Premier Washington Rehabilitation And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Pennsylvania.
- Location
- 36 Old Hickory Ridge Rd, Washington, Pennsylvania 15301
- CMS Provider Number
- 395577
- Inspections on file
- 38
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Premier Washington Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain its automatic sprinkler system in accordance with NFPA standards when electrical MC wire conduit was found resting directly on sprinkler piping above ceiling tiles in the elevator lobby areas on two separate floors, affecting two of fifteen smoke compartments. The Facility Administrator and Director of Maintenance acknowledged these sprinkler system deficiencies during interview.
Surveyors found that oxygen cylinders were stored in crash cart rooms in two separate cores without the required precautionary signage on the doors indicating oxidizing gas storage and no smoking. Observations in two smoke compartments showed oxygen cylinders present in the 3 East and 2 East core crash cart rooms, yet the doors lacked the mandated "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING" signage. The facility administrator and maintenance leadership confirmed that the proper oxygen storage signs were not posted on these doors.
Surveyors identified that a room equipped with an FM-200 non-water-based fire protection system lacked the required warning sign indicating the presence of this extinguishing system. This deficiency affected one of the facility’s smoke compartments and was confirmed during an interview with the facility’s administrator and maintenance leadership.
Multiple grievances and resident council concerns were documented regarding unclean resident bathrooms. Despite staff claims of daily cleaning, observations found several bathrooms visibly soiled, with stained toilets and dust-blocked vents. Interviews with two residents confirmed inconsistent cleaning, and inspections revealed unsanitary conditions, including feces and urine left in toilets. The DON acknowledged the failure to maintain a homelike environment in several units.
A facility failed to maintain proper hazardous area enclosures when a storage room door in the Inventory Control room was found secured open with a rope, preventing it from closing and latching. This deficiency was confirmed by the Assistant Facility Administrator and Maintenance Director, affecting one of fifteen smoke compartments.
The facility failed to maintain the automatic sprinkler system, leading to deficiencies in two smoke compartments. Observations revealed a gap around sprinkler heads in a storage room and a hangar wire attached to a sprinkler branch line above smoke doors. These issues were confirmed by the Assistant Facility Administrator and Maintenance Director.
The facility failed to ensure that a fire extinguisher in the staff break room had the required annual inspection, as observed during a survey. This deficiency was confirmed by the Facility Administrator and Maintenance Director, who acknowledged the lapse in compliance with NFPA 10 standards.
The facility failed to maintain electrical wiring as required by NFPA 70, with an open electrical junction box found in the ceiling of the transfer switch room. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain proper use of electrical power cords and extension cords, affecting two smoke compartments. A microwave was plugged into an extension cord in the Supervisor's office, and a coffee pot and microwave were plugged into a power strip in the Pharmacy break room. These issues were confirmed by the Assistant Facility Administrator and Maintenance Supervisor.
The facility's main kitchen had sanitation issues, including ice build-up on a freezer fan affecting food items and improperly covered ground beef showing oxidation. These conditions were confirmed by the Dietary Manager.
The facility failed to store insulin pens in a safe and sanitary manner, with observations revealing unbagged insulin pens in three medication carts, posing a risk of cross-contamination. LPNs confirmed the pens were not bagged and were unaware of the reason for bagging them. The Director of Nursing acknowledged the facility's failure to prevent cross-contamination.
The facility failed to properly dispose of expired medications and biologicals in one of its medication rooms. Expired heparin lock flush syringes and a partially used bottle of vitamin E supplement were found, contrary to the facility's policy requiring the return or destruction of such items. The Unit Nurse Manager and DON confirmed these findings.
The facility did not post the required contact information for Adult Protective Services (APS) on the nursing units, making it inaccessible to residents, families, and visitors. This was confirmed by the DON during an interview.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on multiple occasions. A review of nursing schedules and census data showed that the hours per patient day (PPD) were below the required threshold on 15 out of 21 days. The Nursing Home Administrator confirmed this deficiency.
The facility failed to serve meals at scheduled times on one nursing unit, with lunch trays consistently arriving late. Staff and resident interviews confirmed the issue, and an observation showed significant delays in meal delivery. The Regional Food Service Director acknowledged the problem and mentioned efforts to address it.
