MORRISONS COVE HOME
Non profit - Corporation
114 Beds
Independent
Data: November 2025
Trust Grade
55/100
#319 of 653 in PA
Photo by The Village At Morrisons Cove
Photo by The Village At Morrisons Cove
Photo by The Village At Morrisons Cove
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Morrisons Cove Home in Martinsburg, Pennsylvania has a Trust Grade of C, which means it is average and sits in the middle of the pack among nursing homes. It ranks #319 out of 653 facilities in the state, placing it in the top half, and #4 out of 9 in Blair County, indicating there are only three local options considered better. The facility appears to be improving, with a decrease in issues from 11 in 2024 to 10 in 2025. Staffing is a relative strength, earning a 4 out of 5 stars, though the turnover rate is concerning at 60%, which is higher than the state average of 46%. While there have been no fines issued, there were significant concerns found during inspections, including failures to provide required notifications regarding emergency hospital transfers for five residents and not updating care plans for four residents to reflect their changing needs.
- Trust Score
- C
- In Pennsylvania
- #319/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Top 48%
No red flags
11 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 10 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Pennsylvania average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 60%
14pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is elevated (60%)
12 points above Pennsylvania average of 48%
The Ugly 32 deficiencies on record
Jan 2025
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for two of 33 residents reviewed (Residents 53, 61).
Findings include:
T...
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Based on observations and staff interviews, it was determined that the facility failed to provide a clean, homelike environment for two of 33 residents reviewed (Residents 53, 61).
Findings include:
The facility's policy titled admissions, dated November 7, 2024, revealed that the policy objective was to provide a safe, clean and homelike environment for residents within 72 hours of admission.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, revealed that the resident was severely cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, and had diagnoses that included sacral wounds and multiple sclerosis.
Observations in Resident 53's room on January 24, 2025, at 1:00 p.m. revealed that an area on the dry wall behind the resident's bed, measuring approximately seven inches long by ten inches wide, with multiple scratches, gouges and nicks in it, and the paint was coming off in several areas.
Interview with the Maintenance Director on January 24, 2025, at 1:10 p.m. confirmed that the dry wall in Resident 53's room was not homelike and needed repaired and painted.
An admission MDS assessment for Resident 61, dated November 14, 2024, revealed that the resident was cognitively intact, had clear speech, was understood and could understand, required assistance with daily care needs, and had diagnoses that included depression and diabetes. A review of Resident 61's clinical record revealed that the resident was moved to a private room on October 1, 2024.
Observations in Residents 61's room on January 21, 2025, at 12:06 p.m. and January 23, 2025, at 1:48 p.m. revealed an area of dry wall behind the resident's bed that measured approximately three inches wide by five feet long, with multiple scratches, gouges and nicks where the brown layer of dry wall was exposed and the paint was coming off. Interview with Nurse Aide 1 on January 23, 2025, indicated that the previous resident had padding on the wall for safety and the damage may be from when they removed the padding from the wall.
Interview with the Maintenance Director on January 23, 2025, at 2:40 p.m. confirmed that the dry wall in Resident 61's room was not homelike and needed repaired and painted.
28 Pa. Code 201.29(j) Resident Rights.
28 Pa. Code 207.2(a) Administrator's Responsibility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's re...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident and/or the resident's representative at the time of transfer for one of 33 residents reviewed (Resident 59).
Findings include:
A nursing note for Resident 59, dated March 16, 2024, indicated that the resident was transferred to the hospital and was being admitted after a change in condition. There was no documented evidence that the resident and/or the resident's representative were provided with written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of the transfer to the hospital.
Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that there was no documented evidence that a written notice of the facility's bed hold policy was provided to Resident 59 and/or the resident's representative at the time of the resident's transfer to the hospital.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(3) Management.
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 clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained as fr...
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Based on review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that a resident's environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 8).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia. A care plan, dated June 14, 2024, revealed that the resident was at risk for falls related to gait/balance problems, as well as a history of non-compliance with transfers and ambulation. The resident was an assist of one staff with a gait belt and a wheeled walker for her transfers.
Nursing notes for Resident 8, dated June 15, 16, and 17, 2025, revealed that the resident had been observed self-ambulating and that despite much education to the resident by staff on the importance of ringing her call bell and waiting for staff assistance, the resident's non-compliance with self-transfers continues.
A nursing note for Resident 8, dated June 26, 2024, revealed that the writer was called to the resident's room due to a fall. The resident had tried to self-ambulate to the bathroom and fell inside of the bathroom. There was no documented evidence that any new interventions to prevent the resident from self-transferring without staff assistance were initiated prior to Resident 8's fall on June 26, 2024.
Interview with the Nursing Home Administrator and the Director of Rehabilitation on January 22, 2025, at 1:12 p.m. revealed that Resident 8 was on therapy case load for strengthening and balance training in attempts to get the resident back to being independent at that time. On June 11, 2024, the resident's transfer status was changed from being independent to being a one assist. The Nursing Home Administrator confirmed that the resident was educated by staff when they observed the resident self-transferring; however, there were no new and/or revised interventions to prevent the resident from self-transferring without staff assistance initiated prior to Resident 8's fall on June 26, 2024.
A nursing note for Resident 8, dated June 21, 2024, revealed that a nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had taken Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) and was using it on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, used toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine.
Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove bedside creams.
As of January 22, 2025, there was no documented evidence that Resident 8's care plan was revised/updated to include that bedside creams should be removed.
Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items.
Interview with Nurse Aide 2 on January 22, 2025, at 2:44 p.m. confirmed that there were two tubes of Calmoseptine in Resident 8's plastic bin in her bathroom. She indicated that this morning the resident rang her call bell and when she responded to the call bell, she found that the resident had self-transferred to the bathroom.
Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's Calmoseptine should not have been in the resident's room.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(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 F0694
(Tag F0694)
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 ensure that physician's orders were followed for the care and maintenance 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 physician's orders were followed for the care and maintenance of intravenous catheters, failed to ensure that intravenous catheters were flushed according to facility policy, and failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for one of 33 residents reviewed (Resident 29).
Findings include:
The facility's policy regarding flushing peripheral catheter (a thin, flexible tube that is inserted into a vein to administer fluids, blood, or medications), dated November 7, 2024, indicated that peripheral intravenous (IV) catheters will be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications. Staff was to use the push-pause technique to instill the normal saline.
Physician's orders for Resident 29, dated November 15, 2024, included an order for the resident to receive one gram (gm) of Meropenem (used to treat infections caused by bacteria) intravenously every six hours for a urinary tract infection for seven days.
Physician's orders for Resident 29, dated November 15, 2024, and discontinued on November 24, 2024, included an order for the resident to receive a 10 milliliter (ml) normal saline flush every shift for IV maintenance until the completion of his antibiotic.
Resident 29's Medication Administration Records (MAR's) for November 2024 revealed that there was no document evidence that staff administered the 10 ml normal saline flush during the dayshift on November 24, 2024, or during the evening shift on November 15, and 22, 2024.
Resident 29's MAR's for November 2024 revealed that staff administered the IV Meropenem on November 15, 2024, at 8:00 p.m.; on November 16 through 21, 2024, at 2:00 a.m., 8:00 a.m., 2:00 p.m. and 8:00 p.m.; and on November 22, 2024, at 2:00 a.m., 8:00 a.m., and 2:00 p.m However, there was no documented evidence that staff flushed the resident's IV catheter with normal sterile saline solution before and after the administration of the Meropenem.
A nursing note for Resident 29, dated November 27, 2024, revealed that the resident's IV catheter was removed at this time. However, there was no documented evidence that Resident 29's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed.
