Transitions Healthcare Shook Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chambersburg, Pennsylvania.
- Location
- 55 South Second Street, Chambersburg, Pennsylvania 17201
- CMS Provider Number
- 395918
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Transitions Healthcare Shook Home during CMS and state inspections, most recent first.
A resident with dementia and HTN had an order for daily losartan with instructions to hold the dose for low BP, but nursing staff did not consistently document BP readings with each administration and only a few BP entries coincided with dosing. On several occasions the medication was held for a low pulse, which was not part of the MD’s hold parameters, and on one occasion it was held for a low BP that did meet the ordered criteria. The DON acknowledged she could not verify that BPs were consistently taken before giving the medication and confirmed that BP values should have been documented with each dose to show compliance with the ordered parameters.
Surveyors identified multiple failures to follow facility food safety policies, including undated bulk dressings and bread products, inadequately covered vegetables in the walk-in cooler, dirty equipment and surfaces, and cups and plates stored upright and uncovered. A cook handled carrots from a bulk container without gloves while manipulating the plastic liner, and the kitchen lacked written cleaning protocols or logs. In two kitchenettes and a rehab unit refrigerator, surveyors found spills, food debris, toaster crumb buildup, unlabeled and undated personal food items, missing or broken thermometers, and plates and dome lids stored upright and uncovered. Review of temperature logs showed staff did not consistently check cold food and beverage temperatures at point of service, despite policies requiring cold foods to be maintained at or below 41°F and all refrigerated foods to be covered, labeled, dated, and monitored.
A nurse failed to maintain a professional appearance and follow identification and entry protocols, affecting a resident’s dignity. Facility policy required staff to wear professional attire (such as scrubs), avoid sweatpants and revealing clothing, and wear name tags. An LPN was observed wearing sweatpants with decorative appliques and a short shirt exposing the abdomen, without a name tag. The LPN acknowledged knowing she was supposed to wear a name tag. Later, the same LPN entered a resident’s room without knocking, still in the same attire and without identification, did not introduce herself, and only stated she had the resident’s medications. Facility leadership later acknowledged the nurse was not appropriately dressed and confirmed expectations for proper identification and self-introduction.
Surveyors found that a resident with muscle weakness and depression did not receive care consistent with their documented bathing preferences. Facility policy required individualized, measurable care plans reflecting residents' expressed wishes. The resident's care plan indicated a preference for weekly showers, but documentation over a one-month period showed only one shower and bed baths otherwise. The resident reported that showers were "few and far between," and the DON acknowledged the resident occasionally refused showers and that, due to the resident's high cognition, staff presumed autonomy rather than ensuring preferences were fully care planned and consistently followed.
The facility failed to revise care plans to reflect resolution of acute conditions for three residents. One resident with hypertension and chronic diastolic CHF continued to have an active influenza care plan focus after the flu had resolved. Another resident with vascular dementia and hearing loss had an active UTI care plan focus that was not updated when the infection cleared. A third resident with Parkinson’s disease and urinary retention had a prior UTI that remained listed as an active problem months after it had resolved. The DON and NHA acknowledged that care plans should be revised to reflect current resident status.
Surveyors found that the facility failed to follow its own policy for medication storage and beyond-use dating. In a medication room, an open multidose tuberculin vial lacked an open date, expired needles remained in stock, and an open vial of insulin lispro had not been discarded per dating requirements. On a medication cart, an open bottle of LiquaCel and an open Lantus insulin pen were also missing open date labels. Staff, including the NHA and DON, confirmed that these items should be dated when opened and expired medications and supplies should be discarded.
A deficiency was cited when staff failed to implement infection control policies for a resident with a stage 3 sacral pressure ulcer and diabetes. Facility policy required enhanced barrier precautions for residents with wounds under specified conditions, yet there was no door signage indicating the need for PPE, no physician order for enhanced barrier precautions, and no related care plan. A wound consult documented an open, healing stage 3 sacral ulcer, but the DON reported she believed the ulcer had closed and that enhanced barrier precautions were no longer necessary.
The facility’s antibiotic stewardship program allowed interrupted antibiotic therapy for a resident with a confirmed Proteus mirabilis UTI. Policy required using C&S results and clinical status to determine whether to start, continue, modify, or discontinue antibiotics, and cited guidance indicated that lapsed or missed doses early in treatment reduce efficacy and that complicated UTIs should be treated with ciprofloxacin 500 mg BID for 7 days. Instead, the provider ordered ciprofloxacin 250 mg BID for 3 days, which was stopped after a RN reported no UTI symptoms, consistent with the ICP’s description that this provider typically uses 3‑day courses with RN reassessment and discontinuation if asymptomatic. Days later, the resident was found to have suprapubic tenderness and was started on a new 7‑day course of ciprofloxacin 500 mg BID for a complicated UTI, demonstrating that the program permitted lapsed antibiotic dosing.
The facility did not maintain stairtower doors within the allowed gap margins on two floors. Observations revealed that the doors on the 1st and 2nd floors of Stairtower A had gaps exceeding 1/8 inch, confirmed by the Director of Maintenance.
The facility was found deficient in maintaining hazardous area enclosures, as the ground floor Pool Area was used for storing medical record boxes and isolation containers without a 1-hour fire-rated barrier. This was confirmed by the Director of Maintenance.
The facility failed to comply with NFPA 101 standards by storing three 96-gallon shredder containers in a non-rated ground floor lobby. The containers exceeded the 32-gallon limit for unattended storage without a 1-hour fire-rated protection. The Director of Maintenance confirmed the non-compliance.
The facility did not post the most recent survey results in an accessible location, as required by regulations. The survey binder in the main entrance lobby contained outdated results from August 2023, despite a more recent survey conducted in March 2025. The Nursing Home Administrator confirmed the expectation for up-to-date survey books.
The facility failed to provide complete transfer notices for three residents hospitalized due to serious medical conditions. The notices lacked essential information such as the transfer location, appeal rights, and contact details for advocacy agencies. The Nursing Home Administrator confirmed these deficiencies during an interview.
A facility failed to monitor and manage a resident's fluid intake, who had a physician-ordered fluid restriction due to chronic health conditions. The resident consumed more fluids than prescribed on two occasions, and there was no documentation of fluid intake during medication administration or communication with the physician about the excess intake. The DON confirmed the lack of monitoring and documentation.
The facility failed to maintain sanitary conditions during food preparation and service. Observations showed staff using the same gloves to handle both meal tickets and food items, and some staff touched food with bare hands. The DON confirmed that tongs and gloves should have been used, and the NHA stated that bare hand contact with food is not acceptable.
A resident reported wanting to attend a church activity but was allegedly told by a nurse aide to go to bed instead. The incident was not reported immediately as required, with delays in both the investigation and notification to the state agency. The facility's policy mandates immediate reporting of such allegations, which was not followed, resulting in a deficiency.
