Friendship Rehab And Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaver, Pennsylvania.
- Location
- 246 Friendship Circle, Beaver, Pennsylvania 15009
- CMS Provider Number
- 395015
- Inspections on file
- 63
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 64 (2 serious)
Citation history
Health deficiencies cited at Friendship Rehab And Health during CMS and state inspections, most recent first.
A resident with a history of TBI, anxiety, and mild neurocognitive disorder became agitated after staff moved a wheelchair he had positioned to avoid blocking his window view, leading to escalating verbal aggression toward staff. Witnesses reported that when the resident approached the nurses’ station with clenched fists and swung at an RN, the RN grabbed the resident’s arm and/or shoulder and took him to the floor, then restrained him there until supervisors arrived. Immediately afterward, the resident complained of severe left hip pain, with clinical signs of injury, and hospital evaluation confirmed a left comminuted displaced intertrochanteric fracture requiring surgical repair. Multiple staff later stated that they are not allowed to restrain residents and would instead use de-escalation, walk away, or call for assistance when residents are aggressive, while the DON acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm.
The facility failed to timely complete and document the results of an abuse investigation after a resident with TBI, anxiety, and mild neurocognitive disorder became increasingly agitated, allegedly attacked staff, and was subsequently taken to the floor by a nurse, resulting in severe left hip pain with leg shortening and external rotation and transfer to the ED. Although an event report was submitted to the State Agency, the investigation report produced later lacked the required PB-22 and did not include the outcome of the investigation, and the DON confirmed the investigation remained incomplete beyond the required timeframe.
A resident with TBI, anxiety, and mild neurocognitive disorder had a care plan that identified refusal of care, inappropriate voiding, and physical aggression as behavior problems, but the plan lacked specific interventions for managing episodes of physical aggression. Staff, including RNs and LPNs, stated they rely on the care plan and orders for guidance when a resident is physically aggressive, yet review of the record showed only general behavioral interventions and no targeted strategies for aggression. The DON confirmed that the care plan did not contain interventions for physical aggression, resulting in a failure to provide person-centered care consistent with facility policy and state nursing service requirements.
Multiple residents reported that the food served at lunch was unappetizing, cold, and lacked flavor, with direct observation confirming that the turkey pot pie was served in a soup-like form and missing key ingredients. The Food Service Director acknowledged the poor quality of the meal, citing issues with a new food vendor and inconsistent cooking staff.
A resident with cognitive impairment and a history of exit-seeking behavior was able to leave the facility unsupervised after learning the elevator code, despite being on a secure unit with a wander guard and scheduled 15-minute checks. Staff failed to consistently document required safety checks, and the resident was not accounted for during routine rounds. The resident was later found by police outside the facility, and staff interviews confirmed lapses in supervision and security protocols.
The NHA and DON did not ensure proper supervision for a resident at high risk for elopement, resulting in the resident leaving the facility and creating an immediate jeopardy situation. This failure was identified through review of job descriptions, facility and clinical records, and staff interviews, and demonstrated noncompliance with professional standards and facility policies.
The facility failed to pay significant outstanding balances to a staffing agency, water vendor, and sewage vendor, resulting in service suspension and legal action by vendors. The Nursing Home Administrator confirmed the facility was not current on payments and was seeking payment plans.
For nine days, the facility did not have a qualified social worker on staff for approximately 388 residents. The new hire's credentials did not meet the required qualifications, and the previous social worker was not present during this period, resulting in a lapse in compliance with social services staffing requirements.
The facility failed to correct previously cited deficiencies regarding non-payment to essential water and sewage vendors, despite QAPI policies and corrective plans. Significant overdue balances remained, with vendors confirming ongoing payment delays and legal action initiated. The NHA acknowledged the QAPI program did not resolve these issues, potentially affecting all residents.
The facility did not ensure that two residents with cognitive impairment or legal guardianship had the capacity or proper authorization to sign admission agreements, and failed to provide three residents or their representatives with a choice regarding transfer to other facilities. These actions were confirmed through record reviews and interviews, showing a lack of informed consent and resident choice in critical processes.
The facility did not properly notify resident representatives about transfers, as required by policy and regulation. In several cases, representatives only learned of the transfers from the residents themselves or from the receiving facility, despite documentation indicating families were aware. Residents affected had a range of cognitive and mental health conditions, and interviews confirmed a consistent lack of direct communication from the facility.
The facility did not ensure that necessary resident information, such as care plan goals and advanced directives, was communicated to receiving health care providers during transfers, nor did it document the reasons for transferring several residents with complex medical and psychiatric conditions. This deficiency was confirmed by the DON and identified through policy review, clinical record review, and staff interviews.
Two residents were unable to use their in-room bathroom for about a month due to it being inoperable and marked with caution tape. Staff confirmed that these residents had to use a restroom on another unit, and maintenance had not addressed the issue recently. The DON acknowledged that no room move or alternative accommodation was offered.
A resident with multiple chronic conditions was given a double dose of morning medications after an LPN, unable to document the administration in the electronic medical record and unaware that the medications had already been given, provided them again at the resident's request. The resident experienced mild shortness of breath and hypotension, leading to a transfer to the ER. The DON confirmed the failure to prevent significant medication errors.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any individual.
A resident was subjected to physical restraints without a documented medical need, in violation of requirements that ensure restraints are only used for medical treatment.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The lack of proper safety measures and oversight increased the risk of preventable incidents for residents.
The facility did not maintain cleanliness and sanitation in the main kitchen and basement storage areas, with observations of standing water, debris, and improperly stored or undated food items. Food storage areas had water leaks, crumbling ceilings, and unlabeled or expired food, all confirmed by management as not meeting required standards.
The facility did not pay significant outstanding bills to two vendors for essential services, with no payment plans in place and vendors considering service interruption. The NHA confirmed the unpaid balances and lack of timely payment, indicating non-compliance with state regulations regarding financial management and resident safety.
The facility did not provide appropriate body soap for resident care, instead instructing staff to use hand soap from sink dispensers. Multiple staff reported bringing in their own soap due to concerns about residents' skin and the unsuitability of hand soap for bathing. Several residents with complex medical needs were affected by this deficiency.
Surveyors found that the facility did not provide a safe, clean, or homelike environment in all resident areas, with issues such as obstructed exits, damaged flooring, peeling walls, exposed metal, dirty bathrooms, and inadequate heating or cooling. Staff and management confirmed these deficiencies, and a resident reported problems with room temperature and water leakage due to broken fixtures.
The facility did not provide required QAPI training to five staff members, including nurse aides, an LPN, and an RN, as confirmed by review of education files and staff interviews. This deficiency was identified through examination of facility assessment documents and was confirmed by the HR Director.
The facility did not provide adequate privacy in restroom facilities on two floors, as several bathroom stalls were missing curtains or had improperly sized curtains. This lack of privacy was confirmed by staff, including an RN, an LPN, and the DON.
The facility did not obtain or act upon required weights for two residents identified as being at nutritional risk, despite their medical conditions and care plans indicating the need for monitoring. This failure was confirmed by the DON and was not in accordance with facility policy.
The facility did not employ a qualified RD for two months, leaving essential responsibilities such as nutritional assessments and therapeutic diet planning unfulfilled, as confirmed by staff and administration interviews.
The facility did not have a registered dietician to review and approve the current menu cycle, resulting in menus being used without proper oversight and creating the potential for conflicting guidance on portion sizes and food consistency for prescribed therapeutic diets.
The NHA and DON did not effectively manage the facility to ensure proper supervision for a resident at high risk for elopement, resulting in an actual elopement and immediate jeopardy. Review of records and staff interviews confirmed that required supervision and adherence to facility policies were not maintained, leading to a failure in providing care according to professional standards.
Two residents, both cognitively intact, lost personal belongings after being told by an LPN to leave labeled items in their old room during a unit move. Staff, following instructions reportedly from the NHA, disposed of the items and took some for personal use, with no inventory process in place. Despite grievances listing the lost property, the facility did not replace any items.
The facility did not maintain an adequate supply of linens on several units, resulting in staff frequently running out of essential items like washcloths and resorting to cutting towels or blankets for use. Residents reported that their care was affected, with makeshift linens used for hygiene and bed changes. Staff and the administrator confirmed the ongoing shortage and the use of alternative, sometimes unsuitable, linens.
The facility did not provide enough nursing staff to meet resident needs on nine of ten units, with staff and residents reporting frequent understaffing, delays in care, and administrative staff covering direct care duties. Agency staff limitations and aides being pulled between units further contributed to inadequate coverage, as confirmed by the DON and administrator.
The facility failed to provide a dignified dining experience by serving cold food items in Styrofoam containers due to staffing challenges and a shortage of reusable service ware. The Director of Dining Services confirmed the issue and acknowledged the need for additional service ware to address the problem.
The facility failed to maintain a clean, safe, and homelike environment on the West Wing 3rd floor. Observations revealed dirty floors, missing mattresses, exposed wiring, and holes in walls. Many rooms lacked privacy curtains and furniture, and some had wood boards covering window holes. The Maintenance Director confirmed the area was used for storage, with only a portion of the unit being resident-ready.
The facility failed to provide necessary furnishings in 17 rooms on the West Wing's third floor, including bed frames, mattresses, and functional furniture. Observations and staff interviews confirmed the deficiency, with the area being used for storage. While some equipment had been ordered, only part of the unit could be made ready for residents promptly.
A facility failed to follow infection control practices during a dressing change for a resident with a coccyx wound. An RN placed a red bag for soiled dressing on the bed and did not change gloves or perform hand hygiene after cleansing the wound, risking cross-contamination. The resident had a history of malnutrition, knee pain, hypertension, and hyperlipidemia.