Interview with the Director of Nursing on January 23, 2025, at 3:05 p.m. confirmed that there was no documented evidence that Resident 29's IV catheter was flushed with the 10 ml of normal saline during the dayshift on November 24, 2024, and during the evening shift on November 15, and 22, 2024; that there was no documented evidence that the resident's IV catheter was flushed with normal sterile saline solution before and after the administration of the Meropenem; and that there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter from November 24 through 27, 2024, when it was removed.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
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 review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to el...
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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 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 33 residents reviewed (Resident 62).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 62, dated December 5, 2024, revealed that the resident was cognitively intact and had diagnoses which included PTSD. A care plan for the resident, dated September 11, 2024, revealed that the resident had a potential for mood problems related to his PTSD.
An interview with Resident 62 on January 22, 2025, at 10:38 a.m. revealed that he was a war veteran and that he had a terrible motor vehicle accident. He stated that he had some trauma from both of those life events.
However, there was no documented evidence that the facility completed an assessment for a history of trauma for Resident 62 to identify specific triggers that could re-traumatize the resident.
Interview with the Nursing Home Administrator on January 22, 2025, at 2:09 p.m. confirmed that there was no documented evidence of an assessment for a history of trauma being completed for Resident 62.
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
Pharmacy Services
(Tag F0755)
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 maintain accountability for controlled medications (drugs with the...
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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 maintain accountability for controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 54).
Findings include:
The facility's policy for controlled substances, dated November 7, 2024, revealed that facility staff should document the time and day of administration, amount administered, and remaining quantity. Each dose of a medication shall be initialed on the Medication Administration Record (MAR) after the medication was actually administered.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood, and could sometimes understand others, required assistance with all care needs, and had diagnosis that included depression.
Physician's orders for Resident 54, dated December 4, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (a narcotic anxiety medication) every six hours as needed for restlessness for 14 days. Physician's orders for Resident 54, dated December 28, 2024, included an order for the resident to receive 0.5 mg of Ativan every six hours as needed for restlessness and anxiety for 30 days.
Review of the December 2024 and January 2025 controlled drug records for Resident 54 revealed that 0.5 mg of Ativan was signed out on December 9, 2024, at 4:30 a.m.; December 11, 2024, at 11:00 p.m.,; and January 11, 2025, at 10:00 p.m. However, there was no documented evidence in Resident 54's clinical record, including the MAR, that the signed-out dose of the controlled medication was administered to the resident on the above-mentioned date and time.
Interview with the Director of Nursing on January 24, 2025, at 12:15 p.m. confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of controlled medications mentioned above were administered to Resident 54.
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
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 correct quality deficiencies 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 corrections for a State Survey and Certification (Department of Health) survey ending January 4, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending January 24, 2025, identified repeated deficiencies related to the revision of care plans and pharmacy procedures, services, and records.
The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending January 4, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.
The facility's plan of correction for a deficiency regarding the pharmacy procedures, services, and records, cited during the survey ending January 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F755, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding pharmacy procedures, services, and records.
Refer to F657 and F755.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed...
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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 proper hand washing/hand hygiene was completed during wound care for one of 33 residents reviewed (Resident 53).
Findings include:
The facility's policy regarding wound care and hand washing/hand hygiene, dated November 7, 2024, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, revealed that the resident was severely cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, received hospice, had diagnoses that included multiple sclerosis and sacral wounds, and had a Stage 4 pressure ulcer (skin breakdown from pressure that exposes fat under the skin). Physician's orders, dated October 29, 2024, included an order to wash around the wound bed with water and antibacterial soap, pat dry, cleanse wound with a four by four (gauze sized four inches by four inches) soaked in 0.25 percent acetic acid solution, apply A and D ointment (a thick skin protective) to the peri wound, loosely pack wound bed and undermining with Aquacel Ag (a type of wound dressing that contains ionic silver), and cover with an abdominal pad and secure.
Observations of Resident 53's wound care on January 23, 2025, at 11:15 a.m. revealed that Licensed Practical Nurse 3 washed her hands and put on a gown and gloves prior to placing a barrier on the bed and cleaning around the wound on the resident's sacrum with water and antibacterial soap. She then patted the area dry, cleaned the sacral wound with 0.25 percent acetic acid solution, patted dry, disposed of the barrier, removed her gloves, washed and dried her hands and donned new gloves, applied A and D ointment on the periphery of the wound, applied Aquacel Ag using a large Q-tip to press the dressing into the wound, and covered the wound with an abdominal pad and secured with tape. Licensed Practical Nurse 3 then touched the resident's skin below the dressing area, adjusted the resident's pillow and protective heal boots, and then used the bed controls to reposition the bed. Licensed Practical Nurse 3 then gathered the supplies, placed items into the garbage, removed her gloves, and washed her hands. Licensed Practical Nurse 3 did not remove her gloves and wash her hands after providing wound care and before adjusting Resident 53's pillow, protective heel boots, and bed controls.
Interview with Licensed Practical Nurse 3 on January 23, 2025, at 11:36 a.m. confirmed that she did not remove her gloves and wash her hands after Resident 53's wound care and prior to providing care to the resident.
Interview with the Director of Nursing on January 23, 2025, at 1:35 p.m. confirmed that Licensed Practical Nurse 3 should have removed her gloves and washed her hands prior to adjusting the pillow, protective heel boots, and bed controls, as that was considered moving from a dirty to a clean task.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Offic...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the Office of the State Long-Term Care Ombudsman, and failed to ensure that a written notice was provided to the resident and/or the resident's responsible party regarding the reason for transfer to the hospital for five of 33 residents reviewed (Residents 1, 29, 35, 54, 59).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 30, 2024, revealed that the resident was cognitively intact, was usually understood, and could usually understand others.
A nursing note for Resident 1, dated July 18, 2024, at 2:30 p.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital.
A nursing note for Resident 1, dated November 20, 2024, at 9:23 a.m., revealed that Resident 1 was experiencing chest pain. The resident said she wanted to go to the hospital and was sent to the hospital. A nursing note for Resident 1, dated November 23, 2024, at 6:23 a.m., revealed that Resident 1 was admitted with congestive heart failure (CHF).
There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital.
A quarterly MDS assessment for Resident 29 revealed that the resident was sometimes understood and could sometimes understand others.
A nursing note for Resident 29, dated January 14, 2025, at 4:56 p.m., revealed that the writer was called to the resident's room at 4:46 p.m. due to a fall. The resident was lying on the floor face down parallel to his bed. The resident was yelling get me up! The resident had a small skin tear present on his left second finger; however, the resident did yell out in pain while leaning him forward. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate.
A nursing note for Resident 29, dated January 15, 2025, at 3:07 p.m., revealed that the resident was going to be admitted to the hospital for 24-hour observation with diagnosis of altered mental status.
There was no documented evidence that a written notice of Resident 29's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital.
An admission MDS for Resident 35, dated May 8, 2024, revealed that the resident was sometimes understood and could sometimes understand others.
A nursing note for Resident 35, dated July 31, 2024, at 8:06 a.m., revealed that the resident was resting in bed with his eyes closed. The resident was not easily arousable to verbal stimuli and staff had to use physical stimuli to awaken the resident. The resident was not verbal that a.m. and slightly confused, and was only oriented to self. The resident's right pupil was sluggish during the assessment. A nursing note at 9:12 a.m. revealed that the physician was aware, and orders were received to send the resident for a CT scan. A nursing note at 9:50 a.m. revealed that the resident was sent to the hospital for further evaluation. A nursing note at 2:25 p.m. revealed that the resident will be admitted for acute head injury with bleeding.
