How many inspection deficiencies does CARING PLACE, THE have?

CARING PLACE, THE has 27 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CARING PLACE, THE?

CARING PLACE, THE has a two-star staffing rating from CMS with 0.32 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CARING PLACE, THE located?

CARING PLACE, THE is located in FRANKLIN, PA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CARING PLACE, THE have?

CARING PLACE, THE has 100 certified beds.

Who owns CARING PLACE, THE?

CARING PLACE, THE is a non profit - church related facility and operates independently (not part of a chain).

What questions should families ask when visiting CARING PLACE, THE?

Families visiting CARING PLACE, THE should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does CARING PLACE, THE compare to other nursing homes?

CARING PLACE, THE has a 1-star overall rating, which is below average compared to other nursing homes in PA. Families should carefully review inspection findings and consider alternatives.

CARING PLACE, THE

Q: What is CARING PLACE, THE's CMS rating?

CARING PLACE, THE has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is CARING PLACE, THE safe?

CARING PLACE, THE has documented safety concerns including a substantiated abuse finding on record. Families should ask about corrective actions taken.

Q: Do nurses at CARING PLACE, THE stick around?

CARING PLACE, THE has high staff turnover at 62%. High turnover can mean less continuity of care as staff change frequently.

Q: Was CARING PLACE, THE ever fined?

Yes, CARING PLACE, THE has been fined $8,018 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is CARING PLACE, THE on any federal watch list?

No, CARING PLACE, THE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

103 N. THIRTEENTH STREET, FRANKLIN, PA 16323 · (814) 432-4491

Non profit - Church related 100 Beds Independent Data: November 2025

Trust Grade

3/100

#539 of 653 in PA

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Last Inspection: July 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Caring Place in Franklin, Pennsylvania has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #539 out of 653, they are in the bottom half of Pennsylvania facilities, and they rank last in Venango County. The facility is showing signs of improvement, having reduced the number of issues from 12 to 7 over the last year. However, staffing is a notable weakness, with a rating of 2 out of 5 stars and a high turnover rate of 62%, which exceeds the state average. Recent inspections revealed serious incidents, including a failure to properly transfer residents, leading to fractures. For example, one resident suffered a left femur fracture because staff did not follow the required two-person transfer protocol. Additionally, neglect was identified as a factor in the harm experienced by another resident, highlighting ongoing compliance issues. While the facility's RN coverage is concerning, being less than 97% of other Pennsylvania facilities, there have been no critical life-threatening deficiencies reported. Overall, families should weigh these strengths and weaknesses carefully when considering this nursing home.

Trust Score: F
In Pennsylvania: #539/653
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $8,018 in fines. Higher than 85% of Pennsylvania facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 27 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 12 issues

2025: 7 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Pennsylvania average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 62%

15pts above Pennsylvania avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $8,018

Below median ($33,413)

Minor penalties assessed

Staff turnover is elevated (62%)

14 points above Pennsylvania average of 48%

The Ugly 27 deficiencies on record

3 actual harm

Jul 2025 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day), failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer, and failed to have complete documentation related to a transfer for three of 20 residents reviewed (Residents R3, R31, and R105). Findings include: Review of facility policy entitled “Bed Hold Notice” dated 2/18/25, indicated “In the event a resident is transferred for hospitalization or therapeutic leave, the facility shall… review its bed hold policy with the resident and/or designated resident representative. This review shall be accomplished at or prior to transfer.” Review of facility policy entitled “Transfer/Discharge Documentation” dated 2/18/25, indicated “Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: The basis for transfer… contact information of practitioner… Resident representative information… Advance directive…” Review of Resident R3’s clinical record revealed an admission date of 12/21/21, with diagnoses that included chronic obstructive pulmonary disease (a disease that obstructs air flow from the lungs), Parkinson’s (a chronic and progressive movement disorder that causes shaking, slows a person’s ability to move and worsens over time), and hypertension (high blood pressure). Review of Resident R3’s clinical record revealed a progress note dated 5/15/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. His/her clinical record lacked evidence indicating that the resident and/or their representative were provided with a copy of the facility bed-hold policy upon transfer. Review of Resident R31’s clinical record revealed and admission date of 11/27/24, with diagnoses that included atrial fibrillation (irregular heartbeat), heart failure, anxiety disorder, and hypertension. Review of Resident R31’s clinical record revealed progress notes dated 12/9/24, 2/14/25, 2/21/25, and 3/15/25, indicating transfers to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. The clinical record lacked evidence indicating that the resident and/or his/her representative were provided with a copy of the facility bed-hold policy upon transfer on 3/15/25, and had incomplete documentation related to the basis of transfer, interventions, and appropriate contacts on 2/14/25, 2/21/25, and 3/15/25. Review of Resident R105’s clinical record revealed an admission date of 3/31/25, with diagnoses that included heart disease, atrial fibrillation, heart failure, hypertension, and anxiety. Review of Resident R105’s clinical record revealed a progress note dated 6/12/25, indicating transfer to the hospital. The clinical record lacked evidence indicating that the resident and/or his/her representative were provided with a copy of the facility bed hold policy upon transfer. During an interview on 7/17/25, at 2:46 p.m. the Director of Nursing (DON) confirmed that the facility lacked evidence that Residents R3, R31, and R105 and/or their representatives were provided with a copy of the bed-hold policy upon transfer that included the cost per day; that the facility lacked evidence that Residents R3 and R31’s necessary clinical information was provided to the receiving healthcare provider upon transfer; and that Resident R31’s clinical record lacked complete documentation. The DON also confirmed that when the transfers occurred the resident and/or his/her representative should have been provided with a bed hold policy, clinical information should be provided to the receiving healthcare provider upon transfer, and documentation should be complete regarding transfers. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c.3) (2) Resident rights

