Pennknoll Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Everett, Pennsylvania.
- Location
- 208 Pennknoll Road, Everett, Pennsylvania 15537
- CMS Provider Number
- 395422
- Inspections on file
- 36
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Pennknoll Village during CMS and state inspections, most recent first.
The facility failed to provide palatable meals at safe and appetizing temperatures, as required by its dietary policy. Resident council minutes and multiple resident interviews described food that was often cold, overcooked or undercooked, hard to chew, and generally not good. During a lunch observation, a resident with mouth pain could not eat hard sliced carrots, and a nurse aide was unable to cut the carrots with a fork. A test tray taken from a meal cart after service showed hot foods at approximately 119–125°F and coleslaw at 55°F, and the meal was found not to be palatable or at an appetizing temperature; the Dietary Director confirmed these temperatures were not appropriate.
A cognitively intact resident who could communicate clearly and required staff assistance for daily care reported that a new television given by a family member was removed after the facility contacted the family to take it back, even though the resident wanted to keep it. The Director of Maintenance confirmed there was no policy or life safety code limiting television size and acknowledged the television was removed. The Nursing Home Administrator also confirmed there was no policy restricting televisions brought in as personal property, yet the resident was still not allowed to retain the television, resulting in a failure to honor the resident’s right to dignity and self-determination.
The facility failed to maintain a safe, clean, and homelike environment when a resident’s room blinds remained broken and non-functional, and two residents were repeatedly observed using Broda chairs that were damaged and unclean. One chair had torn vinyl on both arms and a split headrest seam, while another had a ripped cushion with exposed padding, visible grime, dried brown residue, and food debris. Staff, including an RN, an LPN, and department directors, confirmed the poor condition of the equipment, acknowledged that the chairs should not have been in use, and reported that the scheduled monthly cleaning for one resident’s chair had not yet been completed.
A resident who required two-person assistance for bed mobility and toileting was left unattended by a single nurse aide during incontinent care. The aide attempted to remove the resident from a bedpan alone, resulting in the resident falling from the bed and sustaining a fracture and other injuries. Staff interviews and documentation confirmed that the care plan requiring two-person assistance was not followed.
A resident who required two-person assistance for bed mobility and toileting was being assisted by only one nurse aide during a transfer from a bedpan. The resident shifted weight and fell, resulting in facial injuries, skin tears, and a hand fracture. Documentation and staff interviews confirmed that facility protocols requiring two staff for such care were not followed at the time of the incident.
The facility did not meet the required nurse aide-to-resident staffing ratios during an overnight shift, providing only 5.43 nurse aides for 86 residents, instead of the required 5.73. This deficiency was confirmed through a review of nursing schedules and an interview with the Nursing Home Administrator.
The facility failed to meet the required LPN staffing ratios on several occasions, with insufficient LPNs available during day, evening, and night shifts. This deficiency was confirmed by the Nursing Home Administrator, and no additional higher-level staff were available to compensate for the shortfall.
The facility did not meet the required 3.2 hours of direct resident care per resident on two days, providing only 3.16 and 3.19 hours. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain the automatic sprinkler system, leading to deficiencies in two smoke compartments. Observations revealed a plastic sprinkler line improperly supported by the main line near the 200 hallway smoke doors, and duct work supported by the sprinkler line near the 500 hallway smoke doors. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain documentation of staff training and testing for their Emergency Preparedness Plan, affecting the entire facility. This deficiency was confirmed through interviews with the Facility Administrator and Maintenance Director, highlighting a lack of adherence to regulatory requirements for emergency preparedness training.
The facility failed to serve palatable food at appropriate temperatures, as observed and reported by residents and staff. Complaints included burnt, cold, and bad-tasting food, with specific issues noted during a lunch meal tray line observation. The Director of Dietary confirmed that the fruit cocktail was not kept cold, contributing to the deficiency.
The facility did not resolve ongoing resident grievances about cold food, despite policy requirements for palatable and properly heated meals. Residents reported receiving cold, unpalatable food for over a year, and the Director of Dietary was aware but did not address the issue, as kitchen temperatures were deemed correct.
The facility failed to follow physician's orders for two residents. A resident did not receive prescribed medications on multiple occasions, and another resident's critically low blood sugar levels were not reported to the physician as required. The DON confirmed these deficiencies.
The facility failed to maintain sanitary conditions for food storage and handling. A dietary employee was observed without a hair net or beard guard while handling food, and the solarium refrigerator contained improperly stored and outdated food items. The DON confirmed these items should have been discarded and labeled per policy.
The facility's QAPI committee failed to address repeated deficiencies, including unresolved grievances, outdated care plans, non-compliance with physician's orders, lack of nurse aide performance reviews, and failure to honor residents' food and drink preferences. Despite previous corrective plans, the current survey revealed ongoing issues, indicating ineffective implementation and sustainability of corrective actions.
The facility failed to maintain a clean and homelike environment for two residents. One resident's feeding pump and overbed table were found with sticky and removable substances, and a stethoscope had dried residue. Another resident's room had a wall with scratches and nicks. Staff confirmed these conditions were not in compliance with the facility's policy.
A facility failed to follow its abuse policy when a nurse aide verbally abused a resident, leading to the aide's termination. Additionally, the facility did not verify the professional licensure of an RN with the Pennsylvania State Board of Nursing before hiring, as confirmed by the Director of Human Resources.
The facility failed to provide written notification to the responsible parties and Ombudsman for two residents transferred to the hospital. One resident, who was cognitively intact, was transferred due to breathing difficulties, while another, who was cognitively impaired, was transferred after a fall. The Nursing Home Administrator confirmed the absence of required notifications.
The facility failed to notify two residents or their representatives about the bed-hold policy upon hospital transfer. One resident, cognitively intact, was transferred due to breathing difficulties, while another, cognitively impaired, was transferred after a fall. The Nursing Home Administrator confirmed the lack of documentation for these notifications.
A facility failed to update a resident's care plan to reflect the healing of a pressure ulcer. Despite a wound doctor's note confirming no open wounds, the care plan still listed a pressure ulcer. The DON confirmed the ulcer was healed and the care plan should have been discontinued.