The facility failed to provide beds, mattresses, and functional furniture in 17 rooms on the West Wing's third floor, as observed during a survey. Staff interviews revealed that the area was used for storage and not ready for resident occupancy, with equipment orders pending. The floor had been unused since September 2023, with no plans to decertify beds.
The facility failed to pay bills on time, leading to service disruptions that impacted residents' health and well-being. Essential services like cable TV, milk delivery, garbage collection, and medical transportation were suspended due to nonpayment. Residents missed medical appointments, and staff had to arrange emergency deliveries. Vendors reported ongoing payment issues, and the NHA confirmed the facility's failure to manage financial transactions effectively.
Brighton Rehabilitation And Wellness Center failed to provide an ongoing program of activities due to a cable service disruption caused by non-payment. Several residents, who relied on watching TV as part of their care plan for socialization, were affected. The absence of cable service led to boredom and inactivity, as confirmed by resident interviews and the DON. The issue was resolved after the past due payment was made.
The facility failed to secure transportation for medical appointments due to nonpayment to the transport company, affecting four residents. This resulted in missed critical medical procedures, including CT scans, biopsies, and specialist consultations, impacting residents with conditions such as dementia, osteomyelitis, and GERD.
A resident missed several radiology appointments due to the facility's failure to secure transportation, as they did not have access to a bariatric stretcher and had not paid the transportation company. The resident, with conditions including dementia and high blood pressure, was unable to attend necessary CT scans and a biopsy, which were crucial for determining a potential cancer diagnosis.
A resident with moderate cognitive impairment and a history of brain surgery eloped from a locked unit due to inadequate supervision and failure to complete an elopement risk assessment. The resident expressed a desire to leave and was allowed to go unsupervised to smoke, leading to his departure from the facility. Staff confusion and lack of communication contributed to the incident, creating an immediate jeopardy situation.
A facility failed to ensure nursing staff were trained to care for a resident with a Life Vest, a wearable defibrillator, placing the resident in immediate jeopardy. The resident, with a history of alcoholic cardiomyopathy and other conditions, was managing the Life Vest independently due to staff's lack of training. Interviews revealed that staff, including nurse aides and RNs, had not received training on the Life Vest, leading to a deficiency in care.
The facility failed to maintain sanitary conditions in the main kitchen, with brown debris found in ice machines and on wall fans. The Dietary Manager confirmed the debris and could not verify the last cleaning, indicating a lapse in food safety standards.
A resident eloped from a locked unit, creating an immediate jeopardy situation for all residents. The NHA and DON failed to manage the facility effectively, as outlined in their job descriptions, leading to this incident. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews.
The facility failed to designate a clear medical director, leading to regulatory non-compliance. Despite a contract indicating Employee E40 as responsible for medical directorship, the NHA and DON confirmed that Employee E39 acted as the medical director, attending QAPI meetings. Employee E39 began his role in October 2023, but confusion persisted as multiple individuals were considered for the position.
Brighton Rehabilitation and Wellness Center failed to maintain resident dignity and provide a dignified dining experience. Two residents were not treated with dignity; one was inadequately dressed, and another had writing on a wound dressing. Additionally, all residents were served with plastic utensils during meals, compromising their dining experience.
The facility failed to maintain a clean, safe, and homelike environment in two nursing units. Residents expressed concerns about cleanliness, and observations revealed dirty floors, stained curtains, and dusty areas. These issues were confirmed by LPNs and the DON.
The facility failed to communicate necessary resident information to receiving health care providers during transfers for six residents. This included care plan goals, advanced directive information, and specific instructions for ongoing care. The deficiency was confirmed by the DON, who acknowledged the lack of documentation for these communications.
The facility failed to provide adequate respiratory care for three residents, including one with COPD and another with alcoholic cardiomyopathy. Observations revealed issues such as missing and soiled oxygen equipment components, empty humidification bottles, and undated tubing. These deficiencies were confirmed by nursing staff and the Director of Nursing.
The facility failed to provide trauma-informed care for residents with PTSD, as required by regulations. Five residents with PTSD did not receive Trauma Informed Care Evaluations or individualized care plans addressing their trauma and identifying triggers. Staff interviews confirmed the lack of appropriate assessments and care plans, indicating a systemic failure to implement trauma-informed care practices.
The facility failed to ensure that a physician conducted the initial visits for three residents, as required by regulations. Instead, Certified Registered Nurse Practitioners conducted these visits shortly after the residents' admissions. The deficiency was confirmed by the Director of Nursing, and the residents involved had various medical conditions, including dementia, hypertension, and traumatic brain injury.
Failure to Protect Resident From Physical Abuse Resulting in Hip Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse when a registered nurse (RN) took the resident to the floor during an altercation, resulting in a left comminuted displaced intertrochanteric hip fracture that required surgery. Facility policy on "Abuse: Protection From" stated that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property, and that residents must not be subjected to abuse by anyone, including staff. The resident involved had a history of traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance, but was assessed as cognitively intact with a BIMS score of 13. On the evening of the incident, the resident became agitated after staff moved a wheelchair that he had positioned to avoid blocking his window view, and he began yelling and cursing at a nurse aide (NA) about the wheelchair placement. According to multiple staff statements and nursing documentation, the resident paced in his room, continued yelling, and then left the room to go to the bathroom. After several minutes, he approached the nursing station, yelling and threatening the RN, with witnesses reporting that he had his fists clenched and was swinging at the nurse. The RN reported that when the resident swung at him, he grabbed the resident’s arm and/or shoulder and took him down or assisted him to the floor, then restrained him there until supervisors arrived. Witnesses, including NAs and another RN, consistently described the nurse catching the resident’s swing by the forearm or grabbing his shoulder/arm and putting or sitting him down on the floor, after which the resident was observed lying on his right side in front of the elevator, screaming in pain and holding his left hip. Following the takedown, staff observed that the resident complained of 10/10 left hip pain, with the left leg shortened and externally rotated. The resident told staff and later hospital providers that the nurse had “tackled” him to the floor. Hospital records documented that the resident reported being tackled after an altercation about moving a wheelchair to see the sunset, and confirmed a left comminuted displaced intertrochanteric fracture requiring orthopedic surgical intervention. In subsequent staff interviews, multiple nurses and NAs stated that facility practice when a resident exhibits aggressive behavior is to walk away, call for help or a supervisor, attempt de-escalation, remove triggers, and that they are not allowed to restrain residents or hold them to the ground. The Director of Nursing acknowledged that the facility failed to protect the resident from physical abuse that resulted in actual harm in the form of the hip fracture. The deficiency was cited under multiple Pennsylvania regulatory provisions, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 201.18(b)(1)(3) Management, 201.29(a)(c)(d)(j) Resident Rights, 211.10(c)(d) Resident Care Policies, and 211.12(d)(1)(3) Nursing services. These citations reflect that the resident’s right to be free from abuse and the facility’s obligations regarding resident care policies and nursing services were not upheld in this incident, as evidenced by the RN’s physical handling of the resident that led to a serious injury.
Failure to Timely Complete Abuse Investigation After Staff–Resident Altercation With Serious Injury
Penalty
Summary
The deficiency involves the facility’s failure to timely complete and report an investigative report for an allegation of physical abuse resulting in serious bodily injury. Facility policy on Reporting Unusual Occurrences requires that suspected, alleged, or actual abuse, neglect, misappropriation of resident property, fractures, incidents requiring transfer for medical evaluation, and staff-to-resident altercations be reported to appropriate agencies, with a written report forwarded within five working days. Federal regulation at 42 CFR §483.12(c)(4) similarly requires that, at the conclusion of the investigation and no later than five working days of the incident, the facility must report the results of the investigation. The facility’s Abuse policy states that each resident has the right to be free from abuse, including infliction of injury with resulting physical harm, pain, or mental anguish. Clinical record review showed that the resident had diagnoses including traumatic brain injury, anxiety, and mild neurocognitive disorder with behavioral disturbance. A nursing progress note documented that supervisors were urgently called to a unit for a resident attacking staff; upon arrival, the resident was found lying on his right side, screaming, and complaining of left hip pain. The resident stated that a staff member had “tackled” him and that he had intended to “knock his ass out.” Witness accounts indicated the resident had increasing agitation and attempted to punch the nurse and nurse aides; the nurse reported that when the resident swung at him, he grabbed the resident’s arm/shoulder and took him down to the floor. The resident had 10/10 left hip pain with left leg shortening and external rotation, and the physician ordered transfer to a local emergency room. An event report was submitted to the State Agency the following morning, but the facility’s investigation report produced a week later did not include a PB-22 or the outcome of the investigation. In an interview, the DON confirmed the investigation was not complete and acknowledged the facility failed to timely complete the investigative report for this allegation of physical abuse with serious bodily injury.