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen and change/date oxygen tubing according to physician's orders for two of two residents reviewed for respiratory services (Residents R45 and R58).Findings include: Review of facility policy entitled Oxygen dated 2/18/25, indicated There must be a Physician's Order for oxygen use which includes the route and liter flow. Resident R45's clinical record revealed an admission date of 1/6/25, with diagnoses that included hypertension (high blood pressure), chronic respiratory failure, and muscle weakness. Additional review of the physician's orders revealed an order that reads change and date oxygen tubing weekly every night shift every Thurs. Observation on 7/16/25, at 9:21 a.m. revealed Resident R45's nasal cannula (oxygen tubing that has prongs that go into the nostrils and loops around the ears to secure in place to ensure adequate oxygen delivery) was not dated. It was also noted that the humidifier solution cannister, which is attached to the oxygen concentrator was dated 7/4/25. During an interview at that time Licensed Practical Nurse (LPN) Employee E2 confirmed that the oxygen tubing was not dated and that the humidifier solution cannister was dated 7/4/25. Review of Resident R58's clinical record revealed an admission date of 3/8/24, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), asthma (a long-term lung disease that causes the airways to narrow and make it difficult to breath), and hypertension. Review of Resident R58's physician's orders dated 7/7/25, revealed an order for Oxygen at three liters/minute via nasal cannula as needed to maintain a SP02 (oxygen saturation) greater than 90%. Observations on 7/15/25, at 10:30 a.m. and again at 1:15 p.m. revealed Resident R58 lying in his/her bed with supplemental oxygen in place and the oxygen tank liter flow set at two liters/minute. Observations on 7/16/25, at 9:05 a.m., 9:35 a.m. and again at 10:25 a.m. revealed the resident lying in his/her bed with supplemental oxygen in place and the oxygen tank liter flow set at two liters/minute. During an interview on 7/16/25, at 10:25 a.m. LPN Employee E1 confirmed that Resident R58's oxygen tank was on and set at two liters/minute and was not in accordance with the physician's order dated 7/7/25, for oxygen at three liters/minute. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R12).Findings include: Review of the facility policy Administering Medications, dated 2/18/25, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications the prescriber would be contacted to discuss the concerns. Review of Resident R12's clinical record revealed an admission date of 2/22/25, with diagnoses that included hypertension (high blood pressure), muscle weakness, type II diabetes ( the body does not make enough insulin to control blood sugar), and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, and Friday each week for dialysis treatments. Review of physician's orders dated 4/3/25, indicated that Resident R12 was to have Hydralazine (a medication used to treat high blood pressure), 25 milligrams (mg) three times daily and Metformin (a medication used to treat high blood sugar levels), 500 mg two times daily. Review of June and July 2025, Medication Administration Records (MARs) revealed that Resident R12 did not receive the following medications as ordered with reason given as: Not in Facility Hydralazine and Metformin noon doses on 6/2/25, 6/4/25, 6/6/25, 6/9/25, 6/11/25, 6/13/25, 6/16/25, 6/18/25, 6/20/25, 6/23/25, 6/25/25, 6/27/25, 6/30/25, 7/2/25, 7/4/25, 7/7/25, 7/9/25, 7/11/25, 7/14/25, and 7/16/25. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R12 on dialysis days. During an interview on 7/17/25, at 11:06 a.m. the Director of Nursing confirmed that the above medications for Resident R12 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to assure the call bell was accessible for one of 20 residents reviewed (Resident R103).Review of facility policy entitled Resident Call System dated 2/18/25, indicated Each resident is provided with a means to call staff directly for assistance from his/her bed. Review of Resident R103's clinical record revealed an admission date of 9/10/24, with diagnoses that included anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). Observations on 7/16/25, at 9:05 a.m. revealed Resident R103 in their bed with the head of the bed elevated to a sitting position and his/her call bell was lying under his/her bed. Observation on 7/16/25, at 9:35 a.m. and again at 10:20 a.m. revealed Resident R103 was in their bed with the head of the bed in a slight elevated position and the call bell remained lying under his/her bed. During an interview on 7/16/25, at 10:20 a.m. Licensed Practical Nurse confirmed that Resident R103's call bell was lying under his/her bed and not accessible. He/she also confirmed that Resident R103 should always have access to his/her call bell. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to appropriately discard outdated medications for two of four medication carts reviewed and one of two medication rooms reviewed (first floor C-wing and second floor C-wing medication carts and second floor medication room).Review of facility policy entitled Medication Storage and Handling dated [DATE], indicated Medications will be monitored. to assure that they are not expired. Review of facility policy entitled Administering Medications dated [DATE], indicated When opening a multi-dose container, the date opened is recorded on the container. Review of Active liquid protein label indicated three-month shelf life from date open. Review of manufacturer's guidelines revealed that an open pen of Lispro Insulin must be used within 28 days after opening or be discarded. Review of manufacturer's guidelines revealed that an open vial of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on [DATE], at 11:15 a.m. of the first floor C-wing medication cart revealed an open bottle of Ibuprofen (pain medication) with an expiration date of 5/2025, and an open bottle of Active liquid protein with no date indicating when the liquid protein was open. During an interview on [DATE], at the time of observation, Licensed Practical Nurse Employee E4 confirmed that the open bottle of Ibuprofen was expired, the open bottle of liquid protein lacked an open date, and staff were unable to determine the discard date. He/she also confirmed that the open bottle of Ibuprofen and open bottle of liquid protein should have been discarded. Observation of drug storage on [DATE], at 11:35 a.m. of the second floor C-wing medication cart revealed an open insulin pen of Lispro with an open date of [DATE], and an open vial of insulin Lantus with an open date of [DATE]. During an interview on [DATE], at the time of observation, LPN Employee E2 confirmed that the open insulin pen of Lispro and the open vial of insulin Lantus were beyond their use by dates. He/she also confirmed that the open insulin pen of Lispro and the open vial of insulin Lantus should have been discarded. Observation of drug storage on [DATE], at 11:55 a.m. of the second-floor medication room refrigerator revealed an open bottle of liquid Amoxicillin (antibiotic) with an expiration date of [DATE], four IV (intravenous) bags of Ceftriaxone (an antibiotic given through an IV line) with an expiration date of [DATE], and three IV bags of Cefazolin (an antibiotic given through an IV line) with an expiration date of [DATE]. During an interview on [DATE], at the time of observation with LPN's Employee E2 and E3, they confirmed that the open bottle of Amoxicillin, the four IV bags of Ceftriaxone and the three IV bags of Cefazolin were beyond their use by date and should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services28 Pa. Code 211.12(d)(1) Nursing services