The facility failed to provide adequate activities for residents, as identified through record reviews and interviews. Residents, mostly cognitively intact and dependent on staff, expressed the importance of activities like reading, music, and religious services. However, activity schedules were reduced due to staffing cuts, leading to resident dissatisfaction and limited engagement opportunities.
A facility failed to follow the prescribed transfer protocol for a resident who required two-person assistance. During a transfer by one nurse aide, the resident, diagnosed with acute respiratory failure and muscle weakness, became weak and was lowered to the floor. No injuries were reported, but the Nursing Home Administrator confirmed the transfer should have involved two staff members.
The facility failed to provide adequate nursing staff to transport residents to activities and ensure a licensed nurse was present in the dining area during meals. A resident's grievance highlighted the inability to attend activities due to staffing issues. Observations and interviews revealed that residents preferred dining in the main area but faced long wait times for a nurse, leading them to eat in their rooms. Staff confirmed that serving residents in their rooms was easier due to staffing constraints, and the loss of activity aides further impacted resident transport.
The facility did not complete the required annual performance evaluation for a nurse aide by the due date. The evaluation for the aide was overdue, and there was no documentation to show it had been conducted. This was confirmed by the Director of Human Resources.
The facility did not honor residents' preferences for certain drinks and snacks, such as soda and ice cream, due to budget constraints and corporate menu decisions. Residents expressed dissatisfaction, feeling deprived of joy. The Dietary Manager sometimes used personal funds to fulfill requests, and there was no policy on hot dogs as a choking hazard, despite a past incident.
The facility failed to meet the required NA-to-resident staffing ratios on several occasions, as evidenced by a review of nursing schedules and staffing information. The facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on multiple days, with the number of NAs on duty being below the required levels based on the facility's census data.
The facility failed to meet the required LPN-to-resident staffing ratios on several occasions, as evidenced by a review of nursing schedules and staffing information. On multiple days, the facility did not have enough LPNs scheduled for the day, evening, and night shifts, leading to non-compliance with the regulation effective July 1, 2023. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing.
The facility did not meet the required 3.2 hours of direct resident care per resident on five occasions, providing only between 2.88 and 3.09 hours. This was confirmed through nursing schedules and an interview with the Nursing Home Administrator.
A facility failed to provide a resident with the recommended assistive eating devices. The resident, who had conditions such as tremors and hand contractures, was observed using a large handled spoon instead of the recommended black handled utensils. This discrepancy was confirmed by the Occupational Therapy Director and the Nursing Home Administrator.
The facility failed to conduct weekly wound assessments for two residents with pressure ulcers, despite having care plans in place. One resident had new pressure areas on the heels and coccyx, while another had an open area on the right buttock. Interviews confirmed that the facility did not perform the required assessments, relying instead on an outside wound clinic.
The facility failed to maintain a full-time Director of Nursing (DON) for 35 or more hours a week. The Regional Nurse Consultant has been covering the DON role but is often required to work on the floor, preventing her from completing DON duties. The facility is in the process of hiring a new DON, but the position remains unfilled, resulting in a deficiency.
The facility failed to ensure the consistent services of a full-time DON working 35 or more hours a week. Registered Nurse 1, who started as the interim DON, has not been present in the facility for the past two weeks. This absence was confirmed by the RNAC and the interim Nursing Home Administrator. Additionally, the facility is currently searching for an administrator, DON, and ADON.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and beverages were palatable and served at safe and appetizing temperatures, as required by its own dietary policy dated January 19, 2026. Resident Council/Food Committee minutes documented that residents reported meals were often cold because food sat too long in the carts before being served. Multiple resident interviews corroborated these concerns: one resident stated the food quality was “going downhill,” describing it as overcooked, hard to chew, and cold; another resident reported the food was “awful,” either overcooked or undercooked; and another resident stated that food of any type, at all meals, was “not good” and not hot. Surveyors’ direct observations during lunch service further supported these complaints. One resident with mouth pain was unable to eat sliced carrots because they were too hard, and a nurse aide confirmed she could not cut the carrots with a fork. During observation of lunch meal service from the main kitchen, the second hall cart with a test tray left the kitchen, arrived on the unit, and the last resident was served over a span of approximately 14 minutes. When the test tray was checked immediately afterward, hot items measured 119.2°F to 124.9°F and the coleslaw measured 55°F, and the meal was determined not to be palatable or at an appetizing temperature. The Dietary Director confirmed at the time of observation that the hot foods should have been hotter, the coleslaw colder, and that the food should have been served at a more appetizing temperature.
Resident Not Allowed to Keep Personal Television, Violating Dignity and Self-Determination
Penalty
Summary
Surveyors identified a failure to honor a resident’s right to dignity and self-determination when the facility did not allow a cognitively intact resident to keep her personal television. A quarterly MDS dated January 7, 2026, documented that Resident 20 was always understood, always understood others, was cognitively intact, and required staff assistance for daily care needs. During interviews on January 21 and 22, 2026, the resident reported that her grandson had given her a new television for Christmas, but he was called and told to take it back, and she was not allowed to keep it despite wanting it. The Director of Maintenance confirmed that there was no facility policy or life safety code determining the allowable size of televisions and that the resident’s television was removed. The Nursing Home Administrator also confirmed there was no policy or restriction regarding televisions brought in from outside as personal property, yet the resident’s television was still removed, resulting in a violation of resident rights under 28 Pa. Code 201.29(j).