The facility failed to provide sufficient dietary staff, resulting in delayed and incorrect meal deliveries. Residents reported receiving cold food and missing items, with some meals arriving hours late. The Food Service Director acknowledged staffing shortages and unreliable equipment, contributing to ongoing issues documented in meeting minutes and grievance logs.
The facility failed to serve meals at scheduled times over three days, with significant delays reported by staff and residents. Meals were often late, cold, and missing requested items. The Food Service Director cited staffing shortages and equipment issues as contributing factors. This deficiency violated dietary service regulations.
The facility failed to respect residents' rights in handling personal property, affecting eleven residents. Observations revealed piles of soiled and clean personal items in the laundry area, and staff interviews confirmed that an afternoon shift staff member refused to deliver personal items. The DON acknowledged the facility's failure in this regard.
The facility failed to follow the posted menu and provide residents with their preferred dietary choices during a lunch meal. Observations and interviews revealed discrepancies between the posted and actual menu, leading to residents not receiving meals as per their preferences. Staff and residents reported ongoing issues with late food delivery and missing items on trays, which were confirmed by the Food Service Director.
The facility failed to maintain a clean and homelike environment in five of six nursing units, affecting 33 residents. Observations showed dirty hallways, lounges, and dining areas, with debris and sticky substances. Resident rooms and shared bathrooms had soiled floors, broken sinks, and unsanitary conditions. The Housekeeping/Laundry Supervisor confirmed these issues.
The facility failed to store medications and biologicals properly and securely in three of six medication carts. Medication carts were observed unlocked and unattended, with resident medical information accessible and personal items improperly stored. These actions violated the facility's policies on medication storage and administration.
The facility failed to provide an environment that promoted dignity during medication administration for five residents. Medications were administered in a public area with other residents nearby, compromising the residents' dignity. The Director of Nursing confirmed this failure.
The facility failed to meet professional standards of quality when staff improperly administered insulin to a resident using a syringe instead of the Kwik Pen as per manufacturer's instructions. Both an LPN and an RN admitted to this practice, which was confirmed by the DON.
The facility failed to notify physicians and assess two residents for hyperglycemia and hypoglycemia despite multiple instances of abnormal blood glucose levels. The care plans were not followed, and the physician was not notified of the changes in condition.
Improper Support of Sprinkler Piping by Electrical Conduit in Two Smoke Compartments
Penalty
Summary
Surveyors found that the facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 requirements. During observations on April 27, 2026, an electrical MC wire conduit was seen resting directly on sprinkler piping above the ceiling tiles in the elevator 4 lobby on the 3 East unit at 9:15 a.m. A similar condition was observed at 9:35 a.m. above the ceiling tiles in the elevator 4 lobby on the 2 East unit, where another electrical MC wire conduit was resting on sprinkler lines. These deficiencies affected two of fifteen smoke compartments. In an interview on April 28, 2026, at 1 p.m., the Facility Administrator and Director of Maintenance confirmed the identified automatic sprinkler system deficiencies. No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to the physical environment and maintenance of the sprinkler system components in the identified areas.
Plan Of Correction
1. On April 27, 2026, the electrical MC wire conduit resting on the sprinkler piping above the ceiling tiles in the Elevator 4 Lobby on 3 East was removed and Elevator 4 Lobby on 2 East was removed and properly supported to eliminate contact with the sprinkler system piping. The Director of Maintenance verified that no damage occurred to the sprinkler piping or system 2. The Director of Maintenance conducted a facility-wide inspection above accessible ceiling spaces to identify any additional instances of electrical conduit, wiring, or other materials resting on sprinkler piping. Any additional findings identified during the inspection were immediately corrected at the time of discovery. 3. The Director of Maintenance educated maintenance department on requirements prohibiting any item from being supported by or resting on sprinkler piping. 4. The Director of Maintenance or designee will conduct weekly inspections x4 weeks and then monthly after, of a minimum of five random above-ceiling locations throughout the facility to verify compliance. Findings will be documented and reviewed during the facility's (QAPI) meetings monthly for three months
Failure to Post Required Oxygen Storage Signage in Crash Cart Rooms
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. The code requires that storage rooms or areas containing oxidizing gases, such as oxygen cylinders, have precautionary signage on each door or gate that is readable from 5 feet and includes, at a minimum, the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." During the survey, the facility was evaluated for compliance with these standards, which apply to various quantities of stored gas and require proper construction, separation from combustibles, and appropriate labeling of storage locations. On the survey date, observations showed that oxygen cylinders were stored in two separate crash cart rooms, one in the 3 East core and one in the 2 East core, without any signage indicating oxygen storage on the doors. These observations occurred at 10:13 a.m. in the 3 East core crash cart room and at 11:03 a.m. in the 2 East core crash cart room. The Facility Administrator and Director of Maintenance confirmed during an interview that the doors to these rooms did not have the required oxygen storage signage. The deficiency affected two of fifteen smoke compartments in the facility.
