SURVEY HELL - PENNSYLVANIA'S GREATEST HITS
Over the past few weeks, CMS surveyors hit Pennsylvania nursing homes with a string of citations so spectacular they deserve their own hall of fame. We've decided not to name these facilities by name - partly out of mercy, partly because the real story here isn't about individual operators failing. It's about a system so broken that these disasters are practically inevitable when you're trying to provide quality care on Medicaid rates that haven't kept pace with costs in decades, while navigating Pennsylvania's labyrinth of regulations.
What follows is a collection of the most jaw-dropping violations from recent surveys. Some earned Immediate Jeopardy citations. All of them reveal the chaos that happens when facilities are stretched so thin that basic safety protocols become aspirational rather than operational.
Think of this as a warning: if your facility hasn't been surveyed recently, these are the kinds of landmines waiting for you. And if you think "that could never happen here," remember - the operators running these facilities probably thought the same thing.
Let's dive into Pennsylvania's regulatory theater of the absurd:
THE INSULIN PUMP DISASTER
A diabetic resident came to the facility with an insulin pump that delivers continuous medication. The facility had zero policies for insulin pumps, zero training for staff, and zero clue what they were doing.
What Should Have Happened: Refill the insulin pump with 90 units of Humalog insulin
What Actually Happened: A nurse injected 90 units of insulin directly under the resident's skin - essentially giving him a double dose that sent him to the ER with hypoglycemia
THE STAFF INTERVIEWS WERE LESS THAN GLOWING:
RN Employee E1: "No. I haven't had education on an insulin pump."
LPN Employee E2: Only knew about pumps because her relative had one, thought "they last a long while," didn't know what type the resident had
RN Employee E3: Found it beeping one day, thought it "looked like a very tiny infusion machine"
LPN Employee E6: First day on the job, no orientation, transcribed the wrong insulin type, gave injection instead of refilling pump
The Director of Nursing literally said: "I don't think we have a policy for insulin pumps."
The resident (who had moderate cognitive impairment) ended up teaching the RN how to use his own insulin pump because the nurse had no idea what the beeping device was.
ESCAPE ARTIST EXTRAORDINAIRE
Escape: A cognitively impaired resident with a Wanderguard bracelet escaped the facility when a CNA "accidentally" let him out with the smoking group. The facility's response? "Oops, the alarm doesn't work when we open the door."
The Kicker: They had another resident who staff knew was an elopement risk - she'd already gotten out with visitors once and was constantly trying doors - but they discontinued her Wanderguard after a week because "she didn't communicate any wants to leave." Genius logic.
PAIN MEDS AS THREATS
A nurse practitioner literally threatened to reduce a resident's pain medications if he didn't stop complaining about staff. The resident had chronic pain from osteomyelitis and needed pain meds every 4-6 hours, but when he got upset about delays, the NP wrote: "I discussed at length with resident that it is never ok to treat staff that way, we do not tolerate verbal abuse and will reduce pain medications in future if this behavior persists."
That's using medical care as punishment - textbook abuse. To even write that down is next level genius.
THE UBER ESCAPE
In another incident: A resident was taken to a doctor's appointment, left alone in the lobby, called an Uber, and went to his home instead of returning to the facility. Staff had to file a missing person report with the police. Ouch.
SOME MORE GEMS:
A resident ordered to wear compression gloves for swelling - staff couldn't find them for days
A resident needing glasses for cataracts - facility couldn't get insurance approval so he just went without
Unlabeled food containers everywhere (cooked beef, pickles, potatoes)
Missing temperature logs for days at a time
Meat slicer with no cover, attracting contamination
No tray tickets for a week because their printer broke, so they hand-wrote names on placemats without including allergy information
THE WEIGHT GAIN BLINDNESS
A veteran with congestive heart failure and chronic kidney disease - who was supposed to be weighed 3x weekly due to fluid concerns - gained 20 pounds in 5 days (from 197 to 217 lbs). This 9.22% weight gain screamed "heart failure emergency," but:
Nobody assessed the resident
Nobody notified the physician until 9 days later
The facility's own policy required immediate physician notification for 5% weight changes
THE MEDICATION CART BONUS ROUND
Because why stop at missing narcotics? Surveyors found an entire medication cart unlocked with the narcotic drawer wide open. Just sitting there like a pharmacy buffet.