There was no documented evidence that a written notice of Resident 35's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital.
Interview with the Director of Nursing on January 23, 2025, at 1:40 p.m. confirmed that there was no documented evidence that a written notice of Resident 29 and Resident 35's transfers to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the residents and the resident's responsible party regarding the reason for transfer to the hospital.
A quarterly MDS for Resident 54, dated September 24, 2024, revealed that the resident was usually understood, could usually understand others, and was severly cognitively impaired. A quarterly MDS for Resident 54, dated December 19, 2024, revealed that the resident was sometimes understood and could sometimes understand others.
A nursing note for Resident 54, dated December 6, 2024, at 7:57 p.m., revealed that the writer was called to the nursing desk due to a fall. The resident was witnessed to have fallen on his face from the wheelchair. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluate.
A nursing note for Resident 54, dated December 25, 2024, at 3:57 p.m. revealed that the writer was called to the the resident's room due to a change in condition. The resident was not acting right and was leaning to the right side. The physician was notified, and a new order was received to transfer the resident to the emergency room to be evaluated.
There was no documented evidence that a written notice of Resident 54's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital.
A quarterly MDS assessment for Resident 59, dated December 26, 2024, revealed that the resident was moderately cognitively impaired, had clear speech, was usually understood and usually understands, required assistance with daily care needs, and had diagnoses that included diabetes and heart disease.
A nursing note for Resident 59, dated April 16, 2024, at 12:50 p.m., revealed that the resident had a fall and complained of pain in her forehead, knee, and left arm. The physician was notified, and the resident was sent to the hospital for an evaluation and was admitted .
There was no documented evidence that a written notice of Resident 59's transfer to the hospital was provided to the state Long-Term Care Ombudsman and that a written notice was provided to the resident and the resident's responsible party regarding the reason for transfer to the hospital.
Interview with the Director of Nursing on January 24, 2025, at 9:17 a.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital and/or the reason for hospitalization.
28 Pa. Code 201.14(a) Responsibility of licensee.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on review of policies, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect ch...
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Based on review of policies, clinical records, and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in resident care needs for four of 33 residents reviewed (Residents 8, 26, 53, 66).
Findings include:
The facility's policy regarding care plans, dated November 7, 2024, indicated that nurses and interdisciplinary team members were responsible for updating the resident's care plan to reflect changes in the resident's status.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 13, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included dementia. A care plan for the resident, dated November 25, 2022, revealed that the resident has impaired cognitive function or impaired thought processes related to dementia.
A nursing note for Resident 8, dated June 21, 2024, revealed that the nurse aide reported to the writer that the resident was in the bathroom of her room and when she went in to assist her, she found that resident had used Calmoseptine (used to treat and prevent minor skin irritations like those resulting from diarrhea, burns, cuts, and scrapes) on her dentures instead of her denture cream. The resident said she could not see what she was using, so the nurse aide had her rinse her mouth out, use toothpaste, and brush the inside of the mouth and tongue. Her dentures were then cleaned with toothpaste. The resident claims she did not swallow any of the Calmoseptine.
Facility investigation documents for Resident 8, dated June 21, 2024, revealed that a new intervention was to remove creams kept at the bedside.
As of January 22, 2025, there was no documented evidence that Resident 8's care plan was revised/updated to include that bedside creams should be removed.
Observations of Resident 8's bathroom on January 22, 2025, at 2:00 p.m. revealed that there were two tubes of Calmoseptine in a plastic basin that also contained the resident's mouth care items.
Interview with the Director of Nursing on January 22, 2025, at 3:10 p.m. confirmed that Resident 8's care plan was not revised/updated to include that bedside creams should be removed.
An admission MDS assessment for Resident 26, dated December 9, 2024, indicated that the resident was cognitively impaired, and that she was medicated with an anticoagulant (blood thinner). Physician's orders for Resident 26, dated December 3, 2024, included an order for the resident to receive 20 milligrams (mg) of Xarelto (blood thinner) daily until January 1, 2025, at which time the medication would be discontinued. Resident 26's care plan, dated December 9, 2024, revealed that the resident was medicated with a blood thinner.
There was no documented evidence that Resident 26's care plan was updated to reflect the discontinuation of the blood thinner.
An interview with the Director of Nursing on January 24, 2025, at 9:13 a.m. confirmed that Resident 26's care plan was not updated after the discontinuation of the blood thinner and it should have been.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 53, dated December 20, 2024, indicated that the resident was severely cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had a catheter related to the diagnosis of neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged resulting in difficulty urinating or incontinence).
Clinical notes for Resident 53, dated June 3, 2024, indicated that while performing a.m. care the aide noted a tear of the penis meatus (opening for urine) with scant bleeding.
A physician's order for Resident 53, dated June 4, 2024, included an order to cleanse the penis with soap and water, pat dry and apply bacitracin every shift for skin tear to the meatus (opening for urine). A current care plan indicated treatment to the residents skin tear was ongoing; however, physician orders indicated that the treatments were discontinued on November 6, 2024.
Interview with the Director of Nursing on January 22, 2024, at 9:51 a.m. confirmed that Resident 53's care plan should have been updated to reflect that the treatments to the resident's penis were discontinued, and it was not.
A quarterly MDS assessment for Resident 66, dated September 13, 2024, indicated that the resident was moderately cognitively impaired, usually understood and usually understands, required assistance from staff for his daily care needs, and had heart failure and hypertension (high blood pressure). A care plan dated July 5, 2024, revealed that Resident 66 was at risk for falls due to deconditioning, gait and balance problems, weakness and non-compliance with transfers and ambulation.
A fall investigation for Resident 66, dated October 30, 2024, revealed that the resident had a fall from a high bed. The immediate intervention was to remove the bed remote out of reach from the resident.
There was no documented evidence to indicate that the fall care plan was updated to reflect that the bed remote should be kept out of his reach.
Interview with the Director of Nursing on January 22, 2025, at 9:51 a.m. confirmed that Resident 66's care plan should have been updated to reflect that the bed remote control should not be in reach, and it was not.
28 Pa. Code 211.12(d)(5) Nursing Services.
Sept 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
Notification of Changes
(Tag F0580)
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 the physician was notified about a resident ingesting ...
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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 the physician was notified about a resident ingesting perfume for one of four residents reviewed (Resident 2).
Findings include:
The facility's policy for Accident and Incident Investigation Procedures and Reporting, dated July 17, 2024, indicated that any incident (an unexpected, unintended event that causes or has the potential to cause bodily harm) will be reported immediately to the nursing supervisor on duty. The resident will be assessed, and the physician will be notified.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated August 20, 2024, revealed that the resident was cognitively impaired, required extensive assistance from staff for her daily care needs, and had diagnoses of vascular dementia with behavioral disturbance.
A nursing note for Resident 2, dated August 5, 2024, revealed that the resident was at the nurse's station and grabbed a tiny bottle of perfume that was placed at the nurses station by another resident. The nurse was preparing medications and noticed the resident grab the bottle of perfume and place it to her lips. The nurse grabbed the bottle of perfume from the resident immediately, noting that there was a tiny drop on the resident's lips and also presumed that a tiny sip was ingested by the resident. The nurse offered the resident a drink of water, but the resident refused. The registered nurse assessment indicated no gagging, nausea or vomiting, and vital signs were within the resident's normal limits. An attempt was made to contact the resident's guardian with no answer, and a message was left for a return call.
There was no documented evidence in Resident 2's clinical record to indicate that the physician was notified about the ingestion of perfume on August 5, 2024.