Failure to Maintain Clean, Homelike Environment and Equipment
Penalty
Summary
Surveyors identified that the facility did not maintain a clean, comfortable, and homelike environment for multiple residents. One resident reported that the blinds in her room were broken and would not go up, which was confirmed by the Maintenance Director, who stated the blinds did not function due to a broken string. The Nursing Home Administrator acknowledged that non-functioning blinds that do not move up and down were not homelike and would need to be replaced. Another resident was observed seated in a Broda chair with significant damage to the vinyl covering on both armrests and a torn seam along the entire length of the headrest. A registered nurse confirmed that this resident used the Broda chair, that it was stored in the shower room when not in use, and that the chair’s condition meant it should have been out of circulation and not used. A third resident was repeatedly observed sitting in a Broda chair with a ripped and torn blue pad exposing the white padding, torn corners and sides, and a large accumulation of a brown sticky dried-on substance, grime on the wheels, and scattered food debris. An LPN confirmed the cushion was ripped with padding sticking out and that the chair was not clean. The Housekeeping Director stated there was a monthly wheelchair cleaning schedule, that wheelchairs should be cleaned once a month, and that this resident’s chair was last cleaned on December 7, 2025, and had not yet been cleaned in January 2026.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in harm. The resident in question required extensive assistance from two staff members for bed mobility and toileting, as documented in the care plan and occupational therapy notes. Despite this, a nurse aide provided incontinent care and attempted to remove the resident from a bedpan alone, without the required second staff member. During this process, the resident shifted her weight, slipped through the aide's arms, and fell to the floor between the beds. The incident resulted in bleeding, bruising, skin tears, and a nondisplaced fracture of the third digit of the right hand, as confirmed by emergency room evaluation and X-ray. Interviews with facility staff, including the Director of Therapy and the Director of Nursing, confirmed that the resident was to be assisted by two staff members during bed mobility and toileting hygiene, specifically when removing her from the bedpan. The nurse aide involved acknowledged performing care alone and cited time constraints and the resident's urgency as reasons for not waiting for a second staff member. Documentation and witness statements corroborated that only one staff member was present at the time of the fall, in direct violation of the resident's care plan and facility policy.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision for a resident who required extensive assistance with bed mobility and toileting. According to the care plan and occupational therapy notes, the resident was dependent on two staff members for these activities. However, on the day of the incident, only one nurse aide was present while removing the resident from a bedpan. During this process, the resident shifted her weight, slipped through the aide's arms, and fell to the floor between the beds. Documentation and staff interviews confirmed that the resident was supposed to have two staff assisting during such transfers, but this protocol was not followed at the time of the fall. As a result of the fall, the resident sustained injuries including bleeding and bruising to the face, skin tears, and a nondisplaced fracture of the third digit of the right hand. The incident was corroborated by nurse aide documentation, witness statements, and a fall investigation form, all indicating that only one staff member was present during the transfer. Interviews with the Director of Therapy and the Director of Nursing further confirmed that the resident required two-person assistance for bed mobility and toileting, and that this standard was not met during the incident.
Overnight Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios during the overnight shift on February 28, 2025. The regulation mandates a minimum of one nurse aide per 15 residents overnight, but the facility provided only 5.43 nurse aides for a census of 86 residents, which required 5.73 nurse aides. This deficiency was confirmed through a review of nursing schedules, staffing information, and an interview with the Nursing Home Administrator. No additional higher-level staff were available to compensate for the shortfall in nurse aide staffing.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed 5X per week X 4 weeks, then weekly X 4 weeks. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required Licensed Practical Nurse (LPN) staffing ratios on multiple occasions between February 26, 2025, and March 2, 2025. Specifically, the facility did not provide the minimum number of LPNs per resident during the day, evening, and night shifts as mandated by the regulation effective July 1, 2023. On February 26, 2025, the facility had a census of 85 residents, requiring 3.40 LPNs during the day shift, but only 3.28 LPNs were available. Similarly, the evening shift required 2.83 LPNs, but only 2.68 were present. On February 28, 2025, with a census of 86 residents, the day shift required 3.44 LPNs, but only 3.12 were available, and the night shift required 2.15 LPNs, but only 1.96 were present. On March 2, 2025, the facility again failed to meet the staffing requirements with a census of 85 residents. The day shift required 3.40 LPNs, but only 3.02 were available, and the evening shift required 2.83 LPNs, but only 2.31 were present. Additionally, the night shift required 2.13 LPNs, but only 1.69 were available. The report notes that there were no additional higher-level staff available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required LPN-to-resident staffing ratios during the specified days.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
Deficiency in Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of staffing information and confirmed through staff interviews. Specifically, on two out of five days reviewed, the facility provided only 3.16 hours of direct care on February 28, 2025, and 3.19 hours on March 2, 2025. The Nursing Home Administrator confirmed the shortfall in required care hours during an interview conducted on March 6, 2025.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in two of the seven smoke compartments. During an observation on January 21, 2025, it was noted that a plastic sprinkler line was improperly supported by the main sprinkler line near the smoke doors leading to the 200 hallway. Additionally, duct work was found to be supported by the sprinkler line near the smoke doors leading to the 500 hallway. These deficiencies were confirmed through an interview with the Facility Administrator and the Maintenance Director on the same day.
Plan Of Correction
1. The sprinkler line noted to be found in the proximity of the 200 hall smoke doors will be properly supported with proper hanger. The noted duct work on the sprinkler piping will be properly supported. 2. Additional sprinkler lines will be reviewed for improperly supporting duct work or others piping. 3. The Executive Director/ Designee will educate the Maintenance Director on the importance of NFPA 101 Sprinkler- maintenance and testing specific to maintaining sprinkler piping to be free from supporting other piping and duct work and will continue to monitor in accordance with the standard. 4. Any finding will be reported to the monthly QAPI Committee for further review.
Deficiency in Emergency Preparedness Training Documentation
Penalty
Summary
The facility was found to be deficient in maintaining documentation of staff training and testing related to their Emergency Preparedness (EP) Plan. During a review conducted on January 21, 2025, it was discovered that the facility failed to provide the necessary documentation for sections (iii) and (iv) of the EP Training Program. This deficiency affected the entire facility, indicating a systemic issue in the documentation process. The deficiency was confirmed through an interview with the Facility Administrator and the Maintenance Director on the same day. They acknowledged the lack of documentation for the required emergency preparedness training and testing. This failure to maintain proper records suggests that the facility did not adhere to the regulatory requirements for emergency preparedness training, which mandates maintaining documentation and demonstrating staff knowledge of emergency procedures. The report does not provide specific details about any patients or residents affected by this deficiency, nor does it mention any immediate consequences or risks posed by the lack of documentation. The focus of the deficiency is on the facility's failure to comply with the documentation requirements for emergency preparedness training, which is a critical component of ensuring staff readiness in emergency situations.