The facility failed to develop comprehensive care plans for two residents, one with atrial fibrillation and heart failure, lacking anticoagulant medication planning, and another with dementia, missing cognitive impairment details. These omissions were confirmed by the NHA and DON.
The facility failed to update care plans for two residents. One resident with edema and a physician's order for TED stockings did not have these reflected in their care plan. Another resident's care plan incorrectly included a focus on smoking, despite the facility's non-smoking policy and the resident not being an active smoker. These issues were confirmed by the DON and NHA.
A facility failed to align a resident's advanced directives with their physician orders. The resident, with Alzheimer's and type 2 diabetes, had a POLST form indicating DNR status, but physician orders incorrectly stated Full Code. This inconsistency was confirmed by the Nursing Home Administrator.
A facility failed to provide care consistent with professional standards for a resident with a pressure ulcer. The dressing was not dated or timed, and the RN did not wear a protective gown during the dressing change, violating the facility's policies on dressing changes and enhanced barrier precautions. The resident had a pressure ulcer on the right heel and diabetes, requiring specific wound care orders.
A facility failed to adhere to professional standards for respiratory care for a resident with chronic respiratory failure. The resident's nebulizer equipment was not properly dated or stored, and there were no specific orders for the frequency of equipment cleaning or replacement. The DON acknowledged the expectation for proper dating and storage of the equipment.
A facility failed to monitor the use of risperidone, an antipsychotic medication, for a resident with dementia and anxiety disorder. The facility's policy required behavior and side effect tracking, but the resident's clinical record lacked evidence of such monitoring. The DON confirmed the absence of required monitoring, indicating non-compliance with policy and regulations.
A resident with dementia and COPD, requiring a gluten-free, lactose-free diet, was served a cheeseburger with cheese on a regular bun, contrary to dietary orders. A dietary aide confirmed the error, and the Nursing Home Administrator acknowledged the oversight.
A resident with dementia and frequent falls experienced two significant falls requiring hospital transfers. The facility failed to report these incidents to the Department of Health within the required 24-hour timeframe. The DON confirmed the first fall should have been reported, while the second was not reported due to miscommunication about the resident's condition.
The facility did not meet the required LPN staffing levels during a day shift, with only 2.13 LPNs available for 63 residents, instead of the required 2.52. This shortfall was due to an unfilled call-off, as confirmed by the Nursing Home Administrator.
A resident with dementia and malnutrition was observed with a visible catheter drainage bag that was resting on the floor, contrary to facility policy requiring privacy covers and proper bag positioning. Staff confirmed these care standards were not followed.
The facility did not meet the required NA staffing ratios on certain shifts due to call-outs from inclement weather and illness. On specific days, the number of NAs was below the required minimum for the number of residents present, leading to a deficiency in staffing levels.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident in a 24-hour period, providing only 3.02 hours on one day. The shortfall was due to staff call outs and unfilled open slots, as acknowledged by the Nursing Home Administrator and DON.
A resident with a history of diabetes and hypertension experienced a severe decline in health due to the facility's failure to monitor blood glucose levels and low blood pressure. Despite being placed on alert charting, there were significant gaps in documentation and communication among staff, leading to the resident's hospitalization for hypovolemic shock and cardiac arrest. This deficiency also placed six additional residents in immediate jeopardy.
A resident with a history of anemia, diabetes, and hypertension experienced a decline in condition, including low blood pressure and lethargy, without timely physician notification. Despite being added to alert charting, the resident's condition worsened, leading to an emergency hospital transfer where they were diagnosed with hypovolemic shock and other complications. The facility failed to document and communicate the resident's condition changes, resulting in a delay in treatment.
The facility failed to update care plans for four residents, leading to deficiencies in documenting the use of side rails, pressure injury management, hospice services, and oxygen use. A resident with Parkinson's Disease had side rails not included in their care plan, while another with a pressure injury lacked a comprehensive care plan. Additionally, a resident on hospice and oxygen had no care plan for these services, and another's care plan was not updated for a progressing pressure ulcer.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documenting falls, pressure injuries, and malnutrition. A resident's falls were not recorded, another's pressure injury was missed due to delayed assessment, and a third's malnutrition status was inaccurately documented due to incomplete hospital discharge information.
The facility failed to administer medications and document treatments for three residents. A resident did not receive Aripiprazole for three days without physician notification. Another resident did not receive pain medication before wound treatments, and documentation was missing for treatments on two days. A third resident did not receive prescribed medications for several days, and the physician was not notified.
A resident with dementia and end-stage renal disease developed a stage II pressure injury on the right fifth toe, which was not documented or reported to the physician or wound team. The facility's weekly skin checks failed to identify the injury, and there was no care plan in place. The DON confirmed the treatment order was for an unrelated condition, and the NHA noted the lack of a policy for notifying physicians of changes in condition.
The facility failed to administer medications accurately for two residents. One resident did not receive Aripiprazole for three days due to unavailability, while another resident did not receive buspirone and bupropion for several days due to an order entry error. The Director of Nursing acknowledged the error and the expectation for correct order entry.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, resulting in unreviewed recommendations for two residents. One resident's SSRI therapy monitoring recommendation was not acted upon due to a blank form and unawareness of electronic notes. Another resident's pharmacy reviews were missing for several months, indicating a failure in the facility's documentation process after switching pharmacy services.
Failure to Follow Antihypertensive Medication Parameters and Document BPs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that antihypertensive medication was administered in accordance with professional standards and the physician’s ordered parameters for one resident. The resident had diagnoses including dementia and hypertension and a physician’s order for losartan 50 mg by mouth once daily, with instructions to hold the medication for systolic blood pressure less than 100 or blood pressure less than 100/60. Review of the Medication Administration Records from mid-October through early March showed that losartan was documented as administered on most days, but there was no documentation of the resident’s blood pressure with each administration, and blood pressures were only recorded on six occasions that could possibly coincide with the losartan dosing. Review of the vitals documentation revealed no evidence that blood pressures were taken consistently prior to administering a medication with specific blood pressure parameters. Further review of the clinical record progress notes showed that on three dates the losartan was held and coded as “5=Hold See Progress Notes.” On two of those dates, the medication was held due to a pulse of 56, which was not included in the physician’s parameters for holding the medication. On the third date, the medication was held for a blood pressure of 99/54, which met the ordered hold parameters. During an interview, the DON stated she could not confirm that nurses consistently took the resident’s blood pressure before administering losartan and suggested that nurses may have taken blood pressures and written them on report sheets instead of documenting them in the clinical record. She confirmed that there should have been a corresponding documentation field with the medication administration to record the blood pressure and demonstrate that the physician’s ordered parameters were followed.
