Rose View Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsport, Pennsylvania.
- Location
- 1201 Rural Avenue, Williamsport, Pennsylvania 17701
- CMS Provider Number
- 395767
- Inspections on file
- 25
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rose View Rehab And Care Center during CMS and state inspections, most recent first.
Two residents did not receive required immunizations as per CDC guidelines: one resident consented to but did not receive the current season's influenza vaccine, and another had no record of receiving a pneumococcal conjugate vaccine despite prior administration of Pneumovax 23. These deficiencies were confirmed through record review and staff interviews.
Over a 21-day period, the facility did not meet the required minimum nurse aide-to-resident ratios for day, evening, and overnight shifts, as confirmed by staffing records and the Administrator. The deficiency was identified through a review of census and staffing data, showing consistent understaffing compared to regulatory requirements.
The facility did not provide the required minimum number of LPNs per resident on both day and overnight shifts for the majority of days reviewed, as confirmed by staffing records and administrative interview.
A review of staffing records and an interview with the Administrator confirmed that the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day over a 21-day period, with actual hours per patient day consistently below the regulatory standard.
The facility was found to have a building construction deficiency due to missing ceiling tiles in the first floor Maintenance Storage Room, affecting one of nine smoke compartments. This was confirmed during an exit interview with the Facility Administrator.
The facility did not maintain the exit stair tower enclosure, impacting all floors. An observation revealed that the fire exit hardware on the first floor's west stair tower enclosure exit discharge door was missing an end cap. This issue was confirmed with the Facility Administrator.
The facility has a deficiency in the protection of hazardous areas, such as boiler rooms and laundries, which are not adequately enclosed with a fire barrier or automatic fire extinguishing system. The required smoke-resisting partitions and doors are not installed, posing a risk to safety.
The facility failed to maintain smoke-tight doors in hazardous areas and ensure proper latching of corridor doors, affecting smoke compartments. Observations revealed that the Soiled Utility Room door was not smoke-tight, and the Dietary door failed to close and latch due to door drag. These deficiencies were confirmed during an exit interview with the Facility Administrator.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly documented as having pneumonia after it was resolved, and another was inaccurately recorded as discharged to a hospital instead of home. These errors were confirmed by the facility's administration.
A facility failed to administer bowel protocol medications for a resident experiencing constipation, as documented in their clinical records. Despite physician orders for a sequential administration of Milk of Magnesia, Bisacodyl Suppository, and Fleet's Enema, there was no documentation of these medications being given or refused on several occasions. The DON confirmed the failure to provide the highest practicable care in this instance.
A resident did not receive new glasses recommended by an eye care group, despite a previous appointment. The resident's broken eyeglasses were observed, and the Nursing Home Administrator confirmed the glasses were never delivered.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying specific triggers that could lead to re-traumatization. The care plan included general interventions but lacked details on managing PTSD triggers. The Nursing Home Administrator admitted that the facility did not inquire about the resident's triggers until prompted by a surveyor.
The facility's main kitchen was found to have unsanitary conditions, including missing grout and debris buildup around the dish machine area, and broken tiles with dirt accumulation in the kitchen entrance. These issues were observed during a survey with the dietary manager, raising sanitation concerns in the food preparation area.
A facility failed to administer a pneumococcal vaccine to a resident despite having consent from the responsible party. The resident's immunization history lacked evidence of the vaccine, and the Nursing Home Administrator confirmed the absence of documentation offering the immunization after consent was obtained.
A facility failed to document the disposition of a resident's personal belongings after discharge. A resident was admitted and later discharged home, but the personal belongings inventory form was not signed by the resident or responsible party, and there was no documentation indicating what happened to the belongings.
A facility failed to document the disposition of medications for a resident who expired, including Atorvastatin, Insulin Glargine, and Metformin HCL, among others. This deficiency was identified through a closed clinical record review and staff interview, revealing a lack of documentation in the resident's clinical record upon discharge.
The facility failed to meet required nurse aide-to-resident ratios across multiple shifts, with significant understaffing noted during day, evening, and overnight shifts. Additionally, there was no evidence of the disposition of a resident's medications upon their death, indicating procedural lapses in medication management.
