Manor At St Luke Village,the
Inspection history, citations, penalties and survey trends for this long-term care facility in Hazleton, Pennsylvania.
- Location
- 1711 East Broad Street, Hazleton, Pennsylvania 18201
- CMS Provider Number
- 395636
- Inspections on file
- 29
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Manor At St Luke Village,the during CMS and state inspections, most recent first.
A resident with liver cirrhosis and chronic ascites had a new right tunneled peritoneal catheter placed, but staff did not obtain or document post-procedure care instructions, failed to secure physician orders, and did not update the care plan to address the new device. Documentation and monitoring for the catheter were absent, and facility leadership confirmed these omissions during interviews.
The facility failed to provide clinical rationale for the continued use of PRN psychotropic medications for two residents. One resident with dementia received Lorazepam for 167 days without re-evaluation, and another with cerebral infarction and hemiplegia had Ativan renewed for 90 days without justification. The DON confirmed the absence of necessary documentation.
The facility failed to consistently provide snacks to residents as desired, with seven residents reporting that they are not consistently offered a nourishing evening snack. Despite the facility's policy to provide snacks according to residents' needs and preferences, grievances and meeting minutes indicate that residents have raised concerns about not receiving nighttime snacks. The Nursing Home Administrator was unable to explain the inconsistency in snack provision.
A resident reported inappropriate conduct by a staff member during peri-care, which was not thoroughly investigated by the facility. The facility failed to obtain witness statements, document a nursing evaluation, notify the physician, complete an incident report, secure evidence, or report to the State Survey Agency as required.
A facility failed to create an individualized discharge plan for a resident with Dysarthria following a stroke. Despite the resident's cognitive intactness and expressed desire to discharge, there were no social service notes or documented discharge planning in the care plan. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to administer oxygen therapy according to professional standards for a resident with COPD. The physician's order lacked a specified oxygen flow rate, and the resident was observed receiving oxygen at 2.0 lpm without this detail in the order. The DON confirmed the oversight, highlighting a deficiency in ensuring proper oxygen therapy administration.
The facility failed to implement a comprehensive infection control program, lacking specific provisions for tracking and responding to respiratory infections like COVID-19, Influenza, and RSV. A resident with upper respiratory symptoms was not tested for viral illnesses before being hospitalized and testing positive for RSV. Staff interviews revealed that testing for respiratory illnesses was not routinely conducted, and the infection control data was incomplete, lacking necessary details for effective monitoring.
The facility failed to provide adequate nursing staff, resulting in delayed care and unmet needs for residents. A resident developed a pressure ulcer due to insufficient repositioning, and another did not receive prescribed ambulation assistance. Staffing levels consistently fell below state requirements, impacting the quality of care.
The facility failed to provide timely assistance to residents, as evidenced by grievances and interviews. A resident reported waiting 30 minutes for help, leading to soiling herself, while another stopped using the call bell due to delayed responses. A group interview revealed that residents experienced long waits for care due to insufficient staffing, with some waiting over an hour for assistance. The NHA and DON acknowledged the need for timely responses, confirming the deficiency.
The facility failed to ensure consistent communication and monitoring for two residents requiring dialysis care. The facility did not consistently record post-dialysis weights and failed to monitor fluid intake for residents on fluid restrictions. Interviews with staff confirmed these deficiencies, highlighting a lack of documented evidence that residents' medical statuses were adequately monitored post-treatment.
A resident experienced a room change without receiving the required written notice, following an incident where his roommate inappropriately touched him. The facility did not provide a written explanation to the resident or his representative, violating federal regulations and resident rights.
A facility failed to communicate necessary resident information during transfers to a hospital on two occasions. Essential details such as practitioner contact information, resident representative details, advance directives, and care instructions were not documented or conveyed. The DON confirmed the lack of communication, potentially affecting the resident's safe transition of care.
