SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
For profit - Corporation
56 Beds
AKIKO IKE
Data: November 2025
Trust Grade
73/100
#226 of 653 in PA
Photo by Scenery Hill Healthcare and Rehabilitation Center
Photo by Scenery Hill Healthcare and Rehabilitation Center
Photo by Scenery Hill Healthcare and Rehabilitation Center
1 / 7 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Scenery Hill Healthcare and Rehabilitation Center has a Trust Grade of B, indicating it's a good option for families, meaning it's a solid choice but not exceptional. The facility ranks #226 out of 653 in Pennsylvania, placing it in the top half, and ranks #1 out of 5 in Indiana County, suggesting it is the best local option available. The trend is improving, with issues decreasing from 9 in 2024 to just 2 in 2025, reflecting positive changes over time. Staffing is a strength here, with a 4 out of 5-star rating and a low turnover rate of 28%, which is much better than the state average of 46%. There have been no fines reported, which is reassuring for families considering the home. However, there are some weaknesses to note. Specific incidents have been flagged, such as the failure to ensure safety assessments for air mattresses, which could put residents at risk for accidents. Additionally, the facility did not adhere to food safety standards, with expired food found in storage and inadequate dishwasher temperatures, raising concerns about hygiene. Lastly, one resident's bowel protocol was not followed as ordered, indicating lapses in medication administration. Overall, while there are areas for improvement, Scenery Hill appears to be a reliable choice with some solid strengths.
- Trust Score
- B
- In Pennsylvania
- #226/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 28% annual turnover. Excellent stability, 20 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
73/100
Top 34%
No red flags
9 → 2 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 2 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Low Staff Turnover (28%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (28%)
20 points below Pennsylvania average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
Chain: AKIKO IKE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
Apr 2025
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate trigge...
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Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 28 residents reviewed (Resident 46).
Findings include:
The facility's policy regarding trauma informed care, dated February 13, 2025, indicated that the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.
A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 3, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 46's care plan, dated August 13, 2024, indicated that the resident had PTSD, anxiety, and depression.
There was no documented evidence the facility identified Resident 46's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.
An interview with the Director of Nursing on April 23, 2025, at 3:19 p.m. confirmed that the facility did not identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 46.
28 Pa Code 201.24(e)(4) admission Policy.
28 Pa Code 211.12(a)(d)(3)(5) Nursing Services.
28 Pa. Code 211.16(a) Social 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
Based on review of manufacturer's instructions and observations, as well as staff interviews, it was determined that the facility failed to label multidose vials of tuberculin (solution used to detect...
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Based on review of manufacturer's instructions and observations, as well as staff interviews, it was determined that the facility failed to label multidose vials of tuberculin (solution used to detect tuberculosis infection).
Findings include:
Manufacturer's instructions for Tubersol, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened.
Observations of the facility's medication room on April 23, 2025, at 10:39 a.m. revealed there was one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis).
Interview with the Director of Nursing on April 23, 2025, at 3:58 p.m. confirmed that the bottle of Tubersol was not dated when it was opened and that it should have been.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1) Nursing Services.
Dec 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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania Department of Agriculture Food and Drug Administration Food Code and observations, as well as staff interviews, it was determined that the facility failed to store and ...
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Based on review of Pennsylvania Department of Agriculture Food and Drug Administration Food Code and observations, as well as staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions.
Findings include:
The Pennsylvania Department of Agriculture Food and Drug Administration Food Code, dated 2022, revealed Food Storage: Food shall be protected from contamination from the premise by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination; and at least 15 centimeter (cm) (6 inches) above the floor.
Observations in the basement dry storage area on December 4, 2024, at 11:52 a.m. and 12:39 p.m. revealed that on the left side of the basement from the wall, extending across the room to the drain, there was standing water covering a 12 foot by 12 foot area with a stream that extended to the floor drain next to several metal shelves, which contained the emergency food supply as well as other items that included cans of chicken and dumplings, pureed beef stew, cans of chicken puree, cans of tomato soup, cans of ravioli, boxes of thick and easy Hormel dairy beverage, four cases of bottle water, as well as cases of plastic spoons and forks. All the other dry storage foods were stored on the right side of the basement. There was also a sewer smell in the basement area. The facility had a dehumidify in use by the floor drain.
Interview with the Dietary Manager on December 4, 2024, at 12:02 p.m. confirmed that there was standing water on the basement floor and near the metal shelving. She was unsure what was causing the water, but there was a crawl space behind the wall. She reported the water on the floor to maintenance and confirmed the odor of sewer smell.
Interview with the Nursing Home Administrator and the Maintenance Director on December 4, 2024, at 12:20, 12:32, and 1:20 p.m. revealed that the recent rain and snow had created more ground water but it was cleaned up on Friday. Upon re-examination of the basement area with the Maintenance Director, he confirmed that there was 20 times more water on the floor as compared to Friday, and upon investigation it was determined that a down spout was broken causing the excess water in the basement.
28 Pa. Code 211.6(f) Dietary Services.
May 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for o...
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Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to complete a Nurse Aide Registry verification for one of five nurse aides reviewed upon hire (Nurse Aide 1).
