HAMILTON ARMS CENTER
For profit - Corporation
94 Beds
Independent
Data: November 2025
Trust Grade
48/100
#431 of 653 in PA
Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hamilton Arms Center has a Trust Grade of D, indicating below-average performance with some concerns. It ranks #431 out of 653 facilities in Pennsylvania, placing it in the bottom half, and #24 out of 31 in Lancaster County, meaning there are only a few local options that are better. The facility is showing an improving trend, with reported issues decreasing from 8 in 2024 to just 1 in 2025. Staffing is rated average with a turnover rate of 43%, which is slightly better than the state average, suggesting a relatively stable workforce. However, the facility has faced some concerning issues, such as a failure to properly implement infection control measures and a lack of personal protective equipment in resident rooms, which raises red flags about resident safety. While there are strengths in staffing stability, the overall quality and health measures need significant improvement.
- Trust Score
- D
- In Pennsylvania
- #431/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 43% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- $9,009 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 34%
No red flags
8 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (43%)
5 points below Pennsylvania average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 43%
Near Pennsylvania avg (46%)
Typical for the industry
Federal Fines: $9,009
Below median ($33,413)
Minor penalties assessed
The Ugly 23 deficiencies on record
Jun 2025
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review facility policy clinical records, as well as staff interviews, it was determined that the facility failed to follow the physician's orders for blood sugar checks for two of 8 residents...
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Based on review facility policy clinical records, as well as staff interviews, it was determined that the facility failed to follow the physician's orders for blood sugar checks for two of 8 residents reviewed (Residents 8,9), and failed to follow physician's orders for blood pressure checks for one of 8 residents reviewed (Resident 7).
Findings include:
A facility policy for hypoglycemia (low blood sugar) <70 mg/dL dated, January 2, 2025, revealed that the resident is to be provided with a rapidly absorbed glucose (sugar), the provider notified, stay with the resident and recheck blood sugar in 15 minutes.
An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), for Resident 8, dated March 10, 2025, revealed that he was cognitively impaired and had diagnoses that included end stage kidney disease and diabetes mellitus.
Physician's orders for Resident 8 dated April 18, 2025, revealed the resident was to receive 40 units of Insulin glargine solution 100 units/milliliter solution subcutaneously in the morning, and the physician was to be notified if the resident's blood sugar was <70 mg/dL or >400 mg/dL. The medication was to be held if the resident's blood sugar <80 mg/dL.
A review of the Medication Administration Record (MAR) for Resident 8 for May revealed that on May 10, 2025, the resident's blood sugar was 65 mg/dL, May 15, 2025, the resident's blood sugar was 63 mg/dL, and May 30, 2025, the resident's blood sugar was 59 mg/dL.
There was no documented evidence that the physician was notified of Resident 8's blood sugar per physician's order on the above dates, and no documented evidence that the resident was offered a quick absorbing glucose and blood sugar rechecked on the above dates.
An admission MDS for Resident 9 dated, April 29, 2025, revealed that the resident was cognitively intact, was understood and understood others and had medical diagnosis of end stage kidney disease and diabetes mellitus.
Physician's orders for Resident 9 revealed the resident was to receive blood sugar checks four times a day and notify the physician if blood sugar was >400 or <70 and to initiate hypoglycemic (low blood sugar) protocol.
A review of the MAR for Resident 9 for May revealed that at 9:00 a.m. on May 9, 2025, the resident's blood sugar was 69, 9:00 a.m. on May 11, 2025, the blood sugar was 59, at 9:00 p.m. on May 12, and 2025 the blood sugar was 67.
A nurses note for Resident 9 on May 12, 2025, at 10:13 p.m. revealed that the resident's blood sugar was 67 mg/dL the resident was offered a milk shake and graham crackers and would be reassessed in 30 minutes.
A nurses note for Resident 9 on May 12, 2025, at 11:11 p.m. revealed the resident's blood sugar was rechecked at this time and was 157 mg/dL.
There was no documented evidence that the physician was notified of Resident 9's blood sugar per physician's orders, and no documented evidence the resident was offered a quick absorbing glucose and reassessed after 15 minutes on the above dates and times.
Interview with the Director of Nursing on June 6, 2025, at 2:30 p.m. confirmed that the resident's were not provided with a quick absorbing glucose reassessed in 15 minutes, and the physician was not notified of the resident's blood sugars and should have been.
An Annual MDS assessment for Resident 7 dated May 3, 2025, revealed that the resident was cognitively intact, was understood, and could understand others, and had a medical diagnosis of stroke, coronary artery disease, heart failure, hypertension (high blood pressure), diabetes mellitus, and high cholesterol.
Physician's orders for Resident 7 dated August 7, 2024, revealed the resident was to have his blood pressure taken twice a day in the morning and in the evening.
A review of the MAR for Resident 7 for May 2025 revealed that there was no documented evidence of a blood pressure taken for resident 7 in the morning on May 7 and 21, 2025, and in the evening on May 23, 2025.
Interview with the Director of Nursing on June 5, 2023, at 2:14 p.m. that there were no blood pressures taken for Resident 7 on the above dates and times per physician's orders and there should have been.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
Sept 2024
7 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
Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-coverage (NOMNC) for one resident and faile...
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Based on review of documentation and staff interview, it was determined the facility failed to ensure residents were provided a Notification of Medicare Non-coverage (NOMNC) for one resident and failed to provide Advanced Beneficiary Notice of Non-coverage (ABN) for three of three residents reviewed (Resident 18, Resident 191, Resident 192).
Findings include:
Review of facility documentation for three residents revealed a Notification of Medicare Non-Coverage (NOMNC) was not provided to Resident 192.
