Deficiencies (last 4 years)
Deficiencies (over 4 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
326% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
65% occupied
Based on a November 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Dec 4, 2025
Visit Reason
Annual state survey inspection of Oak Hill Center for Rehabilitation and Nursing to assess compliance with regulatory standards and quality of care.
Findings
The facility was found deficient in multiple areas including psychotropic medication management, care planning, treatment and care according to orders, accident prevention, catheter care, pain management, dialysis care, nurse aide performance evaluations, and dental services. Deficiencies were generally of minimal harm with some affecting a few or some residents.
Deficiencies (9)
F 0605: The facility failed to limit PRN psychotropic medication orders to 14 days, provide side effect monitoring, obtain informed consent, and prevent chemical restraints for some residents.
F 0657: The facility failed to develop and revise comprehensive care plans for residents, including safety precautions for pacemaker and use of enabler bars.
F 0684: The facility failed to provide treatment and care according to orders and professional standards for multiple residents, including missing lab tests, incomplete skin assessments, and failure to notify physicians of abnormal blood glucose.
F 0689: The facility failed to provide adequate supervision and accident prevention measures, such as missing fall mats for a resident at risk for falls.
F 0690: The facility failed to provide appropriate catheter care, including catheter bags in contact with the floor and incomplete documentation of catheter care.
F 0697: The facility failed to provide safe and appropriate pain management, including lack of comprehensive pain assessments and inappropriate administration of PRN pain medications.
F 0698: The facility failed to ensure residents requiring dialysis received care consistent with professional standards and failed to maintain dialysis communication sheets.
F 0730: The facility failed to complete annual performance evaluations for five nurse aides.
F 0791: The facility failed to provide routine and emergency dental services, delaying denture fitting for a resident.
Report Facts
Residents reviewed: 25
Residents reviewed: 5
Nurse aides reviewed: 5
Dialysis treatments: 9
PRN Tylenol doses: 34
PRN Oxycodone doses: 25
Inspection Report
Deficiencies: 1
Date: Sep 11, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of care following a complaint or incident involving delayed hospital transfer and inadequate pain management for a resident with a femur fracture.
Findings
The facility failed to provide timely transfer to the hospital after confirming a femur fracture and did not adequately monitor or manage the resident's pain prior to transfer. Documentation and communication regarding the fracture and pain assessments were insufficient.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resident's preferences, and goals, resulting in actual harm to a resident due to delayed hospital transfer and inadequate pain management.
Report Facts
Pain level scores: 8
Hours delay: 9.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding notification and documentation of x-ray results and pain management. | |
| Nursing Home Administrator | Interviewed about expectations for pain monitoring and documentation prior to hospital transfer. |
Inspection Report
Deficiencies: 1
Date: Aug 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pharmaceutical service requirements and nursing services related to medication administration.
Findings
The facility failed to provide pharmaceutical services to meet the needs of one resident by not administering an ordered medication (Ozempic) due to the medication never being dispensed to the facility. There was no documentation of follow-up with the pharmacy or physician regarding the missing medication.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of one resident by not administering the ordered Ozempic medication. Nursing staff documented administration but no evidence showed the medication was given or follow-up was done regarding the missing medication.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the missing medication and pharmacy follow-up. | |
| Nursing Home Administrator | Interviewed regarding expectations for staff follow-up with pharmacy and physician. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 4, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding neglect and improper provision of food and drink consistency to residents.
Complaint Details
The complaint investigation substantiated neglect when a volunteer provided Resident 1 with thin liquids instead of nectar thickened liquids, causing pneumonia. The volunteer program was suspended and the volunteer was no longer allowed in the facility.
Findings
The facility failed to ensure residents were free from neglect, resulting in actual harm to Resident 1 who developed bilateral lobe pneumonia with small left-sided effusion after being given thin liquids instead of nectar thickened liquids. Additionally, the facility failed to provide drinks prepared to meet individual needs for Residents 1 and 2, with Resident 2 observed receiving thin liquids despite orders for nectar thickened fluids.
Deficiencies (2)
F 0600: The facility failed to protect Resident 1 from neglect when a volunteer provided thin liquids contrary to physician orders, resulting in bilateral lobe pneumonia with small left-sided effusion.
F 0805: The facility failed to ensure drinks were prepared to meet individual needs for Residents 1 and 2, resulting in actual harm to Resident 1 with pneumonia and Resident 2 receiving thin liquids despite orders for nectar thickened fluids.
