Champion City Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 6655 Frankstown Avenue, Pittsburgh, Pennsylvania 15206
- CMS Provider Number
- 395423
- Inspections on file
- 38
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Champion City Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Dietary staff failed to follow safe food storage and infection control practices, including storing cups in a flour bin, improperly storing uncooked ground pork, keeping an open undated bag of hash browns in the freezer, placing cases of ice cream directly on the freezer floor, and leaving individual ice cream containers open. During tray line, a server handled Salisbury steaks with gloved hands and then opened a warming cart without changing gloves, and plate lids remained wet from recent washing. In the dish room, a dietary staff member repeatedly moved from loading dirty dishes to unloading clean dishes without hand hygiene. The Dietary Manager confirmed failures in labeling, dating, and maintaining sanitary conditions, creating potential for cross contamination.
The facility failed to implement an antibiotic stewardship program for 12 of 12 months. Review of the Antibiotic Stewardship policy said antibiotics would be prescribed and administered under the guidance of the program, but the Infection Control Program had no documented evidence of antibiotic monitoring or appropriate use. The DON told the SA that a new infection preventionist had just been hired, found a binder with only lab reports, and confirmed there was no facility tracking of antibiotics.
The facility failed to follow its posted menus and provide complete ordered meal items during two observed lunch services. On one day, residents did not receive all items listed on the menu, including finger foods, gelatin, milk, and prescribed nutritional supplements such as magic cups and peanut butter and jelly sandwiches, as confirmed by an LPN. On another day, instead of the planned entrée and sides, multiple residents were served alternate items without corresponding menu updates, and many trays were missing soup, vegetables, bread pudding, and nutritional supplements. Dietary staff and the dietary manager acknowledged that a different menu was served and that menu changes were not properly reflected.
Surveyors found that the facility did not maintain an effective pest control program in the main kitchen dish room, where multiple sticky traps were full of fruit flies and additional fruit flies were observed while staff were washing dishes. Review of pest-control logs showed repeated crack and crevice spray treatments to the kitchen and related areas over several months, yet fruit flies remained present in the dish room. The Dietary Manager acknowledged that the pest control program in the main kitchen was not effective, and the deficiency was cited under applicable state regulations for licensee and administrator responsibility.
Failure to convey resident funds and close accounts within 30 days for three closed residents. Facility policy required final accounting and return of personal funds after discharge, eviction, or death, but trust fund records still showed balances for residents who had died or been transferred out. The RBO Manager confirmed the accounts remained open and funds were not conveyed as required.
Failure to Document Review of Psychotropic Medication Use: The facility did not ensure psychotropic regimens were free from potentially unnecessary meds for four residents. Pharmacist MRRs repeatedly noted antipsychotics and antidepressants without an allowable dx or due for GDR, but physician responses were missing in the records for multiple residents. Two residents also had no documented MRRs for several months while receiving meds such as quetiapine, olanzapine, alprazolam, mirtazapine, aripiprazole, and lorazepam. The DON stated no MRRs were available before August and confirmed the missing documentation.
Missing transfer documentation, bed-hold notices, and Ombudsman notifications. The facility did not document that required resident information was sent to the receiving provider for several residents transferred to the hospital, including care plan goals and, for some, advance directive and representative information. The facility also did not provide written bed-hold policy information to several residents or representatives and did not notify the State LTC Ombudsman for multiple hospital transfers.
Delayed completion of admission MDS assessments. The facility failed to ensure that comprehensive MDS assessments were completed within the required timeframe for three residents. An RNAC stated the prior position had been vacant for several months, and she confirmed the assessments were not completed on time for the affected residents.
Baseline care plans were not completed with the minimum needed instructions for three residents. One resident had HTN, depression, and PTSD; another had HTN, DM, HLD, and an order for sliding-scale insulin; and a third had HTN, HIV, and viral hepatitis. The plans were missing key items such as dietary, social service, diabetes management, and initial goals, and RN, DON, and clinical leadership confirmed the omissions.
Failure to document post-fall assessments and maintain 1:1 supervision: Two residents with diagnoses including dementia, HTN, and cerebral infarction were found after falls, but the record did not show RN assessments or documented monitoring for delayed complications. In another event, a resident with diabetes, anxiety, and schizophrenia reported suicidal thoughts to a crisis center and was placed on 1:1, but surveyors observed the assigned NA away from the resident and the resident out of sight; the DON confirmed the resident was not being supervised 1:1.
Missing catheter orders, incomplete catheter care, and lack of dignity protections. The facility did not have physician orders for catheters for multiple residents, and catheter care was not consistently provided as scheduled for some residents. In addition, two residents were observed with foley drainage bags hanging without privacy covers, and the DON and an LPN confirmed the missing orders, missed care, and lack of privacy protection.
Failure to provide and maintain respiratory equipment: A resident with OSA had a BI-PAP machine at the bedside with the mask not stored in a bag, and the chart lacked current MD orders and care plan interventions for the device. Two residents with COPD had oxygen/nebulizer equipment that was not stored as required, including tubing and masks left out or hanging on a nightstand, and staff confirmed the equipment was not maintained properly.
The facility failed to maintain consistent communication with the dialysis center for one resident and failed to complete ordered dialysis access site monitoring for three residents. The residents had ESRD and other diagnoses, and records showed missed TAR documentation for access site checks, no communication in one resident’s dialysis binder, and staff sent that resident to dialysis without the binder when it could not be found; the DON confirmed the failures.
Missing Monthly MRR Documentation and Physician Review: The facility failed to document monthly pharmacist MRRs and attending physician review for multiple residents. Records showed repeated pharmacist recommendations involving antipsychotics, antidepressants, anxiolytics, and GDRs for residents with diagnoses such as dementia, depression, anxiety, insomnia, hypertension, and schizoaffective disorder, but the chart often lacked physician responses. The DON confirmed that monthly MRR documentation was incomplete and that some MRRs were being addressed by the facility and psych CRNPs rather than the attending physician.
Improper medication storage and labeling were observed in several medication carts and a medication room. Surveyors found unlabeled or undated insulin, liquid medications, inhalers, loose pills in a medication cup, and food items stored in an IV supplies drawer; an LPN also confirmed a medication cart was left unlocked and unattended in the hallway.
QAA meetings were not held quarterly with all required members present for three of four quarters reviewed. Sign-in sheets showed the DON was absent from two quarterly meetings, and the IP was absent from one quarterly meeting. The RNH Administrator confirmed the missing attendance during interview.
Failure to implement EBP, infection surveillance, and aseptic wound care. A resident with a Foley catheter had no EBP signage on the door and no timely EBP order, while the DON confirmed EBP was not implemented. The facility also could not provide infection surveillance documentation for multiple months, and an LPN failed to clean scissor blades before cutting dressing material during a wound care procedure for a resident with a wound infection and paraplegia.
Failure to Maintain a Qualified Infection Preventionist: The facility did not have a consistent qualified IP onsite to coordinate and oversee the infection prevention and control program for several months. The IP policy required a certified IP with enough scheduled time to manage the program, but review of records showed the facility lacked a certified IP during the identified period. The NHA stated a new IP had been hired, and the DON confirmed the facility had failed to designate a qualified individual responsible for infection prevention activities.
Surveyors found that one floor of the facility was not maintained in a safe, clean, and homelike condition, despite a policy requiring such an environment. During a tour with the Director of Operations, multiple resident rooms were observed with unpainted plaster, missing or loose vent covers, missing bathroom doorknobs, broken window blinds, missing ceiling tiles, and brown or discolored ceiling tiles. One room had a baseboard heater behind the bed that exposed sharp objects. Hallways and a resident common room also had chipped and unpainted walls, brown rusty ceiling tile tracks, and brown ceiling tiles throughout. The Director of Operations confirmed these environmental deficiencies.
A resident with hypertension, hyperlipidemia, and a cognitive communication deficit experienced an acute change in condition, including labored mouth breathing, dry mucous membranes, low BP, and inability to obtain an O2 saturation. A caregiver alerted an LPN, who assessed the resident, notified a supervisor, called 911 per the supervisor’s instruction, and informed the resident’s sister and on-call provider. The resident later stopped breathing as EMTs prepared transfer and CPR was performed until the resident was pronounced deceased. Review of the clinical record showed no documentation that an RN assessed the resident after the change in condition, and the DON confirmed the facility failed to ensure appropriate treatment and care consistent with professional standards.
The facility failed to follow its policy requiring outdoor garbage containers to have tight-fitting lids kept closed when not in continuous use. During an observation of the outdoor trash area, two of four dumpsters were found with their lids open. The Dietary Manager confirmed at the time of observation, and later in interview, that the lids on these dumpsters were not closed and that garbage was not properly contained to prevent potential rodent and insect infestation, resulting in a deficiency under facility management regulations.
Failure to Explain NOMNC to Resident With Severe Cognitive Impairment: A resident with a BIMS score indicating severe cognitive impairment had a NOMNC signed by the resident even though the resident had a son listed as responsible party and POA. The RBM confirmed the facility did not ensure the NOMNC was explained to the resident and representative in a way they could understand.
Failure to protect resident medical information: On the Fifth Floor Nursing Unit, a medication cart was left unattended outside a resident room with the computer screen open and identifiable resident information visible to passersby. An LPN confirmed the observation and that the facility failed to maintain confidentiality as required.
Failure to Complete Pre-Employment Criminal Background Check: The facility failed to complete a state criminal background check before hiring a Nurse Aide. Review of the personnel file showed the employee was hired without the required background check in place, and the HR Director confirmed the screening was not completed prior to the start of employment.
