revealed inconsistent methods for determining which residents required their medications to be crushed, with reliance on standing orders, report sheets, and verbal handoffs, none of which consistently reflected current physician orders or resident needs. The standing order "May crush medications unless contraindicated" was present in every resident chart, making it unclear which residents specifically required crushed medications, and administration orders were missing in the electronic medical record for some residents who had physician orders for crushed medications. Further review of nursing unit report sheets uncovered multiple inaccuracies, such as the inclusion of information for residents who were deceased or discharged, missing or incorrect code status designations, and absent or outdated information regarding medication administration methods. For example, some residents who required crushed medications were not designated as such on the report sheets, and code status information was not updated to reflect current physician orders. In several cases, residents' names were missing from the correct bed locations, or information for previous occupants remained on the sheets. Interviews with nursing staff and the Director of Nursing confirmed a lack of communication between departments, particularly between speech therapy and nursing, regarding which residents required physician orders for crushed medications. The Nursing Home Administrator and Director of Nursing acknowledged that the report sheets used by staff were inaccurate and confirmed the failure to maintain complete and accurate medical records for the affected residents.
Failure to Report and Investigate Possible Neglect Following Resident Aspiration Event
Penalty
Summary
The facility failed to implement its policies and procedures regarding the reporting of possible neglect for one resident. According to the facility's abuse policy, all allegations of neglect must be reported immediately to the Administrator, DON, and the appropriate State Agency. In the case reviewed, a resident with diagnoses including dementia, COPD, and dysphagia had a physician's order to receive medications crushed in pudding or applesauce. However, an LPN provided the resident with whole medications at the resident's request, despite the standing order. The resident subsequently began coughing, experienced respiratory distress, and ultimately ceased to breathe following an aspiration event. Staff attempted emergency interventions, but the resident was pronounced deceased. Documentation and interviews confirmed that whole pills were removed from the resident's mouth during the emergency response. Despite the serious nature of the incident, the facility did not complete an investigation or report the possible neglect to the State Survey Agency as required by policy. Interviews with the DON and Nursing Home Administrator confirmed that no investigation was conducted, and no report was submitted. The failure to follow established procedures for reporting and investigating possible neglect was identified as a deficiency during the survey.
Failure to Investigate Choking Incident and Adhere to Medication Administration Policy
Penalty
Summary
The facility failed to implement its policies and procedures to investigate a choking incident involving one resident, thereby not ruling out possible neglect. According to the facility's abuse policy, all allegations, suspicions, and incidents of abuse, neglect, and injuries of unknown source must be investigated. The resident in question had diagnoses of dementia, COPD, and dysphagia, with a care plan that included strict aspiration precautions but lacked specific goals and interventions for dysphagia or the need for crushed medications. A physician's order was in place for medications to be given crushed in pudding or applesauce until cleared by speech therapy. Despite this, an LPN provided the resident with whole medications after the resident requested them, leading to a choking event. The resident began coughing, experienced respiratory distress, and ultimately ceased to breathe. Staff attempted emergency interventions, including a finger sweep, which removed food matter and whole pills from the resident's mouth and throat, but resuscitation was unsuccessful. Interviews with staff and administration confirmed that no investigation was conducted into the incident, as required by facility policy.
Failure to Develop Person-Centered Care Plan for Crushed Medications
Penalty
Summary
The facility failed to develop a person-centered care plan addressing the need for crushed medications for a resident with a diagnosis of dysphagia, dementia, and COPD. Although the resident's care plan included an approach to adhere to strict aspiration precautions due to increased nutrition/hydration risk, it did not include specific goals or interventions for dysphagia or the requirement for medications to be crushed. A physician's order was in place for medications to be given crushed in pudding or applesauce until cleared by speech therapy, but this was not reflected in the care plan. An LPN provided the resident with whole medications after the resident requested them, following a recent change in diet order. The resident began coughing and experienced respiratory distress, leading to a fatal aspiration event. Staff attempted emergency interventions, but the resident was pronounced deceased. Facility leadership confirmed that a person-centered care plan related to the need for crushed medications was not developed for this resident.