The facility failed to meet the required LPN staffing levels, with deficiencies noted during the day, evening, and overnight shifts. The review revealed multiple instances of understaffing, with the number of LPNs consistently below the required levels, potentially affecting resident care.
The facility did not meet the required 3.2 hours of direct resident care per patient day for 20 out of 21 days reviewed. Nursing care hours ranged from 2.81 to 3.19 hours PPD, falling short of the regulatory requirement. This was confirmed through staffing hour reviews and an administrator interview.
A resident ingested medications intended for another resident after an LPN left them unattended on a bedside table. The resident, who was independent in his wheelchair, experienced hypotension and an altered mental state, requiring emergency medical intervention. This incident highlights a significant medication administration error.
Failure to Ensure Influenza and Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure proper administration of influenza and pneumococcal immunizations for two residents as required by CDC guidelines and federal regulations. For one resident, clinical record review showed that although she had provided informed consent for the influenza vaccine for the current season, there was no evidence in her medical record that she received the vaccine. Staff documented that she was not eligible for the vaccine because she had received it previously, but the record only showed administration for the prior season, not the current one. Interviews with the Nursing Home Administrator confirmed the absence of documentation or evidence that the resident received the influenza vaccine for the current season, despite being eligible and having consented. For another resident, review of immunization records revealed that she had received two doses of the pneumococcal polysaccharide vaccine (Pneumovax 23) prior to admission, but there was no evidence that she had ever received a pneumococcal conjugate vaccine (PCV), as recommended by the CDC for adults of her age group. This finding was confirmed by interviews with the Nursing Home Administrator and the Director of Nursing. The lack of documentation and administration of the recommended vaccines for both residents constituted a failure to comply with immunization requirements.
Failure to Meet Minimum Nurse Aide Staffing Ratios Across All Shifts
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing ratios for all three shifts over a 21-day review period. Specifically, during the day shift, the number of nurse aides consistently fell below the mandated ratio of one nurse aide per ten residents on all 21 days reviewed. The evening shift also did not meet the required ratio of one nurse aide per eleven residents on 16 out of 21 days. Similarly, the overnight shift failed to provide at least one nurse aide per fifteen residents on 20 out of 21 days. These findings were based on a review of staffing records, which detailed the census and number of nurse aides present for each shift and day within the review period. An interview with the Administrator confirmed the accuracy of the staffing data and the facility's failure to meet the minimum nurse aide requirements as outlined by regulation. The report does not mention any specific residents or their medical conditions, nor does it describe any direct patient outcomes related to the staffing deficiencies. The deficiency is solely based on the facility's inability to provide the required number of nurse aides per shift according to the resident census.
Plan Of Correction
P 5520 Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. P5520 1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in attempt to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) as mandated by regulation. Specifically, during the day shift, the facility did not provide at least one LPN per 25 residents for 14 out of the 21 days reviewed. The documented LPN staffing levels on these days were consistently below the required ratio based on the daily census, with several days showing a shortfall in the number of LPNs scheduled compared to what was required. Additionally, on the overnight shift, the facility did not meet the minimum requirement of one LPN per 40 residents for 20 out of the 21 days reviewed. The staffing records indicated that the number of LPNs present was frequently less than the required amount, with some nights having only one LPN when more were needed according to the resident census. These findings were confirmed during an interview with the Administrator, who acknowledged the discrepancies in LPN staffing levels during the specified review period.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. The facility offers bonuses to current staff in an effort to schedule more staff per shift. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day, as mandated effective July 1, 2024. A review of nursing staff care hours for the period from July 11, 2025, through July 31, 2025, showed that on each of the 21 days reviewed, the facility did not meet this minimum standard. The reported hours per patient day (PPD) ranged from 2.41 to 3.05, consistently falling short of the regulatory requirement. This deficiency was confirmed through both a review of staffing records and an interview with the Administrator, who acknowledged the findings. The report does not mention any specific residents or their medical conditions, nor does it provide details about the impact on individual patients. The deficiency is solely based on the facility's failure to meet the mandated nursing care hours across the entire facility during the specified period.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. In order to recruit and retain staff, facility has an active nurse aide training course that runs continuously to hire and train new CNAs. Facility recently put up a recruitment billboard to attract nurses and CNAs. Facility also has active job ads and recruiters who work around the clock to interview and hire new staff. Facility continuously hosts staff morale events, staff spotlights, and monthly caught caring awards to retain current staff. Facility offers bonuses to current staff in an effort to get more staff scheduled per shift. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Building Construction Deficiency: Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by an observation on December 30, 2024. During the inspection, it was noted that the ceiling tiles were missing in two locations within the first floor Maintenance Storage Room. This deficiency affected one of the nine smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator on the same day.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. 1. Both ceiling tiles were replaced with a rated ceiling tile. 2. Other ceiling tiles will be checked to ensure they are in place. 3. Maintenance will be re-educated on ensuring that ceiling tiles are in place. 4. Maintenance Director/ designee will conduct random audits to verify that ceiling tiles are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Stair Tower Enclosure Deficiency
Penalty
Summary
The facility failed to maintain the exit stair tower enclosure, affecting all three floors. During an observation on December 30, 2024, at 10:40 a.m., it was noted that the fire exit hardware on the first floor's west stair tower enclosure exit discharge door was missing an end cap. This deficiency was confirmed during an exit interview with the Facility Administrator later that morning.
