Wecare At Monroeville Rehabilitation And Nsg Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroeville, Pennsylvania.
- Location
- 4142 Monroeville Blvd, Monroeville, Pennsylvania 15146
- CMS Provider Number
- 395670
- Inspections on file
- 53
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 42 (1 serious)
Citation history
Health deficiencies cited at Wecare At Monroeville Rehabilitation And Nsg Ctr during CMS and state inspections, most recent first.
The facility failed to maintain hot water temperatures at or below its policy limit in resident bathroom sinks on one nursing unit, despite a written policy requiring water heaters to be set no higher than 110°F and assigning maintenance staff to monitor and log temperatures. A resident with neuropathy and multiple comorbidities sustained a burn to a finger after using hot water in the bathroom, later presenting with an open wound but remaining alert and oriented. Surveyors found that most tested outlets on the affected unit were above 110°F, with some reaching up to 120°F, and staff identified more than half of the residents as physically able to independently access these hot water outlets, resulting in an Immediate Jeopardy determination.
Surveyors found multiple food safety issues in the main kitchen, including a stand-up ice cream freezer with ice buildup, a bottle of ice, and a bowl with food debris, undated juices stored on a cart in the walk-in freezer, and air circulation fan blades with a black substance. A deep freezer contained a plastic bag labeled as a roast that appeared freezer burned and completely covered with ice. All dietary staff observed in the kitchen had uncovered hair and were not wearing hairnets. The Certified Dietary Manager confirmed improper food storage practices and the failure of staff to use proper hair restraints, creating the potential for cross contamination.
Surveyors found that the main kitchen’s low-temp chemical dish machine was not functioning properly, as repeated testing with chemical strips after multiple runs showed sanitizer levels below 10 ppm instead of the required 50–100 ppm. A dietary manager confirmed that the facility failed to ensure the dish machine was in proper working order.
The facility failed to protect resident confidentiality when two medication carts and a medication packet were left unsecured with resident-identifiable information visible and accessible. One medication cart was left unattended in a hallway with resident information displayed on the computer screen and on papers on top of the cart, as confirmed by an RN. Another unused medication cart in a dayroom was unsecured and contained accessible resident information, including a narcotic book, as confirmed by the ADON. Additionally, a medication plastic packet with resident information was found in an accessible room that was closed for repair. The Nursing Home Administrator acknowledged that these situations constituted a failure to maintain the confidentiality of resident medical information.
The facility failed to maintain a safe, clean, and homelike environment and did not ensure an adequate supply of clean linens, washcloths, and towels on both nursing units. Surveyors observed unfinished drywall, broken walls and ceilings, missing floor transitions in bathrooms, soiled privacy curtains, a brown substance on a room floor, a broken chair, and damaged overbed tables. In the laundry area, only one of two washers was functional and leaking, and only one of three dryers worked, contributing to linen shortages. A resident who could not use diapers due to psoriasis and an allergy required frequent linen changes but reported being told there were not enough linens, while other residents reported frequent shortages of towels and washcloths and staff scrambling to find them. Staff confirmed awareness of linen shortages and the failure to provide a clean, comfortable, homelike environment.
The facility failed to follow physician orders and internal policies for monitoring and responding to abnormal capillary blood glucose (CBG) levels for three residents with diabetes and other comorbidities. Despite orders specifying CBG thresholds for physician notification, multiple CBG readings well above those parameters were documented, including extremely high values, without any recorded physician notification, assessment for hyperglycemia, or monitoring of treatment effectiveness, and care plan interventions were not followed. LPNs reported that their usual practice was to notify providers and document when CBG values were critically high or below 70 mg/dL, but the records for these residents did not reflect that practice, and facility leadership acknowledged that physicians were not notified of these changes in condition.
The facility failed to maintain required dialysis communication documentation for two residents receiving hemodialysis. Facility policy required completion of pre- and post-dialysis communication forms, with dialysis center staff returning completed forms or EHR documentation for review and filing in the medical record. For one resident with HTN, diabetes, and ESRD receiving twice-weekly dialysis, only a single partially completed communication form was found over several months. For another resident with HTN, anxiety disorder, and ESRD receiving thrice-weekly dialysis, no communication forms were found over a similar period. When surveyors requested the dialysis binder, an LPN and other staff were unable to locate it, and the only document produced was the partially completed form the first resident had kept in a personal folder. The DON and Regional DON confirmed that consistent dialysis communication had not been maintained.
The facility did not follow its medication storage policy requiring locked, attended carts. One medication cart in a hallway was observed unlocked and unattended, and another cart, identified as unused due to low census, was left in a dayroom with unsecured medications and no staff present. An RN and the ADON each confirmed that these carts were not properly secured.
The facility failed to provide sufficient nursing staff to meet residents’ basic care needs, resulting in repeated reports of long call light wait times, missed scheduled showers, and inadequate incontinence and hygiene care. Residents described waiting so long for assistance that they soiled themselves, not being rescheduled when showers were missed, and going without regular grooming such as hair and fingernail care. Clinical records lacked documentation of ordered twice-weekly showers for several residents, and the DON could not produce the paper shower logs that were said to be maintained. Multiple grievances and resident council reports over several months cited chronic understaffing, excessive call light response times, and missed showers, while staff interviews confirmed that staffing was often insufficient and residents frequently complained about delays in care.
The facility failed to maintain resident dignity and basic hygiene for multiple residents. A resident was observed lying on a bare mattress without sheets or blankets, despite requesting them, while an RN stated the resident shreds blankets. A cognitively intact resident reported being left in a heavily soiled brief for many hours, with stool and urine soaking his sheets and clothing, and was later seen with long, dirty fingernails despite ordered nail checks not being documented. Another resident who needed help with a urinal reported delayed call light responses. A spouse reported that staff would not assist her husband, who had a bowel movement and no brief on, and stated that two nurses said they do not change briefs. Another resident reported not receiving a shower for eight days, with an itchy scalp and visitors commenting on his odor. The NHA and DON acknowledged that care was not provided in a manner that preserved resident dignity.
The facility failed to respond in a timely and effective manner to repeated concerns raised through the resident council regarding long call light response times, missed or unscheduled showers, and perceived understaffing. Over multiple months, council minutes documented the same unresolved issues, with only a general note that past complaints and corrective actions were reviewed and an explanation that each aide was responsible for many residents, but without clear documentation of actions taken. During a group interview, residents reported that their complaints were recorded but that they were not informed of any resolutions. The NHA, DON, and Regional DON acknowledged that the facility did not adequately respond to these resident council concerns, constituting a failure to honor residents' rights to meaningful participation in resident/family groups.
A resident with multiple medical conditions and neuropathy in the hand reported a bleeding injury to the left index finger, which was later documented as a burn sustained from hot water at the bathroom sink. Nursing staff treated the wound and notified a supervisor, but the facility did not conduct or document a thorough investigation of the injury as required by its abuse/neglect and accident/incident policies. During surveyor observations and interviews, hot water temperatures in several rooms, including the resident’s, were found to be above 110°F, prior water temperature logs could not be located, and maintenance staff believed the acceptable limit was higher. Leadership acknowledged that the facility failed to identify and fully investigate the injury to rule out possible neglect.
The facility failed to post current and accurate daily nurse staffing information at the beginning of each shift. Surveyors observed that the staffing notice displayed in the main lobby showed an outdated date, census, and staffing hours that did not reflect the actual total hours worked by licensed and unlicensed nursing staff directly responsible for resident care on the current day. The NHA confirmed that the required current staffing hours and census information had not been posted.
The NHA and DON did not ensure that bathroom hand sink water temperatures on one of two nursing units were maintained at a safe level, despite their job responsibilities to manage operations and nursing services in accordance with federal, state, and local regulations and to uphold health and safety standards. Surveyors, using job descriptions, clinical records, and staff interviews, found that unsafe hot water temperatures in resident bathroom sinks caused harm to a resident and created an Immediate Jeopardy situation for many residents on the affected unit. Both the NHA and DON acknowledged during interviews that they failed to maintain safe water temperatures in resident bathroom hand sinks.
Surveyors found that the laundry area was not maintained in a clean, sanitary, and functional condition. One of two washers was operating without its front panel and was leaking water onto the floor, while among three dryers, two were marked as broken and the only functioning dryer contained a brown substance inside the drum. The Laundry/Housekeeping Supervisor confirmed these conditions and acknowledged the failure to maintain the laundry room environment in accordance with regulatory requirements.
Surveyors found that the facility failed to follow its own written procedures for testing door alarm systems. The Maintenance Director only checked that doors were locked by attempting to open them, did not perform the required multi-step alarm testing process, and was unable to deactivate an alarm without nursing staff assistance during observation. The NHA confirmed that door alarm systems were not being regularly tested for full functionality as required by facility policy and state regulations.
Two residents did not receive ordered NPWT and consistent wound care. One resident with a diabetic foot ulcer and osteomyelitis was discharged from the hospital with a wound vac order, but the facility did not obtain an active wound vac order for nearly two weeks, never applied the wound vac, and omitted the therapy from the care plan. Internal communications showed the wound vac equipment was malfunctioning, not started, and misplaced, while the resident reported missed dressing changes and dissatisfaction with wound care; the TAR showed multiple missing entries for ordered wet-to-dry and other wound treatments. Another resident with a PICO 14 NPWT dressing to the left femoral region had physician orders and NP notes specifying dressing and battery life, but the care plan lacked PICO-related interventions and the record did not show required dressing or battery changes, with later documentation that the PICO battery was dead and the dressing removed.
Two cognitively intact residents with COPD and cardiac conditions did not receive ordered maintenance inhalers or their documented therapeutic interchange, despite MAR entries indicating administration. One resident had an order for a once‑daily Breo Ellipta inhaler changed to scheduled Ipratropium‑Albuterol nebulizer treatments, and another had orders for a once‑daily Trelegy Ellipta inhaler and PRN Ipratropium‑Albuterol, but their care plans did not reflect respiratory medications or nebulizer use. Surveyors found that neither resident’s inhaler was present on the med cart, the substituted nebulizer ampule boxes were unopened, and an LPN could not explain why the MAR showed doses as given. Both residents later reported they had not been receiving their inhalers, and leadership confirmed the failure to provide appropriate respiratory care.