Report Facts
Residents reviewed: 10
Days antibiotic prescribed: 10
Times volunteer apologized: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Volunteer | Named in neglect finding for providing incorrect liquid consistency to Resident 1 |
| Nursing Home Administrator | NHA | Interviewed regarding volunteer program suspension and facility expectations |
| Employee 4 | Nurse Aide | Interviewed about providing thin liquids to Resident 2 unaware of diet order |
| Employee 6 | Speech Language Pathologist | Interviewed regarding Resident 2's dysphagia therapy and diet orders |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with dietary service regulations, specifically to ensure residents receive meals prepared in forms designed to meet individual needs.
Findings
The facility failed to provide a meal that met the dietary needs of residents requiring mechanical soft and pureed diets. Resident 1 was served a mechanical soft meal instead of the prescribed pureed diet, which was confirmed by staff interviews and observations.
Deficiencies (1)
F 0805: The facility failed to provide meals in the texture prescribed for residents, serving mechanical soft meals instead of pureed meals as required. Resident 1 was served a mechanical soft diet despite a physician order and staff recommendation for a pureed diet.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Social Services | Noted downgrade of Resident 1 to pureed texture diet |
| Employee 2 | Director of Food Services | Provided meal tickets and explained dietary ticket printing process |
| Employee 3 | Speech Therapist | Observed Resident 1 during meal and initiated diet texture change |
| Employee 4 | Registered Nurse | Entered diet order for Resident 1 |
Inspection Report
Routine
Deficiencies: 15
Date: Nov 21, 2024
Visit Reason
Routine inspection of Oak Hill Center for Rehabilitation and Nursing to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident participation in care planning, accurate resident assessments, medication administration, wound care, mobility assistance, feeding tube care, respiratory care, dialysis services, trauma-informed care, use of bed rails/enabler bars, medication storage, dental services, infection control, and safety inspections of bed rails.
Deficiencies (15)
F 0553: Facility failed to ensure two residents were included and provided the right to participate in their person-centered care planning process.
F 0582: Facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage form to two residents to inform them of Medicare coverage changes.
F 0641: Facility failed to ensure resident assessments accurately reflected residents' status for four residents, including significant weight loss and medication tapering.
F 0658: Facility failed to follow professional standards in medication administration for two residents, including failure to add ordered eye drops and improper wound care product use.
F 0686: Facility failed to provide appropriate pressure ulcer care for two residents, including failure to update wound care orders and improper infection control during wound care.
F 0688: Facility failed to provide appropriate care to maintain or improve mobility for two residents, including failure to document range of motion and ambulation assistance.
F 0693: Facility failed to provide appropriate treatment and services for two residents with feeding tubes to prevent complications, including missing orders for site care and syringe changes.
F 0695: Facility failed to provide safe and appropriate respiratory care for one resident, including lack of titrate oxygen order and incomplete equipment maintenance documentation.
F 0698: Facility failed to ensure residents requiring dialysis received consistent services and complete records, including delayed dialysis orders and failure to weigh resident prior to dialysis.
F 0699: Facility failed to complete timely trauma assessments and develop individualized trauma-informed care plans for two residents with PTSD.
F 0700: Facility failed to assess, review risks and benefits, and obtain informed consent for use of enabler bars/side rails for two residents prior to use.
F 0761: Facility failed to ensure prescription medications and treatments were stored in locked compartments and only accessible by authorized personnel for three residents.
F 0791: Facility failed to provide or obtain dental services to meet the needs of one resident, including lack of follow-up dental care after initial visit.
F 0880: Facility failed to ensure enhanced barrier precautions were implemented appropriately for residents on precautions, including lack of PPE availability and improper use.
F 0909: Facility failed to conduct regular inspections of side rails/enabler bars to identify entrapment risks for two residents.
