MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
For profit - Limited Liability company
50 Beds
MB HEALTHCARE
Data: November 2025
Trust Grade
35/100
#604 of 653 in PA
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Maple Winds Healthcare and Rehabilitation, LLC has received a Trust Grade of F, indicating significant concerns and poor overall performance. Ranking #604 out of 653 facilities in Pennsylvania places them in the bottom half, and they are #7 out of 9 in Cambria County, meaning there are only two better options nearby. While the facility is showing improvement in issues, decreasing from 23 in 2024 to 17 in 2025, it still has a high staff turnover rate of 64%, which is concerning compared to the state average of 46%. Staffing is a relative strength with a 4 out of 5 stars rating, alongside good RN coverage that exceeds 75% of other facilities, ensuring that residents receive better oversight. However, there are troubling findings such as improperly stored food that was not dated, failure to follow the posted menu for meals, and incomplete assessments for several residents, highlighting serious areas needing attention.
- Trust Score
- F
- In Pennsylvania
- #604/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 64% 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 62 minutes of Registered Nurse (RN) attention daily — more than 97% of Pennsylvania nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 8%
No red flags
23 → 17 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 17 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Pennsylvania average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 64%
17pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Chain: MB HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (64%)
16 points above Pennsylvania average of 48%
The Ugly 54 deficiencies on record
Jul 2025
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician and the resident's responsible party regarding a chang...
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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 notify the physician and the resident's responsible party regarding a change in condition for one of 35 residents reviewed (Resident 2).
Findings include:
The facility's policy regarding changes in a resident's condition or status, dated March 12, 2025, revealed that physicians, responsible family members or legal representatives would be notified as soon as possible of any changes in the resident's condition.
A quarterly admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 31, 2024, revealed that the resident was cognitively intact and had diagnoses that included diabetes, congestive heart failure, and chronic obstructive pulmonary disease. A review of Resident 2's care plan, dated November 1, 2023, indicated that the resident had a history of acute (sudden onset) respiratory failure.
A nursing note for Resident 2, dated November 13, 2025, at 6:17 p.m. revealed that when staff entered the resident's room to administer medications, the resident was found to be difficult to wake up and hard to arouse. Vital signs were as follows: blood pressure was 180/100, pulse 107, respirations 19, and oxygen saturation was 97 percent while on 4 liters per minute of oxygen, temperature was 96.3 degrees F. Resident 2 was pale and cold to touch with no sweating. The resident had no urine output, and the bladder was distended. The air conditioner was turned off and a blanket was placed on the resident to keep her warm. The registered nurse supervisor was informed. Resident 2 was placed on her BiPAP (Bilevel Positive Airway Pressure machine, a device that assists breathing by delivering pressurized air through a mask). Straight catheter was performed and drained around 650 milliliters of clear yellowish urine. Staff to continue to observe resident for any untoward events. There was no documented evidence in Resident 2's clinical record that the physician or her son was notified about her change in condition.
A nursing note for Resident 2, dated November 18, 2025, at 12:55 p.m. revealed that Resident 2 became pale, unresponsive, and had profuse sweating. The resident had an oxygen saturation of 74 percent and was placed on the BiPAP machine. Resident 2's blood pressure was 110/60 with a temperature of 94.3 degrees. The physician was notified with an order to send to the hospital, and a voicemail was left for the resident's son.
Interview with the Director of Nursing on July 1, 2025, at 1:14 p.m. confirmed that on November 18, 2025, Resident 2 had a change in condition similar to the event on November 13, 2025. However, on November 18, 2025, the physician and son were notified of her declining health status, but on November 13, 2025, per facility policy, the physician and son should have been notified regarding the resident's change in condition, and they were not.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on review of policies and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log ...
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Based on review of policies and facility grievance/complaint logs, as well as staff interviews, it was determined that the facility failed to follow its grievance policies regarding maintaining a log of all grievances received for one of 35 residents reviewed (Resident 13).
Findings include:
The facility's policy regarding grievances/complaints, dated March 12, 2025, indicated that a concern form is initiated when a concern/grievance is brought forward by a staff, family, responsible party and/or resident. After obtaining necessary information from the resident, family, responsible party and/or staff the concern form is completed and submitted to the Social Services Director or the Administrator who then distributes it to the appropriate depart head(s). The Social Service Director will log the form into a concern and grievance log. The Social Services Director will maintain a concern and grievance log as well as ensure concerns/grievances are completed and followed up with in a timely manner including effectiveness. Results of concerns/grievances will be maintained for a minimum of three years.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood and could understand others.
A Grievance Form for Resident 13, dated June 14, 2025, revealed that the resident's daughter came to visit her mom and went into her room to find a dirty brief lying on the bottom of the bed. When she pulled back the covers, she found that her mom had no brief on, and that she was covered with a bowel movement, as well as her bed linens. Staff immediately went in and cleaned her up as well as her bedding. Staff was notified of the incident as well as the Director of Nursing.
A Grievance Form for Resident 13, dated June 15, 2025, revealed that the resident's daughter reported that when she came in to visit the resident the other day (unsure of date) that there were some pills in a med cup on the resident's bedside table and that there were pills in her mom's bed, as well as on the floor. She stated that she did report this to the Director of Nursing. The registered nurses and licensed practical nurses were re-educated about not leaving medications or treatment supplies in residents' rooms.
As of July 2, 2025, a review of the facility's complaint/grievance logs for June 2025 revealed no documented evidence that the concerns from Resident 13's daughter about finding the resident covered in a bowel movement and finding medications at the resident's bedside were listed on the facility's grievance/complaint log.
Interview with the Director of Nursing on July 2, 2025, at 9:10 a.m. confirmed that there was no documented evidence as of July 2, 2025, that Resident 13's daughter's concerns about finding the resident covered in a bowel movement and finding medications at the resident's bedside was listed on the facility's grievance/complaint log.
28 Pa. Code 201.29(c.3)(4) Resident Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 35 residents reviewed (Residents 2, 19, 38), and failed to complete a post discharge summary for one of 35 resident's reviewed (Resident 37)
Findings include:
The facility's policy regarding bed-holds and returns, dated March 12, 2025, indicated that residents and/or representatives are informed (in writing) of the facility and bed-hold policies. An original is to be placed in the resident chart and one given to the family. The facility's policy regarding physician discharge summary revealed that when a resident is discharged the physician will complete and sign a discharge summary that includes the diagnosis, course of treatment, and pertinent test results.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 31, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (a lung disease that causes decreased blood flow to the lungs).
A nurse's note for Resident 2, dated November 13, 2025, at 6:17 p.m., revealed that the resident was difficult to wake up, had an elevated blood pressure of 180/100 with a temperature of 96.3. She was pale, cold to the touch, and was catheterized for a distended bladder. Resident 2's BiPAP machine (a type of non-invasive ventilation device used to help with breathing difficulties) was placed on her, and she was sent to the hospital where she was admitted for acute (sudden onset) respiratory failure.
There was no documented evidence that written notification of transfer was provided to Resident 2 and the resident's representative, that a bed-hold notice was provided to the resident's responsible party, and that the ombudsman was notified of the transfer to the hospital as required.
A quarterly MDS assessment for Resident 19, dated March 31, 2025, indicated that the resident was severely cognitively impaired, required assistance from staff for all daily care needs, and had a diagnoses that included
Alzheimer's and Parkinson's disease and chronic obstructive pulmonary disease with a history of respiratory failure.
Nursing notes for Resident 19, dated November 5, 2025, at 6:05 p.m., revealed that the resident was grey in color, lethargic and difficult to arouse, she was immediately transferred to the hospital and was admitted .
There was no documented evidence that written notification of transfer was provided to the resident and the resident's representative, that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital as required.
An admission MDS assessment for Resident 38, dated March 21, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included paraplegia with nerve damage to the bladder, acute and chronic respiratory failure, and pneumonia.
Nursing notes for Resident 38, dated March 22, 2025, at 9:00 p.m., indicated that the resident was complaining of difficulty breathing and was unable to maintain oxygen rates above 80 percent on room air. He was hard to arouse, had abnormal lung sounds, and a productive cough of thick white mucus. The resident was transferred to the hospital.
A nursing note, dated March 23, 2025, at 3:02 a.m., indicated that Resident 38 was admitted to the hospital with a diagnosis of sepsis (a life threatening response to an infection).
There was no documented evidence that written notification of transfer was provided to the resident and the resident's representative, that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of his transfer to the hospital as required.
Nursing notes for Resident 37 indicated that he was admitted on [DATE], with a diagnosis of parapneumonic effusion (fluid accumulation in the space between the lung and chest wall accompanied by pneumonia). He received physical therapy/strengthening at the facility, and on April 7, 2025, he was discharged back to his previous residence at a personal care home.
There was no documented evidence that a discharge summary (an overview of the residents stay at the facility) was done by the physician as required.
Interview with the Director of Nursing on July 2, 2025, at 2:19 p.m. confirmed that for Residents 2, 19 and 38 there was no written notification of hospital transfer provided to them or their representatives, that a bed-hold notice was not provided to their responsible party, and that the ombudsman was not notified of the transfer to the hospital as required. In addition, the Director of Nursing confirmed that there was no documented discharge summary post discharge from the facility for Resident 37 as required.
28 Pa. Code 201.29(j) Resident Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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 35 residents reviewed (Residents 1, 25).
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 2024, revealed that Section N0415G1 Diuretic Medications was to be coded if the resident took the medication during the seven-day look-back period, and Section N0415K1 Anticonvulsant Medications was to be coded if the resident took the medication during the seven-day look-back period.
Physician's orders for Resident 1, dated May 21, 2025, included an order for the resident to receive 20-25 milligram (mg) of Lisinopril-hydrochlorothiazide (a combination antihypertensive-diuretic medication used to lower blood pressure) in the morning for hypertension (high blood pressure).
Review of the Medication Administration Record (MAR) for Resident 1, dated May 2025, revealed that staff administered the 20-25 milligram (mg) of Lisinopril-hydrochlorothiazide every morning from May 21 through 31, 2025. However, an annual MDS assessment for Resident 1, dated, May 24, 2025, revealed that Section NO415G1 was not coded, indicating that the resident did not receive a diuretic medication during the seven-day look-back assessment period.
Physician's orders for Resident 25, dated October 28, 2022, included an order for the resident to receive 100 mg of Dilantin (an anticonvulsant) every morning and at bedtime for seizures.
Review of the Medication Administration Record (MAR) for Resident 25, dated April 2025, revealed that staff administered the 100 mg tablet of Dilantin to the resident every morning and every bedtime from April 1 through 30, 2025. However, a significant change MDS assessment for Resident 25, dated April 22, 2025, revealed that Section NO415K1 was not coded, indicating that the resident to did not receive an anticonvulsant medication during the seven-day look-back assessment period.
Interview with the Director of Nursing on July 1, 2025, at 1:09 p.m. confirmed the Resident 1 and 25's MDS assessments listed above were coded incorrectly.
28 Pa. Code 211.5(f) Clinical 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 facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized ...
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Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 35 residents reviewed (Resident 9).
Findings include:
A facility policy for Care Plans, dated March 12, 2025, indicated that the resident and his or her representative were encouraged to participate in the development and implementation of the resident's person-centered care plan.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and received an anticoagulant, antiplatelet, and diuretic medication.
Physician's orders for Resident 9, dated September 9, 2024, included an order for the resident to receive 5 milligrams (mg) of Apixaban (anticoagulant-used to prevent blood clots) by mouth every morning and bedtime, 81 mg of Aspirin (antiplatelet) by mouth daily in the morning, and 20 mg of Lasix (diuretic) by mouth daily in the morning.
There was no documented evidence that a care plan was developed to address Resident 9's individual care and treatment needs related to her use of anticoagulant, antiplatelet, and diuretic medications.
Interview with the Director of Nursing on July 1, 2025, at 1:15 p.m. confirmed that a care plan to address the care needs related to Resident 9's need for anticoagulant, antiplatelet, and diuretic medication use was not developed and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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 in accordance with professional standa...
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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 in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 35 residents reviewed (Resident 12).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated June 20, 2025, revealed that the resident was understood, and could usually understand others.