Review of facility documentation for three residents revealed Advanced Beneficiary Notice of Non-Coverage (ABN) was not provided to Resident 18, Resident 191, and Resident 192.
Interview with the Nursing Home Administrator on September 6, 2024, at 9:00 a.m. confirmed that Resident 192 did not receive a NOMNC and Resident 18, Resident 191 and Resident 192 did not receive ABN notification.
28 Pa. Code 201.18(a)(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on clinical record review and interview, it was determined the facility failed to report an allegation of abuse for one of 18 residents reviewed (Resident 13).
Findings include:
Review of Reside...
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Based on clinical record review and interview, it was determined the facility failed to report an allegation of abuse for one of 18 residents reviewed (Resident 13).
Findings include:
Review of Resident 13's clinical progress notes dated July 31, 2024, revealed SSD [social services department] and PT [physical therapy] met with resident for a 48 hour meeting. Resident states he ambulates with a cane and rollator at home. There are 10 steps to enter the apartment building and 13 steps to enter his room. Resident does not have any family that can assist with care, only a significant other that he stays with but isn't involved with providing care. Resident would like to return home with [Home Health] services when the time comes to return home. Resident stated the care could be better as the nursing staff can be grouchy at times. Resident states CNAs are rough when repositioning him and he would like a slower transfer to alleviate pain and anxiousness. SSD contacted resident's daughter to relay all the information discussed during the meeting. [daughter] requested she be emergency contact #1 instead of resident's significant other/roommate. SSD made the change per [daughter's] request.
Interview with the Nursing Home Administrator on September 5, 2024, at 9:00 a.m. revealed that a grievance form was completed by Social Services regarding Resident 13's allegation but no abuse investigation was conducted. The interview further revealed the allegation of abuse was also not reported to the State Agency.
Interview with the Nursing Home Administrator on September 6, 2024, at 9:30 a.m. confirmed an abuse investigation should have been conducted and the abuse allegation should have been reported to the State Agency.
28 Pa. Code 201.18(a)(b)(1)(2)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on clinical record review and interviews, it was determined the facility failed to investigate an allegation of abuse for one of 18 residents reviewed (Resident 13).
Findings include:
Review of ...
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Based on clinical record review and interviews, it was determined the facility failed to investigate an allegation of abuse for one of 18 residents reviewed (Resident 13).
Findings include:
Review of Resident 13's clinical progress notes dated July 31, 2024, revealed SSD [social services department] and PT [physical therapy] met with resident for a 48 hour meeting. Resident states he ambulates with a cane and rollator at home. There are 10 steps to enter the apartment building and 13 steps to enter his room. Resident does not have any family that can assist with care, only a significant other that he stays with but isn't involved with providing care. Resident would like to return home with [Home Health] services when the time comes to return home. Resident stated the care could be better as the nursing staff can be grouchy at times. Resident states CNAs are rough when repositioning him and he would like a slower transfer to alleviate pain and anxiousness. SSD contacted resident's daughter to relay all the information discussed during the meeting. [daughter] requested she be emergency contact #1 instead of resident's significant other/roommate. SSD made the change per [daughter's] request.
Interview with the Nursing Home Administrator on September 5, 2024, at 9:00 a.m. revealed a grievance form was completed by Social Services regarding Resident 13's allegation but no abuse investigation was conducted.
Interview with the Nursing Home Administrator on September 6, 2024, at 9:30 a.m. confirmed an abuse investigation should have been conducted and the abuse allegation should have been reported to the State Agency.
28 Pa. Code 201.18(a)(b)(1)(2)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews it was determined the facility failed to accurately complete Minimum Data S...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews it was determined the facility failed to accurately complete Minimum Data Set (MDS) assessments for two of 18 residents reviewed (Resident 13 and Resident 57).
Findings include:
Review of Resident 13's admission Nutrition Evaluation dated July 31, 2024, revealed Resident 13 does have h/o [history of] wt [weight] loss, 6 percent in 4 months.
Review of Resident 13's admission Minimum Data Set (MDS - periodic assessment of resident needs) dated August 3, 2024, indicated Resident 13 had a significant weight loss of 5 percent or more in the last month or loss of 10 percent or more in last 6 months.
Review of Resident 13's clinical record indicated Resident 13 had a history of weight loss prior to admission; however, it was not a significant weight loss as described in the MDS.
Interview with the Nursing Home Administrator on September 6, 2024, at 10:00 a.m. confirmed Resident 13 did not have a significant weight loss prior to admission and therefore should not have been identified on the MDS with a significant weight loss.
Review of Resident 57's clinical record revealed a physician's order dated October 23, 2023, for hospice (end of life care).
Review of Resident 57's quarterly MDS dated [DATE], revealed under Section O - Special Treatments, Procedures, Programs, that the resident was not marked as receiving hospice services.
Interview with the Nursing Home Administrator and Director of Nursing on September 6, 2024, at 1:05 p.m. confirmed Resident 57's MDS assessment should have indicated the resident was receiving hospice services.
28 Pa. Code 211.5(a)(b)(f) Clinical Records
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
Based on resident and staff interviews and clinical record review, it was determined that the facility failed to clarify and implement physician's orders for one of 18 residents reviewed (Resident 14)...
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Based on resident and staff interviews and clinical record review, it was determined that the facility failed to clarify and implement physician's orders for one of 18 residents reviewed (Resident 14).
Findings include:
Interview conducted with Resident 14 on September 4, 2024, at 9:40 a.m. revealed the resident had issues with frequent constipation.