A resident with muscle weakness, aphasia, and dementia had an MDS coded to show no weight gain even though the chart documented a significant increase in weight over six months. The RNAC confirmed the weight change was not marked on the MDS, resulting in inaccurate assessment coding.
Care plan failed to reflect a resident’s current status. A resident with HTN, depression, and PTSD had physician orders for bilateral upper side rails as enablers for bed mobility and repositioning, and an observation showed the resident in bed with enabler bars on both sides. Review of the current care plan showed no interventions for the side rails, and an RN confirmed the omission.
Nursing was absent from multidisciplinary care conferences for two residents. One resident had diagnoses including a fractured femur, COPD, and dysphasia, and another had ESRD, dialysis dependence, and DM. The care conference sign-in sheets listed social work, dietary, and activities, but not nursing, and the DOSS confirmed nursing was unavailable for the meetings as required.
Failure to Monitor Weight and Nutrition Status: A resident with muscle weakness, aphasia, dementia, and tube feeding had missed monthly weights and later missed ordered weekly weights after hospital returns. The record showed significant weight gain, nutrition notes documenting the gain, and an RD confirmed the facility did not obtain the required weights to monitor the resident’s weight and nutrition status.
Failure to Provide Ordered Special Eating Equipment: A resident with anemia, HTN, and hyperlipidemia had a physician order for a scoop dish for all meals, but staff observed the resident using a regular plate on the lunch tray on two occasions. NAs confirmed the meal ticket indicated a scoop dish was ordered and that the facility failed to provide it.
Inaccurate COVID-19 Vaccine Documentation: The facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for a resident with depression, dementia, and insomnia. The resident’s record showed the vaccine was not up to date, the last COVID-19 vaccination was documented in the chart, and a consent form indicated consent was obtained but the vaccine was not given. The DON confirmed the documentation failure.
A resident with multiple medical conditions reported giving another resident a lottery ticket and cash to redeem and purchase more tickets, but never received the money or tickets back. The DON documented the incident, but the facility did not submit a timely report of the misappropriation allegation to the State field office as required by policy and regulations.
A resident with multiple medical conditions and advanced pressure ulcers did not consistently receive or have documented wound care as ordered. Several days of wound treatments were not recorded, and there was no documentation of refusals or reasons for missed care. Facility leadership confirmed that wound care coverage was not effectively communicated when the wound nurse was unavailable, leading to lapses in treatment and documentation.
Facility staff did not maintain required minimum staffing levels for NAs and LPNs across multiple shifts, as confirmed by census data, schedules, and staff interviews. There were several days when the number of NAs and LPNs on duty fell below mandated ratios, and no additional higher-level staff were present to compensate for these shortages.
Facility staff did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on 16 out of 21 days, as confirmed by review of schedules and census data and acknowledged by the NHA.
Four residents who either requested or had physician orders for podiatry services did not receive professional podiatry care as required. Two residents lacked necessary podiatry consult orders despite relevant medical conditions, while two others with existing orders were not seen by the contracted podiatry provider. Staff interviews confirmed the facility did not follow its process for arranging podiatry consultations.
A resident with multiple medical conditions was found to have a dislocated shoulder, which was discovered by her family and confirmed by X-ray. Although the resident reported the injury occurred during a previous fall and denied harm, the facility did not conduct a thorough investigation into the incident. Additionally, staff did not follow physician orders for two-person transfers, as records showed the resident was transferred by only one staff member. Leadership was unaware of these issues.
A resident with multiple diagnoses did not have physician progress notes written, signed, and dated in a timely manner after required visits. The Medical Director entered these notes between 27 and 32 days after the actual visits, contrary to facility policy and regulatory requirements. The DON and administrator confirmed the deficiency during review.
Two residents who requested or required dental care were not scheduled for dental appointments, despite one having a physician order for a dental consult and the other reporting discomfort with dentures. Staff interviews confirmed the facility did not follow its process for obtaining dental services, resulting in these residents not being seen by the contracted dental provider.
A resident with diabetes, end stage renal disease, and atherosclerosis did not have their medical records provided to their legal representative after a request was made by a law firm. The facility administrator could not produce documentation that the records were sent, despite the request being made months earlier.
The facility did not provide the required 3.2 hours of direct nursing care per resident per day on multiple occasions. A review of nursing schedules and census data revealed that on several days, the provided care hours were below the mandated threshold, with the lowest being 2.54 hours. This was confirmed by the NHA during an interview.
The facility failed to maintain comfortable air temperature levels for 22 residents due to a boiler malfunction that was not promptly addressed. Despite noticing low temperatures, maintenance staff did not take immediate corrective action, and residents reported feeling cold. Temperature logs showed that many areas were below the required range, highlighting a lapse in communication and timely response to maintenance issues.
The facility failed to report an interruption of heating services to the State Agency in a timely manner. The boiler stopped functioning, leading to a loss of heating, but the incident was not reported until several days later.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to unwanted sexual contact with two other residents with severe cognitive impairments. The facility failed to maintain necessary interventions, resulting in an Immediate Jeopardy situation.
The NHA and DON failed to effectively manage the facility to prevent sexual abuse, resulting in immediate jeopardy for all residents. Despite clear responsibilities to ensure compliance and resident safety, both leaders acknowledged they did not fulfill their duties, leading to incidents of sexual abuse involving two residents.
The facility did not review or revise the care plans for two residents with cognitive impairments after incidents involving alleged sexual abuse, resulting in care plans that did not address the residents' current needs or include interventions to prevent further incidents.
The facility failed to maintain sanitary conditions in the main kitchen, specifically in walk-in coolers #3 and #4, where a build-up of dust, grime, and debris was observed on the cold air condenser fan covers and the floor. This non-compliance with the facility's food safety policy was confirmed by the Dietary Director, creating a potential for cross-contamination.
The facility failed to prominently post the grievance policy throughout the nursing units, omitting information on anonymous grievance filing and contact details for the grievance officer. Residents were unaware of the grievance procedures, and the Director of Social Services confirmed these deficiencies.
A facility failed to communicate necessary resident information to receiving health care providers during transfers for three residents. These residents, with various medical conditions such as hypertension, aphasia, anxiety, and hemiplegia, were transferred to the hospital without documentation of care plan goals, advanced directives, or specific care instructions. The DON confirmed the oversight, which violated facility policy and regulatory requirements.
A facility failed to ensure accurate resident assessments for four residents, as per the RAI User's Manual guidelines. Errors included incomplete BIMS interviews and incorrect documentation of a weight-loss regimen. Staff interviews confirmed these inaccuracies, highlighting a significant oversight in maintaining accurate clinical records.
The facility failed to provide necessary assistive devices and services to prevent further decrease in range of motion for several residents. A resident with a history of stroke was not provided with a palm guard for his hand contracture, while another with dementia was without required wedges and splints. A resident with cerebral palsy did not have prescribed splints, and another with muscle weakness was not given a knee extension splint. Staff confirmed the absence of these devices, and the Vice President of Clinical acknowledged the facility's failure.
Improper Food Storage and Infection Control Practices in Kitchen and Dish Room
Penalty
Summary
Facility dietary staff failed to follow safe food storage and handling practices and infection control procedures in the main kitchen and dish room, contrary to facility policy requiring compliance with safe food handling practices. During observation of the main kitchen, surveyors noted two cups stored inside a flour bin, two packages of uncooked ground pork stored improperly, one open and undated bag of hash browns in the freezer, two cases of ice cream stored directly on the walk-in freezer floor, and five individual ice cream items open in the walk-in freezer. During a tray line observation, a server was seen picking up Salisbury steaks with gloved hands, then opening a warming cart door without changing gloves, and plate lid covers used for meal service were still wet from being washed earlier. In the dish room, a dietary staff member was observed repeatedly loading dirty dishes into the washer and then unloading clean dishes from the clean side after the wash cycle without washing hands between handling dirty and clean items. The Dietary Manager confirmed that the facility failed to properly label and date food products and maintain sanitary conditions, creating the potential for cross contamination in the kitchen and dish room. No specific residents or their medical conditions were mentioned in the report.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 12 of 12 months, from March 2025 through February 2026. Review of the facility’s Antibiotic Stewardship policy dated 10/29/25 indicated that antibiotics would be prescribed and administered to residents under the guidance of the facility’s antibiotic stewardship program, but review of the Infection Control Program for the same 12-month period failed to show documented evidence that antibiotic monitoring and appropriate use were completed. During interview, the DON reviewed the infection control documents with the SA and was unable to provide the facility’s antibiotic stewardship program, stating that a new infection preventionist had just been hired and that the facility would be working to get infection control in order. The DON later stated that a binder found in an office contained only lab reports and did not include any facility tracking of antibiotics, and then confirmed that the facility failed to implement an antibiotic stewardship program for the entire 12-month period.