Jun 2025 2 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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Based on review of facility policy, facility documentation and clinical record, and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R2) was free from neglect during care which resulted in actual harm of a left femur (upper leg) fracture. This deficiency is cited as past non-compliance. Findings include: A facility policy entitled, Abuse Prohibition dated 5/27/25, revealed that, Neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety, adequate, and appropriate services, treatment and care, including but not limited to: nutrition, medication, therapies, and activities of daily living. Resident R2's clinical record revealed an admission date of 12/21/21, with diagnoses including stroke, Parkinson's Disease (brain disorder that causes gradual, progressive damage to parts of the brain over many years), and muscle weakness. Resident R2's physician's orders as of 5/19/25, revealed an order dated 2/02/24, to transfer to shower chair with assist of two, please follow instructions in tasks. Resident R2's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) Assessment, dated 4/15/25, under Section G, Functional Status revealed that Resident R2 required extensive assistance of two people to transfer between surfaces. Occupational Therapy documentation dated 5/15/25, indicated as of 5/07/25, Resident R2 required assistance of two staff and a walker to maintain his/her balance. Resident R2's Care Plan History revealed on 5/06/25, staff were instructed to transfer per therapy recommendations-see tasks for instructions. Resident R2's point of care documentation prior to 5/15/25, revealed that he/she was being transferred with a mechanical lift and assistance of two staff, and using a shower gurney. Resident R2's departmental progress notes revealed that on 5/15/25, at 9:21 p.m. staff was called to the shower room to assess Resident R2 after he/she fell, and orders were received to transport Resident R2 to the Emergency Department. At 10:22 p.m. the facility was notified that Resident R2 was admitted to the hospital for treatment of a fractured left femur. Review of the investigation revealed that on 5/15/25, Nurse Aide (NA) Employee E1 reported that he/she was aware that Resident R2 was an assistance of two staff for transfers at the time of the fall and chose to transfer Resident R2 by himself/herself. During an interview on 6/05/25, at 10:40 a.m. the Regional Clinical Consultant and Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that NA Employee E1 had knowingly transferred Resident R2 without the assistance of a second staff. The facility failed to ensure that Resident R2 was free from neglect resulting in actual harm of a left femur fracture from an improper transfer done independently and not with the required two-person assistance. This deficiency is cited as past non-compliance. The NA Employee E1 was removed from the schedule and would not be returning. On 5/15/25, the facility initiated re-educating staff of the abuse policy and conducting procedural competencies on locating the appropriate transfer status of residents prior to providing care. On 5/16/25, the facility initiated audits (observations) of staff completing resident transfers, and continued to audit resident transfers until 6/04/25 with transfers being completed accurately. During an interview on 6/05/25, at 1:30 p.m. the Director of Nursing, Nursing Home Administrator, and the Regional Clinical Consultant confirmed that there is additional training scheduled on 6/10/25, and that the incident is scheduled to be reviewed in Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) meeting scheduled for 6/13/25. Interviews with NA Employees E3, E4, E5, E6, and E7 confirmed that they were re-educated a week or two ago on where to find information regarding a resident's transfer status and the facility abuse policy. The facility has demonstrated compliance since 6/04/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on review of facility documentation and clinical record, and staff interviews, it was determined that the facility failed to appropriately transfer a resident as identified in the plan of care for two of three residents reviewed (Residents R2 and R3), with one transfer which resulted in actual harm of a left femur (upper leg) fracture for one of three residents reviewed (Resident R2). This deficiency is cited as past non-compliance. Findings include: Resident R3's clinical record revealed an admission date of 3/20/25, with diagnoses that included respiratory failure, muscle weakness, abnormal gait and mobility, and need for personal care assistance. Resident R3's Admission/re-admission Nursing Evaluation Section 4 dated 3/20/25, revealed that he/she required the assistance of two staff to transfer. A Physical Therapy evaluation dated 3/20/25, indicated that Resident R3's baseline (starting) transfer ability was with moderate assistance of two. An Occupational Therapy evaluation dated 3/20/25, indicated that Resident R3's baseline toileting ability was toileting in bed, total assist, unsafe for toilet transfer due to O2 (oxygen) dropping. Resident R3's Care Plan History revealed that on 3/20/25, staff were instructed to transfer with walker and assist x 2 (two staff) ambulate with therapy only. Resident R3's Intervention/Task documentation dated March 2025 for transfer/toileting abilities, revealed that he/she required either assistance at level 02: Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort or assistance at level 01: Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of the facility investigation revealed that on 3/22/25, Nurse Aide (NA) Employee E3 reported that he/she attempted to transfer Resident R3 onto the toilet without the assistance of another staff member and that Resident R3's knees buckled and the resident was lowered to the floor. During an interview on 6/05/25, at 11:30 a.m. Occupational Therapist Employee E8 confirmed that Resident R3 was not yet assessed for safe toileting transfers on 3/22/25, and should have been provided a bed pan until safe transfer status was established. During an interview on 6/06/25, at 9:15 a.m. the Regional Clinical Consultant and Director of Nursing confirmed that there was no policy regarding following therapy transfer orders, but that staff are to refer to the resident's Kardex (plan of care) in the electronic health record. Resident R2's clinical record revealed an admission date of 12/21/21, with diagnoses that included stroke, Parkinson's Disease (brain disorder that causes gradual, progressive damage to parts of the brain over many years), and muscle weakness. Resident R2's physician's orders as of 5/19/25, revealed an order dated 2/02/24, to transfer to shower chair with assist of two, please follow instructions in tasks. Resident R2's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) Assessment, dated 4/15/25, Section G, Functional Status revealed that Resident R2 required extensive assistance of two people to transfer between surfaces. Occupational Therapy documentation dated 5/15/25, indicated that as of 5/07/25, Resident R2 required assistance of two staff and a walker to maintain his/her balance. Resident R2's Care Plan History revealed that on 5/06/25, staff were instructed to transfer per therapy recommendations-see tasks for instructions. Resident R2's point of care documentation prior to 5/15/25, revealed that he/she was being transferred with a mechanical lift and assistance of two staff, and using a shower gurney. Resident R2's departmental progress notes revealed that on 5/15/25, at 9:21 p.m. staff was called to the shower room to assess Resident R2 after he/she fell, and orders were received to transport Resident R2 to the Emergency Department. At 10:22 p.m. the facility was notified that Resident R2 was admitted to the hospital for treatment of a fractured left femur. Review of the facility investigation revealed that on 5/15/25, the NA Employee E1 reported that he/she was aware that Resident R2 was assistance of two staff for transfers at the time of the fall and chose to transfer Resident R2 by himself/herself. During an interview on 6/05/25, at 10:40 a.m. the Regional Clinical Consultant and Nursing Home Administrator confirmed that after the investigation was completed, it was discovered that NA Employee E1 had knowingly transferred Resident R2 without the assistance of a second staff. The facility failed to ensure that Resident R2 was free of an accident that resulted in actual harm of a left femur fracture from an improper transfer done independently and not with the required two-person assistance. This deficiency is cited as past non-compliance. The NA Employee E1 was removed from the schedule and would not be returning. On 5/15/25, the facility initiated re-educating staff regarding safe transfers and conducting procedural competencies on locating the appropriate transfer status of residents prior to providing care. On 5/16/25, the facility initiated audits (observations) of staff completing resident transfers, and continued to audit resident transfers until 6/04/25. During an interview on 6/05/25, at 1:30 p.m. the Director of Nursing, Nursing Home Administrator, and the Regional Clinical Consultant confirmed that there is additional training scheduled on 6/10/25, and that the incident is scheduled to be reviewed in Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) meeting scheduled for 6/13/25. Interviews with NA Employees E3, E4, E5, E6, and E7 confirmed that they were re-educated a week or two ago on where to find information regarding a resident's transfer status to prevent accidents. The facility has demonstrated compliance since 6/04/25. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Nov 2024 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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Based on review of facility policies, facility documentation and review of clinical records, and staff interviews, it was determined that the facility failed to appropriately transfer a resident to ensure the resident was free from neglect which resulted in actual harm of a fracture of the right humeral head of the right shoulder for one of 13 residents reviewed (Resident R1). Findings include: The Mechanical Lifts and Slings policy, dated 2/05/24, revealed, Mechanical lift transfer status will be maintained indicating the use of a full mechanical lift or sit to stand mechanical lift. Transfer Status will also be documented in the Plan of Care. Two or more aides must be used for all full mechanical lift transfers. The Identifying Resident Neglect policy, dated 2/05/24, revealed, Neglect includes cases where the facility's indifference to or disregard for resident care, comfort, or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. A review of Resident R1's clinical record revealed an admission date of 4/13/23, with diagnoses that included cerebral infarction due to embolism (a stroke due to a blood clot in the brain), muscle weakness, and major depressive disorder. A review of Resident R1's order summary revealed a physician's order dated 4/14/23, to utilize a mechanical lift with two staff for transfers. A review of Resident R1's ADL (Activities of Daily Living) Self Care Performance Deficit care plan, date initiated 4/25/23, revealed, mechanical lift and assist of two for transfers. A review of Resident R1's clinical record revealed a nursing note written by Registered Nurse (RN) Employee E2, dated 10/27/24, at 2:42 a.m. Called to resident room by LPN [Licensed Practical Nurse] to assess right arm and shoulder d/t [due to] increased pain. Resident has a history of CVA [cerebrovascular accident] which effected right side. Right arm has limited ROM [range of motion] since CVA. Right shoulder appears swollen, no increased warmth. Scarring to shoulder from previous surgery. Resident states shoulder is always swollen but is more painful at this time than usual. No recent falls or known injuries. Ice applied to site and Tylenol given by LPN. Will discuss with on call MD [medical doctor] in a.m. r/t [related to] need for Xray. A review of Resident R1's clinical record revealed a nursing note written by LPN Employee E4, dated 10/27/24, at 2:57 p.m. CRNP [Certified Registered Nurse Practitioner] Employee E5 notified of increased right shoulder and arm pain per LPN. Verbal orders to continue with current pain management regimen and ice as needed. Floor staff updated. A review of Resident R1's clinical record revealed a nursing note dated 10/28/24, at 1:52 p.m. indicating a new order for an X-Ray of the right shoulder was received. The X-Ray was completed on 10/29/24. Review of information submitted by the facility, dated 10/29/24, revealed that an X-Ray of Resident R1's right arm was ordered because he/she was guarding his/her right arm. The X-Ray was completed and dictated on 10/29/24, with results indicating there was an acute minimally impacted fracture of the base of the humeral head in the right shoulder. The result was reported to the Medical Director and Director of Nursing (DON) and at that time an investigation on the weekend of 10/26/24 and 10/27/24 began. The investigation revealed that agency NA Employee E1 was asked to assist another NA Employee E4 with a transfer. When NA Employee E4 arrived to Resident R1's room agency NA Employee E1 already had Resident R1 in bed. It was confirmed that agency NA Employee E1 transferred Resident R1 with no mechanical assistance, independent of any other support. A review of the investigation revealed that NA Employee E4 provided a written statement with an incident date of 10/26/24, and a time of 1:30 p.m. which revealed, It was after lunch and I asked [NA Employee E1] for help to lay [Resident R1] down in bed. When I walked in the room with the lift [NA Employee E1] had a hold of [Resident R1] with his/her hands under his/her arms picking him/her up. I ran over to the side of the bed to help finish transferring him/her. When we got him/her laying down [Resident R1] was saying his/her arm was hurting him/her. [NA Employee E1] was saying something and rubbing his/her arm. We finished changing him/her and got him/her comfortable. This written statement was signed dated 10/29/24. A review of the investigation revealed that agency NA Employee E1 signed the facility's orientation policy related to ensuring staff know where to locate transfer status to ensure safe transfer of all residents on 9/20/24. A review of documentation submitted by the facility, dated 10/29/24, revealed that the facility initiated an investigation and the agency NA Employee E1 was removed from the schedule and would not be returning. During an interview on 11/07/24, at approximately 2:10 p.m. the Nursing Home Administrator (NHA) and DON confirmed that the agency NA Employee E1 had transferred Resident R1 independently and did not use a lift as ordered and care planned. The facility failed to ensure that Resident R1 was provided adequate assistance in accordance with their physician orders and care plan to utilize a mechanical lift and free from neglect, causing a fracture of the right humeral head of the right shoulder from an improper transfer. This deficiency is cited as past non-compliance. On 10/29/24, the facility initiated education for all nursing staff including RN's, LPN's, and NA's to ensure that resident transfers are performed per resident care plans and physician's orders. This plan included the following: Immediate Suspension and Do Not Return of agency NA Employee E1. Immediate education regarding checking transfer status before ambulating or transferring a resident was provided to nursing staff which included RN's, LPN's, and NA's, which occurred from 10/29/24, through 11/06/24. Review of all resident transfer status completed by the Assistant Director of Nursing RN Employee E12 in conjunction with the Therapy Department on 10/31/24. All staff included in the education also completed competencies conducted by the Management Team. Interviews with RN Employee E12, LPN Employees E6, E7, and E8 and NA Employees E9, E10, and E11, confirmed the facility initiated education and competencies starting 10/29/24, which included education on checking transfer status before ambulating or transferring a resident and performing a return demonstration to ensure proper knowledge and technique. Audits were conducted to ensure residents are transferred per their care plans and physician orders, which occurred on all shifts and on all units from 11/05/24, through 11/06/24 with all transfers performed appropriately. The facility has demonstrated compliance with using correct transfer status for residents since 11/06/24. During an interview with the NHA and the DON on 11/07/24, at approximately 2:15 p.m. and review of the facility's immediate actions, education, competencies, and audits, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding transfer status of residents and had achieved substantial compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Aug 2024 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and facility documentation, and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) Form CMS-10055 as required to one of three residents reviewed (Resident R43). Findings include: Review of facility policy dated 2/05/2024, entitled Beneficiary Notices - Medicare A and Medicare Advantage revealed that The facility will notify the Medicare beneficiary when his/her skilled Medicare Part A Services are ending and the beneficiary will be remaining in the facility (SNF ABN, CMS-10055) and that The beneficiary (resident) or resident representative will sign the notice and acknowledge receipt of notice. If the resident or resident representative cannot be present to sign the notice, a certified return receipt letter will be sent via mail. The facility will document on the notice that the resident or resident representative was contacted via phone and that the information was reviewed, expedited appeal and/or formal appeal procedure reviewed and phone numbers provided. The Beneficiary Protection Notification Review revealed that Resident R43 began receiving skilled services on 3/18/24, the last covered day of Part A Service was 3/21/24, and that the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted. There was no evidence that the SNF ABN Form CMS-10055 was provided to the resident or resident representative. During an interview on 8/7/24, at 1:48 p.m., the Nursing Home Administrator confirmed that the required SNF ABN Form CMS-10055 was not issued as required to Resident R43 and/or their representative. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident rights