A resident with dementia, moderate cognitive impairment (BIMS 8), and documented elopement risk was able to leave the building unaccompanied despite a care plan and physician order to monitor wandering behavior. The resident exited through a back door that opened easily, where only a low alarm sounded and the loud alarm remained silent, allowing the resident to be outside briefly before an LPN observed and returned the resident inside. A CNA and another nurse aide account described that no alarms initially sounded when an individual exited, with alarms only activating upon re-entry, demonstrating inadequate supervision and ineffective exit door alarm function for an identified elopement-risk resident.
Surveyors found that two crash carts lacked multiple required emergency items, including code books, ambu-bags, suction kits, PPE, alcohol-based hand rub, and in one case a blood pressure cuff, stethoscope, glucometer, and full oxygen tanks, with incomplete and unsigned daily checklists. At the same time, both facility dryers were inoperable, forcing staff to rely on a small non-commercial dryer and resulting in extensive backlogs of soiled linen and widespread shortages of clean towels and washcloths on multiple halls. Staff reported difficulty bathing residents, described using cut-up bath blankets, dry wipes, baby wipes purchased personally, and clothing protectors in place of standard linen, and leadership confirmed the failures to maintain the crash carts and dryers in safe operating condition.
Surveyors found that staff failed to notify providers of significantly elevated capillary blood glucose (CBG) levels for four residents with diabetes, despite facility policy and care plans directing monitoring and reporting of hyperglycemia. One resident with heart failure and diabetes had multiple CBG readings at or above 500 mg/dL, even though the insulin sliding-scale order required calling the MD for values greater than 500 mg/dL, and no provider notification was documented. Another resident with dementia and diabetes, and a third with ESRD and diabetes, had repeated CBG values over 400 mg/dL without documented notification, including one reading of 489 mg/dL where the order required calling the MD for values over 400 mg/dL. A fourth resident with CAD and diabetes had numerous CBG readings above 400 mg/dL while on scheduled Humalog, again without documented provider notification. The Medical Director stated staff were expected to notify providers of out-of-range blood sugars, generally at 400–450 mg/dL if no specific parameters were ordered, and the NHA and DON acknowledged that physicians were not notified of these increased CBG levels.
Surveyors determined that the facility did not ensure all licensed nursing staff held appropriate CPR certification for healthcare providers. Review of the facility’s CPR policy showed it required American Red Cross or American Heart Association BLS/CPR with hands-on training. However, review of records for three licensed nurses (two LPNs and one RN) revealed they only had online, non-healthcare-provider CPR courses without a hands-on component. The NHA confirmed that these nurses did not have current, hands-on CPR certification consistent with accepted national standards.
Surveyors found that the facility did not maintain documentation of current CPR/BLS certification for a significant number of its licensed nurses. Review of the facility’s CPR policy showed that staff were required to have training in CPR and BLS, including defibrillation, to respond to sudden cardiac arrest. When the NHA provided a list of current LPNs and RNs and submitted available CPR cards, certification cards were missing for multiple LPNs and RNs. The NHA confirmed that the facility lacked documentation verifying current CPR/BLS education and certification for these nursing personnel, as required by state regulations.
Staff were not adequately trained or competent in locating and using AEDs despite a resident population with significant cardiac and circulatory conditions. The facility assessment identified multiple heart and vascular diagnoses, and the CPR/BLS policy required staff to be trained in CPR, BLS, and defibrillation and to retrieve an AED when an individual was found unresponsive. However, surveyors observed that wall-mounted boxes labeled for AEDs on two halls were empty, and the AED was instead stored in an unlabeled lower cabinet in a clean utility room. Several NAs and an LPN either did not know the AED location or incorrectly believed it was in the wall boxes or at the nurses’ stations, and one NA who claimed to know the location could not identify it when questioned. The NHA and DON acknowledged that nursing staff lacked the necessary competencies and skills to provide emergency services.
Surveyors found that the facility failed to follow its own medication storage policy by not removing outdated or improperly maintained supplies from two crash carts. On one hall’s crash cart, they observed an open sterile Yankauer catheter package, multiple expired items including acetaminophen suppositories, 0.9% sodium chloride solution, IV start kits, a concentrator mask with tubing, connection tubing, glucose gel, lubricating jelly packets, an IV catheter, and normal saline flushes. On another hall’s crash cart, they found additional expired or soon-to-expire glucose gel, acetaminophen suppositories, IV start kits, normal saline flushes, and an IV catheter. The NHA and DON acknowledged that medical supplies on both crash carts were not properly stored or disposed of as required.
The governing body failed to align facility policies with CMS requirements, resulting in gaps in CPR/BLS certification and diabetes management. The CPR policy only required a designated CPR team per shift and did not require all clinical staff to maintain current CPR/BLS certification, and the facility could not show that any of its 47 nurse aides were certified, despite the Medical Director’s expectation that all healthcare providers have CPR/BLS. The diabetes clinical protocol lacked guidance on when nursing staff should notify providers of hyperglycemia when physician orders did not specify parameters. A resident with CAD and diabetes had multiple blood glucose readings above 400 mg/dL, up to 533 mg/dL, without documented provider notification, while the Medical Director stated staff should notify providers for such out-of-range values in the absence of specific parameters.
Surveyors found that the facility failed to properly document wound care orders and treatments for four residents with conditions including heart failure, CKD, diabetes, cellulitis, necrotizing fasciitis, gangrene, cerebral palsy, and pressure ulcers. Facility policies required complete documentation of all services and wound care, but physician orders for wound treatments were delayed or missing for one resident’s knee wounds, and treatment administration records lacked entries showing that ordered dressing changes were completed for residents with wounds on the knee, toe, heel, and coccyx. Cognitively intact residents reported that dressings were sometimes missed unless they reminded staff or had specific nurses, and facility leadership acknowledged the failure to appropriately document wound care for these residents.
The facility failed to accurately complete its facility-wide assessment used to determine needed resources for resident care during routine operations and emergencies. The assessment incorrectly listed services such as ventilator care and hypodermoclysis, continued to identify a former NHA and former DON as key personnel, and omitted critical emergency physical resources such as crash carts and AEDs. The current NHA confirmed that the Facility Assessment was not accurately completed.
The facility did not complete or properly implement baseline care plans for newly admitted residents with complex medical conditions, resulting in incomplete or erroneous care instructions within the required timeframe after admission.
The facility did not make grievance boxes accessible to residents in two locations, as both boxes were mounted at 57 inches from the floor, exceeding ADA accessibility guidelines. The Nursing Home Administrator confirmed the lack of accessibility.
Surveyors found that the facility did not provide a clean and homelike environment, with multiple residents' rooms observed to have dried vomit, food and urine odors, blood and feces in bathrooms, dirty linens, and soiled items left on floors and tables. Staff confirmed inadequate housekeeping staffing, and administration acknowledged the failure to maintain cleanliness across both nursing units.
The facility did not document or follow up on grievances submitted by five residents regarding issues such as missed showers, lack of fresh water, being left in a wheelchair, and missed incontinence care. Required sections on grievance forms indicating communication of resolutions were left blank, and the administrator confirmed the lack of follow-up and documentation.
Three residents experienced neglect and/or verbal abuse, including two residents who were left in soiled briefs and bedding for extended periods without proper incontinence care, and another resident who was subjected to verbal abuse by a CNA in a public area. Staff and therapy personnel observed and reported these incidents, with documentation confirming lapses in care and inappropriate staff conduct.
Four residents with conditions such as heart failure, hemiplegia, and multiple sclerosis did not have their prescribed splints, sleeves, or orthoses applied during the day shift, despite LPN documentation indicating otherwise. Therapy staff expressed concern that these devices were often not applied unless therapy intervened, and the administrator confirmed the failure to follow physician orders.
Multiple residents did not receive timely or adequate care due to insufficient nursing staff, resulting in delays in call light responses, lack of personal hygiene, and unmet basic needs such as incontinence care, showers, and meal assistance. Staff and family interviews, as well as documentation and grievance reviews, confirmed ongoing issues with understaffing and unmet resident needs.
A resident with dementia and a history of stroke, who was always incontinent, was not provided incontinence care for several days. Therapy staff found the resident repeatedly soiled and reported this to multiple facility leaders, but the facility failed to report the possible neglect to the appropriate authorities as required by policy.
A resident with multiple chronic conditions required blood work prior to starting systemic medication for psoriasis, as ordered by a dermatologist. The facility failed to complete the required laboratory tests in a timely manner, with documentation and interviews confirming that the necessary blood work was not performed as ordered.
A resident with diabetes and dementia, who had moderate cognitive impairment, was not assessed for the ability to self-administer medications as required by facility policy. The resident's care plan and physician orders did not address self-administration, yet medications were left at the bedside after being administered by an LPN. The facility confirmed it did not determine if self-administration was safe for this resident.
Multiple residents experienced a persistent shortage of clean linens, including bed sheets, bath towels, and washcloths, resulting in delays in receiving clean bedding and personal care items. Staff and management confirmed the ongoing linen shortage, which was attributed to a delayed purchase order, and minimal supplies were observed during a unit inspection.
Three residents did not have consistent access to fresh drinking water, with staff failing to provide water unless specifically requested and ice being unavailable due to broken machines. Fluid intake documentation showed low or missing entries, and water pitchers were not kept filled or within easy reach, despite care plans indicating hydration needs. Facility leadership confirmed the deficiency after interviews and observations.
The facility did not ensure the AED at the nursing station was regularly audited or maintained, as required by policy. Staff were unaware of who was responsible for the AED audit log, and the DON confirmed the absence of maintenance records and manufacturer guidelines for the device.
The facility did not provide the required number of nurse aides on several day, evening, and night shifts, resulting in staffing levels below regulatory requirements. Staffing documents and administrator confirmation showed that the number of NAs scheduled did not meet the mandated ratios for multiple shifts.
On one reviewed day, the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident, instead delivering only 2.90 PPD, as confirmed by the Nursing Home Administrator.
Surveyors found that medication carts were left unlocked and unattended, multi-dose vials were not labeled with open dates, and several medications and medical supplies were expired or had unreadable expiration dates. An LPN confirmed these findings during interviews and observations.
The facility did not provide or document required education on COVID-19, influenza, and pneumococcal vaccines for multiple residents, as confirmed by record review and staff interviews, resulting in noncompliance with clinical record regulations.
Three residents requiring extensive assistance with ADLs, including those with diabetes, morbid obesity, dementia, Down's Syndrome, peripheral vascular disease, and chronic pain, did not receive or were not offered scheduled showers and baths on multiple occasions, as confirmed by facility documentation and staff interviews.