Failure to Investigate and Report Possible Neglect After Resident Choking Death
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) demonstrated the necessary competencies to recognize, report, and investigate possible neglect following a resident's death. The DON, who was designated as the Abuse Coordinator, did not complete an investigation or report the incident to the State Survey Agency after a resident experienced a fatal choking event. The facility's job description for the DON included responsibilities for reporting any known or suspected allegations of abuse or neglect, but these actions were not carried out in this case. The resident involved had diagnoses of dementia, COPD, and dysphagia, with care plans indicating strict aspiration precautions and a physician's order for medications to be given crushed in pudding or applesauce. Despite this, an LPN provided the resident with whole medications at the resident's request, leading to a choking incident. Staff attempted emergency interventions, but the resident died. Interviews confirmed that whole pills were removed from the resident's mouth during the event, and both the DON and the Nursing Home Administrator acknowledged the failure to recognize, report, and investigate the possible neglect that contributed to the resident's death.
Failure to Prevent Significant Medication Error Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to protect residents from significant medication errors, as evidenced by a resident with an active order to have medications crushed receiving their medications whole. This error occurred despite the facility's policies and job descriptions, which require the NHA and DON to ensure compliance with federal, state, and local regulations and to maintain the highest degree of quality care for each resident. The failure to follow the prescribed medication administration led to a critical incident involving the resident. Following the administration of whole medications instead of crushed, the resident experienced a severe adverse event, ceasing to breathe after going into respiratory failure post-aspiration coughing event. The NHA and DON confirmed during interviews that they did not effectively manage the facility to prevent this significant medication error, resulting in an Immediate Jeopardy situation for one of five residents reviewed. The report cites violations of multiple Pennsylvania Codes related to the responsibility of the licensee, management, and nursing services.
Failure to Timely Dispose of Controlled Substance After Resident Discharge
Penalty
Summary
The facility failed to ensure that a controlled substance was disposed of according to acceptable standards of practice for one closed resident record. According to facility policy, discontinued controlled medications are to be removed from the medication cart, stored securely, and destroyed following the controlled medication destruction procedure. However, during an observation of the medication cart, it was found that a controlled substance, Clonazepam (Klonopin) 0.5 mg, prescribed as needed for anxiety, remained in the cart after the resident had been discharged home. The medication was still present and available in the cart, contrary to the facility's policy and standard practice. The resident involved had diagnoses including diabetes, COPD, and panic disorder, and had been discharged home with her son. Staff interviews confirmed that the resident was no longer in the facility, and the DON stated that medications are either discharged with the resident or wasted within a day or two. Despite this, the controlled medication was not removed or disposed of in a timely manner, resulting in non-compliance with pharmacy service regulations.
Failure to Identify and Supervise Elopement Risk Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and did not identify a resident as an elopement risk, resulting in the resident eloping from the unit. Upon admission, the resident, who had diagnoses of dementia, anxiety, and bipolar disorder, was assessed by an LPN and not identified as an elopement risk, despite being disoriented, having memory impairment, and being ambulatory with assistance. The elopement risk assessment was not fully completed, and no elopement care plan was initiated for the resident. Staff interviews revealed that the resident was confused, attempted to get into other residents' beds, and was mobile in a wheelchair, but these behaviors were not recognized as indicators of elopement risk. The resident was last seen on the unit before being found missing, and staff did not immediately follow the facility's elopement policy, including calling a code green as required. The resident was eventually found in the basement, uninjured, after being missing for approximately thirty minutes. The facility's admission process also failed to identify that the resident had previously resided in a secured memory care unit at another facility, and the necessary precautions were not taken upon admission. The staff responsible for the admission assessment did not receive a proper handoff or report from the hospital or family, and the RN Supervisor did not assist with the assessment. Further review indicated that the facility's elopement risk assessment tool was inadequate, as it did not identify residents who were at risk for elopement if they were not ambulatory at the time of admission. The admissions director acknowledged that the process sometimes missed risk factors, and the facility did not reassess the resident for elopement risk when her mobility increased. Additionally, the facility did not ensure that all staff were educated on elopement risks and supervision, and the required procedures were not consistently followed when the resident was found to be missing.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
A resident with diagnoses of dementia, anxiety, and bipolar disorder was admitted to the facility and had a physician's order for ziprasidone HCl (Geodon) 80 mg to be administered orally. The clinical record review revealed that the resident missed five doses of the prescribed medication for both AM and PM administrations. There was no documentation in the clinical progress notes indicating that the physician was notified about the missed doses. During an interview, the Director of Nursing confirmed that the facility failed to provide the ordered medication and did not notify the physician when the medication was unavailable, resulting in a failure to provide appropriate treatment and care as ordered.
