Wecare At South Hills Rehabilitation And Nrsg Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Canonsburg, Pennsylvania.
- Location
- 201 Village Drive, Canonsburg, Pennsylvania 15317
- CMS Provider Number
- 395289
- Inspections on file
- 40
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 44 (3 serious)
Citation history
Health deficiencies cited at Wecare At South Hills Rehabilitation And Nrsg Ctr during CMS and state inspections, most recent first.
The facility did not meet required minimum NA staffing ratios on multiple day, evening, and night shifts during a reviewed period. Staffing records showed that, with a census of approximately 58–59 residents, actual NA hours on several day and evening shifts, and one night shift, were below the hours needed to achieve mandated ratios of 1 NA per 10 residents on days, 1 NA per 11 residents on evenings, and 1 NA per 15 residents overnight. The DON confirmed that the required number of NAs was not provided on the identified shifts.
Administrative staff did not ensure required LPN coverage on certain day and evening shifts, as shown by a comparison of nursing time schedules and census data. On one day shift, the number of LPN hours worked was below what was required for the number of residents present, and on one evening shift, LPN hours were again below the mandated minimum. The DON confirmed that minimum LPN staffing requirements were not met on these shifts.
The facility did not provide the state-required minimum of 3.20 hours of direct nursing care per resident per day (PPD) on multiple reviewed days. Staffing documents and nursing schedules showed that on several days the calculated PPD fell below 3.20, with values ranging from 2.88 to 3.19 hours of direct care per resident. In an interview, the DON acknowledged that the minimum required PPD hours of direct care were not met on those days.
Staff failed to maintain required freezer temperatures in the main kitchen, contrary to facility policy that mandated freezer units be kept at 0°F or below. During an observation, the freezer door was found ajar with a temperature above the required range, and subsequent checks showed the temperature remained elevated while the internal thermostat was set to activate only at temperatures well above 0°F. The freezer remained out of the proper temperature range for about an hour before returning to 0°F. The Director of Maintenance and the Nursing Home Administrator both confirmed that food products in the main kitchen were not properly stored, creating the potential for foodborne illness.
The facility failed to provide sufficient nursing staff to meet residents’ ADL and hygiene needs and to respond promptly to call lights. Observations found several residents with unclean, overgrown fingernails, crusted dandruff, and unshaven facial hair, while documentation showed missed or inconsistently provided showers and bed baths despite residents being in the facility. Multiple residents reported excessive call light response times, delays in getting out of bed and dressed, and frequent short staffing. Staff members described staffing as poor and inconsistent, often working short and covering additional shifts. The NHA and DON acknowledged that nursing staff levels were inadequate to support residents’ highest practicable well-being.
Surveyors identified that the facility did not follow its food storage policy in the main kitchen. The drink/food line cooler lacked an internal thermometer despite policy requiring thermometers in cold storage units, and food items in the refrigerator and deep freezer were stored within a few inches of the ceilings. The Dietary Supervisor confirmed these improper storage practices, which created the potential for foodborne illness and constituted noncompliance with state dietary service regulations.
Surveyors found that the facility did not maintain a clean, safe, and comfortable environment in multiple resident-use areas. Both shower rooms had visibly soiled grout, cracked tiles, protruding hardware, and shower chairs with brown residue and rust. During a resident council interview, several residents reported that the lounges were too cold in the winter, and subsequent temperature checks in the lounges and nearby rooms showed readings well below the facility’s stated comfort range. The Nursing Home Administrator and Maintenance Director confirmed these environmental and temperature issues in the shower rooms, hallways, and lounges.
The facility failed to notify physicians of significantly elevated capillary blood glucose (CBG) levels for two residents with diabetes and did not have clear provider notification parameters in policy, care plans, or physician orders. One resident with dementia and diabetes had a care plan for potential hypo/hyperglycemia that lacked specific physician notification interventions, and multiple very high CBG readings were recorded without documented provider notification. Another resident with epilepsy and diabetes had a care plan referencing Accuchecks and MD notification per protocol, but physician orders did not include blood sugar checks or notification parameters, and several elevated CBG readings also lacked documented provider notification. The NHA and DON confirmed these failures during interview.
The facility failed to maintain and update comprehensive, person-centered care plans for two residents to reflect their current clinical conditions and psychosocial needs. One resident with diabetes, renal insufficiency, obstructive sleep apnea, BPH, neuropathy, pain, and hypertension had multiple active medications, including insulin, an anticoagulant, a diuretic, and oxycodone, but the care plan lacked goals and interventions for managing these disease processes and related issues such as potential constipation. Another resident with traumatic brain dysfunction, anxiety, depression, and PTSD had documented trauma history and ongoing symptoms in psychiatry notes, yet the care plan did not include goals or interventions addressing past experiences, preferences, or strategies to avoid triggers that could lead to re-traumatization. The DON acknowledged that both care plans did not accurately reflect the residents’ current status.
The facility failed to ensure several residents received proper hearing-related services and treatments as ordered and recommended. Some residents with complex medical and cognitive conditions had physician orders for audiology services but no documented audiology assessments. Other residents did receive audiology assessments that identified impacted cerumen and recommended Debrox ear drops, yet no corresponding medication orders appeared on the MAR, and the recommended treatment was not implemented. The DON confirmed that the facility did not ensure residents received appropriate services to maintain hearing abilities.