The facility did not meet the required nurse aide staffing levels on several shifts over a week. Specifically, there were insufficient NAs during the day, evening, and night shifts on multiple days. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on two days, providing only 2.44 PPD and 2.81 PPD. This was confirmed by the Nursing Home Administrator after reviewing staffing documents and schedules.
A resident with severe cognitive impairment and a history of elopement risk managed to leave the facility twice in one day due to inadequate supervision. Despite having an electronic monitoring bracelet, the resident was found outside the facility and attempting to enter a vehicle. The facility's response was insufficient, with lapses in monitoring, documentation, and communication among staff, creating an immediate jeopardy situation for other residents.
A resident with severe cognitive impairment eloped from a facility twice in one day due to staff neglect. Despite being identified as an elopement risk and having an electronic monitoring bracelet, the resident was found outside the facility and later attempting to enter a vehicle with an unknown person. Staff failed to perform necessary checks and assessments, leading to the resident's second elopement. The involved staff members were terminated for their negligence.
Unsafe Hot Water Temperatures Cause Resident Burn and Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident bathroom hand sink water temperatures at a safe level on one of two nursing units, despite having a written policy titled “Safety of Water Temperatures.” The policy required that water heaters servicing resident rooms, bathrooms, common areas, and tub/shower areas be set to no more than 110°F or the maximum allowable temperature per state regulation. It also assigned responsibility to maintenance staff to check thermostats and temperature controls, record these checks in a maintenance log, and conduct periodic tap water temperature checks documented in a safety log. Direct-care staff were to be informed of scalding/burn risk factors in older adults, and nursing staff were to be educated on recognizing and responding to burns. Resident R77’s clinical record showed admission in early March and an MDS indicating diagnoses of hypertension, diabetes, viral hepatitis, and depression. The MDS also documented that the resident required set up/clean up assistance, with the resident completing activities and the helper assisting only before and after the activity. Progress notes indicated that on 3/11, the resident requested a Band-Aid for a left index finger injury, reporting that the finger had been burned on 3/8. The nurse documented that the finger was bleeding, with missing skin, and that the area was cleaned and bandaged. A subsequent progress note the same morning documented that the resident reported sustaining a burn to the distal left index finger from hot water in his bathroom, and that he had neuropathy in his hand with decreased sensation. On assessment, an open area measuring 1.0 cm x 1.0 cm with minimal bloody drainage and no redness or swelling was noted. The resident was described as alert and oriented x4 and able to verbalize understanding of the situation. Surveyor observations on 4/13 found that the hot water in a resident room on the second nursing unit felt uncomfortably too hot to touch. During interviews immediately afterward, two residents on that unit commented that the water “gets hot, real hot” and questioned how hot it was. Review of the facility’s water temperature log showed weekly testing with prior entries ranging from 102°F to 117°F, with testing due that same day. When the Maintenance Director Assistant audited all resident rooms, bathing areas, and a clean utility room, only 4 of 36 outlets were at a safe temperature, 25 of 36 outlets measured between 111°F and 119°F, and 1 of 36 outlets measured between 120°F and 129°F. Specific readings on the second nursing unit included multiple resident room sinks and a shower room sink above 110°F, and a clean utility room sink at 120°F. During interviews, the DON and ADON identified 26 of 41 residents as having the physical ability and dexterity to independently access hot water outlets in sinks and/or shower rooms. The facility’s failure to maintain water temperatures at or below the policy limit on the second nursing unit resulted in a burn injury to Resident R77 and created an Immediate Jeopardy situation for those residents who could independently access the hot water.
Improper Food Storage and Lack of Hair Restraints in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to properly store food products and ensure appropriate use of hair restraints in the main kitchen. During an observation of the kitchen, the stand-up ice cream freezer was found with ice buildup, a bottle of ice, and a bowl containing food debris. In the walk-in freezer, undated juices were stored on a cart, and the air circulation fan blades had a black substance on them. The deep freezer contained a plastic bag identified as a roast that appeared freezer burned and was totally covered with ice. Additionally, all dietary staff present in the main kitchen had uncovered hair and were not wearing hairnets. During an interview, the Certified Dietary Manager (Employee E9) confirmed that the facility failed to properly store food products in the walk-in freezer and deep freezer, which created the potential for cross contamination, and acknowledged that staff failed to properly wear hair restraints.
Dish Machine Not Maintaining Required Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the main kitchen dish machine, a low-temperature chemical sanitizing unit, was in proper working order. On 04/12/2026 between 9:45 a.m. and 10:02 a.m., surveyors observed that chemical test strips used on the dish machine after three runs consistently showed sanitizer levels that did not go above 10 ppm, despite the recommended level being 50–100 ppm. During an interview later that morning at 11:18 a.m., the Certified Dietary Manager confirmed that the facility had failed to ensure the dish machine was functioning properly, as it was not achieving the required chemical concentration for proper operation.
Failure to Secure Medication Carts and Records, Breaching Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents’ medical information when two medication carts and a medication packet were left unsecured with resident-identifiable information visible and accessible. During an observation on 4/12/26 at 10:00 a.m., medication cart #1 was left unattended and unsecured in the hallway with resident-identifiable information displayed on the computer screen and on papers on top of the cart, which a Registered Nurse confirmed was visible to any passerby. At 10:38 a.m., a medication cart in the dayroom that was identified as not being used was also observed unsecured, with accessible resident-identifiable information, including a narcotic book with resident personal information, which the ADON confirmed was accessible to anyone in the dayroom. Additionally, at 11:10 a.m., a medication plastic packet containing resident information was observed lying in an accessible room that was identified as closed for repair. At 12:11 a.m., the Nursing Home Administrator confirmed these findings and that the facility failed to maintain the confidentiality of resident medical information, in violation of 28 Pa. Code 201.29(j) and 28 Pa. Code 211.5(b).
Failure to Maintain Clean, Homelike Environment and Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on both nursing units and did not ensure an adequate supply of clean linens, washcloths, and towels. The facility’s own “Homelike Environment” policy required a clean, sanitary, and orderly environment with clean bed and bath linens in good condition. Surveyor observations showed unfinished drywall and spackling on ceilings and walls in the main hall, and multiple resident rooms with broken drywall, unfinished wall areas, holes near the base of walls, and ceilings with unfinished spackling. Several bathrooms had unfinished drywall and lacked proper floor transitions, and one room had a brown substance on the floor, a broken chair, and soiled privacy curtains. Multiple rooms had soiled privacy curtains and missing covers over bathroom electrical outlets. Laundry operations were also deficient. In the laundry area, one of two washers had its face removed and was leaking onto the floor, and only one of three dryers was functioning. The Laundry/Housekeeping Supervisor confirmed the facility was aware of complaints about running out of linens, washcloths, and towels. Residents reported that towels and sometimes washcloths were frequently in short supply, and that staff had to scramble to find towels. One resident, who could not use diapers due to psoriasis and an allergy and therefore required frequent linen changes, reported being told there were not enough linens; observation of this resident’s room revealed soiled privacy curtains, a broken overbed table, and soiled overbed tables. Empty rooms were observed without linens on the beds, and staff were overheard stating there were not enough linens to place on empty beds. The Maintenance Assistant confirmed that the facility failed to provide a clean, comfortable homelike environment on both nursing units.
Failure to Notify Physicians and Assess Residents for Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and facility policies for monitoring and responding to abnormal capillary blood glucose (CBG) levels, including failure to notify physicians and assess residents for hyperglycemia. Facility policies on Diabetes-Clinical Protocol and Change in Resident’s Condition or Status required that staff monitor blood sugars according to physician-ordered parameters, notify providers when CBG values were outside those parameters, and incorporate those parameters into the MAR and care plan. The Change in Condition policy further required prompt notification of the attending physician when there were changes in a resident’s medical condition, with nurses expected to gather pertinent information before contacting the provider. For one resident with diagnoses including hypertension, diabetes, and end-stage renal disease, physician orders directed staff to notify the physician if CBG exceeded specified thresholds (initially greater than 450, and later greater than 400 during antibiotic therapy). Despite these orders, the resident’s record showed multiple CBG readings significantly above the ordered parameters (ranging from 469 to 522 mg/dL on several dates) with no documentation that the physician was notified. The clinical record and progress notes also lacked evidence that the resident was assessed for hyperglycemia, that blood glucose was rechecked to monitor treatment effectiveness, or that care plan interventions related to blood glucose management were followed. A second resident, with diagnoses including hypertension, diabetes, GERD, renal insufficiency, and dementia, had a physician order for Humalog per sliding scale with instructions to notify the physician if CBG was greater than 401 mg/dL. The eMAR documented numerous CBG values well above this threshold, including readings as high as 999 mg/dL, without any documentation of physician notification. The eMAR and clinical notes did not show assessments for hyperglycemia or monitoring of blood glucose for treatment effectiveness, and there was a failure to follow care plan interventions related to abnormal blood sugars. A third resident, diagnosed with hypertension, diabetes, viral hepatitis, and depression, had an order to notify the physician if CBG exceeded 340 mg/dL. This resident also had multiple CBG readings above the ordered parameter (ranging from 350 to 500 mg/dL) with no documented physician notification, no documented assessment for hyperglycemia, no evidence of monitoring for treatment effectiveness, and failure to follow care plan interventions. Interviews with LPN staff indicated that their understanding of practice was to initiate hypoglycemia protocol and notify the physician for CBG values under 70 mg/dL, and to notify a supervisor and/or physician and document in the MAR and progress notes when CBG values were greater than 400 mg/dL or above ordered parameters. However, the documented practice in the clinical records for the three residents did not reflect these stated procedures. In a subsequent interview, the Nursing Home Administrator, DON, and Regional DON confirmed that the facility failed to notify the physician of changes in condition related to blood glucose for the three identified residents, in violation of state regulatory requirements cited in 28 Pa. Code 201.18(b)(1), 211.10(b)(c)(d), and 211.12(d)(1)(2)(3)(5).
