Mid-valley Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Peckville, Pennsylvania.
- Location
- 81 Sturges Road, Peckville, Pennsylvania 18452
- CMS Provider Number
- 395644
- Inspections on file
- 19
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Mid-valley Health Care Center during CMS and state inspections, most recent first.
The facility did not conduct or document a comprehensive assessment to ensure licensed nursing staff were trained and competent in providing care for residents with PICC lines or other central venous access devices. There was no evidence of staff training, competency evaluations, or established policies and procedures for safe PICC line management, and the DON confirmed the absence of a training program or documentation of staff competencies in this area.
Licensed nursing staff administered IV antibiotics via a PICC line to a resident with multiple infections without documented training or competency in PICC line care. The facility did not have a training program or include PICC line management in annual competency reviews, and could not provide records of staff education or compliance with state nursing regulations.
A resident with congestive heart failure, who was cognitively intact, expressed a desire to be discharged home during care plan and resident council meetings. The facility did not document follow-up or revise the discharge plan to reflect the resident's wishes, and the care plan continued to indicate a need for long-term care without individualized discharge planning or regular re-evaluation.
Surveyors identified that two residents did not have accurate or timely MDS assessments. One resident's seizure disorder was not coded on the MDS despite clinical evidence and ongoing treatment, while another resident's MDS was completed outside the required 14-day window. Staff interviews confirmed these issues, and supporting documentation was not provided.
The facility did not ensure that nursing services were provided in accordance with professional standards of quality, as identified by surveyors during their review of facility practices.
The facility did not meet the required nurse aide to resident ratios on five occasions, with understaffing noted on both day and night shifts. The night shift was consistently short by a fraction of a nurse aide for a census of 32 to 34 residents, and the day shift was short on one occasion. No additional staff were available to cover the deficiency, as confirmed by the Nursing Home Administrator.
The facility did not meet the required RN to resident ratio of 1:250 during the night shift for seven consecutive nights, with no RNs on duty despite a census of 32 to 34 residents. This staffing deficiency was confirmed by facility records and an interview with the Nursing Home Administrator.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan lacked documentation of symptoms, triggers, and specific interventions. The Director of Social Services confirmed the facility did not adhere to professional standards for culturally competent care.
A facility failed to ensure accurate administration and documentation of controlled medications for a resident. A nurse administered Percocet outside the prescribed schedule, mistakenly believing it was a PRN order, and failed to document it in the MAR. This error occurred despite the PRN order being discontinued, compromising the integrity of medication records.
A resident was administered an unnecessary antibiotic regimen due to the facility's failure to adhere to McGeer's criteria for diagnosing UTIs. Despite showing only one symptom of dysuria and a urine culture that did not meet the threshold for a UTI, the resident was prescribed Cipro. Concerns were raised by a nurse about the appropriateness of this treatment, but the CRNP continued the antibiotic citing urinary frequency and a positive urine culture.
The facility failed to meet the required nurse aide staffing ratios for several shifts, with staffing levels below the mandated minimums. This deficiency was identified through a review of nursing time schedules and resident census data, revealing that the facility did not have sufficient nurse aides to meet the regulatory requirements. The Nursing Home Administrator confirmed the facility's failure to provide the minimum nurse aide staffing ratios.
The facility failed to meet state-mandated LPN staffing requirements across multiple shifts from late November to December 2024. On several nights, no LPNs were on duty despite the census indicating the need for at least one. Additionally, the facility fell short of required LPN levels during day and evening shifts, with no higher-level staff available to compensate. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not consistently provide the required minimum of 3.2 hours of direct nursing care per resident daily. On a specific date, the facility only provided 2.92 hours per resident, as confirmed by the NHA.
The facility failed to prevent and manage pressure ulcers for three residents. One resident developed a deep tissue injury that evolved into an unstageable pressure ulcer due to lack of care plan and interventions. Another resident, at risk due to decreased mobility, developed a Stage 3 pressure wound without adequate preventative measures. A third resident's heel blister deteriorated into a Stage 3 ulcer without timely assessment or notification to physicians.