Plan Of Correction
1. On April 27, 2026, propersignage for oxygen was placed onthe 3 east crash cart room and the 2east crash cart room. 2. On April 27th, 2026 the Directorof Maintenance conducted afacility-wide inspection of all oxygencylinder storage locations and crashcart rooms to verify that requiredoxygen signage was present and nooxygen cylinders were improperlystored. 3. The maintenance staff wereeducated to ensure that propersignage for oxygen storage is postedfor all rooms where oxygen is stored. 4. The Director of Maintenance ordesignee will conduct weekly auditsx4 weeks and monthly after for 3months of oxygen storage areas toverify proper signage. Auditfindings will be documented andreviewed during the facility'smonthly QAPI meetings
Missing Warning Sign for FM-200 Fire Suppression System
Penalty
Summary
Surveyors found that the facility failed to maintain a non-water-based fire protection system in accordance with NFPA 99 (2012) 15.12.2. During an observation conducted at 11:40 a.m. on April 28, 2026, it was noted that a room equipped with an FM-200 extinguishing system did not have a required warning sign indicating the presence of this system. This omission was identified in one of 15 smoke compartments. In an interview held at 1:00 p.m. the same day, the Facility Administrator and Director of Maintenance confirmed the absence of the warning signage, thereby confirming the deficiency. No residents or specific patient conditions were mentioned in the report, and no additional contextual details beyond the missing warning sign for the FM-200 system and the staff confirmation of this issue were provided.
Plan Of Correction
1. On April 28, 2026, the required warning signage indicating the room was equipped with an FM-200 extinguishing system was installed at the entrance to the affected room. The Director of Maintenance verified the signage was properly posted and visible in accordance with applicable Life Safety Code and NFPA requirements. 2. On April 28, 2026, the Director of Maintenance conducted a facility-wide inspection of all rooms containing clean agent fire suppression systems, including FM-200 systems, to verify required warning signage was present. Any additional deficient areas identified during the inspection were corrected immediately. 3. Maintenance staff were re-educated regarding NFPA requirements for identification and warning signage associated with clean agent extinguishing systems. 4. The Director of Maintenance or designee will conduct monthly inspections for 3 months of all extinguishing system rooms to verify required signage remains in place and legible. Inspection findings will be documented and reviewed during the facility's (QAPI) meetings.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, specifically in the 3 South nursing unit bathrooms. Facility policy guarantees residents the right to a dignified existence and a safe, homelike environment. However, review of grievance logs over several months revealed multiple complaints regarding dirty resident rooms and bathrooms. Resident council minutes also documented concerns about housekeeping services. Despite staff interviews indicating that resident rooms and bathrooms are cleaned daily, observations on the 3 South unit found several bathrooms visibly soiled with debris and stains on the floors, toilets with stains of unknown origin, and ventilation units blocked with dust. Interviews with residents confirmed that bathrooms were not always cleaned, with one resident stating their shared bathroom was never cleaned and was not used by any of the occupants. Inspection of this bathroom revealed feces and urine in the toilet. Another resident also reported inconsistent cleaning, and their bathroom was found unclean upon inspection. The DON confirmed the poor conditions in multiple bathrooms and acknowledged that the facility failed to maintain a homelike environment on three of four observed nursing units.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, as evidenced by an observation on April 14, 2025. During this observation, it was noted that the door to a storage room within the Inventory Control room was improperly secured open with a rope or string, preventing it from closing and latching as required. This deficiency was confirmed through an interview with the Assistant Facility Administrator and the Maintenance Director on April 15, 2025. The deficiency affected one of the fifteen smoke compartments in the facility.