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and/or revise resident care plans for one of 18 residents reviewed (Resident R38). Findings include: Review of facility policy dated 2/05/2024, entitled Care Planning - Interdisciplinary Team indicated that A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). Resident R38's clinical record revealed an admission date of 11/07/2022, with diagnoses that included Alzheimer's (a disorder affecting the brain causing problems with memory, thinking, and behavior), colon cancer, and fractured left hip. Review of Resident R38's comprehensive care plans revealed that of the 15 care plans present, 15 had an outstanding target date of 6/21/2024. The care plans included the problem categories of: Impaired Skin Integrity, Activities, Constipation, Musculoskeletal, Noncompliance with Transfer Status, Cognitive Status, Communication, ADL Self Care, Bladder Incontinence, Depression, Resistive to Care, Falls, Nutrition, Anti-Anxiety Medication Use, and Pain, During an interview on 8/8/2024, at 12:01 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R38's care plans were not reviewed and/or revised within the required timeframe. 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for three of 18 residents reviewed (Residents R66, R28, and R67). Findings include: Review of the facility policy Administering Medications, dated 2/05/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications that the prescriber would be contacted to discuss the concerns. Review of facility policy entitled Weight Assessment and Interventions dated 2/5/24, indicated Weights will be recorded in the individuals medical record. Review of Resident R66's clinical record revealed an admission date of 7/14/24, with diagnoses that included heart failure, atrial fibrillation, diabetes with diabetic neuropathy, and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, Thursday and Friday each week for dialysis. Current physician's orders for Resident R66 included for the resident to receive Zofran (nausea medication) 4 milligrams (mg) every eight hours, and Protonix (medication to treat stomach acid) 40 mg one time a day. Review of the medication administration record (MAR) for July 2024 revealed there was no documented evidence that the Zofran was administered or refused on July 21, 22, 24, 28 and 30, 2024. The MAR also revealed no documented evidence that the Protonix was administered or refused on July 16, 19, 24, 26, 28 and 29, 2024. Interview with the Director of Nursing on August 8, 2024, at 10:30 a.m. confirmed that there was no documented evidence that Resident R66 was administered or refused the above identified medications for the dates and times identified. Review of Resident R28's clinical record revealed an admission date of 11/21/23, with diagnoses that included congestive heart failure (CHF-a condition in which the left ventricle of the heart is weak, causing fluid to build up), high blood pressure and respiratory failure. Current physician's orders for Resident R28 included an order for weekly weights, every Sunday on day shift for monitoring and an order for a foley catheter (tube placed into the bladder to drain urine). A review of the weekly weights for Resident R28, revealed as of 8/8/24, the last documented weight was on 7/28/24, a period of 11 days without documented evidence that a weight was obtained as ordered. Review of Resident R28's clinical record revealed no evidence of a foley catheter and observations of Resident R28 on 8/6/24, 8/7/24, and 8/8/24, were without a foley. Review of Resident R67's clinical record revealed and admission date of 9/28/23, with diagnoses that included diabetes (a health condition that caused by the body's inability to produce enough insulin), dementia (a disease that affects short term memory and the ability to think logically), and hypertension (high blood pressure). Review of Resident R67's clinical record revealed a physician's order dated 5/6/24, to weigh resident weekly. Review of Resident R67's weekly weights revealed a weight done on 6/10/24, with no weight obtained again until 6/23/24, or a period of 13 days. Then no weight was done again until 7/10/24, a period of 19 days. Then no weight was done again until 7/19/24, a period of nine days, Resident R67 had no weight documented after 7/19/24, as of 8/8/24, a period of 21 days. Interview with the Director of Nursing (DON) on August 11, 2024, at 2:00 p.m. confirmed that there was no documented evidence that weekly weights were obtained as ordered for Residents R28 and R67. He/she also confirmed that weights should be obtained and documented as ordered by the physician. The DON also confirmed at this time that Resident R28 did not have a foley and that the order was not accurate. 28 Pa. Code 211.12(d)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of two residents reviewed for respiratory services (Resident R293). Findings include: Review of facility policy dated 2/05/2024, entitled Oxygen Therapy / Pulse Oximetry indicated Oxygen is considered a drug and can only be administered with a physician's order. Check rate of delivery at least every shift and prn [as needed]. Oxygen may be initiated as an immediate intervention in urgent / emergent situations at the discretion of the licensed nurse. The physician will be notified for appropriate orders. Resident R293's clinical record revealed an admission date of 8/01/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing, cough, mucus production, and wheezing), multiple sclerosis (an autoimmune disease affecting the central nervous system), and anxiety. Observations on 8/06/2024, at 3:30 p.m. and on 8/07/2024, at 10:12 a.m. revealed Resident R293 wearing an oxygen nasal cannula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 2 liters per minute. Resident R293's clinical record lacked evidence of a physician's order for the use of oxygen therapy. During an interview on 8/07/2024, at 10:29 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R293 was being administered oxygen therapy and their clinical record lacked a physician's order for oxygen therapy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14 days for one of six residents reviewed for unnecessary medications (Resident R10) and failed to provided evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of a PRN psychotropic medication for three of six residents reviewed for unnecessary medications (Residents R10, R38, and R293). Findings include: A facility policy dated 2/05/2024, entitled Antipsychotic Medication Use indicated The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Resident R10's clinical record revealed an admission date of 2/27/2017, with diagnoses that included dementia (a disorder affecting the brain causing problems with memory, thinking, and behavior), high blood pressure, and anxiety. A physician's order dated 7/19/2024, identified to administer Ativan (anti-anxiety medication) 0.5 milligrams (mg) by mouth every 4 hours PRN for anxiety, and lacked the required stop date within 14 days or a clinical rationale for continued use. Resident R10's July 2024 Medication Administration Record (MAR) revealed that the PRN Ativan was used four times (7/23/2024 twice, 7/28/2024, and 7/31/2024). Review of the July 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions were attempted prior to the administration of the PRN Ativan two of the four times it was used. Resident R10's August 2024 MAR revealed that the PRN Ativan was used one time (08/01/2024). Review of the August 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Ativan one of one times it was used. Resident R38's clinical record revealed an admission date of 11/07/2022, with diagnoses that included Alzheimer's (a disorder affecting the brain causing problems with memory, thinking, and behavior), colon cancer, and fractured left hip. A physician's order dated 2/20/2024, identified to administer Lorazepam (anti-anxiety medication) 0.5 mg every 12 hours PRN for anxiety for 60 days and another physician's order dated 4/23/2024, identified to administer Lorazepam 0.5 mg every 12 hours PRN for agitation related to anxiety for 6 months. Resident R38's April 2024 MAR revealed that the PRN Lorazepam was used three times (4/08/2024, 4/14/2024, and 4/28/2024). Review of the April 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of three times it was used. Resident R38's May 2024 MAR revealed that the PRN Lorazepam was used four times (5/12/2024, 5/13/2024, 5/17/2024, and 5/26/2024). Review of the May 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam three of two times it was used. Resident R38's June 2024 MAR revealed that the PRN Lorazepam was used nine times (6/03/2024, 6/07/2024, 6/08/2024, 6/14/2024, 6/16/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024). Review of the June 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam three of the nine times it was used. Resident R38's July 2024 MAR revealed that the PRN Lorazepam was used five times (7/04/2024, 7/09/2024, 7/21/2024, 7/26/2024, and 7/27/2024). Review of the July 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of the five times it was used. Resident R293's clinical record revealed an admission date of 8/01/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - chronic lung disease causing difficulty in breathing, cough, mucus production, and wheezing), multiple sclerosis (an autoimmune disease affecting the central nervous system), and anxiety. Resident R293's August 2024 MAR revealed that the PRN Lorazepam was used three times (8/02/2024, 8/04/2024, and 8/07/2024). Review of the August 2024 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions attempted prior to the administration of the PRN Lorazepam two of the three times it was uses. During an interview on 8/08/2024, at 1:51 p.m., the Director of Nursing confirmed that Resident R10's Ativan orders lacked the required stop date within 14 days or a clinical rationale for continued use beyond 14 days and Resident R10, R38, and R293's clinical record lacked evidence that non-pharmacological interventions were being attempted prior to the administration of a PRN anti-anxiety medication for each time it was administered. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in one of one medication rooms reviewed (First Floor) and the facility failed to appropriately discard outdated medications for one of two medication carts reviewed (C wing medication cart). Findings include: Review of facility policy entitled LTC Facility Pharmacy Services and Procedures Manual dated 2/5/24, indicated Once any medication . is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. and If a multi-dose vial of an injectable medication has been opened . the vial should be dated and discarded within 28 days . and Store all drugs . including the storage of Schedule II-V medications in separately locked, permanently affixed compartments . Review of manufacturer's guidelines revealed that an open pen of Humalog Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin must be used within 28 days after opening or be discarded, even if the vial still contains insulin. Observation of drug storage on 8/6/24, at 11:36 a.m. of C wing medication cart revealed an open pen of Lantus Insulin with no date indicating when the pen was opened. Further review of C wing medication cart revealed an open pen of Humalog Insulin with no date indicating when the pen was opened. During interview at the time of observation, Licensed Practical Nurse Employee E3 confirmed that the open Lantus Insulin and the open Humalog Insulin lacked an open date. He/she also confirmed that due to the Lantus and Humalog insulins having no open date both insulins should have been discarded. Observation on 8/6/24, at 11:40 a.m. of the First Floor medication room refrigerator revealed a clear plastic box and inside the clear plastic box were two boxes of Lorazepam (a controlled antianxiety medication). The shelf with the clear plastic box containing the Lorazepam was not permanently affixed to the refrigerator allowing the shelf and Lorazepam to be removed from the refrigerator. During an interview at the time of observation with Registered Nurse Employee E4, he/she confirmed that the clear plastic box containing Lorazepam was not permanently affixed to the refrigerator. He/she also confirmed that the Schedule II-V medications should be store in a separately locked permanently affixed compartment. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations, review of facility policy and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose (sugar) in the blood) for one of seven residents observed during the administration of medications (Resident R75). Findings include: Review of facility policy entitled Blood Glucometer Cleaning dated 2/5/24, indicated Blood glucose meters will be cleaned after each resident use per manufacturer's specifications. Review of manufacturer's guidelines for Evencare Proview indicated The Evencare Proview meter should be cleaned and disinfected between each patient. Observation on 8/6/24, at 4:04 p.m. revealed Licensed Practical Nurse (LPN) Employee E5 removed a BGM machine from the A wing first floor medication cart. He/she then proceeded down the hall to Resident R75's room. LPN Employee E5 obtained the blood glucose level using the BGM on Resident R75. He/she proceeded down the hall to the medication cart which was parked at the nurse's station. LPN Employee E5 opened the top drawer of the A wing first floor medication cart and placed the BGM machine inside of the cart without cleaning the BGM machine. He/she then prepared Resident R75's insulin and proceeded down the hall to administer the insulin to Resident R75. LPN Employee E5 then returned to the A wing medication cart and started to look at his/her next residents orders. During an interview with LPN Employee E5 at the time of the observation he/she confirmed that he/she did not clean the BGM machine before placing it back into the medication cart. He/she also confirmed that the BGM machine should be cleaned after every resident and before being placed back into the medication cart. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to ensure medications were administered according to physician's orders for residents receiving dialysis (method of mechanically cleaning the blood) for one of two residents reviewed for dialysis (Resident R66). Findings include: Review of the facility policy Administering Medications, dated 2/05/24, indicated that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated that if there were any concerns regarding the medications that the prescriber would be contacted to discuss the concerns. Review of Resident R66's clinical record revealed an admission date of 7/14/24, with diagnoses that included heart failure, atrial fibrillation, diabetes with diabetic neuropathy, and end stage renal disease with dependance on renal dialysis, which required being away from the facility on Monday, Wednesday, Thursday and Friday each week for dialysis. Review of physician's orders dated 7/14/24, indicated that Resident R66 was to have Bacitracin-Polymyxin B ophthalmic ointment (antibiotic eye medication for infections) 1000 grams one application into each eye four times a day, Gabapentin (medication for neuropathy pain), 200 milligrams (mg) four times daily, Lanthanum Carbonate (medication for end stage renal disease), 1000 mg with meals, Midodrine HCL (medication for low blood pressure) 10 mg three times daily, and Zofran (an anti-nausea medication) 4 mg every eight hours. Review of the July and August 2024, Medication Administration Records (MARs) revealed that Resident R66 did not receive the following medications as ordered with reason given as: Not in Facility Bacitracin Polymyxin B ophthalmic ointment noon dose on 7/15/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Gabapentin noon dose on 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Lanthanum Carbonate noon dose on 7/17/24, 7/18/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Midodrine noon dose on 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. Zofran two p.m. on 7/24/24, 7/25/24, 7/26/24, 7/29/24, 7/31/24 and 8/5/24. There was no documentation that the physician was notified of a need to hold or alter the time of administration for the above listed medications for Resident R66 on dialysis days. During an interview on 8/08/24, at 2:00 p.m. the Director of Nursing confirmed that the above medications for Resident R66 were not administered on dialysis days as ordered by the physician. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Apr 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that the physician reviewed the residents' total program of care including medications during physician visits for one of nine residents reviewed (Resident R1). Findings include: Review of facility policy entitled, Monthly Medication Regimen Review dated 9/25/23, indicated the intent, To ensure the resident's highest practicable level of physical, mental, and psychosocial well-being and prevent or minimize adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing. Resident R1's clinical record revealed an admission date of 2/21/22, with diagnoses that included multiple subsegmental pulmonary emboli (a blood clot in the lung(s) in more than one artery), muscle weakness, and hypertension (high blood pressure). Resident R1's progress notes revealed that he/she was sent to the emergency room on [DATE], due to a positive doppler scan indicating he/she had a deep vein thrombosis (blood clot) in his/her left lower extremity. Resident R1 returned to the facility on [DATE] with an order for the medication Eliquis (an anticoagulant/blood thinner) 5 milligrams (mg) two times a day for 74 doses. The Certified Registered Nurse Practitioner (CRNP) documented in the progress notes during his/her visits with Resident R1 on 12/28/23, 1/4/24, and 1/11/24, that Resident R1 was to remain on the anticoagulant medication long-term. Review of Resident R1's medication administration record (MAR) revealed Eliquis 5 mg twice a day was administered as ordered from 12/27/23, through 2/1/24. Resident R1 did not receive Eliquis 5 mg twice a day from 2/2/24, through 4/8/24. The CRNP documented in the progress notes during his/her visits with Resident R1 on 2/1/24, 2/16/24, and 3/1/24 that Resident R1 was receiving Eliquis 5 mg twice a day due to an extensive deep vein thrombosis in the left lower extremity. Eliquis 5 mg twice a day was no longer on the current medication list during the identified visits as it had been discontinued after the 2/1/24, administered doses. During an interview on 4/17/24, at 11:40 a.m. the Director of Nursing confirmed that the CRNP did not review Resident R1's current medications during visits and/or communicate with nursing staff and/or the pharmacy to ensure the accuracy of the total program of care to include medications that Resident R1 was receiving. 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa Code 211.5(f)(iv) Medical records