Failure to Follow Posted Menus and Provide Complete Ordered Meal Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its posted menus and ensure that meals met residents’ nutritional needs as required by facility policy and 28 Pa. Code 211.6(a)(b) on dietary services. The facility’s Food and Nutrition Services policy dated 10/29/25 required that each resident receive a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, considering resident preferences. The Tray Identification policy dated 10/29/25 required appropriate identification to distinguish various diets. On the lunch meal of 3/23/26, the written menu called for chicken and biscuits, carrots, cranberries, gelatin, and juice. During observation of this meal on the third floor, multiple residents did not receive all items ordered for them: one resident was missing finger foods, a magic cup, a peanut butter and jelly sandwich, and milk; three residents were missing magic cups; and three residents were missing gelatin. An LPN confirmed these missing food items at the time of the observation. On the lunch meal of 3/24/26, the written menu specified Salisbury steak, carrots, mashed chive potatoes, gravy, soup, and bread pudding. During observation of the trayline service in the main kitchen, 14 residents instead received hamburger or grilled cheese, mashed chive potatoes, and California vegetables. A dietary employee acknowledged serving a different menu, explaining that the morning cook had called off, carrots had been served two days in a row, and the correct food was not provided to the personal care area. The dietary manager confirmed that the facility failed to serve what was on the menu and to update the menu to reflect changes. Additional observations on the third floor that day showed multiple residents missing required items such as soup, vegetables, bread pudding, onions and mushrooms, and magic cups. An LPN again confirmed the missing items for these residents during interview.
Failure to Maintain Effective Pest Control in Main Kitchen Dish Room
Penalty
Summary
Surveyors determined that the facility failed to maintain an effective pest control program in the main kitchen dish room, as evidenced by the presence of numerous fruit flies despite ongoing pest-control treatments. During an observation on 3/26/26 at approximately 9:35 a.m., three gold fly sticky traps in the dish room were found to be full of fruit flies, and additional fruit flies were observed in the area while staff were actively washing dishes. Review of pest-control logs from 9/17/25 through 2/11/26 showed multiple crack and crevice spray treatments to the kitchen, dish room, dining room, maintenance hall, and other areas on specified dates, but these measures did not prevent the continued presence of fruit flies in the dish room. In an interview at 10:00 a.m. on the same day, the Dietary Manager confirmed that the facility had failed to maintain an effective pest control program in the main kitchen. No residents or specific patient conditions were mentioned in the report. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 207.2(a) Administrator's responsibility.
Failure to Convey Resident Funds After Discharge or Death
Penalty
Summary
The facility failed to convey resident funds and close resident accounts within 30 days after discharge, eviction, or death for three closed resident records: CR186, CR187, and CR188. Facility policy titled "Conveyance of Resident Funds" dated 10/29/25 stated that a resident's personal funds and final accounting are to be returned to the resident, the resident's representative, or the resident's estate, as applicable, within 30 days of discharge, eviction, or death. Review of the records showed CR186 was admitted with diagnoses of high blood pressure, hyperlipidemia, and unsteadiness on feet and ceased to breathe at the facility on 2/5/26. CR187 was admitted with diagnoses of high blood pressure, muscle weakness, and dysphagia and was transferred to the hospital on 9/24/25, where the resident ceased to breathe on 9/25/25. CR188 was admitted with diagnoses of hyperlipidemia, anxiety, and high blood pressure and ceased to breathe at the facility on 8/19/25. A review of the facility trust fund account dated 3/23/26 showed balances still held for CR186 in the amount of $3,778.30, CR187 in the amount of $240.54, and CR188 in the amount of $517.07. During interview, the Regional Business Office Manager confirmed the facility failed to convey resident funds and close the accounts within 30 days for all three closed residents.
Failure to Document Review of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that medication regimens were free from potentially unnecessary psychotropic medications for four residents. Review of facility policy showed psychotropic medications were to be clinically indicated and necessary for a specific condition documented in the medical record, and that medication regimen reviews were to be completed monthly with pharmacist recommendations reviewed and addressed by nursing leadership and the attending physician. The deficiency involved antipsychotic, antidepressant, and anti-anxiety medications for residents with diagnoses including dementia, depression, anxiety, insomnia, and schizoaffective disorder. For one resident with dementia, cerebral infarction, and hypertension, the pharmacist repeatedly noted that quetiapine lacked an allowable diagnosis to support its use and later noted the resident was due for a gradual dose reduction; the clinical record did not include a response from the attending physician to those recommendations. The same resident also had an antidepressant recommendation for possible gradual dose reduction, and the record again lacked a physician response, although a CRNP later documented that further reduction would likely worsen symptoms and another note referenced schizoaffective disorder and psychiatric records. For another resident with depression, dementia, and insomnia, the pharmacist repeatedly noted that olanzapine lacked an allowable diagnosis and later recommended a gradual dose reduction, and the record did not include a physician response to those recommendations. For a third resident receiving alprazolam for anxiety, the record did not show medication regimen reviews for several consecutive months. For a fourth resident with depression, schizoaffective disorder, and muscle weakness, the record also did not show medication regimen reviews for several consecutive months while the resident received mirtazapine, aripiprazole, and lorazepam. The DON stated there were no medication regimen reviews available before August 2025 and confirmed the facility failed to provide documentation that the medication regimens were free from potentially unnecessary medications for the four residents.
Missing Transfer Documentation, Bed-Hold Notices, and Ombudsman Notifications
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for five of six residents who were transferred to the hospital or another facility. The clinical records for Residents R8, R12, R35, R180, and R184 did not contain documented evidence that the facility sent specific information needed by the receiving provider, including care plan goals and other information necessary to meet each resident’s specific needs. For some residents, the missing information also included advanced directive information, resident representative information, and specific instructions for ongoing care. Resident R8 had diagnoses of anemia, high blood pressure, and diabetes and was sent to the local emergency room after an uncontrollable nosebleed. Resident R12 had diagnoses of heart failure, cerebral infarction, and multiple sclerosis and was transferred to the hospital before returning to the facility. Resident R35 had diagnoses of anemia, high blood pressure, and hyperlipidemia and was sent to the hospital after a physician assessed a cyst on the back of the resident’s neck. Resident R180 had diagnoses of dementia, dysphagia, and muscle weakness and was transferred to the hospital before returning to the facility. Resident R184 had diagnoses of neurogenic bladder, diabetes, and multiple sclerosis and was transferred to the hospital and did not return. The facility also failed to provide written bed-hold policy information to the resident or resident representative for four of six hospital transfers, including Residents R12, R35, R180, and R184. In addition, the facility failed to notify the Office of the State Long-Term Care Ombudsman for five of six hospital transfers, including Residents R12, R35, R168, R180, and R184. The Nursing Home Administrator confirmed there was no evidence that the State Ombudsman office was notified for the hospital transfers, and the Regional Director of Clinical Services confirmed the missing transfer communication and bed-hold notification for several residents.
Delayed Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were completed within the required time frame for three residents. Review of the RAI User's Manual showed that an admission MDS assessment was to be completed no later than 14 calendar days after admission. Resident R28 was admitted on 1/17/26, had an MDS completion date of 1/30/26, and the MDS was signed off as completed on 2/4/26, five days after the due date. Resident R36 was admitted on 1/21/26, had an MDS completion date of 2/3/26, and the MDS was signed off as completed on 2/4/26, one day after the due date. Resident R48 was admitted on 1/19/26, had an MDS completion date of 2/1/26, and the MDS was signed off as completed on 2/4/26, three days after the due date. During interview, the RNAC stated she had just started in February and that the previous position had been vacant from about November 2025 through January 2026, and she confirmed the facility failed to make certain the assessments were completed in the required time frame.
Baseline care plans were incomplete for three residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission that included the minimum healthcare instructions needed to provide effective, person-centered care for three residents reviewed. The facility policy stated that a baseline care plan must address the resident’s immediate health and safety needs and include initial goals based on admission orders and discussion with the resident or representative, physician orders, dietary orders, therapy services, and social service information until a comprehensive care plan is completed. Resident R6 was admitted with diagnoses including high blood pressure, depression, and PTSD, but the baseline care plan did not include dietary, social service, or initial goals. Resident R24 was admitted with diagnoses including high blood pressure, diabetes, and hyperlipidemia, and had a physician order for Insulin Lispro sliding scale, but the baseline care plan did not include diabetes management, dietary, social service, or initial goals. Resident R147 was admitted with diagnoses including high blood pressure, HIV disease, and viral hepatitis, and the baseline care plan did not include dietary, social service, or initial goals. RN E16, the DON, and the President of Clinical Services confirmed that the baseline care plans were not completed for these residents and that the care plans failed to include the information necessary to properly care for them.
Failure to Document Post-Fall Assessments and Maintain 1:1 Suicide Supervision
Penalty
Summary
The facility failed to perform timely and accurate post-fall documentation and failed to ensure appropriate treatment and care were provided for two residents after falls. Resident R10 had diagnoses including HTN, dementia, and anxiety. After being found on the floor at 2:10 a.m., an LPN documented that the resident was alert and oriented, denied hitting her head and pain, had vital signs taken, and was assisted back to bed. The clinical record did not include documentation that an RN assessed the resident after the fall. Later that morning, an RN documented that the resident was found on the bathroom floor and that the night nurse had reported an earlier fall around 2:00 a.m. The RN note stated the physician and family were notified and that the resident would continue to be monitored. However, the record did not include documentation that the resident was monitored for delayed complications after the suspected fall at either time. Facility policy stated staff were to observe for delayed complications for approximately 48 hours after an observed or suspected fall and document findings in the medical record. Resident R13 had diagnoses including dementia, cerebral infarction, and HTN. After being found lying backwards in a bathtub in another resident’s room, an LPN documented the unwitnessed fall, but the record did not include documentation that an RN assessed the resident afterward. Interviews with staff and the DON confirmed the lack of documented RN assessment. The report also identified Resident R181, who had diagnoses including diabetes, anxiety, and schizophrenia, and who stated to a crisis center that she was having thoughts of suicide. Although the resident was placed on 1:1 supervision, surveyors observed the assigned NA away from the resident and the resident out of sight, and facility leadership confirmed the resident was not being supervised 1:1 to ensure safety.