Plan Of Correction
1. Missing end cap on the first floor west stair tower door was replaced. 2. Other stair tower door enclosures will be checked for missing end caps. 3. Maintenance will be re-educated on ensuring that door enclosures have end caps installed. 4. Maintenance Director/ designee will conduct random audits to verify that exit hardware end caps are in place weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The report identifies a deficiency in the protection of hazardous areas within the facility. Specifically, hazardous areas such as boiler and fuel-fired heater rooms, laundries larger than 100 square feet, repair, maintenance, and paint shops, soiled linen rooms exceeding 64 gallons, trash collection rooms exceeding 64 gallons, combustible storage rooms or spaces over 50 square feet, and laboratories classified as severe hazard are not adequately enclosed. These areas are required to be protected by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system. However, the report indicates that the separation of these areas is not achieved as there is no automatic sprinkler system in place, and the necessary smoke-resisting partitions and doors are not installed as per the standards outlined in sections 8.4 and 19.3.5.9. This lack of compliance with fire safety regulations poses a significant risk to the safety of the facility's occupants.
Plan Of Correction
1. Soiled utility room door will be adjusted for smoke-tight gap. 2. Soiled utility room door gaps will be checked for smoke-tight gap. 3. Maintenance will be re-educated on ensuring that all doors are smoke-tight. 4. Maintenance Director/designee will conduct random audits to verify that doors are smoke-tight weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at QAPI meeting for review and recommendations.
Deficiencies in Door Maintenance Affecting Smoke Compartments
Penalty
Summary
The facility was found to have deficiencies in maintaining hazardous area enclosures and corridor openings, affecting smoke compartments. On December 30, 2024, an observation revealed that the door to the Soiled Utility Room on the second floor was not smoke-tight, which is a requirement for hazardous area enclosures. This deficiency was confirmed during an exit interview with the Facility Administrator. Additionally, another deficiency was noted on the same day when the first-floor Dietary door failed to close and latch properly due to door drag. This issue was also confirmed during the exit interview with the Facility Administrator. Both deficiencies indicate a failure to comply with the requirements for doors protecting corridor openings, which are essential for resisting the passage of smoke and ensuring safety in the event of a fire.