Plan Of Correction
Inventory control room door was open with a rope/string, and was unable to close and latch. The rope/string was removed from the door and closed properly. Maintenance audited throughout the facility with no other door issues found. Education to be completed with all maintenance staff making sure all doors are closed properly throughout the facility. Audits will be completed by maintenance to ensure all doors are not propped open and closed properly, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Automatic Sprinkler System Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, resulting in deficiencies in two of the 15 smoke compartments. During an observation on April 14, 2025, two specific issues were identified: a gap larger than 1/8 inch was found around two sprinkler heads with escutcheons in a storage room inside the Inventory Control room, and a ceiling tile track hangar wire was attached to a sprinkler branch line above the smoke doors near the 2 South Supervisor's office. These deficiencies were confirmed through an interview with the Assistant Facility Administrator and Maintenance Director on April 15, 2025.
Plan Of Correction
Large gap around two sprinkler pipes with escutcheons in the inventory control storage room. Ceiling hanger wire attached to sprinkler branch line above smoke door near 2 south supervisors office. Maintenance adjusted hanger in ceiling to raise the sprinkler head and escutcheon closer to the ceiling tile and replaced the ceiling tile. Maintenance removed hanger from sprinkler. Maintenance conducted audit of facility with no other issues with sprinklers or escutcheons. The maintenance department will be educated on Sprinkler system compliance. Audits will be completed by maintenance to ensure sprinkler system is in compliance, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Fire Extinguisher Annual Inspection Deficiency
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding portable fire extinguishers. During an observation on April 14, 2025, it was noted that the inspection tag on the fire extinguisher located in the 2 core staff break room did not have the required annual inspection. This deficiency was confirmed through an interview with the Facility Administrator and Maintenance Director on April 15, 2025, who acknowledged that the portable fire extinguisher had not undergone the necessary annual inspection as mandated by NFPA 10 standards.
Plan Of Correction
Inspection tag on the fire extinguisher in the 2 core breakroom did not have the annual inspection. Maintenance has ordered new fire extinguishers through Johnson Controls to be delivered. Maintenance conducted an audit of all fire extinguishers in the facility with no other issues found. Maintenance to be educated on compliance for all fire extinguishers. Audits will be completed by maintenance to ensure all fire extinguishers are within compliance, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Electrical Wiring Deficiency in Transfer Switch Room
Penalty
Summary
The facility failed to maintain electrical wiring in accordance with NFPA 70, National Electric Code, as evidenced by an open electrical junction box found in the ceiling of the transfer switch room. This deficiency was observed during a survey on April 14, 2025, at 10:17 a.m. The issue was confirmed through an interview with the Facility Administrator and Maintenance Director on April 15, 2025, at 1:30 p.m. The deficiency was identified in one of the 15 smoke compartments within the facility.
Plan Of Correction
An open electrical junction box on the ceiling of the transfer switch room was identified. The cover for the box was immediately put back on. Maintenance completed an audit throughout the facility with no other junction box issues. The maintenance department will be educated to make sure all junction boxes are covered. Audits will be completed by maintenance to ensure all junction boxes are covered, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Improper Use of Electrical Cords in Facility
Penalty
Summary
The facility failed to maintain proper use of electrical power cords and extension cords, affecting two of 15 smoke compartments. During an observation on April 15, 2025, it was noted that a microwave was plugged into an extension cord in the second floor Supervisor's office. Additionally, a coffee pot and microwave were plugged into a power strip in the Pharmacy break room. These deficiencies were confirmed during an interview with the Assistant Facility Administrator and Maintenance Supervisor on the same day.
Plan Of Correction
Appliances cited were removed from power strip to an appropriate outlet. Maintenance completed audit with no other issues with power strips were identified in the facility. Maintenance staff in serviced on what can and can't be plugged into a power strip. Audits will be completed by maintenance to ensure all power strips are used properly, Weekly X4 weeks and monthly X 2. All audits will be reported to QAPI.
Sanitation Issues in Main Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, which could potentially lead to cross-contamination or foodborne illness. During an observation, condensation and ice build-up were noted on the fan in the freezer, causing ice formation on multiple boxes of frozen goods, as well as on trays of cauliflower and broccoli wrapped in tin foil. Additionally, a metal tray containing approximately half of a ten-pound tube of ground beef was found loosely and partially covered with plastic wrap, showing signs of oxidation on the exposed end. These findings were confirmed by the Dietary Manager during an interview.