Physician's orders for Resident 12, dated May 20, 2025, included an order for the resident to receive one gram (gm) of Meropenem (an antibiotic to treat a variety of serious bacterial infections) intravenously (a medical process that administers fluids, medications and nutrients directly into a person's vein) every eight hours for a urinary tract infection for seven days (a total of 21 doses).
Review of Resident 12's Medication Administration Records (MARs) for May 2025 revealed that staff documented as administering the one gm of Meropenem intravenously on May 22 at 2:00 p.m. and 10:00 p.m.; May 23 through May 27 at 6:00 a.m., 2:00 p.m. and 10:00 p.m.; and on May 28 at 6:00 a.m. and 2:00 p.m. (total of 19 doses).
Interview with the Director of Nursing on July 2, 2025, at 10:45 a.m. confirmed that Resident 12 only received 19 of the 21 doses of IV Meropenem over seven days as ordered by the physician.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possibl...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible by failing to ensure that fall/injury prevention interventions were in place for one of 35 residents reviewed (Resident 9).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, required extensive assistance from staff with daily care tasks, and had limited range of motion to her lower extremities. The resident's care plan, dated June 19, 2025, revealed that the resident was at risk for falls and indicated that fall mats were to be at bedside.
A nursing note for Resident 9, dated June 13, 2025, at 2:50 a.m., revealed that the resident was found lying on the floor on the left side of her bed. New interventions included placing her bed in the lowest position and bilateral fall mats.
Observations of Resident 9 on July 2, 2025, at 8:46 a.m. revealed that the resident was in bed and there were no fall mats on either side of her bed.
Interview with the Director of Nursing on July 2, 2025, at 11:54 a.m. confirmed that Resident 9 should have had bilateral fall mats while in bed.
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 maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for one of 35 residents reviewed (Resident 25).
Findings include:
The facility's policy regarding disposal of narcotics, dated March 12, 2025, indicated that controlled/narcotic medications were to be destroyed in the presence of tow licensed nurses. The two nurses would count together the remaining amount of controlled/narcotic medications to be destroyed. Two nurses would sign and date the Control Drug Record upon witnessing the destruction of the controlled/narcotic medications, logging the amount of medications destroyed.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, revealed that the resident was cognitively impaired, received pain medication routinely and as needed, and received an opioid (a controlled pain medication). Physician's orders, dated April 18, 2025, 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 chronic pain, and physician's orders, dated May 22, 2025, included an order for the resident to receive a 25 mcg Fentanyl patch to be applied every three days for chronic pain.
Review of Resident 25's Medication Administration Record (MAR) for May and June 2025 revealed that a Fentanyl patch was applied to the resident on May 3, 6, 9, 12, 15, 18, 21, 25, 28, and 31, and June 3, 6, 9, 12, 15, 18, and 21, 2025.
A controlled drug count record (tracks each dose of a controlled medication) for Resident 25's Fentanyl patches revealed that one patch was signed out on the controlled drug log on May 3, 6, 9, 12, 15, 18, 21, 25, 28, and 31, and June 3, 6, 9, 12, 15, 18, 21, 2025. There was no documented evidence that two staff members signed that the old patch was destroyed after removal on these dates.
Interview with the Director of Nursing on July 2, 2025, at 9:06 a.m. confirmed that there were not two witness signatures for the destruction of Fentanyl patches on the dates listed above.
28 Pa. Code 211.9(a)(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 F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from ...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 35 residents reviewed (Resident 25) who were receiving hospice services.
Findings include:
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated April 22, 2025, indicated that the resident was cognitively impaired, received hospice services, and had a diagnosis of cancer.
Physician's orders and a care plan for Resident 25, dated April 15, 2025, included an order for the resident to be treated by hospice (end-of-life services) for basal cell carcinoma (skin cancer) of the left upper limb.
As of July 1, 2025, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide or registered nurse charting. The last hospice nurse aide charting located on the resident's hospice chart was dated June 5, 2025, and the last registered nurse charting was dated June 3, 2025.
Interview with the Director of Nursing on July 2, 2025, at 10:10 a.m. confirmed that Resident 25's hospice nurse aide and registered nurse charting was not in the resident's clinical record and/or in the hospice provider's clinical record, and should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) surveys ending June 5, July 11, and December 26, 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 July 2, 2025, identified repeated deficiencies related to care plan revisions; providing quality care; ensuring that the resident's environment was free from accident hazards; maintaining intravenous catheters; preventing issues with the accountability of controlled medications (drugs with the potential to be abused).
The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending June 5, 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 F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan revisions.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 5, 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 F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on July 11, 2024 revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards.
The facility's plan of correction for a deficiency regarding intravenous catheters, cited during the survey ending December 26, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F694, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous catheters.
The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the surveys ending June 5, 2024, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.
Refer to F657, F684, F689, F694, 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
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on review of policies and 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 m...
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Based on review of policies and 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:
The facility's policy for Quality Assurance and Performance Improvement, dated March 12, 2025, revealed that meetings would be held at least quarterly and would include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director.
Review of the attendance records for the facility's Quality Assurance Committee meetings revealed that the Medical Director did not attend any meetings that were held during the first quarter of 2025.
Interview with the Director of Nursing on July 2, 2025, at 2:30 p.m. confirmed that the Medical Director did not attend meetings of the Quality Assurance Committee that were held during the first quarter of 2025.
28 Pa code 201.18(b)(3) 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, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administ...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for three of three residents observed (Residents 2, 29, 45).
Findings include:
The facility's policy regarding hand hygiene, dated March 12, 2025, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications, and after removing gloves.
Observations during the medication pass in A hall on July 2, 2025, at 8:33 a.m. revealed that Licensed Practical Nurse 1 prepared Resident 45's medications and administered them. Without sanitizing her hands, she donned gloves and entered Resident 29's room and took the resident's blood pressure. She doffed her gloves and without hand sanitizing she prepared and administered Resident 29's medications. She then went to Resident 2's room and donned gloves and checked the resident's blood sugar. She doffed her gloves and without hand sanitizing she prepared the resident's medications, donned gloves and administered them. Licensed Practical Nurse 1 exited the resident's room and hand sanitized at the medication cart.
Interview with Licensed Practical Nurse 1 on July 2, 2025, at 9:35 a.m. confirmed that she should have sanitized her hands between residents while doing the medication pass and after she removed her gloves.
Interview with the Director of Nursing on July 2, 2025, at 9:53 a.m. confirmed that Licensed Practical Nurse 1 did not properly sanitize her hands during medication administration and after glove removal, and she should have.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**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 Minimum Data Set assessments were completed in the required timeframe for 10 of 35 residents reviewed (Residents 14, 26, 34, 43, 44, 139, 140, 141, 142, 143).
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 2024, indicated that for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late.
An admission MDS assessment for Resident 26, dated May 21, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 29, 2025, which was two days late.
An admission MDS assessment for Resident 34, dated May 26, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 2, 2025, which was one day late.
An admission MDS assessment for Resident 43, dated May 7, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was six days late.
An admission MDS assessment for Resident 44, dated May 26, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 2, 2025, which was one day late.
An admission MDS assessment for Resident 139, dated April 23, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 1, 2025, which was two days late.
An admission MDS assessment for Resident 140, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late.
An admission MDS assessment for Resident 141, dated May 12, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 19, 2025, which was one day late.
An admission MDS assessment for Resident 142, dated May 18, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on May 29, 2025, which was four days late.
An admission MDS assessment for Resident 143, dated May 19, 2025, revealed that the resident was admitted on [DATE]. The resident's MDS was documented in section Z0500B as being completed on June 12, 2025, which was eight days late.
Interview with the Licensed Practical Nurse Assessment Coordinator (LPNAC - a licensed practical nurse who is responsible for assisting the registered nurse with the completion of MDS assessments) on July 1, 2025, at 9:38 a.m. confirmed that the admission MDS assessments listed above were not completed within the required timeframes.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care n...
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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 care plans were updated to reflect changes in residents' care needs for one of 35 residents reviewed (Resident 13).
Findings include:
The facility's policy regarding care plans, dated March 12, 2025, indicated that each resident will have an individualized interdisciplinary plan of care in place. The comprehensive care plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident and/or resident's representative.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included obstructive uropathy (a condition where there is a blockage in the urinary tract, preventing normal urine flow). A care plan for the resident, dated February 11, 2025, revealed that the resident had an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine); however, on April 16, 2025, the care plan was resolved due to the resident not requiring to have an indwelling urinary catheter any longer.
Physician's orders for Resident 13, dated April 15, 2025, included an order for staff to discontinue the use of the resident's indwelling urinary catheter.
Review of Resident 13's clinical record including nurse aide documentation revealed that the resident has frequently been incontinent of bladder. However, as of July 2, 2025, there was no documented evidence that Resident 13's care plan was revised/updated to reflect that the resident was incontinent of bladder since the removal of her indwelling urinary catheter on April 15, 2025.
Interview with the Director of Nursing on July 2, 2025, at 8:44 a.m. confirmed that there was no documented evidence that Resident 13's care plan was revised/updated to reflect that the resident was incontinent of bladder, since the removal of her indwelling urinary catheter on April 15, 2025.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
📢 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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure urinary output was monitored for one of 35 resident...
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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 urinary output was monitored for one of 35 residents reviewed (Resident 1) who had an indwelling urinary catheter, and failed to ensure proper incontinent care was completed for one of 35 residents reviewed (Resident 13).
Findings include:
The facility's policy regarding urinary output, dated March 12, 2025, revealed that the volume of urine output was to be documented in the resident's chart or electronic medical record.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 24, 2025, revealed that the resident was cognitively intact, required assistance from staff for daily care tasks, had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine), and had diagnoses that included neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve condition). Physician's orders for Resident 1, dated May 26, 2025, included orders for a Foley catheter for neurogenic bladder. A care plan, dated June 24, 2024, revealed that staff were to monitor and document the resident's intake and output.
Nurse Aide documentation for Resident 1, dated May and June 2025, revealed that staff was to document the resident's urine output each shift; however, there was no documented evidence that urine output was recorded on the first shift (6:00 a.m. to 2:30 p.m.) on May 13, June 11, 14, 16, and 20, 2025; on the second shift (2:00 p.m. to 10:30 p.m.) on May 21, June 9 and 20, 2025; and on the third shift (10:00 p.m. to 6:30 a.m.) on June 6 and 30, 2025.
Interview with the Director of Nursing on July 2, 2025, at 10:23 a.m. confirmed that there was no urine output recorded for Resident 1 on the mentioned dates and times.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 13, dated April 9, 2025, revealed that the resident was understood and could understand others. A care plan for the resident, dated September 26, 2023, revealed that the resident had an Activities of Daily Living (ADL) self-care deficit related to her limited mobility, and that she required the assist of two staff with toileting.
Nurse Aide tasks for Resident 13, for May and June 2025, revealed that staff was to document every two hours to indicate if the resident was continent or incontinent of bladder; however, there was no evidence that bladder continence or incontinence was documented on May 14 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 15 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 17 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 24 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; May 25 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 4 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 5 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 6 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 10 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 11 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.; June 13 at 12:00 a.m., 2:00 a.m., and 4:00 a.m.; June 15 at 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m.; and June 25 at 8:00 a.m., 10:00 a.m., and 12:00 p.m.
Nurse Aide tasks for Resident 13, for May and June 2025, revealed that staff was to document the application of barrier cream to the resident's buttocks; however, there was no documented evidence that staff applied the barrier cream to the resident's buttocks during the day shift on May 1, 15, 17, 24, and 26, 2025; during evening shift on May 1, and 2, 2025, and on June 3 and 15, 2025; and during the night shift on May 24, and 31, 2025, and on June 2, 3, 4, and 12, 2025.
Interview with the Director of Nursing on July 1, 2025, at 1:38 p.m. confirmed that there was no documented evidence that Resident 13's bladder continence or incontinence was documented on the above dates and times, and that application of barrier cream to the resident's buttocks was applied on the above dates.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that intravenous catheters were flushed according to facility policy...
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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 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 two 35 residents reviewed (Residents 9, 12).
Findings include:
The facility's policy regarding midline (a thin, flexible tube inserted into a large vein in the upper arm to administer medication or fluids intravenously) maintenance and care, dated March 12, 2025, indicated that staff was to change the transparent dressing every week or as needed if soiled, damp and/or loose. Staff was flush the line according to the physician's orders.
