Mulberry Healthcare And Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Punxsutawney, Pennsylvania.
- Location
- 411 1/2 W Mahoning Street, Punxsutawney, Pennsylvania 15767
- CMS Provider Number
- 395618
- Inspections on file
- 35
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Mulberry Healthcare And Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with cognitive impairment and a left heel pressure ulcer did not receive timely wound care orders upon readmission, and there was no documentation that prescribed wound treatments were completed on two occasions. The DON confirmed the lack of documentation for both obtaining orders and completing treatments as required.
A resident with dementia received PRN hydroxyzine for anxiety on multiple occasions without documented practitioner rationale for extending the order beyond 14 days or specifying its duration, and without evidence that non-pharmacological interventions were attempted prior to administration, as required by facility policy.
A resident who was cognitively impaired and dependent on staff for eating was observed during a meal in a reclined position, with her chair not close enough to the table, making it difficult for her to reach her food. Facility policy required residents to be upright and close to the table during meals, but this was not followed, as confirmed by the DON.
A resident with cognitive impairment and cerebral palsy, who required a wheelchair with leg rests per care plan, was transported without the leg rests attached. During transport, the resident's foot became caught under the wheelchair, resulting in a fall. Staff and facility investigation confirmed that the required assistance device was not used.
A resident with cognitive impairment and mobility needs was provided with bilateral bed enabler bars without a documented assessment for potential safety hazards or entrapment risk prior to installation. The DON confirmed that a required safety assessment was not completed.
Dietary staff served lunch trays containing turkey and vegetables that were found to be cold and not palatable during a meal service. A test tray confirmed that both food items were below appropriate serving temperatures, and the Dietary Manager acknowledged the issue.
Surveyors found that expired grape juice was used for a meal, spills in the cooler were not cleaned, and hamburger patties were left uncovered in the freezer. Dietary staff confirmed these issues and stated that short staffing contributed to the lapses.
The QAPI committee failed to correct and sustain improvements in areas such as safety/accidents, palatable food, food procurement and storage, and infection control, resulting in repeated deficiencies despite previous plans of correction and ongoing monitoring efforts.
A nurse aide did not wear a gown while providing continence care to a resident with a documented MDRO urinary infection, despite facility policy requiring contact precautions for such cases. Both the aide and the DON confirmed that proper PPE should have been used during care.
A review of staffing schedules, census data, and staff interviews revealed that the facility did not meet the required minimum nurse aide-to-resident ratios for day, evening, and night shifts on most days reviewed, with no additional higher-level staff available to compensate for the shortfall.
The facility did not meet required LPN-to-resident staffing ratios on multiple day, evening, and overnight shifts, as shown by a review of nursing schedules and census data. On several occasions, the number of LPNs scheduled was below the mandated minimums, and no additional higher-level staff were available to compensate for these deficiencies. The administrator confirmed the staffing shortfalls during the review period.
The facility did not provide the required minimum of 3.2 hours of direct resident care per resident per day on multiple days, as confirmed by nursing schedules and administrator interview.
Mulberry Healthcare and Rehabilitation Center failed to document the administration of controlled medications for two residents. One resident, who was cognitively intact, had a signed-out dose of Oxycodone-Acetaminophen with no evidence of administration. Another resident, who was cognitively impaired, also had a signed-out dose of Oxycodone with no documentation of administration. The DON confirmed the lack of documentation.
The facility failed to maintain its sprinkler system, lacking spare sprinklers after a failure and using a temporary fix. A replaced sprinkler head was improperly positioned, and there was no documentation for testing older sprinklers. These issues were confirmed by the maintenance director.
The facility failed to maintain smoke barrier requirements in the North Terrace corridor due to a sprinkler head frame failure. This caused air pressure release in the dry sprinkler system, leading to water flow and ceiling collapse, creating a 32" x 48" opening in the smoke barrier. This opening could allow smoke transfer and delay activation of fire safety systems. The maintenance director confirmed the deficiency.
The facility failed to maintain electrical system requirements in one wing, as observed in the North Terrace corridor. Two unsupported junction boxes with missing covers and exposed wiring were found hanging due to ceiling damage from a sprinkler failure. This deficiency was confirmed by the maintenance director.
The facility failed to meet the required NA-to-resident staffing ratios on several occasions, with insufficient NAs available during day, evening, and night shifts. The Director of Nursing confirmed the shortfall, and no additional higher-level staff were available to compensate for these deficiencies.
The facility did not meet the required LPN-to-resident staffing ratios during the night shift on three occasions. On these nights, the number of LPNs present was insufficient to meet the needs of the resident census, as confirmed by the Director of Nursing. No additional higher-level staff were available to address the shortfall.
The facility failed to protect two residents from abuse and neglect. One resident with cerebral palsy fell and was injured when a nurse aide attempted a transfer alone, against the care plan. Another resident with dementia was accidentally hit in the face by a nurse aide during a combative episode. Both incidents demonstrate non-compliance with care plans and inadequate management of resident behavior.
The facility failed to maintain a safe environment by using a mechanical lift missing essential safety latches, risking resident safety during transfers. Additionally, a resident at risk of falls did not have the required fall mats in place, as per their care plan. Staff were unaware of these deficiencies, leading to unsafe conditions.
The facility failed to serve food at appetizing temperatures, as observed during a lunch meal service. The test tray revealed that the coffee, meatballs, pasta, and green beans were below the required temperatures, making them lukewarm and not palatable. The Dietary Manager and Nursing Home Administrator confirmed the inadequacy of the food temperatures.
The facility failed to maintain sanitary conditions in food storage and preparation areas. Observations revealed unsealed and unlabeled food items, expired bread, and a dirty ice machine. Dishes were stored on a dusty shelf with debris, and the Dietary Manager's hair net did not fully cover her hair. Interviews confirmed these deficiencies and the lack of processes to ensure safe food handling.
A facility failed to assess a resident's ability to self-administer medications safely, as required by their policy. An LPN left Lactulose Encephalopathy Oral Solution with the resident without observing its administration, and the Nursing Home Administrator confirmed the absence of an assessment for the resident's self-administration capability.