A resident with multiple diagnoses, including anxiety, was prescribed a reduced dose of Lorazepam. However, the facility failed to administer the correct AM dose due to a lack of updates on the narcotic sheet and medication card, and the pharmacy not sending the correct medication card due to insurance issues. The error was identified by an LPN, and no adverse reactions were reported.
A resident with multiple health conditions did not receive the correct morning dosage of Lorazepam due to a pharmacy delay in delivering the medication card, despite the script being received on time. The facility failed to ensure timely medication administration, resulting in a medication error.
A facility failed to create an individualized care plan for a resident with PTSD, neglecting to identify symptoms, triggers, and specific interventions to prevent re-traumatization. The DON confirmed the lack of culturally competent, trauma-informed care according to professional standards.
A resident with dementia and anxiety was prescribed Macrobid as a prophylactic treatment for a UTI without documented clinical necessity. Despite receiving 25 doses, there was no repeated urinalysis or culture and sensitivity tests to justify the continued use of the antibiotic. The facility's infection prevention protocol was not followed due to the attending physician's insistence.
Failure to Ensure Staff Competency and Policies for PICC Line Care
Penalty
Summary
The facility failed to conduct and document a comprehensive, evidence-based facility assessment to ensure that licensed nursing staff possessed the required training and competencies necessary to provide care for residents with intravenous (IV) therapy through peripherally inserted central catheters (PICCs) or other central venous access devices. The facility assessment identified that specialized services for residents with PICC lines were provided, including IV medication administration and routine PICC line care. However, there was no documented evidence that licensed nursing staff received initial or ongoing training or competency evaluations in accessing and administering medications through central venous access devices, as required by professional standards and the facility's own assessment. Additionally, the facility lacked documented policies or procedures to guide licensed nursing staff in the safe care and management of central venous access devices, including medication administration, dressing changes, or infection prevention measures. The DON confirmed that there was no contract with advanced PICC services, no established training program for PICC line care, and no documentation of staff competencies specific to PICC line management. As a result, the facility could not demonstrate that its licensed nursing staff had the knowledge and skills necessary to provide safe care consistent with regulatory requirements and professional standards of practice.
Failure to Provide PICC Line Training and Competency for Licensed Nursing Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff regarding the care of residents with peripherally inserted central catheters (PICC). Specifically, two LPNs administered intravenous antibiotics through a PICC line to a resident diagnosed with sepsis, bacteremia, pseudomonas aeruginosa infection, and cellulitis, without documented evidence of having received mandatory education or competency assessment for PICC line management. Review of personnel files for both LPNs showed no records of PICC line training prior to their provision of care, and the facility's annual competency reviews did not include PICC line care. The Director of Nursing was unable to provide any training or competency records for staff who provided PICC line care during the survey period. Interviews with the Director of Nursing and Nursing Home Administrator confirmed that the facility had not developed or implemented a training program for PICC line care and had not included this topic in annual competency reviews, despite the requirements outlined in the facility assessment and state regulations. The facility also failed to use its facility assessment to determine the need for such training and did not ensure that staff possessed the necessary skills and competencies before providing care to residents with PICC lines. No documentation was provided to demonstrate compliance with state nursing regulations regarding intravenous therapy education and competency for licensed staff.
Failure to Update Discharge Plan Based on Resident's Stated Preferences
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with a resident's goals and preferences. According to the facility's own Discharge Planning Policy, discharge needs should be identified and a plan developed for each resident, with regular re-evaluation to update the plan as needed. In the case reviewed, a resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, expressed a desire to be discharged home during both a care plan meeting and a resident council meeting. Despite these clear statements of intent, there was no documented follow-up or revision of the resident's discharge plan to reflect her current wishes. Clinical record review showed that the last nursing progress note regarding the resident's discharge plans and goals was several months prior, and the comprehensive care plan had not been updated to address the resident's expressed desire for discharge. The care plan continued to indicate a need for long-term care without evidence of individualized discharge planning or regular re-evaluation as required by policy. The Nursing Home Administrator confirmed the absence of a current discharge goal and plan for the resident, indicating a failure to update the discharge plan in response to the resident's stated preferences.