Report Facts
Residents reviewed: 32
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 20
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Regional Director of Clinical Services | Interviewed regarding malnutrition risk assessment and trauma-informed care |
| Employee 3 | Assistant Director of Nursing | Interviewed regarding medication powder left at bedside |
| Employee 8 | Registered Dietician | Interviewed regarding inaccurate resident weight loss assessments |
| Employee 9 | Nurse Practitioner | Reviewed medication tapering recommendations |
| Employee 11 | Licensed Practical Nurse, Wound Nurse | Observed applying wound care products without physician orders |
| Employee 12 | Infection Control Professional | Interviewed regarding enhanced barrier precautions and PPE use |
| Employee 13 | Licensed Practical Nurse | Interviewed regarding enhanced barrier precautions |
| Employee 14 | Nurse Aide | Observed bagging soiled linen without gown on enhanced barrier precautions |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding medication administration, wound care, respiratory care, dialysis, trauma-informed care, medication storage, and infection control |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed multiple times regarding overall facility compliance and specific deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate treatment and care according to physician orders, resulting in harm to a resident.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1's care related to urinary tract infection treatment and medication administration. The complaint was substantiated as the facility failed to follow physician orders and provide timely care, resulting in harm.
Findings
The facility failed to implement treatment and care according to professional standards, resulting in actual harm to Resident 1, including a urinary tract infection and septic shock. Deficiencies included missed catheter care, delayed and missed medication administration, lack of timely physician response, and incomplete wound care and weight monitoring documentation.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resulting in actual harm evidenced by a urinary tract infection and septic shock for Resident 1. Missed catheter care, delayed antibiotic administration, and failure to obtain timely urine specimens were documented.
Report Facts
White Blood Cell Count: 18.1
White Blood Cell Count: 47.9
Medication Order Duration: 7
Missed Catheter Care Dates: 3
Missed Wound Treatment Dates: 2
Missed Weekly Weight Measures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Registered Nurse | Documented Resident 1's change in condition and nursing progress notes related to the incident. |
| Director of Nursing | Interviewed regarding urine culture order, medication administration, and physician response delays. | |
| Nursing Home Administrator | Interviewed about facility's response to identified care issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide care and services according to professional standards for two residents, specifically related to bathing and weighing protocols.
Complaint Details
The investigation was complaint-driven, focusing on care deficiencies for two residents. The findings were substantiated with evidence from clinical records and staff interviews.
Findings
The facility failed to ensure Resident 3 received showers as ordered and was not weighed according to physician orders. Resident 10 was weighed as ordered, but the facility acknowledged expectations for proper weighing and bathing were not consistently met.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. Resident 3 did not receive scheduled showers on March 8 and March 15, 2024, and was not weighed as ordered on March 13, 2024.
Report Facts
Residents reviewed: 10
Residents affected: 2
Weights recorded: 2
Weight recorded: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident 3 and Resident 10 care and weighing/bathing orders | |
| Nursing Home Administrator | Interviewed regarding expectations for Resident 3 and Resident 10 care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 8, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding neglect and inadequate supervision of a resident, which resulted in a fall and injury.
Complaint Details
The complaint investigation found that Employee 1 neglected Resident 1 by not following the two-person assist care plan during bed mobility, causing Resident 1 to fall and sustain a right femur fracture. Employee 1 was suspended, educated, and given a written warning. The Nursing Home Administrator confirmed the findings.
Findings
The facility failed to ensure Resident 1 was free from neglect and received adequate supervision, resulting in Resident 1 rolling out of bed and sustaining a right femur fracture. Employee 1 did not follow the care plan requiring two-person assist for bed mobility, leading to the fall.
Deficiencies (2)
F 0600: The facility failed to protect residents from neglect, resulting in actual harm to Resident 1 who sustained a right femur fracture after rolling out of bed. Employee 1 did not follow the care plan requiring two-person assist for bed mobility.
F 0689: The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in Resident 1 falling out of bed and sustaining a right femur fracture. Employee 1 rolled Resident 1 away from her and outside the mattress perimeter.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Nurse Aide | Named in findings related to neglect and failure to follow care plan resulting in resident fall and injury. |
Inspection Report
Routine
Deficiencies: 7
Date: Jan 25, 2024
Visit Reason
Routine inspection of Oak Hill Center for Rehabilitation and Nursing to assess compliance with regulatory requirements including resident care, environment, personnel policies, and infection control.
Findings
The facility was found deficient in multiple areas including call bell accessibility, maintaining a safe and clean environment, grievance policy implementation, criminal background checks for employees, assistance with activities of daily living, pressure ulcer care, infection prevention and control practices, and medication administration procedures.
Deficiencies (7)
F 0558: The facility failed to ensure call bell accessibility for two residents, with call bells found out of reach during observations.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for three residents, including damaged walls, dirty floors, dusty shelves, and soiled privacy curtains.