Review of Resident 14's active physician ' s orders as of September 6, 2024, revealed the following orders: A physician's order dated August 8, 2024, for Colace 100 milligrams (mg) every 24 hours as needed for constipation.
A physician's order dated February 24, 2024, for Dulcolax suppository for no bowel movement for 24 hours after administration of Milk of Magnesia.
A physician's order dated August 8, 2024, for Polyethylene Glycol Powder - Give 17 grams by mouth every 24 hours as needed for constipation.
A physician's order dated August 9, 2024, for Senna Plus 8.6-50 mg - Give 1 tablet by mouth as needed for constipation at bedtime.
Further review of Resident 14's physician orders failed to reveal an order for Milk of Magnesia or clarification as to when each of the other medications should be administered for the resident's constipation.
Review of Resident 14's clinical record revealed a GI (gastrointestinal) consult dated August 20, 2024, with recommendations including Senna 8.6 mg daily as needed for constipation if no bowel movement in 2-3 days and to take the Dulcolax suppository as needed if no results from the Senna.
Review of Resident 14's progress notes revealed a nurse's note dated August 21, 2024, acknowledging the recommendations from the GI consult.
Further review of Resident 14's clinical record failed to reveal the resident's attending physician was made aware of the recommendations.
Interview with the Nursing Home Administrator and Director of Nursing on September 6, 2024, at 2:05 p.m. confirmed the facility failed to clarify Resident 14's physician's orders and implement recommendations from the GI consult.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Clinical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on resident interview, clinical record review and staff interview, it was determined that the facility failed to ensure dental services were timely provided for one of 18 residents reviewed (Res...
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Based on resident interview, clinical record review and staff interview, it was determined that the facility failed to ensure dental services were timely provided for one of 18 residents reviewed (Resident 44).
Findings include:
Interview with Resident 44 on September 4, 2024, at 2:00 p.m. revealed that the resident is missing fillings and would like to have teeth pulled. Resident also indicated that food gets stuck in the holes in teeth.
Review of Resident 44's clinical record revealed that the resident's responsible party had authorized Direct Mobile Dental Services (contracted dental provider at the facility) on May 17, 2023, to perform an annual dental exam, necessary x-rays, and cleanings.
Further review of the clinical record revealed no evidence the resident was seen for an annual exam or to address the resident's dental concerns.
Interview with the Director of Nursing on September 6, 2024, at 2:00 p.m. confirmed that there was no evidence that a dental exam had been completed.
28 Pa. Code: 211.15(a) Dental services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, it was determined the facility failed to establish effective Enhanced Barrier Precautions on two of two nursing floors observed. (First Floor and Second Flo...
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Based on observations and staff interviews, it was determined the facility failed to establish effective Enhanced Barrier Precautions on two of two nursing floors observed. (First Floor and Second Floor)
Findings include:
Observation conducted of a resident room on the second-floor nursing unit revealed signage indicating the resident was on Enhanced Barrier Precautions (EBP).
Further observation of the resident room failed to reveal evidence of Personal Protective Equipment (PPE) availability.
Interview with Employee E3 on September 4, 2024, at 10:10 a.m. revealed Employee E3 was unaware of what PPE should have been utilized in the care of residents on Enhanced Barrier Precautions and further was unaware of where to obtain PPE.
Observation of a resident room on the first-floor nursing unit revealed signage indicating the resident was on Enhanced Barrier Precautions.
Further observation of the resident room failed to reveal evidence of Personal Protective Equipment (PPE) availability.
Interview conducted with Licensed Employee E4 on September 4, 2024, at 10:20 a.m. revealed Licensed Employee E4 was unaware of what PPE should have been utilized in the care of residents on Enhanced Barrier Precautions and further was unaware of where to obtain PPE.
Interview conducted with Infection Preventionist Licensed Employee E5 on September 4, 2024, at 11:00 a.m. revealed staff was educated on the use of PPE for EBP residents.
Interview conducted with the Nursing Home Administrator on September 6, 2024, at 11:00 a.m. confirmed staff should be aware of the location and use of PPE for EBP residents.
28 Pa. Code 211.12(a)(b)(c)(d)(1)(2)(3)(5) Nursing Services
Jul 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
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews it was determined that [NAME] Arms Center failed to provide appro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews it was determined that [NAME] Arms Center failed to provide appropriate preparation of the resident prior to transfer and discharge for one of one resident reviewed (Resident R3).
Findings include:
Interview conducted on July 12, 2024 at approximately 5:20 p.m. with Resident R3 revealed concern and frustration with lack of details regarding anticipated discharge to home on July 13, 2024. Resident expressed frustration with lack of knowledge regarding durable medical equipment needed to be able to function in home such as wheelchair, bedside commode and hospital bed.
Review of Resident R3's clinical record revealed resident was admitted on [DATE] with diagnoses including but not limited to following: Diabetes Mellitus (the body has high sugar levels for prolonged periods of time); Surgical amputation of leg, Hyptension (high blood pressure), Chronic Kidney Disease, and Atrial Fibrillation (rapid and irregular beating of the atrial chambers of the heart).
Review of Resident R3's clinical record included a Medicare cut letter indicated skilled nursing services paid by Humana (contractor for Medicare) would terminate on July 12, 2024.
Review of Resident R3's clinical record revealed a discharge planning summary assessment dated [DATE]. Further review of the discharge summary failed to reveal appointment or contact information for primary care physician. Additional review of same document failed to reveal home health agency or durable equipment agency name and contact information.