The facility failed to maintain a safe and homelike environment due to the poor condition of wheelchairs used by three residents. Observations showed that the vinyl material on the armrests was torn and cracked. The Maintenance Director confirmed the need for replacement, highlighting a breach in the facility's policy and resident rights.
The facility failed to provide timely written notification to the state ombudsman, residents, and their responsible parties regarding the reasons for hospital transfers for five residents. This deficiency was confirmed through clinical record reviews and staff interviews, revealing a lack of documentation for transfers due to conditions like kidney failure, a change in condition, and unresponsiveness.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives during hospital transfers for five residents. This deficiency was confirmed by the DON and involved residents with various medical conditions, including kidney failure and unresponsiveness.
The facility failed to accurately complete MDS assessments for five residents, leading to incorrect documentation of medication administration. Errors included unrecorded injections and daily medications such as antiplatelets and antibiotics, as confirmed by the RN Assessment Coordinator.
A facility failed to provide a resident with scheduled showers, as the resident only received a bed bath and a single shower over two months, despite preferring to shower twice weekly. The resident was cognitively intact and required moderate assistance. Interviews confirmed the lack of documentation for the scheduled showers.
The facility failed to follow physician's orders for three residents, leading to deficiencies in medication and care administration. A resident with gastro-esophageal reflux disease received medication after meals instead of before, contrary to orders. Another resident with Alzheimer's and weight loss had inconsistent documentation of nutritional supplement administration, making it unclear if the correct amount was given. A third resident with dementia did not receive prescribed Permethrin cream, and insulin was administered after meals instead of before, as ordered.
The facility failed to document the administration of controlled medications for three residents, despite the medications being signed out. A cognitively impaired resident, a hospice care resident, and a resident with heart failure had instances where Oxycodone and Lorazepam were signed out without corresponding documentation. Interviews with the DON confirmed the lack of documentation, violating facility policy and state regulations.
The facility failed to ensure that pharmacy recommendations for drug irregularities were acted upon by a physician for two residents with Alzheimer's disease. Despite the pharmacist completing Medication Record Reviews with recommended changes, there was no documented evidence of physician review from April to October 2024. The Director of Nursing confirmed the physician's lack of response, violating facility policy and state regulations.
A facility failed to maintain a medication administration error rate below five percent, with two errors identified. An LPN administered Sucralfate to a resident after breakfast instead of before, and Humalog Insulin Lispro was given to another resident post-meal instead of pre-meal, as per physician orders.
The facility failed to properly label and store medications, as a vial of Aplisol was found without a date of opening, and Zofran tablets lacked resident information. A nurse confirmed the labeling omissions, and the nursing home administrator acknowledged the failure to adhere to labeling standards.
The NHA and DON failed to ensure mechanical lifts were equipped with necessary hanger bar latches, compromising the safety of a resident. This oversight violated state regulations and highlighted a deficiency in maintaining a safe environment as per their job responsibilities.
A resident with a feeding tube and pressure ulcers had a Penrose drain inserted post-surgery, which was not to be emptied according to the physician's order. However, staff documented that they emptied the drain, contrary to the surgical note. The DON confirmed the drain should not have been emptied.
The facility's QAPI committee failed to address recurring deficiencies in areas such as MDS assessments, quality of care, and infection control, despite having plans of correction. The committee's ineffectiveness resulted in repeated citations across multiple areas, indicating insufficient compliance with nursing home regulations.
An LPN breached infection control protocols by retrieving a dropped pill with bare hands and taping it for future use, contrary to the facility's medication administration policy. The incident involved a resident who required assistance for daily care needs.
The facility failed to follow the optometrist's recommendations for follow-up appointments for five residents, including those with diabetic eye exams and glaucoma evaluations. There was no documented evidence that these follow-up appointments were completed or that the primary care physician disagreed with the optometrist's plan of care.
Failure to Provide Timely and Documented Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention treatments as ordered for one resident. Upon readmission from the hospital, the resident, who was cognitively impaired and required staff assistance for daily care, had an unstageable pressure ulcer on the left heel. There was no documented evidence that the facility obtained a physician's order for wound treatment until two days after readmission, when the resident was seen by a wound consultant. Additionally, after a treatment order was obtained, there was no documented evidence that the prescribed wound care was completed on two specific dates. The Director of Nursing confirmed the absence of documentation for both the timely acquisition of treatment orders upon readmission and the completion of wound care as ordered on the identified dates.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to facility policy, as needed (PRN) psychotropic medications should only be administered when necessary to treat a specific, documented condition, and any PRN order for such medications extending beyond 14 days requires a documented rationale from the practitioner, including the duration of the order. For a resident with cognitive impairment and a diagnosis of dementia, there was an active PRN order for hydroxyzine to be given every four hours as needed for anxiety. The medication was administered on several occasions over a period exceeding 14 days, but there was no evidence in the clinical record that a practitioner documented a rationale for extending the PRN order or specified the duration of its use. Additionally, the facility did not document that non-pharmacological interventions were attempted prior to administering hydroxyzine on multiple occasions, as required by policy. Interviews with the Director of Nursing confirmed the absence of documentation for both the rationale for extending the PRN order and the use of non-pharmacological interventions before administering the medication. These findings indicate non-compliance with facility policy and regulatory requirements regarding the use of psychotropic medications.
Resident Not Properly Positioned During Meal
Penalty
Summary
A deficiency was identified when a resident, who was cognitively impaired and dependent on two staff members for daily care needs including eating, was not positioned appropriately during a meal. The facility's policy required residents to be as upright as possible with the head tipped slightly forward while eating. However, the resident was observed sitting in a specialized chair with the rear end tilted back, causing her upper torso and head to be reclined. The chair was also not positioned close enough to the table, making it difficult for the resident to reach her plate. The resident attempted to pull herself closer to the table but was unable to do so. The resident's care plan indicated a need for supervision to limited assistance with meals, but these needs were not met during the observed meal. The DON confirmed that the chair should have been upright and closer to the table to allow the resident to reach her food. This failure to follow the facility's policy and the resident's care plan resulted in the resident not being properly positioned for eating.