A facility failed to ensure accurate MDS assessments for a resident. The resident's quarterly MDS assessment incorrectly listed a Multidrug Resistant Organism (MDRO) as an active diagnosis, despite no clinical evidence supporting this. The DON confirmed the error during an interview.
A facility failed to revise a care plan after a resident was alleged to have inappropriately touched his roommate. Despite discussions with the resident, who denied the behavior, the care plan was not updated to address this potential issue. The oversight was confirmed by the DON, highlighting a lapse in monitoring and revising care plans as per protocol.
A resident at risk for pressure injuries developed an unstageable pressure ulcer due to the facility's failure to consistently implement a care plan that included regular turning and repositioning. Despite being dependent on staff for mobility, the resident was not regularly repositioned, leading to the development of a pressure ulcer. The facility's documentation and staff interviews confirmed lapses in care, resulting in a deficiency citation.
A resident with reduced mobility and muscle weakness did not receive the prescribed Restorative Nursing Program (RNP) for ambulation, as confirmed by clinical records and staff interviews. Despite a physician's order and recommendations for ambulation with a wheeled walker, the facility failed to implement the RNP, as noted in the Documentation Survey Report for April and May.
A resident with dementia exhibited multiple behavioral symptoms, including aggression and wandering, but the facility failed to develop an individualized care plan to address these issues. The care plan lacked specific interventions for managing combative behaviors, and there was no evidence of an interdisciplinary approach or staff competency in providing appropriate dementia care.
A resident with GERD, diabetes, and heart failure experienced inappropriate touching by a roommate, leading to discomfort and a room change. Despite the incident, there was no documentation or follow-up on therapeutic social services to address the resident's mental and psychosocial needs, as confirmed by interviews with the Director of Social Services and the DON.
A facility failed to provide timely written notices of facility-initiated transfers to a resident and her representative. The resident was transferred to a hospital on two occasions without documented evidence of a notice of transfer or discharge letter. This deficiency was confirmed by the Nursing Home Administrator and DON.
Failure to Monitor and Care Plan for New Peritoneal Catheter
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for a resident with liver cirrhosis and chronic ascites who had both a left-side thoraco-abdominal drain and a newly placed right tunneled peritoneal catheter. Upon the resident's admission and subsequent readmission, the facility did not obtain or document post-procedure care instructions for the right tunneled peritoneal catheter, as the family had taken the instructions and staff did not contact the interventional radiology department to acquire them. There were no physician orders or care plan entries specific to the care, monitoring, or drainage frequency for the new catheter, and the baseline care plan only referenced abdominal drains in general without distinguishing between the two sites. Clinical documentation, including assessments, progress notes, medication administration records, and treatment administration records, lacked any reference to the right tunneled peritoneal catheter, its care, or monitoring. The readmission assessment noted the presence of a right lower quadrant drain site covered by a surgical dressing, but did not include follow-up appointment details or specific care instructions. Additionally, a change in condition assessment inaccurately described the resident's recent hospitalization as a drain repair rather than the placement of the new catheter, and a skin evaluation prior to discharge did not acknowledge the presence of the right tunneled peritoneal catheter. Interviews with facility leadership confirmed that there was no evidence of continued monitoring, no appropriate physician orders, and no implementation of a care plan for the right tunneled peritoneal catheter. The resident was later sent to the hospital for worsening jaundice and was admitted for sepsis and a mucus plug in the bronchi. The facility's actions and omissions were not in accordance with their own policies or professional standards of nursing practice, as required by state regulations.
Lack of Clinical Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary use of psychoactive drugs by not providing clinical rationale for the continued use of PRN psychotropic medications for two residents. Resident 75, diagnosed with dementia, had a physician's order for Lorazepam 0.5 mg every eight hours as needed for anxiety, which was continued for 167 days without documented clinical rationale or re-evaluation beyond the 14-day limit. The medication was administered 25 times in March 2025, yet there was no physician documentation justifying its continued use. Similarly, Resident 77, with diagnoses including cerebral infarction and hemiplegia, had a PRN order for Ativan 0.5 mg every eight hours for anxiety, which was renewed for 90 days without documented clinical rationale or re-evaluation beyond the 14-day limit. The Ativan was administered 21 times in March 2025. The Director of Nursing confirmed the absence of necessary physician documentation to justify the continuation of these PRN psychotropic medications beyond the 14-day period, as required by regulations.