Findings include:
The facility's abuse policy, dated February 15, 2024, revealed that the facility will not employ or otherwise engage individuals who have had a finding entered into the state Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property.
The personnel file for Nurse Aide 1 revealed that she was hired May 10, 2024. However, there was no documented evidence until May 28, 2024, at 9:41 a.m. that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified.
Interview with the Human Resources Director on May 30, 2024, at 12:57 p.m. confirmed that there was no documented evidence until May 28, 2024, that Nurse Aide 1's standing on the Pennsylvania Nurse Aide Registry was verified.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 18 residents reviewed (Residents 6, 28, 47).
Findings include:
The facility's policy regarding controlled substances, dated February 15, 2024, indicated that the nurse administering the medication is responsible for recording the name of the resident receiving the medication; name, strength, and dose of the medication; time of administration; method of administration; quantity of the medication remaining; and signature of the nurse administering the medication.
The facility's policy regarding medication administration, dated February 15, 2024, indicated that the resident's Medication Administration Record (MAR) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication).
Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10).
Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 27, 2024, at 5:00 a.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time.
Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of oxycodone to Resident 6 on the above date and time.
A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, understands others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication.
Physician's orders for Resident 28, dated May 16, 2024, included an order for the resident to receive one 5-325 mg tablet of hydrocodone-acetaminophen (narcotic pain reliever) every six hours as needed for severe pain (pain scale 7-10 out of 10) for chronic pain.
Resident 28's controlled drug record for May 2024 indicated that one dose of hydrocodone-acetaminophen was signed out for administration to the resident on May 24, 2024, at 8:49 p.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out doses of hydrocodone-acetaminophen were actually administered to the resident on this date and time.
Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that there was no documented evidence that staff administered the signed-out dose of hydrocodone-acetaminophen to Resident 28 on the above dates and times.
An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication as needed, and received an opioid.
Physician's orders for Resident 47, dated April 25 and May 11, 2024, included an order for the resident to receive 5 mg of oxycodone every four hours as needed for severe pain (pain scale 7-10 out of 10).
Resident 47's controlled drug record for April and May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on April 26 at 4:00 p.m., May 5 at 9:51 p.m., May 10 at 9:01 p.m., and May 13, 2024, at 5:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times.
Interview with the Director of Nursing on May 30, 2024, at 10:29 a.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 47 on the above dates and times.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were stored in a secure manner, and failed to securely store medications for one of 18 residents reviewed (Resident 28).
Findings include:
The facility's policy regarding medication administration, dated February 15, 2024, indicated that residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. During administration of medications, no medications are kept on top of the cart. Medications and biologicals were to be stored safely, securely, and properly. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications were allowed access to medications.
Observations on May 29, 2024, at 7:32 a.m. revealed that there was an unattended medication cart sitting in the hallway between resident rooms [ROOM NUMBERS] with a medication souffle cup that contained medications in applesauce. Licensed Practical Nurse 2 came down the hallway, took the medication souffle cup, and went into resident room [ROOM NUMBER].
Interview with Licensed Practical Nurse 2 on May 29, 2024, at 7:54 a.m. confirmed that the medication souffle cup containing the medications should not have been left on top of the medication cart. She indicated that she got called to an emergency.
Interview with the Director of Nursing on May 29, 2024, at 11:40 a.m. confirmed that the medications should not have been left on the medication cart when the medication cart was unattended.
A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, required assistance for daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD - inflammatory lung disease).
Physician's orders for Resident 28, dated May 10, 2024, included an order for the resident to receive two sprays of Flonase (allergy relief nasal spray) every morning for allergies and one puff of Trelegy Ellipta Inhalation Aerosol Powder Breath 200-62.5-25 micrograms for COPD.
Observations of Resident 28 on May 29, 2024, at 11:33 a.m. revealed that she was in bed eating lunch, and there were two medications (a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler) on the overbed table. Resident 28 said the nurse forgot to take the medications back. Interview with Licensed Practical Nurse 2 at 11:39 a.m. revealed that she forgot to take the medications.
Interview with the Director of Nursing on May 30, 2024, at 1:51 p.m. confirmed that Resident 28's medications should have been returned and secured in the medication cart after administration and not kept at bedside.
28 Pa. Code 211.9(a)(1) Pharmacy 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
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for three of 18 residents revi...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for three of 18 residents reviewed (Residents 6, 20, 28).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 14, 2024, revealed that the resident was usually understood, could understand others, had pain occasionally, received pain medication as needed, and received an opioid (a controlled pain medication).
Physician's orders for Resident 6, dated December 28, 2023, included an order for the resident to receive one 2.5 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for severe pain (pain scale 7-10 out of 10).
Resident 6's controlled drug record (a form that accounts for each dose of a controlled drug) for May 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 9, 2024, at 2:27 a.m. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on this date and time.
Resident 6's MAR for May 2024 indicated that one dose of oxycodone was administered to the resident on May 10, 2024, at 2:32 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed out to be administered to the resident on this date and time.