Failure to Maintain Required Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain consistent dialysis communication for two residents who required hemodialysis, contrary to its own Dialysis Management (Hemodialysis) policy. The policy required staff to complete pre-dialysis information on a communication form and send it with the resident to the dialysis center on treatment days, have dialysis center personnel complete and return the form or provide EHR documentation, and then review and complete post-dialysis information for placement in the resident’s medical record. For one resident with hypertension, diabetes, and end stage renal disease, admitted on an unspecified date and ordered for dialysis twice weekly at a named dialysis center, review of records from mid-December through mid-April showed that only a single, partially completed dialysis communication form dated late March was found; all other required forms were absent. For a second resident with hypertension, anxiety disorder, and end stage renal disease, admitted on an unspecified date and ordered for dialysis three times weekly at the same dialysis center, review of dialysis communication forms from the last full health survey in mid-June through mid-April revealed that no forms were present. When surveyors requested the dialysis communication forms, an LPN searched for the dialysis binder, sought assistance from other staff, and was unable to locate it on the nursing unit. The only document located was the partially completed late-March form for the first resident, which was found in the resident’s personal folder in his room. No dialysis binder or communication forms were found for the second resident. The DON and Regional DON confirmed that the facility failed to ensure consistent dialysis communication was maintained, in violation of state regulations regarding clinical records and nursing services.
Unsecured Medication Carts Left Unattended
Penalty
Summary
The facility failed to ensure medications were properly secured in accordance with its own policy and regulatory requirements. The facility’s “Storage of Medications” policy dated 6/1/25 stated that drugs and biologicals must be kept in locked compartments under proper temperature, that only authorized staff may access them, that nursing staff are responsible for maintaining medication storage, that compartments are locked when not in use, and that unlocked medication carts are not to be left unattended. During an observation on 4/12/26 at 10:03 a.m., medication cart #1 was found unlocked and unattended in the hall, and the RN on duty (Employee E8) confirmed the cart was not properly secured. In a separate observation on 4/12/26 at 10:38 a.m., medication cart #4, identified as unused due to low census, was found in the dayroom with unsecured medications and unattended, and the ADON (Employee E7) confirmed the facility failed to secure this cart as well. No specific residents or their medical conditions were mentioned in relation to these unsecured medication carts.
Insufficient Nursing Staff Leading to Delayed Care, Missed Showers, and Poor Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely basic care, including showers, grooming, toileting, and incontinence care, for multiple residents. Facility policies on sufficient and competent staffing and answering call lights require staffing levels that support residents’ highest practicable well-being and call light response within five minutes. However, during a resident group meeting, residents reported that there were not enough staff to provide care, resulting in long waits for assistance, residents soiling themselves, delayed toileting due to untimely call light response, and showers often not being provided. Individual resident interviews and record reviews further demonstrated missed or undocumented showers and inadequate personal hygiene care. Several residents reported not receiving scheduled showers because there were not enough staff, and that missed showers were not rescheduled. Clinical records for multiple residents lacked documentation that showers were provided twice weekly as ordered, and the DON acknowledged that the facility kept paper shower logs but was unable to produce them. One resident had previously filed a grievance about being left in a soiled brief overnight and reported that, even after that grievance, there were still occasions of waiting in soiled briefs when using the call light. This same resident was observed with long, soiled fingernails, and another resident was observed with matted, unkempt hair, with no supporting documentation of ordered showers in their records. Additional evidence from grievances, resident council minutes, and staff interviews corroborated ongoing staffing insufficiencies and resulting care delays. Multiple grievances filed on behalf of individual residents and the resident council over several months documented concerns about understaffing, long call light wait times (including waits greater than thirty minutes), missed showers on scheduled days, lack of rescheduling, inadequate incontinent care, and missed fingernail care. One grievance reported a staff statement that there was one aide for eighty people. Confidential staff interviews confirmed that staff did not feel there were sufficient personnel to meet resident needs and that residents frequently reported long waits for care on prior shifts or days. The NHA and DON acknowledged that the facility failed to provide sufficient nursing staff to support residents’ highest practicable physical, mental, and psychosocial well-being.
Failure to Maintain Resident Dignity and Hygiene Across Multiple Care Situations
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that maintained resident dignity and honored resident rights, as required by facility policy and state regulations. The facility’s Resident Rights policy stated that residents are guaranteed a dignified existence and must be treated with respect, kindness, and dignity, and be free from abuse and neglect. Despite this, one resident with parkinsonism, anxiety disorder, and non-Alzheimer’s dementia, who had a BIMS score of 15 indicating intact cognition, was observed lying in bed on a bare mattress without sheets, blankets, or any linen. When asked, the resident stated she would like sheets and a blanket and reported that “they don’t put them on.” The RN present stated the resident shreds her blankets, which was given as the reason linens were not on the bed. Another cognitively intact resident with a history of cerebrovascular accident, depression, and non-Alzheimer’s dementia, also with a BIMS score of 15, had previously filed a grievance stating he had been left in a soiled brief overnight. He reported that his brief was so soiled it was hanging off him, and that his bowel movement and urine were soaking his sheets and clothing, and that he was last changed at 2:00 p.m. the prior day before reporting the issue at 7:40 a.m. the next morning. During a later interview, he stated that he had been left in a soiled brief a few more times since that grievance. He was also observed with long, soiled fingernails that he had requested to be trimmed, and his clinical record did not contain documentation that finger and toenail checks for cleanliness and length were being performed twice weekly as ordered. Additional residents and a family member reported dignity-related concerns through grievances. One cognitively intact resident with heart failure, anemia, and diabetes, who required assistance with a urinal, reported delays in call light response times when he needed help, stating he could not manage the urinal independently. Another resident with heart failure, non-Alzheimer’s dementia, and anemia, with a BIMS score of 3, had a spouse who filed a grievance stating that no one would help her husband, that he did not have a brief on, and had a bowel movement she could not clean, and that two nurses at the desk told her they do not change briefs. A further cognitively intact resident with heart failure, hypertension, and anemia filed a grievance reporting he had not received a shower in eight days, that his scalp was itchy, and that visitors told him he smelled. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure care was provided in a manner that maintained resident dignity.
Failure to Respond to Resident Council Concerns Over Call Lights, Showers, and Staffing
Penalty
Summary
The facility failed to honor residents' rights to have their concerns addressed through the resident council by not responding to repeated complaints documented over several months. Facility policy dated 1/8/26 stated that the resident council is intended to provide a forum for residents, families, and representatives to give input on facility operations, discuss concerns, and that a Resident Council Response Form would be used to track issues and their resolution, with review by the QAPI committee. Despite this, resident council minutes from August, September, October, November, and February and March documented ongoing complaints about excessive wait times for call lights to be answered, and in November and December additional complaints that showers were not being done as scheduled and that the facility was understaffed. January and February minutes only noted that past complaints and corrective actions were reviewed, but no documentation of those actions was attached or provided upon request. During a group interview on 4/12/26, residents voiced a consensus that facility administration was not resolving their ongoing issues with staffing, call lights, and showers. One resident stated that they voiced complaints in council meetings, staff wrote them down, but residents never received a resolution or were told what was being done about their concerns. March 2026 council minutes included an explanation that each aide had at least 14 residents to care for and could only give undivided attention to one person at a time, but there was no documented resolution of the complaints. In an interview on 4/14/26, the Nursing Home Administrator, DON, and Regional DON confirmed that the facility failed to respond to concerns from the resident council and failed to respond in a timely manner, in violation of 28 Pa. Code 201.18(b)(1) regarding management responsibilities.
Failure to Investigate Resident Burn Injury and Monitor Hot Water Temperatures
Penalty
Summary
The facility failed to conduct a thorough investigation of a resident injury obtained during care to rule out possible neglect. Facility policies on abuse, neglect, exploitation, and accidents/incidents required that all injuries, including injuries of unknown origin, be promptly investigated, documented, and reported by management and nursing supervisors. A resident with diagnoses including hypertension, diabetes, viral hepatitis, and depression, and who required set up/clean up assistance for ADLs, reported on one morning that his left index finger was bleeding, with skin missing, and requested a bandage. The nurse cleaned the area, applied a bandage, and notified the supervisor, but no investigation into the cause of the injury was documented at that time. Later that morning, a subsequent progress note documented that the resident reported sustaining a burn to the distal left index finger from hot water in his bathroom several days earlier. The resident, who had neuropathy with decreased sensation in his hand, stated that a blister had formed and he had popped it. Assessment showed an open area on the left index finger measuring 1.0 cm x 1.0 cm with minimal bloody drainage and no redness or swelling. The resident was alert and oriented and verbalized understanding of the situation. During a later surveyor observation and interviews, water temperatures in multiple rooms, including the resident’s room, were found to range from 111 to 120 degrees, above the expected 110 degrees or below, and maintenance staff were unable to locate prior water temperature logs and believed the limit was 120 degrees. The Nursing Home Administrator and Regional DON confirmed that the facility failed to identify and conduct a thorough investigation of this injury to eliminate possible neglect.
Failure to Post Current and Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted at the beginning of each shift as required. On 4/12/26 at approximately 9:15 a.m., surveyors observed that the nurse staffing information posted in the main lobby on the reception desk displayed the date 4/10/26, along with resident census and staffing hours that did not accurately reflect the current total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care for the current date. During an interview on 4/12/26 at approximately 11:50 a.m., the Nursing Home Administrator confirmed that the facility had failed to post the required current staffing hours and census information for 4/12/26.
Failure to Maintain Safe Water Temperatures in Resident Bathroom Sinks
Penalty
Summary
The deficiency involves the NHA and DON failing to ensure that resident bathroom hand sink water temperatures were maintained at a safe level on one of two nursing units observed, specifically the First and Second Nursing Units. Review of the NHA job description showed that the Administrator was responsible for leading, directing, and managing overall operations in accordance with federal, state, and local regulations, and for organizing and directing resources to maintain the highest degree of quality care for each resident. Review of the DON job description showed that the DON was responsible for organizing, developing, managing, and directing the overall operations of the Nursing Service Department, working directly with the Administrator and Medical Director to ensure the highest degree of quality care, and following all health, sanitary, and infection control policies and established standards of practice. Surveyors determined, based on job descriptions, clinical records, and staff interviews, that the NHA and DON did not fulfill these essential duties because they did not ensure that water temperatures in resident bathroom hand sinks were kept at a safe temperature on the Second Nursing Unit. This failure resulted in harm to Resident R77 and placed residents on the Second Nursing Unit at risk for serious injury from burns, leading to an Immediate Jeopardy situation for 26 of 41 residents. During an interview, the NHA and DON confirmed that they failed to ensure safe water temperatures in resident bathroom hand sinks on the affected nursing units.