Plan Of Correction
1. Door will be replaced so it will close and latch properly. 2. Other doors enclosures will be checked to verify closing and latching. 3. Maintenance will be re-educated on ensuring that all door enclosures are closing and latching. 4. Maintenance Director/ designee will conduct random audits to verify that door enclosures are closing and latching weekly for 4 weeks and then monthly for 2 months thereafter. Audits results will be presented at the QAPI meeting for review and recommendations.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents. Resident 102 was admitted with pneumonia, which was resolved by October 10, 2024. However, the MDS assessment dated November 15, 2024, incorrectly indicated that the resident still had pneumonia, despite no evidence in the clinical record supporting this. The error was confirmed by the Administrator. Resident 108's MDS assessment inaccurately documented a discharge to a hospital setting, while physician progress notes indicated the resident was discharged home. This discrepancy was confirmed by the Nursing Home Administrator. These inaccuracies in MDS assessments were previously cited on December 1, 2023, under the regulation S483.20(g) for the accuracy of assessments.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. F0641 1. MDS corrections were submitted for residents 102 and 108. 2. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section I 2000. Current residents with MDS completed from January 6, 2025, through January 20, 2025, will be reviewed to determine accuracy of section A2105. 3. Education will be completed with Social Services on accuracy of section A 2105 of the MDS. Education will be provided to the RNAC on accuracy of section I 2000 of the MDS. 4. Random audits will be completed by DON or designee weekly for 4 weeks, then monthly for 2 months of residents' MDS to ensure accuracy of sections A 2105 and I 2000. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Administer Bowel Protocol Medications
Penalty
Summary
The facility failed to provide the highest practicable care for a resident regarding the administration of bowel protocol medications. A clinical record review revealed that the resident had difficulty passing stool, as noted in a medical provider's progress note. Despite physician orders for a bowel protocol that included Milk of Magnesia, Bisacodyl Suppository, and Fleet's Enema to be administered sequentially if constipation persisted, there was no documentation indicating that these medications were administered or refused by the resident on several specified dates. The Director of Nursing confirmed the findings that the facility did not initiate the bowel protocol as ordered. The lack of documentation on the medication administration record (MAR) for the specified dates indicates a failure to adhere to the prescribed bowel protocol, which was intended to address the resident's constipation issues. This oversight in medication administration and documentation led to the deficiency noted in the report.
Plan Of Correction
F0684 1. The bowel protocol medication administration cannot be retroactively implemented for resident 48. 2. Audit will be completed for current residents' bowel elimination records from January 6, 2025 - January 13, 2025 to ensure that appropriate bowel protocol interventions are being administered. 3. Education will be provided to licensed staff on ensuring that the bowel protocol is being followed. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months to ensure appropriate bowel protocol interventions are being administered. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Provide New Glasses to Resident
Penalty
Summary
The facility failed to provide proper treatment to maintain vision for a resident with vision concerns. An interview with the resident revealed that she had seen an eye doctor a long time ago and had not received her new glasses. Observation of the resident's overbed table showed a pair of broken eyeglasses with one lens missing. A review of the resident's clinical record indicated that she had an appointment with Health Drive Eye Care Group, which recommended new glasses to be delivered upon arrival. However, an interview with the Nursing Home Administrator confirmed that the resident never received the new glasses ordered several months prior.
Plan Of Correction
1. Resident 41's glasses will be delivered. 2. Current residents will be audited to ensure they have received their glasses if recommended by their optometrist. 3. Education will be completed with social services on ensuring residents receive their glasses timely. 4. Audits will be completed by the Social Services Director or designee monthly for 3 months to validate that residents with recommendations for new glasses receive them. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The clinical record review revealed that the resident was admitted on March 1, 2023, with a diagnosis of PTSD. The care plan for the resident included goals and interventions to improve mood and manage PTSD symptoms, such as administering medications, monitoring for side effects, and providing behavioral health consults as needed. However, the facility did not identify specific triggers related to the resident's PTSD that could lead to re-traumatization. An interview with the Nursing Home Administrator revealed that the facility did not inquire about the resident's PTSD triggers from his wife until after the surveyor's inquiry. The administrator confirmed that the resident's wife was unaware of specific triggers but mentioned that the resident would wake up and move to another room when experiencing PTSD-related issues. This lack of proactive identification and management of PTSD triggers in the care plan led to the deficiency, as the facility did not adequately address the potential for re-traumatization of the resident.
Plan Of Correction
F0699 1. Resident 57 and his wife reported no triggers to his PTSD and would not discuss further. 2. Audit of current residents with diagnoses of PTSD will be audited to ensure they have specific triggers in their PTSD care plans. 3. Education will be completed with social services on identifying and care planning specific triggers for a resident with the diagnosis of PTSD. 4. Random audits will be completed weekly by the Social Services Director or designee for 4 weeks then monthly for 2 months to ensure residents with a diagnosis of PTSD have specific triggers in their PTSD care plans. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Sanitation Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain the food preparation and dishwashing area in a safe and sanitary manner in the main kitchen. During an observation with the dietary manager, it was noted that the flooring tiles surrounding the dish machine area lacked grout, leading to a buildup of liquid and food debris between the tiles. Additionally, multiple vinyl tiles in the kitchen entrance area, surrounding the ice machine and production area, were broken and cracked, accumulating dirt and debris. These conditions present sanitation concerns in a food preparation area. Furthermore, significant black buildup was observed where the tile meets the wall and the transition strip from the kitchen to the dish machine room.