An interview with the Director of Nursing on September 11, 2024, at 12:29 p.m. confirmed that the physician was not notified about Resident 2 ingesting perfume on August 5, 2024, and should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Jan 2024
10 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 and personnel files, as well as staff interviews, it was determined that the facility failed to complete a criminal background check prior to hire for one of one temporary ...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a criminal background check prior to hire for one of one temporary nurse aides (Temporary Nurse Aide 1).
Findings include:
The facility's policy regarding criminal background checks, dated August 18, 2023, indicated that the employee would be screened for a history of abuse using the state police criminal background check procedure. Results of the criminal background check must be available within 30 days from the hire date.
The personnel file for Temporary Nurse Aide 1 revealed that she was hired on October 10, 2023, but as of January 4, 2024, there was no evidence that a criminal background check was completed.
Interview with the Nursing Home Administrator on January 4, 2024, at 3:02 p.m. confirmed that there was no documented evidence that Temporary Nurse Aide 1 had a criminal background check.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required timeframe for two of five residents reviewed (Residents 29, 279).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days.
An annual comprehensive MDS assessment for Resident 29, with an ARD of November 21, 2023, was due to be completed by December 4, 2023, but was not signed as completed until December 5, 2023, which was one day from the ARD until completion.
The RAI User's Manual, dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date plus 13 calendar days).
An admission MDS assessment for Resident 279 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was incomplete as of January 4, 2024, which was 19 days after admission.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 4, 2024, at 4:05 and 4:37 p.m. confirmed that the above comprehensive and admission MDS assessments were not completed in the required time frame.
28 Pa. Code 211.5(f) Medical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for one of 32 residents review...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for one of 32 residents reviewed (Resident 41).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated November 24, 2023, indicated that the resident was cognitively impaired, required substantial assistance from staff for her daily care needs, and had a diagnosis of peripheral vascular disease (a condition that reduces blood flow to the arms and legs).
Observations of Resident 41 on January 2, 2024, at 11:20 a.m. revealed that the resident was sitting in her room in a wheelchair and she was wearing a geri leg (a stocking that protects the skin) on her right lower extremity.
A nurse's note for Resident 41, dated December 28, 2023, at 11:15 a.m. revealed that she had complained of right lower extremity tenderness while at therapy. Documentation revealed that there was diffuse redness and moderate swelling and tenderness with warmth to her right lower extremity.
Physician's orders for Resident 41, dated December 28, 2023, included an order for the resident to wear a geri leg to her right lower extremity that may be removed with care and Keflex (an antibiotic) two times a day for cellulitis (a bacterial skin infection) of her right lower extremity through January 7, 2024.
There was no documented evidence that a care plan was developed to address Resident 41's cellulitis and antibiotic treatment.
An interview with the Director of Nursing on January 4, 2024, at 3:10 p.m. confirmed that Resident 41 did not have a care plan for cellulitis and antibiotic therapy and there should have been one.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in ...
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Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for three of 32 residents reviewed (Residents 40, 48, 53).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated October 25, 2023, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included dementia, Parkinson's and stroke.
A care plan for Resident 40, last revised on October 25, 2023, indicated that the resident was taking a sleep aid for insomnia. Physician's orders, dated October 25, 2023, included an order to discontinue Resident 40's melatonin.
Interview with the Director of Nursing on January 4, 2024, at 3:10 p.m. confirmed that Resident 40's care plan should have been revised when her melatonin was discontinued, and it was not.
A quarterly MDS assessment for Resident 48, dated September 29, 2023, revealed that the resident was cognitively impaired, required extensive assistance with care needs, had a Stage 2 pressure ulcer (partial-thickness skin loss into but no deeper than the dermis) and had diagnoses that included venous insufficiency (valves in the veins do not close properly causing blood to back-flow), non-pressure ulcer to left lower leg, and skin cancer of left lower limb including the hip.
A care plan for Resident 48, last revised on October 19, 2023, indicated that the resident was receiving a treatment to her mid back, right lower side, and right achilles.
Physician's orders, dated October 27, 2023, included an order to discontinue treatment to Resident 48's right achilles because it was healed.
Physician's orders, dated December 29, 2023, included an order to discontinue treatment to Resident 48's mid back and right lower side because they were healed.
There was no documented evidence in Resident 48's clinical record to indicate that her care plan was revised when the treatments were discontinued.
Interview with the Director of Nursing on January 4, 2024, at 3:10 p.m. confirmed that Resident 48's care plan should have been revised when her areas were healed and treatments were discontinued, and it was not.
An entry MDS assessment for Resident 53, dated December 12, 2023, revealed that the resident was cognitively impaired, required assistance of two staff for her daily care needs, and had an indwelling catheter (a flexible tube used to empty the bladder) placed after hip surgery.
A care plan for Resident 53, last revised December 12, 2023, indicated that the resident had an indwelling catheter and included interventions for indwelling catheter care.
Physician's orders, dated December 18, 2023, indicated that Resident 53's indwelling catheter was discontinued.
Interview with Director of Nursing on January 4, 2024, at 1:05 p.m. confirmed that Resident 53's care plan should have been revised to indicate that the indwelling catheter was discontinued and it was not.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that weekly skin checks were performed accurately for one o...
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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 weekly skin checks were performed accurately for one of 32 residents reviewed (Resident 49) and failed to administer chewable aspirin as ordered by the physician for one of 32 residents reviewed (Resident 279).
Findings include:
The facility's policy regarding preventative skin care, dated February 9, 2023, revealed that the facility will maintain or improve current skin integrity through identification of residents at risk for skin break down and placing interventions which meet their individual needs to minimize their risk for altered skin integrity. Care plans would be established for all residents at risk, which would include interventions to reduce the risk of skin breakdown.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated November 3, 2023, revealed that the resident was severely cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included Parkinson's disease (progressive nerve disorder that causes abnormal movements). Current care plans for Resident 49 indicated that the resident was on anticoagulant therapy (blood thinning medication) and was to have a daily skin assessment with any abnormalities reported to the nurse, and that the resident has fragile skin with the potential for breakdown with an intervention to consult dermatology for the treatment of actinic keratosis (precancerous dry rough skin) on her neck.
Observations of Resident 49 on January 2, 2024, at 11:58 a.m. revealed that she was lying in bed sleeping, the head of the bed was elevated, and there was a lunch tray in front of her. There was a reddened scabbed area on her left temple at the end of her eyebrow line.
A bath communication form, dated January 2, 2024, at 8:00 p.m., indicated that Resident 49 had no concerns with rashes, bruises, redness, or open areas. The form was completed by a nurse aide, then signed by two other licensed staff.
Observations of Resident 49 on January 3, 2024, at 3:55 p.m. revealed that she was in bed sleeping. There was a dark red area approximately the size of a quarter on her left temple at the end of her eyebrow line with dried blood. Interview with Nurse Aide 3 on January 3, 2024, at 4:01 p.m. revealed that the resident has anxiety issues and may have done that to herself. Interview with Licensed Practical Nurse (LPN) 4 on January 3, 2024, at 4:06 p.m. revealed that she had not rounded yet to she the resident, confirmed that there was a reddened area with dried blood, and said the resident will pick and scratch herself. LPN 4 did not receive any report of a new skin concern or find any recent documentation regarding a new skin concern.
An incident report for Resident 49, dated January 3, 2024, at 4:30 p.m., revealed that there was an observed area on the left temple measuring 1.0 centimeters (cm) x 0.5 cm. The area appeared to be scratched open, with a scant amount of blood. Resident 49 had a complete bed bath last evening and no areas were noted during that time when the skin assessment was completed.
