STATE COLLEGE, PA - Federal and state inspectors documented multiple safety violations at Hearthside Rehab Center during a March 2025 inspection, including the absence of life-saving emergency equipment for a dialysis patient and widespread gaps in nursing staff competency verification.
Critical Emergency Equipment Missing for Dialysis Patient
Inspectors discovered that a resident receiving hemodialysis three times weekly had no emergency supplies available to address potential life-threatening complications from her chest catheter. The resident, who had a tunneled central line catheter inserted under the skin for long-term dialysis access, lacked essential emergency items including sterile gauze, hemostats (tools used to control bleeding), needleless connectors, and medical tape.
During the March 11 inspection, surveyors observed the resident in her room and conducted a thorough search of her bedside drawers, closet, and wheelchair bag with her permission. No emergency supplies were found in any location. The resident confirmed she had maintained an emergency kit while living at home but had not been provided one since her admission to the facility on January 7, 2025—more than two months prior to the inspection.
This gap in emergency preparedness is particularly concerning given the resident's medical profile. Clinical records showed she was taking anticoagulant medications, which thin the blood and increase bleeding risk. Her care plan, last revised on January 15, 2025, specifically identified her as having "potential for bleeding or hemorrhage related to the use of anticoagulant medication." The plan instructed staff to "hold pressure and apply a pressure dressing" in case of catheter site bleeding and to call 911 if bleeding became uncontrollable.
Central line catheters for dialysis carry inherent risks of serious complications. The catheter provides direct access to major blood vessels, and any disconnection, damage, or bleeding event requires immediate intervention. Without readily available emergency supplies, staff would face critical delays in responding to hemorrhage or catheter malfunction—situations where seconds can determine outcomes.
Medical protocols for dialysis patients with central lines universally recommend keeping emergency kits immediately accessible. These kits should contain the specific items missing from this resident's room: hemostats to clamp the catheter line if disconnection occurs, sterile supplies to maintain infection control, and materials to apply direct pressure to bleeding sites. The absence of these supplies represented a failure to prepare for foreseeable medical emergencies.
According to the inspection report, an emergency kit was observed hanging above the resident's bed during a follow-up visit on March 12—one day after inspectors identified the violation. The resident was away at dialysis during this observation.
Widespread Staff Competency Documentation Failures
Inspectors identified a systemic failure to verify that nursing staff possessed appropriate competencies for essential resident care tasks. The facility could not provide any documentation demonstrating that four nurses had the required skill sets for administering medications, managing urinary catheters, performing dressing changes, or providing enteral tube feedings.
The scope of this deficiency affects a significant portion of the resident population. At the time of inspection, facility documentation revealed 118 residents were receiving medications, eight had indwelling urinary catheters, seven had pressure ulcers requiring dressing changes, and three received nutrition through enteral feeding tubes. Each of these care tasks requires specific clinical knowledge and technical proficiency to perform safely.
The four staff members lacking competency documentation included two registered nurses (RNs) and two licensed practical nurses (LPNs). When inspectors requested records showing these employees had demonstrated competency in medication administration, catheter care, wound dressing changes, and tube feeding management, the facility could provide nothing.
Competency verification serves as a fundamental patient safety mechanism in healthcare settings. While nursing licenses confirm baseline educational preparation and testing, competencies demonstrate that individual staff members can perform specific procedures correctly in actual practice. Competency assessments typically involve direct observation of clinical skills, written testing on protocols, and documentation of supervised practice.
For medication administration, competency verification ensures nurses understand the facility's specific systems for medication storage, documentation, and safety checks. It confirms they can accurately identify residents, verify medication orders, recognize potential drug interactions, and respond appropriately to adverse reactions.
Catheter care competencies address infection prevention techniques, proper insertion and maintenance procedures, recognition of complications such as urinary tract infections or catheter obstruction, and appropriate documentation of output and catheter condition.
Wound dressing change competencies verify staff can assess wound characteristics, select appropriate dressing materials, maintain sterile technique, recognize signs of infection or deterioration, and document wound measurements and appearance accurately.
Enteral tube feeding competencies confirm staff understand proper positioning to prevent aspiration, verification of tube placement, administration techniques, recognition of complications such as tube displacement or feeding intolerance, and emergency procedures if problems arise.