Failure to Account for and Properly Destroy Controlled Substances
Penalty
Summary
The facility failed to ensure that controlled substances were accurately accounted for and destroyed appropriately for one resident. According to facility policy, all Schedule II medications and those with potential for abuse or diversion should be tracked using a declining inventory record, and incoming and outgoing nurses are required to count these medications at each shift change. In this case, a card containing 13 tablets of oxycodone was delivered for a resident with diagnoses including peripheral vascular disease, osteoporosis, and atrial fibrillation. The RN supervisor signed for the medication, but the agency nurse who received it did not sign it into the controlled drug tracking log and instead subtracted the card, stating the order was discontinued. The medication was not placed into the locked medication cart, and the discrepancy was only discovered when the resident requested the medication and it could not be located. Further review revealed that the agency nurse also signed for additional narcotics that were to be destroyed, but destruction forms were not completed, and the facility was not following the required process of having two licensed staff destroy medications. Interviews with facility leadership confirmed that the facility failed to verify that narcotics were being disposed of appropriately and that controlled substances were not properly accounted for or destroyed as required by policy.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions over a 14-day period. Specifically, on the day shift of March 15, 2025, the facility did not provide the required number of NA hours for a census of 97 residents, falling short by 2.5 hours. On the evening shift of March 16, 2025, with a census of 99 residents, the facility was short by 2.5 hours. Additionally, on the night shifts of March 6, 13, and 16, 2025, the facility failed to meet the required NA hours for a census of 97 and 99 residents, with deficits ranging from 3.5 to 9.5 hours. These deficiencies were confirmed by the Nursing Home Administrator during an interview on March 18, 2025.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on staffing Nurses Aides to include expectations of HPPD and ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review ratio and PPD compliance for upcoming schedules. DON/ designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.
LPN Staffing Shortage on Day Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift on March 15, 2025. A review of the facility's census data and nursing time schedules from March 3, 2025, through March 16, 2025, revealed a staffing shortage on the day shift of March 15, 2025. On this day, the facility had a census of 97 residents, requiring 36.04 LPN hours, but only 25.00 actual LPN hours were provided. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 18, 2025.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on staffing Licensed Practical Nurses (LPN) to include expectations of LPN ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review LPN ratio compliance for upcoming schedules. DON/ designee will monitor LPN ratios 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.20 hours of direct resident care per patient daily (PPD) on two specific days. A review of staffing documents and nursing staff schedules from March 3, 2025, through March 16, 2025, revealed that on March 6, 2025, the facility provided 3.18 PPD, and on March 16, 2025, it provided 3.03 PPD. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 18, 2025, who acknowledged the failure to meet the required PPD hours on the specified dates.
Plan Of Correction
The facility cannot retroactively correct past staffing issues. To prevent this from reoccurring, the Scheduler will be reeducated on minimum overall nursing hour staffing to include expectations of HPPD and ratios by the DON/ designee. The facility will hold staffing meetings 5 days per week, consisting of the Nursing Home Administrator, Director of Nursing, Human Resources, and Scheduler, to review ratio and PPD compliance for upcoming schedules. DON/ designee will monitor PPD hours 5 days a week and ongoing to ensure compliance. Ad hoc education will be provided as needed. The results of the meeting will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Conduct Annual Fire Door Inspection
Penalty
Summary
The facility failed to perform the required annual fire door assembly inspection, which affects the entire facility. During a documentation review on March 17, 2025, it was revealed that there was no documentation available to confirm that an annual fire door assembly inspection had been conducted. This was further confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of documentation for the completed inspection.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0761 Maintenance, Inspection & Testing Doors. The Maintenance Director is performing an annual fire door assembly inspection. The Maintenance Director will ensure an annual fire door assembly inspection is completed per regulation.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain hazardous area enclosures, as evidenced by an observation on March 17, 2025. During the inspection, it was noted that the door to the transfer switch room, located across from the boiler room, did not latch properly when tested. This deficiency affected one of the eight smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0321 Hazardous Area Enclosures. The door to the transfer switch room was repaired and now latches as appropriate. The Maintenance Director completed an audit of hazardous area enclosures and no other noncompliant areas were identified. The Maintenance Director will complete a random audit of hazardous area enclosures weekly times two weeks then monthly times 2 months.