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to properly conduct thorough monthly drug regimen reviews to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities for one of nine residents reviewed (Resident R1). Findings include: Review of a facility policy entitled, Monthly Medication Regimen Review dated 9/25/23, indicated, The licensed pharmacist conducting the medication regimen reviews will provide a written report of irregularities. This report will be provided to the attending physician, medical director, and director of nursing (DON). The report shall list the residents name, relevant medication, and irregularity the pharmacist has identified. Resident R1's clinical record revealed an admission date of 2/21/22, with diagnoses that included multiple subsegmental pulmonary emboli (a blood clot in the lung(s) in more than one artery), muscle weakness, and hypertension (high blood pressure). Resident R1's progress notes revealed that he/she was sent to the emergency room on [DATE], due to a positive doppler scan indicating he/she had a deep vein thrombosis (blood clot) in his/her left lower extremity. Resident R1 returned to the facility on [DATE], with an order for the medication Eliquis (an anticoagulant/blood thinner) 5 milligrams (mg) two times a day for 74 doses. Resident R1's clinical record revealed the licensed pharmacist performed a monthly regimen review on 1/5/24, and indicated that the Eliquis 5 mg twice a day for 74 doses was added due to deep vein thrombosis in the left lower extremity. Physician progress note from 1/11/24, included remain on anticoagulant long term. Review of Resident R1's February 2024 Medication Administration Record (MAR) revealed that the last administration of Eliquis 5 mg was on 2/1/24, with doses administered at 8:00 a.m. and 8:00 p.m. Physician progress note of 3/1/24 identified .recently placed on Eliquis due to LLE [extensive left lower extremity] DVT [deep vein thrombosis]. Review of Resident R1's March 2024 MAR revealed no indication that Eliquis was ordered or administered. The monthly regimen reviews conducted on 2/5/24, and 3/19/24, were not thorough as they failed to identify documentation of irregularities regarding the Eliquis 5 mg. The medication twice a day had been discontinued abruptly yet Resident R1 had a history of pulmonary emboli and deep vein thrombosis in the left lower extremity. The progress notes completed by the Certified Registered Nurse Practitioner on 12/28/23, 1/4/24, 1/11/24, indicated Resident R1 was to remain on Eliquis 5 mg twice a day long-term and indicated Resident R1 remained on Eliquis 5 mg twice a day 2/1/24, 2/16/24, and 3/1/24, despite the order having been discontinued once the 2/1/24 doses were administered. Pharmacy review from 3/19/24-no irregularities noted and no reference to Eliquis for Resident R1. During an interview on 4/17/24, at 11:40 a.m. the Director of Nursing confirmed that the licensed pharmacist did not properly conduct a thorough monthly regimen review to prevent, identify, report, and resolve medication related problems, medication errors, or other irregularities for Resident R1. 28 Pa. Code 211.9(a)(1) Pharmacy Services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to fully investigate an injury of unknown origin in a timely manner for one of one residents reviewed (Resident R1). Findings include: Review of facility policy entitled Incidents and Accident Reports, Resident dated 9/2023, revealed An incident report is completed whenever there is an occurrence ., The following is a list of the types of occurrences for which an incident report is prepared . Injury of unknown origin and Those incidents requiring investigation . will be reported to the Administrator and Director of Nursing . Review of Resident R1's clinical record revealed an admission date of 11/16/23, with diagnoses that included hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones), hypertension (high blood pressure), and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone). Review of Resident R1's nursing documentation revealed a progress note dated 12/12/23, that identified he/she was seen by his/her physician and a new order was given from his/her physician for x-rays of left shoulder, left humerus, and left foot and deformity. Further review of Resident R1's nursing documentation revealed a progress note dated 12/13/23, that indicated x-ray results were received by the facility. Physician was updated on Resident R1's acute fracture of the fifth metatarsal (foot bone between the ankle and toe) and gave an order to have Resident R1 seen by an orthopedic physician (a physician that specializes in bone care). Review of Resident R1's care plan revealed a care plan dated 12/14/23, for left foot fracture related to previous fall. Review of a Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 12/15/23, section J 1800 indicated Resident R1 had not had any falls since admission/reentry. Review of facility incident report for December 2023, revealed no evidence that Resident R1 had any type of incident. Review of Resident R1's clinical record lacked evidence that an investigation was started or completed, regarding the identified of the fracture of the fifth metatarsal. Further review of clinical record lacked evidence of interviews from staff present at the time of the incident or handwritten statements from staff. During an interview on 2/8/2024, at 11:46 a.m. the Nursing Home Administrator (NHA) confirmed that there was no investigation started or completed on Resident R1's injury of unknown origin. NHA also confirmed that the injury of unknown origin should have been investigated. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