Food Storage, Sanitation, Labeling, and Temperature Control Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with its own policies and professional food safety standards in the main kitchen, two kitchenettes, and a resident unit refrigerator. Policy review showed requirements for stock rotation, dating and labeling of food, maintaining clean and functional refrigeration with thermometers, and ensuring all refrigerated foods are covered, labeled, dated, and monitored. Policies also required that foods brought from outside sources be labeled with resident name and date, stored apart from facility food, and that all refrigeration units have internal thermometers. Another policy required cold foods to be stored and maintained at or below 41°F and that temperatures be checked periodically and at point of service for foods sent to units. During a kitchen tour with the Director of Food Services, surveyors observed multiple violations of these policies. In dry storage, large containers of honey Dijon mustard dressing and ranch dressing were undated. In the walk-in cooler, pans of broccoli were inadequately covered, and a drawer containing ladles had a dark substance along its edge. There was substantial grease residue on the floor near an unused deep fryer. A cook was observed scooping carrots from a large box lined with a plastic bag without wearing gloves, using one hand to hold the scoop and the other to hold and then roll down the plastic bag back into the box; the Director of Food Services confirmed gloves should have been worn. Additional findings included undated hamburger buns and hot dog rolls on a bread rack, food debris on the floor of a dessert refrigerator, and trays of cups and stacks of plates stored upright in the dish room. The Director of Food Services acknowledged these findings and stated she expected evening staff to clean the kitchen daily but had no written cleaning protocols or logs. In the first-floor kitchenette, surveyors found spills inside the reach-in refrigerator door, food debris in the bottom of a side-by-side refrigerator/freezer, light food splatter in the microwave, a dark spill in a dry-goods cabinet, and moderate crumbs in the toaster crumb tray. Plates and dome lids were stored upright and uncovered in preparation for lunch. On the upper-level rehabilitation unit, the unit refrigerator contained a bottle of coffee creamer, a squeeze bottle of butter, and two cans of soda with no names or dates, and there was no thermometer present. In the second-floor kitchenette, there were spills and food debris in the refrigerator, a broken thermometer in the side-by-side refrigerator portion, crumbs in the toaster crumb tray, and plates and dome lids stored upright and uncovered. Review of food temperature logs over several days showed staff did not consistently check cold food or beverage temperatures at point of service. In an interview, the NHA confirmed he expected proper labeling and storage of foods, proper dish storage, adherence to food temperature checks per policy, and glove use during food preparation.
Failure to Maintain Professional Appearance and Proper Identification, Affecting Resident Dignity
Penalty
Summary
The facility failed to promote care in a manner that enhanced a resident's dignity and respected resident rights when a nurse did not follow the facility’s dress code and identification policies and did not properly announce herself before entering a resident’s room. Facility policy required that each resident be treated with respect and dignity in an environment that promotes quality of life, and the employee handbook specified that all staff must maintain a professional appearance, including a prohibition on sweatpants and a requirement for non-revealing blouses. Nursing staff were required to wear a uniform or scrub suit, with supervisory staff responsible for determining appropriateness, and all employees were to wear proper identification. During an observation on the second-floor nursing unit, an LPN was seen wearing sweatpants with Hello Kitty appliques and a short blue and white striped shirt that exposed her abdomen, and she was not wearing a name tag. In an immediate interview, the LPN confirmed her role and acknowledged she was supposed to wear a name tag, stating it might be in her purse or on her jacket. Later, during an interview with a resident in her room, the same LPN entered without knocking, still dressed in the same attire without a name tag, did not identify herself, and only stated that she had the resident’s medications. In a subsequent interview, facility leadership acknowledged that the LPN was not appropriately dressed and confirmed that staff were expected to wear proper identification and identify themselves prior to entering a resident’s room.
Failure to Implement Person-Centered Care Plan for Resident Bathing Preferences
Penalty
Summary
Surveyors identified a failure to implement a comprehensive, person-centered care plan that reflected a resident's preferences and needs. Facility policy dated September 28, 2022, required each resident to have an individualized comprehensive care plan with measurable objectives and timetables that address medical, nursing, mental, and psychosocial needs and reflect the resident's expressed wishes regarding care and treatment goals. Resident 3's clinical record showed diagnoses of muscle weakness and depression. His care plan documented a bathing preference for a shower once a week, with this preference dated January 14, 2024. During an interview, Resident 3 reported that he did not receive showers very often and described them as "few and far between." Review of shower and bath documentation from February 3, 2026, through March 4, 2026, showed he received only one shower on February 15, 2026, and bed baths at all other times. In an interview, the DON stated that the resident occasionally refused showers and that his autonomy of care was presumed due to his high level of cognition and ability to voice concerns or requests to staff. The DON confirmed that the resident's preferences should have been care planned so all staff providing care would be aware and could make efforts to accommodate them.
Failure to Update Care Plans After Resolution of Acute Conditions
Penalty
Summary
The facility failed to review and revise resident care plans to reflect changes in condition and resolution of acute issues, as required by its policy and regulatory standards. The facility’s policy "Care Plan-Comprehensive" stated that assessments are ongoing and care plans are revised as information about the resident and the resident's condition change. For one resident with hypertension and chronic diastolic congestive heart failure who was treated for influenza from January 30, 2026, through February 6, 2026, the care plan contained an active focus for influenza dated January 30, 2026, that was not revised after the influenza resolved in early February 2026. The DON confirmed that the influenza had resolved and that the care plan should have been revised at that time. Another resident with vascular dementia and hearing loss was treated for a UTI from February 1–4, 2026, yet the care plan still showed an active UTI focus dated February 1, 2026, and had not been revised when the infection resolved. A third resident with Parkinson’s disease with dyskinesia and urinary retention had a UTI on November 1, 2025, that was resolved with treatment, but review of the care plan on February 4, 2026, showed the UTI remained listed as an active problem. During interviews, the NHA acknowledged that care plans should be revised when conditions such as UTIs resolve and agreed that care plans should reflect the resident’s current status.