Failure to Maintain Clean and Functional Laundry Room Environment
Penalty
Summary
Surveyors determined that the facility failed to maintain a clean, sanitary, and functional environment in the laundry room based on direct observation and staff interview. During an observation on 4/12/26 at 12:27 p.m., the washing area was found to have two washers, with the one working washer missing its complete front panel and leaking water across the washroom floor. In the same area, there were three dryers, two of which were marked with signs indicating they were broken, and the only functioning dryer had a brown substance inside the dryer drum. In an interview conducted on 4/12/26 at 12:28 p.m., the Laundry/Housekeeping Supervisor (Employee E1) confirmed that the facility had failed to ensure a clean, sanitary, and functional laundry environment. These findings were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(b)(1)(3) regarding management responsibilities.
Failure to Properly Test and Verify Door Alarm Functionality
Penalty
Summary
The deficiency involves the facility’s failure to ensure that door alarm systems were regularly tested for full functionality, as required by facility procedures and state regulations. Facility documents showed that the Maintenance Manager’s job description included maintaining competency in fire prevention and safety and facility maintenance requirements, and written alarm testing instructions specified a detailed multi-step process to verify delayed egress operation, alarm activation, automatic door opening, alarm reset, signage, nurse station panel activation, and annual keypad battery replacement. However, during a surveyor interview and observation, the Maintenance Director demonstrated that he did not follow these written procedures. During an observed test of a door alarm, the Maintenance Director was unable to deactivate the alarm and required nursing staff to respond to the alarming door to silence the alarm and reactivate the locking mechanism. When questioned on how he ensured door alarms were functional, he stated that he only attempted to open the door to confirm it was locked, and acknowledged that this action did not verify the alarm’s functionality. In a separate interview, the Nursing Home Administrator confirmed that the facility failed to make certain that door alarm systems were regularly tested for functionality, in violation of 28 Pa. Code 201.14(a) and 201.18(b)(1)(3).
Failure to Provide Ordered NPWT and Wound Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed wound treatments, including NPWT/wound vac therapy, and to follow physician orders for wound care for two residents. One resident with heart failure, diabetes, and a diabetic foot ulcer complicated by osteomyelitis was discharged from the hospital with debridement, antibiotic beads, and an order for a wound vac. Despite multiple clinical notes from physicians and wound NPs on several dates referencing that the left foot had antibiotic beads and a wound vac and requesting clarification or confirming that podiatry still recommended a wound vac, there was no active wound vac order in the facility record until nearly two weeks after admission. The resident’s care plan for diabetic ulcers did not include the need for a wound vac, and facility communications showed that a wound vac delivered to a sister facility was malfunctioning, not started, and then misplaced and later located, while the resident never actually received wound vac therapy. For this same resident, the facility substituted wet-to-dry dressings in place of the wound vac but failed to consistently document that ordered wound care was provided. The TAR showed multiple dates and shifts with no documentation of wet-to-dry dressing changes and missing documentation for several other ordered wound treatments, including petrolatum gauze and various wound care orders to the left mid foot, left posterior thigh, right mid foot, right shin, and right medial lower leg. The resident reported never receiving a wound vac, being unhappy with wound care, and stated that he did not always receive wound care as scheduled and often had to request dressing changes. The resident also disputed documentation that he was pleased with wound progress and stated that while the wound did not deteriorate, there was negligible improvement. The second resident had bacteremia, hypertension, and a history of stroke and was admitted with a PICO 14 NPWT dressing to the left femoral region per hospital discharge paperwork and physician orders. The plan of care for actual skin impairment did not include goals or interventions for the use of the PICO dressing. Progress notes and wound NP documentation confirmed that the PICO dressing and battery pack were in place and intact on multiple dates, with instructions that the dressing had a seven-day life and the battery pack a 14-day life, and that the dressing should be replaced at day seven or when saturated, conserving the battery pack until it turned off. However, the clinical record lacked documentation that the dressing portion was changed at the required seven-day intervals or that the battery pack was changed at 14 days, and a later note indicated the PICO battery was dead and the dressing was removed. The Nursing Home Administrator and DON confirmed that the facility failed to provide prescribed treatment and services related to wound care for these two residents.
Failure to Provide Ordered Respiratory Medications and Accurate MAR Documentation
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and medication administration for two residents with COPD and other cardiac conditions. Facility policy required medications to be administered safely, timely, as prescribed, and fully documented, including date, time, dosage, route, and results. For one resident with atrial fibrillation and COPD, the MDS showed a BIMS score of 15, indicating cognitive intactness. Physician orders dated 1/20/26 directed that this resident receive Breo Ellipta once daily, with a documented therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every eight hours. Review of the MAR from 2/1/26 through 2/24/26 showed multiple days when Breo Ellipta was marked as received, some days marked as held, and one day undocumented, but there was no documentation of the timing or administration of the substituted Ipratropium‑Albuterol nebulizer treatments. The resident confirmed he had not been receiving his Breo Ellipta inhaler. A second resident, admitted with diagnoses including coronary artery disease and COPD and a BIMS score of 14, had a plan of care for shortness of breath related to Flu A and COPD that did not include the use of respiratory medications or nebulizer treatments. Physician orders dated 1/30/26 directed that this resident receive Trelegy Ellipta once daily and Ipratropium‑Albuterol inhalation aerosol every six hours as needed for COPD, with a pharmacy‑supplied therapeutic interchange to Ipratropium‑Albuterol nebulizer solution every six hours as needed. Review of the MAR from 2/1/26 through 2/24/26 showed Trelegy Ellipta documented as received on most days, with several days marked as held and one day undocumented. Despite these MAR entries, the resident later confirmed he had not been receiving his Trelegy Ellipta inhaler. On observation of the medication cart on the 100‑unit hall, neither resident’s Breo Ellipta nor Trelegy Ellipta inhalers were present. Instead, unopened pharmacy‑supplied boxes of Ipratropium‑Albuterol nebulizer ampules labeled as therapeutic interchange were found, with full supplies and no ampules removed. An LPN confirmed that the inhalers were not in the cart and that no Ipratropium‑Albuterol ampules had been used, yet could not explain why the MAR reflected that both residents had received their inhalers during the morning medication pass. Later observation in the shared room showed both residents receiving nebulizer treatments, and interviews at that time confirmed that neither resident had previously received nebulizer treatments in the facility. The nursing home administrator and DON acknowledged that the facility failed to provide appropriate respiratory care for these two residents.
Elopement of At-Risk Resident Due to Inadequate Supervision and Door Alarm Failure
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident who had been identified as at risk for unsafe wandering. The resident had diagnoses including atherosclerotic heart disease, age-related debility, and dementia, with a BIMS score of 8 indicating moderate cognitive impairment. An Elopement Risk Evaluation documented that the resident was at risk for elopement, and the care plan stated the resident would remain safe within the facility unless accompanied by staff or another authorized person. A physician’s order directed staff to monitor the resident’s wandering behavior. Despite these assessments and orders, the resident was able to leave the building unaccompanied. On the day of the incident, the resident exited the facility through a back exit door on one of the units. The resident was last seen inside by a CNA at 5:18 p.m. and was found outside and brought back into the building by an LPN at 5:20 p.m., wearing regular indoor clothing in 50-degree Fahrenheit weather. A progress note documented that the back door opened easily and that only a low alarm sounded while the loud alarm remained silent when the resident exited. An employee statement from a nurse aide described a similar situation in which a male individual, assumed to be a family member, walked toward exit doors and left the building without any alarms sounding, with alarms only activating when he re-entered the facility about ten minutes later. These events demonstrate that the resident, previously identified as an elopement risk, was able to leave the facility due to inadequate supervision and malfunctioning or ineffective door alarm systems.
Failure to Maintain Operable Crash Carts and Laundry Equipment Leading to Linen Shortages
Penalty
Summary
The deficiency involves the facility’s failure to maintain essential emergency and laundry equipment in safe and operable condition. Surveyors observed that the 100-Hall crash cart was missing multiple items listed on the Emergency Cart Daily Checklist, including a blank code book, band-aids, needles with syringes, gowns, masks, goggles or face shield, alcohol-based hand rub, an ambu-bag, 14 French suction kits, Christmas tree adapters, a non-rebreather mask, and a nasal cannula. Review of the 100-Hall Emergency Cart Checklist showed multiple days where the cart contents were not documented, and several days where the checklist was marked complete without a staff signature; there was also no checklist available for a subsequent month. The 200-Hall crash cart was also found missing numerous required items, including a blank code book, blood pressure cuff and stethoscope, glucometer, flashlight or penlight, alcohol pads, band-aids, disposable razors, needles with syringes, gloves, gowns, masks, goggles or face shield, IV start kits, alcohol-based hand rub, an ambu-bag, a full oxygen tank (all three present were empty), a nebulizer kit, and 14 French suction kits. Documentation for the 200-Hall cart similarly showed multiple days without documentation of items present, and on some days the glucometer was noted as missing. The deficiency also includes failure to maintain operable dryers and adequate linen supply. In the laundry room, surveyors observed an uncountable number of bags and carts filled with soiled linen, and a laundry worker reported that the facility’s industrial dryers had been inoperable for several days, requiring use of a smaller, non-commercial resident dryer that could not keep up with laundry volume. Multiple observations of linen carts on both the 100-Hall and 200-Hall revealed repeated shortages or absence of towels and washcloths, with some carts having none and others having only a few. Staff interviews confirmed that residents were not receiving showers due to lack of clean towels, that staff were cutting up bath blankets to make washcloths, and that some staff were using personally purchased baby wipes, dry wipes, or clothing protectors to bathe and dry residents. The Nursing Home Administrator and DON acknowledged that the facility failed to ensure two crash carts and two facility dryers were in safe operating condition.