Plan Of Correction
Resident R36 was repositioned immediately at the time of the survey. The meal was checked for appropriate temperature and the resident was assisted to complete her meal. Occupational Therapy also evaluated resident R36 to ensure she had the most appropriate chair and made any recommendations for best possible positioning during meals. Education was provided to staff regarding proper positioning during meals. The Director of Nursing or designee will complete audits daily x 5 days at random meals to ensure proper positioning of residents in the dining room x2 weeks, then weekly x 4 weeks, then monthly x 2 months with results to Quality Assurance.
Failure to Use Wheelchair Leg Rests During Resident Transport
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and a diagnosis of cerebral palsy, who required assistance for daily care and used a specialized wheelchair with leg rests per care plan, was transported without the required leg rests. Facility policy states that wheelchair footrests are necessary to support the legs and prevent feet from getting caught under the wheelchair, which could result in a fall. Despite this, a nurse aide pushed the resident in the wheelchair to the dining room without the leg rests attached. During the transport, the resident's foot became caught under the wheelchair, causing the resident to fall out of the chair onto his hands and knees. Staff interviews and facility investigation confirmed that the leg rests were not used as required by the resident's care plan, and the Director of Nursing acknowledged that footrests should have been in place during transportation.
Plan Of Correction
Resident R50 was not injured at the time of the incident. Nurse aide 2 was suspended at the time of the incident as part of the facility's self-reported investigation for failure to follow facility policy. All staff were re-educated on the facility policy regarding use of leg rests while in a wheelchair. The Director of Nursing or designee will complete daily random observation audits of residents being transported in their wheelchairs to ensure safe practice. Audits will be completed daily x5 for 2 weeks, then weekly x4, then monthly x2, with results to Quality Assurance.
Failure to Assess Bed Rail Entrapment Risk Prior to Installation
Penalty
Summary
A deficiency was identified when a resident, who was cognitively impaired and required staff assistance for daily care needs, was provided with bilateral bed enabler bars as per physician's orders. The resident's clinical records and observations confirmed the presence of these enabler bars on the bed. However, there was no documented evidence that an assessment for potential safety hazards or risk of entrapment from the bed rails was completed prior to their installation. This was confirmed during an interview with the Director of Nursing, who acknowledged that a bed rail/enabler safety assessment had not been performed for the resident.
Plan Of Correction
Resident R36 was evaluated by the Occupational Therapist to ensure that bilateral bed-enabler bars were the most appropriate. An "In bed positioning/siderail evaluation" was completed on resident R36. The Director of Nursing or designee is completing a review of all residents currently utilizing enabler bars to ensure that an up-to-date assessment is complete. Nursing staff will be provided education on the process for utilization of enabler bars on resident beds and proper completion of quarterly assessments. The Director of Nursing or designee will complete audits for completion weekly x4, then biweekly x4, then monthly x2, with results to the Quality Assurance Committee.
Unpalatable and Cold Food Served During Meal Service
Penalty
Summary
During a lunch meal service, dietary staff prepared and delivered food trays to the north hall. The process began at 11:41 a.m. with the preparation of the meal cart, which was completed and left the kitchen at 11:58 a.m., arriving on the north hall at 11:59 a.m. Trays were distributed to residents starting at 12:00 p.m. and completed by 12:05 p.m. A test tray was evaluated at 12:16 p.m., revealing that the turkey was 120.4 degrees Fahrenheit and the capri blend vegetables were 120 degrees Fahrenheit. Both items were found to be cold and not palatable. The Dietary Manager confirmed during an interview that the turkey and vegetables were cold and not palatable.
Plan Of Correction
The hot plate warmer was turned up to ensure sufficient heating of the plates during meal service. All staff were re-educated on proper temperatures during meal service. The Dietary Manager will audit food temperatures at the end of meal service for random meals daily x5 for 2 weeks, then 3 times per week for 2 weeks, then weekly x4 with results to Quality Assurance. Any food temperatures found to be outside of range or unpalatable will be replaced for an alternative preferred item. F 0804
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation within the facility's main kitchen. Specifically, a crate of grape juice cartons that had expired was found and had been used for the breakfast meal. Additionally, there were spills of milk and an unidentified substance on the cooler floor that had not been cleaned up. A tray of hamburger patties was also found open and exposed to air in the freezer, rather than being properly covered and sealed. Interviews with dietary staff confirmed these deficiencies. A dietary aide acknowledged that the expired grape juice should have been discarded, the spills should have been cleaned, and the hamburger patties should have been covered. The Dietary Manager also confirmed these findings, noting that the expired juice should have been thrown out, spills should have been addressed, and the hamburger patties should not have been left exposed. The manager attributed these lapses to short staffing in the kitchen.
Plan Of Correction
The expired grape juice that was gotten out of the freezer was discarded, the cooler wiped down for spills, and the open box of hamburger patties was discarded immediately by the dietary staff. The dietary staff was educated on checking labels for expiration, keeping spills cleaned up, and sealing boxes properly when closing along with general dietary sanitation reminders. The Dietary Manager is responsible for ongoing audits of sanitation in the kitchen, and these audits will be completed daily x5 for 2 weeks, then weekly x 4, then monthly ongoing to ensure monitoring and compliance with results to Quality Assurance.
Repeated QAPI Failures in Addressing Key Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The report details that, following a previous survey, the facility developed plans of correction that included quality assurance systems to maintain compliance with nursing home regulations. However, the most recent survey identified repeated deficiencies in several key areas, including safety/accidents, palatable food, food procurement and storage, and infection control. Specifically, the QAPI committee was cited as ineffective in maintaining compliance with regulations regarding safety/accidents, as evidenced by a repeated deficiency under F689. Similarly, deficiencies related to palatable food (F804), food procurement and storage (F812), and infection control (F880) were also repeated, despite previous plans of correction that indicated these areas would be monitored by QAPI. The recurrence of these deficiencies demonstrates that the QAPI committee did not successfully address or sustain improvements in these areas. The findings are based on a review of the facility's plans of correction from a prior survey and the results of the current survey, which showed that the same issues persisted. The report references specific regulatory citations and indicates that the QAPI committee's monitoring and corrective actions were not effective in resolving the identified problems.