Plan Of Correction
1. The required Bi-annual EP training was completed on 1/22/25 with staff. 2. There is only one required Fed EP; therefore, no additional reviews were needed. 3. The Executive Director will educate the Maintenance Director and Director of Clinical Services on the importance of 42 CFR 483.73- ΕΡ training and properly documenting the trainings. This will also be added to new hire trainings. 4. This will continue to be monitored; any findings will be reported to the monthly QAPI Committee for further review.
Failure to Serve Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve palatable food at appropriate temperatures, as evidenced by observations and interviews with residents and staff. Meeting minutes from the food committee in 2024 indicated complaints about burnt, cold, and bad-tasting food. Interviews with two residents on January 12, 2025, revealed dissatisfaction with the taste and temperature of the food, with one resident noting an excess of pork and cold meals. Observations on January 14, 2025, during the lunch meal tray line showed that the food items, including macaroni and cheese, chicken, mashed potatoes, fruit cocktail, and coffee, were not at appetizing temperatures. The macaroni and cheese was 141 degrees F, the chicken was 136.5 degrees F and dry, the mashed potatoes were 136.5 degrees F and not palatable, the fruit cocktail was 61 degrees F and warm, and the coffee was 138.3 degrees F. The Director of Dietary confirmed that the fruit cocktail was warmer than preferred, as it was not kept cold after being removed from the refrigerator.
Plan Of Correction
1. Action to immediately correct the appearance and palatability of food was not possible retroactively. 2. All residents have the potential to be affected by this issue. The Dietary Manager will observe random tray passes by completing test trays. 3. The Dietary Manager will re-educate the dietary staff on the proper food temperatures and palatability. The Dietary Manager or designee will educate dietary staff regarding the proper temperature and palatability of food procedure. 4. Nursing staff will also receive education/re-education regarding passing meal trays in a timely manner to preserve temperatures. 5. Dietary Manager will conduct test tray audits 5x weekly for 4 weeks and then monthly. Quality Assurance Performance Improvement will monitor findings.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to address ongoing resident grievances regarding the serving of cold food, as evidenced by a review of facility policy, Food Committee meeting minutes, and interviews with residents and staff. The facility's policy, dated March 18, 2024, stated that food should be palatable, attractive, and served at a safe and appetizing temperature. However, Food Committee meeting minutes from January through August 2024 and October through December 2024 documented resident complaints about receiving cold food. During a meeting with residents on January 13, 2025, they confirmed that they had been served cold and unpalatable food for at least one year and had requested food at the correct temperature. The Director of Dietary acknowledged awareness of these complaints but did not address the issue, citing that food temperatures were correct when checked in the kitchen.
Plan Of Correction
1. Action to immediately correct the appearance and palatability of food was not possible retroactively. The Dietary Manager/designee will monitor the temperature and palatability of food served. 2. Grievances in the last 30 days will be reviewed by the Executive Director (ED) to ensure ongoing efforts to resolve grievances. 3. The Executive Director reeducated the Social Services Director and Department Managers on the facility's grievance guidelines and time frames for resolution. 4. The ED/designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 585 to ensure ongoing efforts to resolve grievances including dietary complaints. Monitor conducted via weekly grievance reviews times 4 weeks. The Dietary Manager/designee to conduct weekly meetings with the residents who choose to attend, to monitor the overall satisfaction of the food served weekly X 4 weeks, biweekly X 1 month, then monthly as needed. Findings reported to the Quality Improvement Performance Improvement committee and updated as indicated. Quality monitoring schedule modified based on findings.
Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. Resident 40, who is cognitively intact and has diagnoses including high blood pressure, diabetes, and Parkinson's, did not receive medications as ordered on multiple dates in December 2024. The medications included Cetirizine, Synthroid, Miralax, Diltiazem, and Tylenol. An interview with Resident 40 confirmed that he had not been receiving his medications according to the physician's orders, and the Director of Nursing verified the lack of documentation for medication administration on the specified dates. Resident 53, who is cognitively impaired and requires assistance with daily care, had physician's orders for blood sugar monitoring and notification if levels were outside specified parameters. On two occasions, the resident's blood sugar levels were critically low, but there was no documented evidence that the physician was notified as required. The Director of Nursing confirmed that the physician was not informed of the low blood sugar readings, which was a failure to follow the physician's orders.
Plan Of Correction
1. The facility cannot retroactively correct Medication Administration Record (MAR). Physician updated on blood sugar readings and interventions of identified resident. 2. Charts of residents receiving routine blood sugar checks reviewed for notification parameters. 3. The Director Of Nursing/Designee will educate licensed staff on Physician orders and Administering Medications Policy and document education. 4. Audits of medication administration records to confirm signatures on 5 residents 5x per week x2 weeks, weekly x4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight. Audits of 5 residents receiving blood sugar checks for documentation of notifications per physician orders 5x per week x2 weeks, Weekly x4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.
Failure to Maintain Sanitary Food Storage and Handling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not storing and serving food under sanitary conditions. During an initial tour of the main kitchen, a dietary employee was observed removing a cake from the cooler without wearing a hair net or beard guard, which he acknowledged was against the facility's policy. This lack of proper attire in the kitchen represents a breach in maintaining sanitary conditions during food handling. Additionally, a review of the solarium refrigerator revealed multiple food items that were improperly stored. These items included undated or outdated food with resident names, such as ice cream, ranch dressing, applesauce, pudding, chocolate milk, pumpkin pie, deviled eggs, celery, spaghetti, moldy meat and cheese, a sandwich roll, grilled chicken breast with mashed potatoes, and cottage cheese. The refrigerator also contained a removable brown substance on the door. The Director of Nursing confirmed that these items should have been discarded and labeled according to the facility's policy, indicating a failure to maintain proper food storage practices.