Review of Resident R3's clinical record including progress notes failed to reveal discharge planning details of follow up appointments with primary care physician, home health agency contacted and providing follow up care, or durable medical equipment requested and delivery information for the scheduled discharge of Resident R3.
Interview with Director of Nursing on July 12, 2024 at approximately 6:30 p.m. when the above information was conveyed.
The facility failed to ensure appropriate tranfer and discharge preparation for Resident R3.
28 Pa Code 211.16(a) Social Services
Oct 2023
6 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and interviews with staff it was determined that the facility failed to follow physician orders regarding breakfast during dialysis days for one of two residents reviewed (Resident 34) and monitor weights for one out of 24 residents reviewed (Resident 48).
Findings include:
Review of Resident 34's diagnosis list revealed an active diagnosis of Chronic Kidney Disease Stage 5 (kidneys have lost the ability to filter waste from an individual's blood).
Review of Resident 34's orders revealed an active order for 'Dialysis (blood purifying treatment given when kidney function is not optimum.) days/times: Tuesday/Thursday/Saturday with a start date of August 7, 2023.
Review of Resident 34's clinical record revealed an active order for Early breakfast due to dialysis schedule with a start date of August 7, 2023.
Further review of Resident 34's clinical record revealed a care plan intervention of DIALYSIS: Specify appointment days Tuesday-Thursday-Saturday. Have ready to leave by 5:00am. Dialysis bag meals with an implementation date of August 5, 2023.
Review of Resident 34's clinical record revealed a progress note dated August 26, 2023 at 6:22 a.m. stating Resident left for dialysis this AM not having received breakfast. Multiple calls made down to the kitchen with no answer. RN Supervisor made aware and called kitchen, spoke with staff and was told kitchen staff would bring up a breakfast for resident, though nothing came up and resident left for dialysis.
Interview conducted with the Director of Nursing (DON) on October 4, 2023, at approximately 11:15 a.m. confirmed that Resident 34 did not receive breakfast on August 26, 2023 prior to leaving for dialysis.
Resident 48 was admitted to the facility on [DATE], with the diagnosis of congestive heart failure (Congestive heart failure (CHF) is a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply. Blood and fluids collect in your lungs and legs over time).
Review of the Physician orders for daily weights on July 20, 2023, and state to notify the physician if the resident gains two to three pounds overnight or 5 pounds in one week to monitor for fluid retention (CHF).
Further clinical record review revealed Resident 48's weight on August 17, 2023, was 171 and on August 18, it was 175.2 (an increase of 4.5 pounds). There was no documentation that the physician was notified. On August 23, a weight of 175 pounds was recorded on August 24 it was 177 lbs. (an increase of 2 pounds) was recorded with no further documentation that the physician was notified. On September 1, 2023, the resident weight was 174.4 pounds on September 2, a weight of 177.8 (an increase of 3.4 pounds) was recorded. No further documentation that the physician was notified. On September 7, 2023, a weight of 180 pounds was recorded and is a 5.6-pound increase. No further notes stating the physician was notified of this increase.
Review of the clinical record revealed a nursing note for September 10, 2023, that Resident 48 was requesting an as needed aerosol treatment for complaints of cough/shortness of breath. Resident was tolerating treatment when resident's eyes closed and slumped over in bed. Provided physical stimuli, tapping on feet, rubbing chest . Call was placed to 911.
Review of hospital records dated September 10, 2023, revealed the resident presented in the emergency room with a cough and shortness of breath. Resident 48 was given Lasix and diuresised (the increase of urine production) 16 pounds.
An interview with the Director of Nursing on October 6, 2023, at 9:30 a.m. revealed that the facility had no further documentation and failed to notify the physician of the weight gain on all the dates mentioned above.
The facility failed to ensure that physician orders were followed regarding early breakfast for Resident 34 and weights being monitored for Resident 48.
28 Pa Code: 211.5(f) Clinical records
28 Pa Code: 211.12(d)(1) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that sufficient and competent nursing staff were engaged to revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that sufficient and competent nursing staff were engaged to review resident charts and ensure labs were drawn for one of one resident reviewed (Resident 24).
Findings include:
Review of Resident 24's diagnosis list revealed an active diagnosis of Paroxysmal Atrial fibrillation (type of irregular heartbeat).
Review of Resident 24's clinical record revealed progress note dated June 4, 2023 at 3:54 p.m. indicating Resident noted to have missed Coumadin dose x 3 days. [MD] notified and order received to give resident Coumadin 4 mg (miligrams) PO (by mouth) this evening, resume current dose for June 4, 2023, June 5, 2023, June 6, 2023, and June 7, 2023, and to draw a PT/INR (test is used to see if your blood is clotting normally and if warfarin/coumadin is effective in treating clotting disorders) on June 8, 2023. Resident assessed and with no ill effects. NHA notified by phone. DON notified by phone. Resident's daughter, [NAME], notified by phone.
Interview conducted on October 6, 2023, at approximately 10: 15 a.m. with Licensed nurse, Employee E5, who is author of the progress note, indicated that staff failed to review Resident 24's clinical record to ensure labs were completed.
Review of Resident 24's clinical record revealed the PT/INR blood draw was not performed as directed by physician.
Interview conducted with Registered nurse, Employee E4 on October 6, 2023, at approximately 10:45 a.m. reported that night shift is responsible for checking Epic (form of electronic medical record system) that is used by lab services to ensure that labs were drawn and document the results and contact the resident's physician if necessary.
Interview conducted with the Director of Nursing (DON) on October 6, 2023, at approximately 12:10 p.m. confirmed the information noted above. The Director of Nursing provided surveyor with documentation of in-service training of Coumadin/INR Process along with updates to the facilities patients on coumadin which states 2. Any resident on coumadin should have a separate order stating the following Resident is on coumadin please check for any new orders or labs. This will be pushed out for all shift charge nurses to sign off on.