Plan Of Correction
The facility has an established Quality Assurance Performance Improvement Plan with monthly committee meetings to review ongoing performance issues, audits, and ways for improvement. The Nursing Home Administrator maintains meeting minutes and data collection. This survey plan of correction will be reviewed with the committee members and ongoing audits reported through the committee. Additional attention will be paid to correction of repeat deficiencies in the areas of safety, palatable food, food procurement, and infection control. Staff will be educated on the actionable items for correction to draw attention to needed compliance. Ongoing reporting will be reviewed at monthly meetings.
Failure to Follow Contact Precautions for Resident with MDRO Infection
Penalty
Summary
A deficiency was identified when a nurse aide failed to follow proper infection prevention and control protocols while providing continence care to a resident with a documented multi-drug resistant organism (MDRO) infection in the urine. The facility's policy required the use of contact precautions, including wearing a gown, when caring for residents with conditions that increase the risk of environmental contamination and transmission, such as excessive wound drainage or incontinence. Despite these requirements, the nurse aide was observed providing care without wearing a gown. The resident involved was cognitively intact, required assistance with daily care, was frequently incontinent of bowel and bladder, and had a recent diagnosis of urinary tract infection with a positive urine culture for MDRO. Both the nurse aide and the Director of Nursing confirmed during interviews that the appropriate personal protective equipment, specifically a gown, should have been used during care. This failure to adhere to established infection control protocols was directly observed and confirmed through staff interviews.
Plan Of Correction
Nurse aide 4 was educated at the time of the survey on appropriate Personal Protective Equipment needed for resident R42's Enhanced Barrier Precautions. The Infection Control Nurse reviewed residents requiring Enhanced Barrier Precautions to ensure all line listing and signage was up to date. Staff was provided education regarding Enhanced Barrier Precautions and identification of residents requiring these precautions. The Infection Control Preventionist will complete random audits of care requiring Enhanced Barrier Precautions daily x5 for 2 weeks then weekly x 4, then monthly x2 months with results to Quality Assurance.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide-to-resident staffing ratios as mandated by regulation effective July 1, 2024. Specifically, the facility did not provide at least one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift for the majority of days reviewed. This deficiency was identified through a review of nursing schedules, staffing information, and facility census data for multiple weeks in June, July, and September 2025. On numerous occasions, the number of nurse aides scheduled and providing care was below the required minimum based on the facility's census. For example, on several days when the census required between 4.5 and 5.3 nurse aides during the day shift, the actual number of nurse aides present ranged from as low as 3.03 to 5.1. Similar shortfalls were observed during the evening and night shifts, with the number of nurse aides often falling below the calculated requirement for the given census. There were no additional higher-level staff available to compensate for these staffing deficiencies. The deficiency was confirmed through interviews with facility staff, including the Nursing Home Administrator, who acknowledged that the required nurse aide-to-resident ratios were not met on the days in question. The report does not mention any specific residents affected or detail any medical histories or conditions related to the deficiency. The findings are based solely on staffing records, census data, and staff interviews.
Failure to Meet Minimum LPN Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required minimum staffing ratios for Licensed Practical Nurses (LPNs) across multiple shifts and dates, as mandated by regulation effective July 1, 2023. Specifically, the facility did not provide at least one LPN per 25 residents during the day shift for 11 out of 21 days reviewed, one LPN per 30 residents during the evening shift for six out of 21 days, and one LPN per 40 residents during the overnight shift for 12 out of 21 days. These deficiencies were identified through a review of nursing schedules, staffing information, and facility census data. Detailed examination of the facility's nursing time schedules and census data for the weeks of June 8-14, July 1-7, and September 17-23, 2025, revealed that the number of LPNs scheduled was consistently below the required ratios. For example, on several days when the census required between 1.84 and 2.12 LPNs during the day shift, the actual number of LPNs scheduled ranged from 1.00 to 2.06. Similar shortfalls were observed during the evening and overnight shifts, with the number of LPNs scheduled falling below the required minimums based on the resident census. No additional higher-level staff were available to compensate for these staffing deficiencies on the dates in question. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required LPN-to-resident staffing ratios for the identified dates. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Meet Minimum Direct Care Staffing Hours
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by regulation effective July 1, 2024. Review of nursing schedules for selected weeks in June, July, and September 2025 showed that on 19 out of 21 days reviewed, the facility did not meet this staffing requirement. The direct care hours per resident ranged from 2.51 to 3.15 on these days, consistently falling short of the regulatory minimum. This deficiency was confirmed through both documentation review and an interview with the Nursing Home Administrator, who acknowledged that the required daily hours of direct resident care were not met on the specified days. No additional details about specific residents, their medical history, or their condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility attempts to staff to meet state required number of staff hours for a minimum of 3.2 hours of direct resident care per resident per day. The facility offers shift bonuses for pick-up shifts and for additional hours in case of call-offs. Registered nurses, licensed practical nurses, and nursing administration all assist to help fill in as needed. An active recruitment campaign is ongoing, which includes sign-on bonuses, shift differentials, and employee referral bonuses. Agency staff are contracted as available to fill in needed shifts. The Nursing Home Administrator and Director of Nursing meet daily to review staffing sheets to ensure proper staffing. Time and attendance are reviewed daily for ratios and staffing numbers. These calculations are recorded daily in labor tracking and submitted to the facility's management company ongoing.
Failure to Document Administration of Controlled Medications
Penalty
Summary
Mulberry Healthcare and Rehabilitation Center was found to be non-compliant with federal and state regulations regarding pharmacy services. The facility failed to ensure the accountability of controlled medications for two residents. For Resident 2, who was cognitively intact and required assistance for daily care needs, there was a physician's order for 325 mg of Oxycodone-Acetaminophen to be administered every 12 hours as needed. However, a review of the controlled drug record for January 2025 showed that a dose was signed out on January 8, 2025, but there was no documented evidence in the resident's clinical record that the medication was administered. Similarly, for Resident 5, who was cognitively impaired and required assistance with daily care needs, there was a physician's order for 5 mg of Oxycodone to be administered every eight hours as needed. The controlled drug record for January 2025 indicated that a dose was signed out on January 14, 2025, but again, there was no documented evidence in the clinical record that the medication was administered. An interview with the Director of Nursing confirmed the lack of documentation for the administration of Oxycodone to both residents on the specified dates.