Failure to Discard Expired Medications and Label Opened Medications
Penalty
Summary
Surveyors identified that the facility did not follow its own medication storage policy regarding expiration dating and labeling of opened medications and supplies. In the 2nd floor medication storage room, an open multidose vial of tuberculin solution was observed without an open date label, despite facility policy requiring certain medications to be dated when opened due to shortened expiration periods. In the same storage room, a box of 25-gauge needles with an expiration date of February 28, 2026, remained present after that date, and an open vial of insulin lispro was labeled with an open date of January 17, 2026, indicating it had not been discarded in accordance with beyond-use dating requirements. On the 2nd floor medication cart, surveyors observed an open bottle of LiquaCel and an open Lantus insulin pen, both lacking open date labels, even though these products require shortened expiration dating once opened. Staff interviews confirmed that tuberculin solution, LiquaCel bottles, insulin pens, and other specified medications and supplies are expected to be labeled with open dates when first used and that expired medications and supplies should be discarded. The Nursing Home Administrator and DON acknowledged that the facility’s expectation is for medications to be labeled with open dates and for expired items to be disposed of, which had not occurred in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the implementation of enhanced barrier precautions for a resident with a pressure ulcer. Facility policy titled "IC-Enhanced Barrier Precautions," revised April 1, 2024, stated that enhanced barrier precautions apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained, and when contact precautions do not otherwise apply. Clinical record review for Resident 5 showed diagnoses including a stage 3 pressure ulcer of the sacral region and diabetes. A wound team consult dated March 2, 2026, documented that the resident had a stage 3 sacral pressure ulcer. On multiple observations of the resident’s room door, surveyors did not see any signage indicating that the resident was on enhanced barrier precautions or that PPE was required when providing care. During observation of the resident’s stage 3 pressure ulcer treatment, the ulcer was noted to be healing but still presented as an open area on the sacrum. Review of the physician’s orders did not show any order for enhanced barrier precautions for this resident, and review of the care plan did not reveal any care plan addressing the need for enhanced barrier precautions. In an interview, the DON stated she believed the resident’s pressure ulcer had closed and that enhanced barrier precautions were no longer needed. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Antibiotic Stewardship Program Allowed Lapsed UTI Treatment
Penalty
Summary
The deficiency involves the facility’s antibiotic stewardship program allowing lapsed or interrupted antibiotic therapy for a resident with a confirmed urinary tract infection (UTI). Facility policy on Antibiotic Stewardship requires that when a culture and sensitivity (C&S) is ordered, it will be completed and the lab results and current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. National Institute of Health resources cited in the report state that lapsed or missed doses, particularly early in treatment, reduce treatment efficacy and allow for development of drug resistance, and FDA recommendations indicate that treatment for Proteus mirabilis complicated UTIs should be 500 mg of ciprofloxacin twice daily for 7 days. Despite these standards, the facility’s practice, as described by the Infection Control Preventionist (ICP), is that residents under this provider’s care are usually treated for only 3 days with antibiotics for a UTI with a positive culture, with discontinuation if a RN assessment finds no symptoms, and possible later restart if symptoms recur at the provider’s next visit. Resident 60 had diagnoses including Parkinson’s disease with dyskinesia and urinary retention, and a UTI confirmed by culture on November 28, 2025, showing >100,000 CFU/ml Proteus mirabilis. On that date, the provider ordered ciprofloxacin 250 mg by mouth twice daily for 3 days, and the resident received doses from the evening of November 28 through the morning of December 1, when the antibiotic was stopped per the initial order after the provider’s designated RN reported the resident had no UTI symptoms. The resident was then seen again on December 3, when suprapubic tenderness was noted on physical assessment, and the provider ordered a new course of ciprofloxacin 500 mg twice daily for 7 days for a complicated UTI. The Nursing Home Administrator stated that antibiotic usage is referred to the provider. The surveyors concluded that this pattern of short-course treatment with potential interruption and later restart, in the context of a confirmed Proteus mirabilis UTI and cited national guidance, demonstrated that the facility’s antibiotic stewardship program allowed for lapsed doses of antibiotic usage.
Stairtower Door Gap Deficiency
Penalty
Summary
The facility failed to maintain the stairtower doors within the allowed gap margins on two of three floors. During an observation on April 15, 2025, at 1:20 PM, it was noted that the doors on the 1st and 2nd floors of Stairtower A had gaps greater than 1/8 inch. This was confirmed in an interview with the Director of Maintenance at the same time.
Plan Of Correction
1st and 2nd Floor Stairtower A doors will be corrected to be within the allowed gap margins. Maintenance Staff were educated on Stairways and Smokeproof Enclosures. Stairways used as exits cannot have gaps greater than 1/8 gap. Director of Plant Operations or designee will audit 1 time a month. Audits will be reported at QAPI.
Deficiency in Hazardous Area Enclosure
Penalty
Summary
The facility failed to comply with the requirements for hazardous area enclosures, as evidenced by the use of the ground floor Pool Area for storing multi-medical record boxes and red isolation containers. This area was not enclosed with a 1-hour fire-rated barrier as required for hazardous areas. The observation was made on April 15, 2025, at 1:50 PM, and confirmed through an interview with the Director of Maintenance at the same time. The storage of hazardous items outside a protected area indicates a deficiency in maintaining the necessary fire safety standards.
Plan Of Correction
The medical records and red isolation containers in the ground floor pool area are being moved offsite. Maintenance staff was educated on storing items in the building in 1 hour protected area only. Director of Plant Operations or designee will audit 1-time a month unused rooms in the building to ensure items are stored within a 1 hour protected area. Results will be reported at QAPI.
Non-compliance with NFPA 101 for Trash Container Storage
Penalty
Summary
The facility was found to be non-compliant with NFPA 101 standards regarding the storage of soiled linen and trash containers. During an observation on April 15, 2025, at 1:35 PM, it was noted that three 96-gallon shredder containers were stored in the ground floor lobby. This area did not have a 1-hour fire-rated protection, which is required for storing containers exceeding 32 gallons when not attended. The Director of Maintenance confirmed that the containers were not stored in a rated assembly, leading to the deficiency.
Plan Of Correction
The three 96-gallon shredder containers were moved to an area with 1 hour protected rating. Maintenance staff was educated a 1-hour protected rating space is required for storage of soiled-linen and trash containers exceeding 32 gallons. Director of Plant Operations or designee will audit 1 time a week for a month; if compliance is achieved; then random audits monthly of soiled-linen and trash containers exceeding 32 gallons are stored in a 1-hour protected space. Audit results will be reported at QAPI.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to comply with the requirement to post the most recent Federal or State survey results in a location that is readily accessible to residents, family members, and legal representatives. During an observation on April 1, 2025, it was noted that the survey binder located in the main entrance lobby contained survey results dated August 2023, despite a more recent survey having been conducted on March 19, 2025. In an interview conducted on April 2, 2025, the Nursing Home Administrator acknowledged the expectation that the survey books should be up to date and confirmed that they had been updated. However, the failure to post the most recent survey results was identified as a deficiency, indicating non-compliance with the regulatory requirements outlined in 42 CFR Part 483 Subpart B and the 28 PA Code.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute 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. 1. At time of discovery, the survey binder was updated to include the most recent surveys. 2. Education was provided by the Director of Operations to the Nursing Home administrator on updating the binder after a survey is cleared and the results are posted. 3. An audit will be conducted weekly x 4 by the NHA or designee to verify that any surveys within the prior week have been included in the public binder. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Inadequate Transfer Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide adequate notice of transfer for three residents who were hospitalized. The deficiencies were identified through clinical record reviews, facility document reviews, and staff interviews. The residents involved had serious medical conditions, including atrial fibrillation, acute kidney failure, chronic diastolic congestive heart failure, and chronic respiratory failure with hypoxia. These conditions necessitated their transfer to a hospital. The facility's document titled 'Notice of Proposed Involuntary Discharge or Transfer' was found lacking in several required elements. Specifically, the notices did not include the location of transfer, a statement of the residents' appeal rights, or the mailing addresses of the entities responsible for receiving appeal requests. Additionally, the notices omitted the mailing addresses for the Office of the State Long-Term Care Ombudsman and the agencies responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders. During an interview, the Nursing Home Administrator confirmed that the facility's transfer notices did not contain all the required information. This oversight affected three residents who were transferred to the hospital, as their notices were incomplete and did not comply with the regulatory requirements for transfer or discharge notifications.