Missing catheter orders, incomplete catheter care, and lack of dignity protections
Penalty
Summary
The facility failed to obtain physician orders for urinary catheters for three residents. Resident R4’s record showed diagnoses of left femur fracture, COPD, and dysphasia, but the physician order dated 8/14/25 did not include the catheter, balloon size, or a valid medical diagnosis for the catheter. During interview, the DON confirmed there were no orders for R4’s catheter as required. Resident R9’s record showed diagnoses of muscle weakness, aphasia, and dementia, and the MDS indicated an indwelling catheter. Review of the clinical record did not reveal a physician’s order for a catheter or a care plan for catheter care. The treatment record directed staff to provide catheter care every shift beginning 3/4/26, but catheter care was not documented on the evening shift of 3/12/26, the evening shift of 3/16/26, and the night shift of 3/20/26. The DON confirmed that R9 did not have a current catheter order, did not have a catheter care plan, and did not receive catheter care on those shifts. Resident R125’s record showed diagnoses of muscle weakness, kidney failure, and high blood pressure, and the MDS indicated an indwelling catheter. A progress note documented that the foley catheter was intact, patent, and draining yellowish urine, but the clinical record did not reveal a physician’s order for the catheter. The treatment record indicated catheter care every shift starting 3/18/26, but the resident did not receive catheter care from readmission on 3/11/26 through 3/17/26. During observation, R125’s catheter bag was hanging on the bedframe without a privacy cover, and the NA confirmed the lack of a privacy cover. Resident R180’s record showed diagnoses of dementia, dysphagia, and muscle weakness, and the MDS indicated an indwelling catheter. The resident was admitted with a foley catheter, but the record showed a physician order without a diagnosis for the catheter and without a catheter diagnosis in the care plan. During observation, R180’s catheter bag was hanging on the wheelchair without a privacy cover, and the LPN confirmed the lack of a privacy cover.
Failure to Provide and Maintain Respiratory Equipment
Penalty
Summary
Appropriate respiratory care was not provided for a resident with obstructive sleep apnea who had a BI-PAP machine at the bedside. During observation, the resident’s bedside stand had the BI-PAP machine with the mask lying on top of the stand and not stored in a bag as required. Review of the resident’s current physician orders did not include instructions for the BI-PAP machine, and the current care plan did not include interventions for the BI-PAP machine. An LPN confirmed the BI-PAP mask was not stored in a bag, and an RN later confirmed the resident did not have current physician orders or a care plan intervention for the BI-PAP machine. The facility also failed to maintain oxygen equipment for two residents receiving respiratory treatments. One resident with COPD had oxygen in use by nasal cannula at 4 liters per minute every shift, with orders to change oxygen tubing and filter weekly and to use ipratropium-albuterol solution via nebulizer as needed; during observation, the oxygen concentrator was beside the bed, the oxygen tubing and nebulizer tubing were dated, and the nebulizer tubing and mask were not stored in a bag when not in use. Another resident with COPD had a physician order for Nebusal inhalation nebulization solution twice daily, and during observation the resident’s nebulizer was hanging on the nightstand drawer wrapped around the pull handle and not stored in a bag. Staff confirmed the tubing and nebulizer equipment were not stored as required, and the DON confirmed the facility failed to provide appropriate respiratory care for the two residents.
Dialysis Communication and Access Site Monitoring Failures
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for Resident R171 and failed to ensure monitoring of dialysis access sites was completed for Residents R11, R47, and R171. The facility policy required ongoing assessment of residents receiving hemodialysis, communication and collaboration with the dialysis facility, and monitoring and documentation of the access site upon return from dialysis for bleeding or other complications. Resident R11 had diagnoses including high blood pressure, ESRD, and hemiplegia, and had a physician order to check the right chest tunneled dialysis catheter for bleeding or signs of infection every shift. The March 2026 TAR showed missed documentation on multiple shifts. Resident R47 had diagnoses including high blood pressure, ESRD, and muscle weakness, and had an order to observe the left chest dialysis site for signs of infection, redness, edema, bleeding, and drainage every shift; the March 2026 TAR showed missed documentation on multiple shifts. Resident R171 had end-stage kidney disease, dependence on dialysis, and muscle weakness, with an order to go to dialysis and monitor the right subclavian dialysis catheter every shift. The communication binder for R171 contained no communication, staff stated the resident was sent to dialysis without the binder because it could not be found, and the medical record did not show access site monitoring since admission. The DON confirmed the failures for R11, R47, and R171.
Missing Monthly MRR Documentation and Physician Review
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews (MRRs) were completed monthly and reviewed by the resident's attending physician for five residents. The report states that a licensed pharmacist was to review each resident's medication regimen at least monthly, provide the MRR reports to the DON and medical director, and that the DON was to review the recommendations with the attending physician, respond to the report, and document any actions taken. During survey review and staff interviews, the DON confirmed that the facility did not have monthly MRR documentation for the residents identified in the report. For one resident with diagnoses including dementia, cerebral infarction, and hypertension, multiple pharmacist recommendations were documented regarding quetiapine use without an allowable diagnosis and the need for gradual dose reduction (GDR) of escitalopram and quetiapine. The clinical record did not include responses from the attending physician for several of these recommendations. Although a CRNP addressed some of the MRRs, the record still lacked physician responses for the pharmacist's recommendations. For another resident with depression, dementia, and insomnia, the record contained several pharmacist recommendations concerning olanzapine and mirtazapine, including lack of an allowable diagnosis and GDR considerations. The clinical record did not include responses from the attending physician for those recommendations. The DON confirmed that the facility failed to provide documentation that MRRs were completed and reviewed monthly for this resident. Additional residents had similar gaps. One resident with hypertension, anxiety, and depression had only one MRR in the record for a later period, and the DON confirmed no further MRRs were completed for that resident. Another resident with hypertension, anxiety, and depression had pharmacist recommendations regarding omeprazole, duloxetine, and alprazolam, with the record lacking attending physician responses for the recommendations. A fifth resident with depression, schizoaffective disorder, and muscle weakness had pharmacist recommendations regarding aripiprazole and lorazepam, and the record again lacked attending physician responses. The DON stated that monthly MRRs were being addressed by the facility and psych services CRNPs rather than the resident's attending physician for several of the residents.
Improper Medication Storage and Labeling
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in multiple medication storage areas, including the Second Floor Medication Cart, Third Floor Medication Cart, Fourth Floor Front Medication Cart, Sixth Floor Back Medication Cart, and the Sixth Floor Medication Room. Facility policy stated medications were to be stored in original labeled containers, with expired, discontinued, or contaminated medications removed from storage, and that all medications except Emergency Drug Kits were to be kept in locked cabinets, carts, or medication rooms accessible only to authorized personnel. During observations, surveyors found multiple unlabeled or improperly labeled items in medication carts, including insulin products without open dates or expiration dates, bottles and inhalers without dates opened, and a medication cup in a drawer containing several loose pills. In the Sixth Floor Medication Room, a drawer labeled IV Supplies contained pudding and applesauce cups. Surveyors also observed the Fifth Floor East Front Medication Cart in the hallway outside a resident room, unlocked and unattended. LPN staff confirmed each of these observations during interviews.
QAA Committee Meetings Lacked Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three of four quarters reviewed, covering April 2025 through June 2025, July 2025 through September 2025, and October 2025 through December 2025. Review of QAA Committee meeting sign-in sheets showed that the Director of Nursing was not in attendance for the July through September 2025 and October through December 2025 meetings, and the Infection Preventionist was not in attendance for the April through June 2025 meeting. During an interview on 3/27/26 at 12:55 p.m., Regional Nursing Home Administrator Employee E25 confirmed that the facility failed to conduct QAA meetings at least quarterly with all of the required committee members for three of four quarters.
Failure to Implement EBP, Infection Surveillance, and Aseptic Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident admitted with a Foley catheter. The resident’s MDS dated 3/6/26 listed dementia, dysphagia, and muscle weakness, and the record showed an indwelling catheter. During observation on 3/23/26, the resident was sitting by the nurse’s station with the Foley catheter bag hanging on the wheelchair. The resident’s room did not have EBP signage on the door, and a review of physician orders on 3/23/26 did not include orders for EBP related to the indwelling catheter upon admission. An LPN confirmed the missing signage and lack of a timely EBP order, and the DON confirmed the facility failed to implement EBP for this resident. The facility also failed to maintain an infection control program with a system of surveillance for possible communicable diseases or infections for nine of twelve months, and failed to prevent cross contamination during a wound dressing change for another resident. The DON was unable to provide infection surveillance documentation for March, April, May, September, October, November, and December 2025, and January and February 2026, and stated the facility had recently hired a new infection preventionist and needed to get infection control in order. For the dressing change, a resident with wound infection, depression, and paraplegia had orders for cleansing the left heel, applying Santyl, calcium alginate, and a dry dressing daily and as needed. During the 3/26/26 wound care observation, an LPN failed to clean scissor blades before cutting the calcium alginate, and later confirmed the scissors were not cleaned prior to use.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite to be responsible for implementing the infection prevention and control program for seven of 12 months, from February 2025 through September 2026. Review of the facility’s Infection Preventionist policy dated 10/29/25 showed that the Infection Preventionist is responsible for coordinating, implementing, and updating the infection prevention and control program, and that the role requires enough scheduled time to assess, develop, implement, monitor, and manage the program, address training requirements, and participate in required committees. During the entrance meeting on 3/23/26, the Nursing Home Administrator stated a new Infection Preventionist had been hired and identified as the facility’s IP. However, review of the Infection Control Program on 3/25/26 showed the IP certificate for Employee E29 was dated 3/24/26, and review of IP certificates showed the facility did not have a certified IP from March 2025 through September 12, 2025. The Director of Nursing confirmed on 3/25/26 that the facility failed to designate a qualified individual onsite responsible for implementing programs and activities to prevent and control infections during those dates.