Plan Of Correction
Residents R2 and R5 were not adversely affected and were provided pain medications as needed as evidenced on the Controlled Narcotic Sign Out Sheet. The Licensed Practical Nurse who missed a signature on the Medication Administration Record was provided re-education/disciplinary action regarding the missed signature. The Director of Nursing is completing an audit of all current Controlled Narcotic Sign Out Sheets for the past two weeks to ensure that a corresponding notation is present in the Resident's Electronic Medication Administration Record. All licensed nurses will be re-educated regarding ensuring signatures are present on both documents for any controlled substances provided. An additional check will be initiated with each change of shift for two nurses to verify all controlled substances given during the shift have a corresponding notation in the Electronic Medical Record. The Director of Nursing or designee will complete random double checks of the documents to ensure both signatures are present daily x5, then weekly x4, then monthly x2 with results to Quality Assurance.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its sprinkler system adequately, as evidenced by several deficiencies observed and confirmed through interviews. On January 7, 2025, it was revealed that the facility did not have a supply of spare sprinklers following a sprinkler head failure on December 24, 2024. The maintenance staff had to use a pipe plug to repair the system temporarily, and there was no evidence that a spare sprinkler was obtained after the vendor replaced the sprinkler system on January 3, 2025. This lack of preparedness and failure to maintain necessary supplies was confirmed by the maintenance director. Further deficiencies were observed in the North Terrace corridor, where a replaced sprinkler head was located too close to a section of flexible duct, reducing its coverage area. Additionally, the facility failed to provide documentation for the replacement or representative sample testing of fast response sprinklers, which were dated from 1999 and present throughout the attic area. These issues were also confirmed by the maintenance director, indicating a lack of proper maintenance and documentation for the sprinkler system.
Plan Of Correction
Certasite (the facility vendor for the fire sprinkler system) was contacted regarding the issues following a sprinkler head failure. They will be providing a back up supply of sprinkler heads to keep on site for utilization in case of additional sprinkler head issues. Receipt of parts and repairs will also be provided for documented proof of completion. Upon repair of the ceiling flexible duct pieces will be relocated greater than 18 inches from each sprinkler head. The system will be repaired, tested, and signed off by the vendor upon completion of all needed repairs. Certasite will be asked to provide documentation after assessment of each sprinkler head to show safety and functionality of the fast response system.
Smoke Barrier Deficiency in North Terrace Corridor
Penalty
Summary
The facility failed to maintain smoke barrier requirements in the North Terrace corridor, as observed on January 7, 2025. The deficiency was identified when a sprinkler head frame failure led to the release of air pressure in the dry sprinkler system, causing water flow throughout the attic area and ceiling above the corridor. This incident resulted in sections of the ceiling collapsing, creating an opening approximately 32" x 48" in the smoke barrier. This opening could potentially allow the transfer of smoke and delay the activation of sprinkler and fire alarm components in the area. The maintenance director confirmed the smoke barrier deficiency during an interview.
Plan Of Correction
The significant damage to the ceiling in the North hallway caused by the malfunction of the sprinkler head was removed, including the old damaged materials of insulation, drywall, and any items attached to the ceiling. The ceiling was then repaired using fire-resistant materials, and new insulation was applied, resolving the opening to the smoke barrier.
Electrical System Deficiency in North Terrace Corridor
Penalty
Summary
The facility failed to maintain and inspect electrical system requirements as per NFPA 70 and NFPA 99 in one of its four wings. During an observation on January 7, 2025, at 1:17 p.m., it was noted that the North Terrace corridor had two unsupported junction boxes with missing covers and exposed wiring. These junction boxes were left hanging from the wiring due to ceiling damage caused by a sprinkler failure. This deficiency was confirmed through an interview with the maintenance director at the time of the survey.
Plan Of Correction
Assessment was completed of the significant water damage that affected the ceiling on the North hall, including the old junction box and items that were attached to the ceiling. The junction box was removed by the electrician, and consolidation of the necessary wires to the area was provided into a new junction device, which was then secured beneath the newly repaired ceiling.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on several occasions between December 4 and December 10, 2024. On December 5, 2024, the facility had a census of 44 residents, necessitating 4.40 NAs during the day shift, but only 3.00 NAs were available. Similarly, on December 9, 2024, with a census of 42 residents, the evening shift required 3.82 NAs, yet only 3.13 NAs were present. Additionally, the night shift on December 4, 2024, required 3.00 NAs for a census of 45 residents, but only 2.00 NAs were available. The night shifts on December 8 and December 9, 2024, also fell short of the required staffing levels, with only 2.00 NAs available when 2.93 and 2.80 NAs were needed, respectively. The Director of Nursing confirmed during an interview on December 11, 2024, that the facility did not meet the mandated NA-to-resident staffing ratios on the specified days. The report indicates that no additional higher-level staff were available to compensate for these deficiencies, highlighting a consistent shortfall in staffing levels across multiple shifts and days.
Plan Of Correction
The facility attempts to schedule staff to meet the ratios per current state regulations. The facility offers shift bonuses to employees who pick up extra shifts or stay over in case of a call off. Registered Nurses, Licensed Practical Nurses, and Nursing Administration all assist to fill in as supplemental staff. An active recruitment campaign is ongoing including sign on bonuses, shift differentials, and employee referral bonuses. Admissions are being limited and denied due to staffing challenges. Nursing Administration will continue to review staffing ratios daily and attempt to cover call off holes as needed. Day sheets will be reviewed daily x5 weekly x2 then biweekly ongoing with payroll review with reports to Quality Assurance.
LPN Staffing Deficiency During Night Shift
Penalty
Summary
The facility failed to meet the required staffing ratios for Licensed Practical Nurses (LPNs) during the night shift on three occasions between December 4 and December 10, 2024. Specifically, on December 4, the facility had a census of 45 residents, necessitating 1.13 LPNs, but only 0.25 LPNs were available. On December 8, with a census of 44 residents, 1.10 LPNs were required, yet only 1.00 LPN was present. Similarly, on December 10, the census was 42, requiring 1.05 LPNs, but only 1.00 LPN was on duty. The Director of Nursing confirmed these staffing deficiencies, and no additional higher-level staff were available to compensate for the shortfall.