An interview with the Director of Nursing on January 4, 2024, at 9:19 a.m. revealed that a weekly skin assessment was completed every Tuesday evening with showers and bathing for Resident 49. The Director of Nursing confirmed that there were no skin areas of concern documented during that weekly skin assessment, and if the area was visible it should have been documented.
The facility's policy, dated August 18, 2023, indicted that the five rights of medication were to be followed, which includes checking for the right resident, the right drug, the right dose, the right route and the right time. The policy indicated the medication label was to be compared against the Medication Administration Record (MAR). Prior to administration of any medication, the medication and dosage schedule on the resident's MAR were to be compared to the medication label. If the label and the MAR were different, the physician's orders were to be checked for correctness.
Physician's orders for Resident 279, dated December 19, 2023, included an order for the resident to receive 81 mg of chewable aspirin daily for a diagnosis of cerebrovascular disease. Observations of Licensed Practical Nurse 5 during medication administration on January 4, 2024, at 8:47 a.m. revealed that the medication label was for aspirin EC (enteric coated) 81 milligrams (mg) daily; however, the MAR indicated aspirin chewable 81 mg daily.
An interview with the Director of Nursing on January 4, 2024, at 3:13 p.m. confirmed that Resident 279 received the wrong type of aspirin.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(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 ensure the accountability of controlled medications (drugs with the potenti...
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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 the accountability of controlled medications (drugs with the potential to be abused) for two of 26 residents reviewed (Residents 29, 48).
Findings include:
The facility's policy regarding medication administration, dated August 18, 2023, indicated that as needed medications (PRN) were documented with the date and time of administration, dose, route of administration, complaints, or symptoms for which the medication was administered, and the signature or initials of person recording effects on the medication administration record (MAR).
A nursing note for Resident 29, dated December 9, 2023, revealed that she fell and had several head and facial lacerations, her left shoulder appeared to be out of place, and she had an open laceration to the left wrist area with cartilage or bone showing.
Physician's order for Resident 29, dated December 20, 2023, revealed that the resident was ordered 5 milligrams (mg) of Oxycodone immediate release (a narcotic pain medication) by mouth every six hours as needed for severe pain.
Observations of Resident 29 on January 2, 2024, at 12:04 p.m. revealed that the resident was in bed wearing an ace wrap and a brace on her left wrist, and she was moaning in pain.
Review of Resident 29's controlled drug records for December 2023 and January 2024 revealed that a dose of Oxycodone was signed-out once on December 24, 2023, at 9:45 p.m.; December 26, 2023, at 9:00 p.m.; and December 31, 2023, at 9:30 p.m. However, the resident's clinical record, including the MAR, contained no documented evidence that Oxycodone was actually administered to the resident on these dates.
A quarterly MDS assessment for Resident 48, dated September 29, 2023, revealed that the resident was cognitively impaired; required extensive assistance with care needs; had a Stage 2 pressure ulcer; had diagnoses that included venous insufficiency, non-pressure ulcer to the left lower leg, skin cancer of the left lower limb including the hip; and was receiving controlled pain medication.
Physician's orders for Resident 48, dated July 31, 2023, included an order for the resident to receive a 12 micrograms (mcg) Fentanyl (a narcotic pain patch) patch to be applied every three days for pain.
Physician's orders for Resident 48, dated November 10, 2023, included an order for the resident to receive a 25 mcg Fentanyl patch to be applied every three days for pain.
The Medication Administration Record (MAR) and a controlled drug count record (tracks each dose of a controlled medication) for Resident 48, dated October 2023, revealed that a 12 mcg Fentanyl patch was applied to the resident on October 8 and 23, 2023. There was no documented evidence that two licensed nurses signed that the old patch was destroyed after removal on these dates.
The MAR and a controlled drug count record for Resident 48, dated December 2023, revealed that a 25 mcg Fentanyl patch was applied to the resident on December 8, 2023. There was no documented evidence that two licensed nurses signed that the old patch was destroyed after removal on that date.
Interview with the Director of Nursing on January 4, 2024, at 4:55 p.m. confirmed that the oxycodone for Resident 29 was signed out on the narcotic sheet but was not documented as administered on the medication administration record, and confirmed that there was no documented evidence that two licensed personnel performed the destruction of Resident 48's Fentanyl patches as required.
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 facility policy, observations, and staff interviews, it was determined that the facility failed to securely store medications in one of three medication carts reviewed (South cart).
Findings...
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Based on facility policy, observations, and staff interviews, it was determined that the facility failed to securely store medications in one of three medication carts reviewed (South cart).
Findings include:
The facility's policy regarding medication administration (preperation and general guidelines), dated August 18, 2023, indicated that during medication administration the medication cart is kept closed and locked when out of sight of the medication nurse.
Observations of the South medication cart on January 4, 2024, at 9:14 a.m. revealed that the medication cart was left unattended and unlocked when Registered Nurse 1 entered a resident room to administer medications. The cart was not in the sight of the medication nurse. Interview with Registered Nurse 6 on January 4, 2023, at 9:23 a.m. revealed that the medication cart should be closed and locked when not in her sight.
Interview with the Director of Nursing on January 4, 2024, at 1:05 p.m. revealed that the medication cart should be closed and locked at all times when not in the line of sight of the medication nurse.
28 Pa. Code 211.9(a)(1) Pharmacy 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 correct quality deficiencies 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) surveys ending February 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 4, 2024, identified repeated deficiencies related to following abuse policies and quality of care.
The facility's plan of correction for a deficiency regarding following abuse policies, cited during the survey ending February 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F607, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following abuse policies and conducting background checks upon hire.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding quality of care for residents.
Refer to F607 and F684.
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
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the...
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Based on review of attendance records for the facility's Quality Assurance Committee, as well as staff interviews, it was determined that the facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings.
Findings include:
Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director or designee did not attend any meetings from April 2023 through December 2023.
Interview with the Nursing Home Administrator on January 4, 2024, at 3:48 p.m. confirmed that there was no documented evidence that the Medical Director or designee attended any meetings in the last three quarterly meetings reviewed. Meetings were scheduled on days that the Medical Director rounded in the facility, but there was no documented evidence that his signature was obtained.
28 Pa. Code 201.18(e)(1)(2)(3) Management.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Se...
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Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 32 residents reviewed (Residents 32, 34).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415I Antiplatelet Medications (medication used to prevent blood from clotting) was to be coded if the resident took the medication during the seven-day look-back period.
Physician's orders for Resident 32, dated October 4, 2019, included an order for the resident to receive 81 milligrams of aspirin (an antiplatelet) every day. The resident's Medication Administration Record (MAR) for October 2023 revealed that the resident received aspirin daily during the seven-day look-back assessment period.
A significant change MDS for Resident 32, dated October 2, 2023, revealed that Section N0401I was not coded, indicating that the resident did not receive antiplatelet medication during the seven-day look-back assessment period.
The RAI User's Manual, dated October 2023, indicated that Section B0700 (make self understood) should be coded with either clearly understood, usually understood, sometimes understood, or rarely/never understood. Section C0100 (should brief interview for mental status be conducted) should be completed if the resident is at least sometimes understood verbally, in writing, or using another method. Section C0100 was to be coded No (0) or Yes (1) to determine whether a Brief Interview for Mental Status (BIMS) (an assessment to determine a resident's cognitive status) should be attempted with the resident. The instructions for determining if a BIMS interview should be attempted indicated that if the resident was at least sometimes understood (verbally or in writing) then the BIMS interview was to be attempted with the resident and coded in Sections C0200 through C0500. If the resident was rarely/never understood, then the BIMS interview was not to be attempted, and a Staff Assessment of Mental Status was to be completed instead and coded in Sections C0600 through C1000.