Failure to Maintain Safe, Clean, and Homelike Environment on One Floor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the third floor, as required by its "Homelike Environment" policy dated 10/29/25. During a tour of the third floor with the Director of Operations, surveyors observed multiple rooms with physical plant deficiencies, including unpainted plaster on bathroom walls, missing vent covers, missing bathroom doorknobs, broken window blinds, and missing or loose ceiling tiles in resident rooms. Several bathrooms and hallway areas had brown or discolored ceiling tiles, and one resident room had a baseboard heater mounted on the wall behind the bed that exposed sharp objects. Additional observations on the third floor included hallway ceiling tile tracks with a brown, rusty color throughout the hallway, chipped and marked hallway walls that were not painted, and a resident common room near an exit door with unpainted plaster on the walls. Ceiling tiles throughout the hallway were also noted to be brown. During an interview at the conclusion of the tour, the Director of Operations confirmed these findings and acknowledged that the facility failed to provide a clean, safe, comfortable, and homelike environment for the third floor.
Failure to Ensure RN Assessment After Resident’s Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident experiencing a change in condition was assessed by an RN in accordance with professional standards and facility policy. The RN job description required RNs to assess residents for changes in status, notify the physician and family or representative, and document accordingly. The resident involved had diagnoses including hypertension, hyperlipidemia, and a cognitive communication deficit. On the day of the incident, a caregiver notified an LPN that the resident needed a nurse. When the LPN entered the room, the resident had labored, mouth breathing, dry mucous membranes, low blood pressure, and an oxygen saturation that could not be obtained. The LPN documented that the supervisor was notified, that the supervisor came to assess the resident and instructed the LPN to call 911, and that the LPN notified the resident’s sister and on-call provider. The LPN further documented that the resident was breathing with a faint pulse when EMTs arrived, and that the resident stopped breathing as EMTs prepared to transfer the resident, at which point CPR was initiated and continued until the resident was pronounced expired. Review of the clinical record showed no documentation that an RN assessed the resident after the change in condition was identified. In an interview, the Director of Nursing confirmed that the facility failed to ensure residents were provided appropriate treatment and care in accordance with professional standards of practice for this resident.
Improper Containment of Garbage in Outdoor Dumpsters
Penalty
Summary
The facility failed to properly contain garbage in two of four outside dumpsters, contrary to its own policy and state regulations. The facility’s policy on food-related garbage and refuse disposal, dated 10/29/25, required that all garbage and refuse containers be provided with tight-fitting lids or covers and be kept covered when stored or not in continuous use. During an observation of the outdoor trash receptacles on 3/23/26 at 9:30 a.m., dumpster one and dumpster three were noted to have lids/covers that were not closed. The Dietary Manager (Employee E21), present during the observation, confirmed that the lids on dumpsters one and three were not closed. In a subsequent interview on 3/24/26 at 12:30 p.m., the Dietary Manager further confirmed that the facility failed to properly contain garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation, constituting noncompliance with 28 Pa. Code 201.18(b)(3) Management. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the improper handling and containment of garbage in the facility’s outdoor dumpsters as observed and confirmed by staff.
Failure to Explain NOMNC to Resident With Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was explained to a resident and the resident's representative in a form and manner they could understand. Review of the resident's record showed that the resident was admitted to the facility and had a designated son as responsible party and power of attorney. The resident's cognitive screen showed a BIMS score of 5, which indicates severe cognitive impairment. Despite this, the NOMNC form dated 9/29/25 was signed by the resident. During an interview on 3/26/26, the Regional Business Office Manager stated that a resident with a low BIMS score should not be signing their own paperwork if they have family or a representative available to do so, and confirmed that the facility failed to ensure the NOMNC was explained to the resident and representative in a form and manner they understood. The deficiency was cited under 28 Pa. Code 201.14(a), 201.18(b)(2), 201.24(b), and 201.29(a).
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on the Fifth Floor Nursing Unit. Facility policy stated that personal privacy and confidentiality of all resident personal and medical records would be safeguarded. During an observation on 3/26/26 at 8:34 a.m., the 5 East Front medication cart outside a resident room was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at 8:35 a.m., an LPN confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information as required.
Failure to Complete Pre-Employment Criminal Background Check
Penalty
Summary
The facility failed to properly screen an employee by not completing a criminal background check before the start of employment for one of five personnel files reviewed, Nurse Aide Employee E6. Facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated the facility would conduct employee background checks and would not knowingly employ or engage individuals with findings related to abuse, neglect, exploitation, misappropriation, or mistreatment, or with certain disciplinary actions against a professional license. Review of Employee E6's personnel file showed a hire date of 1/9/26, but the file did not contain a completed state criminal background check prior to that hire date. During interview, the Human Resources Director confirmed the facility failed to properly screen the employee by not conducting the criminal background check before employment began.
Inaccurate MDS Coding for Significant Weight Gain
Penalty
Summary
The facility failed to ensure an accurate resident assessment for Resident R9 by incorrectly coding Section K0310 on the MDS as 0, indicating no or unknown weight gain, despite the resident having a significant weight increase documented in the clinical record. The RAI User's Manual states that Section K0310 should reflect whether the resident experienced a weight gain of 5% or more in the past 30 days or 10% or more in the past 180 days, and whether that gain was planned and physician-prescribed. Resident R9 was admitted with diagnoses of muscle weakness, aphasia, and dementia. The weight record showed 140.7 pounds on 9/6/25, no weights obtained in October or November 2025, 142.9 pounds on 12/21/26, 141.7 pounds on 1/10/26, 170.2 pounds on 2/5/26, and 170.5 pounds on 3/3/26, reflecting a 21.2% increase in six months. During an interview on 3/27/26, the RNAC confirmed the facility failed to indicate the significant weight gain on the MDS and stated that weight changes had not been marked.
Care Plan Did Not Reflect Resident’s Current Use of Bed Enablers
Penalty
Summary
The facility failed to develop a care plan for one of four residents, Resident R6, to accurately reflect the resident’s current status. The facility policy on Care Plan, Comprehensive Person-Centered, last reviewed 10/29/25, stated that a comprehensive, person-centered care plan should include measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs, and should identify problem areas, causes, and targeted interventions. Resident R6 was admitted to the facility on [DATE] and had diagnoses including high blood pressure, depression, and PTSD, according to the MDS dated 2/9/26. Resident R6’s physician orders dated 6/4/25 indicated bilateral upper side rails as enablers for bed mobility and repositioning. During an observation on 3/23/26 at 10:08 a.m., Resident R6 was in bed and the bed had enabler bars on both sides. Review of the current care plan showed that it did not include interventions for the bilateral upper side rails as enablers for bed mobility and repositioning. During an interview on 3/25/26 at 1:43 p.m., RN Employee E16 confirmed that Resident R6’s care plan did not include interventions for the bilateral upper side rails as enablers for bed mobility and repositioning.
Nursing Absent From Multidisciplinary Care Conferences
Penalty
Summary
The facility failed to promote a multidisciplinary approach with care conferences for two residents reviewed, R4 and R159. Resident R4 was admitted to the facility and had an MDS dated 2/18/26 indicating diagnoses of fracture left femur, chronic obstructive pulmonary disease, and dysphasia. Resident R4's multidisciplinary care conference sign-in sheet dated 3/12/26 listed social worker, dietary, and activities, but nursing was not present. Resident R159 was admitted to the facility and had an MDS dated 1/3/26 indicating diagnoses of end stage renal disease, dependence on renal dialysis, and diabetes mellitus. Resident R159's multidisciplinary care conference sign-in sheet dated 2/26/26 also listed social worker, dietary, and activities, with nursing absent. During an interview on 3/26/26 at 11:15 a.m., the Director of Social Services confirmed nursing was unavailable during the care conference meetings dated 2/26/26 and 3/12/26 as required.
Failure to Monitor Resident Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor Resident R9’s weight and nutrition status by not obtaining required weights. The resident was admitted with diagnoses of muscle weakness, aphasia, and dementia, and the MDS indicated that 51% or more of total calories were received through tube feeding. The facility policy stated that residents are to be weighed on admission and at intervals established by the interdisciplinary team, with monthly review of weight trends and follow-up for significant weight changes. Resident R9’s weight record showed no weights obtained in October 2025 or November 2025, despite a prior weight of 140.7 pounds on 9/6/25 and later weights documented in December 2025 and January 2026. The record also showed significant weight increases after hospital returns. Resident R9 returned from the hospital on 2/5/26 with a weight of 170.2 pounds, which was documented as a 20.1% increase from January 2026, and a nutrition note on 2/11/26 stated the resident had a significant weight gain from the prior month. The resident returned again from the hospital on 3/3/26 with a weight of 170.5 pounds, and a nutrition note on 3/7/26 stated the resident had a significant weight gain in February and weekly weights for four weeks on readmission were to be monitored. A physician order dated 3/7/26 directed weekly weights for four weeks, but no weights were obtained after 3/3/26. The RD confirmed in interview that the facility failed to obtain the monthly weights in October and November 2025 and the weekly weights ordered on readmission.