Failure to Include Interventions for Physical Aggression in Behavior Care Plan
Penalty
Summary
The facility failed to develop a complete, person-centered care plan with measurable interventions for a resident with documented behavioral issues, including physical aggression. Facility policy required an individualized, interdisciplinary care plan for each resident, initiated on admission and updated with each significant event, to address actual and potential issues, manage risk factors, and promote the resident's highest practicable level of functioning. The resident in question had diagnoses of traumatic brain injury (TBI), anxiety, and mild neurocognitive disorder with behavioral disturbance. The current care plan identified a behavior problem of refusal of care and aggression, including voiding in inappropriate areas, refusal to bathe or change clothes or linens, disturbing other residents' televisions and remotes, and physical aggression. The stated goal was for the resident to have fewer episodes of refusal of care and no aggression by the review date, with general interventions such as anticipating and meeting needs, encouraging appropriate expression of feelings, providing emotional support, and obtaining psychology consults as needed. Despite listing physical aggression as a behavior problem, the care plan did not include any specific interventions or instructions for staff to use when the resident was experiencing physical aggression. Multiple nursing staff, including RNs and LPNs, reported in interviews that they would look to the care plan, physician orders, or behavioral care plans for guidance on how to respond to a resident exhibiting physical aggression, indicating their expectation that such interventions should be present in the care plan. Upon review of the resident's care plan during the survey, an RN acknowledged that interventions for physical aggression were missing. The Director of Nursing also confirmed that the resident's current care plan lacked interventions for physical aggression and that the facility failed to develop a care plan that included instructions to provide person-centered care for this resident, in violation of applicable state regulations regarding resident care policies and nursing services.
Failure to Provide Palatable and Attractive Food at Lunch
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food at a safe temperature during the lunch meal on 12/29/25. Multiple residents expressed dissatisfaction with the food, describing it as unappetizing, cold, lacking flavor, and generally of poor quality. Resident interviews revealed consistent complaints about the food's taste and appearance, with several residents stating that the quality had declined in recent months. A review of the facility menu indicated that turkey pot pie, honey glazed carrots, fruited gelatin, and beverages were scheduled for lunch, but residents reported the food was barely edible or not appetizing. During direct observation, the turkey pot pie served was found to be in a fluid, soup-like form, lacking the expected consistency and appearance. One resident's meal was missing key ingredients, containing only a single pea and no carrots. The Food Service Director acknowledged that the meal did not turn out well and attributed the poor quality to issues with a new food vendor and inconsistent cooking staff. The deficiency was confirmed by both resident feedback and staff admission, as well as direct observation of the meal served.
Failure to Prevent Elopement Due to Inadequate Supervision and Lapses in Safety Protocols
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for elopement, resulting in the resident leaving the facility without staff knowledge. The resident, who had a history of cognitive impairment, poor decision-making skills, and demonstrated exit-seeking behavior, was assessed as an elopement risk and had interventions in place, including placement on a secure unit with a wander guard and scheduled 15-minute checks. Despite these interventions, the resident was last seen in the dining room and was later found missing during medication rounds. Staff statements indicated that the resident was observed in the dining room and walking the unit, but there were gaps in supervision and incomplete documentation of required safety checks. The resident was able to exit the unit by accessing the elevator after learning the code, which was reportedly spoken aloud by staff. The resident then left the building and was located by police approximately 600 yards from the facility. Documentation revealed that the required 15-minute safety checks were incomplete or missing for several days, including the day of the elopement, and staff were unable to account for the resident during routine checks. The resident later stated that he was able to leave because he knew the elevator code and expressed a desire to leave the facility. Interviews with staff and review of facility records confirmed that the facility did not maintain adequate supervision or ensure the effectiveness of elopement prevention measures for this high-risk resident. The failure to consistently perform and document safety checks, as well as to secure the elevator code, directly contributed to the resident's ability to elope. This incident created an immediate jeopardy situation for the resident, as confirmed by the Director of Nursing and survey findings.
Removal Plan
- R3 was assessed for injury.
- Physician orders were reviewed, and plan of care was updated.
- R3's care plan was updated to include a change from Q 15-minute checks to 1:1 observation based on length of time needed to exit unit.
- Family and provider were notified.
- A root cause analysis was conducted.
- Maintenance changed elevator code.
- All stairwell doors and exterior doors were checked to ensure functionality with no issues identified.
- Education on facility elopement policy, notifying maintenance if a resident learns the elevator code, and making sure stairwell doors are closed and locked after use was implemented.
- QAPI meeting was held to review root cause analysis and elopement policy.
- Director of Nursing confirmed that R3 elopement risk assessment correctly identified him as an elopement risk and was up to date.
- Elopement risk assessments were reviewed and confirmed up to date and accurate for all residents.
- For residents assessed to be at risk for elopement, care plans were confirmed to include interventions to minimize risk of successful elopement.
- All staff were confirmed to have received elopement education.
- Director of Nursing will audit all admissions/readmissions to ensure elopement risk assessment is completed and residents at risk of elopement have interventions listed in their care plan to reduce the risk of successful elopement.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The facility failed to ensure effective management and supervision for residents identified as high risk for elopement, resulting in an actual elopement event that created an immediate jeopardy situation. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) showed that both roles are responsible for ensuring compliance with federal, state, and local regulations, as well as maintaining the highest degree of quality care. However, based on facility and clinical records, as well as staff interviews, it was determined that the NHA and DON did not fulfill these responsibilities, specifically by not providing the required supervision for high-risk residents. This lapse led to a resident elopement, indicating a failure to provide care and treatment in accordance with professional standards of practice and facility policies.
Failure to Pay Vendors in a Timely Manner
Penalty
Summary
The facility failed to pay bills in a timely manner, resulting in significant outstanding balances to multiple vendors. Review of the Nursing Home Administrator's job description confirmed responsibility for managing the facility in accordance with all applicable regulations and for all financial transactions. Financial documents revealed that the facility was placed on a weekly payment plan with a staffing agency after accruing a debt of $3,829,128.60. The staffing agency suspended services due to non-payment, which were only reinstated after a payment was received. Additionally, the facility owed substantial amounts to both water and sewage vendors, with the water vendor reporting an outstanding balance of $274,465.77 and the sewage vendor $217,024.70. The water vendor had initiated court action to recover payments, and the sewage vendor reported having to send monthly reminders for overdue payments. The Nursing Home Administrator confirmed the facility's failure to remain current with these vendors and indicated that payment plans were being sought.
Failure to Employ Qualified Social Worker for Required Period
Penalty
Summary
The facility failed to employ a qualified full-time social worker for approximately 388 residents over a nine-day period. Documentation review showed that the previous social worker's last day was 8/29/25, and the new hire began on 8/6/25, but there was a gap in qualified coverage from 8/30/25 to 9/7/25. The new social worker's personnel file did not include evidence of a qualifying degree, as transcripts revealed a Bachelor of Arts in history with a minor in anthropology, which does not meet the requirements for a qualified social worker. The previous social worker returned to work on 9/8/25, but during the nine-day gap, the facility did not have a qualified social worker on staff as required by regulations.
Failure to Resolve Vendor Payment Deficiencies Through QAPI
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies related to the non-payment of essential service vendors, specifically water and sewage vendors. Despite having a policy that requires quarterly QAPI meetings to identify and address areas of non-compliance, and a plan of correction that included auditing and communication protocols for vendor payments, the facility did not maintain current payments to these vendors. Documentation and interviews revealed that outstanding invoices for water and sewage services remained unpaid, with significant amounts owed to both vendors. During the survey, vendor representatives confirmed that large sums were overdue, with the water vendor stating that court action had been initiated to recover payments and the sewage vendor reporting ongoing delays and the need for repeated reminders. The Nursing Home Administrator acknowledged the failure to remain current on these payments and confirmed that the QAPI program did not resolve the previously identified deficiencies. This ongoing issue has the potential to affect all residents in the facility.
Failure to Ensure Resident Rights in Admission and Transfer Processes
Penalty
Summary
The facility failed to ensure that residents with cognitive impairments or legal guardianship had their rights upheld during the admission and transfer processes. Specifically, one resident with a moderate cognitive impairment, as indicated by a BIMS score of 11 and diagnoses including traumatic brain injury and mood disorder, signed the admission notice agreement despite lacking the capacity to understand its terms. Staff interviews confirmed that this resident struggled to comprehend the billing process and did not have the capacity to understand the admission agreement. Another resident, who had a court-appointed guardian due to an intellectual disability and schizoaffective disorder, also signed admission paperwork instead of the guardian, contrary to legal requirements. Additionally, the facility did not provide residents or their representatives with a choice regarding transfer destinations for three residents. One resident with severe cognitive impairment and Alzheimer's disease was transferred to another facility without the representative being informed of options or being contacted by the original facility. Another resident with multiple chronic conditions was transferred without the representative being involved in the selection of the new facility. A third resident, with severe cognitive impairment and schizophrenia, was also transferred without the representative being informed or given a choice, and the representative only learned of the transfer from the receiving facility. These deficiencies were identified through review of facility policies, resident records, and staff and representative interviews. The findings indicate that the facility did not ensure informed consent or resident choice in key processes, particularly for residents with cognitive impairments or those under guardianship, as required by federal and state regulations.
Failure to Notify Resident Representatives of Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were appropriately notified of decisions to transfer residents for seven out of nine residents reviewed. According to the facility's own policy, notification of the resident and their representative regarding transfers and the reasons for such transfers must be documented in the clinical record. However, clinical record reviews and interviews with resident representatives revealed that in multiple cases, representatives were not informed by the facility about the transfers. Instead, they learned of the transfers either from the residents themselves or from staff at the receiving facilities. Several residents involved had significant cognitive or mental health diagnoses, including schizoaffective disorder, bipolar disorder, dementia, Alzheimer's disease, and schizophrenia. BIMS scores for these residents ranged from cognitively intact to severely impaired, indicating varying levels of ability to understand and communicate about their care. Despite documentation in progress notes and social service notes stating that families were aware of the discharges, interviews with representatives consistently indicated a lack of direct communication from the facility regarding the transfers. The deficiency was identified through a combination of policy review, clinical record examination, and interviews with both staff and resident representatives. The findings showed a pattern where representatives were not given the opportunity to participate in or be informed about the transfer process, with some expressing confusion and concern about not being notified or consulted. This failure to notify was found to be in violation of state regulations regarding resident rights and facility management responsibilities.