Plan Of Correction
1. The involuntary transfer notification form cannot be recreated for (Residents 47, 50, and 58) who received it. The involuntary transfer/discharge form has been updated to include the required elements. 2. The Director of Operations/designee has provided education to the NHA and DON on the correct formatting of this notification. An audit was completed for involuntary Transfer/Discharges starting March 1, 2025. Of these 12 involuntary transfers, 3 remain in the hospital and will receive the corrected form listing the address and phone number of the entity which receives request for appeal along with PA State Long Term Care Ombudsman, Advocacy Agency for Intellectual or Developmental Disability and Advocacy Agency for Mental Disorder or Related Disability addresses and phone numbers. 3. An audit will be conducted weekly x 4 of involuntary transfer/discharge notifications to ensure that the proper form is used for these instances. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Monitor and Manage Resident's Fluid Intake
Penalty
Summary
The facility failed to adequately monitor and manage the hydration status of a resident with specific fluid restrictions due to chronic health conditions. The resident, who has chronic diastolic congestive heart failure, atrial fibrillation, and chronic respiratory failure with hypoxia, had a physician-ordered fluid restriction of 1500 cc per day. However, the facility's policy did not specify how to manage fluid intake for residents with such restrictions, and there was no documentation on how the resident's fluid intake was distributed throughout the day or monitored daily. On two occasions, the resident's fluid intake exceeded the prescribed limit, with 3370 cc consumed on one day and 1560 cc on another. There was no documentation of fluid intake during medication administration, nor was there evidence that the physician was informed of the excess fluid intake. During an interview, the DON confirmed the lack of documentation and monitoring, acknowledging that the resident's fluid intake should have been tracked and communicated to the physician when limits were exceeded.
Plan Of Correction
1. At time of discovery the fluid restriction batch orders were updated for R50 to be reflective of her specific restrictions and the distribution of those fluids from dietary and nursing. There were no negative outcomes identified. 2. Education was provided to the nursing and dietary departments by the DON/designee on proper reading of the fluid restriction orders, dietary and nursing's role in maintaining these orders relative to the patient's plan of care. An audit was completed of Residents on fluid restrictions and had their orders changed to be reflective of her specific restrictions and the distribution of those fluids from dietary and nursing. 3. An audit will be conducted for patients on fluid restrictions k x 2 weeks then monthly x 2 months to ensure that fluid restrictions are being properly administered per order. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Sanitation Deficiency in Food Handling
Penalty
Summary
The facility failed to ensure food was prepared and served under sanitary conditions in both the first and second-floor dining rooms. Observations revealed that Employee 7, a Dietary Aide, wore gloves while handling paper meal tickets and then used the same gloves to retrieve hamburger buns and touch cheese slices. Similarly, Employee 5, a Cook, was observed wearing gloves while touching paper meal tickets and then using the same gloves to handle hamburger buns and cheese slices. These actions were contrary to the facility's policy, which prohibits bare hand contact with food and requires gloves to be changed when they become contaminated. Additionally, during the lunch meal service, Employee 8, a Nurse Aide, was observed using her bare hands to slide a bun off a burger to add cheese, and Employee 6, another Nurse Aide, was seen touching residents' sandwiches with bare hands while assisting them. The Director of Nursing confirmed that staff should have used tongs and worn gloves when handling food. The Nursing Home Administrator also stated that staff should not touch resident food with bare hands, indicating a failure to adhere to professional standards for food service safety.
Plan Of Correction
1. E5, E6, E7 and E8 were provided education on using gloves or tongs when handling resident food. 2. Education will be provided by the DON/designee to the nursing and dietary staff on food handling. 3. An audit will be conducted by the DON or designee during 2 breakfasts, 2 lunches, and 2 dinners weekly x 4 weeks to ensure proper food handling during meal service. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, as required by their policy and federal regulations. The incident involved a resident who expressed a desire to attend a church activity but was allegedly told by a nurse aide that she would be going to bed instead. This incident was reported to a registered nurse the following day, who then informed a social worker. However, the investigation into the alleged abuse did not commence until four days after the incident, and the state regulatory agency was not notified until five days after the incident. The delay in reporting was acknowledged by the Director of Nursing, who noted that the administration was not made aware of the incident until several days after it occurred. The facility's policy mandates immediate reporting of such allegations to the appropriate authorities, but this protocol was not followed in this case. The resident involved was upset and crying when recounting the incident, indicating the emotional impact of the event. The failure to report the incident in a timely manner constitutes a deficiency in the facility's adherence to required procedures for handling allegations of abuse.
Plan Of Correction
1. The facility cannot retro entry of the PB-22 that was not submitted timely for R52. The resident was not assessed at the time of the event due to staff not reporting. 2. The facility has a new Director of Nursing and education provided by the regional nurse/designee on timely reporting of PB-22 submissions. An audit was completed, and no other residents were identified as having similar experience. 3. An audit will be conducted by the NHA/designee via line listing of reportable events weekly x 4 to ensure that any reportable requiring a PB-22 has timely submission of the documentation. All staff completed abuse training in March 2025 which included immediately reporting alleged violations. Abuse training is completed regularly - 2 times a year. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Deficiencies in Comprehensive Care Plan Development
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in their care. For one resident, diagnosed with atrial fibrillation and heart failure, the care plan did not include any planning for the use of anticoagulant medication or monitoring for side effects, despite a physician's order for Apixaban. This oversight was identified during a review of the resident's clinical record and confirmed in an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for accurate care plan development. Another resident, diagnosed with dementia and chronic obstructive pulmonary disease, had no information related to her cognitive impairment or dementia diagnosis included in her care plan. This resident had been admitted to the facility after multiple emergency room visits due to confusion, with a significant cognitive impairment noted in her MOCA score. The absence of this critical information in her care plan was confirmed during an interview with the Nursing Home Administrator, who stated that the cognitive impairment/dementia diagnosis should have been included.
Plan Of Correction
1. The Care plans identified for dementia (R24) and anticoagulation (R13) were updated upon discovery. 2. No other care plans were identified as not including a diagnosis or medication. Education was provided by the Regional Nurse/designee to the IDT team on ensuring Care plan accuracy with medications and diagnosis to their respective discipline. 3. An audit will be conducted by the RNAC or designee on care plans on 5 patients per week x 2 weeks then 5 patients monthly x 2 months for patients with a dementia diagnosis or on anticoagulation treatment. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised to reflect their current status. For one resident, diagnosed with dementia, anxiety disorder, and depression, the clinical record indicated the presence of edema in both lower legs and a physician's order for TED stockings. However, the resident's care plan did not include a focus on the edema or the use of TED hose, which was confirmed by the Director of Nursing during an interview. Another resident, diagnosed with congestive heart failure and cognitive function issues, had a care plan that included a focus area on smoking, despite the facility's non-smoking policy. The care plan mentioned a smoking evaluation and orientation to smoking areas, although the resident was not an active smoker. This discrepancy was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged that the smoking focus should have been removed from the care plan.