The policy regarding flushing the peripheral intravenous access (the insertion of a short, flexible catheter into a peripheral vein, typically in the hand or arm, to deliver medications, fluids or other therapies directly into the bloodstream), dated March 12, 2025, indicated that the following regimen should be used when flushing an intravenous catheter: Normal Saline flush (used to help prevent IV catheters from becoming blocked and also to help remove any medication that may be left at the catheter site), administration of medications or fluids, Normal Saline flush, and then Heparin flush (a medication used to maintain the openness of intravenous catheters) if ordered.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 9, dated April 10, 2025, revealed that the resident was cognitively intact, had a multi-drug resistant organism (bacteria that is resistant to multiple antibiotics), received an antibiotic, and had IV access.
Physician's orders for Resident 9, dated April 10, 2025, included an order for the resident to receive 500 milligrams (mg) of Meropenem intravenously every shift for a urinary tract infection for 20 administrations, and 10 milliliters (mL) of Sodium Chloride 0.9 percent intravenously for a routine flush every shift.
Review of Medication Administration Records (MARs) for Resident 9, dated April 2025, revealed that staff documented administering the 500 mg of Meropenem intravenously every shift from April 10, 2025, at 6:00 a.m. through April 16, 2025, at 2:00 p.m. However, there was no documented evidence that staff flushed Resident 9's peripheral IV with Normal Saline solution before and after the administration of the Meropenem.
Interview with the Director of Nursing on July 2, 2025, at 10:42 a.m. confirmed that there was no documented evidence that Resident 9's IV was flushed with Normal Saline solution before and after the administration of the Meropenem on the above dates.
Physician's orders for Resident 12, dated May 20, 2025, included an order for the resident to receive one gram (gm) of Meropenem (an antibiotic to treat a variety of serious bacterial infections) intravenously (a medical process that administers fluids, medications and nutrients directly into a person's vein) every eight hours for a urinary tract infection for seven days.
A nursing note for Resident 12, dated May 22, 2025, revealed that the resident's midline was placed in her upper right arm without difficulty. A nursing note for Resident 12, dated May 29, 2025, revealed that the resident's right upper arm midline was removed with no complications. There was no documented evidence that Resident 12's physician was contacted for orders regarding the care and maintenance of the resident's midline from May 22 through 29, 2025, when it was removed.
Review of Medication Administration Records (MARs) for Resident 12, dated May 2025, revealed that staff documented as administering the one gm of Meropenem intravenously on May 22, 2025, at 2:00 p.m. and 10:00 p.m.; May 23 through May 27, 2025, at 6:00 a.m., 2:00 p.m. and 10:00 p.m.; and on May 28, 2025, at 6:00 a.m. and 2:00 p.m. However, there was no documented evidence that staff flushed Resident 12's midline with Normal Saline solution before and after the administration of the Meropenem.
Interview with the Director of Nursing on July 2, 2025, at 10:42 a.m. confirmed that there was no documented evidence that Resident 12's physician was contacted for orders regarding the care and maintenance of the resident's midline from May 22 through 29, 2025, when it was removed, and that there was no documented evidence that the resident's midline was flushed with Normal Saline solution before and after the administration of the Meropenem on the above dates.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen and dry storage room was dated once opened.
Findings...
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Based on facility policy, observations, and staff interviews, it was determined that the facility failed to ensure that food stored in the kitchen and dry storage room was dated once opened.
Findings include:
The facility policy regarding food storage, dated March 12, 2025, revealed that any food item once opened should be labeled with an open date.
Observations in the dry storage room on June 30, 2025, at 8:53 a.m. revealed that there was one 10-pound bag of pasta that was opened and not dated with an open date.
Observations in the kitchen refrigerator on June 30, 2025, at 9:01 a.m. revealed two opened and undated 5-pound bags of cheese, one with parmesan and the other with a mixture of cheddar and mozzarella.
Observations in the kitchen on June 30, 2025, at 9:07 a.m. revealed that there was approximately ten pounds of flour and twenty-five pounds of rice that were opened and not labeled with an open date.
Interview with the Dietary Manager and Director of Nursing on June 30, 2025, at 8:45 a.m. and 11:32 a.m. respectively, confirmed that all open food items in the kitchen should be labeled with a date once they are opened.
28 Pa. Code 211.6(f) Dietary Services.
Dec 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on review of facility policy, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for two of six res...
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Based on review of facility policy, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity for two of six residents reviewed (Residents 2, 6).
Findings include:
The facility's policy regarding Resident Rights, dated May 6, 2024, revealed that the facility would protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for daily care needs.
Observations of Resident 2 on December 26, 2024, at 8:36 a.m. revealed that the resident had no curtain or blind covering the window to the outside. His bed was on the window side of the room and the window faced the facility's main parking lot.
A significant change MDS assessment for Resident 6, dated December 16, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for her daily care needs.
Observations of Resident 6 on December 26, 2024, at 8:43 a.m. revealed that she was in her bed and that her bed was near the window in her room. The window had no blinds or curtains, and the window faced the facility's main parking lot.
Interview with Resident 2 on December 26, 2024, at 8:36 a.m. revealed that he has asked for a curtain or blind for his window because he uses the urinal and the bedside commode and dresses himself and he feels exposed to the parking lot. He stated that he is not able to pull his privacy curtain around his bed because it is located behind his bed on the window side of the bed and he is not physically able to grab it. He further stated that he does not like his privacy curtain pulled closed at all times because he likes to watch his TV and likes to be able to look outside.
Interview with the Director of Housekeeping on December 26, 2024, at 8:53 a.m. revealed that blinds have been ordered for Resident 2's and Resident 6's windows, but they have not arrived yet. She was not sure how long the rooms have been without curtains or blinds.
28 Pa. Code 201.29(j) Resident Rights.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to ensure personal privacy for one of six resident reviewed (Resident ...
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Based on review of facility policies, observations, and resident and staff interviews, it was determined that the facility failed to ensure personal privacy for one of six resident reviewed (Resident 2).
Findings include:
The facility's policy regarding Resident Rights, dated May 6, 2024, revealed that the facility would protect and promote the rights of each resident, particularly those rights that pertain to a dignified existence.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, and required assistance from staff for daily care needs.
Observations of Resident 2 on December 26, 2024, at 8:36 a.m. revealed that the resident had no curtain or blind covering the window to the outside. His bed was on the window side of the room, and the window faced the facility's main parking lot.
Interview with Resident 2 on December 26, 2024 at 8:36 a.m. revealed that he has asked for a curtain or blind for his window because he uses the urinal and the bedside commode and dresses himself, and he feels exposed to the parking lot. He stated that he is not able to pull his privacy curtain around his bed because it is located behind his bed on the window side of the bed, and he is not physically able to grab it. He further stated that he does not like his privacy curtain pulled closed at all times because he likes to watch his TV and likes to be able to look outside.
Interview with the Director of Housekeeping on December 26, 2024, at 8:53 a.m. revealed that blinds have been ordered for Resident 2's and Resident 6's windows, but they have not arrived yet. She was not sure how long the rooms have been without curtains or blinds.
28 Pa. Code 201.29(j) Resident Rights.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was c...
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Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed for an injury of unknown origin, to rule out that abuse and/or neglect were involved for one of five residents reviewed (Resident 5).
Findings include:
The facility's policy regarding abuse and neglect, dated May 6, 2024, indicated that the Director of Nursing/designee conducts the investigation. Reviews the accident/incident report; obtains written statements of staff assigned to the resident for the shift during which the allegation is noted, and 24 hours prior if indicated; and interviews witnesses, if any, and obtains statements.
The facility's policy regarding incident/accident reporting, dated May 6, 2024, indicated that in the case of an incident or injury of unknown etiology, an investigative report of injury unknown origin and investigative report of skin tear/bruise of unknown etiology are completed, as needed. All employees assigned to the resident involved in an incident/accident will fill out the employee statement form.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 1, 2024, revealed that the resident was understood, could understand others, with a Brief Interview for Mental Status (BIMS -a structured cognitive interview) of 02 indicating that the resident had a severe cognitive impairment, and had a diagnosis which included Alzheimer's disease and Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns). A care plan for the resident, dated June 10, 2024, revealed that the resident tends to refuse care/medications.
A readmission assessment for Resident 5, dated November 13, 2024, revealed that the resident returned to the facility after an admission to the hospital. Her upper extremities had no edema (a medical condition that occurs when fluid builds up in the body's tissues, causing swelling) and scattered bruising was noted to the resident's hands and arms.
A skin assessment for Resident 5, dated November 16, 2024, revealed that the resident had multiple small bruises noted to her bilateral hands. No other areas noted.
A physician's note for Resident 5, dated November 19, 2024, revealed that the resident was seen due to being readmitted to the facility for problems of confusion, pneumonia, and sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury). That her mental status is back to her baseline, and her extremities had no edema.
A nursing note for Resident 5, dated November 19, 2024, revealed that the resident was noted to have an increase in pain to her right wrist, as well as swelling. The resident has multiple bruises to her bilateral hands and arms from a previous hospitalization. The resident was in therapy and complained of the increased pain with movement.
Investigation documents for Resident 5, dated November 19, 2024, revealed the writer was called to the therapy department due to the resident complaining of pain to her right hand/wrist with movement. Slight swelling of the wrist area was noted. Fingers were warm and had a positive radial pulse. The resident had light, yellow bilateral bruising of the arms and hands from readmission from the hospital. The resident is unable to verbalize what happened.
A witness statement completed by Nurse Aide 3, dated November 19, 2024, revealed that she did not work with Resident 5.
A witness statement completed by Nurse Aide 2, dated November 19, 2024, revealed that she did not have any contact with Resident 5.
There was no documented evidence that the facility's investigation was expanded to include interviews with all staff who had potential contact with Resident 5 in and around the time that the resident complained of pain and swelling to her right wrist on November 19, 2024.
Interview with the Director of Nursing on December 26, 2024, at 1:32 p.m. confirmed that she had no documented evidence that the investigation was expanded to include interviews with all staff who had potential contact with Resident 5 in and around the time that the resident complained of pain and swelling to her right wrist on November 19, 2024.
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)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
Based on review of facility policies, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that peripherally-inserted central ...
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Based on review of facility policies, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed per physician's orders for one of six residents reviewed (Resident 2).
Findings include:
The facility's policy regarding PICC line maintenance and care, dated May 6, 2024, indicated that staff are to change the dressing every week.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated December 3, 2024, revealed that the resident was always understood, always understood others, was cognitively impaired, required assistance from staff for daily care needs, and that he was receiving intravenous medications (IV).
Physician's orders for Resident 2, dated December 18, 2024, included and order for the resident to have the PICC line dressing changed every week.
Review of Resident 2's Medication Administration Record (MAR), dated December 2024, revealed that staff had not documented the resident's PICC line dressing change in the month of December.
Observations of Resident 2 on December 26, 2024, at 8:34 a.m. revealed that his PICC line dressing was dated December 13, 2024 and that it was not sticking to his arm and that he had cut the cuff off one of his socks and put it around his arm to hold the PICC line dressing in place.
Interview with Resident 2 on December 26, 2024, at 8:34 a.m. revealed that he had not had his PICC line dressing changed since December 13, 2024. He stated that he had been asking them to change it because the current one was not sticking and he was concerned it would fall off and the PICC line would get pulled out.
Interview with Registered Nurse 1 on December 26, 2024, at 8:53 a.m. revealed that his PICC line dressing should have been changed weekly and that she was not sure why there were no dressings available to change it.
Interview with the Director of Nursing on December 26, 2024, at 10:34 a.m. revealed that Resident 2's PICC line dressing was on back order from the pharmacy and that she was not sure why it was not obtained from another source. She stated that Resident 2's PICC line dressing should have been changed per the physician's orders.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's directions for use, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident e...
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Based on review of manufacturer's directions for use, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to follow the manufacturer's directions for use of a high-back reclining wheelchair for one of three residents reviewed (Resident 1), resulting in a fall.