Interview with the Director of Nursing on May 30, 2024, at 9:25 a.m. confirmed that Resident 6's MAR was not documented accurately. She indicated that the nurse was working night shift and that the administration of the oxycodone on May 10, 2024, at 2:32 a.m. on the resident's MAR should have been documented as being administered on May 9, 2024, at 2:27 a.m.
A quarterly MDS assessment for Resident 20, dated May 15, 2024, indicated that the resident was alert and oriented and had diagnoses that included diabetes.
Physician's orders for Resident 20, dated February 10, 2024, included an order for the resident to receive 2 liters per minute of oxygen using nasal cannula (tubes inserted into the nostrils to deliver oxygen) as needed for shortness of breath. The resident's care plan, dated March 26, 2024, indicated that 2 liters of oxygen was to be administered as needed for shortness of breath.
Observations on May 28 at 10:28 a.m. and May 29, 2024, at 11:53 a.m. revealed that Resident 20 was in bed with oxygen on at 2 liters per minute. However, the resident's MAR for May 2024 revealed that there was no documented evidence that Resident 20 received oxygen on May 28 or 29, 2024.
Interview with the Director of Nursing on May 30, 2024, at 11:58 a.m. confirmed that Resident 20's oxygen use on May 28 and 29, 2024, was not documented in the resident's clinical record.
A significant change MDS assessment for Resident 28, dated May 16, 2024, revealed that the resident was understood, could understand others, was cognitively intact, had hospice services, received pain medication as needed, and received an opioid medication.
Physician's orders for Resident 28, dated May 23, 2024, included an order for the resident to receive 10 mg of Morphine Sulfate (narcotic pain reliever) every four hours as needed for pain.
Resident 28's MAR for May 2024 indicated that one dose of Morphine Sulfate was administered to the resident on May 25, 2024, at 9:04 a.m. However, the resident's controlled drug record contained no documented evidence that the oxycodone was signed-out to be administered to the resident on this date and time.
Interview with the Director of Nursing on May 30, 2024, at 10:27 a.m. confirmed that Resident 28's MAR was not accurately documented.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending June 22, 2024, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending May 30, 2024, identified repeated deficiencies regarding ensuring that the resident's environment was free of accident hazards, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), and ensuring that clinical records were complete and accurately documented.
The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the survey ending on June 22, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards.
The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending June 22, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.
The facility's plans of correction for deficiencies regarding complete medical record documentation, cited during the surveys ending on June 22, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding complete medical records.
Refer to F689, F755, F842.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was a free o...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was a free of accident hazards as is possible, by failing to complete safety assessments for air mattress use for three of 18 residents reviewed (Residents 20, 44, 47).
Findings include:
The facility's policy regarding air mattresses, dated February 15, 2024, indicated that the facility would would provide residents with a bed that met their needs and was comfortable, and air mattresses were reserved for residents with pressure ulcers.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated May 15, 2024, revealed that the resident was cognitively intact, had limited range of motion of the lower extremities, and had a pressure ulcer.
Physician's orders for Resident 20, dated February 23, 2024, included an order for the resident's bed to be equipped with a low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown.) for a Stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). The resident's care plan, dated February 26, 2024, revealed that the resident had a pressure sore and used an air mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 20's bed.
Observations on May 29, 2024, at 8:19 a.m. and 11:53 a.m. revealed that Resident 20 was in bed with an air mattress in place.
An admission MDS assessment for Resident 44, dated March 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had one Stage II pressure ulcer, two Stage III pressure ulcers, and six venous and arterial ulcers present on admission.
Physician's orders for Resident 44, dated March 21, 2024, included an order for the resident's bed to be equipped with a low air loss mattress. There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 44's bed.
Observations on May 28, 2024, at 11:20 a.m. revealed that Resident 44 was in bed with an air mattress in place.
An admission MDS assessment for Resident 47, dated May 1, 2024, revealed that the resident was cognitively intact, had limited range of motion of the upper and lower extremities, and had diagnoses that included a stroke.
Physician's orders for Resident 47, dated May 9, 2024, included an order for the resident's bed to be equipped with a low air loss mattress with bolsters (raised edges). The resident's care plan, dated April 26, 2024, revealed that the resident used an air mattress. was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 47's bed.
Observations on May 30, 2024, at 11:43 a.m. revealed that Resident 47 was in bed with an air mattress in place.
Interview with the Director of Nursing on May 30, 2024, at 10:30 a.m. confirmed that there were no specific assessments completed to ensure that the use of an air mattress was safe for Residents 20, 44, and 47.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food and wash dishes in accordance with professional standards for food s...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to store food and wash dishes in accordance with professional standards for food service safety, by failing to ensure that food was discarded in a timely manner and that the dishwasher had an appropriate washing cycle temperature.
Findings include:
The facility's dietary policy regarding food storage, dated February 15, 2024, revealed that food was stored in a manner that complied with safe food handling practices.
Observations in the kitchen on May 28, 2024, at 9:02 a.m. revealed that there was a plastic container of pizza sauce that was dated May 19, 2024. Interview with the Dietary Manager on May 28, 2024, at 9:13 a.m. revealed that the sauce should have been discarded after seven days.
Manufacturer's instructions for the Ecolab ES-2000 Dish machine, dated 2009, indicated that the washing operational temperature was to be 120 degrees Fahrenheit (F).