F 0585: The facility failed to provide residents access to grievance forms within reach for wheelchair-bound residents and failed to post required grievance official information in identified areas.
F 0606: The facility failed to perform criminal background checks prior to or upon hire for three employees as required by policy.
F 0677: The facility failed to provide care and services regarding facial shaving for two residents who required assistance.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents, with multiple missed wound care treatments and undated wound dressings.
F 0880: The facility failed to implement an effective infection prevention and control program, including incomplete infection control logs, improper use of PPE, and failure to follow isolation precautions for a resident with COVID-19.
Report Facts
Residents reviewed: 34
Employees reviewed: 5
Residents reviewed: 32
Residents reviewed: 2
Residents with infections: 18
Residents with infections: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 3 | Licensed Practical Nurse | Named in call bell accessibility findings |
| Employee 4 | Licensed Practical Nurse | Named in medication administration and infection control findings |
| Employee 5 | Named in infection control findings related to PPE use | |
| Employee 6 | Nurse Aide | Named in criminal background check deficiency |
| Employee 7 | Housekeeper | Named in criminal background check deficiency |
| Employee 8 | Nurse Aide | Named in criminal background check deficiency |
| Director of Nursing | Interviewed regarding multiple findings including call bell accessibility, facial shaving, wound care, infection control, and medication administration | |
| Regional Director of Clinical Services | Interviewed regarding environmental concerns, criminal background checks, wound care, and infection control |
Inspection Report
Routine
Deficiencies: 22
Date: Jan 25, 2024
Visit Reason
Routine inspection of Oak Hill Center for Rehabilitation and Nursing to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident rights, care planning, medication management, infection control, dietary services, and safety protocols. Several residents were affected by issues such as failure to ensure dignity, inadequate care plans, medication irregularities, improper infection control practices, and failure to provide appropriate adaptive equipment and services.
Deficiencies (22)
F 0550: Facility failed to ensure residents' right to a dignified existence by staff entering rooms without knocking for two residents.
F 0558: Facility failed to accommodate resident needs regarding call bell accessibility for two residents whose call bells were out of reach.
F 0584: Facility failed to maintain a safe, clean, and homelike environment for three residents, including damaged walls, dirty floors, and soiled privacy curtains.
F 0585: Facility failed to provide residents access to grievance forms within reach for wheelchair-bound residents and failed to post required grievance official information.
F 0606: Facility failed to perform criminal background checks prior to or upon hire for three employees.
F 0641: Facility failed to ensure accurate resident assessments for five residents, including incorrect coding of diagnoses and treatments.
F 0656: Facility failed to develop comprehensive care plans for three residents, lacking plans for Foley catheter use, hearing difficulty, and antipsychotic medication use.
F 0657: Facility failed to review and revise care plans timely for four residents, including respiratory care, hospice care, PTSD, and fall prevention interventions.
F 0677: Facility failed to provide care and services regarding facial shaving for two residents who required assistance.
F 0685: Facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one resident; hearing aids were delayed and not properly documented.
F 0686: Facility failed to provide appropriate pressure ulcer care for two residents, including missed wound treatments and undated dressings.
F 0688: Facility failed to provide restorative nursing care for range of motion exercises for one resident, with no documentation of program completion.
F 0690: Facility failed to provide appropriate care to prevent urinary tract infections for one resident whose catheter was observed lying on the floor.
F 0692: Facility failed to provide oversight and monitoring of nutritional status and implementation of nutrition interventions for three residents, including missed fortified foods and inconsistent weight monitoring.
F 0695: Facility failed to provide safe and appropriate respiratory care for three residents, including undated nebulizer tubing, lack of care plan and physician order for oxygen, and improper storage of respiratory equipment.
F 0756: Facility failed to ensure licensed pharmacist medication regimen reviews were reviewed and acted upon timely for five residents, with missing documentation and delayed responses to recommendations.
F 0761: Facility failed to ensure drugs and biologicals were labeled with open dates and stored properly; multi-use Tubersol vials were open without dates and past recommended use period.
F 0790: Facility failed to provide routine and emergency dental services for one resident, who missed multiple scheduled dental appointments and had untreated dental issues.
F 0810: Facility failed to provide adaptive feeding devices and appropriate assistance for one resident, including missing scoop plate, plate guard, and Kennedy cup during observed meal.