A quarterly MDS for Resident 34, dated October 20, 2023, revealed that Section B0700 was coded rarely/never understood and Section C0100 was coded (yes), indicating that the BIMS interview was attempted.
An interview with the Registered Nurse Assessment Coordinator (RNAC- a registered nurse who is responsible for the completion of MDS assessments) confirmed on January 4, 2024, at 4:32 p.m. that the assessments for Residents 32 and 34 were coded incorrectly.
28 Pa. Code 211.5(f) Clinical records.
Feb 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding resid...
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Based on observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding residents while standing for one of 35 residents reviewed (Resident 11).
Findings include:
Observations in the first floor dining room during the lunch meal on February 6, 2023, at 11:45 a.m. revealed that Resident 11 was seated at the dining table in her wheelchair and Nurse Aide 1 stood to the resident's left side while feeding her.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 18, 2022, revealed that the resident was confused at times and required extensive assistance of one staff member for eating.
An interview with Nurse Aide 1 on February 6, 2023, at 11:49 a.m. confirmed that she was standing while feeding Resident 11 and that she should have been seated.
Interview with the Director of Nursing on February 7, 2023, at 2:35 p.m. confirmed that Nurse Aide 1 should have been seated and at Resident 11's eye level while feeding her.
28 Pa. Code 201.29(j) Resident rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and interviews with staff, it was determined that the facility failed to ensure that medications were not left at the...
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Based on review of facility policies and clinical records, as well as observations and interviews with staff, it was determined that the facility failed to ensure that medications were not left at the bedside for residents that were not assessed for self administration for one of 35 residents reviewed (Resident 61).
Findings include:
The facility's policy for medication administration general guidelines, dated August 4, 2022, indicated that if the resident is not in their room or unavailable to receive medications during the pass, staff are to flag the medication administration record and return to the resident to provide the medication. The residents are to always be observed after administration to ensure that the doses are completely taken.
A diagnosis record for Resident 61, dated June 23, 2022, included atherosclerotic heart disease (ASHD- thickening and hardening of the heart artery), chronic kidney disease, and osteoarthritis.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated November 29, 2022, indicated that she was alert and oriented, required extensive assistance of one for transfers and bed mobility, required set up for her meals, and had impaired range of motion on both upper and lower extremities.
Current physician's orders for Resident 61 included orders for 600-800 milligram/Unit of Calcium Plus Vitamin D3, one tablet by mouth one time a day for osteoporosis; 36000-114000 unit Creon Oral Capsule, Delayed Release, one capsule by mouth with meals for digestive aid; 325 mg of ferrous sulfate (iron supplement), one tablet by mouth in the morning; 10 mg of Claritin, one tablet by mouth one time a day for nasal drainage; 1 gram of sodium chloride, one tablet by mouth one time a day; one multivitamin tablet, one time a day; 75 mg of clopidogrel bisulfate (Plavix) one tablet by mouth one time a day; 81 mg of aspirin, delayed release, one time a day every other day; 5000 micrograms of biotin, one tablet by mouth one time a day; 50 mg of zinc, one tablet by mouth one time a day; 500 mg of Vitamin C, one tablet by mouth one time a day; and 25 mg Metoprolol Tartrate (used to treat high blood pressure), 0.5 tablet by mouth two times a day.
The January 6, 2023, medication administration record (MAR) for Resident 61 indicated that the above 12 medications were provided to the resident at 8:55 a.m. by Registered Nurse 3.
Observations of Resident 61 on February 6, 2023, at 10:13 a.m. in her room revealed that she was in her wheelchair and there was a medication cup on her over-bed stand with multiple pills noted inside. Interview with Resident 61 at that time indicated that she was in the bathroom when the nurse administered her eye drops that morning, and that she just did not have time to take her medications yet.
Interview with Registered Nurse 6 on February 6, 2023, at 10:36 a.m. indicated that she was unaware that the resident did not take her medications and she then proceeded to assist her with taking them. She further indicated that they are to observe residents taking their medications and that she should not have left them in the resident's room.
There was no documented evidence that Resident 61 was assessed to determine if she was capable of self administration of her medications.
Interview with the Nursing Home Administrator on February 7, 2023, at 10:40 a.m. confirmed that Resident 61 was not evaluated for self administration of medications and that the staff should ensure medications are taken.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification for one of one nurse aides revie...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a nurse aide registry verification for one of one nurse aides reviewed upon hire (Nurse Aide 7).
Findings include:
The facility's policy regarding licensure and certification, dated August 4, 2022, revealed that the purpose of the policy was to ensure that applicants for positions requiring license/certifications shall be employed only after verification of their license/certification and that current copies of such license/certifications shall be maintained by the respective departments. Each department head shall be responsible for verifying licensure and certifications of prospective employees through the appropriate board and maintaining a copy of the license/certification in the personnel file.
The personnel file for Nurse Aide 7 revealed that she was rehired on January 4, 2023, after leaving the facility in August 2022. As of February 8, 2023, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified prior to rehire.
Interview with the Human Resources Director on February 8, 2023, at 12:02 p.m. confirmed that Nurse Aide 7 left employment at the facility in August 2022 and that her nurse aide registry check was not completed as required upon rehire on January 4, 2023.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment by failing to ensure that physician's ...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment by failing to ensure that physician's orders and/or care-planned interventions were followed for two of 35 residents reviewed (Residents 18, 78).
Findings include:
The facility's policy for injectable medication, dated August 4, 2022, indicated that staff were to check the order on the medication administration record to see that an injection was currently ordered and due. Staff were to check the five rights of medication administration three times during the administration procedure: once when the medication was selected, once while preparing the medication for administration, and once before the the medication was put away and administered. The five rights of medication are the right patient, the right drug, the right dose, the right route, and the right time.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 18, dated November 21, 2022, revealed that Resident 18 was understood, could understand, was moderately cognitively impaired, required extensive assistance for daily care needs, was independent with eating after set up, had diagnoses that included diabetes mellitus, and received insulin injections.
Physician's orders for Resident 18, dated December 21, 2022, included an order for the resident to receive 6 units of Lispro (insulin medication used to treat high blood sugar) subcutaneously (injection into fatty tissue just under the skin) before meals, to be held if the blood glucose was below 100 milligrams per deciliter (mg/dL). A care plan for Resident 18, dated December 26, 2020, indicated that the resident had diabetes mellitus, Type II, and diabetic medications were to be given as ordered by the physician.
A review of Resident 18's medication administration record for January 2023 revealed that that 6 units of Lispro was administered prior to the breakfast meal on January 28, 2023, for a blood glucose reading of 90 mg/dL, and on January 29, 2023, for a blood glucose reading of 79 mg/dL. There is no documented evidence that the medication was held per the physician's order.
Interview with the Director of Nursing on February 8, 2023, at 11:28 a.m. confirmed that Resident 18's insulin appeared to be administered outside of the parameters, and there was no documented evidence that the routine order was held per physician's orders.
An admission MDS for Resident 78, dated October 31, 2022, revealed that the resident was understood, could understand, and required extensive assistance from staff for her daily care tasks, including with bed mobility and transfers, and had diagnoses that included Cerebral Vascular Accident (CVA - commonly known as a stroke) with hemiplegia (paralysis to one side of the body). A care plan for the resident, dated November 19, 2022, revealed that the resident had a self-care performance deficit and was to be out of bed for all meals. A care plan, dated January 27, 2023, revealed that the resident was at nutritional risk related to her current medical status and was to be out of bed for all meals.