Observations of the dishwasher on May 30, 2024, at 12:32 p.m. revealed that the wash cycle of the dish machine only reached a washing temperature of 100 degrees F. The Dietary Manager indicated that she did not have any temperature concerns that morning.
Interview with the Nursing Home Administrator on May 30, 2024, at 1:03 p.m. confirmed that the manufacturer's instructions indicated that the dish machine's operational temperature was to be 120 degrees F.
28 Pa. Code 211.6(f) Dietary Services.
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident's re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident's representative in writing regarding the reason for hospitalization for one of 18 residents reviewed (Resident 29).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated March 11, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, had diagnoses that included heart failure and kidney failure, and was on hemodialysis (a process for removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally).
Resident 29's niece was listed in the clinical record as the responsible party and first emergency contact.
Nursing notes for Resident 29 on December 25 and 30, 2023; January 25, 2024; March 1, 2024; and May 26, 2024, indicated that the resident was transferred to the hospital for further evaluation, treatment and admission.
MDS discharge assessments for Resident 29, dated December 25 and 30, 2023; January 25, 2024; March 1, 2024; and May 26, 2024, revealed that the resident was admitted to the hospital on those dates.
There was no documented evidence in Resident 29's clinical record to indicate that the resident's representative was notified in writing of the purpose for the resident's transfers and admissions to the hospital from [DATE] through May 2024.
Interview with the Social Services Director on May 30, 2024, at 4:10 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 29's transfers and hospitalizations from December 2023 through May 2024, because the facility makes verbal notification only.
Interview with the Director of Nursing on May 30, 2024, at 4:22 p.m. confirmed that there was no documentation that the resident's representative was notified in writing of Resident 29's transfers and hospitalizations from December 2023 through May 2024.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
Aug 2023
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
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condit...
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Based on review of manufacturer's direction for use, as well as observations and staff interviews, it was determined that the facility failed to ensure essential equipment was in safe operating condition in the facility's laundry area.
Findings include:
Manufacturer's directions for Washer-Extractor, dated September 1988, revealed that dangerous voltages are present in the electrical control box and at the motor terminals. Power should be disconnected from the machine before removing the control box cover and before attempting any service procedures. Only specially trained personnel should turn power on when cover is removed. Replace all panels that are removed for maintenance. Do not operate the machine with missing guards or with broken or missing parts. Do not bypass any safety devices.
Observations in the laundry department on August 30, 2023, at 10:40 a.m. revealed the laundry area had two washing machines. One washing machine had a sign on it stating it was out of order. The second washing machine was observed with the top cover that houses the electrical components of the machine not in place. The washing machine was plugged in. There was a small ladder to the left of the machine.
Interview with the Laundry Manager on August 30, 2023, at 10:40 a.m. revealed that the first washing machine is out of service and the second washing machine will not start a spin cycle on its own. Staff must climb the ladder and push a button in the top of the machine (where electrical components are housed) to start a spin cycle after every wash and rinse cycle the machine does, totaling two times for every load of laundry. There are four staff in the facility responsible for operating the washing machine.
Interview with the Maintenance Director on August 30, 2023, at 10:50 a.m. revealed that the first washing machine broke approximately four months ago, and the second washing machine has been functioning improperly for approximately two months. He is unable to order parts or get repairs done on the current washing machines because they are older and parts are not available. There is no contact being made in the washing machine's electrical box, which starts the spin cycle, making it the staff's responsibility to push a button to cause the contact needed to start the spin cycle. A new washer has been approved by the owners of the facility and has been ordered. Interview with the Maintenance Director confirmed that the washing machine is not functioning in a safe operating condition.
Interview with the Nursing Home Administrator on August 30, 2023, at 11:26 a.m. revealed that the current washing machine is not functioning in a safe manner and that a new washing machine has been ordered and paid for and is in the process of being shipped to the facility.
28 Pa. Code 207.2 (a) Administrator's responsibility.
Jun 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent ...
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Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for two of 29 residents reviewed (Residents 10, 19) who were at risk for falls, and the facility failed to ensure that residents were transported in a safe manner for one of 29 residents reviewed (Resident 13).
Findings include:
The facility's policy regarding falls, dated February 15, 2023, indicated that based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated April 20, 2023, revealed that the resident was cognitively impaired, required extensive assistance for bed mobility, was dependent for transfers, and had diagnoses that included hemiplegia/hemiparesis (weakness or the inability to move on one side of the body). Physician's orders, dated May 21, 2023, included an order for the resident to have a fall mat on the right side of the bed when in bed, and the resident's care plan, dated May 22, 2023, indicated that the resident was at risk for falls and was to have a fall mat on the right side of the bed when in bed.
A facility incident/accident report and investigation, dated May 21, 2023, revealed that Resident 10 was found lying on the right side of his bed. The resident stated that he rolled out bed onto the floor.
Observations on June 21, 2023, at 3:11 p.m. revealed that Resident 10 was in bed and there was no fall mat on the right side of the bed
Interview with Registered Nurse 1 on June 21, 2023, at 3:17 p.m. confirmed that there was no fall mat on the right side of Resident 10's bed.