28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services.
28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
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 upon clinical record review, it was determined the facility failed to provide medications as ordered by the physician and failed to coordinate with pharmacy services to find an alternative medic...
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Based upon clinical record review, it was determined the facility failed to provide medications as ordered by the physician and failed to coordinate with pharmacy services to find an alternative medication for unavailable medications for one of 18 residents reviewed (Resident 83).
Findings include:
Review of Resident 83's diagnosis list revealed diagnoses including cerebrovascular accident (CVA - stroke) and cognitive deficit as a result of the CVA.
Review of Resident 83's physician orders dated June 9, 2023, revealed an order for Methylphenidate (type of stimulant used to assist with cognitive deficits) HCl 5 mg (milligrams) to be administered two times per day.
Review of Resident 83's progress notes for July 2023, August 2023, September 2023, and October 2023 revealed that on multiple occasions Methylphenidate was not administered related to the medication being unavailable.
Further review of Resident 83's progress notes revealed multiple phone calls and messages to resident's physician to notify the physician of the unavailability of the medication.
Interview with the Director of Nursing on October 5, 2023, at 10:00 a.m. revealed that the medication has been unavailable related to a nationwide shortage of the medication.
Review of Resident 83's clinical record failed to reveal evidence of information from the pharmacy related to the shortage and failed to reveal evidence that Resident 83's physician and the pharmacy coordinated to attempt to find a replacement for the Methylphenidate.
Review of Resident 83's progress notes dated October 6, 2023, revealed In this situation, the Department of Health expressed concern regarding a resident's medication, Ritalin, due to its unavailability on account of being on back order. The primary objective was to explore the possibility of obtaining an alternative medication to address the resident's missed doses. Upon contacting the provider, it was explained that Adderall could potentially serve as an alternative to Ritalin. However, it was clarified that Adderall also faces back-order issues, which would present the same challenges encountered with Ritalin. These challenges were attributed to unresolved matters with the Drug Enforcement Administration. To further address the situation, the resident's spouse was informed about the provider's response, as well as the conversation that took place. The spouse shared the contact information of the resident's current neurologist, providing the phone number. It was suggested that contacting the neurologist may offer additional alternatives for medication. An attempt was made to establish direct contact with the neurologist, but unfortunately, it was unsuccessful. Consequently, this information would be passed on to the incoming Nursing supervisor. The supervisor would be briefed on the situation and tasked with placing a follow-up call to the neurologist. The purpose of this call would be to obtain information regarding any additional alternative medications that could help address the current delay issue. The goal is to ensure that the resident's medication needs are met and that suitable alternatives are considered in light of the back-order situation affecting both Ritalin and Adderall.
Review of Resident 83's Medication Administration Records (MAR) for July 2023, revealed one missed; August 2023 revealed 3 missed doses; September 2023 revealed 9 missed doses and October 2023 revealed 4 missed doses to date.
The facility failed to explore alternative medications with Resident 83's neurologist, physician, and pharmacy until October 2023 when it was brought to their attention during the survey.
28 Pa. Code 201.18(a)(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interviews, it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed (R...
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Based on clinical record review and staff interviews, it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed (Resident 33).
Findings include:
Review of Resident 33's clinical record revealed a progress note dated September 3, 2023, at approximately 6:00 p.m. stating This report serves to address medication error related to the administration of Oxycodone to resident. The error occurred during an admission process on August 30th, 2023. admitting nurse had contacted the doctor to request a script for Oxycodone 5mg, with an intended administration of 0.5 tablet every 12 hours. However, inadvertently, admitting nurse failed to document this medication order in the EMAR (electronic medication administration record). On September 3rd, 2023, while reviewing all the admissions for the past week, the admitting nurse discovered the error and immediately took corrective action.
Upon further examination of Resident 33's clinical records, it was revealed Resident 33 was prescribed additional pain relief medication in the form of Acetaminophen Extra Strength Oral Tablets (Tylenol), with a dosage regimen of 2 tablets administered orally every 6 hours for the management of pain.
Additional review of Resident 33's Electronic Medication Administration Record (eMar) revealed that the facility recorded the resident's pain assessments following each instance of Acetaminophen Extra Strength administration. Resident 33 consistently reported a pain score of zero after each administration.
Interview was conducted with the Director of Nursing (DON) on October 4, 2023, at approximately 1:22 p.m., confirmed that Resident 33 missed 6 Oxycodone .5 mg administrations.
The facility failed to ensure Resident 33 was free of significant medication errors.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based upon observation, it was determined the facility failed to adequately label and store medication on two of three medication carts observed (second floor - low cart and second floor - long hall c...
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Based upon observation, it was determined the facility failed to adequately label and store medication on two of three medication carts observed (second floor - low cart and second floor - long hall cart).
Findings include:
Observation of the medication cart labeled Second floor - low on October 5, 2023 at 1:00 p.m. revealed one unopened and unrefrigerated Novolog Insulin (medication used to treat high blood sugar levels) Pen; one opened and undated Lantus Insulin Pen and one opened and undated vial of Novolog insulin.
Observation of the medication cart labeled Second floor - long hall on October 5, 2023 at 1:15 p.m. revealed one opened and undated Lantus Insulin pen and one unopened and unrefrigerated Humalog insulin pen.
The above information was conveyed to the Director of Nursing on October 6, 2023 at 11:00 a.m.
The facility failed to properly store and label medications.