Improper Storage of Insulin Pens in Medication Carts
Penalty
Summary
The facility failed to store medications in a safe and sanitary manner, specifically concerning the storage of insulin pens in medication carts. During observations, it was noted that insulin pens were stored unbagged in three of the four medication carts reviewed, which included the Three South front cart, Three East front cart, and Two East back cart. This practice posed a risk of cross-contamination. Licensed Practical Nurses (LPNs) responsible for these carts confirmed the insulin pens were not bagged and expressed unawareness of the reason for storing them in bags. The Director of Nursing confirmed the facility's failure to prevent the risk of cross-contamination by not storing insulin pens in bags. The facility's policies on Infection Prevention Control Program Core Practices and Medication Storage, both reviewed on March 4, 2025, indicated the need for maintaining medication storage in a clean, safe, and sanitary manner. However, the observations and interviews revealed a lack of adherence to these policies, leading to the identified deficiency.
Improper Disposal of Medications in Medication Room
Penalty
Summary
The facility failed to ensure proper disposal of medications and biologicals in one of its medication rooms, specifically Unit 1 [NAME] medication room. During an observation, five heparin lock flush syringes with an expiration date of 9/30/24 and an opened, partially used bottle of vitamin E supplement with an expiration date of 3/25 were found. The facility's policy on the storage of medications, dated 3/4/25, mandates that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed. The Unit Nurse Manager and the Director of Nursing confirmed these observations, indicating a failure to adhere to the facility's medication disposal policy.
Failure to Post APS Contact Information
Penalty
Summary
The facility failed to comply with the requirement to post contact information for Adult Protective Services (APS) in areas accessible to residents, families, and visitors. During observations conducted on April 10, 2025, at 8:30 a.m., it was noted that the APS contact information, including name, address, email, and phone number, was not posted on the first, second, and third floor nursing units. This deficiency was confirmed during an interview with the Director of Nursing at 8:51 a.m. on the same day, who acknowledged that the APS contact information was not available in the required areas.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on 15 out of 21 days. This deficiency was identified through a review of nursing time schedules and staff interviews. The specific dates where the facility did not meet the required hours were documented, with the provided nursing schedules and census information revealing that the hours per patient day (PPD) fell below the required 3.2 hours on these days. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an electronic communication.
Plan Of Correction
1. Facility did not meet minimum required PPD for the dates of (12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 1/12/25, 1/13/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 2/17/25, 2/19/25 and 2/21/25). 2. Review of PA Code 211.12 completed by NHA and DON. Education then provided to scheduler by DON. 3. Facility contracts with multiple staffing agencies. Additionally, the facility also has an active recruitment and retention committee in an attempt to retain staff. There are also consistent advertisements on both Apploi and Indeed and often has a running ad in local paper. The facility currently offers sign on bonus, referral bonus for recruiting new staff, extra shift bonuses when we are projecting low, flexible scheduling, and nursing management staff rotate extra shifts. 4. NHA, DON, and facility Staff Scheduler will review projected current day's PPD, weekly projection as able, and previous day actual PPD 5 x week for 4 weeks.
Delayed Meal Service on Nursing Unit
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times for one of its nursing units, specifically the 1 [NAME] nursing unit. The facility's Meal Delivery Policy, dated 2/28/24, indicated that meals should be served at designated times. However, a review of the [NAME] Meal Delivery Log, revised 8/24/24, showed that lunch trays were consistently delivered late, with the first tray cart arriving at 12:52 p.m. and the second at 12:59 p.m. Staff interviews revealed that food carts were never on time for all three meals, with some deliveries delayed until 2:00 or 3:00 p.m. An observation on 11/14/24 confirmed that the first tray cart arrived at 1:33 p.m., 41 minutes late, and the second at 1:43 p.m., 44 minutes late. Resident interviews corroborated these findings, with one resident expressing dissatisfaction with the timing and quality of the meals. The Regional Food Service Director acknowledged awareness of the issue and mentioned ongoing efforts to address it through staff education and training. The Nursing Home Administrator and the Regional Food Service Director confirmed the facility's failure to adhere to scheduled meal times, as required by 28 Pa. Code: 211.6 (c) Dietary services.