Plan Of Correction
1. The identified care plan was updated to reflect that patient R55 was not an active smoker and this was resolved. R 48 care plan was updated to include the use of Ted hose to control edema. 2. No other care plans were identified as needing updated secondary to a change in plan of care. Education was provided by the Regional Nurse/designee to the IDT team on ensuring Care plan accuracy with medications and diagnosis to their respective discipline. 3. An audit will be conducted by the RNAC or designee on care plans for 5 patients per week x 2 weeks then 5 patients monthly x 2 months on patient care plans. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Discrepancy in Advanced Directives for a Resident
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident's advanced directives. Resident 51, who has Alzheimer's disease and type 2 diabetes mellitus, had a POLST form indicating a Do Not Resuscitate (DNR) status, dated December 23, 2024. However, the resident's physician orders, dated July 3, 2024, incorrectly stated Full Code, meaning resuscitation should be attempted if the resident was found without a pulse and not breathing. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the resident's orders should have reflected her DNR status.
Plan Of Correction
1. At time of discovery, the resident R51 code status was updated to reflect the wishes to be a DNR. 2. A whole house audit was completed upon discovery and all patients had correlating orders and POLSTs reflective of their wishes. 3. Education was provided by the Director of Nursing to Social Services and licensed clinical staff to ensure that the POLST is reflective of any advanced directive orders. New admissions and any patient with a change in code status will be audited weekly x 4 to ensure proper code status is reflective in the order. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Adhere to Dressing Change and Barrier Precautions Policies
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to treat and prevent pressure ulcers. Specifically, the facility did not adhere to its own policy regarding dressing changes and enhanced barrier precautions. During an observation of a dressing change for a resident with a pressure ulcer on the right heel, it was noted that the dressing was not dated or timed, which is a requirement according to the facility's policy. This lack of documentation made it impossible to determine when the dressing was last applied. Additionally, the registered nurse performing the dressing change did not wear a protective gown, as required by the facility's enhanced barrier precautions policy. The resident in question had a diagnosis of a pressure ulcer on the right heel and diabetes, which necessitated specific wound care orders, including the use of medihoney and gauze. The Director of Nursing confirmed that the dressing should have been dated and that the nurse should have followed the enhanced barrier precautions policy.
Plan Of Correction
1. At time of discovery the nurse was provided education by the DON/NHA on enhanced barrier precautions. The facility cannot retro date the dressing change regardless that the MAR indicates the dressing had been changed the day prior. 2. All other dressings were appropriately dated, and all other enhanced barrier precautions were properly followed. Education was provided by the DON/Designee to the licensed clinical staff on the dating of completed treatments and enhanced barrier precautions. 3. An audit will be conducted for 5 patients per week x 2 weeks then 3 patients weekly for 2 months for patients with dressing changes and or enhanced barrier precautions. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Adhere to Respiratory Care Standards
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident requiring such care. The facility's policy on aerosol therapy mandates that nebulizer equipment should be cleaned and dried after each use, with disposable parts replaced weekly. However, a review of Resident 50's clinical records revealed a lack of specific orders regarding the frequency of nebulizer tubing and mask changes or the cleaning of the medication chamber and mask. Observations in the resident's room showed that the nebulizer tubing was not dated, and the mask was left on top of the machine instead of being stored in a bag. Resident 50 has a medical history that includes chronic diastolic congestive heart failure, atrial fibrillation, and chronic respiratory failure with hypoxia. The resident had a physician's order for Ipratropium-Albuterol Inhalation Solution to be administered via nebulizer four times a day. During an interview, the Director of Nursing indicated that the nebulizer tubing should be dated and the mask bagged when not in use, which was not the case for Resident 50, leading to the deficiency noted in the report.
Plan Of Correction
1. Upon discovery, the R 50 had their tubing dated and bagged. 2. No other residents were identified with missing tubing or bags. Education was provided by the DON/designee on proper labeling and storage of respiratory equipment. 3. An audit will be conducted for 5 patients on respiratory equipment weekly x 2 weeks then monthly x 2 months to ensure that respiratory equipment is properly stored and dated. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor the use of psychotropic medications, specifically for one resident who was prescribed risperidone, an antipsychotic medication, for dementia. The facility's policy required the completion of a 'Behavior/Interventions' sheet or other behavior tracking form to document relevant resident data, target behaviors, the number of episodes, intervention codes, and outcomes by shift. However, a review of the resident's clinical record revealed a lack of evidence for side effect monitoring or tracking of the target behaviors that the medication was intended to address. During an interview, the Director of Nursing confirmed that there was no behavior and side effect monitoring in place for the resident's use of risperidone, despite it being a requirement. The resident's diagnoses included dementia and anxiety disorder, which necessitated careful monitoring of the effects and necessity of the psychotropic medication. The absence of such monitoring indicates a failure to comply with the facility's policy and federal regulations regarding the use of psychotropic drugs.
Plan Of Correction
1. Upon discovery, R24's behavior monitoring with the type of behavior being exhibited and the side effect monitoring were updated on the MAR. 2. A baseline audit was completed on residents receiving psychotropic medications to ensure that behavior monitoring and side effects were listed on the MAR. Education was provided by the DON/designee to the licensed clinical staff to ensure that when psychotropic medications are ordered, behavior monitoring and side effects are present on the MAR when the order is entered. 3. An audit will be conducted by the DON/designee on 5 patients on psychotropic medications weekly x 4 weeks to ensure that behavior monitoring and side effects are present on the MAR. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to ensure that a resident was served food that accommodated their allergies and intolerances. Resident 32, who has diagnoses including dementia and chronic obstructive pulmonary disease, had a physician's order for a gluten-free, lactose-free diet effective from July 7, 2023. However, on March 31, 2025, the resident was observed consuming a cheeseburger on a regular bun, which did not comply with the dietary restrictions. During an interview, a dietary aide confirmed that the resident was mistakenly served a cheeseburger with cheese and a non-gluten-free bun. The resident's meal ticket for that lunch clearly indicated the need for a gluten-free, lactose-free diet, which was not followed. The Nursing Home Administrator acknowledged the expectation that the resident should have been served the appropriate diet and mentioned that education was provided to staff.