Interview with the Director of Nursing on June 22, 2023, at 10:20 a.m. confirmed that a fall mat should have been in place on the right side of the bed when Resident 10 was in bed, and when he refused to have the fall mat in place there should have been an alternative intervention in place to prevent injury if there was a fall from the bed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 4, 2023, revealed that the resident had cognitive impairment, was usually understood, could understand, needed supervision for her locomotion on and off the unit, had full range of motion of her upper and lower extremities, and used a walker. Physician's order for Resident 13, dated March 2, 2023, revealed that she could ambulate independently in the facility and her room with a front-wheeled walker.
An activities care plan for Resident 13, dated November 4, 2022, had an intervention for staff to assist with transport to and from activities of choice.
Observations on June 21, 2023, at 9:34 a.m. revealed that Licenced Practical Nurse (LPN) 2 pushed Resident 13 in a wheelchair without foot rests from the South Wing to the Activity room. During the transport, Resident 13's feet were approximately one to two inches above the floor. Interview with LPN 2 at that time revealed that Resident 13 was able to self propel in her wheelchair. Licensed Practical Nurse 2 asked the resident to propel herself the rest of the way, but she refused. At that time LPN 2 took the foot rests out of a bag on the back of the wheelchair and attached them to the chair.
Interview with the Director of Nursing on June 21, 2023 at 10:09 a.m. confirmed that Resident 13 was independent with ambulation, but when she was tired she used a wheelchair. However, the leg rests should be in place when a resident is being transported by staff.
A quarterly MDS assessment for Resident 19, dated April 21, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff with daily care tasks including transfers and positioning in bed, did not walk, had a history of falls, and had diagnoses that included dementia.
A care plan for Resident 19, dated March 31, 2022, revealed that the resident was at risk for falls due to weakness, side effects of medication, and a history of falls. Interventions included in the care plan, dated May 5, 2022, included for the resident to use a pressure-sensitive alarm on her bed, with staff checking functioning and placement every shift, and to use a pressure-sensitive pad to her wheelchair, with staff checking placement and function every shift.
A review of nursing notes and the facility's fall investigation for Resident 19, dated January 12, 2023, at 12:20 p.m., revealed that the resident was observed in her room sitting on the floor beside her bed. She had a fall from her bed and had no pressure alarm in place at the time of the fall as care planned. Nursing notes and a facility fall investigation, dated April 30, 2023, at 5:56 a.m., revealed that the resident was observed on the floor in her room from a fall and personal pressure alarms were not in place at the time of the fall as care planned.
Interview with the Director of Nursing on June 21, 2023, at 4:04 p.m. confirmed that Resident 19 should have had personal alarms in place as care planned during the falls on January 12, 2023, and on April 30, 2023, but did not.
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
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen therapy as ordered b...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen therapy as ordered by the physician for two of 29 residents reviewed (Residents 19, 30), and failed to ensure an oxygen-in-use sign was in place for one of 29 residents reviewed (Resident 19).
Findings include:
The facility's policy regarding oxygen therapy, dated February 15, 2023, indicated that a physician's order would be obtained for oxygen, and the order would include the flow rate to be administered and a sign would be in place indicating that oxygen was in use.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated April 21, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff with daily care tasks, used supplemental oxygen, and had diagnoses that included chronic obstructive pulmonary disease (disease that causes difficulty breathing).
Physician's orders for Resident 19, dated February 12, 2023, included for the resident to receive 2 Liters per minute (L/min) of oxygen by nasal cannula continuously at night while sleeping and as needed.
An observation of Resident 19 on June 22, 2023, at 8:22 a.m. revealed that the resident was in bed with oxygen in place via nasal cannula at 4 L/min. There was no signage in place indicating that oxygen was in use, per the facility's policy.
An interview with the Director of Nursing on June 22, 2023, at 8:32 a.m. confirmed that Resident 19 was receiving supplemental oxygen at 4 liters per minute when she should have been receiving 2 liters per minute as ordered by the physician. An interview at 3:06 p.m. confirmed that there was no sign posted indicating that oxygen was in use in the room and should have been.
A diagnosis record for Resident 30, dated August 22, 2023, revealed that the resident had diagnoses that included chronic respiratory failure (a lung condition which causes difficulty breathing). Physician's orders, dated January 25, 2023, included orders for the resident to receive oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils). A care plan for Resident 30, dated February 1, 2023, indicated that the resident was to receive oxygen at 2 liters per minute via nasal cannula.
Observations of Resident 30 on June 21, 2023, at 9:15 a.m. revealed that the resident was in her chair with the oxygen in use and the flow rate was 2.5 liters per minute. Observations of Resident 30 on June 21, 2023, at 11:10 a.m. revealed that the resident was in her chair with the nasal cannula in her nose; however, the oxygen was off. Observations of Resident 30 on June 21, 2023, at 12:39 p.m. and 1:29 p.m. revealed that the resident was in her chair with oxygen in use at a flow rate of 2.5 liters per minute instead of 2 liters as ordered by the physican.