Plan Of Correction
The facility attempts to schedule staff to meet the ratios per current state regulations. The facility offers shift bonuses to employees who pick up extra shifts or stay over in case of a call off. Registered Nurses, Licensed Practical Nurses, and Nursing Administration all assist to fill in as supplemental staff. An active recruitment campaign is ongoing including sign on bonuses, shift differentials, and employee referral bonuses. Admissions are being limited and denied due to staffing challenges. Nursing Administration will continue to review staffing ratios daily and attempt to cover call off holes as needed. Day sheets will be reviewed daily x5 weekly x2 then biweekly ongoing with payroll review with reports to Quality Assurance.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by incidents involving two residents. Resident 2, who had cerebral palsy and required substantial assistance for transfers, was involved in an incident where a nurse aide attempted to transfer her alone using an ETAC device, contrary to the care plan that required two staff members. This resulted in the resident falling and subsequently experiencing increased pain in her shoulder and neck. The nurse aide admitted to transferring the resident alone to catch up on tasks, despite being trained on the proper procedure. In another incident, Resident 3, who had dementia and required substantial assistance, was involved in an altercation during morning care. The resident, who was combative, threatened to bite a nurse aide, leading the aide to jerk her arm away and accidentally hit the resident in the face. Despite a suggestion from another aide to pause and reapproach the resident, the first aide continued care, escalating the situation until the resident hit her, breaking her glasses. The nurse aide's reaction was confirmed to be inappropriate, as staff should have stopped and reapproached the resident when he was not combative. These incidents highlight the facility's failure to protect residents from neglect and abuse, as staff did not adhere to care plans and did not manage combative behavior appropriately. The actions of the staff involved led to physical harm and distress for the residents, demonstrating a lack of compliance with the facility's abuse policy and state regulations.
Failure to Maintain Safe Environment and Adhere to Care Plans
Penalty
Summary
The facility failed to ensure that the residents' environment was free from accident hazards by not equipping a mechanical lift with the necessary hanger bar latches. The Invacare 450 Full Body Mechanical Lift, used for transferring residents, was missing three of the six required hanger bar latches, which are essential for preventing the sling from detaching during transfers. This deficiency was observed during the transfer of a resident who required assistance due to conditions such as heart failure, high blood pressure, and morbid obesity. Staff interviews revealed a lack of awareness about the missing latches and the importance of these safety features. Additionally, the facility did not adhere to care-planned interventions for a resident at risk of falls. The resident, who was cognitively impaired and had a history of falls, was supposed to have bilateral fall mats as part of their care plan. However, during an observation, the fall mats were found folded and not in use, contrary to the care plan requirements. This oversight was confirmed by a registered nurse and the Nursing Home Administrator, indicating a failure to implement the necessary fall prevention measures. These deficiencies highlight the facility's failure to maintain a safe environment for its residents by not ensuring the proper functioning and use of equipment and by not following individualized care plans designed to mitigate fall risks. The lack of awareness and adherence to safety protocols placed residents in potentially hazardous situations.
Removal Plan
- Invacare Lift Reliant 450 model was removed from use and tagged out for maintenance.
- Secondary lift Joerns Hoyer 700 will be utilized for all full body mechanical lifts until clips can be obtained for the Invacare lift.
- The Nursing Home Administrator contacted Invacare and Direct Supply companies for replacement of the latch kit for replacement of missing hanger bar latch clips.
- Staff will be educated to assess lifts prior to each use and alert the Maintenance Director for any missing hanger bar latch clips or any identified issues with mechanical lifts.
- The Maintenance Director or designee will assess the mechanical lifts for any ongoing need for repairs.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as required by their policy dated May 16, 2024. This policy mandates that all hot food items should be at or above 135 degrees Fahrenheit, and cold items should be at or below 41 degrees Fahrenheit. During a lunch meal service observation on October 16, 2024, it was noted that the last cart containing a test tray left the kitchen at 12:05 p.m. and arrived at the short hall at 12:07 p.m. The trays were distributed to residents, with the last resident being served at 12:19 p.m. Upon checking the test tray at 12:20 p.m., the coffee was found to be 110 F, the meatballs 122 F, the pasta 133 F, and the green beans 80 F, all of which were lukewarm and not palatable. The Dietary Manager confirmed these temperatures were inappropriate, and the Nursing Home Administrator acknowledged that food should be at 135 degrees F and palatable.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by several observations and staff interviews. In the main kitchen's walk-in freezer, a bag of donut holes and a bag of cookie dough were found unsealed and unlabeled with the dates they were opened. Additionally, in the dry storage area, several loaves of bread were discovered with expiration dates that had already passed. The ice machine in the main kitchen was observed to have a brown, removable substance around the opening where the ice was located. During the lunch meal tray line, dishes were found on a utility cart shelf that was dusty and had debris and soiled oven mitts on it. Furthermore, the Dietary Manager was observed wearing a hair net that did not completely cover all her hair. Interviews with the Dietary Manager and the Nursing Home Administrator confirmed these deficiencies. The Dietary Manager acknowledged that all opened items in the kitchen should be secured and labeled with the date they were opened, and admitted there was no process in place to document when bread was removed from the freezer. She also confirmed that the ice machine should not have a removable substance on it, and that dishes should be stored in a clean area. The Nursing Home Administrator confirmed that these issues should not be occurring and that there should be a process in place to ensure safe food handling and storage in the kitchen.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for the ability to self-administer medications safely. According to the facility's medication administration policy, residents may self-administer medications only if the attending physician and the interdisciplinary care planning team determine that the resident has the decision-making capacity to do so safely. However, for one resident, there was no assessment conducted to determine if they were safe to self-administer their medications. During an observation of medication administration, an LPN prepared the resident's medications, including Lactulose Encephalopathy Oral Solution, and left it on the over-bed table without observing the resident take it. The LPN confirmed that she left the medication with the resident and intended to return to check if it was taken. The Nursing Home Administrator confirmed that the LPN should have observed the resident taking the medication and acknowledged the lack of an assessment to determine the resident's ability to self-administer medications.