Failure to Communicate Resident Information and Document Transfer Reasons
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers and did not document the reasons for transfers to alternate health care providers for seven residents who experienced facility-initiated transfers. Facility policy requires notification of the resident and, if known, their family or representative, as well as documentation of the reason for transfer in the clinical record. However, reviews of the clinical records for these residents showed no evidence that such notifications or documentation occurred. For each of the seven residents involved, the clinical records lacked documentation that specific information was communicated to the receiving health care provider. This information should have included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all necessary details to meet the resident's needs at the receiving facility. The records also failed to include the reasons for each resident's transfer. The residents affected had various diagnoses, including schizoaffective disorder, anxiety, insomnia, bipolar disorder, high blood pressure, dementia, Alzheimer's disease, anemia, hyperlipidemia, hypothyroidism, COPD, malnutrition, schizophrenia, low blood pressure, peripheral vascular disease, and chronic kidney disease. During an interview, the DON confirmed that the facility did not ensure the required communication and documentation for these transfers. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and it was found to be in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Failure to Accommodate Residents' Restroom Needs
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents whose shared bathroom had been inoperable for approximately one month. During an observation, caution tape was found around the commode in their bathroom, and staff interviews confirmed that the residents had been unable to use their own restroom for an extended period. Instead, they were required to use a restroom located on another nursing unit. Maintenance staff acknowledged not having addressed the issue in the past week, and the Director of Nursing confirmed that the residents were not offered a room move or other reasonable accommodations during this time.
Significant Medication Error Due to Double Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of high blood pressure, dementia, and anxiety was administered a double dose of their morning medications. The incident happened after the resident requested their medications from an LPN, who, due to a lack of clear communication and documentation between nursing staff during a shift change, provided the medications without realizing they had already been administered by the previous nurse. The medications given twice included Aspirin, Centrum Silver, Isosorbide Mononitrate Extended Release, and Lisinopril-Hydrochlorothiazide. Following the double administration, the resident exhibited mild shortness of breath and hypotension, prompting a call to the physician and subsequent transfer to the emergency room. The facility's policy required medications to be administered as prescribed and documented immediately after administration. However, the LPN was unable to document the administration in the electronic medical record at the time and relied on verbal communication, which led to the oversight. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by state regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Use of Physical Restraints Without Medical Necessity
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from preventable incidents.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
The facility failed to maintain proper cleanliness and sanitation in both the main kitchen and basement storage areas, as well as to properly date and store food products to prevent foodborne illness. Observations included mixing bowls and warming pans not being inverted, brown staining and standing water behind the hand washing station, paper debris and discarded gloves on the floor, and food items in the walk-in coolers and storage rooms that were either not labeled with dates or were past their expiration dates. Additional issues included caulking peeling from the ceiling in the spice storage room, streaking on the walls in the dry storage room, and packaging materials discarded on the floor. Further inspection of the basement kitchen storage areas revealed water dripping from the ceiling, puddles on the floor, crumbling ceiling material, and debris present. The basement freezer contained paper debris and food items that were not properly labeled. These findings were confirmed by the Dietary/Facility Manager and the Nursing Home Administrator during interviews, acknowledging the failure to maintain cleanliness, sanitation, and proper food storage practices as required by facility policy.
Failure to Pay Essential Service Bills in a Timely Manner
Penalty
Summary
The facility failed to pay outstanding bills to two vendors in a timely manner, as required by state regulations. Documentation provided by Vendor 1 and Vendor 2 showed significant unpaid balances, with Vendor 1's outstanding bill exceeding $200,000 and Vendor 2's bill accumulating to nearly half a million dollars. The vendors confirmed that there were no payment plans in place with the facility. The accounts payable ledgers provided by the facility corroborated these outstanding balances for both vendors. Vendor representatives indicated that the unpaid bills were for essential services, and one vendor was considering shutting down water services due to non-payment. Interviews with the Nursing Home Administrator (NHA) revealed a lack of direct involvement or oversight regarding the payment of these bills, with the NHA stating that the accounts payable office was responsible for handling payments. The NHA later acknowledged the failure to pay the vendors in a timely manner. The facility's failure to manage its financial obligations for essential services was found to be non-compliant with state licensure regulations, which require timely payment of bills necessary for resident health and safety.
Failure to Provide Appropriate Body Soap for Resident Care
Penalty
Summary
The facility failed to accommodate the body soap needs of four out of five residents, as evidenced by staff interviews, observations, and review of facility policy and records. The facility's policy requires providing necessary care and services to maintain residents' well-being, but staff reported that the facility stopped purchasing body soap for resident care. Instead, staff were instructed to use hand soap from the sink dispensers, which was confirmed by multiple nurse aides and housekeeping staff. Some staff members reported bringing in their own soap from home due to concerns about residents' already dry skin and the inappropriateness of using hand soap for bathing. Observations and interviews confirmed that the soap available in residents' rooms was labeled as Gentle Foam Soap, intended for hand cleansing, not for use as body wash. Central supply and housekeeping staff corroborated that the facility had discontinued purchasing individual bottles of body soap and was now using hand soap in resident care areas. The affected residents had various medical conditions, including high blood pressure, hemiparesis, hemiplegia, schizophrenia, stroke, COPD, chest pain, and urinary tract infection. The deficiency was cited under state regulations for responsibility of the licensee, resident care policies, and nursing services.
Failure to Maintain Safe, Clean, and Homelike Environment Across All Resident Areas
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for residents across all ten resident areas, as evidenced by multiple observations and staff confirmations. Surveyors observed obstructions such as a table and chair placed in front of an exit door, damaged flooring, holes in lounge floors, dented and scratched doors, and exposed metal in various locations. Additional findings included black marks on shower room floors, torn and peeling wallpaper and trim, broken blinds, and corroded surfaces with food debris and dried liquids. Several bathrooms and resident rooms had structural damage, such as peeling plaster, broken tiles, and water leakage, as well as dirty or stained privacy curtains. Interviews with staff, including LPNs, nurse aides, the Dietary/Facility Manager, and the Director of Nursing, confirmed the presence of these deficiencies. Residents were directly affected, as in the case where a resident reported that the air or heat did not work due to an unreachable outlet and that water leaked from a pipe behind broken tiles when the toilet was flushed. Housekeeping and maintenance services were found lacking, with staff noting that certain areas had not yet been cleaned or repaired. The observations and interviews demonstrated that the facility did not maintain a sanitary, orderly, and comfortable interior as required by facility policy and federal regulations. The issues were widespread, affecting all resident areas, and included both environmental hazards and failures in routine maintenance and cleaning. These deficiencies were confirmed by multiple staff members and management during the survey.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five staff members, including nurse aides, an LPN, and an RN. Review of the facility assessment indicated that all employees were to receive mandatory education, including QAPI, through self-directed coursework, with completion tracked by the Director of Education. However, upon review of the education files for these staff members, there was no documentation of QAPI training present. During staff interviews, the Human Resource Director confirmed that these five staff members had not received the required QAPI training. The deficiency was identified through review of facility assessment documents, employee education files, and staff interviews, and was cited under state regulations regarding staff development, management, and the responsibility of the licensee.
Failure to Provide Privacy and Dignity in Restroom Facilities
Penalty
Summary
The facility failed to ensure resident privacy and dignity on the Second and Fifth Main Floors, as required by its Resident Rights policy. On the Second Floor, the men's restroom was observed to be missing a curtain for one of two bathroom stalls, compromising privacy. On the Fifth Floor, the main south patient's restroom lacked an appropriately sized curtain for the first stall and had no curtain at all for the fourth stall. These deficiencies were confirmed by staff interviews, including an RN, an LPN, and the Director of Nursing, who acknowledged the absence of privacy measures in these restrooms. No information was provided regarding the specific medical history or condition of the residents affected at the time of the deficiency.
Failure to Monitor Resident Weights and Nutrition Status
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents by not obtaining required weights or responding to weight changes as outlined in facility policy. According to the policy, residents are to have their weights recorded weekly for the first four weeks after admission or readmission, and monthly thereafter, with all weights transcribed into the electronic record. For one resident, there were no recorded weights for two consecutive months, despite the resident being identified as at nutritional risk and having diagnoses including hypertension, hyperlipidemia, and diabetes. For another resident, only two weights were recorded over an extended period, despite a care plan indicating the need for weight monitoring due to nutritional risk and diagnoses of anemia, hypertension, and depression. Staff interviews, including with the Director of Nursing, confirmed that the facility did not obtain the required weights or act upon changes in weight for these two residents. The deficiency was identified through a review of facility policy, clinical records, and staff interviews, and was cited under relevant state regulations for management and nursing services.
Failure to Employ Qualified Registered Dietitian
Penalty
Summary
The facility failed to employ a qualified Registered Dietitian (RD) for two out of twelve months, specifically during June and July 2025, as required by facility policy and state regulations. According to staff interviews, the Dietary Manager confirmed the absence of an RD, and the Nursing Home Administrator stated that the previous RD had resigned, leaving the position vacant during this period. Facility policy and the RD job description indicate that the RD is responsible for assessing residents' nutritional needs, developing therapeutic diets, making diet recommendations, and providing nutritional assessment and consultation. The lack of a qualified RD meant these responsibilities were not fulfilled as required during the identified months.