Plan Of Correction
1. No specific residents were cited in deficiency of 812 on the Annual Survey. Dietary Employee 11 was educated about wearing appropriate hair and beard net. Opened containers of food products that were undated were discarded. 2. Dietary Manager to complete kitchen rounds to verify that dietary employees always have hair and beard net in the dietary kitchen's areas and confined in a hair net or cap and have facial hair properly restrained. Food is labeled, dated, stored properly and variances to be corrected. 3. Dietary Manager or designee to review labeling/dating and staff attire policy which details dietary staff to verify food is labeled, dated, and stored properly and that employees have hair off the shoulders and confined in a hair net or cap and have facial hair properly restrained. Nursing Home Administrator or designee will complete weekly kitchen tours with dietary manager to ensure compliance. 4. Dietary Manager or designee to complete quality monitoring of food to assure food is labeled, dated, and stored properly and proper confinement of hair 5 X per week times 4 weeks then monthly. 5. The Dietary Manager or designee to present findings of quality monitoring at the Quality Assurance Performance Improvement Meeting monthly times one year. Quality monitoring schedule modified based on findings.
Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in a survey ending January 15, 2025. These deficiencies included unresolved grievances, outdated care plans, non-compliance with physician's orders, lack of nurse aide performance reviews, and failure to honor residents' food and drink preferences. The facility had previously developed plans of correction for these issues following a survey ending February 23, 2024, which included audits and reporting to the QAPI committee. However, the current survey revealed that these corrective measures were ineffective. The specific deficiencies cited in the current survey were under F585 for unresolved grievances, F657 for care plan updates, F684 for following physician's orders, F730 for nurse aide performance reviews, and F807 for honoring food and drink preferences. Despite the facility's efforts to address these issues through their QAPI committee, the repeated nature of these deficiencies indicates a failure to effectively implement and sustain corrective actions. The report highlights the facility's ongoing struggle to address and rectify these recurring issues, as evidenced by the ineffective performance of the QAPI committee in ensuring compliance with nursing home regulations.
Plan Of Correction
1. Previous leaderships have failed to comply with the regulation deficiency of 867. Current Nursing Home Administrator will monitor the scope of practice 867. 2. The Executive Director or designee will ensure that grievances were resolved, care plans were revised/updated, quality of care that physician's orders were followed, nurse aide's performance reviews were conducted, and food and drink preferences were honored. 3. The Director of Nursing (DON)/designee reeducated the licensed staff on the facility's care plan policy. The DON/designee reeducated the licensed nursing staff of the quality of care that physician's orders were followed. The DON/designee will ensure that the nurse aide performance's reviews were conducted. Executive Director (ED) reeducated the Human Resources Coordinator (HRC) and the Director of Nursing on the facility's employee job performance evaluation policy. The Human Resources Coordinator will notify the Director of Nursing of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner. 4. The Executive Director reeducated the department managers on the facility's Quality Improvement Performance Improvement (QAPI) policy and on the elements of QAPI. 5. The Director of Nursing/designee to conduct Quality Improvement monitoring of regulation F657 in correcting deficient practices related to revising/updating care plans. Audits will be completed of care plans on residents with pressure ulcers for goal dates to review and update care plan weekly X 8 weeks. The DON/designee to conduct Quality Improvement of regulation F684 in correcting deficient practices related to quality of care, following physician's orders. Audits of 5 residents receiving blood sugar checks for documentation of notifications per physician orders 5X per week X 2 weeks, weekly X 4. The HRC/Designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 730 to ensure nurse aide performance evaluations were completed annually based on hire date. QI monitoring conducted via nurse aide personnel file review weekly for 8 weeks. 6. Findings to be reported to the QAPI committee meeting and updated as indicated. Quality Improvement schedule modified based on findings.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the rooms of two residents. Observations of one resident revealed that her feeding pump was covered with a moderate amount of a light brown, sticky substance, and her overbed table had areas with a yellowish/white removable substance. Additionally, a stethoscope hanging from the feeding pump had a large amount of a bright white, dried substance on it. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that these items should have been clean but were not. In another resident's room, the wall behind the bed was found to have multiple scratches, cuts, and nicks. The Maintenance Director confirmed that the room required repairs and painting. These observations indicate a failure to provide a clean and homelike environment as per the facility's policy.
Plan Of Correction
1. Feeding pump, over bed table and stethoscope cleaned at time of survey. 2. All feeding pumps were identified and cleaned. 3. The Director of Nursing/Designee will educate staff on Cleaning and disinfecting resident care items. 4. Residents with feeding pumps will have audits completed for cleanliness of pumps and equipment 5x per week x2 weeks, then weekly x4 and monthly x1. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight. 1. Maintenance notified of wall scratches needing repair - Wall repaired. 2. Review completed of resident rooms to identify any other walls in need of repair. 3. The Director of Nursing/Designee will educate staff on Maintenance policy and maintenance request forms and document education. 4. Mock surveyors will monitor walls in resident rooms x5 per week x 2 weeks, then weekly x4, then Monthly x1. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.
Failure to Follow Abuse Policy and Verify Licensure
Penalty
Summary
The facility failed to adhere to its abuse policy for one of the residents reviewed, identified as Resident 28. The resident, who was cognitively intact and dependent on staff for all daily care needs, was subjected to verbal abuse by Nurse Aide 3. On October 31, 2024, Nurse Aide 3 was overheard telling Resident 28 to "shut up," which was confirmed by the facility's investigation. This incident led to the termination of Nurse Aide 3, as it was determined that the aide did not follow the facility's abuse policy. Additionally, the facility did not complete a professional licensure verification for one of the employees reviewed, Registered Nurse 2, with the Pennsylvania State Board of Nursing prior to her hire. Registered Nurse 2 was hired on September 10, 2024, but as of January 13, 2025, four months after her hire date, there was no documented evidence of licensure verification. This was confirmed by the Director of Human Resources, indicating a failure to comply with the facility's policy on verifying professional licensure before employment.