Inconsistent Provision of Snacks to Residents
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of scheduled facility mealtimes, resident committee meeting minutes, grievances filed with the facility, select facility policy, and resident and staff interviews. The facility's policy states that snacks and beverages should be provided as identified in residents' individual plans of care, with bedtime snacks offered to all residents and additional snacks available upon request. However, the time between dinner and breakfast the next day exceeds 14 hours, and grievances and meeting minutes indicate that residents have raised concerns about not receiving nighttime snacks. During a group interview, seven residents reported that they are not consistently offered a nourishing evening snack, with some residents stating that the facility does not have snacks available when requested and that staff do not always distribute them. Despite bringing this issue to staff's attention, residents expressed frustration that nothing has improved over the last few months. The Nursing Home Administrator was unable to explain why residents are not receiving the snacks as desired, confirming that it is the facility's policy to offer and serve nourishing snacks in accordance with residents' needs, preferences, and requests.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough and complete investigation of an allegation of sexual abuse involving a resident, identified as Resident 63. The resident, who was admitted with diagnoses including congestive heart failure and chronic kidney disease, reported discomfort and inappropriate conduct by Employee 1 during peri-care. The resident expressed feeling assaulted when Employee 1's fingers went into her rectum, which meets the facility's definition of sexual abuse. Despite this serious allegation, the facility did not follow its own policy or federal guidelines for investigating such claims. The facility's inaction included failing to obtain written statements from witnesses or other staff, not documenting a comprehensive nursing evaluation, and not notifying the attending physician. Additionally, the facility did not complete an incident report, secure physical evidence, or report the investigation results to the State Survey Agency within the required timeframe. Interviews with the NHA and DON confirmed the lack of evidence for a completed investigation, highlighting a significant deficiency in handling the abuse allegation.
Failure to Develop Individualized Discharge Plan
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 58, who was admitted with diagnoses including Dysarthria following a stroke. The resident was cognitively intact, as indicated by a BIMS score of 15, and expressed a desire to discharge from the facility during a psychiatry consult. However, there were no social service notes or documented evidence in the resident's comprehensive care plan regarding discharge planning. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of a current discharge goal and plan for the resident.
Oxygen Therapy Administration Deficiency
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered in accordance with professional standards of care for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The deficiency was identified when a review of the clinical records revealed that the physician's order for the resident's oxygen therapy did not specify the required oxygen flow rate per liter. The resident was observed receiving oxygen at 2.0 liters per minute via nasal cannula, but the physician's order only indicated that oxygen should be administered as needed for blood oxygen saturation levels below 88%, without specifying the flow rate. During interviews, the Director of Nursing confirmed that the physician's order lacked the necessary details regarding the oxygen flow rate, which is a requirement for administering oxygen therapy according to professional standards. The resident, who was cognitively intact, was unaware of her prescribed oxygen liter flow rate. This oversight in the physician's order and the facility's failure to ensure compliance with professional standards of care led to the deficiency being cited.