Menu Cycle Not Reviewed or Approved by Registered Dietician
Penalty
Summary
The facility failed to have the current menu cycle properly reviewed and approved by a registered dietician for the period specified. Review of facility policy and the registered dietician's job description indicated that the dietician is responsible for assessing the nutritional needs of the resident population, developing therapeutic diets, and making diet recommendations. However, interviews with the Dietary Manager and the Nursing Home Administrator revealed that the facility did not have a registered dietician at the time, as the previous dietician had resigned. As a result, the menus in use were not reviewed or approved by a qualified dietician as required. This lack of oversight created the potential for conflicting guidance regarding portion sizes and food product consistency for prescribed therapeutic diets. The deficiency was identified through review of facility policies, documents, observations, and staff interviews, which confirmed that the facility failed to ensure the menus met regulatory requirements for dietician approval and oversight.
Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy
Penalty
Summary
The facility failed to ensure effective management and supervision of residents at high risk for elopement, resulting in an actual elopement incident that created an immediate jeopardy situation. Review of job descriptions, facility and clinical records, and staff interviews revealed that both the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not fulfill their responsibilities to manage the facility in accordance with applicable laws, regulations, and standards of practice. Specifically, the NHA was responsible for operating the facility and ensuring policies were uniformly applied, while the DON was responsible for directing nursing services to maintain the highest quality of care. Despite these defined roles, the facility did not provide the required supervision for residents identified as high risk for elopement. This lack of proper oversight and adherence to facility policies led to a resident elopement, which was identified as an immediate jeopardy event. The report cites that the facility did not ensure residents received treatment and care in accordance with professional standards of practice and facility policies, as required by state regulations. The findings are based on direct review of policies, job descriptions, and interviews, confirming that the fundamental principles of resident care and supervision were not upheld.
Failure to Safeguard and Replace Resident Property During Room Transfer
Penalty
Summary
The facility failed to protect the personal property of two residents, resulting in the loss and theft of their belongings during a unit relocation. Both residents, who were cognitively intact as indicated by their BIMS scores of 15, were instructed by a unit manager to leave their additional items in their former room due to limited space in their new room. The items were packed, labeled, and left in the old room, but no inventory sheet was provided to the residents, nor were they instructed to create one. Subsequently, staff members, acting on instructions reportedly from the Nursing Home Administrator (NHA), cleared out the room and disposed of the residents' belongings in the facility dumpster. Some staff also took items for personal use, believing they had permission from the NHA. Multiple staff interviews revealed a lack of a formal process for inventorying resident belongings during room transfers or unit shutdowns. Staff members involved in the removal of items stated they were told by supervisors and the NHA to clear out the room and dispose of its contents, with some being told they could take items if desired. The Director of Social Services and the Director of Maintenance/Laundry/Housekeeping both confirmed they were unaware of any established process for safeguarding or inventorying resident property during such transitions. The residents discovered their labeled bins empty and later found their belongings had been discarded. Despite the residents submitting detailed grievance forms listing the missing items, including clothing, electronics, personal effects, and sentimental items, the facility did not replace any of the lost property as of the time of the report. The Nursing Home Administrator confirmed that no items had been replaced. The facility's failure to safeguard resident property and to follow its own policy regarding inventory and protection of personal belongings led to the loss and theft of the residents' possessions.
Inadequate Linen Supply Compromises Resident Care
Penalty
Summary
The facility failed to maintain an adequate supply of linens readily available to staff on four of ten units, as evidenced by observations and interviews. On multiple units, linen carts were found to have minimal quantities of essential items such as sheets, towels, and especially washcloths, despite high census numbers. Staff reported frequently running out of washcloths and resorting to cutting towels, bath blankets, or sheets to use as makeshift washcloths. Some staff had to leave their units to obtain additional linens, and there was uncertainty among laundry staff regarding the quantity and delivery of linens. The Nursing Home Administrator confirmed that alternative washcloths of varying quality were purchased, but staff expressed concerns about their suitability for resident care. Residents reported that due to the linen shortage, their care was compromised, with some stating that pillowcases or sheets were used for personal hygiene, or that bed changes were made with inappropriate linens such as flat sheets instead of fitted sheets. Staff interviews corroborated these accounts, indicating that the lack of linens was a persistent issue and that makeshift solutions were commonly employed. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the ongoing problem with linen supply on the affected units.
Insufficient Nursing Staff Across Multiple Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents across nine of ten units, as evidenced by staff and resident interviews, direct observations, and census counts. On multiple units, there were only two nurse aides present for nearly 50 residents, and in some cases, aides were pulled from one unit to another, leaving units understaffed. Staff members, including unit managers and agency nurses, confirmed that staffing was inadequate, with administrative staff and supervisors often stepping in to cover shifts or pass medications. There were also instances where nurse aides reported being the only aide on the floor after certain times, and some units started shifts with only one or one and a half aides for dozens of residents. Residents reported delays in receiving medications, and staff described frequent occurrences of working without a nurse present on the unit, requiring nurses from other floors or office staff to administer medications. Agency staff turnover and restrictions on agency use further contributed to staffing challenges. The Director of Nursing and Nursing Home Administrator acknowledged ongoing staffing difficulties, confirming that the facility did not have enough nursing staff to provide necessary care and services to maintain residents' highest practicable well-being.
Deficiency in Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents during a lunch meal service. Observations made by surveyors revealed that cold food items, including desserts and salads, were portioned into Styrofoam containers and placed on trays for direct service to resident units. This practice was confirmed by the Director of Dining Services (DDS) Employee E1, who acknowledged the use of Styrofoam service ware for the lunch meal service. During an interview, DDS Employee E1 explained that the use of Styrofoam was due to staffing challenges, which resulted in an inability to clean dirty dishes from breakfast service in time for lunch. This led to a shortage of reusable service ware for cold items and desserts. Employee E1 confirmed that to eliminate the use of Styrofoam, the facility would need to order more service ware from a vendor. The facility's actions were found to be in violation of resident rights to a dignified dining experience.
Plan Of Correction
1. The food service department purchased an amount of non-disposable ware to ensure those items that are accidentally thrown out during meals and or not returned to the kitchen after meals do not hinder the food service department's ability to put out non-disposable ware. 2. The food service director or designee audited number of non-disposable ware for total needed from meals need per census to ensure enough non-disposable ware was available. 3. The food service director and assistant were re in serviced by the NHA to ensure Residents retain the right to a dignified dining experience. 4. The food service director or designee will audit meals daily for a month to ensure Residents retain the right to a dignified dining experience.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for one of its nursing units, specifically the West Wing 3rd floor. The deficiency was identified through a review of facility policy, observations, and staff interviews. The facility's policy, dated 10/1/24, mandates a safe, clean, comfortable, and homelike environment, allowing residents to use personal belongings. However, during an interview, the Nursing Home Administrator stated that the West Wing 3rd floor could be ready for occupancy at a moment's notice, but it would require cleaning and furnishing. Observations on the West Wing 3rd floor revealed multiple issues across various rooms. Several rooms were found with dirty floors, missing mattresses, exposed wiring, and holes in walls with drywall plugs. Many rooms lacked privacy curtains and furniture, and some had missing light bulbs. Additionally, some rooms had wood particle boards covering window holes where air conditioning units had been removed. The lounge area and other spaces were cluttered with maintenance supplies and equipment, further contributing to the unkempt environment. During an interview, the Maintenance Director confirmed that the West Wing 3rd floor was used for storing beds and other items, with only about 20 bed frames being usable. Equipment to furnish the floor had been ordered, with the first order received on the day of the observation. However, only about three-quarters of the unit could be made resident-ready within 24 hours. The facility's failure to maintain a clean, safe, comfortable, and homelike environment was acknowledged by the Maintenance Director.
Plan Of Correction
1. The rooms are confirmed to be clean equipped with the regulatory requirements. 2. The NHA initially audited this unit with the director of plant ops and environmental services and confirmed it was available for operation in the event of an emergency. 3. The NHA or designee re-inserviced the director of plant operations and environmental services to ensure all units, even units without residents on them, are prepared for use in the event of an emergency. 4. The NHA will audit weekly to ensure the unit continues to be properly available for use in the event of an emergency.
Deficiency in Resident Room Furnishings on West Wing
Penalty
Summary
The facility failed to provide essential furnishings in resident rooms on the West Wing's third floor, affecting 17 out of 17 rooms. During an observation, it was noted that several rooms were missing bed frames, mattresses, and functional furniture. Specifically, rooms with dual and quad occupancy were lacking these necessary items, which are required to ensure a safe and comfortable environment for residents. The absence of these furnishings was confirmed through both observation and staff interviews. Interviews with the Nursing Home Administrator and the Maintenance Director revealed that the third floor of the West Wing was being used for storage of beds and other items. The Maintenance Director acknowledged that while some equipment had been ordered and received, only about three-quarters of the unit could be made ready for residents within 24 hours. This situation indicates a failure to meet the regulatory requirements for providing a proper living environment for residents, as outlined in the facility's policy and federal regulations.
Plan Of Correction
1. The rooms are confirmed to be clean and equipped with the regulatory requirements. 2. The NHA initially audited this unit with the director of plant ops and environmental services and confirmed it was available for operation in the event of an emergency. 3. The NHA or designee re-inserviced the director of plant operations and environmental services to ensure all units, even units without residents on them, are prepared for use in the event of an emergency. 4. The NHA will audit weekly to ensure the unit continues to be properly available for use in the event of an emergency.
Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for a resident, identified as Resident R1. The deficiency was observed when a Registered Nurse (RN), Employee E3, placed a red bag for soiled dressing and treatment supplies on the resident's bed, which is against the facility's infection control policy. Furthermore, the RN did not change gloves or perform hand hygiene after cleansing the wound and before applying Triad cream and a clean dry dressing, which could lead to cross-contamination. Resident R1 had a coccyx wound that required daily cleansing with normal saline, application of Triad cream, and covering with a dry dressing, as per the physician's order. The resident's medical history included diagnoses of protein-calorie malnutrition, knee pain, hypertension, and hyperlipidemia. The failure to adhere to infection control protocols during the dressing change was confirmed by RN Employee E3 during an interview, acknowledging the lapse in proper procedures.
Plan Of Correction
1. R1 was seen by wound consultant and suffered no ill effects from dressing change. 2. Director of nursing immediately educated employee E3 on wound care policy and procedure. 3. Director of Nursing/designee will in-service licensed nurses on policy and procedure for dressing changes. 4. Director of Nursing/designee will audit 3 dressing changes weekly for 2 weeks, then 2 dressing changes weekly for 2 weeks, then 3 dressing changes monthly to ensure compliance with infection control standards during wound care. Audit findings will be shared with QAPI committee.
Deficiency in Resident Room Furnishings on West Wing
Penalty
Summary
The facility failed to obtain the Department of Health's approval before removing beds from resident bedrooms, resulting in a lack of beds, mattresses, and functional furniture in 17 out of 17 rooms on the West Wing's third floor. Observations revealed that multiple rooms, including dual and quad occupancy rooms, were missing essential items such as bed frames, mattresses, and furniture. This deficiency was identified during a survey conducted on April 10, 2025, where it was noted that the West Wing third floor was not equipped for resident occupancy. Interviews with facility staff, including the Nursing Home Administrator and the Maintenance Director, confirmed that the third floor of the West Wing had been used for storage and was not ready for immediate resident use. The Maintenance Director mentioned that equipment to furnish the area had been ordered, but only a portion of the unit could be made resident-ready within 24 hours. The Director of Nursing stated that the floor had not been in use since September 24, 2023, and the Nursing Home Administrator confirmed that there were no plans to decertify any beds in the facility.
Plan Of Correction
1. The rooms are confirmed to be clean and equipped with the regulatory requirements. 2. The NHA initially audited this unit with the director of plant ops and environmental services and confirmed it was available for operation in the event of an emergency. 3. The NHA or designee re-inserviced the director of plant operations and environmental services to ensure all units, even units without residents on them, are prepared for use in the event of an emergency. 4. The NHA will audit weekly to ensure the unit continues to be properly available for use in the event of an emergency.
Facility's Nonpayment Leads to Service Disruptions
Penalty
Summary
The facility failed to pay bills in a timely manner for essential services, impacting residents' health, psychosocial well-being, and safety. Interviews with staff and vendors revealed that the facility's nonpayment led to the suspension of services such as cable television, milk delivery, garbage collection, and medical transportation. The Nursing Home Administrator (NHA) was responsible for financial transactions, and the failure to pay these bills resulted in significant service disruptions. Residents were directly affected by these service interruptions. A Resident Representative expressed concerns about the lack of cable television, which was dismissed by the facility as non-essential. Additionally, the facility ran out of milk, and the Food Service Director had to arrange an emergency delivery. The Medical Transport Vendor suspended services for over a month due to unpaid bills, causing four residents to miss medical appointments. Vendors reported ongoing issues with the facility's payment practices. The Garbage Collection Vendor required upfront payments due to previous nonpayment issues, and the Dairy Product Vendor had to suspend services until payments were made. The Cable Vendor confirmed that services were suspended due to nonpayment but were restored after receiving overdue payments. The NHA acknowledged the facility's failure to pay bills timely, affecting essential services for residents.
Plan Of Correction
1. Outstanding invoices from vendors documented by surveyor were paid to terms or developed a payment plan. There were and are no current service interruptions from contracted vendors and no change in vendor services. 2. An initial audit conducted by the administrator confirmed vendors identified; third-party medical transportation and cable were brought to terms or a payment plan was developed to ensure services continue. Dairy vendor and refuse vendor continue to be paid timely and are still in use. 3. The accounts payable office representative and management team were re-inserviced by the administrator to ensure essential service vendors who are identifying delays in payment should be communicated directly to the Administrator. 4. The administrator was designated to audit ongoing to ensure vendors are paid to terms or have a payment plan in place to ensure services continue. Audit findings will be shared with QAPI.
Cable Service Disruption Affects Resident Activities
Penalty
Summary
Brighton Rehabilitation And Wellness Center was found to be non-compliant with the requirement to provide an ongoing program of activities that meet the interests and support the well-being of each resident. This deficiency was identified during an abbreviated survey conducted in response to six complaints. The facility failed to provide cable television for four and a half days in March 2025 due to non-payment of the cable bill, which affected the residents' ability to engage in their preferred activity of watching TV. This lapse in service was confirmed by the Director of Nursing (DON) and was corroborated by resident interviews. Several residents, including those with care plans indicating a risk for decreased socialization due to physical limitations, expressed dissatisfaction with the lack of television access. Residents R5, R6, R7, R8, R9, and R10 all reported that watching TV was a significant part of their daily routine and an intervention for their socialization needs. The absence of cable service led to feelings of boredom and inactivity among the residents, as they were unable to participate in their usual entertainment activities. The issue was further highlighted by resident interviews, where they expressed frustration and disappointment over the situation. Some residents had alternative means of entertainment, such as using a smartphone, but this was not a viable option for everyone. The facility's failure to maintain cable service, a key component of the residents' activity program, was confirmed by the cable vendor, who stated that services were suspended due to a past due payment, which was eventually settled to restore service.
Plan Of Correction
1. Basic TV remained active. Cable TV was returned to service on 3/25/25. Alternative activities for Residents were conducted as applicable to ensure psychosocial wellbeing. 2. An audit was conducted to identify Residents who were care planned for cable TV as an activity and had their care plan reviewed or updated for alternative activities in the event of a loss of cable TV by the activity's director or designee, to ensure psychosocial wellbeing. 3. The NHA will re-inservice the Activity Director to ensure alternative activity preferences for residents care planned for cable TV as an activity, to ensure psychosocial wellbeing. 4. Residents on admission will have their preference audited to ensure psychosocial wellbeing for a period of one week by the activity director or designee. Audit findings will be shared with QAPI.
Failure to Secure Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure that residents received appropriate treatment and care by not securing transportation to medical appointments for four residents. The deficiency was identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on 'Special Needs' requires assistance in arranging transportation for services not covered, and the 'Resident Rights' policy emphasizes the right to access services outside the facility. However, the facility did not adhere to these policies, resulting in missed medical appointments for the residents. Resident R1, who was admitted with diagnoses including high blood pressure and dementia, missed critical CT scans and a biopsy due to the lack of a bariatric stretcher for transportation. The transportation issues were attributed to nonpayment to the transport company, which led to the inability to secure necessary transportation. Similarly, Resident R2, diagnosed with dementia and GERD, missed an EGD appointment due to the same transportation payment issues. The facility's failure to resolve these payment issues directly impacted the residents' ability to receive timely medical care. Resident R3, with a history of osteomyelitis, missed several appointments with an infectious disease specialist and a wound care specialist due to transportation complications. Resident R4 also missed a scheduled colonoscopy for the same reason. Interviews with the transportation scheduler and the DON confirmed that the facility's inability to pay the transportation company resulted in these missed appointments, highlighting a significant lapse in the facility's responsibility to provide necessary care and treatment to its residents.
Plan Of Correction
1. The third-party transportation vendor was returned to service. R1, R2, R3, R4 attended their scheduled appointment with no negative effect to care identified. 2. An audit will be conducted to identify Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 3. The NHA will re-inservice the transportation director to ensure Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 4. Residents who require transportation to an appointment will be audited for two weeks by the transportation director. Audit findings will be shared with QAPI.
Failure to Secure Transportation for Radiology Appointments
Penalty
Summary
The facility failed to assist Resident R1 in securing transportation to a radiology appointment, as required by their policies. Resident R1, who was admitted to the facility with diagnoses including high blood pressure, dementia, and age-related physical debility, missed several scheduled CT scans and a biopsy due to the facility's inability to provide necessary transportation. The facility's policy mandates assistance in arranging transportation for services not covered, but Resident R1's appointments were missed because the facility did not have access to a bariatric stretcher and had not paid the transportation company. Interviews with staff revealed that the facility was unable to secure transportation from early February to late March due to nonpayment to the transportation company. The Director of Transportation and the Transportation Scheduler confirmed that Resident R1 missed appointments because the facility could not pay for the transport service that provided a bariatric stretcher. The Director of Nursing also confirmed the facility's failure to obtain transportation for Resident R1's radiology appointments, which was necessary for determining a potential cancer diagnosis.
Plan Of Correction
1. The third-party transportation vendor was returned to service. Resident R1 attended their scheduled appointment with no negative effect to care identified. 2. An audit will be conducted to identify Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 3. The NHA will re-inservice the transportation director to ensure Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 4. Residents who require transportation to an appointment will be audited for two weeks by the transportation director. Audit findings will be shared with QAPI.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in an elopement incident. The resident, who was admitted to a locked unit, was moderately impaired with a BIMS score of 10 and had a history of brain surgery and mood disorder. Despite these conditions, the facility did not complete an elopement risk assessment upon admission, nor did they reassess the resident when he displayed exit-seeking behaviors, such as expressing a desire to leave and being irate about his situation. The resident's care plan was not updated to reflect his elopement risk, and staff failed to monitor him adequately. On the day of the elopement, the resident was allowed to leave the unit unsupervised to smoke, despite being on a locked unit. Staff interviews revealed confusion about the resident's privileges and lack of clear communication regarding his supervision needs. The resident was able to leave the facility and was later found at a friend's house in another city. The facility's failure to complete necessary assessments and provide appropriate supervision led to the resident's elopement, creating an immediate jeopardy situation. Staff were not adequately informed or trained on how to handle residents with exit-seeking behaviors, contributing to the oversight that allowed the resident to leave the facility without proper authorization or supervision.