Plan Of Correction
1. Resident 28 currently resides in the facility and is safe for overall well-being. Nurse Aide 3 has been terminated on 11/4/2024. Registered Nurse 2's professional licensure verification with the Pennsylvania State Board of Nursing had been completed on 1/13/2025. 2. On 2/3/2025, the Nursing Home Administrator and Director of Nursing began re-education for all staff on abuse policy including procedure for reporting abuse, neglect, and resident rights. On 2/6/2025, in-service education began for all staff by the Social Services Director on abuse policy including procedure for reporting abuse, neglect, and resident rights. 3. Measures/systemic changes made to ensure that the deficient practice will not recur. Quarterly training will be conducted by the Social Worker for staff on abuse, neglect, and resident rights. Training for all staff on abuse, neglect, and resident rights to include reporting of abuse and neglect for newly hired employees. 4. The Social Services Director will complete resident interviews for abuse monitoring with interviewable residents weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. The Social Services Director will complete resident observation for indicators of abuse for residents considered non-interviewable weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. 5. Resident interviews for abuse monitoring will be reviewed by the Nursing Home Administrator weekly for 4 weeks, then monthly for 3 months, then quarterly thereafter. The facility plans to monitor performance to make sure solutions are sustained. 6. The Nursing Home Administrator will report all findings of resident interviews for abuse monitoring to the Quality Assurance and Performance Committee monthly for a minimum of 3 months.
Failure to Notify Responsible Parties and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to the resident, responsible party, and Ombudsman regarding the reason for hospitalization for two residents. According to the facility's Transfer/Discharge Notification policy, before a resident is transferred or discharged, the facility must notify the resident and their representative in writing and send a copy to the Ombudsman. However, this procedure was not followed for two residents who were transferred to the hospital. Resident 68, who was cognitively intact and required assistance for daily care, was transferred to the hospital after experiencing difficulty breathing. Despite the transfer, there was no documented evidence of written notification to the resident's responsible party and the Ombudsman. Similarly, Resident 70, who was cognitively impaired and dependent on staff, was transferred to the hospital following a fall that resulted in a head laceration. Again, there was no documented evidence of written notification to the responsible party and the Ombudsman. The Nursing Home Administrator confirmed the lack of written notices for both residents.
Plan Of Correction
1. The facility cannot retroactively perform notifications for residents Transferred/Discharged. 2. Will review the past 2 weeks of hospital discharges for notification. 3. The Director Of Nursing/Designee will educate Licensed staff on- Transfer/Discharge Notification and Right to Appeal and document education. 4. Audits of notifications and documentation to be completed on residents Transferred/Discharged to the hospital 5x per week x2 weeks, Weekly x4 and Monthly x1. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify appropriate parties about its bed-hold policy upon the transfer of two residents to the hospital. The facility's policy, dated March 18, 2024, mandates that written notice of bed-hold information be provided to each resident and their representative in accordance with state and federal law. However, for Resident 68, who was cognitively intact and required assistance for daily care needs, there was no documented evidence of such notification when she was transferred to the hospital on October 28, 2024, due to difficulty breathing. Similarly, Resident 70, who was cognitively impaired and dependent on staff for daily care needs, was transferred to the hospital on April 3, 2024, after a fall resulted in a bleeding laceration to the back of her head. Again, there was no documented evidence that the resident or her responsible party was notified about the bed-hold policy at the time of transfer. The Nursing Home Administrator confirmed the lack of documentation for both residents, acknowledging that a bed-hold notice should have been issued.
Plan Of Correction
1. The facility cannot retroactively notify of Bed Hold policy. 2. Will review the last 2 weeks of hospital transfers for bed hold notification. 3. The Director of Nursing/Designee will educate licensed staff on Bed Hold Policy and procedure and document education. 4. Audits of notifications will be completed on residents transferred out of facility to hospital 5x per week x2 weeks, Weekly x4, and Monthly x1. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 29, to reflect changes in her care needs. The facility's policy requires that an individualized person-centered plan of care be established and updated by the interdisciplinary team in accordance with state and federal regulatory requirements. A quarterly Minimum Data Set (MDS) assessment indicated that Resident 29 was cognitively impaired, dependent on staff for activities of daily living, and had diagnoses including dementia and high blood pressure. A consult note from a wound doctor confirmed that Resident 29 had no open wounds as of January 7, 2025. However, the current care plan, dated July 9, 2024, still listed a pressure ulcer on the resident's right heel. An interview with the Director of Nursing confirmed that the pressure ulcer was healed and the care plan should have been discontinued.
Plan Of Correction
1. The identified right heel care plan resolved at time of survey. 2. Facility pressure ulcer care plans reviewed for goal dates or need of resolution. 3. The Director Of Nursing/Designee will educate licensed staff on- Plan of Care Policy and document education. 4. Audits will be completed of care plans on residents with pressure ulcers for goal dates to review and update plan of care weekly x 8 weeks. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.
Inadequate Activity Provision for Residents
Penalty
Summary
The facility failed to provide adequate and ongoing activities to meet the needs of seven residents, as identified through clinical record reviews and interviews. These residents, who were mostly cognitively intact and dependent on staff for daily care, expressed the importance of participating in activities such as reading, listening to music, engaging in group activities, and attending religious services. However, the activity calendars for December 2024 and January 2025 showed a reduction in the number of activities offered compared to previous months. This reduction was attributed to the termination of two activity aides and the cutback in hours for the Activity Director, leading to fewer activities being scheduled. Residents expressed dissatisfaction with the reduced activity schedule during a resident council meeting and in interviews, highlighting the importance of activities like bingo, music, and religious services. The reduction in bingo sessions was particularly concerning as it affected residents' ability to earn points to purchase items, which was crucial for those without family support. Observations of a Sunday Social activity revealed a lack of engagement, with residents sitting quietly without refreshments. The Activity Director acknowledged the residents' requests for more activities but cited staffing and scheduling constraints as barriers to meeting these needs.
Plan Of Correction
1. Minimum Data Set (MDS) department will conduct a thorough review of all resident assessments to accurately identify individual interests, abilities, and needs. Activities Director will update all activities care plans to reflect specific activity preferences and goals for each resident. 2. Activities Director will update all activities care plans to reflect specific activity preferences and goals for each resident. 3. Executive Director will educate the Activities Director to develop a diverse and engaging activities calendar that caters to a variety of interests, including physical, cognitive, social, and spiritual needs. Incorporate resident input through suggestion boxes, resident council meetings, and individual discussions. As well as to design activities with varying levels of intensity to accommodate different abilities. 4. Activities Director/Designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 679 to ensure residents engage in activities programs that involve with residents' interests and abilities 5X a week for 4 weeks, then monthly. Findings to be reported to the Quality Improvement Performance Improvement (QAPI) committee meeting and updated as indicated. QI schedule modified based on findings.
Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to adhere to the prescribed transfer status for a resident, leading to a deficiency. Resident 68, who was cognitively intact and required two-person assistance for transfers, was involved in an incident where only one nurse aide attempted to transfer the resident from the bed to a wheelchair. During this transfer, the resident became weak and was slowly lowered to a sitting position on the floor. The resident, who had diagnoses of acute respiratory failure and muscle weakness, was assessed after the incident and found to have no injuries or complaints of pain. The Nursing Home Administrator confirmed that the transfer should have been conducted by two staff members, as per the resident's care requirements.
Plan Of Correction
1. Incident report/Investigation completed at time of incident. Immediate intervention, education and Relias training given to direct staff involved. 2. Care plan and Kardexs audited on residents for transfer statuses. 3. The Director Of Nursing/Designee will educate nursing staff on- Lifting and moving residents, Transfer/Mobility evaluation Low Lift, and Low Lift program and document education. Annual education to continue per facility protocol on transferring residents. 4. Audits/Staff interviews will be completed on 3 random staff members to ensure staff knowledge of where to obtain resident transfer status information 3x weekly x 2 weeks, then weekly x 4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.
Insufficient Staffing Affects Resident Activities and Dining
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, specifically in transporting them to activities and ensuring a licensed nurse was present in the main dining area during lunch and dinner. A grievance from a resident indicated that they were unable to attend activities due to the unavailability of nursing aides for transportation. Observations and interviews revealed that residents preferred to eat in the dining room but were not aware it was open, and they experienced long wait times for a nurse, leading them to eat in their rooms instead. Staff interviews confirmed that it was easier to serve residents in their rooms due to staffing constraints. The dietary delivery schedule showed specific times for meal deliveries, but the dining room was underutilized, with only one resident present during lunch. Interviews with nurse aides and the dietary manager confirmed that residents were not using the dining room due to staffing issues, as nurse aides were too busy with daily care tasks and lacked assistance from activity aides who had been let go. The Director of Nursing was unaware of the reasons behind the dining room's underuse and confirmed that residents should have been transported to activities by nurse aides.
Plan Of Correction
1. Facility unable to fix retroactively. Dining room times to be displayed along with daily meals outside of dining room. 2. Audits to be completed for each hall to obtain which residents would like to attend the dining room for meals. Dining services to be updated on current resident preference of meal location. 3. All staff will be educated on resident rights and dining room times. 4. Audit of dining room attendance will be completed 5x per week x2 weeks then weekly x 4. ED/Scheduler will review schedules 5x weekly to ensure adequate staffing to get residents to the dining room. Findings will be monitored by the Executive Director and reported to QAPI Committee for additional oversight. 5. Audit of activity attendance to be completed 5x per week x2 weeks then weekly x 4. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Improvement Committee for additional oversight.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, Nurse Aide 10 did not have a documented performance evaluation completed by the due date of September 24, 2024. As of January 15, 2025, there was no evidence of the evaluation being conducted. This deficiency was confirmed through a review of personnel files and an interview with the Director of Human Resources, who acknowledged the absence of the required documentation.
Plan Of Correction
1. No residents were identified with this alleged deficient practice. 2. The Human Resource Coordinator (HRC) reviewed the employee files for Certified Nurse Aides (CNA) who have been employed for at least one year to ensure performance evaluations were completed annually. Follow up completed based on findings. 3. The Executive Director (ED) reeducated the HRC and the Director of Nursing (DON) on the facility's employee job performance evaluation policy. The HRC will notify the DON of upcoming performance evaluations so that the appropriate supervisor can ensure that they are completed in a timely manner. 4. The HRC/Designee to conduct Quality Improvement (QI) monitoring of regulation deficiency of 730 to ensure nurse aide performance evaluations were completed annually based on hire date. QI monitoring conducted via nurse aide personnel file review weekly for 8 weeks. Findings to be reported to the Quality Improvement Performance Improvement (QAPI) committee meeting and updated as indicated. QI schedule modified based on findings.
Failure to Honor Resident Food and Drink Preferences
Penalty
Summary
The facility failed to honor residents' drink and food preferences, as revealed through observations and interviews with residents and staff. During a group interview, residents expressed dissatisfaction with the lack of availability of preferred items such as soda, dippy eggs, hot dogs, sausage, kielbasa, and ice cream. They reported that soda was only available when they were sick, and they were denied requests for these items, leading to feelings of joylessness. The Dietary Manager and Nursing Home Administrator confirmed that the facility's menu, determined by corporate, did not include these items due to budget constraints and safety concerns. The Dietary Manager mentioned that she sometimes used her own money to purchase requested items, and there was no facility policy regarding hot dogs as a choking hazard, despite a past choking incident.