Inadequate Infection Control Program and Tracking
Penalty
Summary
The facility failed to develop and implement a comprehensive infection control program, as evidenced by the lack of specific provisions for tracking, analyzing, and responding to respiratory infections such as COVID-19, Influenza, and RSV. The infection control policy, last revised in January 2025, did not include guidelines for consistent monitoring and investigation of infections, nor did it provide for the implementation of isolation precautions for respiratory illnesses. The Infection Preventionist and Director of Nursing confirmed the absence of additional policies to address these issues. The facility's infection control tracking logs were found to be inadequate, lacking evidence of a functional method for monitoring and investigating infections. The logs did not document trends, clusters, or changes in infection rates, and there was no documentation indicating that residents with upper respiratory symptoms were tested for viral illnesses. Specifically, Resident 1, who was admitted with metabolic encephalopathy and diabetes, exhibited symptoms of an upper respiratory infection but was not tested for any respiratory virus before being transferred to the hospital, where they tested positive for RSV. Interviews with facility staff revealed that while COVID-19 testing supplies were available, testing was not routinely conducted for symptomatic residents unless indicated by the facility's COVID-19 assessment form. The facility no longer implemented isolation precautions for COVID-19, and testing for other respiratory illnesses was not part of the routine protocol. The infection control data collected was incomplete, lacking details such as resident room locations, infectious organisms, and treatments provided, and there was no documented analysis of infection trends or follow-up measures to prevent the spread of infections.
Inadequate Staffing Leads to Delayed Care and Pressure Injuries
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care and delayed responses to residents' requests for assistance. Multiple grievances and resident council meeting minutes highlighted the ongoing staffing shortages, with residents expressing concerns about the lack of timely care. Interviews with residents and their families revealed that residents often waited extended periods for assistance, leading to incidents of incontinence and frustration among residents and their families. Resident 88, who was admitted with conditions including atrial fibrillation and acute kidney failure, was particularly affected by the staffing deficiencies. Her baseline care plan required regular turning and repositioning to prevent pressure injuries, but documentation showed that these interventions were not consistently performed. As a result, Resident 88 developed an unstageable pressure ulcer, which was not present upon admission. The facility's failure to adhere to the care plan and provide adequate staffing contributed to the development of this pressure injury. Additionally, Resident 75, who required ambulation assistance as part of a Restorative Nursing Program, did not receive the prescribed care. Despite physician orders and therapy recommendations, the resident was only walked once in 29 days, indicating a lack of implementation of the care plan. The facility's staffing levels consistently fell below the state minimum requirements, further exacerbating the inability to provide necessary care to residents.
Staffing Shortages Lead to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This deficiency was identified through a review of grievances, resident group meeting minutes, and interviews with residents, families, and staff. Specific instances included a grievance from a resident who was not offered a shower due to staff shortages, and multiple residents reported long wait times for assistance, particularly on weekends. Resident 88 reported waiting 30 minutes for staff to respond to her call bell, resulting in soiling herself, and her family member expressed concerns about inadequate staffing leading to her being left in bed for extended periods, potentially contributing to a pressure injury. During interviews, Resident 298 mentioned experiencing pain and stopping the use of the call bell due to delayed responses. A group interview with alert and oriented residents revealed a consensus that the facility lacked sufficient staff to meet residents' needs promptly, leading to long waits for care. Residents 23, 30, and 64 shared experiences of waiting over an hour for assistance, with Resident 30 noting that she and her husband, both dependent on staff, faced significant delays. The Nursing Home Administrator and Director of Nursing acknowledged the need for timely responses to residents' requests for assistance, confirming the deficiency in providing dignified care.