Plan Of Correction
1. The facility submitted an immediate corrective action plan to on-site surveyors on 2/11/2025. 2. All residents in the facility had updated elopement assessments completed on 2/11/2025. New admissions to the facility are being audited daily to ensure elopement risk assessment is completed on admission. Facility policy on elopements was revised on 2/11/2025 to clarify what classifies a resident as being at risk for elopement. The elopement binder at the reception desk was updated. 3. Staff in all departments were re-inserviced on completion of elopement assessments and identifying exit-seeking behaviors by the nursing administration team. The facility has contracted with Core Tactics to conduct on-site directed in-servicing to all staff on 3/11/2025-3/12/2025 on recognizing elopement risks. 4. The Director of Nursing or designee will complete a 30-day audit of all new admissions started on 2/12/2025 to ensure elopement risk assessments are complete and residents who are at risk for elopement have care plan interventions in place to minimize the risk of successful elopement. Audit findings will be shared with the QAPI committee.
Removal Plan
- The facility made contact with R456 and family who returned to the facility and signed out of the facility Against Medical Advice. Facility will reassess all residents for elopement risk. Assessments will be confirmed completed.
- All residents assessed to be at risk of elopement will have care plan and interventions implemented to reduce the risk of successful elopement. Residents being housed on east side locked units who are not identified as needing a locked unit will have a physician order permitting them to leave unit unsupervised.
- Administrator and Director of Nursing will review facility elopement policy and revise as necessary.
- All facility staff will be re-in serviced on elopement policy and identifying exit seeking behaviors upon arrival for next scheduled shift. Any staff not scheduled to work will be contacted by telephone to receive education.
- Director of nursing will audit all new admissions to ensure elopement risk assessment is complete and newly admitted residents who are at risk for elopement have care plan interventions in place to reduce the risk of successful elopement.
- Policy revision, staff education and ongoing audits will be shared QAPI committee.
Lack of Staff Training on Life Vest Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to care for a resident with a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified through a review of the manufacturer's guidelines, facility policy, clinical records, and staff interviews. The deficiency placed one resident, identified as Resident R811, in immediate jeopardy, impacting their health and safety. Resident R811 was admitted to the facility with a Life Vest, as indicated in their clinical records. The resident had a history of alcoholic cardiomyopathy, sarcoidosis of the lung, and depression. Despite the presence of a physician's order to check the Life Vest placement and battery daily, the resident's care plan did not include any problem, goal, or interventions for the care and management of the Life Vest. Interviews with the resident and various staff members revealed a lack of training and understanding regarding the Life Vest, with staff members admitting they had not received training on its use. Observations and interviews further highlighted the facility's failure to provide adequate training to its staff. Several staff members, including nurse aides and registered nurses, confirmed they had not been trained on the Life Vest at the facility. This lack of training and understanding among the staff led to a situation where the resident was managing the Life Vest independently, including changing the battery, which should have been part of the staff's responsibilities. The facility's inaction in ensuring staff competency in handling the Life Vest directly contributed to the deficiency and the immediate jeopardy situation for Resident R811.
Plan Of Correction
1. Care plan and physician orders for care of life vest for R811 were updated. 2. An audit was done of residents requiring life vest in facility; there were none. 3. Admissions director was in-serviced by director of nursing on notifying nursing administration of any admissions to facility requiring life vest prior to admission. Director of nursing will in-service nursing leadership on identifying and reporting educational needs for equipment or procedures to nursing administration. Nursing staff were educated on care of the life vest, including how the life vest works, what audible alerts mean, cleaning of the vest, and removing for hygiene. Facility has contracted with Core Tactics for onsite in-service training to occur on 3/11/2025 and 3/12/2025 for use and care of resident with life vest. 4. Director of nursing or designee will audit new admissions for 30 days to ensure residents with special equipment needs are communicated to the nursing department and needed education is provided. Audit results will be shared with QAPI.
Removal Plan
- Facility will implement immediate education for nursing staff for care and operation of the Life Vest, to include what alerts mean, first responder instructions, emergency patient management, showering and laundering of vest. All additional staff will be in-serviced on care and operation of the Life Vest prior to the next shift worked. Any staff not scheduled will be contacted via telephone and educated prior to the next scheduled shift.
- Resident R811's care plan will be revised to include use of the Life Vest. Physician orders for R811 will be reviewed to ensure orders for care and operation of the Life Vest are present and being followed.
- The NHA and DON will review the policy and procedure for use of the Life Vest to be revised as necessary. Policy for ensuring equipment needs on new admissions will be reviewed and revised to include communication of equipment needs by admissions staff to nursing staff prior to admission. Admissions director will be re-inserviced on communicating equipment needs to nursing department. Education needs regarding use of equipment will be assessed and provided prior to use.
- The NHA will audit all new admissions to ensure all equipment needs for new admissions are being met and staff are educated on equipment prior to use. Education, policy revision, and ongoing audits will be shared with Quality Assurance and Performance Improvement (QAPI) committee.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, which created the potential for cross-contamination. During an observation, brown debris was found in two ice machines, and brown, fuzzy debris was observed on three wall fans. The Dietary Manager, Employee E24, confirmed the presence of debris in the ice machines and was unable to confirm the last time they were cleaned. This lack of proper maintenance in the kitchen was acknowledged by Employee E24, indicating a failure to uphold food safety standards, potentially leading to foodborne illness.
Plan Of Correction
1. Ice machines were cleaned. The fan(s) were cleaned and removed. 2. The kitchen was audited to ensure sanitary conditions were maintained. 3. The director of food services was re-inserviced by the NHA to ensure the kitchen maintains sanitary conditions. 4. The director of food services or designee will audit the ice machines monthly to ensure ice machines and fans are clean of debris. Audit findings will be reviewed with QAPI committee.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident from a locked unit, which resulted in an immediate jeopardy situation for all 461 residents. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were found to have not effectively managed the facility to prevent this incident. The job descriptions for both the NHA and the DON clearly outline their responsibilities to manage the facility in accordance with federal, state, and local standards and to ensure the highest degree of quality care is provided to residents. However, their failure to fulfill these essential duties led to the elopement incident. The report highlights that the NHA and DON were notified of their failure to manage the facility effectively, which created an immediate jeopardy situation. The specific regulations cited include the responsibility of the licensee, management, and the administrator's responsibility, as well as nursing services. The deficiency was identified through a review of job descriptions, clinical records, and staff interviews, indicating a systemic failure in the administration and nursing services to adhere to required guidelines and regulations.
Plan Of Correction
1. Assessments and care plans were reassessed by the nursing department for all residents to ensure accurate identification of elopement risk. All employees were re-inserviced by nursing administration on proper assessment and care-planning to identify elopement-like behaviors. 2. The NHA and Director of Nurses were re-inserviced by Core Tactics consulting firm representative on elopement risk and policy and procedure and their respective job descriptions to ensure residents were free from the risk of elopement. 3. The NHA and Director of Nursing audit monthly for three months following initial daily audit x 30 days to ensure residents at risk for elopement have an assessment and care plan for elopement risk.
Failure to Designate a Medical Director
Penalty
Summary
The facility failed to designate a physician to serve as the medical director, as required by regulations. The review of facility documents and staff interviews revealed inconsistencies in the designation of the medical director. The facility's medical director contract indicated that a Doctor of Osteopathic Medicine, Employee E40, was responsible for medical directorship services. However, information submitted to the Department of Health listed Employee E38 as the designated medical director since 2016, despite the Nursing Home Administrator (NHA) stating that Employee E38 had not been the medical director since their tenure began. Instead, Employee E39 was noted to have taken over the role at the beginning of 2024. Further interviews revealed confusion and lack of clarity regarding the medical director's role. The NHA mentioned that multiple individuals were considered the medical director, and the facility utilized a group for these services. The Director of Nursing confirmed that Employee E40 was not frequently present in the facility and had delegated the role to Employee E39, who attended Quality Assurance and Performance Improvement (QAPI) meetings. Employee E39, during an interview, stated that he worked under Employee E40 and functioned as the facility's medical director, having started his visits in October 2023. This lack of a clear, designated medical director led to the deficiency noted in the report.
Plan Of Correction
1. A letter was submitted to the Department informing them of a change in medical director. 2. The NHA will review at least quarterly any administrative changes that might require notification to the Department and notify the Department timely.
Resident Dignity and Dining Experience Deficiencies
Penalty
Summary
Brighton Rehabilitation and Wellness Center was found to be non-compliant with certain resident rights requirements as per 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The facility failed to maintain the dignity of two residents. One resident, admitted in 2015, was observed self-propelling in a wheelchair wearing only a sweatshirt, socks, and a brief, without proper lower body clothing. A Licensed Practical Nurse acknowledged this issue, indicating a failure to ensure the resident was dressed appropriately, thus compromising the resident's dignity. Another resident, admitted in 2024, had a pressure ulcer on the right buttock, and during wound care, a nurse wrote on the dressing after it was applied, which was confirmed as a failure to maintain the resident's dignity. Additionally, the facility did not provide a dignified dining experience for residents during observed lunches. All residents in the dining rooms were served with plastic utensils instead of metal silverware, which was confirmed by the Dietary Manager. This practice was consistent over multiple days and was noted during tray line observations, indicating a systemic issue in providing a dignified dining experience for the residents.