Physician's orders for Resident 78, dated November 18, 2022, included an order for the resident to be out of bed for all meals.
Observations of Resident 78 on February 6, 2023, at 11:27 a.m. revealed that staff entered the resident's room with her lunch tray. At 11:48 a.m. the resident was lying in bed with the head of the bed raised up and she was eating her lunch.
Observations of Resident 78 on February 8, 2023, at 8:11 a.m. during medication administration, revealed that the resident was lying in bed with the head of the bed raised up and she was eating her breakfast.
Interview with Licensed Practical Nurse 8 on February 8, 2023, at 1:05 p.m. confirmed that Resident 78 was in bed for her lunch meal on February 6, 2023, and for her breakfast meal on February 8, 2023. She confirmed that there was no documented evidence that the resident had refused to get out of bed for her meals.
Interview with the Director of Nursing on February 8, 2023, at 2:02 p.m. confirmed that Resident 78 should have been out of bed for her meals as ordered by the physician and care planned, unless the resident refused. He also confirmed that there was no documented evidence that the resident had refused to be out of bed.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
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 and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 35 ...
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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 a safe environment was provided for one of 35 residents reviewed (Resident 8).
Findings include:
The facility's policy regarding disposal of medications and medication related supplies, dated August 4, 2022, revealed that immediately after use, syringes and needles are placed into puncture resistant, one-way containers (sharps) specifically designed for that purpose.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 22, 2022, revealed that the resident was understood, could understand, required limited assistance with her daily care tasks, and did not receive any injections and/or insulin during the review period.
Review of Resident 8's clinical record revealed no orders in which the resident would have received any type of injection.
Observations of Resident 8 on February 6, 2023, at 10:12 a.m. revealed that the resident was sitting in the doorway in her wheelchair. When the surveyor presented to the resident, she indicated that she had something in her room. The resident allowed the surveyor to enter her room and showed the surveyor an insulin syringe that was lying on her over-bed table and there were no staff in the area.
Interview with Licensed Practical Nurse 9 on February 6, 2023, at 10:12 a.m. confirmed that the insulin syringe should not have been in Resident 8's room.
Interview with Director of Nursing on February 7, 2023, at 10:30 a.m. confirmed that there should not have been an insulin syringe in Resident 8's room.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous fluids were infused as ordered for one o...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous fluids were infused as ordered for one of 35 residents reviewed (Resident 41).
Findings include:
The facility's policy for intravenous (IV - directly into a vein) administration of fluids and electrolytes, dated August 4, 2022, indicated that the medical record should include the date and time that the infusion was administered and the amount of solution administered. The staff are to document the procedure in the medical record and on the intake and output record.
A quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 41, dated December 22, 2022, indicated that she was confused, required extensive assistance of two for bed mobility and transfers, and extensive assistance of one for hygiene. The current diagnosis record for Resident 41 included diabetes (disease that caused high blood sugar), acute kidney failure, and pneumonia.
Physician's orders for Resident 41, dated December 20, 2022, at 1:15 p.m. included an order for an IV administration of sodium chloride 0.9 percent (a sterile salt water solution) 250 cubic centimeters (cc) per hour in the afternoon for one hour, then decrease to 60 cc per hour, for a total of 2 liters (2000 cc), due to abnormal BUN and creatinine levels (labs related to kidney function).
There was no documented evidence in Resident 41's clinical record to indicate that the IV of sodium chloride 0.9 percent was provided as ordered.
Interview with the Nursing Home Administrator on February 7, 2023, at 12:52 p.m. confirmed that there was no documented evidence that the IV administration of sodium chloride 0.9 percent was provided as ordered.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 35 reside...
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Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 35 residents reviewed (Resident 78).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated October 31, 2022, revealed that the resident was understood, could understand, and required extensive assistance from staff for her daily care tasks including with bed mobility and transfers. A care plan for the resident, dated November 19, 2022, revealed that the resident had a self-care performance deficit and was to be out of bed for all meals. A care plan, dated January 27, 2023, revealed that the resident was at nutritional risk related to her current medical status and the resident was to be out of bed for all meals.
Physician's orders for Resident 78, dated November 18, 2022, included an order for the resident to be out of bed for all meals.
Observations of Resident 78 on February 8, 2023, at 8:11 a.m. during medication administration revealed that the resident was lying in bed with the head of the bed raised up and she was eating her breakfast.
Nurse aide documentation for Resident 78, dated February 8, 2023, indicated that the resident was out of bed for her breakfast meal at 9:32 a.m.
Interview with Licensed Practical Nurse 8 on February 8, 2023, at 1:05 p.m. confirmed that Resident 78 was in bed for her breakfast meal on February 8, 2023, and that the documentation indicated that the resident was out of bed for her breakfast meal.
Interview with the Director of Nursing on February 8, 2023, at 2:02 p.m. confirmed that the documentation indicated that Resident 78 was out of bed for her meal and that it should have been documented that the resident was in bed for her meal.
28 Pa. Code 211.5(f) Clinical records.
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 correct quality deficiencies 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) surveys ending March 24, 2022, and July 30, 2022, 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 February 8, 2023, identified repeated deficiencies regarding physician orders and/or care plan interventions not being followed and ensuring that the resident's environment was free of accident hazards.
The facility's plans of correction for deficiencies regarding physician orders and/or care plan interventions not being followed, cited during the survey ending March 24, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding physician orders and/or care plan interventions not being followed.
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 March 24, 2022, and July 30, 2022, 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.
Refer to F684, F689.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
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 current infection control guidelines, facility policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the faci...
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Based on review of current infection control guidelines, facility policies and documents, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infection and prevent cross-contamination during the COVID-19 pandemic.
Findings include:
Pennsylvania Department of Health PAHAN - 663 regarding Interim Infection Prevention and Control Recommendations for Healthcare Settings during the COVID-19 Pandemic, dated October 4, 2022, revealed Personal Protective Equipment (PPE): Health Care Professionals (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This is also known as Transmission-based Precautions for COVID-19. Additional information about using PPE is available from CDC in Protecting Healthcare Personnel.
The facility's policy regarding COVID-19 Co-horting, dated August 4, 2022, revealed that full PPE will be used to care for residents in Red and Yellow zones.
An admission Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 84, dated November 11, 2023, revealed that the resident was usually understood, could usually understand, and required extensive assistance from staff for his daily care tasks. A care plan for the resident, dated January 31, 2023, revealed that the resident had a respiratory infection related to being COVID positive on January 30, 2023, and staff were to wear full PPE (goggles, mask, and gown ect.) every shift.
Physician's orders for Resident 84, dated January 30, 2023, included an order for infection precautions and staff were to wear full PPE (goggles, mask, and gown ect.) every shift for COVID positive.
A progress note for Resident 84, dated January 30, 2023, at 6:55 p.m. revealed that the resident was assisted to his room and COVID precautions started. A COVID Antigen test was administered, with positive results.
Interview with the Nursing Home Administrator and Director of Nursing on February 6, 2023, at 8:30 a.m. revealed that staff were to wear full PPE, which included eye protection, N95 mask, a gown, and gloves when entering a resident's room that is positive for COVID.
Observations on February 6, 2023, at 10:40 a.m. revealed that Resident 84's call light was on. Nurse Aide 10 donned a gown, a N95 mask, and gloves and entered the resident's room without any eye protection.
Interview with Nurse Aide 10 on February 6, 2023, at 10:51 a.m. confirmed that she should have placed eye protection on prior to entering Resident 84's room.
Interview with the Director of Nursing on February 7, 2023, at 10:30 a.m. confirmed that Nurse Aide 10 should have worn eye protection when entering Resident 84's room.