28 Pa. Code 211.12(a)(d)(1)(2)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policies and procedures and observation, it was determined the facility failed to provide appropri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon review of facility policies and procedures and observation, it was determined the facility failed to provide appropriate infection control and failed to follow appropriate transmission-based precautions during medication administration and food delivery for two of two nursing units (first floor nursing unit and second floor nursing unit).
Findings include:
Review of facility policy and procedure titled Administering Medications revealed Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
Review of facility policy and procedure titled Isolation - Categories of Transmission Based Precautions - Droplet Precautions - revealed Masks will be worn when entering the room. Gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions.
Observation of medication administration on October 4, 2023, at 8:30 a.m. revealed Licensed Employee E3 administer medication to three residents. Two of the three residents were on Transmission Based Precautions for COVID-19.
Observation of Licensed Employee E3 on October 4, 2023, at 8:31 a.m. revealed Licensed Employee E3 administer medications to Resident 57. After administration, Licensed Employee E3 did not wash hands or utilize hand sanitizer.
Observation of Licensed Employee E3 on October 4, 2023, at 8:40 a.m. revealed Licensed Employee E3 administer medications to Resident 82. Resident 82 is on transmission-based precautions for COVID-19.
Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 82 and did not wash hands or utilize hand sanitizer after administering the medications.
Observation of Licensed Employee E3 on October 4, 2023, at 8:46 a.m. revealed Licensed Employee E3 administer medications to Resident 72. Resident 72 is on transmission-based precautions for COVID-19.
Licensed Employee E3 did not wear a gown or goggles while administering medications to Resident 72 and did not wash hands or utilize hand sanitizer after administering the medications.
Licensed Employee E3 then proceeded to prepare medications for the next resident scheduled to receive medications.
Observations conducted at approximately 12:33 p.m. on October 4, 2023, on the first floor during food delivery revealed lapses in infection control procedures. Dietary staff was observed delivering food to a resident in room [ROOM NUMBER], who was under droplet precautions due to testing positive for COVID-19, without wearing gloves.
Dietary staff left room [ROOM NUMBER] without removing her personal protective equipment (PPE) and neglected to wash her hands. She then entered room [ROOM NUMBER], which housed another resident under droplet precautions, without using gloves. Afterward, she exited room [ROOM NUMBER], donned a pair of gloves, and returned to room [ROOM NUMBER].
At 12:34, the dietary staff exited room [ROOM NUMBER], removed all PPE, and disposed of it in the appropriate trash receptacle. Dietary staff failed to wash her hands before handling two food trays, which she handed over to another staff member for delivery to residents who were not under droplet precautions.
The dietary staff left the floor before an interview could be conducted. Surveyor asked E4 RN the name of the dietary staff member, E4 did not recognize the dietary staff member and could not provide the surveyor with her name. The dietary staff member was not observed in the facility for the remainder of the survey.
An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on October 4, 2023, at approximately 1:13 p.m., revealed administration were aware of staff members failing to adhere to droplet precautions on the first floor. Administration reported corrective actions were underway, including staff reeducation.
The facility failed to provide appropriate infection control measures during the administration of medications and food delivery.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services
Nov 2022
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident interview it was determined that [NAME] Arms Center failed to a comprehensive care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident interview it was determined that [NAME] Arms Center failed to a comprehensive care plan was implemented for one of two residents reviewed (Resident R1).
Findings include:
Review of clinical record of Resident R1 revealed diagnoses including but not limited to following: Muscle Weakness; Abnormalities of Gait; Osteoporosis (decrease bone density and softening of the bone); and Anemia.
Review of Resident R1's [NAME] (instructions for care) revealed under heading of transferring, Transfers: Full body mechanical lift with assistance of 2.
Review of Resident R1's care plan revealed resident needed full mechanical lift (Hoyer lift) during transfers.
Review of physcian orders dated November 4, 2022 revealed an order for Advance to WBAT (Weight Bearing as Tolerated), advance with physical therapy.
Review of clinical record of Resident R1's progress notes dated November 11, 2022 (11:40 a.m.) revealed, Nurse was called in to assess resident secondary to resident being lowered to the ground. When [nurse] entered the room, resident was lying on her bed in her room, brushing her hair with no apparent s/s (signs/symptoms) of distress noted. When [nurse] asked resident what happened and she/he informed that she/he lost her/his balance while transferring from the shower chair to the bed and the staff lowered her to the floor.
Review of facility documentation revealed, nursing assistance were placed on leave pending outcome of investigation.
Further review of facility documention revealed nurse aides were given disciplinary action for not following care plan for transfers.
Interview with Resident R1 on December 21, 2022 at approximately 4:30 p.m. revealed resident informed the nurses and nurse aides that she was able to perform a stand/pivot transfer and has been giving permission to do stand/pivot transfer since specialist gave permission on November 4, 2022.
Further interview with Resident R1 revealed she/he performed the stand/pivot transfer with two staff to transfer from bed to shower chair but when returning to room to perform second transfer, indicated positioning was incorrect. Resident R1 stated that felt weakness in her legs and unable to hold self standing. The resident stated that the nurse aides did not bring the mechanical lift to transfer nor offer to retrieve the lift for use during transfers.
The above information was conveyed to the Nursing Home Administrator on January 20, 2023 at approximately 11:28 a.m.
The facility failed to ensure a comprehensive care plan for transfers was in place and followed by nursing staff.
28 Pa Code 211.11(a) Resident care plan
28 Pa Code 211.12(d)(3)(5) Nursing services
Nov 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based upon clinical record review, it was determined that the facility failed to notify the physician of changes in resident's blood glucose levels as ordered for one of one resident reviewed (Residen...