Findings include:
Operation instructions for the Medline Standard Manual Wheelchairs, dated December 30, 2021, revealed that to ensure safety in using this Medline wheelchair, all warnings and safety information and all instructions must be followed. Failure to do so may result in serious bodily injury or damage to the chair. Recliner models only: DO NOT use the recliner wheelchair without the anti-tip devices installed. Anti-tippers MUST be always attached, and both must be adjusted to the same height. Ensure the anti-tippers are secured as evidenced by the spring buttons fully protruding out of the holes. Anti-tippers (included with select models): Rear anti-tippers help keep the chair from tipping and are recommended attachments for additional safety. The use of anti-tippers is required on all recliner models. Recliner operation (recliner models only) WARNINGS: Anti-tippers MUST be always attached. Ensure both ant-tippers are adjusted to the same height.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated June 27, 2024, revealed that the resident was usually understood and could usually understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly known as a stroke) and Parkinson's disease. A care plan for the resident, dated May 30, 2024, revealed that the resident had an actual skin impairment to his right second toe and right heel, and that the resident was to utilize a high-back reclining wheelchair with wedge cushion (gently tilts the hips, pelvis and spine forward) and foot buddy (cushioned back and side panels prevent feet from slipping off footrests) for out-of-bed positioning.
An occupational therapy note for Resident 1, dated May 1, 2024, revealed that the resident demonstrated fair to poor positioning in a standard wheelchair with a foot buddy, wedge cushion, and backrest cushion. Resident 1 reported back pain and was requiring an adjustment in his wheelchair when assessed. The plan was to contact the medical supplier to acquire a high-back reclining wheelchair that the resident can self-propel with necessary back support. The current backrest support was not sufficient to reduce out-of-bed pain/discomfort.
An occupational therapy note for Resident 1, dated May 23, 2024, revealed that the resident trialed a 20-inch high-back reclining wheelchair this date with good upright positioning following the initial adjustment. Food buddy, wedge cushion carried over, and bilateral elevating leg rests adjusted to the most appropriate length. Because the resident's wheelchair brakes were found to be in good working order without reoccurring issues, and there were no attempts at self-transfers noted, the anti-rollback system (a weight-sensitive braking mechanism that automatically locks rear wheelchair wheels when a resident stands) was no longer indicated.
Physician's orders for Resident 1, dated May 28, 2024, included an order for the resident to utilize a high-back reclining wheelchair with wedge cushion and foot buddy for out-of-bed positioning.
A progress note for Resident 1, dated June 20, 2024, revealed that the resident was in his special wheelchair in A hall self-propelling towards the nursing station when his chair fell straight back. His head appeared to have hit the little pillow connected, not the floor, but they cannot be sure. The resident stated, I fell! The resident was set up while still in the wheelchair by five staff members.
An interdisciplinary team note for Resident 1, dated June 21, 2024, revealed that therapy reviewed the resident's wheelchair, and the anti-tippers were adjusted to be closer to the floor. Camera footage was also examined and confirmed that the resident was self-propelling in the hallway and was noted to tip backwards while self-propelling.
An occupational therapy screening note for Resident 1, dated June 21, 2024, revealed that the resident's wheelchair had tipped backwards on the previous evening. The wheelchair was assessed and found to be in good working order. The anti-tippers were adjusted to the downward position to prevent future tipping. The wheelchair was not able to be tipped backwards when assessed. Will continue to monitor.
Interview with Occupational Therapist 1 on July 11, 2024, at 9:05 a.m. revealed that Resident 1 was placed in the high-back reclining wheelchair due to having a lot of back pain. He indicated that when the wheelchair arrived at the facility, he would have been the one to go over the wheelchair prior to the wheelchair being given to the resident. He indicated that after the incident on June 20, 2024, he performed an evaluation of the resident's wheelchair and noted that the rear anti-tippers on the wheelchair were installed upside down. He indicated that the wheelchair came that way from the manufacturer. He confirmed that during the initial evaluation he missed that the rear anti-tippers were not installed properly and he did not install them properly until after the incident.
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.
Jun 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 27 residents reviewed (Resident 35).
Findings include:
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, indicated that the resident was sometimes understood and could sometimes understand, was cognitively impaired, and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach, and the resident was to have her bed and chair alarms on and operational while she was in her bed or chair.
Observations of Resident 35 on June 3, 2024, at 10:31 a.m. revealed that the resident was lying in bed, and the call bell was in her nightstand drawer with the drawer closed and was not within her reach. The resident's bed alarm was unplugged at this time.
Interview with Licensed Practical Nurse (LPN) 1 at that time revealed that Resident 35 could use her call bell and that it should have been placed within her reach. LPN 1 also indicated that the resident was to have a bed alarm while in bed and that it currently was not plugged in and functioning as it should have been.
Interview with Director of Nursing on June 6, 2024, at 9:01 a.m. confirmed that the bed alarm should have been plugged in and functioning and the call bell should have been within reach.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 address and maintain advance directives as part of the clinical re...
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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 address and maintain advance directives as part of the clinical record for one of 27 residents reviewed (Resident 29).
Findings include:
The facility's policy regarding advance directives (instructions regarding the provision of health care and life sustaining measures when the resident is incapacitated), dated May 6, 2024, indicated that upon admission residents and/or their responsible party are asked if an advanced directive or living will exists. If an advanced directive or living will exists, it is reviewed and placed in the resident's chart. If an advanced directive or living does not exist, the resident and/or their responsible party are asked if they wish to complete one. Advanced directives are reviewed with the residents as needed by social worker and acknowledgment forms are filed in the resident's medical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated April 25, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included cerebral infarction (lack of blood supply to the brain resulting in brain death to parts of the brain) and depression (a mood disorder).
There was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record.
Interview with the Director of Nursing on June 5, 2024, at 1:00 p.m. confirmed the there was no documented evidence that advance directives were addressed with Resident 29 and maintained as part of her clinical record.
28 Pa. Code 201.29(a)(d) Resident Rights.
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 ensure that the status of nursing licenses was checked with the State Board ...
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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 ensure that the status of nursing licenses was checked with the State Board of Nursing for one of two nurses reviewed (Licensed Practical Nurse 2) and failed to complete a Nurse Aide Registry verification for one of three nurse aides reviewed (Nurse Aide 3).
Findings include:
The facility's policy regarding abuse, neglect or mistreatment, dated May 6, 2024, indicated that potential employees must pass the pre-employment screening process to be hired at the facility. Potential employees must pass a criminal background check inquiring for a history of abuse, neglect, or mistreatment of residents as defined by the requirements of federal regulations. This search includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.
The personnel file for Licensed Practical Nurse 2 revealed a start date of February 10, 2019. However, there was no documented evidence until July 12, 2019, that her license was verified with the state board prior to her working.
The personnel file for Nurse Aide 3 revealed a start date of March 26, 2024. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified.
Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Licensed Practical Nures 2's start date was February 10, 2019, and her license was not verified with the State Board of Nursing until July 12, 2019. She also confirmed that Nurse Aide 3 had a start date of March 26, 2024, and did not have a registry verification completed prior to her start date.
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
Deficiency F0657
(Tag F0657)
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 a resident's care plan was updated/revised to reflect the resident's specifi...
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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 a resident's care plan was updated/revised to reflect the resident's specific care needs for three of 27 residents reviewed (Residents 13, 29, 43).
Findings include:
A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, required assistance from staff for personal care needs, and had a mechanically altered therapeutic diet. A care plan for Resident 13, dated June 21, 2022, revealed that she had an impaired nutritional status and required a mechanically altered therapeutic diet with thickened liquids that was to be provided as ordered.
Physician's orders for Resident 13, dated May 9, 2024, included orders for the resident tor receive a carbohydrate controlled, mechanically soft textured diet, with thin consistency liquids, and may have salads per speech therapy.
A nutrition note for Resident 13, dated May 15, 2024, indicated that the previous diet of mechanical soft with nectar thick liquids was changed to thin liquids on May 9, 2024.
Interview with The Director of Nursing on June 5, 2024, at 1:45 p.m. confirmed that Resident 13's care plan should have been revised to reflect the current diet orders of May 9, 2024.
A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others, required assistance with care needs, had a Foley catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had a diagnosis of neuromuscular dysfunction of the bladder (bladder lacks control due to nerve or muscle problems).
A physician's order for Resident 29, dated March 22, 2024, indicated that the resident was ordered an 18 French (size of catheter), 5-15 milliliter (ml) balloon (size of balloon used to secure in place once inserted) Foley catheter. A care plan for Resident 29, dated January 16, 2024, indicated that the resident had a 16 French, 10 ml balloon Foley catheter.
Observations of Resident 29 on June 5, 2024, at 2:22 p.m. revealed that the resident had an 18 French, 5-15 ml balloon foley catheter in place.
Interview with The Director of Nursing on June 5, 2024, at 3:55 p.m. revealed that Resident 29's care plan should have been revised to reflect the correct size of Foley catheter ordered and it was not.
A baseline care plan for Resident 43, dated May 15, 2024, revealed that the resident was receiving antibiotics through a Peripherally Inserted Central Catheter or PICC line (type of long tube that is inserted through a vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period).
Physician's orders for Resident 43, dated May 17, 2024, included an order that the PICC line was discontinued and able to be removed.
Observations of Resident 43 on June 3, 2024, at 12:22 p.m. revealed that the resident no longer had a PICC line in place and was no longer receiving antibiotics.
Interview with Resident 43 on June 3, 2024, at 12:25 p.m. revealed that the resident stopped receiving antibiotics and had the PICC line removed two days after being admitted to the nursing facility,
Interview with The Director of Nursing on June 4, 2024, at 3:39 p.m. revealed that Resident 43's care plan should have been revised to reflect that the resident was no longer receiving antibiotics and had the PICC line removed.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a r...
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Based on review of Pennsylvania's Nursing Practice Act, clinical records, and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a fall for one of 27 residents reviewed (Resident 13).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs.
A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that the resident was out of bed on the floor between her bed and the wall. Upon entering her room, she was lying on her left side, legs extended in front of her, and her hands reaching in the air.
A fall investigation, dated February 17, 2024, at 9:00 p.m., revealed that a comment was added to the note section of the investigation by a registered nurse stating, Resident was assessed status post fall and agree with the assessment done by the nurse on duty. The fall investigation was privileged and confidential and was not part of the medical record.
There was no documented evidence in the clinical record that Resident 13 was assessed by a registered nurse following her fall on February 17, 2024.
Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that there was no documented evidence in the clinical record of a registered nurse assessment at the time of Resident 13's fall on February 17, 2024.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations for one of six residents reviewed (Res...
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Based on review facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow treatment recommendations for one of six residents reviewed (Resident 6).
Findings include:
A facility policy regarding pressure ulcer prevention and management, dated May 6, 2024, revealed that a wound care nurse consult would include assessment and finding, which may include stage, measurements, appearance, and treatment recommendations in the consult report.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 27, 2024, indicated that the resident was usually understood and could usually understand others, was dependent on staff for care, and was at risk for a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure).
Physician's orders for Resident 6, dated May 15, 2024, included an order for the resident to have his right heel cleansed, patted dry, Medihoney (wound ointment) applied, then covered with bordered gauze once daily and as needed for a pressure wound.
A skin and wound note for Resident 6, dated May 30, 2024, at 1:05 p.m. revealed that the resident was seen by the wound consultant, who recommended to change the frequency of the right heel dressing to twice a day and as needed.
As of June 5, 2024, there was no documented evidence that Resident 6's wound care was completed twice a day as recommended by the wound consultant.
Interview with the Director of Nursing on June 5, 2024, at 3:06 p.m. and 3:32 p.m. confirmed that the Registered Nurse Supervisor who completed rounds with the wound consultant did not update the order, and the treatment was not completed twice daily as recommended by the wound consultant and should have been.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that contracture management services were provided as care plann...
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Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that contracture management services were provided as care planned for one of 27 residents reviewed (Resident 25).
Findings include:
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated March 20, 2024, revealed that the resident was able to make herself understood and was able to understand others, was dependent on staff for her daily care needs, and had diagnoses that included hemiplegia (muscle weakness or partial paralysis on one side of the body).
Occupational Therapy orders for Resident 25, dated January 10, 2024, included an order for the resident to have passive range of motion (when someone physically moves or stretches a part of your body) to all joints in her left hand twice a day. A care plan for Resident 25, dated May 1, 2024, revealed that the resident was on a restorative nursing program for range of motion.