Sept 2023 8 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of eighteen residents reviewed (Resident R49). Findings include: Review of facility policy entitled Computer Terminals/Workstations dated 9/25/23, indicated computer terminals will be positioned so that screens are not visible to public or other unauthorized staff. During observation of medication administration for Resident R49 on 9/26/23, at approximately 3:45 p.m. Licensed Practical Nurse (LPN) Employee E2 prepared medication for a resident from Unit A second floor medication cart parked in the hall against the wall outside the resident room with the computer open sitting on top of medication cart facing into the hallway. LPN Employee E2 then proceeded into the resident room to administer medication. LPN Employee E2 did not cover resident/medication information that was on the computer on top of the medication cart with information visible to those walking in the hallway. LPN Employee E2 was unable to view the computer on top of the medication cart parked in the hall against the wall while in the resident's room. During an interview on 9/26/23, at the time of the observation, LPN Employee E2 confirmed that he/she left the medication cart with the computer open and did not cover resident/medication information that was on the computer on top of the medication cart. LPN Employee E2 also confirmed that resident information was to be covered when not within view. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for two of 19 residents reviewed (Residents R20 and R64). Findings include: Review of Resident R20's clinical record revealed an admission date of 9/08/23, with diagnoses that included dementia (disorder of the mental processes caused by brain disease), depression, fractured left knee, diabetes and high blood pressure. Review of Resident R20's clinical record revealed that an antidepressant (medication to treat depression) medication Zoloft was ordered on admission 9/08/23. Review of the admission MDS dated [DATE], Medications Section N0410C indicated that Resident R20 did not receive an antdepressant medication during the seven-day look back period (from 9/07/23 to 9/14/23). During an interview on 9/28/23, at 12:05 p.m. the Director of Nursing (DON) confirmed that Section N0410C of the admission MDS dated [DATE], was incorrectly coded for Resident R20 regarding antidepressant medications. Review of Resident R64's admission record revealed an admission date of 1/25/23, with diagnoses that included hypothyroidism (below normal thyroid functioning), Chronic Obstructive Pulmonary Disease (condition where your lungs do not have adequate air flow), low potassium level, and high blood pressure. Observation of Resident R64's room revealed and enabler bar (a device attached to the bed to assist in turning and repositioning) attached to the top of the right side of her bed. Observation revealed no evidence of a restraint being used with Resident R64. Review of the MDS dated [DATE], Restraints and Alarms revealed section P0100 identified that a bed rail was used daily. Review of Resident R64's care plans revealed no care plan for the use of restraints, review of the resident physician orders revealed no order for restraints. During an interview on 9/28/23, at 1:35 p.m. the DON revealed that there were no residents in the facility utilizing restraints. The DON confirmed that Section P0100 of the MDS dated [DATE], was incorrectly coded for Resident R64 regarding restraints. 28 Pa. Code 211.5(f) Clinical records