Plan Of Correction
1. At time of discovery, R 32 had an incident report completed, notifications and follow up was also completed as well as immediate education to E5 that served the roll and cheese. There were no adverse outcomes from a gluten free and lactose free resident eating ½ a dinner roll and cheese. 2. Education has been provided by the Dietary manager to the dietary staff on reading tray card tickets to ensure the proper diet is provided. No other residents have been identified as being served food that they may have allergies and/or intolerances to. 3. An audit will be conducted by the Dietary manager/designee on 5 patients tray cards to tray weekly x 2 weeks then monthly x 2 months to ensure that the proper diet is being sent to the resident. 4. Results of the audit will be taken to QAPI for review of findings and further interventions if indicated.
Failure to Report Resident Falls Within Required Timeframe
Penalty
Summary
The facility failed to report serious incidents involving a resident to the Department of Health within the required 24-hour timeframe. Resident 48, who had diagnoses including dementia, anxiety disorder, and frequent falls, experienced two significant falls that required hospital transfers. The first incident occurred on February 16, 2025, when the resident fell, resulting in a hematoma on the forehead and abrasions on the arm and finger, leading to a hospital transfer for further evaluation and treatment. The second incident took place on February 23, 2025, when the resident fell again, sustaining a bump on the forehead and a scratch on the arm, and was transferred to the hospital due to a closed head injury and ambulatory dysfunction. The facility did not report either of these incidents to the Pennsylvania Department of Health's event reporting system. During an interview, the Director of Nursing confirmed that the first fall should have been reported but was not. The second fall was not reported because the transfer was attributed to the resident's ambulatory dysfunction rather than the fall itself. The DON was not informed about the hematoma at the time of the incident, which contributed to the failure to report the incident as required.
Plan Of Correction
1. R48 was reported as required on 4/8/25. 2. No other ERS reporting was identified as not submitted. Education was provided by the Regional Clinical nurse or designee to the new DON on ERS reporting requirements. 3. Incident reports will be audited by the DON or designees to ensure that any incidents requiring reporting is completed timely weekly x 4. 4. Audits will be taken to QAPI for review and further interventions if warranted.
LPN Staffing Deficiency on Day Shift
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) during the day shift on October 5, 2024. The regulation mandates a minimum of one LPN per 25 residents, but the facility only had an LPN ratio of 2.13 for a resident census of 63, falling short of the required 2.52 LPNs. This deficiency was identified through a review of staffing documents and confirmed during an interview with the Nursing Home Administrator, who acknowledged the shortfall was due to a call-off that could not be filled.
Plan Of Correction
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the ratios and replacement of staff if indicated. 3. Daily staffing meeting will be implemented with NHA, DON staff coord or designees to review staffing and appropriate ratios. If a call off occurs the Charge Nurse will contact Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. A ratio audit will be completed by NHA or designee daily for 5 days then weekly x3. Audits will be taken to QAPI for review and further interventions if warranted.
Failure to Provide Proper Catheter Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide appropriate catheter care and maintain resident dignity for a resident with dementia and protein-calorie malnutrition. During observation, the resident was found in bed with her catheter drainage bag and its contents visible from the doorway, and the bag was resting on the floor. Facility policies require that catheter drainage bags be covered for privacy and kept below the level of the bladder without touching the floor. Staff interviews confirmed that these requirements were not met at the time of observation.
Staffing Deficiency Due to Call-Outs
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on specific shifts during the week of February 2 - 8, 2025. On February 2, the night shift had 59 residents but only 3.90 NAs, falling short of the required 3.93 NAs. On February 6, the day shift had 59 residents with only 5.40 NAs, below the required 5.90 NAs. On February 8, the day shift had 61 residents with 5.57 NAs, not meeting the required 6.10 NAs, and the night shift had 61 residents with only 2.52 NAs, significantly below the required 4.07 NAs. During an interview, the Nursing Home Administrator and Director of Nursing explained that the facility did not intentionally staff below the minimum requirements but faced challenges due to call-outs caused by inclement weather and illness, which prevented them from filling all open slots.
Plan Of Correction
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the ratios and replacement of staff if indicated. 3. A staffing ratio document will be completed daily by the scheduler and reviewed at morning meetings. The ratio document will be updated with any changes in the schedule and reviewed with the DON/Admin Nurse to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. An audit of the ratio document against the deployment sheet will be completed daily for 1 week, weekly for 2 weeks and then biweekly X 2 weeks. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.
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 nursing care per resident in a 24-hour period on February 8, 2025. A review of staffing and resident census data for the week of February 2 - 8, 2025, showed that on February 8, the facility provided only 3.02 hours of direct care per resident. During an interview on February 10, 2025, the Nursing Home Administrator and Director of Nursing acknowledged the shortfall and attributed it to staff call outs and the inability to fill all open slots, which resulted in the facility being understaffed on that day.
Plan Of Correction
1. Facility identified no adverse outcome from days identified. 2. Education will be provided by the Administrator to the Nursing Administration, scheduler, and charge nurses on calculation of the minimum of 3.2 hours of direct resident care for each resident and replacement of staff if indicated. 3. A staffing direct resident care document will be completed daily by the scheduler and reviewed at morning meetings. The direct resident care document will be updated with any changes in the schedule and reviewed with the DON/Admin Nurse to ensure proper coverage. If a shortage is discovered, will call Part Time and PRN staff, and contract agency staffing to meet staffing ratios. 4. An audit of the direct resident care document against the deployment sheet will be completed daily for 1 week, weekly for 2 weeks and then biweekly X 2 weeks. Results of the audit will be taken to QAPI for review of findings and further interventions if warranted.
Failure to Monitor and Respond to Change in Condition
Penalty
Summary
The facility failed to provide adequate care and services to Resident 1 after a change in condition, leading to a severe decline in health and eventual hospitalization. Resident 1, who had a history of iron deficiency anemia, Type 2 Diabetes Mellitus, hyperlipidemia, and hypertension, was not properly monitored for blood glucose levels despite having orders for insulin administration. The facility's policy required monitoring of blood glucose levels, but there were no documented readings during Resident 1's stay. On May 24, 2024, Resident 1 was found to have a critically high blood glucose level of 552, which was only discovered upon transfer to the hospital. Additionally, the facility failed to monitor and document Resident 1's low blood pressure, which was noted on several occasions but not communicated to the physician or adequately addressed. Despite being placed on alert charting for not feeling well and having low blood pressure, there were significant gaps in documentation and communication among staff. The nursing progress notes lacked entries for critical periods, and the alert charting list was incomplete, indicating a failure to follow through with the facility's procedures for monitoring changes in condition. The lack of proper monitoring and communication resulted in Resident 1 experiencing hypovolemic shock, cardiac arrest, and ultimately death. This deficiency also placed six additional residents in immediate jeopardy due to similar failures in monitoring changes in condition. The facility's inaction and failure to adhere to its policies contributed to the adverse outcomes for Resident 1 and posed significant risks to other residents with changes in condition.