Failure to Notify Providers of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians of significantly elevated capillary blood glucose (CBG) levels for four residents with diabetes, contrary to facility policy and physician expectations. The facility’s Diabetes – Clinical Protocol stated that physicians would order appropriate interventions for diabetes management. The Centers for Disease Control definition of hyperglycemia was cited, and the facility’s care plans for several residents directed staff to monitor, document, and report signs and symptoms of hyperglycemia as needed. Despite these directives, multiple documented CBG readings far above normal ranges were not followed by documented provider notification. One resident with heart failure and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and a physician order for Humalog insulin per sliding scale, with instructions to call the physician if blood sugar exceeded 500 mg/dL. The resident’s blood sugar record showed numerous readings at or above 500 mg/dL, including values such as 547, 589, 525, 594, 571, 561, 509, and 570 mg/dL, without documentation that the physician was notified. Another resident with dementia and diabetes had a care plan to monitor and report hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record showed multiple elevated readings, including 410, 404, 539, 412, and 400 mg/dL, again without documentation of provider notification. A third resident with end stage renal disease and diabetes had an order for Humalog insulin per sliding scale with instructions to call the physician if blood sugar exceeded 400 mg/dL. The blood sugar record showed a reading of 489 mg/dL without documentation that the physician was notified. A fourth resident with coronary artery disease and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record contained numerous elevated readings above 400 mg/dL, including values such as 412, 441, 423, 464, 481, 533, 457, 428, 445, 460, 500, 488, and others, with no documentation of provider notification. In interviews, the Medical Director stated that staff were expected to notify providers of out-of-range blood sugars and, in the absence of specific parameters, to notify at levels of 400–450 mg/dL unless otherwise specified. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to notify physicians of increased CBG levels for four of six reviewed residents.
Failure to Ensure Licensed Nursing Staff Maintain Proper Hands-On CPR Certification
Penalty
Summary
Surveyors found that the facility failed to ensure that certain nursing personnel maintained current CPR certification for healthcare providers that included a hands-on session, as required by facility policy and accepted national standards. The facility’s written policy on emergency procedures for cardiopulmonary resuscitation required staff to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support/CPR. The Nursing Home Administrator provided a list of currently employed LPNs and RNs, and review of CPR certification cards for three of 27 licensed nurses (two LPNs and one RN) showed that their certifications were from online-only CPR classes intended for non-healthcare providers and did not include any hands-on component. In an interview, the Nursing Home Administrator confirmed that the facility had not ensured these nurses held appropriate, hands-on CPR certification for healthcare providers in accordance with accepted national standards. No specific residents, medical histories, or clinical events related to CPR use were described in the report; the deficiency was identified through policy review, staff record review, and staff interviews.
Failure to Maintain Documentation of Current CPR/BLS Certification for Licensed Nurses
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation that nursing personnel had current education and certification in basic life support (BLS), including cardiopulmonary resuscitation (CPR), as required to provide emergency care prior to the arrival of emergency medical personnel and in accordance with physician orders and residents’ advance directives. The facility’s CPR policy stated that personnel must have completed training on initiation of CPR and BLS, including defibrillation, for victims of sudden cardiac arrest. During the survey, the Nursing Home Administrator provided a list of currently employed LPNs and RNs and then supplied available CPR certification cards; however, CPR certification cards were not available for 15 of 27 licensed nurses, including multiple LPNs and RNs. In an interview, the Nursing Home Administrator confirmed that the facility did not maintain documentation showing that these nursing personnel had current CPR/BLS education and certification, in violation of 28 Pa. Code 201.14(a) and 211.12(d)(1)(5). No specific residents, medical histories, or clinical events were described in the report; the deficiency centers on the lack of documented current CPR/BLS certification for a substantial portion of the licensed nursing staff.
Failure to Ensure Staff Competency and AED Accessibility for Cardiac Emergencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to provide emergency services, including use and location of automated external defibrillators (AEDs), despite a resident population with significant cardiac and circulatory conditions. The facility assessment listed common diagnoses such as congestive heart failure, coronary artery disease, angina, dysrhythmia, hypertension, orthostatic hypotension, peripheral vascular disease, risk for bleeding or blood clots, deep venous thrombosis, and pulmonary thrombo-embolism. The facility’s CPR/BLS policy required personnel to be trained in CPR, BLS, and defibrillation for sudden cardiac arrest and directed staff to retrieve an AED and initiate the BLS sequence when an individual was found unresponsive. National Heart, Lung, and Blood Institute information cited in the report identified heart problems, including coronary artery disease, arrhythmias, atrial fibrillation, angina, cardiomyopathy, heart valve disease, and heart failure, as key risk factors for cardiac arrest. During observations, surveyors noted that wall-mounted boxes on two halls were labeled as containing AEDs but were empty. When asked to locate the AED, an RN initially texted an LPN for assistance and the AED was ultimately found stored in an unlabeled lower cabinet in a clean utility room, not in the labeled wall boxes. Multiple nurse aides and an LPN either did not know where the AED was located or incorrectly believed it was in the wall boxes or at the nurses’ stations. Only one nurse aide initially stated she knew the location but was unable to identify it when questioned further. The Nursing Home Administrator and Director of Nursing were informed that staff could not accurately describe the AED locations and confirmed that the facility failed to ensure nursing staff had the competencies and skill sets necessary to provide emergency services, affecting eight of nine sampled staff members.
Expired and Improperly Maintained Supplies on Crash Carts
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that drugs and medical supplies on two crash carts were properly stored and disposed of in accordance with facility policy and professional standards. The facility’s “Storage of Medications” policy, dated 1/8/26 (previously 6/1/25), required that discontinued, outdated, or deteriorated drugs be returned to the dispensing pharmacy or destroyed. During an observation of the 100-Hall crash cart, surveyors found multiple items that were either expired or not properly maintained, including a Yankauer catheter with its sterile packaging open, a box of acetaminophen suppositories expiring 12/2024, a bottle of 0.9% sodium chloride solution expiring 5/18/24, IV start kits expiring 4/30/24 and 9/7/25, a concentrator mask with tubing expiring 03/2025, connection tubing expiring 06/2012, a box of glucose gel expiring 02/2025, lubricating jelly packets expiring 06/10/2021, an IV catheter expiring 9/1/22, and normal saline flushes expiring 2/3/25 and 10/31/25. A similar observation of the 200-Hall crash cart revealed additional expired or soon-to-expire medical supplies, including a box of glucose gel expiring 02/2025, a box of acetaminophen suppositories expiring 12/2024, IV start kits expiring 5/16/25 and 8/31/24, normal saline flushes expiring 2/3/25, and an IV catheter expiring 8/31/25. These findings demonstrated that the facility did not consistently remove or properly manage outdated or deteriorated medications and supplies on both crash carts as required by its own policy. In a subsequent interview, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that medical supplies on the two crash carts were properly stored and/or disposed of, in violation of 28 Pa Code 201.14(a) regarding the responsibility of the licensee.
Failure of Governing Body to Align Policies With CMS Requirements for CPR Certification and Hyperglycemia Management
Penalty
Summary
The governing body failed to implement and align facility policies with Centers for Medicare & Medicaid Services (CMS) requirements, resulting in deficiencies related to CPR/BLS certification and diabetes management. Review of the facility’s governing body policy showed it was responsible for establishing and implementing policies for management and operation of the facility. However, the facility’s CPR policy only required a designated CPR team per shift (including at least one nurse, one LPN/LVN, and two CNAs with CPR/BLS certification) and did not include the CMS requirement that all clinical staff maintain current CPR certification through a provider with hands-on practice and in-person skills assessment. The facility reported having 47 nurse aides actively employed but was unable to provide evidence that any of them had CPR/BLS certification. The Medical Director confirmed that all healthcare providers employed by the facility were required to have CPR/BLS certification, demonstrating a discrepancy between practice, policy, and federal requirements. The governing body also failed to ensure that the facility’s diabetes clinical protocol provided clear direction to nursing staff on when to notify providers of hyperglycemia in the absence of specific physician orders. The diabetes policy listed possible physician-ordered interventions but did not specify notification parameters for elevated blood glucose levels. One resident with coronary artery disease and diabetes had a care plan instructing staff to monitor, document, and report signs and symptoms of hyperglycemia as needed, and an order for scheduled Humalog insulin with meals, but the physician’s orders did not include specific notification parameters. The resident’s blood sugar records showed multiple significantly elevated readings (ranging from 412 mg/dL to 533 mg/dL) without documentation that a provider was notified. The Medical Director stated his expectation that staff notify providers of out-of-range blood sugars greater than 400–450 mg/dL when parameters are not specified, and acknowledged that, because the facility policy did not define notification requirements and some physician orders lacked parameters, nursing staff would be unaware of general or specific notification requirements. The Nursing Home Administrator and DON acknowledged that the governing body failed to implement policies aligned with CMS requirements.
Failure to Document and Maintain Wound Care Orders and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and wound care orders in accordance with its own policies and accepted professional standards. The facility’s Charting and Documentation policy required that all services provided, progress toward care plan goals, and changes in condition be documented in the medical record, and the Wound Care policy required documentation of the date and time wound care was given. The facility assessment indicated it would provide care for skin ulcers and injuries. Despite these requirements, surveyors identified multiple instances where wound care orders were missing or delayed and where ordered treatments were not documented as completed on the treatment administration records (TARs). For one resident with heart failure and chronic kidney disease who had an abscess on the right knee and a new wound on the right medial knee, a wound nurse practitioner ordered gentamicin ointment for both wounds, with the abscess to be changed daily and the medial wound twice daily. However, there was no physician’s order entered for the right medial knee wound until several days after the NP note, and the existing order for the right knee abscess was discontinued with no new order until the same later date. The TAR for the right medial wound also lacked documentation of completed dressing changes on multiple specified dates and times. Another resident, cognitively intact with hypertension and cellulitis and care-planned for potential pressure ulcers, had a physician’s order for twice-daily dressing changes to the left second toe, but the January TAR showed missing documentation of completed dressing changes on several evenings and mornings. This resident stated that he did not know what the staff’s problem was and expressed that it seemed like they did not care. A third cognitively intact resident with diabetes, necrotizing fasciitis, and gangrene, care-planned for actual/potential skin integrity impairment, had an order for twice-daily dressing changes to the left heel. The January TAR lacked documentation of completed dressing changes on multiple specified dates and times. This resident indicated that sometimes she had to remind staff and that if she did not ask or did not get a certain nurse, the dressing changes did not get done. A fourth resident with diabetes and cerebral palsy, care-planned for an actual pressure ulcer and with physician’s orders for daily coccyx dressing changes, also had multiple dates on the January TAR where the dressing changes were not documented as completed. The Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to appropriately document wound care orders and treatments for four of seven reviewed residents, in violation of state clinical records requirements.
Inaccurate and Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to accurately complete its facility-wide assessment used to determine necessary resources for competent resident care during routine operations and emergencies. Review of the Facility Assessment Tool dated 1/23/26 showed that in the section titled “Services and Care,” the facility listed ventilator care and hypodermoclysis even though this did not reflect accurate information. In the section titled “List of Key Personnel,” the assessment still identified the previous Nursing Home Administrator and the previous Director of Nursing instead of current leadership. In the section titled “Physical Resources,” the assessment failed to include crash carts and AEDs, which are emergency equipment maintained and used in urgent situations. During an interview, the current Nursing Home Administrator confirmed that the facility failed to accurately complete the Facility Assessment. No specific residents or their medical conditions were identified in the report as being directly involved in this deficiency.