Plan Of Correction
F0812 1. Grout in the dishroom around the dish machine area was cleaned and a vendor will be secured to complete the grout replacement. A vendor will be secured to fix the vinyl tiles around the ice machine and production area inside the entrance area. The threshold from the kitchen to the dish machine room was cleaned. 2. Audit will be completed of the dish room to ensure the grout is present and kitchen floor to ensure there are no cracked or broken vinyl tiles. Other thresholds in the kitchen will be checked to ensure they do not have black buildup. 3. Education will be completed with maintenance staff on maintaining the kitchen floor tiles and grout. Education will be completed with dietary staff on keeping the kitchen thresholds free of black buildup. 4. Random audits will be completed by the Dietary Manager or designee weekly for 4 weeks then monthly for 2 months to ensure the threshold from the kitchen to the dish room is free of black buildup. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal immunization, as required. Resident 5 was admitted to the facility on December 3, 2018, and a review of their immunization history showed no evidence of receiving the recommended pneumococcal vaccine. Although a Pneumococcal Immunization Informed Consent was signed by Resident 5's responsible party on November 18, 2024, granting permission for the vaccination, there was no documented evidence that the facility offered or administered the pneumococcal immunization to the resident after obtaining consent. During an interview with the Nursing Home Administrator on December 20, 2024, it was confirmed that the facility did not have documentation showing that the pneumococcal immunization was offered to Resident 5 following the consent. This deficiency was noted in the context of a previous citation for similar issues related to nursing services.
Plan Of Correction
1. Resident 5 refused to have his pneumococcal vaccine administered and it was documented. 2. Audit will be completed of current residents to ensure those residents who consented to receive the pneumococcal vaccine have received it or documented refusal. 3. Education will be provided to the Infection Preventionist on ensuring those residents who consent to the pneumococcal vaccine receive it. 4. Random audits will be completed weekly for 4 weeks then monthly for 2 months to ensure residents who have newly consented to receiving the pneumococcal vaccine are offered it. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Disposition of Resident's Belongings Post-Discharge
Penalty
Summary
The facility failed to meet the regulation regarding the protection of personal and property rights of residents, specifically concerning the return of personal property after discharge. This deficiency was identified through a clinical record review and staff interview, which revealed that there was no evidence documenting the disposition of a resident's personal belongings following their discharge. Resident 108 was admitted to the facility on February 8, 2024, and discharged home on November 11, 2024. However, the personal belongings inventory form for Resident 108 was not signed by the resident or their responsible party upon discharge, and there was no documentation in the closed clinical record indicating what happened to the resident's personal belongings after they left the facility.
Plan Of Correction
P1210 1. A signed belonging sheet cannot be retroactively produced for resident 108. 2. Audit will be completed of residents who have discharged from facility from January 6, 2025, to January 13, 2025, to ensure that disposition of their personal property was completed. 3. Education will be provided to licensed nursing staff on ensuring disposition of residents' personal property is completed and documented at the time of discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months, on residents who have discharged from the facility to ensure disposition of their personal property is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Medication Disposition for Deceased Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 110, who expired at the facility on November 19, 2024. A closed clinical record review revealed that there was no documented evidence regarding the disposition of several medications prescribed to Resident 110. These medications included Atorvastatin, Cyanocobalamin, Insulin Glargine, Melatonin, Metoprolol Succinate, Pantoprazole Sodium, Magnesium Oxide, Metformin HCL, and Ranolazine. The deficiency was identified based on a closed clinical record review and staff interview, which confirmed the lack of documentation in the clinical record upon the resident's discharge. The facility's failure to document the disposition of these medications is a violation of the regulation requiring control and accountability of medications awaiting final disposition, as well as proper documentation of the actual disposition of medications.