28 Pa. Code 211.12(d)(1) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on a review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to provided a homelike environment during meals in the dining rooms for...
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Based on a review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to provided a homelike environment during meals in the dining rooms for three of three nursing unit dining rooms.
Findings include:
The facility's policy for resident dining preferences, dated August 4, 2022, indicated that dining should be a home- inspired environment that was appealing, safe and clean, and only provide trays in the dining room by resident requests or as care planned.
Observations in the first floor dining room on February 6, 2023, at 11:45 a.m. revealed that there were ten residents eating their lunch meals with their plates on heated serving plates and all items were on a tray. Observations on February 7, 2023, at 11:48 a.m. revealed that there were eight residents eating their lunch meal with their plates on heated serving plates and all items were on a tray.
Review of the residents' clinical records revealed that there were no documented preferences or medical reasons for the residents to be provided their meals on trays or on heated serving plates.
Interview with Nurse Aide 2 on February 7, 2023, at 1:07 p.m. revealed that resident meals in the dining room are always provided on trays and heated serving plates.
Observations in the second floor dining room on February 6, 2023, at 11:34 a.m. revealed that there were 10 residents eating their lunch meals with their plate on an insulated meal delivery base and all other meal items (napkin, flatware, drink containers, ice cream, bowls, etc) were on a tray. Observations on February 7, 2023, at 11:43 a.m. revealed that there were seven residents with their plate on an insulated meal delivery base and all other meal items were on a tray.
Review of the residents' clinical records revealed that there was no documented preferences or medical reasons for the residents to be provided their meals on trays or on heated serving plates.
Interview with Nurse Aide 3 and Registered Nurse 4 on February 7, 2023, at 11:59 a.m. and 12:03 p.m., respectively, revealed that resident meals in the dining room are always provided on trays and heated serving plates.
Observations in the third floor dining room on February 6, 2023, at 11:22 a.m. revealed that there was one resident eating the lunch meal with the plate on an insulated meal delivery base and all other meal items were on a tray. Observations on February 7, 2023 at 11:33 a.m. revealed that there was one resident eating her lunch meal with her plate on an insulated meal deliver base and all meal items were on a tray.
Review of the residents' clinical records revealed that there was no documented preferences or medical reason for the residents to be provided meals on trays or insulated meal delivery bases.
Interview with Nurse Aide 5 on February 7, 2023, at 11:49 a.m. indicated that she provided set up for Resident 25 for the lunch meal in the dining room, and that she never thought of removing the food items from the tray for a homelike dining experience but would remember to do so in the future.
Interview with the Nursing Home Administrator on February 7, 2023, at 3:38 p.m. confirmed that the facility could be doing better with providing a homelike dining experience for the residents listed above.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 207.2(a) Administrator's responsibility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
Based on review of Centers for Medicare and Medicaid Service memos, information submitted by the facility, and clinical records, as well as staff interviews, it was determined that the facility failed...
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Based on review of Centers for Medicare and Medicaid Service memos, information submitted by the facility, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents and their representatives and families were informed by 5:00 p.m. the next calendar day following subsequent occurrences of a confirmed COVID-19 infection for four of 35 residents reviewed (Residents 45, 76, 83, 84).
Findings include:
The Centers for Medicare and Medicaid Services (CMS), QSO-20-29-NH memo, dated May 6, 2020, indicated that facilities must inform residents, their representatives, and families of those residing in facility by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. This information must not include personally identifiable information, but must include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered, and include any cumulative updates for residents and their representatives and families at least weekly or by 5:00 p.m. the next calendar day following the subsequent occurrence of either, each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.
The facility's record of COVID-19 positive staff tests revealed that at least one staff tested positive on January 13, 2023.
The facility's record of COVID-19 positive resident tests revealed that at least one resident tested positive on January 12, 2023.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 83, dated January 19, 2023, revealed that the resident was understood, could understand, was cognitively intact, and required extensive assistance from staff for his daily care tasks.
A nursing note for Resident 83, dated January 12, 2023, at 3:33 p.m. revealed that the resident tested positive for COVID-19. The resident and his daughter were notified; however, there was no documented evidence that residents and their representatives and families were notified by 5:00 p.m. the next calendar day following Resident 83's confirmed COVID-19 infection.
The facility's record of COVID-19 positive resident tests revealed that at least one resident tested positive on January 28, 2023.
An admission MDS assessment for Resident 76, dated November 28, 2022, revealed that the resident was understood, could understand, was cognitively intact, and required extensive assistance from staff for his daily care tasks.
A nursing note for Resident 76, dated January 28, 2023, at 1:58 p. m. revealed that the resident tested positive for COVID-19. The resident and his nephew were notified; however, there was no documented evidence that residents and their representatives and families were notified by 5:00 p.m. the next calendar day following Resident 76's confirmed COVID-19 infection.
The facility's record of COVID-19 positive resident tests revealed that at least one resident tested positive on January 30, 2023.
An admission MDS assessment for Resident 84, dated January 11, 2023, revealed that the resident was understood, could understand, was cognitively intact, and required extensive assistance from staff for his daily care tasks.
A nursing note for Resident 84, dated January 30, 2023, at 19:40 p.m. revealed that the resident tested positive for COVID-19. The resident and his brother were notified; however, there was no documented evidence that residents and their representatives and families were notified by 5:00 p.m. the next calendar day following Resident 84's confirmed COVID-19 infection.
The facility's record of COVID-19 positive staff tests revealed that at least one staff tested positive on February 6, 2023.
The facility's record of COVID-19 positive resident tests revealed that at least one resident tested positive on February 6, 2023.
A quarterly MDS assessment for Resident 45, dated December 16, 2022, revealed that the resident was understood, could understand, was cognitively intact, and required extensive assistance from staff for his daily care tasks.
A nursing note for Resident 45, dated February 6, 2023, at 7:42 a.m. revealed that the resident tested positive for COVID-19. The resident and his daughter-in-law were notified; however, there was no documented evidence that residents and their representatives and families were notified by 5:00 p.m. the next calendar day following Resident 45's confirmed COVID-19 infection.
Interview with the Nursing Home Administrator on January 8, 2023, at 4:40 p.m. confirmed that she did update the facility's phone system with a message indicating that there was positive cases in the facility and post signs in the facility for residents and visitors to visualize. She could not provide any documented evidence that residents and their representatives and families were informed by 5:00 p.m. the next calendar day following the above occurrences of confirmed COVID-19 infections.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 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.
Concerns
- • 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (55/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Morrisons Cove Home's CMS Rating?
CMS assigns MORRISONS COVE HOME an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Morrisons Cove Home Staffed?
CMS rates MORRISONS COVE HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Morrisons Cove Home?
State health inspectors documented 32 deficiencies at MORRISONS COVE HOME during 2023 to 2025. These included: 31 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Morrisons Cove Home?
MORRISONS COVE HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 114 certified beds and approximately 63 residents (about 55% occupancy), it is a mid-sized facility located in MARTINSBURG, Pennsylvania.
How Does Morrisons Cove Home Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, MORRISONS COVE HOME's overall rating (3 stars) matches the state average, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Morrisons Cove Home?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Morrisons Cove Home Safe?
Based on CMS inspection data, MORRISONS COVE HOME 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 3-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 Morrisons Cove Home Stick Around?
Staff turnover at MORRISONS COVE HOME is high. At 60%, the facility is 14 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Morrisons Cove Home Ever Fined?
MORRISONS COVE HOME 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 Morrisons Cove Home on Any Federal Watch List?
MORRISONS COVE HOME 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.