Interview with Licensed Practical Nurse 3 on June 22, 2023, at 2:52 p.m. confirmed that Resident 30's oxygen was not set at the correct flow rate of 2 liters per minute.
Interview with the Director of Nursing on June 22, 2023, at 9:06 a.m confirmed that Resident 30's oxygen was not set at the correct flow rate of 2 liters per minute.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 29 residents reviewed (Resident 20).
Findings include:
The facility's policy regarding medication administration, dated February 15, 2023, indicated that the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated May 17, 2023, revealed that the resident was cognitively intact, required extensive assistance to total dependence on staff for daily care needs, received pain medication routinely and as needed, had pain frequently, and received an opioid (a controlled pain medication). Physician's orders, dated May 11, 2023, included orders for the resident to receive 5 milligrams (mg) of oxycodone (a narcotic pain medication) every eight hours as needed for severe pain of 7 to 10 (on a scale of 1 to 10, where 10 is the worst pain).
A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 20, dated May, 2023, indicated that an oxycodone dose was signed out on May 13, 2023, at 12:25 p.m.; on May 17, 2023, at 8:50 p.m.; and on May 20, 2023, at 3:45 p.m. However, the resident's clinical record, including the Medication Administration Record (MAR) and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were administered to the resident on these dates and times.
An interview with the Director of Nursing on June 22, 2023, at 11:19 a.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone on the above dates and times.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(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
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that controlled medications that had to be refrigerated were st...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that controlled medications that had to be refrigerated were stored in a separately locked, permanently affixed container in one of one medication refrigerators reviewed.
Findings include:
The facility's policy regarding medication storage, dated February 15, 2023, indicated that Schedule II through V medications (medications with the potential to be abused) will be stored in a separately locked, permanently affixed compartment.
Observations of the medication refrigerator in the medication room on June 22, 2023, at 9:24 a.m. revealed that there was an apartment-size refrigerator. Inside the refrigerator there was a locked metal box that was chained to the refrigerator for the storage of narcotic medication. However, there was one bottle of lorazepam (schedule IV anxiety medication) oral concentrate 2 milligrams per milliters sitting in the refrigerator and not secured in the locked box. Interview with Registered Nurse 4 at the time of the observation confirmed that the bottle was not stored in the metal lock box because there was not enough room as the locked box was full.
Interview with the Director of Nursing on June 22, 2023, at 3:06 p.m. confirmed that the bottle of lorazepam was not stored in a separately locked and permanently affixed container and it should have been.
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
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication ...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration for two of 29 residents reviewed (Residents 16, 30).
Findings include:
The facility's standard precautions policy, dated January 25, 2023, indicated that after gloves were removed, hands were to be washed to avoid transfer of microorganisms. An anti-germicidal product or hand washing was to be used between contact with residents and gloves should be worn when administering insulin.
Observations during medication administration for Resident 16 on June 21, 2023, at 10:55 a.m. revealed that Licensed Practical Nurse 6 donned gloves, used a blood glucose monitor (a hand held device used to monitor blood sugar), and obtained the resident's blood sugar. The nurse then removed her gloves and without washing her hands or using hand sanitizing gel, Licensed Practical Nurse 6 put on new gloves and obtained a blood sugar result for Resident 30. The nurse then took her gloves off, cleansed her hands with hand sanitizing gel, and administered insulin to the resident without wearing gloves. Interview with Licensed Practical Nurse 6 at that time confirmed that while working with Resident 16 she did not use antimicrobial gel or wash her hands after removing her gloves and she did not wear gloves while administering insulin to Resident 30 and should have.
Interview with the Infection Control Nurse on June 21, 2023, at 3:18 p.m. confirmed that Licensed Practical Nurse 6 should have washed her hands or used hand sanitizing gel after removing her gloves, between residents during medication administration, and during insulin administration.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident who consented to have the influenza and/...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident who consented to have the influenza and/or pneumococcal vaccine received the vaccine for one of five residents reviewed (Resident 13).
Findings include:
The facility's policy regarding vaccination of residents, dated February 15, 2023, revealed that all resident will be offered vaccines that aid in preventing infectious diseases unless the vaccine was medically contraindicated or the resident has already been vaccinated. The resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. All residents would be assessed upon admission. The facility's policy regarding influenza (flu) vaccines, dated February 15, 2023, revealed that residents will be offered the flu vaccine annually between October 1 and March 31. The facility's policy regarding pneumococcal (pneumonia) vaccines, dated February 15, 2023, revealed that prior to or upon admission the residents were assessed for eligibility to receive the pneumococcal vaccine series and would be offered the vaccine within 30 days of admission.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 4, 2022, revealed that the resident was understood, could understand, and required limited assistance from staff for her daily care tasks. Section O0250 A of the MDS (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in this facility for this year's influenza vaccination season due to not being in the facility during the influenza vaccination season. Section O0300 A of the MDS (Pneumococcal Vaccination) revealed that the resident did not receive the pneumococcal vaccine.
An informed consent for the influenza vaccine form for Resident 13, dated October 29, 2022, revealed that the resident gave consent to receive the influenza vaccine. An informed consent for the pneumococcal vaccine form for Resident 13, dated October 29, 2022, revealed that the resident gave consent to receive the pneumococcal vaccine.