Deficiency in Kitchen Fire Suppression System Maintenance
Penalty
Summary
The facility failed to properly install and maintain equipment protected by the kitchen hood fire suppression system, affecting one of eight smoke compartments. During an observation, it was noted that a wheeled gas-fired deep fryer in the kitchen was not equipped with an approved method to ensure it returned to its designated location after being moved for maintenance and cleaning. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director. Additionally, a document review revealed that the facility did not provide documentation for the completion of kitchen fire suppression testing and maintenance for the first six months of 2024. This lack of documentation was also confirmed during the interview with the Facility Administrator and Maintenance Director. These findings indicate a failure in maintaining the necessary fire safety protocols as required by NFPA 101 standards.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0324 Cooking Facilities. Observation #1 – wheeled gas-fired deep fryer was appropriately secured to ensure that the appliance is returned to the designated location after any maintenance or cleaning. Observation #2 is unable to be corrected. The Kitchen Fire Suppression Testing/Maintenance has been completed and is current. The Maintenance Director will continue to ensure that Kitchen Fire Suppression system is tested and maintenance completed per regulation. The Maintenance Director/designee will perform random audits of the securement of the deep fryer weekly x 2 weeks then monthly x 2 months.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by observations and interviews conducted on March 17, 2025. Five deficiencies were identified, affecting four out of eight smoke compartments. Specifically, items were stored within 18 inches of sprinkler heads in the Storage Room on the third floor and in a storage closet in the Physical Therapy room. Additionally, gaps greater than 1/8 inch were found in ceiling tiles in the Classroom/Storage Room and Tele-data closet in the basement, as well as in the Electric room across from the Laundry room. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0353 Sprinkler System. The observation 1a. The stored items within 18 inches of a sprinkler head was removed. The observation 1b. Observed gap in ceiling tile in basement classroom/storage room was repaired. The observation 1c. Observed gap in ceiling tile teledata room was repaired. The observation 1d. Observed gap in ceiling tile electric room was repaired. The observation 1e. The stored items within 18 inches of a sprinkler head was removed. The Maintenance Director/designee will perform random audits of ceiling tile to ensure no gaps greater than 1/8 inch and storage areas to ensure there are no items within 18 inches of a sprinkler head weekly times 2 weeks then monthly times 2 months.
Fire Extinguisher Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a portable fire extinguisher in accordance with NFPA 10 standards. During an observation on March 17, 2025, at 10:20 a.m., it was noted that the pressure gauge on the fire extinguisher located in the Physical Therapy area near the kitchen indicated that it required recharging before it could be used. This deficiency affected one of the eight smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director later that day confirmed that the fire extinguisher was not ready for use.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0355 Fire Extinguishers. The fire extinguisher in the physical therapy department was replaced. The Maintenance Director will perform a house audit of fire extinguishers to ensure that they are maintained and ready for use per regulation. The Maintenance Director/designee will perform random audits on the fire extinguishers weekly times 2 weeks then monthly.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of eight smoke compartments. During an observation on March 17, 2025, at 10:45 a.m., it was noted that the smoke barrier doors adjacent to the Receiving Room on the first floor had an excessive gap between their meeting edges. This gap compromised the doors' ability to resist the passage of smoke, which is a critical safety requirement. An interview with the Facility Administrator and Maintenance Director later that day confirmed the presence of the excessive gap, acknowledging the deficiency in the smoke barrier doors' functionality.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0374 Smoke Barriers. The observed smoke barrier door excessive gap was repaired. The Maintenance Director observed the facility's smoke barrier doors and found no other issues identified. The Maintenance Director/designee will randomly audit the smoke barrier doors weekly x 2 weeks, then monthly to ensure there are no excessive gaps to allow passage of smoke.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct the required number of fire drills, as evidenced by a lack of documentation for six out of twelve required drills over the past year. Specifically, there was no documentation for the second and third shift fire drills in the second quarter, the third shift in the third quarter, and all shifts in the fourth quarter. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the absence of documentation for these fire drills.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0712 Fire Drills. The previous month's fire drills are unable to be corrected. Current fire drills are up to date. The Maintenance Director will ensure fire drills are held per regulation and policy. The NHA/designee will perform random audit monthly to ensure the fire drills are held per regulation and policy.