Nursing tasks for Resident 25 included that the resident was to have passive range of motion to all joints in her left hand scheduled twice a day. Documentation for this task revealed that the resident only received passive range of motion one time per day on May 8, 9, 10, 11, 12, 18, 19, 20, 28, 30, and June, 1, 2024.
An interview with Occupational Therapist 4 on June 4, 2024, at 2:59 p.m. revealed that passive range of motion programs for restorative nursing is recommended by therapy. The recommendations are then reviewed by the Director of Nursing, scheduled to be completed twice a day by nursing staff, and added to the care plan by the Licensed Practical Nurse Assessment Coordinator. Recommendations for Resident 25 included passive range of motion twice a day.
Interview with the Director of Nursing on June 6, 2024, at 10:18 a.m. confirmed that there was no documented evidence to confirm that Resident 25 received passive range of motion twice a day per the recommendations and should have.
28 Pa. Code 211.12(d)(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 observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.
Findings include
A quarterly Minimum Dat...
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Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.
Findings include
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 244, dated May 28, 2024 revealed that the resident understood others and was understood, was cognitively intact, required assistance from staff for personal care needs, and has a diagnosis of gout (a build up of uric acid that causes pain and inflammation).
Observations on June 3, 2024, at 10:49 a.m. revealed that there was a round white pill on the floor of Resident 244's room.
Physician orders for Resident 244, dated May 13, 2024, included an order for the resident to be administered 100 milligrams (mg) of Allopurinol in the morning for gout.
Interview with Licensed Practical Nurse 5 on June 3, 2024, at 10:59 a.m. confirmed the white pill with 349 IJ was identified as Allopurinol (a medication used to treat gout), and Resident 244 was currently prescribed the medication.
Interview with the Director of Nursing on June 3, 2024, at 2:06 p.m. confirmed that the medication should have been labeled and secured, not on the resident's floor.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(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 facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 2...
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Based on facility policy, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of 27 residents reviewed (Resident 13).
Findings include:
The facility's policy regarding nursing documentation, dated May 6, 2024, revealed that all documentation confirms that care was provided. Documentation identifies the resident's status, clinical findings and interventions. It is the staff's responsibility in documentation, which acts as proof that care was provided. All documentation was to be done in the electronic record Point Click Care (PCC).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated May 14, 2024, revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance staff for personal care needs.
A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was lying on her fall mats on her back, with legs extended in front of her.
A fall investigation, dated February 21, 2024, at 6:45 p.m., revealed that Resident 13 was found sitting on the floor in her room with her alarm sounding. The investigation was privileged and confidential, and not part of the clinical record. The notes section of the investigation revealed that the registered nurse was present during the fall assessment and the resident was able to tolerate passive range of motion to the bilateral lower extremity. The bilateral lower extremities were equal in length, and no internal or external rotation was noted.
There was no documented evidence that a registered nurse assessment was documented in the clinical record.
Interview with the Director of Nursing on June 4, 2024, at 12:58 p.m. confirmed that the resident was assessed by a registered nurse and confirmed that there was no documentation of the assessment in the clinical record.
28 Pa. Code 211.5(f) Clinical Records.
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 and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
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Based on review of the facility's plans of correction 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 State Survey and Certification (Department of Health) survey ending June 1, 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 June 5, 2024, identified repeated deficiencies related to failure to develop resident care plans, failure to provide quality of care, failure to maintain complete and accurate medical records, and failure to maintain a complete and accurate accounting of controlled medications.
The facility's plans of correction for deficiencies regarding developing and implementing comprehensive care plans, cited during the survey ending June 1, 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 F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending June 1, 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.
The facility's plan of correction for a deficiency regarding failure to maintain a complete and accurate accounting of controlled medications, cited during the survey ending June 1, 2023, 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 F755, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining a complete and accurate accounting of controlled medications.
The facility's plan of correction for a deficiency regarding the accuracy of residents' clinical records, cited during the survey ending June 1, 2023, 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 F842, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding maintaining accurate clinical records.
Refer to F656, F684, F755, F842
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
Deficiency F0947
(Tag F0947)
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 based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that based on nurse aides' hire dates, the facility failed to ensure that nurse aides completed at least 12 hours of inservice education for one of five nurse aides reviewed (Nurse Aide 6).
Findings include:
The facility's policy regarding nurse aide inservice training, dated May 6, 2024, indicated that the facility will maintain an ongoing educational program for the development and improvement of skills of the facility's personnel, including at a minimum, annual in-service training. Certified Nursing Assistants are required to complete at a minimum 12 hours total annually.
Nurse aide education records revealed that based on their hire dates Nurse Aide 6 did not have at least 12 hours of education annually as follows:
Nurse Aide 6's hire date was May 18, 2018, and inservice records revealed that she had no annual education completed between May 2022 and May 2024.
Interview with the Human Resources Director on June 5, 2024, at 10:40 a.m. confirmed that Nurse Aide 6 did not have the required 12 hours of annual education based on her hire date.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for were followed for three of 27 r...
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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 physician's orders for were followed for three of 27 residents reviewed (Residents 11, 27, 35) and failed to ensure that neurological checks were completed following an unwitnessed fall for one of 27 residents reviewed (Resident 13).
Findings include:
A facility policy related to physician's orders, dated May 6, 2024, indicated that medications, treatments, and care is provided to residents upon written and/or verbal order.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin, and had diagnoses that included diabetes.
Physician's orders for Resident 11, dated October 18, 2023, included an order for the resident to receive 44 units of Glargine insulin (a long-acting insulin) subcutaneously (injected just under the skin) daily at bedtime and hold if blood sugar is less than 150 milligrams per deciliter (mg/dl).
A review of Resident 11's Medication Administration Record (MAR) for April 2024 revealed that the resident's bedtime blood sugar was 118 mg/dl on April 17, 2024; 148 mg/dl on April 24, 2024; 146 mg/dl on April 26, 2024; and 123 mg/dl on April 30, 2024. Glargine insulin was documented on the MAR as having been administered on the above stated dates.
Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that Glargine insulin was administered to Resident 11 on the above stated dates and should not have been.
A facility policy related to falls, dated May 6, 2024, revealed that resident falls were reported, their causes identified when possible, and timely interventions were established to help reduce the probability of repeated incidents.
A quarterly MDS assessment for Resident 13, dated May 14, 2024 revealed that the resident was able to make herself understood and understood others, was moderately cognitively impaired, and required assistance from staff for personal care needs.
A licensed practical nurse's note for Resident 13, dated February 21, 2024, indicated that she was found lying on her fall mats on her back with her legs extended in front of her.
A review of Resident 13's medical chart revealed no documented evidence that neurological checks were completed for the unwitnessed fall on February 21, 2024.
Interview with the Director of Nursing on June 5, 2024, at 9:19 a.m. confirmed that neurological checks should be completed after unwitnessed falls, and was unable to find them for Resident 13 for the fall occurring on February 21, 2024.
An admission MDS assessment for Resident 27, dated May 15, 2024, revealed that the resident was cognitively impaired and required extensive assistance for daily care needs.
Physician's orders for Resident 27, dated May 24, 2024, included an order for the resident to have a treatment for a skin tear on her left forearm. A review of Resident 27's Treatment Administration Record (TAR) for May 2024 revealed no documented evidence that the treatment for the skin tear on Resident 27's left forearm was completed as ordered by the physician.
Interview with the Director of Nursing on June 4, 2024, at 11:30 a.m. confirmed that treatments for the skin tear on Resident 27's left forearm were not completed as ordered.
A quarterly MDS assessment for Resident 35, dated March 8, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, and had one fall with injury.
A nurse's note for Resident 35, dated May 14, 2024, revealed that the resident had an unwitnessed fall at bedside, the resident was assessed, and neurological checks (a neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired) were to be completed.
A review of Resident 35's medical chart revealed no documented evidence neuro checks were completed for the unwitnessed fall on May 14, 2024.
Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that neuro checks should be completed after unwitnessed falls.
A facility policy for Bowel Protocol, dated May 6, 2024, revealed that a resident should have a soft, formed bowel movement every third day or sooner.
Physician's orders for Resident 35, dated November 30, 2023, included an order for the resident to receive a 5 mg tablet of Dulcolax (a laxative that stimulates bowel movements) by mouth as needed for constipation on Day 3 with no bowel movement and a Dulcolax suppository 10 mg rectally as needed for constipation on Day 4 with no bowel movement.
Nurse's note for Resident 35, dated April 10, 2024, revealed the resident's last bowel movement was April 4, 2024, and there was no documented evidence that bowel protocol was administered.
Interview with Director of Nursing on June 5, 2024, at 12:53 p.m. revealed that the bowel protocol was not initiated for Resident 35 on Day 3 and Day 4 with no bowel movement and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
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 four of 27 residents reviewed (Residents 2, 11, 29, 34).
Findings include:
The facility's policy regarding medication administration, dated May 6, 2024, revealed that all medications were ordered, acquired, and administered in accordance with Pennsylvania State Regulations as governed by the Centers of Medicare and Medicaid Services, and in accordance with all policies and procedures of the facility. If a medication was to be administered at a specific time, the specific time may be based upon resident's choice.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 7, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated as a 5 out of 10 on a pain scale, and was receiving controlled pain medication. A care plan, dated November 1, 2023, revealed that Resident 2 had pain related to rhabdomyolysis (muscle injury where muscles break down).
Physician's orders for Resident 2, dated February 29, 2024, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (an opioid pain medication) immediate release every eight hours as needed for moderate to severe pain for a pain scale rating of 6 to 10 for 14 days. Physician's orders for Resident 2, dated March 15, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every eight hours as needed for pain. Physician's orders for Resident 2, dated March 29, 2024, included an order for the resident to receive 5 mg of Oxycodone immediate release every six hours as needed for chronic pain.
Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 2 for March 2024 through June 2024 indicated that a dose of Oxycodone was signed out on March 3, 2024, at 10:19 a.m.; March 28, 2024, at 3:35 p.m.; April 1, 2024, at 6:30 a.m.; April 15, 2024, at 6:30 a.m.; April 29, 2024, at 6:30 a.m.; May 1, 2024, at 6:30 a.m.; May 9, 2024, at 6:30 a.m.; May 29, 2024, at 6:30 a.m.; and June 2, 2024, at 6:30 a.m.
However, a review of Resident 2's MAR and nursing notes revealed no documented evidence that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times.
Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 2's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above stated dates and times.
A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication.
Current physician's orders for Resident 11 included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone-acetaminophen (an opioid pain medication) every four hours as needed for a pain scale of 4 to 10.
Review of the controlled drug record for Resident 11 for March and May 2024 indicated that a dose of Hydrocodone-acetaminophen was signed out on March 8, 2024, at 1:00 a.m. and on May 14, 2024, at 9:40 a.m.
However, a review of Resident 11's MAR and nursing notes revealed no documented evidence that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times.
Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 11's clinical records to indicate that the signed-out doses of Hydrocodone-acetaminophen were administered to the resident on the above stated dates and times.
A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others, had complaints of pain rated a 7 out of 10 on a pain scale, and was receiving controlled pain medication.
Physician's orders for Resident 29, dated January 21, 2024, included an order for the resident to receive 50 mg of Tramadol (an opioid pain medication) every eight hours as needed for moderate to severe pain.
Review of the controlled drug record for Resident 29 for March and June 2024 indicated that a dose of Tramadol was signed out on March 17, 2024, at 11:27 a.m. and on June 3, 2024, at 12:05 a.m.
However, a review of Resident 29's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.
Interview with the Director of Nursing on June 5, 2024, at 3:55 p.m. confirmed that there was no documented evidence in Resident 29's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.
A quarterly MDS assessment for Resident 34, dated February 5, 2024, revealed that the resident was understood and could understand others, was cognitively impaired, had complaints of pain rated as an 8 out of 10 on a pain scale, and was receiving controlled pain medication.
Physician's order for Resident 34, dated February 28, 2024, included an order for the resident to receive 50 milligrams (mg) of Tramadol every six hours as needed for moderate to severe pain for a pain scale rating of 4 to 10.
Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 34 for March 2024 through June 2024 indicated that a dose of Tramadol was signed out on March 4, 2024, at 7:30 p.m.; March 15, 2024, at 9:00 p.m.; March 17, 2024, at 9:00 p.m.; and May 28 ,2024, at 9:00 p.m.
Review of Resident 34's MAR and nursing notes revealed no documented evidence that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.
Interview with the Director of Nursing on June 5, 2024, at 10:15 a.m. confirmed that there was no documented evidence in Resident 34's clinical records to indicate that the signed-out doses of Tramadol were administered to the resident on the above stated dates and times.
28 Pa. Code 211.9(a)(h) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to respond timely to pharmacy recommendations for four of 27 reside...
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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 respond timely to pharmacy recommendations for four of 27 residents reviewed (Residents 3, 11, 35, 36) and failed to obtain completed pharmacy recommendations for physician review for two of 27 residents reviewed (Residents 10, 29).
Findings include:
The facility's policy for drug regimen review, dated May 6, 2024, indicated that a drug regimen review is performed by a licensed pharmacist for every resident each month. The pharmacist will report any medication irregularities and recommendations to the attending physician on a pharmacy review sheet. The physician will respond to the pharmacist's recommendation on the review sheet, and it will be returned to the facility to be acted upon. The review sheet will be filed in the resident's chart in the physician progress section and will be kept in the chart for one full year.
A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 3, dated April 12, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, received insulin (a medication preperation of the hormone insulin), and had a diagnosis of diabetes (disease causing high blood sugar levels).
A pharmacy review sheet for Resident 3, dated March 5, 2024, included a recommendation that a correction needed to be made to Resident 3's orders due a change in insulin dose at bedtime. There was no documented evidence that the pharmacy recommendation was addressed timely by the physician.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendation for Resident 3 on March 5, 2024, was not addressed timely by the physician.
A quarterly MDS assessment for Resident 11, dated May 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, received insulin and controlled pain medication, and had diagnoses that included diabetes.
Review of a pharmacy review sheet for Resident 11, dated March 5, 2024, revealed a recommendation that the resident may be due for blood work related to drug therapy. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 11 on March 5, 2024, were not addressed timely by the physician and should have been.
A quarterly Minimum Data Set (MDS) (assessment of a resident's abilities and care needs) for Resident 35, dated March 8, 2024, revealed that the resident was cognitively impaired, was dependent on staff for daily care needs, and received an antianxiety medication (a drug used to treat anxiety) and an antidepressant medication (a drug used to treat depression).
Progress notes for Resident 35, dated March 5, 2024; April 12, 2024; and May 13, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 35 on March 5, 2024; April 12, 2024; and May 13, 2024, were not addressed timely by the physician and they should have been.
An annual MDS assessment for Resident 36, dated May 14, 2024, revealed that the resident was cognitively intact, was dependent on staff for daily care needs, and was receiving an antianxiety medication (used to control anxiety) and a medication for insomnia (used to control sleep).
Review of a pharmacy recommendation for Resident 36, dated March 5, 2024, revealed a recommendation that it may be appropriate to discontinue one of the medications for anxiety and insomnia and that a correction was made to Resident 3's orders. However, there was no documented evidence that the pharmacy recommendations were addressed timely by the physician.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 36 on March 5, 2024, were not addressed timely by the physician and they should have been.
A significant change MDS assessment for Resident 10, dated May 2, 2024, revealed that the resident was understood and could understand others, was dependent for care needs, received controlled pain medication, and had diagnoses that included atrial fibrillation (irregular heart rhythm).
A progress note for Resident 10, dated February 19, 2024, revealed that a pharmacy review was done and that recommendations were made. However, there was no documented evidence that the pharmacy recommendations were received for the physician to review.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 10 on February 19, 2024, were not obtained for the physician to review and should have been.
A quarterly MDS assessment for Resident 29, dated April 25, 2024, revealed that the resident was understood and could understand others and was receiving controlled pain medication, antipsychotic medications (used to treat mental health disorders), antidepressant medications (used to treat depression) and anticoagulant medications (used to treat or prevent blood clots).
A progress note for Resident 29, dated March 5, 2024, revealed that a pharmacy review was done and recommendations were made. However, there was no documented evidence that the pharmacy recommendations were obtained for physician review.
Interview with the Director of Nursing on June 5, 2024, at 1:34 p.m. confirmed that the pharmacy recommendations for Resident 29 on March 5, 2024, were not obtained for physician review and they should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu.
Findings include:
A facility's ...
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Based on review of the facility's written menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu.
Findings include:
A facility's policy regarding menu management, dated May 6, 2024, revealed that menus were to be posted on menu boards located in the dining room and hallway. Temporary changes to the menu will be posted daily on the menu boards. To ensure consistency, all meals served will strictly adhere to the pre-approved menus.
The facility's written and posted weekly menu for the lunch meal on June 3, 2024, revealed that the residents were to receive bread with margarine.
Observations during the lunch meal on June 3, 2024, at 12:08 p.m. revealed that the residents did not receive bread or margarine for the lunch meal.
Interview with the Dietary Manager on June 3, 2024, at 12:58 a.m. revealed that a new cook eliminated the bread from the menu for lunch and she did not know why, but the residents should have been provided bread and margarine with their meal.
28 Pa. Code 211.6(a) Dietary Services.
28 Pa. Code 201.29(j) Resident Rights.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
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 permit the readmission of a hospitalized resident without providin...
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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 permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of three residents reviewed (Resident 1).
Findings include:
The facility's policy regarding notice requirements for transfer/discharge of a long-term resident, dated October 6, 2023, indicated that the facility must permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident, or the health of individuals in the facility would otherwise be endangered. The facility must also be sure to document the danger that failure to transfer or discharge would pose.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, exhibited no behaviors, and had diagnoses that included osteomyelitis (a serious infection of the bone that can be either acute or chronic), diabetes, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and aquired absence of the right great toe.
A nursing note for Resident 1, dated December 20, 2023, revealed that the resident arrived around 12:45 p.m. via med van in a wheelchair and was alert but confused.
Nursing notes for Resident 1, dated December 27, 28, and 30, 2023, and January 3 and 4, 2024, revealed that the resident was being noncompliant with his nonweight bearing status to his right leg and when staff attempted to re-educate and re-direct him, he would become agitated and threaten them.
Nursing notes for Resident 1, dated January 6 and 7, 2024, revealed that the resident was being more cooperative with his nonweight bearing status to his right leg.
A nursing note for Resident 1, dated January 8, 2024, at 1:59 a.m. revealed that the resident has continuously and purposely gotten out of his bed and gone down to his knees beside his bed on his fall mat and
awaits staff intervention (requesting to lift him up). He was assisted to his wheelchair and he was taken to the nurses' station for close observation. The resident would then get up on his own without assistance, would not allow staff to assist him, and states that the staff don't know what the f**k they are doing. At least four staff persons, including this writer, attempted to educate him about his risk of falling and hurting himself, and the safety issues, as well as his increased risk for infection with his foot and walking on a dirty floor with no socks or foot covering. For safety reasons and his continued noncompliance and intentional acting-out behaviors, he will have included in his care plan that he is able to put himself on the fall mat beside his bed. A nursing note at 3:31 a.m. revealed that the nurses responded to the resident's room for the bed alarm sounding between approximatley 3:30 a.m. and 4:00 a.m. and the resident was kneeling on the floor. Incontinent care was provided at that time. Approximately five minutes later the bed alarm sounded again, and nursing staff responded to find him kneeling on the floor again. An order was obtained to transport the resident to the hospital for continuing to possibly harm himself as well as having an acute change in mental status. Emergency services (9-1-1) was contacted and the resident was transported out of the facility at approximately 4:30 a.m. A nursing note at 10:18 a.m. revealed that the resident was being admitted to the hospital with a diagnosis of altered mental status and toe infection.
There was no documented evidence that the facility could not meet Resident 1's needs related to behaviors, and no documented evidence that the resident's discharge was based on a valid discharge reason. The facility did not wait until he was treated and discharged from the hospital to determine if the facility could not meet the resident's needs.
Interview with the Director of Nursing on January 26, 2024, at 2:15 p.m. confirmed that there was no documented evidence in the clinical record of the reasons why the facility was not able to meet the resident's needs. She indicated Resident 1 was very noncompliant and was wandering in other residents' rooms as well as being verbally aggressive toward staff. He also threatened to punch me in the f*****g face when I was just trying to get him a drink. We did talk about it as a team and with the physician that we were not able to meet his care needs here at the facility, and that is why it was decided that he would not be able to return here.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of three ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of three residents reviewed (Resident 1).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 27, 2023, revealed that the resident was understood, understands, and had a diagnosis which included osteomyelitis (a serious infection of the bone that can be either acute or chronic) and aquired absence of the right great toe.
A wound healing center note for Resident 1, dated January 2, 2024, revealed that staff was to leave the dressing on the resident's foot for three days and then apply betadine dressings daily.
Review of Resident 1's Treatment Administration Record (TARs) for January 2024 revealed that staff completed the betadine dressing to the resident's right foot on January 5, 2024. However, there was no documented evidence that the betadine dressing was completed on January 6 and 7, 2024, as per the wound healing center's recommendations.
Interview with the Director of Nursing on January 26, 2024, at 12:00 p.m. confirmed that there was no documented evidence that the betadine dressing was completed as per the wound healing center's recommendations on January 6 and 7, 2024.
Interview with Registered Nurse 1 on Janaury 26, 2024, at 1:30 p.m. revealed that she completed the betadine dressing to Resident 1's right foot on January 6 and 7, 2024. She indicated that she recalls that the resident was always noncompliant and standing on that foot and that the dressing was off his foot on the 6th, so she went in and completed the treatment. She indicated that she also completed the treatment on the 7th as well.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident ...
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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 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 three of three residents reviewed (Residents 1, 2, 3).
Findings include:
The facility's policy regarding bed holds (holding a resident's bed while the resident is absent from the facility for hospitalization), dated October 6, 2023, indicated that the admission director/designee will contact the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital. The original copy of the facility's bed-hold policy was to be placed in the resident's chart and the copy can be given to the family. This can be in person or sent via email. If the representative is present, then they can be informed at that time. Then document in the resident's electronic medical record that the resident/representative was notified either via phone call or in person and received a copy and the original was placed in the chart. When making a phone call to the resident/resident representative to inform them of their options, indicate their choice made on the form. Document on the form that the call was made, and the date and time of the call.
Nursing notes for Resident 1, dated January 8, 2024, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfer to the hospital.
Nursing notes for Resident 2, dated December 30, 2023, revealed that the resident was admitted to the hospital on this date. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of her transfer to the hospital.
Nursing notes for Resident 3, dated August 9, 2023; November 17, 2023; December 3, 2023; and December 16, 2023, revealed that the resident was admitted to the hospital on those dates. However, there was no documented evidence that a written copy of the facility's bed-hold policy was provided to the resident and/or responsible party at the time of his transfers to the hospital.
Interview with the Nursing Home Adminstrator on January 26, 2024, at 1:20 p.m. confirmed that a copy of the facility's bed-hold policy was not provided to Residents 1, 2 and 3 or their responsible parties at the time of their transfers to the hospital.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(3) Management.
Jun 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
Based on 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 a significant change Minim...
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Based on 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 a significant change Minimum Data Set assessment for one of 22 residents reviewed (Resident 19).
Findings include:
Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) revealed that the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. The RAI Manual revealed that staff should complete a significant change MDS when a resident has a decline that will not normally resolve itself without interventions by staff, impacts more than one area of the resident's health status, and requires interdisciplinary review and/or revision of the resident's care plan. The RAI Manual revealed that staff should complete a significant change MDS when a terminally ill resident enrolls in a hospice program (Medicare-certified or state-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home.
A quarterly MDS assessment, dated April 27, 2023, revealed that Resident 19 was cognitively impaired, required limited to extensive assistance from staff for daily care needs, and was not receiving hospice services.
A physician's order for Resident 19, dated May 12, 2023, included an order for the resident to be admitted to hospice services on May 4, 2023. A care plan, dated May 4, 2023, indicated the the resident was receiving hospice services.
There was no documented evidence in Resident 19's clinical record to indicate that a significant change MDS was completed per the RAI manual.