Deficiencies in Dialysis Care and Monitoring
Penalty
Summary
The facility failed to ensure consistent communication and monitoring for two residents requiring dialysis care. The facility's policy on Coordination of Hemodialysis Services mandates communication between the facility and the dialysis center, including the use of a Dialysis Communication form to document pre and post-dialysis weights and other relevant information. However, for Residents 76 and 54, the facility did not consistently record post-dialysis weights, which are crucial for monitoring potential complications after dialysis treatments. Resident 76, diagnosed with End Stage Renal Disease (ESRD), was prescribed hemodialysis three times a week and a fluid restriction of 1,000 cc per day. The facility's records showed a lack of consistent monitoring of the resident's fluid intake from meals and medications, and the plan of care did not specify the fluid amounts provided at meals and snacks. Similarly, Resident 54, also diagnosed with ESRD and dementia, was prescribed dialysis and a fluid restriction of 1,500 cc per day. The facility failed to accurately record and monitor the fluid intake for this resident as well. Interviews with facility staff, including a Registered Nurse Supervisor and the Director of Nursing, confirmed the deficiencies in documenting fluid intakes and post-dialysis weights. The facility did not follow up with the dialysis center to ensure that post-dialysis weights were collected and recorded, leading to a lack of documented evidence that the residents' medical statuses were adequately monitored post-treatment.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident or their representative before making a room change, as required by federal regulatory guidance under S483.10(e)(6). This deficiency was identified during a review of the clinical record and interviews with the resident and staff. The resident, who was admitted with diagnoses including gastro-esophageal reflux disease, diabetes, and heart failure, experienced an incident where his roommate inappropriately touched him, making him feel uncomfortable. Although the resident did not initially report the incident, a staff member informed him that his room would be changed because the police were going to arrest his roommate. The room change occurred without providing the resident or his representative with a written explanation of the reasons for the move. Interviews with the Director of Social Services and the Nursing Home Administrator confirmed the lack of documentation and written notice regarding the room change. The facility did not comply with the requirement to inform the resident and/or their representative in writing about the room change, which is a violation of resident rights as outlined in 28 Pa Code 201.29 (a).
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for one resident. Specifically, the clinical record review revealed that a resident was transferred to the hospital on two separate occasions, December 13, 2023, and March 15, 2024, without documented evidence of communication of essential information. This information included the contact details of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, special instructions or precautions for ongoing care, and comprehensive care plan goals. During an interview, the Director of Nursing confirmed the absence of evidence that the necessary information was communicated to the receiving health care institution or provider for the resident's transfers. This lack of communication could potentially impact the safe and effective transition of care for the resident, as the receiving facility was not provided with critical information needed for the resident's ongoing care.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the status of a resident. Specifically, a review of a resident's quarterly MDS assessment indicated that the resident had a Multidrug Resistant Organism (MDRO) listed under active diagnoses. However, upon reviewing the clinical records, there was no evidence to support that the resident had an acute or colonized MDRO. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MDS entry was an error.
Failure to Revise Care Plan for Alleged Inappropriate Behavior
Penalty
Summary
The facility failed to revise a comprehensive care plan in response to an allegation of inappropriate behavior by a resident. Resident 13, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes, was involved in an incident where his roommate, Resident 49, alleged that Resident 13 touched him inappropriately while he was sleeping. Despite the social service staff and the Nursing Home Administrator discussing the incident with Resident 13, who denied the behavior and expressed feeling safe, there was no documented evidence that the care plan was reviewed or revised to address this potential behavior. The care plan for Resident 13 focused on mood problems related to depression and other personal issues, with interventions such as medication administration, activity programs, and behavioral health consults. However, it lacked any updates or revisions concerning the allegation of inappropriate touching, as noted in the Social Service Progress note. This oversight was confirmed during an interview with the Director of Nursing, indicating a failure to address and monitor the potential behavior as required by the facility's protocols.