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for four of 19 residents reviewed (Residents R20, R92, R73, and R196). Findings include: Review of a facility policy entitled, Baseline Care Plan Guidelines dated 9/25/2023, revealed that the facility will provide a written summary to the resident/resident representative of the baseline care plan and discharge plan. Review of Resident R20's clinical record revealed an admission date of 9/08/23, with diagnoses that included dementia (disorder of the mental processes caused by brain disease), depression, fractured left knee, diabetes and high blood pressure. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of Resident R92's clinical record revealed an admission date of 9/03/23, with diagnoses that included fractured lower leg, history of falling, difficulty in walking and depression. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of R73's clinical record revealed an admission date of 8/18/23, with diagnoses including acute and chronic respiratory failure, type II diabetes, difficulty in walking, cognitive communication deficit (difficulty communicating), and dysphagia following a cerebral infarction (difficulty swallowing following a stroke). The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. Review of Resident R196's clinical record revealed an admission date of 9/18/23, with diagnoses including fracture of the left lower leg, muscle weakness, and history of falling. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or resident representative. During an interview on 9/28/23, at 12:56 p.m. the Assistant Director of Nursing confirmed there was no evidence that a written summary of the baseline care plan was provided to Residents R20, R92, R73, and R196 and/or the resident's representative. 28 Pa. Code 211.5(f) Clinical records

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to include reconciliation of all pre-discharge medications with the resident's post-discharge medications in the resident's discharge summary, for one of four closed records reviewed (Resident R94). Findings include: Review of a facility policy entitled, Disposition of Medication Policy dated 9/25/2023, indicated that disposition will be recorded in the electronic health record or paper form. Review of Resident R94's clinical record revealed an admission date of 7/6/23, with diagnoses that included, diabetes, low blood pressure, depression, and muscle weakness. Resident R 94's clinical record also revealed a discharge date of 8/5/23. Review of discharge summary lacked evidence of reconciliation of discharge medications on discharge. Review of nursing documentation lacked evidence of the type or number of medications sent home with resident on discharge. Review of Resident R94's physician orders indicated Resident R94 was receiving fourteen prescribed medications at time of discharge. During interview on 9/29/23, at 9:10 a.m. with the Nursing Home Administrator he/she confirmed that there was no documentation to account for Resident R94's s pre-discharge medications. During interview on 9/29/23, at 11:15 a.m. with the Assistant Director of Nursing he/she confirmed that there was no documentation of what medications or number of medications were sent home with Resident R94. He/She also confirmed that discharge medications should have a reconciliation of type of medication, amount of medication and signatures of nurse and resident/resident representative on discharge summary. 28 Pa. Code 211.5(d)(f) Clinical records