Failure to Provide Ordered Special Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment for Resident R35, whose physician orders dated 7/4/25 directed the resident to use a scoop dish for all meals. The admission record showed the resident was admitted to the facility on [DATE], and the MDS listed diagnoses of anemia, high blood pressure, and hyperlipidemia. During an observation on 3/23/26 at 12:40 p.m., Resident R35 was seen with a regular white plate on the lunch tray instead of a scoop dish, and NA E6 confirmed the meal ticket indicated the use of a scoop dish and that the facility failed to provide it as ordered. A second observation on 3/24/26 at 12:48 p.m. again showed Resident R35 with a regular white plate on the lunch tray, and NA E18 confirmed the meal ticket indicated the use of a scoop dish and that the facility again failed to provide the ordered equipment.
Inaccurate COVID-19 Vaccine Documentation
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for one of five residents, Resident R16. Facility policy stated that each resident is to be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated, and that the resident or representative may accept or refuse the vaccine. Review of R16’s clinical record showed the resident was admitted to the facility and had diagnoses of depression, dementia, and insomnia. The resident’s MDS dated 2/17/26 coded COVID-19 vaccine status as 0, meaning the resident was not up to date. Record review also showed that R16 last received a COVID-19 vaccination on 10/19/24, and a COVID-19 Vaccine Consent Form-Resident documented that consent for the vaccine was obtained on 10/29/25, but the resident did not receive it. During interview on 3/25/26 at 10:26 a.m., the DON confirmed the facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for R16.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to submit a timely report of an allegation of misappropriation of resident property to the local State field office for one of five sampled residents. According to facility policy, all suspicions of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and to other officials as required by state law, with 'immediately' defined as within two hours for abuse or serious bodily injury, or within 24 hours for other allegations. Review of records showed that a resident, admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness, reported giving another resident a scratch-off lottery ticket worth $65 and $30 in cash to redeem and purchase additional tickets. The other resident took the ticket and cash, left the facility, and did not return. Facility documentation, including a grievance form and incident report completed by the DON, confirmed the allegation was known to facility management. However, review of incidents submitted to the State Agency revealed that this allegation, which occurred on 12/24/25, was not reported to the State field office as required. The deficiency was identified during an interview with the Nursing Home Administrator, confirming the facility's failure to report the incident in a timely manner as per policy and regulatory requirements.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a facility failed to ensure that a resident with pressure ulcers was assessed and provided necessary treatment and services consistent with professional standards of practice. The facility's wound care policy required documentation of wound care procedures, including the type of care given, assessment data, and the resident's response. However, review of the Treatment Administration Record (TAR) for a resident with Stage 3 and Stage 4 pressure ulcers revealed multiple dates where wound treatments were not documented as completed, and there was no documentation of refusals or reasons for missed treatments. The resident in question had significant medical conditions, including metabolic acidosis, pulmonary embolism, and hypertension, and was documented as having both Stage 3 and Stage 4 pressure ulcers. Physician orders were in place for specific wound care treatments, and the care plan directed staff to administer treatments as ordered and monitor for effectiveness. Despite these orders, the clinical record showed gaps in the documentation of wound care, with several days lacking evidence that treatments were performed or that the resident refused care. Interviews with facility leadership confirmed that dressing changes were not documented as completed and that there was a lack of effective communication regarding coverage for wound care when the wound nurse was unavailable. The Director of Nursing acknowledged that the wound nurse may have been assigned to other duties, and coverage for daily wound care was not effectively communicated to other staff, resulting in missed or undocumented treatments for the resident's pressure ulcers.
Plan Of Correction
R1 has discharged from this facility. A 7-day look-back audit will be completed on wound dressing documentation to ascertain no other residents were affected. The DON will educate the Wound Nurse and Nursing Staff on the facility wound care policy. The DON/Designee will audit wound dressing documentation weekly for 2 weeks to ensure documentation is completed. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Meet Minimum Nurse Aide and LPN Staffing Requirements
Penalty
Summary
The facility administrative staff failed to meet required minimum staffing levels for nurse aides (NAs) and licensed practical nurses (LPNs) over a 21-day review period. Specifically, there were multiple days when the number of NAs on duty did not meet the mandated ratios for day, evening, and overnight shifts. For the day shift, the facility did not provide at least one NA per 10 residents on five days. On the evening shift, the required one NA per 11 residents was not met on two days, and for the overnight shift, the one NA per 15 residents requirement was not met on ten days. These shortages were confirmed through a review of census data, nursing time schedules, and staff interviews, with no evidence of additional higher-level staff compensating for the deficiencies. Additionally, the facility did not meet the minimum LPN staffing requirements. On seven days, the day shift did not have at least one LPN per 25 residents, and on two days, the evening shift did not have one LPN per 35 residents. These findings were also confirmed by census data, time schedules, and staff interviews. The Nursing Home Administrator acknowledged the staffing shortages and confirmed that the required staffing levels were not maintained, with no compensatory measures in place.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open CNA positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure CNA ratios are being met. Scheduler will continue to monitor CNA ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed. NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open LPN positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10am to 2pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure LPN ratios are being met. Scheduler will continue to monitor LPN ratios to ensure the facility has sufficient staffing. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
Facility administrative staff failed to provide the minimum required 3.2 hours of direct general nursing care per resident per day on 16 out of 21 days, as evidenced by a review of nursing time schedules and census data. On multiple dates, the provided nursing care per patient day (PPD) fell below the regulatory minimum, with values ranging from 2.77 to 3.18 hours for census counts between 153 and 165 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging that the facility did not meet the mandated nursing care hours on the specified days. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
NHA will educate DON/Scheduler on minimum staffing hours/regulations on new staffing guidelines effective July 1, 2024. Facility has advertised for open nursing care positions. Interviews will be conducted as applicants apply. Open interviews have been scheduled for every Thursday in January 2026, 10 am to 2 pm. Scheduler will meet daily with NHA/DON/Designee to review staffing schedule for a period of 2 weeks to ensure the facility is providing the minimum general nursing hours to each resident. Scheduler will calculate HPPD throughout the day to ensure the facility has sufficient staff. Results of these audits will be reviewed in the Quality Improvement Committee for recommendations as needed.
Failure to Provide Professional Podiatry Services
Penalty
Summary
The facility failed to obtain professional podiatry services for four residents who either requested to see a podiatrist or had physician orders for podiatry consultation. Clinical record reviews and interviews revealed that two residents did not have orders to consult podiatry despite their medical conditions, which included multiple sclerosis, mononeuropathy, unsteadiness on feet, cognitive communication deficits, anxiety, and depression. Additionally, two other residents had physician orders to consult podiatry and follow up as needed, but documentation showed they were not seen by the contracted podiatry provider as ordered. One resident reported that their toenails had become long, and observation confirmed thick and elongated toenails. Staff interviews confirmed that the process for podiatry consultation involved notifying the social worker and adding residents to a list, but this process was not followed for the affected residents. The DON and Nursing Home Administrator acknowledged that the facility failed to obtain professional podiatry services for these residents, as required by facility policy and physician orders. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Investigate Injury of Unknown Origin and Follow Transfer Protocols
Penalty
Summary
The facility failed to initiate a thorough investigation into an injury of unknown origin for one resident. The resident, who was cognitively intact and had diagnoses including bipolar disorder, enteropathy, and hypertension, was observed by her son to have a small bulge on her left shoulder. Medical evaluation and an X-ray confirmed a dislocated shoulder. The resident reported that the injury occurred during a fall in August and denied experiencing pain or harm from others. Despite this, the facility did not conduct a comprehensive investigation into the circumstances surrounding the injury. Further review revealed that physician orders required the resident to be transferred with the assistance of two staff members, but records indicated she was transferred by only one staff person. Interviews with the NHA and DON confirmed they were unaware of the concerns regarding the injury and the transfer process. The lack of a thorough investigation and failure to follow transfer protocols constituted a deficiency under the cited regulations.