An interview with the Director of Nursing on June 1, 2023, at 2:19 p.m. confirmed that a significant change MDS was not completed.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on 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 ...
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Based on 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 one of 22 residents reviewed (Resident 12).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0300 (Injections) was to be coded if the resident received an injection in the last seven days or since admission/entry or reentry if less than seven days, and that Section N0350 (Insulin) was to be coded for the number of days the resident received insulin (an injected medication to lower blood sugar levels), that Sections N0410A (Antipsychotic Medication) and N0410C (Antidepressant Medication) were to be coded with the number of days the resident received these types of medications during the seven-day assessment period, and Section N0450A was to be coded (1) Yes if the resident received an antipsychotic medication since admission/entry or reentry, or since the prior MDS assessment, whichever was more recent.
Physician's orders for Resident 12, dated September 30, 2021, included an order for the resident to receive 34 units of Lantus (insulin) at bedtime, two 400 milligram (mg) tablets of Seroquel (an antipsychotic medication) at bedtime for schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), one 16 mg tablet of Perphenazine (an antipsychotic medication) at bedtime for mood disorder, and one 75 mg tablet of Sertraline (an antidepressant) twice a day for depression.
Review of Resident 12's Medication Administration Record (MARs), dated March 2023, revealed that the resident received injections of Insulin, the antipsychotic medications of Seroquel and Perphenazine, and the antidepressant medication of Sertraline March 1 through 31, 2023, as ordered by the physician. However, a quarterly MDS assessment, dated March 10, 2023, revealed that Section N0300 was coded with a 0 (zero) indicating that the resident did not receive any injections, Section N0350 was coded with a 0 (zero) indicating that the resident did not receive any Insulin, Sections N0410A and N0410C were coded with a 0 (zero) indicating that the resident did not receive an antipsychotic and an antidepressant, and Section N0450A was coded as 0 (zero) No, indicating that the resident did not receive antipsychotic medication since admission/entry or re-entry, or since the prior MDS assessment.
Interview with the Director of Nursing on June 1, 2023, at 1:40 p.m. confirmed that Sections N0300, N0350, N0410A, N0410C, and N0450A of Resident 12's quarterly MDS assessment for March 10, 2023, were coded inaccurately.
28 Pa. Code 211.5(f) Clinical records.
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, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 22 residents re...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 22 residents reviewed (Resident 7).
Findings include:
Physican orders for Resident 7, dated February 3, 2023, included an order for the resident to be administered oxygen at 1 to 5 liters per minute (lpm) via nasal canula for shortness of breath/comfort.
Observations of Resident 7 on May 30, 2023, at 10:06 a.m. and 3:10 p.m. and on May 31, 2023, at 9:51 a.m., 12:53 p.m., and 3:04 p.m. revealed that the oxygen was being administered at 5 lpm.
However, Resident 7's treatment record revealed that on May 30 and 31, 2023 the oxygen was documented as being administered at 2 lpm.
Interview with Registered Nurse 1 on May 31, 2023, at 3:04 p.m. confirmed that on May 30 and 31 the oxygen was being administered to Resident 7 at 5 lpm; however, it was documented as 2 lpm.
Interview with the Director of Nursing on May 31, 2023, at 3:37 p.m. confirmed that staff should not have documented Resident 7's oxygen administration at 2 lpm if it was being administered at 5 lpm.
28 Pa. Code 211.5(f) Clinical records.
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 and/or maintain compliance with 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 State Survey and Certification (Department of Health) for the surveys ending May 11, 2022, and April 6, 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 June 1, 2023, identified repeated deficiencies related to inaccurate Minimum Data Sets (MDS), care plan development and implementation, feeding tube management, pharmacy services, food procurement/storage/preparation/service, and infection control.
The facility's plans of correction for deficiencies regarding inaccurate MDS, cited during the survey ending May 11, 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 F641, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
The facility's plans of correction for deficiencies regarding careplan creation and implementation, cited during the survey ending May 11, 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 F656, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
The facility's plans of correction for deficiencies regarding feeding tube management, cited during the survey ending May 11, 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 F693, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
The facility's plans of correction for deficiencies regarding pharmacy services, cited during the survey ending May 11, 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 F755, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
The facility's plans of correction for deficiencies regarding food procurement/storage/preperation/serving, cited during the survey ending May 11, 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 F812, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending May 11, 2022 and April 6, 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 F880, revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.
Refer to F641, F656, F693, F755, F812, F880.
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 appropriate signage was posted for a resident ...
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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 appropriate signage was posted for a resident with special infection control isolation needs for one of 22 residents reviewed (Resident 13) and failed to ensure that proper infection control practices were followed during medication administration for one of 22 residents reviewed (Resident 7)
Findings include:
A review of the facility's policy regarding Medication Administration, dated October 12, 2022, revealed that staff follow established facility infection control procedures for the administration of medications.
Current physician's orders for Resident 7 included orders for the resident to receive 20 milligrams (mg) Celexa (anti-depressant) and 25 mg Spironolactone (blood pressure medication). Observations during medication administration on May 31, 2023, at 8:57 a.m. revealed that Registered Nurse 1 dropped the Celexa on the medication cart and picked it up with her bare hands and then placed it in the medication cup. She then dropped the Spironolactone on the medication cart and picked it up with her bare hands. She then administered the medications to Resident 7.
Interview with Registered Nurse 1 on May 31, 2023, at 9:14 a.m. revealed that she should not have touched Resident 7's medication with her bare hands.
Interview with the Director of Nursing on May 31, 2023, at 3:47 p.m. confirmed that staff were not to touch residents' medications with their bare hands.
The facility's policy regarding isolation precautions, dated October 12, 2022, indicated that when a resident was placed on transmission-based precautions, appropriate notification was placed on the room entrance door so that personnel and visitors were aware of the need for and the type of precaution.
A urine culture, dated May 15, 2022, indicated that Resident 13 had extended-spectrum beta-lactamase (ESBL-occurs when bacteria break down antibiotics, thereby making infections very hard to treat) of the urine. Physician's orders for Resident 13, dated May 22, 2023, included orders for contact precautions due to ESBL of the urine.
Observation on May 30, 2023, at 10:14 a.m. and 10:36 a.m. revealed that there was no infection control sign posted at the entrance to the resident's room.
Interview with the Director of Nursing on May 31, 2023, at 3:41 p.m. confirmed that there should have been an infection control sign by Resident 13's room door.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of four of 22 residents reviewed (Residents 2, 11, 13, 29).
Findings include:
The facility's policy regarding comprehensive care plans, dated October 12, 2023, indicated that each resident would have an individualized interdisciplinary plan of care in place. The comprehensive care plan would be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident/representative.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2023, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots) and a diuretic medication (a medication used to remove excess fluid from the body).
Current physician's orders for Resident 2, included orders for the resident to receive 20 milligrams (mg) of Xarelto (an anticoagulant medication) every evening related to atrial fibrillation (irregular heart beat) and 20 mg Furosemide every morning for heart failure.
The resident's Medication Administration Records (MAR's) for April and May 2023 revealed that the resident received Xarelto and Furosemide.
There was no documented evidence that a care plan was developed related to the use of anti-coagulant and diuretic medications.
A nursing note for Resident 2, dated January 6, 2023, at 4:44 p.m. revealed that she spilled hot tea on her left leg. A nursing note, dated May 19, 2023, at 12:00 p.m. revealed Resident 2 spilled hot tea on herself and had a light pinkish area on the upper left front thigh near her groin.
There was no documented evidence that a care plan was developed related to the resident spilling hot tea on herself.
Interview with the Director of Nursing on June 1, 2023, at 12:23 p.m. confirmed that there were no care plans in place to address Resident 2's use of anti-coagulant and diuretic medications or spilling hot tea on herself.
A quarterly MDS assessment for Resident 11, dated May 12, 2023 revealed that the resident received a diuretic medication.
Physician's orders for Resident 11, dated February 2, 2023, included an order for the resident to receive 40 mg Furosemide every morning for heart failure.
The resident's MAR's for April and May 2023 revealed that the resident received Furosemide.
There was no documented evidence that a care plan was developed related to the use of diuretic medications.
Interview with the Director of Nursing on June 1, 2023, at 12:23 p.m. confirmed that there was no care plan in place to address Resident 11's use of diuretic medications.
A urine culture for Resident 13, dated May 15, 2022, indicated that the resident had extended-spectrum beta-lactamase (ESBL-occurs when bacteria break down antibiotics, thereby making infections very hard to treat) of the urine. Physician's orders for Resident 13, dated May 22, 2023, included orders for contact precautions due to ESBL of the urine.
There was no documented evidence that a care plan was developed related to Resident 13's isolation precautions.
Interview with the Director of Nursing on May 31, 2023, at 3:41 p.m. confirmed that there was no care plan developed to address Resident 13's isolation precautions.
An admission MDS assessment for Resident 29, dated May 4, 2023, revealed that the resident received an anticoagulant and antibiotic medications, and used oxygen,
Current physician's orders for Resident 29, included orders for the resident to receive 5 mg of Eliquis (an anticoagulant medication) every morning and at bedtime related to atrial fibrillation, 875-125 mg of Amoxicillin- Potassium Clavulanate (antibiotic) every morning and at bedtime related to infection and inflammatory reaction due to cardiac or vascular devices, and 1-5 liters per minute of oxygen via nasal cannula for shortness of breath.
The resident's MAR's for April and May 2023 revealed that the resident received Eliquis, Amoxicillin-Potassium Clavulanate, and oxygen.
There was no documented evidence that a care plan was developed related to the use of anti-coagulant and antibiotic medications or oxygen use.
Interview with the Director of Nursing on June 1, 2023, at 12:16 p.m. confirmed that there were no care plans developed to address Resident 29's use of Eliquis, Amoxicillin-Potassium Clavulanate, or oxygen.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about elevated blood sugar results for one...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about elevated blood sugar results for one of 22 residents reviewed (Resident 16).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated April 2, 2023, revealed that the resident was understood, understands, required extensive assistance for her daily care needs, had a diagnosis which included diabetes (disease that interferes with blood sugar control), and received insulin (medication that lowers blood sugar levels). A care plan for the resident, dated May 12, 2022, revealed that the resident has diabetes and staff was to obtain accuchecks (a fingerstick blood sugar test) as ordered.
Physician's orders for Resident 16, dated September 30, 2021, included an order for the resident to receive Lispro (Insulin) according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals for diabetes. The sliding scale included giving 2 units for a blood sugar of 141-180 milligrams/deciliter (mg/dL); 4 units of insulin for a blood sugar of 181-220 mg/dL; 6 units of insulin for a blood sugar of 221-260 mg/dL; 8 units of insulin for a blood sugar of 261-300 mg/dL; 10 units for a blood sugar of 301-340 mg/dL; and 12 units for a blood sugar of 341 or greater and call the physician.
Resident 16's Medication Administration Record (MAR) for March, April, and May 2023 revealed that on March 11, 2023, at 11:45 a.m. the resident's blood sugar was 347 mg/dL; on March 18, 2023, at 11:45 a.m. it was 388 mg/dL; on April 13, 2023, at 7:15 a.m. it was 342 mg/dL; on April 13, 2023, at 4:40 p.m. it was 387 mg/dL; on May 6, 2023, at 7:15 a.m. it was 379 mg/dL; on May 15, 2023, at 4:40 p.m. it was 358 mg/dL; and on May 30, 2023, at 7:15 a.m. it was 379 mg/dL. There was no documented evidence that the physician was notified about the resident's blood sugar being above 341 mg/dL on these dates and times.
Interview with the Director of Nursing on May 31, 2023, at 2:35 p.m. confirmed that there was no documented evidence that the physician was notified about Resident 16's elevated blood sugars, as ordered.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral feedings (feeding throu...
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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 physician's orders for enteral feedings (feeding through a tube inserted directly into the stomach) were followed and clarified for one of 22 residents reviewed (Resident 9).
Findings include:
The facility's policy regarding guidelines for enteral feedings, dated October 12, 2022, indicated that staff are to ensure that the enteral feeding is provided as ordered. That nursing staff will check gastric residual (the amount of liquid that remains in the stomach following administration of enteral feed) every shift or more frequently as indicated. Residuals of 50 milliliters (ml) or more suggests that the feeding should be held for at least one hour.