Failure to Conduct Required Community-Based Exercise
Penalty
Summary
The facility failed to meet the emergency preparation testing requirements as outlined in the emergency preparedness plan. Specifically, the deficiency was identified during a document review conducted on March 17, 2025, at 8:40 a.m. The review revealed that the facility did not fulfill the annual requirement for conducting a community-based, full-scale exercise. This exercise is a critical component of the emergency preparedness plan, designed to ensure that the facility is adequately prepared to respond to emergencies. The deficiency was confirmed during an interview with the Facility Administrator and the Maintenance Director on the same day at 1:30 p.m. During this interview, it was acknowledged that the facility had not conducted the required community-based exercise. This lapse indicates a failure to adhere to the regulatory requirements set forth for emergency preparedness in long-term care facilities. The absence of the community-based, full-scale exercise suggests a gap in the facility's emergency preparedness efforts. Such exercises are essential for testing the effectiveness of the emergency plan and ensuring that staff are well-prepared to handle potential emergencies. The failure to conduct this exercise as required could potentially impact the facility's ability to respond effectively in the event of an actual emergency.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0039 Testing Requirements. The facility had previously conducted a community based full scale exercise on March 11, 2025. The facility completed a tabletop exercise on March 25, 2025. The NHA/Designee will ensure the facility completes a community based full scale exercise and tabletop exercise per the regulation.
Failure to Conduct Monthly Emergency Lighting Tests
Penalty
Summary
The facility failed to perform the required monthly tests of the emergency lighting system for three out of the last twelve months, specifically in October, November, and December 2024. This deficiency was identified during a document review conducted on March 17, 2025, at 9:10 a.m., which revealed the absence of documentation for these tests. An interview with the Facility Administrator and Maintenance Director later that day confirmed the lack of documentation for the emergency lighting tests during the specified months, affecting the entire facility.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0291 Emergency Lighting. The facility is unable to correct the lack of previous month's documentation. The facility's emergency lighting is a hard wired system. The Maintenance Director is currently performing monthly emergency lighting inspections per regulation. The NHA/designee will randomly audit the Maintenance Director emergency lighting inspection log monthly.
Failure to Conduct Monthly Exit Sign Inspections
Penalty
Summary
The facility failed to perform monthly exit sign inspections for three out of the last twelve months, specifically in October, November, and December 2024. This deficiency was identified during a document review conducted on March 17, 2025, at 8:50 a.m., which revealed the absence of documentation for these inspections. An interview with the Facility Administrator and Maintenance Director later that day confirmed the lack of documentation at the time of the survey. This oversight affected the entire facility, as exit and directional signs are required to be continuously illuminated and served by the emergency lighting system in accordance with NFPA 101 standards.
Plan Of Correction
The Nursing Home Administrator (NHA) provided re-education to the Maintenance Director on 0293 Exit Signage. The facility is unable to correct the lack of previous month's documentation. The Maintenance Director is currently performing monthly exit sign inspections per regulation. The NHA/designee will randomly audit the Maintenance Director exit signage inspection log monthly.
Failure to Maintain Clean Kitchen Equipment
Penalty
Summary
The facility failed to maintain clean equipment in the Main Kitchen, which could lead to foodborne illness. During an observation and interview, the Certified Dietary Manager confirmed that a fan, which was directed towards clean dishes coming out of the dish machine, was covered in a gray, fuzzy substance. This indicates a failure to adhere to the facility's policy on kitchen sanitation and cleaning schedules, which requires food and nutrition services staff to maintain kitchen sanitation through compliance with a comprehensive cleaning schedule.
Plan Of Correction
The dietary manager cleaned the fan. No other concerns were noted during the survey. The dietary manager completed an audit of the kitchen to address any additional findings. To prevent this from recurring, the RDCS educated dietary staff on maintaining clean equipment and the regulatory requirements of F812. To monitor and maintain ongoing compliance, the dietary manager/designee will audit the kitchen fan for cleanliness weekly for 4 weeks, then monthly for 2 months. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Improper Garbage Disposal in Outdoor Dumpster
Penalty
Summary
The facility failed to properly contain and dispose of garbage in one of its two outdoor dumpsters, specifically dumpster one, which could lead to potential rodent and insect infestation. This deficiency was identified during an observation and interview conducted on March 11, 2025, at 12:45 p.m., when the Certified Dietary Manager, Employee E21, confirmed that the lid of dumpster one was not closed. A subsequent observation on March 13, 2025, at 8:29 a.m. also noted that the lid of dumpster one remained open. During an interview at 8:30 a.m. on the same day, the Nursing Home Administrator confirmed the facility's failure to properly contain and dispose of garbage in the outdoor trash receptacles, acknowledging the potential for rodent and insect infestation.
Plan Of Correction
The dumpster lid was closed upon observation. Moving forward, the NHA/designee will ensure the facility properly contains and disposes of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation. To prevent this from recurring, the RDCS educated housekeeping, laundry, and dietary staff on the regulatory requirements of F814. To monitor and maintain ongoing compliance, the NHA/designee will audit the dumpster lid to ensure it is closed 2x/day x4 weeks, then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
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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