Physician Progress Notes Not Timely Entered After Resident Visits
Penalty
Summary
The facility failed to ensure that a physician timely wrote, signed, and dated progress notes at each required visit for one of four residents reviewed. Specifically, for a resident with diagnoses including urinary tract infection, muscle weakness, and cognitive communication deficit, progress notes were entered, signed, and dated significantly after the actual visits occurred. For example, one progress note was entered 27 days after the visit, another 31 days later, and a third 32 days later. These late entries were made by the Medical Director following the resident's readmission and subsequent follow-up care. Clinical record review and staff interviews confirmed that the physician did not comply with the facility's policy and regulatory requirements for timely documentation. The Nursing Home Administrator and DON acknowledged that the required physician documentation was not completed within the specified timeframes for this resident, as mandated by state regulations regarding nursing services, physician services, and clinical records.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that dental appointments were scheduled for two residents who requested or required dental care. Resident Council Minutes indicated that two residents expressed a desire to see the dentist, but review of their clinical records and interviews confirmed that neither had been seen by the facility's contracted dental provider. One resident, with diagnoses including anxiety, depression, and chronic pain syndrome, had a physician order for a dental consult as needed but had not received dental services. The other resident, diagnosed with high blood pressure, dementia, and constipation, was observed with upper dentures and reported a sore on the gums from chewing, yet did not have a dental consult order or documentation of a dental visit. Staff interviews revealed that the process for obtaining dental services involved notifying the social worker and adding residents to a list when a dental consult was needed. However, this process was not followed for the two residents in question. The DON and Nursing Home Administrator confirmed that the facility failed to obtain dental services for these residents, as required by facility policy and state regulations.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide access to medical records for one resident, as required. Documentation showed that a request for the resident's medical records was made by a law firm on behalf of the resident's daughter, who was also listed as the emergency contact and on the resident's death certificate. The resident had diagnoses including diabetes mellitus, end stage renal disease, and atherosclerosis. During a staff interview, the Nursing Home Administrator was unable to provide documentation that the requested medical records were sent, despite the request having been made several months prior.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on 11 out of 21 days. This deficiency was identified through a review of nursing schedules and census information for the periods of 3/1/25-3/7/25 and 4/8/25-4/21/25. On specific dates, the facility's nursing care hours per resident fell below the required threshold, with the lowest being 2.54 hours on 3/6/25. The Nursing Home Administrator confirmed this shortfall during an interview on 4/23/25.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased HPPD on 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, 4/12, 4/16, 4/18, and 4/20/2025. The Director of Nursing, HR and Scheduler will be re-educated on the state requirement for HPPD by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 3.2 HPPD, then the facility will reach out to current staff and staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable air temperature levels for 22 out of 25 residents, as required by federal regulations. The deficiency was identified during a survey, which included a review of facility policies, observations, and staff interviews. The facility's policy on providing a homelike environment mandates maintaining temperatures between 71°F and 81°F. However, the boiler, which is essential for heating, malfunctioned on April 5th, and was not repaired until April 8th, leading to temperatures in resident areas falling below the required range. Interviews with maintenance staff revealed inconsistencies in the timeline of the boiler malfunction and the monitoring of temperatures. Maintenance Employee El stated the boiler stopped functioning on April 5th, while Maintenance Employee E2 believed it was on April 6th. Despite noticing low temperatures, Maintenance Employee E2 did not take immediate corrective action. Residents reported feeling cold over the weekend, with some resorting to wearing additional clothing for warmth. Temperature logs provided by the facility showed that on April 7th, 16 out of 18 monitored areas had temperatures below 71°F, with some as low as 57°F. The Nursing Home Administrator confirmed the failure to maintain comfortable temperatures and was not informed of the boiler issue until April 6th. This deficiency highlights a lapse in communication and timely response to maintenance issues, impacting the residents' comfort and safety.
Plan Of Correction
The boiler was repaired by Gasco on 4/7/25. R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22 were assessed by the DON on 4/14/25 with no negative findings. The Maintenance department will be educated by the NHA on the facility policy for Homelike Environment and immediately reporting concerns regarding temperatures to the NHA by 4/25/25. All residents have the potential to be affected. The Director of Operations performed random temperature checks on 4/8/25 throughout resident units to ensure temperatures were within appropriate range. No concerns identified. The NHA/Designee will perform 5 random temperature checks per week x 4 weeks on resident care units to ensure temperatures are within appropriate range. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Failure to Report Heating Service Interruption
Penalty
Summary
The facility failed to report an interruption of heating services to the State Agency in a timely manner. On April 6, 2025, the boiler stopped functioning, leading to a loss of heating in the building. Maintenance Employee E2 confirmed during an interview that the boiler malfunction occurred on Sunday afternoon, April 6, 2025. However, the Nursing Home Administrator was not informed of the malfunction until later that day at 4:36 p.m. Despite the loss of heating services, the facility did not include this incident in their reported incidents from April 6 to April 9, 2025. It was only on April 9, 2025, during an electronic communication at 2:31 p.m., that the Nursing Home Administrator confirmed the facility's failure to report the heating service interruption to the State Agency. This oversight constitutes a deficiency in the facility's obligation to notify the appropriate authorities of significant disruptions in services.
Plan Of Correction
The Nurse Home Administrator (NHA) reported the interruption of heating services via ERS on 4/9/25. The NHA will be educated by the Regional Administrator on the PA reporting requirements BY 4/23/25. All maintenance, dietary, and laundry/housekeeping employees will be educated by NHA on reporting interruption of services to NHA promptly. The Regional Administrator will audit daily audits completed by maintenance for the boilers, air temperatures, and water temperatures along with the work order system used by maintenance to ensure that disruption of any service is reported to the state agency. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
Corner View Nursing and Rehabilitation Center failed to protect a resident with severe cognitive impairment from unwanted and non-consensual sexual contact by another resident with a known history of sexually inappropriate behavior. The resident with the history of inappropriate behavior had previously engaged in unsolicited sexual contact with another resident, which was documented by the facility. Despite this history, the facility did not implement adequate supervision or interventions to prevent further incidents. The resident with the history of inappropriate behavior was admitted to the facility with diagnoses including dementia, mood disorder, and paranoid schizophrenia, and was assessed as moderately impaired. After the initial incident of inappropriate behavior, the facility updated the resident's care plan to include 15-minute checks, but these were discontinued the following day without developing further interventions to ensure the safety of other residents. This lack of continued supervision and intervention led to another incident where the resident was found in a compromising position with a severely cognitively impaired resident. The facility's failure to maintain adequate supervision and update care plans appropriately for residents with known behavioral issues resulted in an Immediate Jeopardy situation. The affected residents, both with severe cognitive impairments, were unable to protect themselves or consent to the interactions, highlighting the facility's responsibility to ensure their safety and well-being.
Plan Of Correction
Resident R1 was discharged to the hospital on 3/20/25 and will not return to the center. Resident R2 was assessed on 2/18/25 by nursing for any adverse effects of the alleged event and found no harm. Resident R2's responsible party and physician were contacted by nursing and sent to acute care hospital for in-depth evaluation on 2/18/25. R2 returned to the facility on 2/18/25 with no new orders and found to be at baseline. Psych consulted and assessed on 2/19/25 with no negative findings. R3 was assessed by nursing on 3/20/25 for any adverse effects of the alleged event and found no harm. R3's responsible party and physician were contacted and Resident sent to acute care hospital for in-depth evaluation by nursing on 3/20/25. Resident returned to the facility on 3/20/25 with no new orders and found to be at baseline. Psychosocial assessments performed by Social Services with no negative findings. Psychological services were consulted. House education done by 4/3/25, by DON/Designee provided to all staff reviewing identifying types of abuse, anonymous reporting, and reporting abuse. Megan law list check ran on all residents on 3/20/25, by DON/Designee. DON/Designee will audit all new admissions since 3/20/25, to ensure Megan law list checks were performed prior to admission. This was completed on 4/3/2025 by the DON. The DON/Designee was educated by the VP of Clinical Services on 4/2/25, on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk. The DON/Designee completed sexual activity scales on 4/2/25 on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed. No residents identified to be at high risk. The Directed In-Service will be presented to all staff by AAE Consulting Services for F600 Free from Abuse and Neglect on 5/1/25, with online video availability for any staff unable to attend the live sessions. Staff unable to attend will receive abuse education training prior to next scheduled shift. DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly x three months and as needed. The social services director/designee will interview 3 residents weekly x 4 weeks for abuse concerns. Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated on 4/2/25. Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Removal Plan
- Resident R2 was assessed by nursing for any adverse effects of the alleged event and found no harm. Resident R2's responsible party and physician were contacted. Resident sent to acute care hospital for in-depth evaluation. Resident returned to facility with medication and found to be at baseline. Psych consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
- Resident R3 was assessed for any adverse effects of the alleged event and found no harm. Resident R3's responsible party and physician were contacted. Resident sent to acute care hospital for in-depth evaluation. Resident returned to facility with medication and found to be at baseline. Psychosocial assessments performed with negative findings. Psychological services were consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
- Root cause analysis identified that facility failed to provide adequate supervision to the alleged perpetrator.
- House education done by DON/Designee provided to all staff reviewing identifying type of abuse, anonymous reporting and reporting abuse.
- Megan law list check ran on all residents by DON/Designee. DON/Designee will audit all new admissions to ensure Megan law list checks were performed prior to admission.
- The DON/Designee was educated by the VP of Clinical Services on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk.
- The DON/Designee will perform sexual activity scale on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed.
- DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly times three months and as needed.
- Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated.
- Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Failure to Prevent Sexual Abuse Due to Ineffective Facility Management
Penalty
Summary
The facility failed to ensure that necessary care and services were provided to prevent sexual abuse for two residents, resulting in an immediate jeopardy situation for all residents. The Nursing Home Administrator (NHA) and Director of Nursing (DON) did not effectively manage the facility to comply with federal and state regulations, as evidenced by their inability to prevent incidents of sexual abuse involving two residents. This failure was confirmed through review of job descriptions, clinical records, and staff interviews. The NHA was responsible for overseeing daily operations, ensuring regulatory compliance, and upholding resident safety, while the DON was tasked with directing nursing services to maintain quality care. Despite these defined responsibilities, both the NHA and DON acknowledged during interviews that they did not fulfill their duties to prevent sexual abuse, directly leading to the deficiency. The report specifically cites the lack of effective management and oversight as the cause of the failure to protect residents from harm.