Plan Of Correction
1. R149 was offered a blanket to cover his lap. Employee E3 was educated on maintaining dignity by dating dressings for residents prior to placing on the body. Residents whom received plastic cutlery on 2/10/25 through 2/12/2025 suffered no ill effects. 2. Walking rounds were done on 2/13/2025 by assistant director of nursing to ensure that residents who were out of bed were covered appropriately. No issues identified. 3. Director of nursing or designee will in service licensed nursing staff on dating wound dressings prior to placing on a resident. Director of nursing or designee will educate nursing staff on maintaining dignity by ensuring residents are covered appropriately. Administrator or designee will in-service dietary staff on providing metal cutlery unless otherwise ordered. 4. Director of nursing or designee will observe 5 dressing changes weekly for 2 weeks, then 3 dressing changes weekly for 2 weeks, then 3 dressing changes monthly for 2 months to ensure dressings are dated prior to being placed on resident. Director of nursing/designee will audit 6 units weekly for 2 weeks, then 3 units weekly for 2 weeks, then 3 units monthly for 2 months to ensure residents are covered appropriately. Audit findings will be shared with QAPI committee. Administrator or designee will audit meal trays weekly for 4 weeks to ensure metal cutlery is being provided.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for two of its nursing units, specifically the Four and Five Main Nursing Units. During a resident council group interview, two out of eleven residents expressed concerns about the cleanliness of the facility. Observations on the Four Main Nursing Unit revealed a dirty floor in Room 430 with garbage, sticky and black marks, an unclean bedside commode, and a dirty overbed table. These findings were confirmed by an LPN. Further observations on the Five Main Nursing Unit showed multiple brown-stained ceiling tiles, dust around ceiling vents, dirty and stained privacy curtains in residents' common bathrooms, and stained window curtains in Rooms 512-2 and 513-3. The common room ceiling fan and ceiling tiles were dusty, and patches on the hallway walls were unpainted. Additional observations on the Four Main Nursing Unit included brown-stained ceiling tiles, a missing piece of metal from a vent in a common bathroom, and stained privacy curtains in Rooms 406-1 and 416-2. These findings were confirmed by another LPN and the Director of Nursing.
Plan Of Correction
1. Room 430 was cleaned; trash was removed from room, floor was mopped, bedside commode was emptied and sanitized, and overbed table was cleaned. The ceiling in room 409 was cleaned. Missing metal from vent in 4 main common bathroom was fixed. Stained ceiling tiles on units 4 main and 5 Main were replaced. Ceiling vents and common room ceiling fan on 5 main. Privacy curtains were changed in rooms 406, 416, 512, 513, 518 and common bathroom on 5 main. Wall patches on 5 main will be painted. 2. Maintenance director and Environmental Services director will round units to check for items in need of cleaning or repair; items will be addressed by respective departments. 3. Administrator or designee will in-service maintenance and environmental services departments on maintaining a safe, comfortable, clean home-like environment. 4. Administrator or designee will round 5 units weekly for 2 weeks, then 3 units weekly for 2 weeks, then 5 units monthly for 2 months to ensure maintenance and environmental service issues are being addressed in a timely manner. Audit findings will be shared with QAPI committee.
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 six residents who were transferred. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The residents involved in the transfers were expected to return to the facility, yet there was no documented evidence that essential information, such as care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information, was communicated to the receiving provider. Resident R39, admitted on 9/7/24, was transferred to the hospital on 11/24/24. The clinical record lacked documentation of communication of the resident's care plan goals and other necessary information to the hospital. Similarly, Resident R49, admitted on 2/26/24, was transferred on 11/11/24, and Resident R73, admitted on 6/20/24, was transferred on 7/7/24, both without documented communication of essential information to the receiving health care providers. Additional cases included Resident R169, admitted on 4/10/24 and transferred on 12/2/24, Resident R460, admitted on 12/15/20 and transferred on 2/15/24, and Closed Resident Record CR611, admitted on 7/14/23 and transferred on 12/18/24. In each case, the facility failed to document the communication of necessary information to the receiving health care provider. The Director of Nursing confirmed this failure during an interview, acknowledging that the facility did not meet the required standards for communication during resident transfers.
Plan Of Correction
1. Facility is unable to retroactively correct the deficiency as it relates to R39, R49, R73, R169, R460 and CR611. 2. Director of nursing reviewed facility policy on hospital transfers. Policy was updated to reflect documentation of documents sent to receiving hospital. 3. Director of nursing or designee will in-service licensed staff on completing facility transfer form indicating documents sent to receiving hospital when transferring a resident to an outside hospital. 4. Director of nursing or designee will audit 5 hospital transfers weekly for 2 weeks, then 3 hospital transfers for 2 weeks, then 3 hospital transfers monthly for 2 months to ensure documentation of records sent with resident are present. Audit findings will be shared with QAPI committee.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for three residents. Resident R42, who was admitted with diagnoses including COPD and diabetes, was observed with an oxygen concentrator that had missing and soiled components. The tubing and humidifier were not dated, and the filter sponge was missing, with visible debris in the filter chamber. This was confirmed by a Unit Manager RN during an observation. Resident R235, admitted with COPD, diabetes, and toxic liver disease, had an empty humidification bottle, which was confirmed by a Unit Manager RN. Resident R811, with diagnoses including alcoholic cardiomyopathy and sarcoidosis of the lung, was observed with a nasal cannula connected to an empty, undated humidification bottle. The physician orders for Resident R811 did not include oxygen administration or equipment maintenance, despite the baseline care plan indicating oxygen as ordered. The Director of Nursing confirmed the facility's failure to meet professional standards for respiratory care for these residents.
Plan Of Correction
1. Oxygen concentrator for R42 was replaced, tubing and humidification bottle were changed. Humidification bottle for R235 was changed. Physician orders for oxygen were obtained for R811, oxygen tubing and humidification bottle were changed. 2. Director of nursing or designee will do a house audit of residents requiring oxygen to ensure orders are present for weekly changes of oxygen delivery equipment. 3. Director of nursing or designee will educate licensed nursing staff on following physician orders for changing oxygen delivery equipment and dating oxygen tubing and bottles when put in use. 4. Director of nursing or designee will audit 5 residents requiring oxygen weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure that orders for changing oxygen delivery equipment are present and tubing and humidification bottles are dated.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care to residents who are trauma survivors, as required by regulations. Specifically, the facility did not conduct Trauma Informed Care Evaluations for residents with PTSD, nor did it develop individualized care plans that addressed past trauma and identified triggers that could cause re-traumatization. This deficiency was identified for five residents, each with a diagnosis of PTSD, among other medical conditions. The facility's policy on trauma-informed care, dated 10/1/24, mandates the development of individualized care plans in collaboration with residents and their families to address past trauma and decrease exposure to triggers. Resident records revealed that assessments and care plans lacked the necessary components to address PTSD. For instance, Resident R33, admitted with major depressive disorder, opioid dependence, and PTSD, did not have a Trauma Informed Care Evaluation or a care plan with goals or interventions for PTSD. Similarly, Residents R51, R141, R168, and R296 also lacked appropriate assessments and care plans for PTSD. Interviews with facility staff confirmed these deficiencies, indicating a systemic failure to implement trauma-informed care practices for residents with PTSD.
Plan Of Correction
1. R296 is no longer in facility. Care plans for R51, R33, R141, and R168 were updated to reflect triggers that may exacerbate PTSD symptoms. 2. A house audit will be completed to ensure all residents with a PTSD diagnosis have potential triggers identified in their plan of care. 3. Director of nursing or designee will in-service social workers on identifying triggers associated with a PTSD diagnosis so that the plan of care includes interventions to mitigate stressors. 4. Director of nursing or designee will audit 2 residents with a PTSD diagnosis weekly for 4 weeks to ensure care plan includes identified triggers and interventions to mitigate stressors. Audit findings will be shared with QAPI committee.
Failure to Ensure Physician Conducted Initial Visits
Penalty
Summary
The facility failed to ensure that a physician completed the initial visit for three residents, as required by regulations. According to the clinical records, Resident R116 was admitted on June 6, 2024, and their initial visit was conducted by a Certified Registered Nurse Practitioner (CRNP) on June 7, 2024, instead of a physician. Similarly, Resident R229, admitted on December 5, 2024, had their initial visit conducted by a CRNP on December 6, 2024. Resident R422, admitted on December 10, 2024, also had their initial visit conducted by a CRNP on December 11, 2024. These actions were not in compliance with the requirement that the initial visit must be conducted by a physician. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not ensure a physician completed the initial visits for the three residents. The residents involved had various medical conditions, including dementia, hypertension, depression, osteomyelitis, spina bifida occulta, lymphedema, traumatic brain injury, and anxiety. The failure to have a physician conduct the initial visits was a deviation from the regulatory requirements outlined in §483.30(c).
Plan Of Correction
1. R116, R229 and R422 were seen by a physician and had history and physical completed. 2. An audit was done of admissions for the previous 30 days to ensure residents were seen by a physician for a full history and physical; no issues identified. Verbiage for NP visits needed prior to initial physician visit has been changed to "medical stabilization visit." 3. Director of nursing will meet with medical director to review regulatory requirements related to physician visits. 4. Director of nursing or designee will audit 2 new admissions weekly for 4 weeks to ensure initial history and physical is completed by a physician. Audit findings will be shared with QAPI committee.
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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