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Based upon clinical record review, it was determined that the facility failed to notify the physician of changes in resident's blood glucose levels as ordered for one of one resident reviewed (Resident 70).
Findings include:
Review of Resident 70's diagnosis list revealed diagnoses including Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).
Review of Resident 70's current physician orders revealed a physician's order dated April 19, 2022 stating Fingerstick blood glucose Notify MD (Medical Doctor) if blood sugar greater than 300; if blood glucose is below 70 initiate hypoglycemic protocol.
Review of Resident 70's August 2022 Medication Administration Record revealed that on August 21, 2022, Resident 70's blood glucose was 372 milligrams/deciliter (mg/dl); on August 22, 2022, Resident 70's blood glucose was 320 mg/dl and on August 24, 2022, Resident 70's blood glucose was 303 mg/dl.
Further review of Resident 70's clinical record failed to reveal evidence that Resident 70's physician was notified of the above blood glucose levels that were above 300 mg/dl.
Interview with the Director of Nursing on November 4, 2022, at 11:00 a.m. confirmed that Resident 70's physician was not notified of Resident 70's above-mentioned blood glucose levels.
The facility failed to notify Resident 70's physician of Resident 70's blood glucose levels.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 10/18/2021
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 upon review of personnel records and staff interview, it was determined that the facility failed to ensure newly hired employees received abuse training for one of five personnel records reviewe...
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Based upon review of personnel records and staff interview, it was determined that the facility failed to ensure newly hired employees received abuse training for one of five personnel records reviewed (Employee E5).
Findings include:
Review of personnel files revealed that the facility failed to provide Employee E5 with abuse training prior to the start of employee's employment.
Interview with Human Resources assistant, Employee E4 on November 4, 2022 at 1:00 p.m. confirmed that abuse training was not provided to Employee E5 prior to the start of employment.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
28 Pa. Code 201.18(a)(b)(1)(2) Management
Previously cited 10/18/2021
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
Based upon clinical record review and review of facility documentation, it was determined that the facility failed to investigate allegations of abuse for two of 18 residents reviewed (Resident 73 and...
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Based upon clinical record review and review of facility documentation, it was determined that the facility failed to investigate allegations of abuse for two of 18 residents reviewed (Resident 73 and Resident 190).
Findings include:
Review of Resident 73's clinical progress notes dated May 23, 2022, revealed It was reported to this nurse by CNA [nurse aide] that resident reported that 'someone' hit her in the head. When resident was interviewed she stated that she did not see the person. Upon assessment there was no apparent injuries noted to residents head, no bruising or edema. This was reported to LPN nursing supervisor who also conducted an assessment of resident head and reported no findings of injury. Resident was asked about level of pain to which she responded 'I don't have pain.'
Review of Resident 73's clinical progress notes dated June 29, 2022 revealed resident very anxious and tearful as she describes someone coming into her room at night and is hitting her over and over again. Resident assessed by this nurse to find skin intact, with no discoloration or deformities, resident denies pain but says someone comes in and beats her and she wants it to stop. Resident re-assured staff will make frequent rounds to make sure she is safe with over head light at resident's request.
Facility failed to provide documentation that investigation occurred regarding the above allegations by Resident 73.
Interview with the Director of Nursing on November 4, 2022, at 11:00 a.m. confirmed that no investigation occurred into Resident 73's allegations of abuse as noted above.
Review of Resident 190's clinical progress notes dated September 18, 2022, revealed RN in room at 1505 [3:05 p.m.] to speak with roommate when resident reports male resident had entered her room before breakfast and was pushing her bedside table into her arm. Resident states male entered her room in wheelchair 'sometime this morning' and aggressively grabbed her bedside table which was in front of her as she sat on the side of the bed. Resident reports male resident grabbed onto her bedside table and aggressively shoved it into her left arm, at which time resident raised hand to stop male resident from shoving table into her arm, and then was hit in the palm of the left hand by the table.
Review of clinical records for Resident 190 revealed an x-ray was ordered for Resident 190's left wrist, forearm and elbow.
Further review of Resident 190's clinical record and facility documentation failed to reveal evidence that an investigation was conducted into the above-mentioned incident.
Interview with the Director of Nursing on November 4, 2022 at 11:00 a.m. confirmed that no investigation occurred into Resident 190's allegations of abuse as noted above.
The facility failed to investigate allegations of abuse.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
28 Pa. Code 201.18(a)(b)(1)(2) Management
Previously cited 10/18/2021
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 upon clinical record review it was determined that the facility failed to ensure residents are free from accidents and hazards for one of 18 sampled residents reviewed (Resident 73).
Findings in...
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Based upon clinical record review it was determined that the facility failed to ensure residents are free from accidents and hazards for one of 18 sampled residents reviewed (Resident 73).
Findings include:
Review of Resident 73's progress notes dated April 29, 2022, revealed It was reported to RN supervisor that resident consumed a small amount of PeriGuard Barrier cream. Resident stated that she thought it was cream cheese.
Review of Resident 73's IDT [interdisciplinary team] notes dated May 2, 2022 revealed resident has diagnosis of dementia, no ill effects observed, poison control offered no new recommendations other than continued monitoring.
Intervention: staff education on treatments and appropriate techniques for administration barrier creams and the like.
Interview with the Director of Nursing and Nursing Home Administrator on November 4, 2022 at 1:15 p.m revealed that no investigation into the above-mentioned incident occurred and no staff education was provided as per above stated intervention.
The facility failed to ensure residents are free from accidents and hazards.