Plan Of Correction
1. A disposition of medication for resident 110 cannot be retroactively produced. 2. An audit will be completed of residents who have discharged from the facility from January 6, 2025, to January 13, 2025, to ensure that a disposition of medication is completed upon discharge. 3. Education will be provided to licensed nursing staff on ensuring a disposition of medication is completed upon resident discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months on residents who have discharged from the facility to ensure disposition of medication is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Staffing and Medication Management Deficiencies
Penalty
Summary
The facility was found to have deficiencies in nursing services, specifically in maintaining the required nurse aide-to-resident ratios during various shifts. The report highlights that for 15 out of 21 days reviewed, the facility did not meet the minimum requirement of one nurse aide per 10 residents during the day shift. Similarly, the evening shift was understaffed for eight out of 21 days, failing to meet the one nurse aide per 11 residents requirement. The overnight shift was also deficient, with 17 out of 21 days not meeting the one nurse aide per 15 residents standard. These findings were confirmed through a review of nursing care hours and staff interviews. Additionally, the report notes a specific incident involving Resident 110, where there was no evidence of the disposition of the resident's medications upon their death. This was confirmed during an interview with the Nursing Home Administrator. The lack of documentation regarding the handling of medications post-mortem indicates a lapse in the facility's procedures for managing resident medications, contributing to the overall deficiencies identified in the report.
Plan Of Correction
1. Findings of nurse aide nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one nurse aide per 10 residents during day shift and one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure nurse aide coverage. 3. Scheduling manager will be educated on the requirements there must be a minimum of one nurse aide per 10 residents during day shift and a minimum of one nurse aide per 11 residents on evening shift and one nurse aide per 15 residents on overnight shift. 4. Director of Nursing or Designee will conduct random audits to verify that nurse aide day shift, evening shift ratios and overnight shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by the regulation effective July 1, 2023. Specifically, the facility did not maintain the minimum staffing levels of one LPN per 25 residents during the day shift, one LPN per 30 residents during the evening shift, and one LPN per 40 residents during the overnight shift. This deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Administrator. The review covered specific periods in November and December 2024, revealing multiple instances where the number of LPNs on duty was below the required levels. During the day shift, the facility was understaffed on six occasions, with the number of LPNs ranging from 4 to 4.16, while the required number ranged from 4.32 to 4.44 based on the census. The evening shift was understaffed on one occasion, with 3.44 LPNs instead of the required 3.63. The overnight shift showed the most significant deficiency, with 14 instances of understaffing, where the number of LPNs ranged from 2 to 2.08, while the required number ranged from 2.68 to 2.80. These findings indicate a consistent failure to meet the staffing requirements, potentially impacting the quality of care provided to the residents.
Plan Of Correction
P5530 1. Findings of LPN nursing staff care ratios cannot be retroactively corrected. 2. Facility will provide a minimum of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure LPN coverage. 3. Scheduling manager will be educated on the requirements of one Licensed Practical Nurse per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift and a minimum of one LPN per 40 residents during the night shift. 4. Director of Nursing or Designee will conduct random audits to verify that LPN day shift, evening shift and night shift meet the requirements weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Failure to Meet Minimum 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 patient day (PPD) for 20 out of the 21 days reviewed. Specifically, during the periods from November 10 to November 16, November 24 to November 30, and December 13 to December 19, 2024, the facility consistently fell short of the required nursing care hours. The daily PPD ranged from 2.81 to 3.19 hours, with most days not reaching the mandated 3.2 hours. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Administrator on December 19, 2024.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.
Resident Ingests Wrong Medications Due to LPN Error
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by an incident involving Resident 4. During a medication administration, Employee 1, a licensed practical nurse, left medications intended for Resident 3 unattended on a bedside table while Resident 3 was being assisted to the bathroom. Resident 4, who was in the same room and independent in his wheelchair, ingested the medications left for Resident 3. This error was discovered when Employee 1 returned to the room after retrieving a pain pill for Resident 4. As a result of ingesting the wrong medications, Resident 4 experienced hypotension and an altered mental state, necessitating emergency medical intervention. The resident was sent to the emergency department, where he was treated with intravenous fluids and observed for several hours. Despite initial stabilization, Resident 4 experienced another episode of hypotension, requiring further medical attention. The incident highlights a significant lapse in medication administration protocols, leading to adverse health effects for Resident 4.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