F 0812: Facility failed to procure, store, prepare, distribute, and serve food in accordance with professional standards; nutritional supplements and opened food items in pantries were not date marked.
F 0868: Facility failed to hold Quality Assurance Committee meetings at least quarterly for two quarters in 2023.
F 0880: Facility failed to implement an effective infection control program, including incomplete infection logs, lack of antibiotic usage reports, improper glove use, and failure to wear required PPE for a resident with COVID-19.
Report Facts
Residents reviewed: 34
Residents reviewed for medication: 26
Residents reviewed for dental care: 29
Residents reviewed for adaptive feeding: 26
Residents reviewed for infection control: 2
Residents affected: 2
Residents affected: 5
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Employees affected: 3
Inspection Report
Renewal
Census: 26
Capacity: 40
Deficiencies: 4
Date: Nov 30, 2023
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility to assess compliance with licensing requirements and to review the submitted plan of correction.
Complaint Details
The inspection included a complaint investigation component, but no substantiation status was explicitly stated in the report.
Findings
The inspection identified multiple deficiencies including a direct care staff member lacking required documentation of a high school diploma or GED, incomplete evacuation of residents during a fire drill, incorrect posting of menus, and discrepancies in glucometer date/time settings and blood sugar readings. Plans of correction were accepted and implemented by early January 2024.
Deficiencies (4)
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Resident #3 was not evacuated during a fire drill conducted on 10/8/23.
Menus posted were not for the current week or one week in advance as required.
Glucometer machines showed incorrect date/time and discrepancies between glucometer readings and Medication Administration Report for Residents #1 and #2.
Report Facts
License Capacity: 40
Residents Served: 26
Total Daily Staff: 31
Waking Staff: 23
Deficiencies cited: 4
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide written notice before room changes and to protect residents from mental abuse.
Complaint Details
The complaint investigation substantiated that Resident 1 was moved to a different room without written notice and was subjected to mental abuse by staff carrying picket signs with her picture. The facility confirmed these incidents during interviews and record reviews.
Findings
The facility failed to ensure that residents received written notice before room changes and failed to protect a resident from mental abuse involving staff making and carrying picket signs with the resident's picture. Both issues affected a few residents and were confirmed through policy review, clinical records, and interviews.
Deficiencies (2)
F 0559: The facility failed to ensure that residents received written notice, including the reason, before room changes. Resident 1's room was changed without prior written notice while she was at the Emergency Room.
F 0600: The facility failed to protect Resident 1 from mental abuse when staff made and carried picket signs with her picture to demonstrate what it felt like to be filmed without permission.
Report Facts
Residents Affected: 1
Residents Affected: 1
Inspection Report
Deficiencies: 1
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with food service standards, specifically ensuring that food and drink are palatable, attractive, and served at a safe and appetizing temperature.
Findings
The facility failed to provide food that was palatable and served at a safe and appetizing temperature during one meal observed on the [NAME] Hallway. Test tray temperatures were below the facility's policy range, and several residents reported that the food was cold or not appetizing.
Deficiencies (1)
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature. Test tray temperatures for pureed ham, mashed potatoes, and mashed sweet potato/brussel sprouts mixture were below the required range of 120-140 degrees.
Report Facts
Test tray temperature: 116.4
Test tray temperature: 121.1
Test tray temperature: 113.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Conducted test tray temperature measurements and provided information on ideal serving temperature |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to notify a resident's representative of the resident's death.
Complaint Details
The complaint was substantiated. The facility did not notify the resident's representative of the resident's death, which was confirmed during record review and staff interviews.
Findings
The facility failed to notify the responsible party of Resident 1's death despite hospice staff notifying them. The facility provided education to nursing staff on the expectation to notify family when a resident passes, regardless of hospice involvement.
Deficiencies (1)
28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services and 28 Pa Code 201.29(a)(l)(2) Resident rights: The facility failed to notify the resident's representative of the resident's death as required by policy and regulation.
Report Facts
Residents Affected: 1
Inspection Report
Complaint Investigation
Census: 25
Capacity: 40
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on 04/11/2023.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 32
Waking Staff: 24
Residents Served: 25
License Capacity: 40
Residents Age 60 or Older: 25
Residents with Mobility Need: 7
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop and implement a comprehensive care plan and to ensure resident safety during transport, following an incident resulting in a resident's fractured patella.