Inaccurate and Untimely MDS Assessments Identified
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents, as required by the Resident Assessment Instrument (RAI) Manual. For one resident with a history of Type 2 diabetes mellitus, diabetic neuropathy, major depressive disorder, and seizure disorder, the clinical records, medication administration records, and care plans all indicated an active diagnosis of seizure disorder and ongoing treatment with Divalproex. However, the quarterly MDS assessment did not reflect the seizure disorder as a current diagnosis, despite multiple sources confirming its presence and treatment. For another resident with nonrheumatic aortic stenosis and cellulitis of the left lower limb, the quarterly MDS assessment was not completed within the required 14-day timeframe following the assessment reference date. The MDS was finalized 15 days after the reference date, exceeding the regulatory limit. Interviews with facility staff confirmed these deficiencies, and the facility was unable to provide documentation to support the accuracy of the MDS coding for these residents.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines and expectations for quality in nursing services. No additional details regarding specific residents, staff actions, or particular incidents are provided in the report excerpt.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five occasions out of 21 shifts reviewed. Specifically, on January 20, 21, 22, and 23, 2025, the night shift was understaffed with only 2 nurse aides present, whereas the required number was slightly higher based on the census of 32 to 34 residents. Additionally, on January 25, 2025, the day shift was also understaffed with 3 nurse aides instead of the required 3.20 for a census of 32. There were no additional higher-level staff available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on January 27, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. We are continuing to use available resources provided including Indeed, Appolli, signing contracts with nursing agencies as needed. We are attending job fairs in the area. Wages remain competitive in the industry. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet RN Staffing Requirements
Penalty
Summary
The facility failed to meet the required Registered Nurse (RN) to resident ratio of 1 RN per 250 residents during the night shift for seven consecutive nights. Specifically, from January 20 to January 26, 2025, the facility did not have any RNs on duty during the night shift, despite having a census ranging from 32 to 34 residents, which necessitated at least one RN per shift. The absence of RNs on these nights was confirmed by a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for this deficiency, leading to non-compliance with the staffing regulation effective July 1, 2023.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Registered Nurses hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Registered Nurse ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Registered Nurses for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
Mid Valley Health Care Center failed to develop and implement an individualized, person-centered plan of care to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The deficiency was identified during a revisit survey conducted on January 2, 2025, which revealed that the facility did not address the resident's PTSD diagnosis in their care plan. Specifically, the care plan lacked documentation of symptoms or identified triggers related to PTSD and did not include resident-specific interventions aimed at minimizing triggers and preventing re-traumatization. An interview with the Director of Social Services confirmed that the facility did not provide culturally competent, trauma-informed care in accordance with professional standards of practice. The facility failed to consider the resident's experiences and preferences to mitigate triggers and promote emotional safety, as required by 42 CFR Part 483 Subpart B and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
Plan Of Correction
Step 1 Resident #2 was reevaluated by in-house Psych provider to accurately assess appropriateness of PTSD Diagnosis. In-house Psych Provider has provided a more appropriate diagnosis for Resident, plan of care has been updated to include same. Step 2 To identify others with the likelihood to be affected, all Residents identified with a current PTSD diagnosis were evaluated for appropriateness of diagnosis by in-house Psych provider. The DON/designee will audit care plans to ensure that the cause of trauma and triggers are identified with personalized interventions implemented to manage same or have diagnosis removed and plan of care updated if PTSD diagnosis was found to be inaccurate. Step 3 To prevent a future reoccurrence, DON/designee will educate the Interdisciplinary Team that Residents identified to have a PTSD diagnosis will have their plan of care updated with the cause of trauma and potential triggers, with personalized interventions implemented. To prevent a future reoccurrence, the DON/designee will educate the Interdisciplinary Team that if a PTSD diagnosis is identified with no known trauma or triggers identified, the in-house Psych Provider will be consulted to evaluate the appropriateness of the diagnosis, providing documentation to support or refute PTSD diagnosis. Step 4 To monitor and maintain ongoing compliance the Social Worker/designee will audit all new admissions or any Resident obtaining a new diagnosis of PTSD to ensure accuracy of the diagnosis and their plan of care contains the identified trauma and potential triggers with personalized interventions implemented to manage PTSD weekly x 4 and then monthly x 2. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Failure in Controlled Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate accounting and administration of controlled medications for a resident, leading to a deficiency in pharmacy services. A review of the clinical records and controlled drug records revealed that a resident, admitted with cervical spondylosis, history of falls, and transient ischemic attacks, had a physician's order for Percocet 5-325 mg, ½ tablet by mouth once daily at bedtime. However, on December 25, 2024, a registered nurse signed out a dose of Percocet for the resident at 4:00 AM but failed to document the administration in the medication administration record (MAR) as required. Further investigation showed that the nurse administered the medication outside the prescribed bedtime schedule, mistakenly believing it was a PRN order, despite the PRN order being discontinued earlier in the month. This error was documented in a safety event report, and it was confirmed that the nurse did not recognize the discontinuation of the PRN order, leading to the medication error. The facility's failure to adhere to procedures and protocols for the accurate administration and documentation of controlled substances compromised the integrity of the controlled medication records.