Deficiency in Wheelchair Maintenance
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for residents, specifically concerning the condition of wheelchairs used by three residents. Observations revealed that the vinyl material on the armrests of the wheelchairs for Residents 6, 33, and 53 was torn and cracked. These observations were made on October 17, 2024, at different times throughout the day. An interview with the Maintenance Director confirmed that the armrests were indeed cracked, torn, and peeling, and acknowledged that they should be replaced. This deficiency is a violation of the facility's policy for maintaining a homelike environment and resident rights as per the relevant Pennsylvania codes.
Failure to Notify of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the state ombudsman, residents, and their responsible parties regarding the reasons for transfers or discharges to the hospital for five residents. This deficiency was identified through a review of clinical records and staff interviews. Specifically, there was no documented evidence of written notices for Residents 8, 30, 36, 55, and 102, who were transferred to the hospital for various medical conditions, including kidney failure, a change in condition, a need for a blood transfusion, unresponsiveness, and other health issues. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not provide the required written notices. The residents involved had various medical conditions, such as heart failure, high blood pressure, morbid obesity, a left hip fracture, diabetes, and Alzheimer's disease. The lack of documentation and notification violated the residents' rights and the facility's discharge policy as outlined in the relevant state codes.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to a hospital for five residents. This deficiency was identified through a review of policies, clinical records, and staff interviews. Specifically, there was no documented evidence that Residents 8, 30, 36, 55, and 102, or their responsible parties, were notified about the facility's bed-hold policy when they were transferred to the hospital. The transfers occurred due to various medical conditions, including kidney failure, a change in condition, a need for a blood transfusion, unresponsiveness, and an unspecified admission. The Director of Nursing confirmed that the required written bed-hold information was not provided at the time of transfer for these residents. The report highlights that the facility did not comply with the regulatory requirements to inform residents or their representatives about the bed-hold policy, which is a critical aspect of managing hospital transfers and ensuring continuity of care. The deficiency was noted under the Pennsylvania Code, specifically sections 201.14(a) and 201.18(b)(3), which pertain to the responsibility of the licensee and management.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for five residents, as required by the Resident Assessment Instrument (RAI) User's Manual. The deficiencies were identified in the coding of Section N, which records the administration of injections, insulin, and select medications during the seven-day assessment period. For Resident 5, the MDS assessment inaccurately indicated that no injection was received, despite documentation showing the resident received a pneumonia vaccine. Similarly, Resident 8's assessment failed to record the administration of aspirin, an antiplatelet medication, which was given daily during the look-back period. Further inaccuracies were found in the assessments of Residents 27, 46, and 47. Resident 27's MDS did not reflect the use of an antibiotic ointment, which was administered daily. Residents 46 and 47 were both on a regimen of aspirin, an antiplatelet medication, yet their assessments did not indicate this. These errors were confirmed through interviews with the Registered Nurse Assessment Coordinator, who acknowledged the incorrect coding in the MDS assessments for these residents.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident was provided with showers as scheduled. The resident, who was cognitively intact and required moderate assistance for personal care needs, preferred to shower twice a week on Wednesday and Sunday evenings. However, a review of the resident's bathing records for September and October 2024 showed that the resident only received a bed bath on one occasion and a shower on another, with no documentation of showers on the other scheduled days. Interviews with the resident's daughter and the Director of Nursing confirmed the lack of documented evidence of the resident receiving the scheduled showers.
Medication and Care Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, leading to deficiencies in medication administration and care. For Resident 10, who was cognitively intact and diagnosed with gastro-esophageal reflux disease, the physician's order required the administration of 1 gram of Sucralfate before meals and at bedtime. However, on October 16, 2024, the medication was administered after the resident had consumed breakfast, contrary to the prescribed order. This was confirmed by both the LPN involved and the Nursing Home Administrator. Resident 37, who was cognitively impaired with Alzheimer's disease and experiencing significant weight loss, was prescribed a specific regimen of a nutritional supplement to prevent further weight loss. The review of the Medication Administration Record (MAR) revealed inconsistencies in the administration of the supplement, with varying amounts given at different times and some doses missed entirely. The Director of Nursing confirmed the lack of consistent documentation, making it unclear whether the resident received the correct amount of supplement as ordered. For Resident 47, who was cognitively impaired with a history of falls and diagnosed with dementia and blood pressure issues, there were two instances of non-compliance with physician's orders. The resident was supposed to receive Permethrin cream for a rash, but there was no documentation of its administration on the specified date. Additionally, the resident was to receive Humalog Insulin Lispro before meals based on a sliding scale, but it was administered after breakfast on October 16, 2024. Both the LPN and the Nursing Home Administrator confirmed the deviation from the prescribed order.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for three residents, as revealed through a review of policies, clinical records, and staff interviews. For Resident 5, who is cognitively impaired and requires assistance for daily care, there was no documented evidence of the administration of Oxycodone/Acetaminophen on several occasions despite the medication being signed out. Similarly, Resident 28, who is cognitively intact and receiving hospice care, had a dose of Lorazepam signed out without documentation of administration. Resident 30, also cognitively intact and diagnosed with heart failure, had multiple instances where Oxycodone was signed out without corresponding documentation in the clinical record. Interviews with the Director of Nursing confirmed the lack of documentation for the administration of these controlled medications on the specified dates. The facility's policy requires staff to document medication administration in the resident's medical record, which was not adhered to in these cases. This deficiency was identified under the regulations 28 Pa. Code 211.9(h) Pharmacy Services and 28 Pa. Code 211.12(d)(1) Nursing Services.