Plan Of Correction
1. Residents' drink and food preferences will be honored depending on the resident's diet order and menu's availabilities. 2. Current residents will be reviewed for completion of food preference data collection. Residents and residents' families may bring in desired food and drinks. 3. Facility do not honor tubular food as relation to a choking hazard in other facility. Facility will provide same substance of tubular food, but not in tubular forms. Company did not developed a policy in regards to the facility not serving tubular meats. 4. Dietary and Nursing staff will receive training by the Nursing Home Administrator or designee on food preferences and will be reviewed upon admission, annually and as needed. 5. The Certified Dietary Manager or designee will conduct quality review of three resident meals weekly X 4 weeks, then monthly as needed to ascertain that food preferences are being honored. 6. Dietary Manager or designee to present findings of rounds/audits along with root cause analysis of any identified issues with findings to be reviewed to the Quality Assurance Performance Improvement Committee Meeting monthly for further analysis and corrective actions.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, the facility did not maintain the minimum staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on several days, including December 26, 2024, January 1, 2025, January 5, 2025, January 9, 2025, and January 10, 2025, where the number of NAs on duty was below the required levels based on the facility's census data. On December 26, 2024, the facility had a census of 84 residents, requiring 5.60 NAs for the night shift, but only 4.55 NAs were available. Similarly, on January 1, 2025, with a census of 84, the evening shift required 7.64 NAs, but only 7.46 were present. On January 5, 2025, with a census of 87, the day shift required 8.70 NAs, but only 7.85 were available, and the night shift required 5.80 NAs, but only 5.44 were present. On January 9, 2025, with a census of 88, the day shift required 8.80 NAs, but only 8.00 were available, the evening shift required 8.00 NAs, but only 7.75 were present, and the night shift required 5.87 NAs, but only 5.54 were available. Finally, on January 10, 2025, with a census of 89, the night shift required 5.93 NAs, but only 4.73 were present. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on January 15, 2025.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed 5X per week X 4 weeks, then weekly X 4 weeks. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules and staffing information. On December 31, 2024, the facility had a census of 85 residents, necessitating 2.83 LPNs for the evening shift, but only 2.40 LPNs were scheduled. On January 1, 2025, with a census of 84 residents, the day shift required 3.36 LPNs, yet only 3.30 LPNs were present. Additionally, the night shift on the same day required 2.10 LPNs, but only 1.18 LPNs were available. On January 3, 2025, the facility census was 86, requiring 3.44 LPNs for the day shift, but only 2.86 LPNs were scheduled. On January 5, 2025, with a census of 87 residents, the day shift required 3.48 LPNs, but only 3.27 LPNs were present, and the night shift required 5.80 LPNs, but only 5.44 LPNs were scheduled. The deficiency was confirmed through an interview with the Nursing Home Administrator on January 15, 2025, who acknowledged that the facility did not meet the required LPN-to-resident staffing ratios on the specified days. The report indicates that no additional higher-level staff were available to compensate for the staffing shortfalls, leading to non-compliance with the regulation effective July 1, 2023, which mandates specific LPN-to-resident ratios for different shifts.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on five occasions between December 25, 2024, and January 14, 2025. Specifically, the facility provided only 3.09 hours on December 25, 2024; 3.02 hours on January 1, 2025; 2.98 hours on January 3, 2025; 2.91 hours on January 5, 2025; and 2.88 hours on January 9, 2025. This deficiency was confirmed through a review of nursing schedules and an interview with the Nursing Home Administrator on January 15, 2025.
Plan Of Correction
1. The facility cannot retroactively correct nursing staffing hours and ratios. 2. The facility is focusing on the retention of existing nursing staff and recruiting new staff through the efforts of the staffing committee and human resource department. 3. The Executive Director (ED) re-educated the scheduler and nursing supervisors on the staffing ratios and hours per patient day (HPPD). Staffing meetings to review the calculations for nursing staff ratios and HPPD for accuracy. 4. The ED or Designees to conduct Quality Improvement (QI) monitoring of daily schedules to ensure the ratio of care/minimum PPD will be met. QI monitoring conducted via OnShift Daily Schedules reviewed weekly x 4 weeks, then once a month as needed. Findings reported to the Quality Improvement Performance Improvement (QAPI) committee and updated as indicated. QI monitoring schedule modified based on findings.
Failure to Provide Recommended Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices for eating in accordance with occupational therapy recommendations for a resident. The resident, who was cognitively intact and dependent on assistance for personal hygiene and eating, had medical conditions including tremors, spinal stenosis, hand contractures, and kyphosis. Occupational Therapy recommended the use of slightly built-up black handled utensils for meals. However, during a breakfast observation, the resident was found using a large handled spoon, which she found difficult to use due to her hand/finger contractures. Interviews with the Occupational Therapy Director and the Nursing Home Administrator confirmed that the resident should have been provided with the black handled utensils as recommended.
Failure to Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to ensure proper assessment and documentation of pressure ulcers for two residents. Resident 1, who was cognitively impaired and required assistance with daily care, had new pressure areas identified on the heels and coccyx. Despite physician's orders for treatment, there was no documented evidence of weekly wound assessments or documentation from late July through early September. Similarly, Resident 3, who had a traumatic brain injury with paraplegia and cellulitis, had an open area on the right buttock. Although there were physician's orders for wound care, only two weeks of wound documentation were found during the same period. Interviews with facility staff confirmed that weekly wound assessments were not conducted as required by the facility's policy. The residents were followed by an outside wound clinic, which determined the wound treatments, but the facility was still responsible for completing the assessments. The Nursing Home Administrator acknowledged that the care plans for both residents included weekly wound assessments that were not performed by the facility.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure the consistent services of a full-time Director of Nursing (DON) for 35 or more hours a week. The job description for the DON outlines the responsibility of planning, organizing, developing, and directing the overall operation of the nursing service department in accordance with federal, state, and local standards. However, interviews with the Regional Nurse Consultant and the Nursing Home Administrator revealed that the facility has not had a full-time DON for several weeks. The Regional Nurse Consultant has been attempting to cover the DON position but is frequently required to work on the floor as a registered nurse, preventing her from fulfilling the DON duties. The facility is in the process of hiring a new DON, but the position remains unfilled, leading to the deficiency.
Failure to Ensure Full-Time Director of Nursing
Penalty
Summary
The facility failed to ensure the consistent services of a full-time Director of Nursing (DON) working 35 or more hours a week. The job description for the DON indicates that the role involves planning, organizing, developing, and directing the overall operation of the nursing service department in accordance with federal, state, and local standards. Registered Nurse 1 started as the interim DON on May 1, 2024, but has not been present in the facility for the past two weeks. This absence was confirmed by the Registered Nurse Assessment Coordinator (RNAC) and the interim Nursing Home Administrator during interviews conducted on May 13 and May 16, 2024. Additionally, the facility is currently searching for an administrator, DON, and an Assistant Director of Nursing (ADON), as they do not have an ADON at present. The interim Nursing Home Administrator confirmed that there was no documented evidence that Registered Nurse 1 worked 35 or more hours a week in the facility as the DON. This lack of consistent leadership in the nursing department is a violation of the facility's responsibilities as outlined in 28 Pa Code 201.3 Definitions, 28 Pa Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(6) Management, and 28 Pa. Code 211.12(b)(c)(d) Nursing Services.
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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