Plan Of Correction
Step 1 Resident #1 had a head-to-toe assessment completed upon discovery of medication error, no adverse effects were identified, and MD/RP notification was completed. Step 2 To identify other Residents with the likelihood to be affected, the DON/Designee will audit Declining Count Narcotic logs of all controlled substances for the past 14 days to ensure all medications were administered and documented in the Emar logs as per physician orders. Any medication found to be administered in error will have a Medication Error event report completed with proper MD/RP notification. Step 3 To prevent a future recurrence, the DON/Designee will educate all licensed nurses on the 5 Rights of medication administration, including the proper procedure to follow if a change in direction sticker is present on a medication card or narcotic log. Step 4 To monitor and maintain ongoing compliance, the DON/Designee will complete a Medication Pass competency on 5 Random licensed nurses weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the NHA/Designee will interview 3 Random licensed nurses on proper procedure to follow during medication pass, if a change in direction sticker is present on a medication card or narcotic log, weekly x 4 and then monthly x 2. To monitor and maintain ongoing compliance, the DON/Designee will audit all Declining Count Narcotic logs to ensure the medication was documented in the Emar and on the log as per physician orders, 3x/week x 4 weeks, and then weekly x 8 weeks. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Unnecessary Antibiotic Administration Due to Non-Adherence to Criteria
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically antibiotics. Resident #3 was admitted with diagnoses including dementia, dysphagia, and a history of urinary tract infections (UTIs). Despite these conditions, the resident did not exhibit sufficient symptoms to meet the criteria for initiating antibiotic therapy according to McGeer's criteria, which the facility uses to guide treatment decisions for suspected UTIs. The clinical record review revealed that Resident #3 only showed one symptom of dysuria and no additional systemic urinary symptoms. A subsequent evaluation by a certified registered nurse practitioner (CRNP) noted urinary frequency but no other UTI symptoms such as burning, hematuria, fever, or mental status changes. A urine culture showed 50,000-100,000 CFU/mL of Escherichia coli, which did not meet the threshold for diagnosing a UTI. Despite this, the CRNP ordered Cipro, an antibiotic, for five days, which was administered to the resident. The decision to prescribe and administer Cipro was made despite the absence of sufficient clinical indicators for a UTI, as documented in the resident's clinical record. Employee #3, a registered nurse and former Director of Nursing, expressed concerns about the appropriateness of the antibiotic therapy and emphasized the importance of adhering to McGeer's criteria and the facility's antibiotic stewardship program. However, the CRNP confirmed the decision to continue the antibiotic treatment, citing the resident's urinary frequency and positive urine culture as justification, leading to the administration of an unnecessary antibiotic regimen.
Plan Of Correction
Step 1 Resident #3 completed antibiotic course for UTI, appearing to suffer no ill effects prior to survey. Step 2 To identify others with the likelihood to be affected, the DON/designee will complete an audit of the Residents currently ordered antibiotic treatment to ensure McGeer's criteria was followed. Any Residents identified to not meet McGeer's criteria will have documentation evaluated to ensure justification from the Clinician addresses specific reasoning for continued use of antibiotic therapy. Step 3 To prevent a future reoccurrence, the DON/designee will educate all licensed nurses in the facility and Clinicians on McGeer's criteria, to ensure antibiotic initiations meet McGeer's criteria. If the order does not meet McGeer's criteria, the Clinician will be notified, and proper justification will be provided from the Clinician indicating specific reasoning for the same. Step 4 To monitor and maintain ongoing compliance, the DON/designee will audit all new antibiotic initiations to ensure new orders meet McGeer's criteria. If the order does not meet McGeer's criteria, a justification statement will be provided from the Clinician regarding the specific reasoning for continued use of the antibiotic therapy, 3x/week x 4 weeks and then weekly x 8. Results of audits will be forwarded to Facility QAPI committee for further review and provide any necessary recommendations as needed.