Insufficient Dietary Staff Leads to Meal Delivery Issues
Penalty
Summary
The facility failed to provide sufficient dietary staff to perform essential kitchen duties, leading to significant delays and issues with meal delivery. Observations and interviews revealed that food trucks were consistently late, resulting in residents receiving meals hours after the scheduled time. Staff reported that trays were often incorrect, and residents complained about receiving cold food, missing items, and poor taste. The Food Service Director acknowledged the staffing shortages and the challenges in managing the kitchen effectively, noting that equipment such as hotplate warmers were unreliable. Residents expressed dissatisfaction with the meal service, citing late deliveries and inadequate food quality. One resident reported having to purchase their own condiments due to missing items on trays. The Dietary Council Meeting Minutes and Grievance logs from May to July 2024 documented ongoing issues with late and cold food, as well as complaints about not receiving ordered items. The Food Service Director confirmed the facility's failure to maintain adequate dietary staffing, which contributed to these deficiencies.
Failure to Serve Meals on Time
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times over a period of three days. The Meal Delivery policy, dated 2/28/24, allowed for a ten-minute delay in food truck delivery times, but required an explanation if the delay exceeded this period. Despite this policy, staff and residents reported significant delays in meal delivery, with some meals arriving two to three hours late. Staff Employee E2 noted that food trucks were consistently late, and residents did not receive the meals they requested. Resident R5 reported receiving cold food, particularly at breakfast, and mentioned that dinner was served as late as 9:00 p.m. Resident R7 echoed these concerns, stating that trays were consistently late, lacked condiments, and often had missing items. The Food Service Director, Employee E3, acknowledged the issues with meal delivery, citing staffing shortages and malfunctioning hotplate warmers as contributing factors. During an observation, the lunch cart delivery was noted to be fifteen minutes late, further confirming the facility's failure to adhere to scheduled meal times. The Director of Nursing, Nursing Home Administrator, and Lucent Regional Manager confirmed the facility's inability to serve meals on time for the identified days. This deficiency was in violation of 28 Pa. Code: 211.6 (c) Dietary services.
Failure to Respect Residents' Rights in Handling Personal Property
Penalty
Summary
The facility failed to respect the residents' rights in handling and protecting their personal property and clothing, as observed during a survey. Eleven out of thirteen residents interviewed reported issues with the management of their personal items. During an observation of the facility's laundry areas, surveyors noted multiple heaping piles of soiled and clean personal items on carts, indicating a backlog and mishandling of residents' belongings. Interviews with staff revealed that the afternoon shift staff member refused to deliver personal items, despite being written up several times. The Laundry Housekeeping Manager expressed an inability to replace this staff member due to staffing shortages. The Director of Nursing confirmed the failure to deliver personal clothing, acknowledging the facility's failure to respect residents' rights in this regard.
Failure to Follow Menu and Provide Preferred Dietary Choices
Penalty
Summary
The facility failed to adhere to the posted menu and provide residents with their preferred dietary choices during a lunch meal. Observations and interviews revealed that the facility did not follow the displayed menu for one of the three observed meals, specifically the lunch meal on 7/23/24. The posted menu on the 3 East and 3 South Nursing Units was not the menu being used, as confirmed by the Diet Clerk, who stated that the facility was actually in week 1 of the menu cycle. This discrepancy led to residents not receiving the meals as per their preferences. Interviews with staff and residents highlighted ongoing issues with meal service, including late food delivery and missing items on trays. Staff Employee E2 mentioned that food trucks were consistently late, resulting in residents receiving meals as late as 8:00 p.m. Additionally, Resident R7 expressed frustration over the lack of condiments and the need to purchase their own sugar and salt. The Food Service Director confirmed that the trays did not contain all the requested items for three residents, further indicating the facility's failure to meet dietary needs as per the posted menu.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment across five of six nursing units, affecting 33 out of 52 residents. Observations revealed that the main entrance hallways leading to various nursing units and the main dining room were spoiled with black substances and debris. The main resident lounges on multiple nursing units were cluttered with wheelchairs, staff equipment, and littered with paper, food debris, and sticky substances. Additionally, the main hallways and dining room floors were found to be dirty and covered with debris. Specific resident rooms and shared bathrooms were observed to have soiled floors, broken sinks with sharp edges, and other unsanitary conditions. For instance, shared bathrooms and rooms had brown and black substances, sticky floors, soiled linens, and full garbage cans. Some residents' wheelchairs were heavily soiled, and several rooms had broken sinks with sharp edges. The Housekeeping/Laundry Supervisor confirmed these findings, acknowledging the facility's failure to provide a clean, comfortable, and homelike environment for the affected residents.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in three of six medication carts. Specifically, the One Front Hall medication cart was observed unlocked with the Electronic Health Record (EHR) visible on the laptop screen and four medication cups labeled with resident room numbers left on top of the cart. An LPN confirmed that the cart was left unattended and unlocked with resident medical information accessible to unauthorized individuals. Similarly, the Three East Back Hall medication cart was also left unattended and unlocked, as confirmed by another LPN. Additionally, the Three South Front Hall medication cart contained unlabeled personal items such as hand cream, hand sanitizer, and lip moisturizer, which were confirmed by an LPN to be improperly stored biologicals. Further observations revealed that the Three East Front Hall medication cart was left unattended and unlocked in the hall outside a resident's room, making it accessible to residents, staff, and visitors. An RN confirmed that she left the medication cart unattended and unlocked. These actions are in violation of the facility's policies on medication storage and administration, which require medication carts to be securely locked when out of the nurse's view and medications to be stored properly to prevent unauthorized access.