Failure to Act on Pharmacy Recommendations for Drug Irregularities
Penalty
Summary
The facility failed to ensure that pharmacy recommendations related to drug irregularities were acted upon by a physician for two residents. The facility's policy requires that a licensed pharmacist perform a monthly drug regimen review and notify the physician of any irregularities, with the expectation that the physician will make necessary adjustments. However, for Resident 7, who was cognitively impaired with Alzheimer's disease, there was no documented evidence that the physician reviewed the Medication Record Reviews (MRRs) with recommended medication changes on multiple occasions from April to October 2024. Similarly, for Resident 37, also cognitively impaired with Alzheimer's disease, there was no documented evidence that the physician reviewed the MRRs with recommended medication changes from April to October 2024. An interview with the Director of Nursing confirmed that the physician had not been responding to the pharmacist's recommendations since April 2024, resulting in the MRRs for both residents not being addressed. This lack of action violated the facility's policy and state regulations regarding clinical records and nursing services.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as evidenced by observations during medication administration on October 16, 2024. Two medication errors were identified out of 35 opportunities, resulting in an error rate of 5.71 percent. The first error involved Resident 10, who was prescribed 1 gram of Sucralfate to be taken before meals and at bedtime for gastric protection. However, the medication was administered after the resident had consumed breakfast, contrary to the physician's orders. The second error involved Resident 47, who was prescribed Humalog Insulin Lispro based on a sliding scale to be administered before meals. The resident's blood sugar level indicated that 5 units of insulin should be given before breakfast. However, the insulin was administered after the resident had eaten. Interviews with the LPN confirmed that both medications were administered incorrectly, not adhering to the prescribed timing before meals as per the physician's orders.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as evidenced by observations and staff interviews. During a review of the medication refrigerator, a vial of Aplisol was found without a safety cap and lacked a label indicating the date it was opened. This was confirmed by a registered nurse, who acknowledged that neither the vial nor its box was labeled with the date of opening, contrary to the manufacturer's instructions that require opened vials to be discarded after 30 days. Additionally, an inspection of the East medication cart revealed 10 tablets of Zofran in foil packs that were not labeled with any resident information. A licensed practical nurse confirmed the absence of labeling and was unable to identify the resident to whom the medication belonged. The nurse subsequently disposed of the medication in the approved disposal container. The nursing home administrator confirmed that both the Aplisol and Zofran should have been properly labeled according to the facility's policy and professional standards.
Failure to Ensure Safety of Mechanical Lifts
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure the effective management of the facility, leading to a deficiency in compliance with state regulations and codes. Specifically, they did not ensure that mechanical lifts used for transferring residents were equipped with hanger bar latches, which are necessary for the safety of the residents. This oversight jeopardized the health and safety of one of the 29 residents reviewed, identified as Resident 30. The job descriptions for both the NHA and the DON, dated May 16, 2024, outlined their responsibilities to maintain a safe environment and ensure the highest degree of quality care in accordance with regulatory standards. However, the deficiency cited under the Code of Federal Regulatory Groups for Long-Term Care, specifically 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F689), indicated that they did not fulfill these essential duties. The report also references specific Pennsylvania codes, including 28 Pa. Code 201.14(a), 28 Pa. Code 201.18(e)(1), and 28 Pa. Code 211.12(d)(1)(5), which further emphasize the responsibility of the licensee and management in maintaining nursing services.
Inaccurate Documentation of Penrose Drain Management
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident. The resident, who was cognitively intact, had a feeding tube, and pressure ulcers, underwent surgery to clean out a pressure ulcer. A Penrose drain was sewn into the resident's pressure ulcer in the right hip and through the right buttock to create a tract for the wounds to heal. The physician's order specified that the Penrose drain should not be emptied and should be left alone for two weeks before removal. However, the Medication Administration Review indicated that staff had emptied the Penrose drain, contrary to the surgical note and physician's order. An interview with the Director of Nursing confirmed that the Penrose drain should not have been emptied, and staff should not have documented that they drained it.
Ineffective QAPI Committee Leads to Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address and correct recurring deficiencies identified in both previous and current surveys. The deficiencies included issues with the accurate completion of Minimum Data Set (MDS) assessments, quality of care, accidents and hazards, pharmacy services, medication storage, food procurement and sanitation, complete and accurate medical records, and infection control practices. Despite having plans of correction in place from the previous survey, the facility continued to exhibit the same deficiencies in the current survey. The facility's plans of correction involved conducting audits and reporting the results to the QAPI committee for review. However, the QAPI committee was ineffective in maintaining compliance with regulations across multiple areas, as evidenced by repeated citations under F641, F684, F689, F755, F761, F812, F842, and F880. The ongoing deficiencies suggest that the QAPI committee's efforts were insufficient in ensuring the facility's adherence to nursing home regulations and standards of care.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for one resident. The medication administration policy, dated May 16, 2024, requires that only licensed personnel administer medications and follow infection control procedures such as handwashing and aseptic techniques. However, during a medication pass, an LPN was observed dropping a pill into a drawer of the medication cart. Instead of discarding the contaminated pill, the LPN retrieved it with bare hands and taped it to the back of the medication card for future use. The incident involved a resident who was alert, able to understand, and required assistance for daily care needs, as indicated by an MDS assessment dated September 9, 2024. The LPN admitted to retrieving the pill with bare hands and acknowledged that this action was inappropriate. The Nursing Home Administrator confirmed that the LPN's actions were against the facility's infection control policy.
Failure to Follow Optometrist's Recommendations for Follow-Up Appointments
Penalty
Summary
The facility failed to follow the optometrist's recommendations for follow-up appointments for five residents. Resident 2 was advised to return in six to nine months for a dilated fundus exam after a diabetic eye exam, but there was no documented evidence that this recommendation was followed or that the primary care physician disagreed with the plan of care. Similarly, Resident 3, who was also seen for a diabetic eye exam, had no documented follow-up for the recommended six to nine months return visit. Resident 4, who presented with blurry vision, was also advised to return in six to nine months for a dilated fundus exam, but again, there was no documentation of this follow-up or any disagreement from the primary care physician. Resident 6, seen for a diabetic eye exam, had the same lack of follow-up documentation for the recommended six to nine months return visit. Lastly, Resident 7, who was evaluated for glaucoma, was advised to return in three to six months for various eye tests, but there was no documented evidence that this follow-up occurred or that the primary care physician disagreed with the optometrist's plan of care. An interview with the Nursing Home Administrator confirmed that there was no documented evidence of the recommended follow-up appointments for these five residents. The facility's failure to ensure these follow-up appointments were completed as recommended by the optometrist constitutes a deficiency in providing necessary vision and hearing services to the residents. This deficiency was identified based on clinical record reviews and staff interviews, highlighting a significant lapse in the continuity of care for these residents.
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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