Staffing Deficiency in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios for several shifts between November 24, 2024, and December 31, 2024. The regulation mandates a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. However, the facility did not comply with these requirements for thirteen shifts out of the 42 shifts reviewed. This deficiency was identified through a review of nursing time schedules, resident census data, and staff interviews. On multiple occasions, the facility's staffing levels were below the required minimums. For instance, on November 24, 2024, with a census of 36 residents, only 3.0 nurse aides were available during the evening shift, whereas 3.6 were required. Similarly, on November 25, 2024, with a census of 35 residents, only 3.0 nurse aides were present during the evening shift, falling short of the 3.5 required. These staffing shortages were consistent across various shifts, including day, evening, and night shifts, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the minimum nurse aide staffing ratios during an interview on January 2, 2025. The report highlights that the facility did not have sufficient nurse aides to meet the regulatory requirements, and no excess higher-level staff were available to address the shortfall. This lack of adequate staffing was a recurring issue across the reviewed period, affecting the facility's ability to provide the required level of care to its residents.
Plan Of Correction
PA 5520 Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Facility Fails to Meet LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the state-mandated minimum staffing requirements for Licensed Practical Nurses (LPNs) across multiple shifts. Specifically, the facility did not provide the required number of LPNs during the day, evening, and night shifts on several occasions between November 24, 2024, and December 31, 2024. The deficiency was identified through a review of nursing time schedules and staff interviews, which revealed that the facility consistently fell short of the required LPN staffing levels. On several nights, the facility had no LPNs on duty, despite the census data indicating the need for at least one LPN. For instance, on November 24, 2024, the facility census was 36, necessitating 1.0 LPNs on the night shift, yet only 0.5 LPNs were present. Similarly, on November 25 and 26, 2024, the facility census required 1.0 LPNs, but no LPNs were on duty. This pattern of insufficient staffing continued on multiple nights, with no additional higher-level staff available to compensate for the deficiency. The deficiency was further compounded by inadequate staffing during the day and evening shifts. On several occasions, the number of LPNs on duty was below the required level based on the facility census. For example, on November 29, 2024, the day shift required 1.32 LPNs, but only 1.00 LPN was present. The facility's failure to meet the staffing requirements was confirmed by the Nursing Home Administrator during an interview on January 2, 2025.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits 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 consistently provide the minimum required general nursing care hours to each resident daily. A review of the facility's staffing levels revealed that on December 31, 2024, the facility provided only 2.92 direct care nursing hours per resident, which is below the mandated minimum of 3.2 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 2, 2025, at 11:00 AM, who acknowledged the failure to meet the required staffing levels.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of general nursing care hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated general nursing hours of 3.20 hours of general nursing care to each resident. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of direct care nursing hours per resident. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum of 3.20 hours needed for the facility. Audits will be completed 3x/week weekly x 4 and then monthly x 2. The results of the audits will be forwarded to the facility QAPI committee for further review and.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent pressure ulcer development for three residents. Resident 89, who was admitted with multiple diagnoses including chronic foot drop and cellulitis, did not receive the necessary interventions to prevent pressure ulcers despite being at moderate risk. The facility did not implement hospital discharge orders for compression and elevation of the resident's surgically repaired limb, and there was no care plan addressing the risk of pressure ulcers. Consequently, Resident 89 developed a deep tissue injury on the left heel, which evolved into an unstageable pressure ulcer. Resident 18, who was at risk for pressure ulcer development due to decreased mobility and weakness, did not have a turning/repositioning program in place. Despite being on hospice care and dependent on staff for all activities of daily living, the facility failed to provide documented evidence of preventative measures to avoid pressure ulcer development. As a result, Resident 18 developed a Stage 3 pressure wound on the left inner buttock, indicating a lack of adequate interventions to prevent skin breakdown. Resident 8, admitted with conditions including dementia and diabetes, was not thoroughly assessed upon admission, and preventative measures were not timely implemented. The resident's right heel blister deteriorated into a Stage 3 pressure ulcer without timely notification to the attending physician or podiatrist. The facility did not document applied treatments or interventions, and the resident's clinical record lacked evidence of effective preventative measures to deter the blister from worsening.