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to provide evidence that non-pharmacological interventions (interventions attempted to calm a resident other than medication) were attempted prior to the administration of an as needed (PRN) psychotropic (mind altering) medication for one of five residents reviewed for unnecessary medications (Resident R30). Findings include: Review of facility policy entitled, Behavioral Management-General Policy, dated 9/25/23, stated management of aggression requires behavioral interventions through a behavior management program and interdisciplinary care planning, staff in-service education on behavior management and techniques, sequential use of psychotropic medications if necessary, and most aggressive behavior can be managed by a combination of behavioral interventions and psychopharmacology. Review of Resident R30's clinical record revealed an admission date of 7/25/23, with diagnoses that included fracture of the left ulna, muscle weakness, difficulty in walking, unspecified dementia (disorder of the mental processes caused by brain disease), and psychotic disorder with delusions (seeing and hearing things that are not there). The clinical record revealed that on 8/4/2023, Resident R30's physician ordered Haldol injection solution (medication used to treat psychosis) inject 1 milliliter (ml) intramuscularly every six hours PRN for psychosis and on 8/17/23, Resident R30's physician ordered Clonazepam (medication ordered to treat anxiety) 0.5 milligrams (mg) every six hours PRN for anxiety. Review of the August 2023 Medication Administration Record (MAR) for Resident R30 revealed that the PRN Haldol was used on 8/4/23, 8/10/23, 8/12/23, 8/15/23 and the PRN Clonazepam was used on 8/17/23, 8/19/23, 8/22/23, and 8/26/23. Review of August 2023 MAR and clinical record progress notes revealed that there was no evidence of non-pharmacological interventions being attempted prior to the administration of the PRN Haldol for the four administrations and Clonazepam for the four administrations in August 2023. During an interview on 9/28/23, at 12:56 p.m. the Assistant Director of Nursing confirmed that R30's clinical record lacked evidence that non-pharmacological interventions were attempted prior to the PRN administration of psychotropic medications and that non-pharmacological interventions should be attempted and documented in the clinical records when using PRN psychotropic medications. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and manufacturer's recommendations, observations, and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of four medication carts observed and failed to ensure that medications were properly dated when opened and discarded in a timely manner in one of two medication rooms reviewed (Unit A second floor medication cart and first floor medication room). Findings include: Review of a facility policy entitled, Storage of Medications dated 9/25/23, indicated that compartments containing medications are locked when not in use and carts used to transport such items are not left unattended. Review of facility policy entitled Administering Medications dated 9/25/23, indicated that during administration of medications, the medication cart will be kept closed and lock when out of view and multi-dose containers will have date opened recorded on the container. Review of manufacturer's recommendations for Tubersol PPD (solution used for tuberculosis testing upon admission and for employment), indicated that vials which are entered and in use for 30 days should be discarded. Observation on 9/26/23, at approximately 3:40 p.m. revealed that Licensed Practical Nurse (LPN) Employee E2 prepared medication for a resident from Unit A second floor medication cart parked in the hall against the wall outside the resident room with the drawers of the medication cart facing into the hallway. LPN Employee E2 then proceeded into the resident room to administer medication. LPN Employee E2 did not securely lock Unit A second floor medication cart. Employee E2 was unable to view medication cart and drawers of the medication cart from inside the room while left unattended. During an interview on 9/26/23, at the time of the observation, LPN Employee E2 confirmed that he/she left the medication cart unlocked while it was parked in the hallway against the wall outside the resident room, which was out of view during medication administration. LPN Employee E2 confirmed that the medication cart should be locked when not within view. Observation of drug storage on 9/27/23, at approximately 9:30 a.m. in first floor medication storage room refrigerator revealed an opened vial of Tubersol without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, LPN Employee E1 confirmed that the opened Tubersol vial lacked an open date and staff were unable to determine the discard date. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1) Nursing services

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to maintain accurate clinical records for one of 18 residents reviewed (Resident R79). Findings include: Review of facility policy entitled Charting and Documentation dated 9/25/2023, indicated that documentation in the medical record will be complete and accurate. Review of Resident R79's clinical record revealed an admission date of 1/25/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-a condition that obstructs air flow in the lungs with symptoms of difficulty breathing, coughing and shortness of breath), diabetes, dysphagia (difficulty swallowing) and dementia (a disease that affects short term memory and the ability to think logically). Review of Resident R79's clinical record nursing documentation revealed that on 8/6/23, at 10:29 a.m. Resident R79 was sent to the emergency room for evaluation, then on 8/6/23 at 12:03 p.m. nursing documentation revealed that Resident R79 was being admitted to the hospital. Further review of Resident R79's clinical record revealed skilled nursing documentation on 8/6/23, at 3:15 p.m. that Resident R79 had voiced no concerns and the nurse was going to continue to monitor. Review of Minimum Data Set (MDS-a period assessment of resident care needs) dated 8/6/23, section A2000 revealed a discharge date of 8/6/23, section A2100 revealed discharge status of 03 --acute hospital. During interview on 9/28/23, at 12:08 p.m. the Director of Nursing confirmed that Resident R79 was not in the facility on 8/6/23 at 3:15 p.m. and that the resident was admitted to the hospital. He/she also confirmed that skilled charting on residents should not be completed when residents are not physically in the facility. 28 Pa. Code 211.12(d)(1) Nursing Services 28 Pa. Code 211.5(f) Clinical records

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program that contained a system of reports related to monitoring antibiotic usage and resistance data for 12 consecutive months reviewed (September 2022-September 2023). Findings include: Review of a facility policy entitled Antibiotic Stewardship dated 9/25/23, indicated that administrative and management personnel with clinical oversight responsibilities will receive initial orientation and ongoing training on how to access the current facility antibiogram (a collection of data usually in the form of a table summarizing the percent of individual bacterial pathogens [disease causing organisms susceptible to different antimicrobial agents]. Review of facility infection control reports/documentation revealed there was no evidence to support that the facility had an antibiogram for 12 consecutive months (September 2022-September 2023). During an interview on 9/28/23, at 1:00 p.m. the Infection Preventionist confirmed that the facility had not obtained antibiograms from the participating lab to monitor antibiotic usage and resistance data for 12 consecutive months. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 3 harm violation(s). Review inspection reports carefully.
• 27 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
• Grade F (3/100). Below average facility with significant concerns.
• 62% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Caring Place, The's CMS Rating?

CMS assigns CARING PLACE, THE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Caring Place, The Staffed?

CMS rates CARING PLACE, THE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 62%, which is 15 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 88%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Caring Place, The?

State health inspectors documented 27 deficiencies at CARING PLACE, THE during 2023 to 2025. These included: 3 that caused actual resident harm and 24 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Caring Place, The?

CARING PLACE, THE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 97 residents (about 97% occupancy), it is a mid-sized facility located in FRANKLIN, Pennsylvania.

How Does Caring Place, The Compare to Other Pennsylvania Nursing Homes?

Compared to the 100 nursing homes in Pennsylvania, CARING PLACE, THE's overall rating (1 stars) is below the state average of 3.0, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Caring Place, The?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Caring Place, The Safe?

Based on CMS inspection data, CARING PLACE, THE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Caring Place, The Stick Around?

Staff turnover at CARING PLACE, THE is high. At 62%, the facility is 15 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 88%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Caring Place, The Ever Fined?

CARING PLACE, THE has been fined $8,018 across 1 penalty action. This is below the Pennsylvania average of $33,159. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Caring Place, The on Any Federal Watch List?

CARING PLACE, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 100
Avg. Residents: 97
Occupancy: 97.0%
Ownership: Non profit - Church related
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
3 Actual Harm citations: -15
27 Deficiencies: -10
Fines ($8,018): -2
Abuse Finding: -15
Final Score: 3/100

Nearby Alternatives

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 395959