Review of the Medication Administration Records (MARs) for October 2022 through June 2023, as well as the clinical record for Resident 13, revealed no documented evidence that the resident received the influenza vaccine for the 2022-2023 flu season or the pneumococcal vaccine as requested.
Interview with the Infection Control Registered Nurse 7 on June 21, 2023, at 12:47 p.m. confirmed that consents were obtained for Resident 13 to receive the flu and pneumococcal vaccines; however, there was no documented evidence that the vaccines were administered.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to offer the COVID-19 vaccine; provide education about the benefits, risks, and p...
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Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to offer the COVID-19 vaccine; provide education about the benefits, risks, and potential side effects associated with the vaccine; or obtain consent or declination for the vaccine for one of five residents reviewed (Resident 21).
Findings include:
The facility's policy regarding vaccinations of residents, dated February 15, 2023, revealed that all resident will be offered vaccines that aid in preventing infectious diseases unless the vaccine was medically contraindicated or the resident has already been vaccinated. The resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. All residents would be assessed upon admission.
The facility's policy regarding coronavirus disease (COVID-19) vaccines, dated February 15, 2023, revealed that residents who are eligible to receive to the COVID-19 vaccine were strongly encouraged to do so. The resident or resident representative has the opportunity to accept or refuse a COVID-19 vaccine and to change his/her decision. COVID-19 vaccine education, documentation, and reporting were overseen by the Infection Preventionist and coordinated by his or her designee. Before the COVID-19 vaccine was offered, the resident was provided with education regarding the benefits, risks, and potential side effects associated with the vaccine.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated December 8, 2022, revealed that the resident was understood, could usually understand, and required extensive assistance from staff for her daily care tasks.
Review of Resident 21's clinical record, including the Medication Administration Records (MARs) for December, 2022 through June 2023 revealed no documented evidence that the COVID-19 vaccine was offered; that education regarding the benefits, risks, and potential side effects associated with the vaccine were provided; or that consent or declination of the vaccine was obtained.
Interview with Infection Control Registered Nurse 7 on June 21, 2023, at 1:42 p.m. confirmed that there was no documented evidence that the COVID-19 vaccination was offered to Resident 21, that education was provided about the vaccine, or that a consent or declination was obtained.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for o...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that bowel protocols were followed as ordered by the physician for one of 29 residents reviewed (Resident 10).
Findings include:
The facility's policy regarding medication administration, dated February 15, 2023, indicated that medications were to be administered in accordance with prescribed orders, including any required time frame.
Physician's orders for Resident 10, dated March 25, 2021, included orders for the resident to receive 30 milliliters (ml) of Milk of Magnesia (MOM - an oral laxative) as needed for constipation if no bowel movement by the third day (9 shifts); one Dulcolax suppository (a laxative inserted rectally) as needed if no bowel movement within 24 hours after administration of Milk of Magnesia; and one Fleets enema (a liquid inserted rectally to stimulate a bowel movement) as needed for constipation if no bowel movement by the end of the following shift after administration of the suppository, and the physician was to be notified if it was ineffective. Physician's orders, dated February 26, 2023, included orders for the resident to receive 10 mg of Bisacodyl (oral laxative) as needed for constipation and physician's orders, dated December 19, 2022, included orders for the resident to receive 17 Grams of polyethylene glycol as needed for constipation.
Resident 10's bowel records for May and June 2023 revealed that the resident had a bowel movement on May 15, 2023, and did not have a bowel movement from May 16-19, 2023. The Medication Administration Records (MAR's) revealed that staff did not administer Milk of Magnesia on May 18, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that there was no laxative administered on May 19, 2023, which would have been day four without a bowel movement, and 10 mg of Dulcolax was administered orally on May 20, 2023, and the resident had a bowel movement.
The resident had a bowel movement on May 20, 2023, and did not have a bowel movement from May 21-24, 2023. The Medication Administration Records (MAR's) revealed that staff did not administer Milk of Magnesia on May 23, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that 10 mg of Bisacodyl was administered orally on May 24 and 25, 2023, which was ineffective for a bowel movement, and 17 Grams of polyethylene glycol was administered orally on May 25, 2023, and the resident had a bowel movement.
The resident had a bowel movement on May 26, 2023, and did not have a bowel movement from May 27-30, 2023. The Medication Administration Records (MAR's) revealed that staff did not administer Milk of Magnesia on May 29, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that 10 mg of Bisacodyl was administered orally on May 30 and 17 grams of polyethylene glycol were administered, which were ineffective for a bowel movement, and on May 31, 2023, 10 mg of Bisacodyl was administered orally and the resident had a bowel movement.
The resident had a bowel movement on June 5, 2023, and did not have a bowel movement from June 6-9, 2023. The Medication Administration Records (MAR's) revealed that staff did not administer Milk of Magnesia on June 8, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that there was no laxative administered on June 9, 2023, which would have been day four without a bowel movement, and 10 mg of Dulcolax was administered orally on June 10, 2023, and the resident had a bowel movement.