Failure to Promote Dignity During Medication Administration
Penalty
Summary
The facility failed to provide an environment and care that promoted dignity during medication administration for five residents. Observations revealed that medications were administered in a public area, specifically at tables in the middle of the nursing unit, with other residents seated nearby or walking around. This practice was inconsistent with the facility's policy on medication administration, which emphasizes safe and timely administration, and the policy on resident rights, which mandates treating all residents with kindness, respect, and dignity. Resident R226, diagnosed with dementia, depression, and muscle weakness, was observed receiving medications at a table in the middle of the nursing unit. Similarly, Resident R178, with diagnoses including dementia, anxiety, and depression, was also administered medications in the same public setting. Resident R119, who has diabetes, high blood pressure, and schizoaffective disorder, was observed receiving medications at a table in the middle of the unit, surrounded by other residents. Resident R131, diagnosed with schizoaffective disorder, diabetes, and anxiety, and Resident R214, with diabetes, COPD, and chronic atrial fibrillation, were also administered medications in the same undignified manner. Notably, Resident R214 was asked about insulin injection preferences in a public setting, which compromised his dignity. The Director of Nursing confirmed the failure to provide an environment that promotes dignity during medication administration for these residents.
Improper Insulin Administration
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality for Resident R214. The resident, who was admitted with diagnoses including diabetes, depression, and muscle weakness, had a physician order for Lantus Kwik Pen insulin administration. However, during an observation of medication administration, an LPN was seen drawing insulin from the Kwik Pen using a syringe, which is against the manufacturer's instructions. The LPN admitted to using this practice frequently, as did another RN, indicating a systemic issue within the facility. The facility's policy on employee competence requires staff to demonstrate the knowledge and skills necessary to perform their duties correctly. Despite this, the staff's improper use of the insulin pen was confirmed by the Director of Nursing, who acknowledged that the facility failed to meet professional standards of quality in this instance. This deficiency was identified through a combination of clinical record reviews, staff interviews, and direct observation, highlighting a significant lapse in adherence to proper medication administration protocols.
Failure to Notify Physicians and Assess Residents for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia for two residents. Resident R14 had a diagnosis of diabetes and was prescribed Lispro insulin with specific instructions to notify the physician if blood sugar levels were less than 60 or greater than 450. On multiple occasions, Resident R14's CBG levels were significantly above the threshold, but the facility did not assess for hyperglycemia, monitor the effectiveness of treatment, follow care plan interventions, or notify the physician of the abnormal results. Similarly, Resident R229, who also had a diagnosis of diabetes, had physician orders to notify the physician if blood glucose levels were greater than 400. Despite several instances where Resident R229's CBG levels exceeded this threshold, the facility did not assess for hyperglycemia, recheck blood sugar levels, follow care plan interventions, or notify the physician of the abnormal results. The care plans for both residents included specific instructions to monitor and report signs and symptoms of hyperglycemia, which were not followed. Interviews with various nursing staff, including LPNs and RNs, revealed that they were aware of the procedures for handling abnormal blood glucose levels but failed to execute them. The Director of Nursing confirmed that the facility did not notify the doctor of changes in condition related to blood glucose, did not follow care plan interventions, and did not recheck blood sugars for the affected residents.
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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