28 Pa. Code 201.18(a)(b)(1)(2) Management
Previously cited 10/18/2021
28 Pa. Code 211.12(c)(d)(1)(2)(5) Nursing Services
Previously cited 10/18/2021
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, and staff interview, it was determined that the facility failed to provide routine drugs and b...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review, and staff interview, it was determined that the facility failed to provide routine drugs and biologicals to one out of 8 residents reviewed (Resident 35).
Findings include:
Review of Resident 35's medical diagnosis revealed Resident 35 has a diagnosis of Multiple Sclerosis (disease in which the immune system eats away at the protective covering of nerves).
Review of Resident 35's orders revealed a physician's order for Glatiramer Acetate solution Prefilled Syringe 20 MG/ML (milligram/milliters) inject 20 mg subcutaneously at bedtime for multiple sclerosis.
Review of Resident 35's progress notes revealed on October 15, 2022, [NAME] Arms Center did not have Resident 35's Glatiramer Acetate to administer.
Review of Resident 35's eMAR (electronic medication administration record) revealed from October 15, 2022, to October 21, 2022, [NAME] Arms Center failed to administer Glatiramer Acetate (an immunomodulator mediation used to treat multiple sclerosis) to Resident 35.
Interview conducted with the Nursing Home Administrator (NHA) on November 4, 2022, at 10:13 a.m. produced copies of an email chain between the NHA and PharmScript, LLC (the Pharmacy that [NAME] Arms uses) which revealed PharmScript incorrectly processed Resident R35's Glatiramer Acetate order as Refill Too Soon. This error resulted in Resident 35 missing 7 consecutive daily dosages.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services
28 Pa. Code 211.9(a)(1) Pharmacy Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident interviews, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction o...
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Based on resident interviews, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of two units (2nd floor).
Findings include:
Interview with Resident 51 on November 1, 2022, at 11:30 a.m. revealed that the food is often cold at breakfast.
Interview with Resident 59 on November 1, 2022, at 2:05 p.m. revealed that the food is not always hot.
During a group interview with four alert and oriented residents on November 2, 2022, at 10:30 a.m., residents indicated the the food is frequently cold.
Observation of the lunch meal on November 2, 2022, revealed that the food cart left the kitchen at 12:25 p.m. and arrived on the 2nd floor at 12:30 p.m. Staff began passing trays from the cart at 12:42 p.m. The last resident was assisted with their meal at 1:03 p.m., at which time a test tray was evaluated with the Food Service Director (FSD), Employee E3. The test tray revealed the following temperatures: country fried steak 101 degrees F, mashed potatoes 96 degrees F, and Italian blend vegetables 98 degrees F.
Interview with the FSD at that time revealed that these temperatures were not acceptable and should be between 140-145 degrees F at the point of service.
28 Pa. Code: 201.18 (b)(3) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide evidence that education was provided to residents on the risks and...
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Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide evidence that education was provided to residents on the risks and benefits of the COVID-19 vaccine for three of five residents reviewed that refused the COVID-19 vaccine (Residents 70,79, and Resident 82).
Findings include:
Review of facility policy Covid-19 Immunizations and Reporting Policy, undated, revealed that the facility will provide to each resident prior to being offered Covid-19 vaccine an educational sheet based on vaccine being offered/provided. The educational sheet is a CDC (Centers for Disease Control) approved form and will address benefits and risks and potential side effects associated with the vaccine. The resident's medical record will include documentation, that indicates, at a minimum the following: resident or resident representative was provided education regarding the benefits and potential risks associated with Covid-19 vaccine
Review of Resident 70's clinical record revealed an admission date of August 11, 2021. Review of clinical record for Resident 70 revealed no documented evidence that Resident 70's representatives were educated regarding the risks and benefits of the COVID-19 vaccination.
Review of Resident 79's clinical record revealed an admission date of May 2, 2022.
Review of Resident 82's clinical record revealed an admission date of May 3, 2022.
Review of the clinical records for Resident 79 and Resident 82 revealed no documented evidence that each of the resident or their representatives were educated regarding the risks and benefits of the COVID-19 vaccination.
An interview with the Nursing Home Administrator on November 4, 2022, at 12:30 p.m. confirmed that there was no documentation indicating that education was provided to the residents or their representatives.
28 pa. Code 201.18(b)(1)Management.
Previously cited 10/18/21
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.
- • 43% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Hamilton Arms Center's CMS Rating?
CMS assigns HAMILTON ARMS CENTER an overall rating of 2 out of 5 stars, which is considered 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 Hamilton Arms Center Staffed?
CMS rates HAMILTON ARMS CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 43%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Hamilton Arms Center?
State health inspectors documented 23 deficiencies at HAMILTON ARMS CENTER during 2022 to 2025. These included: 23 with potential for harm.
Who Owns and Operates Hamilton Arms Center?
HAMILTON ARMS CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 94 certified beds and approximately 90 residents (about 96% occupancy), it is a smaller facility located in LANCASTER, Pennsylvania.
How Does Hamilton Arms Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, HAMILTON ARMS CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (43%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Hamilton Arms 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 Hamilton Arms Center Safe?
Based on CMS inspection data, HAMILTON ARMS 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 2-star overall rating and ranks #100 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 Hamilton Arms Center Stick Around?
HAMILTON ARMS CENTER has a staff turnover rate of 43%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Hamilton Arms Center Ever Fined?
HAMILTON ARMS CENTER has been fined $9,009 across 3 penalty actions. This is below the Pennsylvania average of $33,169. 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 Hamilton Arms Center on Any Federal Watch List?
HAMILTON ARMS 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.