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure sore development for a resident, identified as Resident 88. The resident was admitted with conditions including atrial fibrillation and acute kidney failure, and was assessed to be at risk for pressure injuries. Despite a care plan that included turning the resident every two hours, providing incontinence care, and applying preventative skin care, documentation revealed that these interventions were not consistently implemented. The resident was found to have an unstageable pressure ulcer on the coccyx, which was not present upon admission, indicating a lapse in the care plan execution. The resident's clinical records and interviews with the resident and family members highlighted that the resident was not regularly turned or repositioned as required. The resident was dependent on staff for mobility and was often left in bed until late in the morning. The Braden Scale assessments were inconsistent with the resident's actual condition, as the resident was found to be incontinent of urine multiple times and walked only occasionally. The lack of timely response to the resident's call bell and insufficient staff to provide necessary care were also noted. The wound's progression was documented, showing initial improvement followed by fluctuations in size, indicating ongoing issues with wound management. Interviews with the Director of Nursing and Nursing Home Administrator confirmed the facility's responsibility to prevent pressure injuries, yet they could not provide evidence of adherence to the care plan. The deficiency was cited under specific state codes, highlighting failures in medical records, resident care policies, and nursing services.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to provide restorative nursing services as planned to maintain the mobility and functional abilities of Resident 75. The resident, who was admitted with diagnoses including reduced mobility, muscle wasting, muscle weakness, and unsteadiness on feet, had a physician's order dated March 22, 2024, for Restorative Nursing Program (RNP) ambulation. However, during an interview on May 28, 2024, Resident 75 reported that staff were not walking her as ordered, and she had only been walked once in the past 29 days despite informing the staff about this issue. A review of the resident's clinical records, including a Physical Therapy Discharge Summary and a Rehab Services Restorative Nursing/Functional Maintenance Referral form, indicated that the resident was to receive ambulation with a wheeled walker for up to 300 feet with contact guard assist. Despite these recommendations and a physician's order for physical therapy dated May 23, 2024, the facility's Documentation Survey Report for April and May 2024 revealed that the RNP for ambulation was not implemented. Interviews with the Director of Therapy Services and the Director of Nursing confirmed the lack of documented evidence that the prescribed RNP program was provided to Resident 75.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia, who exhibited multiple behavioral symptoms. The resident, who was admitted with diagnoses including dementia, overactive bladder, and myasthenia gravis, was noted to be severely cognitively impaired. The resident displayed various behavioral symptoms such as physical aggression towards others, verbal aggression, and other disruptive behaviors like wandering, disrobing in public, and urinating on the floor. These behaviors were documented to have a significant negative impact on the resident and potentially on other residents. Despite the resident's documented behaviors and the negative impact, the facility's care plan did not adequately address these issues. The care plan included interventions such as administering medications, anticipating needs, and providing positive interactions, but it failed to address the resident's combative behaviors, such as smacking and hitting staff. Additionally, the care plan did not include specific interventions for managing these physically combative behaviors, nor was there evidence of an interdisciplinary approach to the resident's dementia care. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the facility had not updated the resident's care plan to address the known dementia-related behaviors. There was no evidence that the facility had developed an interdisciplinary approach or ensured that staff had the necessary competencies to provide appropriate services. Furthermore, there was no indication that the facility attempted to provide meaningful activities to promote the resident's engagement and enhance their mental health and well-being.
Failure to Provide Therapeutic Social Services for Resident's Well-being
Penalty
Summary
The facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of a resident, identified as Resident 89. The resident, who was admitted with diagnoses including gastro-esophageal reflux disease (GERD), diabetes, and heart failure, experienced an incident where his roommate inappropriately touched him, making him feel uncomfortable and uneasy. Although the resident did not initially report the incident, a staff member informed him that his room would be changed due to the roommate's impending arrest. The resident's room was subsequently changed, but there was no documentation of the incident or the reasons for the room change in the clinical records. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of documentation regarding the incident and the provision of therapeutic social services to Resident 89. The Director of Social Services acknowledged that Resident 89 had expressed discomfort about his roommate's behavior, but there was no documented follow-up or evidence of counseling services provided to address the resident's mental and psychosocial needs. This lack of documentation and follow-up indicates a failure to meet the regulatory requirements for medically-related social services.
Failure to Provide Transfer Notices
Penalty
Summary
The facility failed to provide timely written notices of facility-initiated transfers to a resident and the resident's representative. Specifically, Resident 21 was transferred to a community hospital on two occasions, December 11, 2023, and March 15, 2024, without documented evidence of a notice of transfer or discharge letter being provided to the resident or her representative. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the lack of documentation for the required notices for both transfer events.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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