Failure to Notify Physician of Resident's Decline
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a change in condition for a resident, leading to a delay in treatment. The resident, who had a medical history including iron deficiency anemia, Type 2 Diabetes Mellitus, hyperlipidemia, and hypertension, experienced a significant decline in health. On May 22, 2024, the resident reported feeling unwell, with a notably low blood pressure of 85/58, and was added to alert charting and the physician list. However, the physician was not immediately informed, and the resident's condition continued to deteriorate. Over the following days, the resident's condition worsened, with consistently low blood pressure readings documented on a daily assignment sheet but not in the clinical record. The resident exhibited symptoms such as lethargy, fatigue, and difficulty in physical therapy sessions, yet there was no evidence of physician assessment or notification. On May 24, 2024, the resident's condition became critical, with a blood sugar level of 552 and a pulse ox of 84% on room air, prompting an emergency transfer to the hospital. The lack of timely physician notification and documentation of the resident's declining condition resulted in a delay in medical intervention. The resident was eventually diagnosed with hypovolemic shock, hypotension, gastrointestinal bleeding, and acute kidney injury at the hospital, where resuscitation efforts were unsuccessful. Interviews with facility staff revealed a breakdown in communication and documentation, contributing to the failure to provide adequate care and oversight for the resident.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that the care plans for four residents were reviewed and revised to reflect their current status. Resident 18, diagnosed with Parkinson's Disease and osteoarthritis, had bilateral upper side rails on their bed, but this was not included in their care plan despite an active physician order for side rails. The Nursing Home Administrator confirmed that the use of side rails should have been documented in the care plan. Resident 27, with chronic venous insufficiency, congestive heart failure, and hypertension, had an active pressure injury since admission, but the care plan lacked a comprehensive plan for this condition. Although there was an intervention for wound treatment, the NHA expected a comprehensive care plan for the pressure injury. Resident 41, diagnosed with protein calorie malnutrition, bullous pemphigoid, and anxiety disorder, was using oxygen and had been admitted to hospice services, but the care plan did not include these aspects. The NHA acknowledged that the care plan should have included hospice services and oxygen use. Resident 45, with a stage 3 pressure ulcer and hospice status, had a care plan that was not revised to reflect the progression of their pressure ulcer from stage 2 to stage 3 until several months later. Both the Regional Nurse and the NHA confirmed that the pressure ulcers should have been included in the care plan.
Inaccurate Resident Assessments in MDS Evaluations
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) evaluations. Resident 7, diagnosed with muscle weakness and mobility issues, experienced falls on two occasions in March 2024, which were not documented in her April 2024 MDS assessment. The Nursing Home Administrator confirmed that these incidents were not captured, indicating a lapse in accurately reflecting the resident's status. Resident 27, with chronic venous insufficiency, congestive heart failure, and hypertension, had an active hospital-acquired pressure injury since admission in February 2024. However, his March 2024 Admission MDS incorrectly indicated no pressure injury, as the Registered Nurse Assessment Coordinator missed this due to the wound doctor's delayed assessment. Similarly, Resident 41, diagnosed with protein-calorie malnutrition and admitted to hospice care, had her malnutrition status inaccurately recorded in her April 2024 Significant Change MDS. The error occurred because the diagnosis was not included in her discharge summary from the hospital.
Failure to Administer Medications and Document Treatments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents. Resident 7, diagnosed with anxiety and major depressive disorders, had an order for Aripiprazole, an antipsychotic medication, which was not administered from May 1-3, 2024. The nursing progress notes indicated the medication was unavailable, and there was no documentation that the physician was notified of the missed doses. During an interview, the Nursing Home Administrator confirmed the physician should have been informed. Resident 41, with diagnoses including bullous pemphigoid and protein calorie malnutrition, had a physician order for pain medication to be administered before wound treatments. However, the MAR did not document the administration of pain medication prior to the treatments, and the TAR showed missing documentation for wound treatments on May 11 and 28, 2024. Interviews with LPNs revealed a lack of awareness of the pain medication order and missing documentation for the wound treatments. Resident 154, diagnosed with major depressive and anxiety disorders, was not administered buspirone, bupropion, and Vesicare medications for several days following admission. The MAR indicated these medications were not available from May 23-28, 2024, and there was no documentation of physician notification regarding the missed doses. The Nursing Home Administrator stated that it was expected for the physician to be notified when medications were not administered.
Failure to Document and Treat Pressure Injury
Penalty
Summary
The facility failed to provide adequate care and services to prevent and treat pressure injuries for a resident diagnosed with dementia and end-stage renal disease. The resident had an active physician order to monitor dry blisters on toes, with specific instructions for dressing changes if drainage was noted. However, during a treatment observation, the resident was found to have an open blister on the right fifth toe, consistent with a stage II pressure injury. This injury was not documented in the resident's clinical record, and there was no notification to the physician or wound team, nor was there a care plan in place for the pressure injury. The facility's weekly skin checks did not identify the pressure injury, and the Director of Nursing confirmed that the existing treatment order was for an unrelated skin condition. The Nursing Home Administrator acknowledged the facility's expectation for new wounds to be reported to the attending physician and wound team, but the facility lacked a policy regarding notification of the physician for changes in a resident's condition. The absence of documentation and assessments prevented the facility from determining when the pressure injury first appeared.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of medications for two residents. Resident 7, diagnosed with anxiety disorder and major depressive disorder, had an order for Aripiprazole, an antipsychotic medication, to be administered once daily. However, the Medication Administration Records (MAR) indicated that the medication was not documented as administered from May 1 to May 3, 2024. Nursing progress notes revealed that the medication was not available in the cart, and reordering attempts were made, but the medication remained unavailable. The Nursing Home Administrator had no additional information regarding the unavailability of the medication. Resident 154, who was admitted with diagnoses of major depressive disorder and anxiety disorder, expressed concerns about not receiving all prescribed medications. Upon admission, Resident 154 was ordered buspirone and bupropion, but the MAR showed these medications were not administered from the evening shift of May 23 to the day shift on May 28, 2024. The progress notes indicated that the medications were not received from the pharmacy due to an error in entering the medication orders into the electronic health record, which led the pharmacy to believe delivery was not needed. The Director of Nursing confirmed the error and stated that it was expected for orders to be entered correctly.
Failure in Monthly Drug Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, and that any irregularities were reported and acted upon. For Resident 7, the pharmacist recommended a CBC to monitor SSRI therapy, but this recommendation was not reviewed or acted upon. The facility received an email from the pharmacist with a blank recommendation form, leading them to assume no recommendations were made. Additionally, the facility was unaware that the pharmacist was entering notes into the resident's electronic health record. Further recommendations regarding PRN orders for Resident 7 were also not reviewed or acted upon in a timely manner. For Resident 41, the facility failed to provide evidence of pharmacy medication regimen review notes for several months. The facility had switched pharmacy services, and the new process involved faxing recommendations to the physician for review. However, the DON was unable to locate Resident 41's pharmacy reviews with physician responses for the specified months. This indicates a failure in the facility's process to ensure that medication regimen reviews were conducted and documented properly.
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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