The resident had a bowel movement on June 15, 2023, and did not have a bowel movement from June 16-20, 2023. The Medication Administration Records (MAR's) revealed that staff did not administer Milk of Magnesia on June 18, 2023, as ordered, which was the third day without a bowel movement. The resident's MAR revealed that 10 mg of Bisacodyl was administered orally and 17 grams of polyethylene glycol were administered on June 19, 2023, which were ineffective for a bowel movement, and 17 grams of polyethylene glycol was administered on June 20, 2023, which was ineffective for a bowel movement. The MAR revealed that 10 mg of Dulcolax was administered orally on June 21, 2023, and the resident had a bowel movement.
Interview with the Director of Nursing on June 22, 2023, at 11:19 a.m. confirmed that Resident 10's physician's orders for constipation were not followed on the above days and the physican's orders for constipation should have been clarified.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for ...
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Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 29 residents reviewed (Residents 39).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated May 1, 2023, revealed that the resident was able to make herself understood and could understand others, required extensive assist of staff for daily care needs, and had diagnoses that included stroke.
Physician's orders for Resident 39, dated November 14, 2021, included an order for the resident to be restricted to 1200 milliliters (ml) of fluids in every 24-hour period.
A hydration care plan for Resident 39, dated March 24, 2023, indicated that the resident was to maintain a fluid restriction of 1200 ml a day. Nursing was to provide 120 ml of fluid on day shift, 120 ml of fluid on evening shift, and 120 ml of fluid on night shift. Dietary was to provide 840 ml of fluid per day.
A review of fluid intake records for Resident 39 for May 2023 and June 2023 revealed fluid intakes on May 3, 2023, of 1360 ml; May 4, 2023, of 1300 ml; May 5, 2023, of 1400 ml; May 7, 2023, of 1460 ml ; May 8, 2023, of 1300 ml; on May 11, 2023, of 1320 ml; on May 17, 2023, of 1340 ml; on May 19, 2023, of 1760 ml; on May 23, 2023, of 1340 ml; on June 10, 2023, of 1560 ml; on June 12, 2023, of 1700 ml; on June 13, 2023, of 1560 ml; on June 14, 2023, of 1890 ml. On these dates and times, the fluid intake for the resident exceeded the 1200 ml fluid intake ordered by the physician.
An observation and interview with Resident 39 on June 22, 2023, at 12:44 p.m. while she was sitting in the activity room with a 240 ml can of cola in front of her from her lunch tray, revealed that she can get a soda whenever she asks for one; however, she only occasionally asks for one.
An interview with the Dietary Manager on June 22, 2023, at 12:55 p.m., as well as a review of the resident's meal ticket and menu choices for the week of June 18-24, 2023, revealed that Resident 39 only gets 240 ml of soda on her tray for every meal. Soda is all she drinks. Other fluid intakes for that week included soup for one meal on two occasions and jello for one meal on two other separate occasions. The Dietary manager stated that this was a typical week.
An interview with Nurse Aide 5 on June 22, 2023, at 12:58 p.m. revealed that Resident 39 is on a fluid restriction and only drinks what is on her tray.
An interview with the Director of Nursing on June 22, 2023, at 12:36 p.m. revealed that the fluid restriction totals for Resident 39 on the above dates and times were inaccurately documented. The dietary department only sends fluids that the resident is allowed to have, and she is not given more by nursing staff; however, the nurse aides improperly documented the fluid intake for their shifts, and re-education on documenting fluid intakes needs completed.
28 Pa Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(5) Nursing services
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- • 28% annual turnover. Excellent stability, 20 points below Pennsylvania's 48% average. Staff who stay learn residents' needs.
Concerns
- • 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 73/100. Visit in person and ask pointed questions.
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About This Facility
What is Scenery Hill Healthcare And Rehabilitation Center's CMS Rating?
CMS assigns SCENERY HILL HEALTHCARE AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Scenery Hill Healthcare And Rehabilitation Center Staffed?
CMS rates SCENERY HILL HEALTHCARE AND REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 28%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Scenery Hill Healthcare And Rehabilitation Center?
State health inspectors documented 21 deficiencies at SCENERY HILL HEALTHCARE AND REHABILITATION CENTER during 2023 to 2025. These included: 20 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Scenery Hill Healthcare And Rehabilitation Center?
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by AKIKO IKE, a chain that manages multiple nursing homes. With 56 certified beds and approximately 50 residents (about 89% occupancy), it is a smaller facility located in INDIANA, Pennsylvania.
How Does Scenery Hill Healthcare And Rehabilitation Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, SCENERY HILL HEALTHCARE AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (28%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Scenery Hill Healthcare And Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Scenery Hill Healthcare And Rehabilitation Center Safe?
Based on CMS inspection data, SCENERY HILL HEALTHCARE AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Scenery Hill Healthcare And Rehabilitation Center Stick Around?
Staff at SCENERY HILL HEALTHCARE AND REHABILITATION CENTER tend to stick around. With a turnover rate of 28%, the facility is 18 percentage points below the Pennsylvania average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Scenery Hill Healthcare And Rehabilitation Center Ever Fined?
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Scenery Hill Healthcare And Rehabilitation Center on Any Federal Watch List?
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER 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.