Failure to Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans that included necessary instructions to provide effective and person-centered care for all ten residents reviewed. Clinical record reviews and staff interviews revealed that, for each resident, the baseline care plan was either incomplete or contained errors within the required timeframe following admission. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to address residents' physical, psychosocial, and functional needs, but this was not achieved for any of the residents in the sample. The residents affected had a range of complex medical conditions, including Alzheimer's disease, bipolar disorder, dementia, diabetes, spina bifida, bladder cancer, endocarditis, atrial fibrillation, encephalopathy, chronic obstructive pulmonary disease (COPD), wedge fracture, prostate cancer, heart failure, and throat cancer. Despite these significant diagnoses, the baseline care plans were not completed within the required period after admission, with some remaining incomplete for up to 21 days. The Nursing Home Administrator confirmed the failure to develop and implement appropriate baseline care plans for all residents reviewed.
Grievance Boxes Not Accessible to Residents
Penalty
Summary
The facility failed to provide accessible grievance boxes for residents in both the front and rear hallways. Observations revealed that the openings for grievance forms in both locations were mounted at 57 inches from the floor, exceeding the ADA Standards for Accessible Design, which recommend operable parts be mounted between 15 and 48 inches above the floor to accommodate individuals using wheelchairs. The Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents in these two locations. This deficiency was identified through review of facility policy, direct observation, and staff interviews.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple observations and staff interviews. Specific incidents included dried vomit remaining under a resident's bed for four days, food and a urine odor present on another resident's floor, and a room with blood on the restroom light switch, feces and blood on the bathroom floor, and a dirty commode and sink. Additional findings included dirty overbed tables, refuse on the floor, unclean walls, a wall outlet with a loose faceplate and a gouge, and a handwritten sign warning not to use the outlet. The Environmental Services Supervisor confirmed that only three housekeepers were currently employed, which may have contributed to the lack of cleanliness. Further observations revealed a soiled brief on a restroom floor, feces on bed linens, and rooms with overwhelming urine odors, with one staff member stating that the urine was embedded in the mattresses. Other rooms were found to be unclean, with soiled gloves on overbed tables and bags of soiled linen left on the floor. These deficiencies were confirmed by the Nursing Home Administrator, who acknowledged the facility's failure to provide a clean and homelike environment on both nursing units and for seven of twelve residents reviewed.
Failure to Document and Follow Up on Resident Grievances
Penalty
Summary
The facility failed to document and/or follow up on grievances and concerns presented by staff and residents for five residents. According to the facility's grievance policy, all grievances should be addressed promptly, with written notice of outcomes provided to the resident or their representative. However, review of grievance forms for five residents revealed that the sections indicating whether the resident or their representative was informed of the resolution, and the name of the person informed, were left blank in each case. These grievances included concerns about not receiving showers, not receiving fresh water, being left in a wheelchair, and not receiving incontinence care. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not document or follow up on these grievances as required. The lack of documentation and follow-up was consistent across all five reviewed cases, indicating a failure to comply with both facility policy and regulatory requirements regarding resident rights and grievance procedures.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from verbal and emotional abuse and/or neglect, as evidenced by incidents involving three residents. One resident with dementia and a history of stroke, who was cognitively intact but frequently incontinent, was found by staff to be in a heavily soiled brief and bed linen, with visible redness and a scabbed area on the toe. Documentation showed a significant gap in incontinence care, with the resident stating he had not been changed for an extended period and reporting that this neglect was a recurring issue. Staff statements corroborated the resident's account, describing the resident's condition as deplorable and noting that concerns had been reported multiple times without resolution. Another resident with dementia and a history of stroke, who was always incontinent and had moderate cognitive impairment, was also not provided with incontinence care on multiple occasions. Therapy staff reported finding the resident in extremely soiled briefs and bedding, with a strong odor and visible soiling, and documented that these findings were brought to the attention of supervisory staff. Care records indicated several days without documented incontinence care, further supporting the neglect. A third resident with diabetes and heart failure, who had moderate cognitive impairment, was subjected to verbal abuse by a nurse aide. The resident reported being called an offensive name by the staff member while in a public area of the facility, and this was confirmed by statements from other employees. The incident was witnessed by two staff members, and the resident expressed feeling surprised and offended by the verbal abuse.
Failure to Follow Physician Orders for Splints and Orthoses
Penalty
Summary
Surveyors determined that the facility failed to follow physician orders for four out of five residents reviewed. Residents with diagnoses such as heart failure, hemiplegia, multiple sclerosis, and seizure disorder had active physician orders and care plans specifying the use of various splints, protective sleeves, gloves, and orthoses to be worn daily during the day shift as tolerated. However, during observations, these residents were found in their rooms without the prescribed devices in place. Despite this, documentation in the treatment administration records (TARs) by LPNs indicated that the devices had been applied as ordered. Interviews with therapy staff revealed concerns that splints and braces were often not applied unless therapy staff intervened. The Nursing Home Administrator confirmed that the facility did not follow physician orders for these residents. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in multiple instances where residents did not receive timely or adequate care. Observations and interviews revealed that residents were left in soiled clothing and bed linens, experienced malodorous conditions, and did not receive regular personal hygiene care such as showers, nail care, and grooming. Documentation showed lapses in incontinence care and meal intake recording, with some residents not having their care needs addressed for extended periods. Residents and their families reported significant delays in call light responses, with some call lights going unanswered for up to 50 minutes. Several residents and staff members stated that the facility was understaffed, leading to unmet needs such as assistance with toileting, bathing, and getting out of bed. Therapy staff corroborated these findings, noting that residents often appeared unclean and were not being assisted as required. Resident Council minutes and grievance reviews further supported these findings, documenting ongoing concerns about insufficient staffing, lack of timely care, and unmet basic needs such as fresh water, snacks, and linen changes. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary services to maintain the highest practicable well-being of the residents involved.
Failure to Report Possible Neglect of a Resident
Penalty
Summary
The facility failed to implement its policies and procedures for reporting possible neglect of a resident. According to facility policy, any suspicion of abuse, neglect, exploitation, or misappropriation must be reported immediately to designated authorities, including the state licensing agency, ombudsman, resident's representative, adult protective services, law enforcement, the resident's attending physician, and the facility medical director. Immediate reporting is defined as within two hours for allegations involving abuse or serious bodily injury, or within 24 hours for other allegations. In this case, documentation and staff interviews revealed that a resident with dementia, a history of stroke, and moderate cognitive impairment was not provided with incontinence care for multiple days, despite being always incontinent of bowel and bladder as documented in the care plan and MDS assessment. Therapy staff observed the resident to be extremely soiled on consecutive days, with soiled clothing and bedding, and reported these findings to the nurse supervisor, Administrator, Director of Rehabilitation, Social Services, and Human Resources. However, the facility failed to submit a report of possible neglect to the State Survey Agency as required by policy. The Nursing Home Administrator later confirmed that the facility did not implement the required reporting procedures for this incident involving possible neglect.
Failure to Obtain Ordered Laboratory Services for a Resident
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one of three residents. According to the facility's policy, laboratory tests are to be obtained, processed, reviewed, and acted upon in a timely manner by qualified staff. A resident with chronic kidney disease, heart failure, high blood pressure, and psoriasis was evaluated by a dermatologist, who determined that systemic medication was needed for uncontrolled psoriasis. The dermatologist ordered blood work to be completed prior to starting the medication. However, review of the clinical record showed no documentation that the required blood tests were completed within the specified timeframe. Progress notes indicated that the resident inquired about the bloodwork, but staff could not locate any related orders initially. Later, the dermatology office confirmed that labs were ordered and needed to be completed before starting the medication. Although a laboratory order was eventually entered, the blood drawn was related to an unrelated order, and there was no documentation that the correct blood tests were completed. Both the Nursing Home Administrator and the resident confirmed that the required blood tests had not been completed as ordered.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether it was safe for a resident to self-administer medications, as required by its own policy. The policy states that if a resident chooses to self-administer medication, an assessment must be conducted to determine the resident's ability to do so safely and accurately. In this case, a resident with diagnoses of diabetes and dementia, and documented moderate cognitive impairment, was not assessed for the ability to self-administer medications. The resident's care plan did not include goals or interventions related to self-administration, and there was no physician order authorizing self-administration of medications. During observations, the resident was found with a medicine cup containing five prescribed medications on her bedside table at two separate times, indicating that medications were left within her reach. The medication administration record showed that an LPN had administered the medications, but the medications remained at the bedside for an extended period. The Nursing Home Administrator confirmed that the facility did not determine if it was safe for the resident to self-administer medications, resulting in noncompliance with regulatory requirements.
Failure to Maintain Adequate Linen Supply for Resident Comfort and Hygiene
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents across both nursing units due to a persistent shortage of linens, including bed sheets, bath towels, and washcloths. Residents reported frequent unavailability of clean linens, with one resident stating that after an accident in bed, staff had to search the building for clean sheets, sometimes taking up to an hour. Another resident expressed uncertainty about the availability of clean sheets, and a third resident confirmed a daily shortage of bath towels, washcloths, and sheets. These concerns were also documented in resident council meeting grievance reports, which noted ongoing issues with insufficient linen supplies. During a tour of the units, a linen cart inspection revealed only a minimal supply of linens available. Staff interviews, including those with the Director of Housekeeping and Laundry, as well as nurse aides, confirmed the ongoing linen shortage. The Director of Housekeeping and Laundry attributed the shortage to a delayed linen purchase order due to billing issues. Both the Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to meet the required standards for providing a safe, clean, and homelike environment for the affected residents.
Failure to Provide Consistent Access to Fresh Drinking Water
Penalty
Summary
The facility failed to ensure that fresh drinking water was consistently and readily accessible to residents, resulting in inadequate hydration and failure to meet resident preferences and comfort for three of ten residents. Observations and interviews revealed that residents often had to request water, which was not always provided, and that ice was unavailable due to broken ice machines. Documentation showed low daily fluid intake for the affected residents, with some days lacking any documentation of intake. Water pitchers were not consistently filled or kept within easy reach, as required by the facility's Certified Nursing Assistant job description. Residents involved included individuals with care plans addressing inadequate food and beverage intake, as well as those with a history or risk of dehydration due to conditions such as nausea, vomiting, and diarrhea. During rounds, it was observed that water and ice were not routinely offered, and residents confirmed they had not received water or ice as expected. Facility leadership acknowledged the failure to provide consistent access to fresh drinking water, which was corroborated by both staff and resident interviews.