Failure to Update Care Plans After Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents were reviewed and revised to accurately reflect their current needs and required services following significant incidents. For one resident with dementia, mood disorder, and paranoid schizophrenia, a care plan update was made after an incident involving sexually inappropriate behavior with another resident. However, the care plan did not include specific interventions to prevent further sexually inappropriate behaviors or address supervision and the safety of other residents. The resident was moderately cognitively impaired at the time of the incident. For another resident with Alzheimer's disease, dementia, and major depressive disorder, who was severely cognitively impaired and rarely able to communicate or make decisions, the care plan was not updated after she was found in another resident's room, partially undressed, following a suspected sexual encounter. The care plan did not reflect any review or revision to address the alleged sexual abuse. Facility leadership confirmed that care plans were not appropriately updated for these residents after the incidents.
Unsanitary Conditions in Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, which was identified during a survey. The deficiency was observed in the main kitchen, specifically in walk-in coolers #3 and #4. The cold air condenser fan covers in both coolers had a significant build-up of dust, grime, and dark-colored debris. Additionally, the floor of walk-in cooler #3 had a build-up of grime and dried food debris beneath stored cases of milk. These observations were made during a walkthrough with the Dietary Director, Employee E25, who confirmed the unsanitary conditions. The facility's policy titled "Food Safety Requirements: Sanitation of the Kitchen" mandates that food service staff maintain kitchen sanitation through adherence to a comprehensive cleaning schedule. However, the observed conditions in the walk-in coolers indicate non-compliance with this policy, creating the potential for cross-contamination. The Dietary Director acknowledged the failure to maintain the kitchen equipment in a sanitary state, which is a violation of the facility's responsibility to ensure food safety as per federal and state regulations.
Plan Of Correction
No residents were negatively affected by the deficient practice. The fan assembly, fan covers, and floors were cleaned of dust, food, and grime build-up in walk-in coolers #3 and #4. The Maintenance Director was educated by the Administrator on the need to put the walk-in cooler fan assembly and cover on a preventive maintenance schedule so that they are cleaned on a quarterly basis. Dietary staff were educated on the need to pull all stored materials on the floor prior to mopping the floor in all walk-in coolers. Maintenance has placed the fans on the walk-in coolers on a quarterly preventative maintenance program so they will be on a scheduled cleaning program. The floors in the walk-in are now placed on the daily cleaning checklist. The Dietary manager will audit the cleanliness of the walk-in coolers twice weekly for 4 weeks and then weekly for 2 months. Audits and education will be submitted to the QAPI committee for review and approval so the issue does not recur.
Grievance Policy Posting Deficiency
Penalty
Summary
The facility failed to ensure that the grievance policy was prominently posted throughout the facility, as required by regulations. Observations revealed that from the second to the sixth floor nursing units, the grievance policy was not displayed, and there was no information on how to file grievances anonymously. Additionally, the postings did not include the necessary contact information for the grievance officer, such as their business address, email, and phone number. Interviews with residents and staff further highlighted the deficiency. During a resident group meeting, residents expressed that they were unaware of the grievance policy and the procedure for filing grievances anonymously. This lack of awareness among residents indicates that the facility did not effectively communicate the grievance process to them. The Director of Social Services confirmed the facility's failure to post the grievance policy prominently and to include all required information. This oversight affected all five nursing units, as none had the necessary postings or information available to residents, which is a violation of the residents' rights to voice grievances without fear of reprisal.
Plan Of Correction
Residents will be educated on the facility Grievance Policy in writing and at the monthly Resident Council meeting by the Grievance Coordinator (Social Worker). The education will include the locations of the posted Grievance Policy, the process to file an anonymous grievance, the location of grievance forms and drop-off locations, and the name of the grievance coordinator along with his/her name, business phone number, business address and email address. The administrator will ensure that the Grievance Policy is posted on each nursing unit with the grievance forms, drop-off box, the name of the grievance coordinator along with a business phone number, business address, and email address. Social Workers will be educated by the Administrator on the Grievance Policy, where it needs to be posted along with the grievance forms, drop-off boxes, and the posting indicating how to reach the Grievance Coordinator (Social Worker) via letter, phone and email. On a daily basis, the Grievance Coordinator will audit each location to ensure the grievance policy and grievance coordinator information remains posted when he/she is collecting completed grievance forms from the drop-off box.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three residents who were transferred to the hospital. The deficiency was identified through a review of clinical records and staff interviews, which revealed that the facility did not document or convey essential information such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. Resident R80, who was admitted to the facility with diagnoses of hypertension, hyperlipidemia, and aphasia, was transferred to the hospital without the required documentation and communication of necessary information. Similarly, Resident R105, diagnosed with anxiety, bipolar disorder, and depression, was transferred without the facility providing the receiving provider with the necessary details to ensure continuity of care. Resident R124, who had a history of high blood pressure, stroke, and hemiplegia, was also transferred to the hospital without the facility communicating the required information. The Director of Nursing confirmed the facility's failure to communicate the necessary resident information for these transfers, which was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
Resident R80 and Resident R124 both returned to the facility and experienced no negative outcome from the deficient practice. Resident R105 did not return. Nursing staff will be educated on the need to transfer Residents with specific healthcare information to meet the resident's specific needs including the Resident's Representative, advanced directives, care plan goals, and specific instructions to provide for his/her care needs. Nursing staff will be required to document in the medical record that upon discharge, Residents were transferred with healthcare related documents including healthcare information to meet the resident's specific needs, the Resident's Representative, advanced directives, care plan goals, and specific instructions to provide for his/her care needs. The DON will review all transfers daily at the clinical meeting to ensure the documentation was completed. The DON will report Resident transfers monthly to the QAPI committee including the healthcare information that was sent with the Resident.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for four out of twelve residents. The Resident Assessment Instrument (RAI) User's Manual provides specific instructions for completing Minimum Data Set (MDS) assessments, including the Brief Interview for Mental Status (BIMS) and weight loss coding. However, the facility did not adhere to these guidelines, resulting in inaccurate assessments. For instance, Resident R51's MDS indicated that a BIMS interview should be conducted, but the section was left incomplete with dashes. Similarly, Residents R90 and R117 were also supposed to receive BIMS interviews, but their assessments were similarly incomplete. Resident R164's assessment inaccurately indicated that the resident was on a physician-prescribed weight-loss regimen. The clinical records did not support this claim, as there was no documentation from physicians or nutritionists indicating such a regimen. The Registered Dietitian and Registered Nurse Assessment Coordinator confirmed that the weight loss information was entered in error. This discrepancy highlights a failure in accurately documenting the resident's nutritional status. Interviews with facility staff, including the Director of Social Services and the Vice President of Clinical Services, confirmed the inaccuracies in the assessments. The staff acknowledged the errors and the failure to follow the RAI guidelines, which led to the inaccurate documentation of the residents' cognitive and nutritional statuses. These inaccuracies in the MDS assessments reflect a significant oversight in the facility's responsibility to maintain accurate clinical records.
Plan Of Correction
Residents R90, R117, R164 experienced no negative effects of the deficient practice. Resident R64 no longer resides in the facility. RNAC will educate the Social Workers on proper completion of BIMS Assessment per the RAI guidelines. RNAC will educate the Dietitian and CDM on how to determine significant weight loss, how to determine when a significant weight loss occurs, and when to code if a weight loss is physician prescribed per RAI guidelines. The RNAC will audit all new MDS assessments weekly for one month, and then 12 MDS Assessments weekly for one month to ensure accuracy of the MDS. Audits and education will be submitted to the QAPI Committee for review and approval.
Failure to Provide Necessary Assistive Devices
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent further decrease in range of motion for five residents. Resident R15, who was admitted with a history of stroke, anemia, and atrial fibrillation, was observed multiple times without the prescribed palm guard for his left hand contracture. Despite physician orders and care plans indicating the need for the palm guard, it was not applied, as confirmed by an LPN. Resident R22, diagnosed with non-Alzheimer's dementia, bipolar disorder, and high blood pressure, was observed without the required bilateral wedges, heel lift boots, and knee extension splint. The equipment was found on top of the wardrobe closet, and a nurse aide confirmed that the resident had not used the devices for several days due to staffing issues. Similarly, Resident R43, with schizophrenia and seizure disorder, was observed with a left-hand contracture without a splint, which was not ordered as required. Resident R45, with cerebral palsy and quadriplegia, was not wearing the prescribed splints for his elbows and hands during observations. A nurse aide confirmed the absence of these devices. Lastly, Resident R50, with an acquired absence of the right leg and muscle weakness, was not provided with the left knee extension splint as ordered. The resident reported minimal use of the splint since admission, and staff were unaware of its location. The Vice President of Clinical confirmed the facility's failure to provide the necessary treatment and services for these residents.
Plan Of Correction
Resident # 50 no longer resides at the facility. Resident #s 15, 22, 43, 45 were assessed by the DON/Designee with no negative findings. Resident #15's left palm guard was placed on the resident. Heel lift boots were applied and bilateral wedges and left knee extension splint placed on resident # 22 per physician orders. Resident #43 was assessed by therapy for the need of a splint on 1/9/25. Bilateral hand splints and bilateral elbow splints were placed on resident # 45. All residents with orders for splints, wedges, and heel lift boots have the potential to be affected. The DON/Designee will audit all residents with orders for splints, wedges, and heel lift boots to ensure they are applied as ordered. Findings will be corrected at the time of the initial audit. The DON/Designee will educate licensed nurses and CNAs on applying as ordered. The DON/Designee will audit all residents with orders for splints, wedges, and heel lift boots weekly x 4 weeks to ensure they are applied as ordered. Audits and education will be submitted to the QAPI Committee for review and approval.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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