A care plan for Resident 9, dated January 2, 2021, revealed that the resident required an enteral feeding related to Dysphagia (swallowing difficulties), nothing by mouth (NPO), and weight fluctuations. Staff was to check for tube placement and gastric contents/residual volume per facility protocol/procedure and hold the feeding as per physician's orders.
Physician's orders for Resident 9, dated April 14, 2023, included an order for the resident to receive 400 ml of Osmolite 1 Cal (a type of enteral feeding) four times a day. If the enteral feeding residual was greater than 200 ml, staff was to hold the enteral feeding and call the physician.
Physician's orders for Resident 9, dated May 22, 2023, included an order for the resident to receive 400 ml of Osmolite 1.2 Cal four times a day. If the enteral feeding residual was greater than 200 ml, staff was to hold the enteral feeding and call the physician.
Medication Administration Records (MARs) for Resident 9, dated April and May 2023 revealed that staff administered the 400 ml of Osmolite 1 Cal on April 14, 2023, at 5:00 p.m. and 9:00 p.m.; on April 15 through April 30, 2023; May 1 through 4, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.; and on May 5, 2023 at 9:00 a.m. However, there was no documented evidence that staff obtained and/or documented the amount of any tube feeding residual.
Review of the MARs for Resident 9 for May 2023 revealed that staff administered the 400 ml of Osmolite 1.2 Cal on May 22, 2023, at 5:00 p.m. and 9:00 p.m.; May 23, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m.; and on May 24, 2023, at 9:00 a.m. However, there was no documented evidence that staff obtained and/or documented the amount of any tube feeding residual.
Physician's orders for Resident 9, dated May 22, 2023, included an order for the resident to receive 400 ml Osmolite 1.0 Cal four times a day until the Osmolite 1.2 Cal arrives. However, there was no documented evidence that staff clarified with the resident's physician if the enteral feeding residuals should be checked and if the enteral feeding residual was greater than 200 ml to hold the enteral feeding and call the physician.
Review of the MARs for Resident 9 for May 2023 revealed that staff administered the 400 ml of Osmolite 1.0 Cal on May 24, 2023, at 1:00 p.m., 5:00 p.m. and 9:00 p.m. and May 25 through 31, 2023, at 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. However, there was no documented evidence that staff obtained and/or documented the amount of any tube feeding residual per the facility's policy.
Interview with the Director of Nursing on June 1, 2023, at 12:16 p.m. confirmed that there was no documented evidence that staff obtained Resident 9's tube feeding residuals and no documented evidence that staff clarified with the resident's physician if the enteral feeding residuals should be checked and if the enteral feeding residual was greater than 200 ml to hold the enteral feeding and call the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure 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 22 residents reviewed (Residents 2, 17).
Findings include:
The facility's policy regarding documentation of medication administration, dated October 12, 2022, indicated that each resident would have an individualized interdisciplinary plan of care in place. The comprehensive care plan was to be reviewed and revised on a quarterly basis, with a significant change in condition, on re-admission, and as needed or requested by the resident/representative. The comprehensive care plan was to be resident centered and on-going, focusing on each individual resident as a unitary being.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2023, revealed that the resident could make herself understood and understand others, was alert and oriented, had frequent pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication).
Physician's orders, dated September 1, 2022, included an order for the resident to receive 5 milligrams (mg) of Oxycodone (a narcotic pain medication) every eight hours as needed for moderate/severe pain and physician's orders, dated May 10, 2023, included an order for the resident to receive 5 mg of Oxycodone every four hours as needed for moderate/severe pain.
A controlled drug accountability record (tracks each dose of a controlled medication) for Resident 2's Oxycodone revealed that one tablet was signed out on the controlled drug log at 6:00 p.m. on April 6; at 9:30 p.m. on April 22; at 9:40 a.m. on April 29; at 12:45 p.m. on April 30; at 4:40 p.m. on May 14; and at 11:00 a.m. on May 20, 2023. There was no documented evidence, including on the MAR, that the signed-out doses of Oxycodone were administered to Resident 2 on these dates and times.
Interview with the Director of Nursing on June 1, 2023, at 9:42 p.m. confirmed that the 5 mg doses of Oxycodone that were signed out on Resident 2's controlled medication log on the mentioned dates and times were not documented on the MAR as being administered.
Physician's orders for Resident 17, dated March 23, 2023, included an order for the resident to receive 0.5 milliliter (ml) of a 20 mg/ml solution of Morphine (a narcotic pain medication) every one hour as needed for pain/shortness of breath.
Resident 17's controlled substance proof-of-use record for April 2023 revealed that licensed staff signed out 0.5 ml dose of Morphine for administration to the resident on April 23, 2023, at 8:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Morphine was actually administered to the resident on April 23, 2023, at 8:00 p.m.
Physician's orders for Resident 17, dated April 26, 2023, included an order for the resident to receive one 1 mg tablet of Lorazepam (a narcotic antianxiety medication) every two hours as needed for anxiety/restlessness.
Resident 17's controlled substance proof-of-use record for April 2023 revealed that licensed staff signed out 1 mg dose of Lorazepam for administration to the resident on April 27, 2023, at 9:40 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Lorazepam was actually administered to the resident on April 27, 2023, at 9:40 p.m.
Interview with the Director of Nursing on June 1, 2023, at 9:42 a.m. revealed that she could not locate any documentation regarding why the Morphine and Lorazepam were signed out but not administered to Resident 17, or any documentation that the Morphine and Lorazepam were administered after being signed out on the above dates and times.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to store food in a sanitary manner.
Findings include:
A review of the facility's po...
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Based on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to store food in a sanitary manner.
Findings include:
A review of the facility's policy regarding Cleaning and Disinfecting of Refrigerators, dated October 12, 2022, revealed that the refrigerators are to be cleaned on a weekly basis and as needed.
Observations in the pantry refrigerator on May 30, 2023, at 12:26 p.m and May 31, 2023, at 2:07 p.m. revealed that there was a large spill of a brown, sticky, removable substance down the back of the refrigerator wall and accumulated under the bottom drawer.
Interview with the the Dietary Manager on May 31, 2023, at 2:11 p.m. confirmed that the spill should have been cleaned up when the refrigerator was re-stocked earlier that day and it was not.
28 Pa. Code 211.6(f) Dietary services.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 infection control practices were follow...
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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 infection control practices were followed during wound care for one of four residents reviewed (Resident 1).
Findings include:
The facility's policy regarding hand washing, dated October 12, 2022, indicated that hands were to be washed before handling clean or soiled dressings, gauze pads, etc. The use of gloves did not replace hand washing/hand hygiene.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated March 10, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff with daily care activities, had limited range of motion of the upper and lower extremities, had a deep tissue injury (DTI- purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that required treatments, and had diagnoses that included hemiplegia (weakness to one side of the body).
Physician's orders, dated March 29, 2023, included an order to clean the area to the resident's right hip with wound cleanser, apply medical grade honey (honey based treatment) to the wound base daily and as needed, and cover with a foam dressing. Physician's orders, dated April 4, 2023, included an order to clean the resident's DTI to the left outer heel with wound cleanser, apply skin prep (protective barrier), and leave open to air.
A Certified Registered Nurse Practitioner (CRNP - a registered nurse with advanced training) note, dated April 4, 2023, revealed that Resident 1 had an unstageable pressure ulcer to the right hip that measured 2.0 x 3.0 x 0.2 centimeters (cm) that was previously a DTI.
Observations on April 6, 2023, at 2:17 p.m. revealed that Registered Nurse 1 cleaned the wound on the resident's outer left heel with wound cleanser and then applied skin prep, and never washed her hands or performed hand hygiene after cleaning the area to the left outer heel. She then removed the old dressing on the resident's right hip and cleaned the area with wound cleanser, applied medical grade honey to the wound base, and covered the wound with a foam dressing. She did not wash her hands or perform hand hygiene after removing the old dressing to the right hip and cleansing the wound.
Interview with Registered Nurse 1 on April 6, 2023, at 2:32 p.m. confirmed that she should have washed her hands after removing Resident 1's old right hip wound dressing and cleansing the wounds, and she did not.
Interview with the Director of Nursing on April 6, 2023, at 2:32 p.m. confirmed that Registered Nurse 1 should have washed her hands after removing Resident R1's old dressings and cleansing the wounds.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Jan 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling ...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for one of five residents reviewed (Resident 3).
Findings include:
The facility's policy regarding care and maintenance of urinary catheters (a tube inserted and held in the bladder to drain urine), dated January 26, 2022, indicated that all drainage bags are to be kept in a privacy/dignity bag when at the bedside or when a resident is in a wheelchair.
A diagnosis record for Resident 3, dated December 20, 2022, revealed that the resident had diagnoses that included urinary retention (difficulty emptying the bladder). Physician's orders, dated December 29, 2022, included an order for the resident to have a urinary catheter, 18 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place).
Observations on January 12, 2023, at 10:30 a.m. revealed that Resident 3 was in bed and his catheter bag was lying in direct contact with the floor. There was no privacy bag or other type of barrier between the bag and the floor.
Interview with Nurse Aide 3 on January 12, 2023, at 11:35 a.m. confirmed that Residents 3's catheter bag should have been in a privacy bag and should not have been touching the floor.
Interview with the Acting Director of Nursing on January 12, 2023, at 3:27 p.m. confirmed that catheter bags should be in a privacy bag and should not be in direct contact with the floor.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Comprehensive Assessments
(Tag F0636)
Minor procedural issue · This affected multiple residents
**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 six residents reviewed (Residents 1, 6).
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 for admission MDS assessments, the assessment completion date was to be no later than the resident's admission date plus 13 calendar days and annual comprehensive MDS assessments were to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days.
An admission MDS assessment for Resident 1 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was still in progress and not completed on January 12, 2023, which was 14 days after admission.
An annual MDS assessment for Resident 6 revealed that the resident had an assessment reference date of November 14, 2022, and the MDS assessment was still in progress and not completed as of January 12, 2023, which was 45 days after it should have been complete.
Interview with Acting Director of Nursing/Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 12, 2023, at 3:25 p.m. confirmed that the MDS comprehensive assessments were not completed within the required timeframe.
28 Pa. Code 211.5(f) Clinical records.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0638
(Tag F0638)
Minor procedural issue · This affected multiple residents
Based on 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 ensure that Quarterly Minimum Data ...
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Based on 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 ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for two of six residents reviewed (Residents 1, 4).
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 residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days.
A quarterly MDS assessment for Resident 1, with an ARD of December 5, 2022, remained in progress on January 12, 2023, which was 38 days after the assessment period.
A quarterly MDS assessment for Resident 4, with an ARD of November 21, 2022, remained in progress on January 12, 2023, which was 52 days after the assessment period.
Interview with the Acting Director of Nursing, Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 12, 2023, at 3:25 p.m. confirmed that the MDS's were not completed within the required timeframe.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "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
- • 54 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
- • 64% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Maple Winds Healthcare And Rehabilitation, Llc's CMS Rating?
CMS assigns MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Maple Winds Healthcare And Rehabilitation, Llc Staffed?
CMS rates MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 64%, which is 17 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Maple Winds Healthcare And Rehabilitation, Llc?
State health inspectors documented 54 deficiencies at MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC during 2023 to 2025. These included: 52 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Maple Winds Healthcare And Rehabilitation, Llc?
MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MB HEALTHCARE, a chain that manages multiple nursing homes. With 50 certified beds and approximately 42 residents (about 84% occupancy), it is a smaller facility located in PORTAGE, Pennsylvania.
How Does Maple Winds Healthcare And Rehabilitation, Llc Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC's overall rating (1 stars) is below the state average of 3.0, staff turnover (64%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Maple Winds Healthcare And Rehabilitation, Llc?
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 Maple Winds Healthcare And Rehabilitation, Llc Safe?
Based on CMS inspection data, MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC 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 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Maple Winds Healthcare And Rehabilitation, Llc Stick Around?
Staff turnover at MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC is high. At 64%, the facility is 17 percentage points above the Pennsylvania average of 46%. 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 Maple Winds Healthcare And Rehabilitation, Llc Ever Fined?
MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC 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 Maple Winds Healthcare And Rehabilitation, Llc on Any Federal Watch List?
MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC 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.