Complaint Details
The complaint investigation was substantiated. Resident 1 suffered a fractured patella during transport due to the facility's failure to ensure footrests were applied on wheelchairs. The facility lacked a policy on wheelchair footrest use at the time of the incident.
Findings
The facility failed to develop a complete care plan for Resident 1, including proper ambulation device and assistance level. Additionally, the facility did not have a policy requiring footrests on wheelchairs during transport, which led to Resident 1's foot getting caught and fracturing the patella.
Deficiencies (3)
28 Pa. Code 211.11(a) Resident care plan. The facility failed to develop and implement a comprehensive care plan for Resident 1, omitting key details about ambulation device and assistance required.
28 Pa. Code 211.12(d)(3)(5) Nursing services. The facility failed to provide adequate nursing services as required by regulation.
28 Pa. Code 201.18(b)(1)(e)(1) Management and 28 Pa. Code 211.10(c)(d) Resident care policies. The facility failed to implement a policy requiring footrests on wheelchairs during transport, resulting in Resident 1's fractured patella.
Report Facts
Residents reviewed: 3
Date of injury: Feb 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Physical Therapist | Documented physical therapy assessments and was involved in Resident 1's transport during which injury occurred |
| Employee 2 | Registered Nurse | Provided progress notes and statements regarding Resident 1's injury and care |
| Employee 3 | Licensed Practical Nurse | Provided witness statement and documented Resident 1's pain and care post-injury |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
The inspection was conducted following complaints regarding inadequate supervision during resident transport and failure to provide a therapeutic diet as ordered.
Complaint Details
The complaint investigation substantiated that Resident 1 was injured during transport due to improper wheelchair securement. Resident 2 did not receive the prescribed therapeutic diet due to an incorrect diet order upon admission.
Findings
The facility failed to ensure adequate supervision and assistance to prevent an accident during transport for one resident, resulting in injury. Additionally, the facility failed to provide a resident with a prescribed therapeutic diet, instead ordering a regular diet upon admission.
Deficiencies (2)
F 0689: The facility failed to ensure residents received adequate supervision and assistance to prevent an accident during transport for one of five residents reviewed. Resident 1's wheelchair tipped backwards during transport due to unsecured front straps, causing a head injury.
F 0800: The facility failed to provide a nourishing, well-balanced diet meeting the daily nutritional needs for one of four residents reviewed. Resident 2 was ordered a regular diet instead of the prescribed consistent carb, decaf cardiac diet.
Report Facts
Residents reviewed for transport supervision: 5
Residents reviewed for therapeutic diets: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 1 | Transport driver involved in the wheelchair securement incident. | |
| Director of Nursing | Director of Nursing | Interviewed regarding diet order error for Resident 2. |
| Nursing Home Administrator | Nursing Home Administrator | Confirmed education and safety checklist implementation after transport incident. |
Inspection Report
Renewal
Census: 32
Capacity: 40
Deficiencies: 5
Date: Nov 17, 2022
Visit Reason
The inspection was conducted as a renewal and complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The inspection identified several deficiencies including unlabeled batteries in the carbon monoxide alarm, uncovered trash receptacles, lint accumulation in dryers, missing vehicle registration, and medication storage and documentation issues. All deficiencies had plans of correction submitted and were implemented by January 9, 2023.
Deficiencies (5)
Batteries installed in the Carbon Monoxide Alarm near the kitchen were not labeled with the date they were installed.
Trash receptacle in the resident spa bathroom was not covered.
Approximately 6 inch accumulation of lint in the lint trap of dryer #2 and dryer #3.
The home did not have a copy of the current registration for its 2017 Toyota Bus used to transport residents.
Glucometer readings did not match the eMAR for Resident 1; glucometer was not calibrated to the correct date and time. Medication discrepancies found for Residents 1 and 2.
Report Facts
Residents Served: 32
License Capacity: 40
Staffing Hours: 43
Staffing Hours: 32
Current Residents: 2
Residents Age 60 or Older: 32
Residents with Intellectual Disability: 1
Residents with Mobility Need: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to battery replacement, trash receptacle lid placement, lint cleaning, and vehicle registration handling | |
| Clinical Director | LPN | Named in medication storage and glucometer calibration deficiencies |
| Housekeeping Supervisor | Named in lint removal and dryer safety training | |
| Executive Director | Contacted owner to obtain vehicle registration |
Viewing
Loading inspection reports...