THE ESCAPE ARTIST - WHEN THIS RESIDENT RAN OUT OF CIGARETTES HE:
Waited until nobody was at the front desk
Leaned over the desk and pushed the secret door unlock button (which he'd observed staff using)
Walked out with his walker
Opened the front porch gate
Headed down the street to find a store
The facility's response? "It was unknown that Resident R1 left the building" until a staff member who'd already gone home for the day spotted him standing by the road and gave him a ride back.
THE RESIDENT'S CRYSTAL-CLEAR POSITION: When interviewed, the resident was refreshingly honest: "If I need a cigarette I will. I am an adult, they cannot hold me here against my will." He had figured out the door mechanism and wasn't shy about using it again.
ANOTHER CASE OF ESCAPE
This facility managed to lose a cognitively impaired resident who was assessed as having "poor decision-making skills" and "demonstrated exit seeking behavior." Their brilliant safety plan? Put him in a recliner and hope for the best.
The Timeline of Failure:
7:10 PM: Staff sees resident in lounge area
7:30 PM: Staff puts him back in his room
7:30-7:55 PM: Nobody supervises him
7:50 PM: Police find him four blocks away, barefoot, in someone's backyard with no memory of how he got there
The Best Part: The RN Supervisor initially lied and said she "saw the resident walk outside" and that "staff offered him a ride and he refused." Video footage later proved this was completely false - she had left the front desk unattended, leaving the front door unsupervised.
The Kicker: The facility never called 911 or local police. They only learned their resident was missing when 911 called THEM asking if this guy belonged to them. A random passerby saw a barefoot man wandering and called police.
The Family's Response: When contacted, the resident's sister-in-law said: "I'm not surprised, I hate to say that; however, he has done this at every facility he has been in with the exception of one and that was following a surgery."
Wow an honest relative - that's rare.
INVESTIGATION FAILURES
In another case: When residents got injured during transfers, the facility's "thorough investigation" involved interviewing staff who weren't even assigned to the residents and skipping the people who actually provided care. For one resident with unexplained bruising, they interviewed 4 people - only 1 of whom actually cared for the resident in the previous 72 hours.
THE REAL STORY NOBODY WANTS TO ADMIT
These aren't isolated incidents from a few "bad apple" facilities. This is what happens when you try to staff a nursing home on Medicaid rates that lose $60-80 per patient per day, in a state that uses your money to fund its budget schemes while acting like they're doing you a favor. When you're hemorrhaging cash on every Medicaid admission, you can't compete for quality staff. When you can't compete for quality staff, you get nurses who don't know how insulin pumps work, CNAs who leave cognitively impaired residents unsupervised, and administrators too overwhelmed to implement basic safety protocols.
None of this excuses what happened at these facilities. When you accept a nursing home license, you're accepting responsibility for human lives - the most vulnerable people in our society. Medicaid underfunding is real, the financial pressure is crushing, and the system is fundamentally broken. But residents still deserve safe care, proper medication administration, and basic supervision. If you can't provide that, you shouldn't be operating, regardless of what Medicaid pays. The failures documented in these surveys represent real people who suffered because facilities couldn't - or wouldn't - meet minimum standards of care.
That said, Pennsylvania's regulators will write up every single one of these violations, slap facilities with fines and deficiency citations, and demand corrective action plans. But they won't address the fundamental problem: you cannot sustainably provide safe, quality care when your largest payer reimburses you at 30-50% below cost.
The state will keep running its provider tax schemes, pocketing federal matching funds, and watching facilities struggle - then acting shocked when surveys reveal the predictable consequences of chronic underfunding.
Every one of these citations represents a real person who didn't get the care they deserved. Operators must do better, even in impossible circumstances. But fixing the citations without fixing the funding is like putting a band-aid on a bullet wound. Until Pennsylvania and CMS address the Medicaid crisis, these survey reports will keep coming - different facilities, same systemic failures, same impossible math that forces impossible choices.