Failure to Maintain AED in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential equipment, specifically the Automatic External Defibrillator (AED) located at the Nursing Station (Side 2), was maintained in safe operating condition. During an observation, it was found that the last documented AED audit was conducted several years prior, and there was no current maintenance log or record of regular checks as required by facility policy. Staff, including an RN and the DON, were unaware of who was responsible for completing the AED audit log, and the facility did not have the manufacturer's guidelines for the AED available. The DON confirmed that there were no other complete AED audit logs and acknowledged the failure to maintain the AED according to policy.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on one day, as mandated by regulation. The Nursing Home Administrator confirmed these staffing shortfalls during an interview, and the documentation reviewed detailed the census and actual NA hours compared to the required hours for each shift where deficiencies occurred.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated the NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5 times weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on one of six reviewed days. Specifically, staffing documents and nursing schedules showed that on 6/29/25, the provided direct care hours were only 2.90 per patient daily (PPD), which is below the required threshold. This deficiency was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the facility did not provide the minimum required hours of direct care on the identified date. No additional details regarding the residents' medical history or condition at the time of the deficiency were provided in the report.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off-duty staff, calling sister facilities, or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4, then monthly x2, to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified that the facility failed to store drugs and biologicals in a safe, secure, and orderly manner on at least one of four medication carts, specifically the 100 Hall cart, which was observed left open and unattended with the computer screen displaying patient information. Additionally, multi-dose vials on both the 100 and 200 Hall carts were not labeled with the date opened, and several medications were found to be expired or had unreadable expiration dates. These findings were confirmed during staff interviews and direct observation. Further inspection of the Medication Room and Central Supply Room revealed multiple expired medical supplies and medications, including blood collection tubes, test slides, disposable thermometers, IV start kits, and various medications such as Dairy Aid, Preservision, Geri-tussin, and IV administration sets. The facility's policies require that medication carts remain locked when unattended and that multi-dose containers be labeled with the date opened, but these procedures were not followed as evidenced by the observations and staff verification.
Failure to Provide and Document Vaccine Education
Penalty
Summary
The facility failed to provide and document required education regarding COVID-19, influenza, and pneumococcal vaccinations for several residents, as outlined in its own policies. Specifically, three residents received the COVID-19 vaccine, two residents received or refused the influenza vaccine, and five residents received the pneumococcal vaccine without documented evidence that education on the benefits, risks, and potential side effects was provided prior to vaccination. These findings were confirmed through clinical record reviews, which showed that the education was not completed or documented for the affected residents. Interviews with the Nursing Home Administrator and Regional Administrator further confirmed that the facility did not provide or document the necessary vaccine education for the identified residents. The deficiency was cited under 28 Pa. code: 211.5(f) Clinical Records, as the facility's failure to follow its own policies resulted in incomplete documentation and lack of education for residents regarding their vaccinations.
Failure to Provide Scheduled Showers and Baths for Dependent Residents
Penalty
Summary
The facility failed to ensure that showers and baths were provided or offered as scheduled for three residents who required extensive assistance with activities of daily living (ADLs). According to facility policy, residents unable to perform ADLs independently should receive appropriate support and assistance with hygiene and bathing. Clinical record reviews showed that one resident with diabetes, a right ankle foot ulcer, and morbid obesity required extensive assistance of two people for ADLs but did not receive scheduled showers on three occasions in April. Another resident with dementia and Down's Syndrome, requiring extensive assistance of one person, missed scheduled showers on six occasions in April. A third resident with diabetes, peripheral vascular disease, and chronic pain, requiring extensive assistance of two people, did not receive scheduled showers on five occasions in April. These findings were confirmed through review of facility shower schedules, ADL-Shower Task documentation, and staff interviews. The Nursing Home Administrator acknowledged that showers and baths were not provided or offered as scheduled for the three residents. The deficiency was cited under 28 Pa. Code: 211.12(1) Nursing services, 211.10(d) Resident care policies, and 211.12 (2)(5) Nursing services.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a seven-day period. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on six out of seven days, one NA per 11 residents during the evening shift on three out of seven days, and one NA per 15 residents during the night shift on four out of seven days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on two specific days, April 12 and April 13, 2025. On these days, the facility provided only 2.44 PPD and 2.81 PPD, respectively. This deficiency was identified through a review of staffing documents and nursing staff schedules covering the period from April 11 to April 17, 2025. The Nursing Home Administrator confirmed during an interview on April 18, 2025, that the facility did not meet the required PPD hours on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing bonuses as needed to ensure sufficient nursing staff. Additionally, the facility will continue to maintain efforts to recruit and retain staff to meet care needs and ensure residents are receiving appropriate care and services. The regional staff educated NHA/DON on ensuring sufficient nursing staff to meet residents' needs and ensure that the facility is holding daily staffing meetings. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4 weekly then monthly x2 to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident R1, who had severe cognitive impairment and was at risk for elopement. Resident R1 had a history of Alzheimer's disease, bipolar disorder, schizophrenia, and a seizure disorder, which contributed to her wandering behavior. Despite being identified as an elopement risk and having an electronic monitoring bracelet ordered, Resident R1 managed to leave the facility without staff knowledge on multiple occasions. On the day of the incident, Resident R1 was observed outside the facility on two separate occasions. Initially, she was found outside near another resident's room and was brought back inside by staff. Later, she was seen in the parking lot and was found attempting to get into a vehicle. Staff intervened and managed to bring her back into the facility. The facility's records and staff interviews revealed that there were lapses in monitoring and documentation, including failure to perform risk management, vital checks, and notify the family or physician promptly. The situation was further complicated by a busy evening where multiple incidents occurred simultaneously, including another resident attempting to leave, a choking episode, and a seizure incident. The facility's response was inadequate, as evidenced by the lack of immediate and thorough assessments, failure to update care plans, and insufficient communication among staff. This failure to provide adequate supervision and monitoring created an immediate jeopardy situation for 19 of the 91 residents in the facility.
Removal Plan
- Facility recovered resident and provided safety. RN assessed resident and provided safety.
- Physician and Resident Representative notified of event.
- Wander guard device checked for placement and function.
- All door alarms checked for function and lock mechanism to ensure facility is secure.
- Resident care plan reviewed and updated to ensure accurate and appropriate interventions in place.
- Witness statements obtained, and headcount checks completed.
- Supervisor conducted door securement and alarm audit and initiated a 4 point system to monitor doors to ensure security.
- Supervisor posted staff at each door while audit conducted to ensure doors are shut, locked, and alarms are on and functioning.
- DON directed RN supervisor and assigned nurse to ensure Resident receives an assessment, notify physician and family of incident, and ensure resident is monitored to prevent reoccurrence.
- RN Supervisor performed assessment on the resident for injuries; none noted.
- Door audits completed to ensure doors are secure. Door alarm checks completed to ensure alarms are functioning.
- New alarms ordered to ensure that alarm sounds are loud enough to hear.
- Facility notified the attending physician to report findings and conditions of the resident and the resident's legal representative.
- Documentation of incident in residents record completed.
- Resident's care plan and orders reviewed and updated to ensure Wanderguard and exit seeking behaviors addressed in care plan and orders as appropriate.
- All residents assessed for Elopement Risk.
- Residents newly identified to have potential for elopement had care plans updated with appropriate interventions.
- Facility-initiated house audit for exit/entry points to ensure alarm function and doors lock appropriately.
- Facility conducted whole house resident head count to ensure accountability of residents.
- House audit conducted on resident wanderguard orders to ensure accuracy.
- All Wanderguards placed on residents assessed for function, care plans updated as needed.
- Elopement Books audited to ensure accuracy and placed at each nurses station and reception area.
- RN Supervisor provided a discipline due to not following DON directive to ensure that Resident was assessed and notifications occurred and documented.
- RN terminated due to failing to complete these tasks.
- Nurse assigned to resident on cart also failed to ensure resident was accounted for and skin checks performed following incident. DON provided discipline to this nurse for failure to complete tasks. Termination resulted.
- All residents in house will be assessed for elopement risk by the Director of Nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated with interventions to prevent elopement by the Director of Nursing or designee.
- All residents identified to be elopement risk will have wanderguard placed and added to Elopement Binder per protocol.
- House audit on all doors and exit points will be conducted by Maintenance to ensure that facility is secure and alarms are functional.
- House audit on all wanderguards will be conducted to ensure placement and function.
- Facility Director of Nursing or designee will conduct education to all facility staff regarding dementia/behavior in LTC residents, Elopement risk and mitigation, and Elopement Policy and Procedures to include keeping doors secure.
- Education will be completed for all clinical staff on Elopement Risks, Assessments, Care Plans, and Supervision of Residents by the Director of Nursing or designee.
- Elopement Books with identified resident photos will be placed on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Audits will be conducted on all doors/exits by Supervisor twice per shift daily and then weekly thereafter.
- Maintenance Director or designee will conduct daily (twice per shift) audit on doors to ensure secure and alarmed. Audit will remain ongoing.
- All new admissions will be reviewed for elopement risks by IDT and ongoing.
- Elopement assessments will be audited for compliance by IDT and will remain ongoing.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
Neglect Leads to Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the actual harm of an elopement. The resident, identified as Resident R1, had severe cognitive impairment and was at risk for elopement due to conditions such as Alzheimer's disease, bipolar disorder, schizophrenia, and a seizure disorder. Despite being identified as an elopement risk and having an electronic monitoring bracelet ordered, the resident managed to leave the facility without staff knowledge. On the day of the incident, Resident R1 was observed outside the facility on two separate occasions. Initially, the resident was found outside near another resident's room and was brought back inside by staff. However, later the same day, the resident was seen in the parking lot and was found attempting to get into a vehicle with an unknown community member. The resident was eventually brought back to the facility by a staff member who intervened. The facility's staff, including RN Employee E2 and RNS Employee E4, failed to complete necessary assessments and implement 15-minute checks after the first elopement attempt, which allowed the resident to elope a second time. The Director of Nursing confirmed that these failures in protocol contributed to the resident's ability to leave the facility again, leading to the termination of the involved staff members.
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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