The Director of Nursing confirmed to inspectors on March 14 that the facility had no documentation ensuring the four identified employees possessed the specific competencies and skill sets required to care for residents' needs in these areas.
Inadequate Support for Grieving Resident
The facility failed to provide timely medically-related social services to a resident experiencing severe grief and declining health following her husband's death. The resident was informed of her spouse's passing, but social services did not document any intervention focused on grief support until 11 days later.
Clinical records painted a picture of progressive deterioration. On the day the resident learned of her husband's death, nursing notes indicated she "cried for a while with family present" and was "doing well while they were visiting." The following day, staff documented she was "mildly depressed today due to the passing of her spouse."
Within weeks, the resident's condition worsened significantly. A dietary note documented that her son reported she had no appetite since her spouse passed away. The resident confirmed she was "eating less and less." The dietician noted a "significant decreased appetite in the past three months" and notified the physician.
The situation escalated further when the resident stated she "wanted to die." When the social worker responded, the resident appeared unwell with emesis visible in her basin. She clarified that she "did not want to die but that she is just not feeling well and hoping once she is no longer sick, she will feel better overall."
By early February, nursing staff documented the resident's son and daughter-in-law expressing concern that "she was giving up due to wanting to be with her husband in heaven." During an interview with inspectors, the resident acknowledged she had not had an appetite since her husband died, knew she was losing weight, and felt "ok but sad."
Despite these documented indicators of complicated grief and declining physical condition, the facility's response was inadequate. Social services documented meeting with the resident regarding "her depression after her husband passed away" on the date noted, with the resident stating she was "doing okay and is still feeling sad" and trying to "keep her mind busy with leisure activities."
Grief following spousal loss represents a significant medical and psychological event requiring proactive support, particularly in elderly populations. Complicated grief can lead to serious health consequences including depression, loss of appetite, weight loss, social withdrawal, and decline in overall medical condition. Research consistently demonstrates that widowhood increases mortality risk, particularly in the months immediately following the loss.
Best practices in long-term care settings call for immediate grief support interventions, including assessment of the resident's coping mechanisms, emotional support, connection with spiritual or counseling services if desired, monitoring for signs of complicated grief or clinical depression, coordination with family members, and consideration of whether psychiatric consultation or antidepressant medication may be appropriate.
The Administrator acknowledged to inspectors that the facility provided no evidence of medically-related social services including "interventions to provide support during the grieving process and the offer of psych services related to her depressive symptoms."
Pharmacy Oversight Documentation Gaps
The facility failed to maintain records of pharmacy recommendations or evidence that physicians addressed those recommendations for five residents. Monthly medication regimen reviews are required by regulation, with pharmacist recommendations documented and physicians required to respond to those recommendations.
For these five residents, pharmacy notes indicated reviews had been completed and recommendations made to physicians on multiple dates between July 2024 and February 2025. However, the facility could not produce the actual pharmacist reports detailing the recommendations or any documentation showing physicians had reviewed and responded to those recommendations.
This represented a repeat violation—the facility had been cited for the same deficiency in April 2024. The absence of documented pharmacy recommendations and physician responses creates gaps in medication safety oversight and prevents verification that residents receive appropriate pharmaceutical care.
Additional Issues Identified
Inspectors documented several other deficiencies during the March 2025 survey:
Dementia care planning: The facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss for one resident, despite assessing her as having dementia in May 2024. Her care plan indicated "impaired cognitive function related to diagnosis vascular dementia" but lacked specific interventions addressing her dementia-related needs.
Dietary leadership qualifications: The facility employed a part-time registered dietitian who primarily worked remotely with occasional onsite visits during overnight hours when food service operations were not active. The full-time dietary manager lacked required qualifications—she was not a certified dietary manager, did not hold certification as a food service manager, had no national certification for food service management and safety, and did not possess a degree in food service management. Federal regulations require facilities without a full-time qualified dietitian to employ a full-time qualified director of food and nutrition services.
The inspection findings reveal systemic gaps in emergency preparedness, staff training verification, and care plan development at Hearthside Rehab Center. These deficiencies span multiple departments and affect fundamental aspects of resident safety and quality of care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthside Rehab Center from 2025-03-14 including all violations, facility responses, and corrective action plans.
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