Medication Administration Error Due to Inaccurate Dose
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication to a resident. The resident, who was admitted with diagnoses including symbolic dysfunction, chronic atrial fibrillation, arthritis, and protein-calorie malnutrition, was prescribed Lorazepam for anxiety. A consultant pharmacist recommended a gradual dose reduction of Lorazepam, which the physician agreed to with modifications. The physician's order specified a reduction to 0.25 mg for the AM dose while maintaining 0.5 mg for the PM dose. Despite the physician's order, the resident continued to receive 0.5 mg of Lorazepam in the AM instead of the prescribed 0.25 mg. This discrepancy was due to a failure to update the narcotic sheet and medication card to reflect the new order. The pharmacy received the script for the reduced dose but did not send the 0.25 mg medication card due to insurance reasons. This error was identified by an LPN working the medication cart, and it was noted that the error had been ongoing since the physician's order was issued. The Director of Nursing confirmed that the nursing staff did not follow acceptable standards of nursing practice during medication administration, resulting in a medication error. The facility's Event Report classified the incident as a Medication Error Review, identifying the error as an incorrect dose, incorrect label, and medication not available. No adverse drug reactions were reported for the resident as a result of this error.
Medication Administration Error Due to Pharmacy Delay
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of medications for a resident, identified as Resident 18. The resident was admitted with multiple diagnoses, including symbolic dysfunction, chronic atrial fibrillation, arthritis, and protein-calorie malnutrition. A physician's order dated June 7, 2024, prescribed Lorazepam to be administered at 0.25 mg in the morning and 0.5 mg in the evening. However, a review of the clinical records and pharmacy documentation revealed that the resident continued to receive 0.5 mg of Lorazepam in the morning instead of the prescribed 0.25 mg from September 8, 2024, through September 23, 2024. This discrepancy was due to the pharmacy not sending the correct medication card because of insurance reasons, despite having received the script on time. The facility's documentation, including a nurse's note and an event report, classified this as a medication error. There was no documented evidence that the pharmacy communicated the receipt of the new physician order or when the correct dosage would be delivered. Interviews with the Nursing Home Administrator confirmed the facility's failure to ensure the timely acquisition and administration of medications as ordered to meet the residents' needs. This deficiency was noted under the relevant state codes for pharmacy and nursing services, as well as medical records.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident was admitted with PTSD, a condition characterized by symptoms such as flashbacks, nightmares, severe anxiety, and uncontrollable thoughts related to a traumatic event. Upon review, it was found that the resident's care plan did not identify specific PTSD symptoms or triggers, nor did it include resident-specific interventions to minimize these triggers and prevent re-traumatization. An interview with the Director of Nursing confirmed that the facility could not demonstrate the provision of culturally competent, trauma-informed care in line with professional standards, which should account for the resident's experiences and preferences to mitigate potential triggers.
Unnecessary Antibiotic Use for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. Resident 8, who was admitted with diagnoses including dementia with behavior disturbances, congestive heart failure, and anxiety, was prescribed Macrobid as a prophylactic treatment for a urinary tract infection. Despite the absence of documented clinical necessity, the resident received 25 doses of the antibiotic. The attending physician ordered the medication based on the resident's ongoing behaviors, such as constant calling out and nervousness, without repeated urinalysis or culture and sensitivity tests to justify the continued use of the antibiotic. The Assistant Director of Nursing/Infection Preventionist reported that the facility's infection prevention program requires an assessment using McGreer's Criteria to determine the necessity of antibiotic therapy. However, this protocol was not followed for Resident 8 due to the attending physician's insistence on continuing the antibiotic treatment. The Director of Nursing confirmed the failure to ensure the resident's medication regimen was free from unnecessary medication, as the criteria for prophylactic antibiotic use were not met.
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.
Trusted data from CMS and state health departments
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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