Surveyors found that the facility failed to follow its own policies and professional standards for respiratory care for multiple residents. A resident with a trach had no documented trach tube type/size in orders or care plan, and the bedside suction canister was unchanged for an extended period and partially filled with secretions. Another resident’s oxygen tubing and humidifier bottle were not dated as ordered. Two residents using CPAP had their masks left out on bedside stands instead of stored in labeled plastic bags when not in use. A resident using BiPAP had the mask on the floor, reported being unable to apply it without staff help, stated staff did not assist consistently, and reported discomfort with the mask without being offered alternative options. The DON acknowledged these failures in trach care, respiratory care, and equipment maintenance.
The facility failed to employ a qualified Food Service Director to manage daily dietary operations for an extended period. A dietary supervisor reported not being certified and indicated that the RD only worked part‑time across two facilities. The NHA confirmed the RD was present only two days per week and acknowledged the facility lacked documentation showing that the dietary supervisor met the qualifications for the Food Service Director role, resulting in noncompliance with state management requirements for food and nutrition services.
The facility failed to ensure informed consent for a binding arbitration agreement by having two cognitively impaired residents, each only oriented to person and with very low BIMS scores, sign an “Alternative Dispute Resolution Agreement” included in the admission packet. The agreement waived court, jury, and most appeal rights for non‑payment disputes, yet there is no indication it was explained in a form or language the residents could understand or that a representative participated. The NHA and DON acknowledged that the facility did not ensure these residents understood the conditions of the binding arbitration agreement.
Surveyors identified multiple infection control and food safety lapses, including wound care for a resident with a stage 4 pressure ulcer performed by two LPNs without gowns, failure to change a soiled underpad with wound drainage, and lack of hand hygiene between glove changes. Two ice machines had drainpipes coiled directly into drains without an air gap and had debris and used items stored underneath and around them, contrary to facility policy for sanitary ice maintenance. Two residents’ in-room refrigerators had temperature logs that had not been updated for several months, and a nurse aide provided high-contact morning care to a resident on Enhanced Barrier Precautions for MDRO and a wound without wearing a gown, despite posted signage and physician orders.
Surveyors found that the facility failed to maintain accessible bathroom call bell systems for two residents. Policy required that each resident have a means to call staff from toileting and bathing areas, and ADA standards require emergency pull cords to be reachable within a defined height range. Observations showed that in two bathrooms the call lights consisted only of a short three-inch chain protruding from the wall, with no attached string or call pendant, preventing proper use of the system. The NHA and DON confirmed that the call bell system in these rooms did not provide a fully functioning means for residents to summon staff assistance, resulting in a cited deficiency under applicable state regulations.
A resident with heart failure, anxiety, depression, and behavioral issues related to intellectual disability and poor safety awareness missed two scheduled private therapy sessions after their Legal Guardian removed the resident’s personal cell phone, which contained the therapist’s contact information. The DON reported the resident had a standing weekly therapy call but acknowledged the facility did not have the therapist’s name or number documented and did not contact the Legal Guardian to obtain this information so the calls could continue using a facility phone, resulting in a failure to provide necessary behavioral health services.
A resident with dementia, obesity, lack of coordination, and a history of right hip ORIF, who was care-planned and assessed to require two-person assistance for bed mobility and turning, was provided incontinence care by a single nurse aide. The aide turned the resident onto her side and left the resident in that position to wet a towel in the bathroom, during which time the resident rolled out of bed and was later found on the floor. The resident had an order for bilateral enabler bars for positioning, but documentation did not show whether these were in use or that protective measures against neglect were ensured. After the resident complained of pain, the physician ordered X‑rays to rule out possible injury or fracture, and facility leadership acknowledged the failure to protect the resident from neglect.
A resident with Alzheimer’s dementia, mobility limitations requiring two-person assistance for bed mobility, and an order for bilateral enabler bars was found on the floor after being turned onto her side by one NA who then left the room to wet a towel, during which the resident rolled out of bed. Facility documentation did not clarify whether the enabler bar was in use and did not show that the resident was protected from neglect while the physician was contacted and X-rays were ordered for reported pain. The NHA and DON acknowledged that the facility did not promptly conduct a thorough neglect investigation or submit the completed investigation results to the State Survey Agency within the required timeframe.
A resident with Alzheimer's dementia, impaired coordination, obesity, and a history of right hip ORIF was care-planned and assessed on the MDS as needing two-person assistance for bed mobility and turning, and had an order for bilateral enabler bars for positioning. Despite this, a NA entered the room alone to provide incontinence care, turned the resident onto her side, and left the resident in that position while going to the bathroom to wet a towel, during which time the resident rolled out of bed and was found on the floor. Documentation did not clarify whether enabler bars were in use, and there was no documented investigation into why care was provided by only one staff member, even though staff interviews confirmed that substantial/maximal assistance required two staff. The administrator and DON acknowledged that the resident did not receive proper assistance and supervision, resulting in pain and the need for X‑rays to rule out injury.
Surveyors found that staff failed to follow facility policies for IV therapy in two residents. One resident with COPD and heart failure had an implanted venous port with a physician order for weekly dressing changes, but the baseline care plan lacked port-care instructions and the port dressing was observed without required labeling of date and time. Another resident receiving TPN for hydration and nutrition had detailed physician orders for infusion rates, yet the TPN bag was observed infusing without documented verification of contents, hang date, or staff initials, contrary to facility policy. An RN and the DON confirmed these failures.
The facility failed to implement trauma-informed care for two residents with known or reported trauma histories. One resident had documented PTSD and dementia on the MDS and was receiving psychotropic medications, yet the care plan did not address PTSD, identify trauma triggers, or include interventions to prevent re-traumatization. Another resident’s legal guardian reported a history of being victimized by predators related to cell phone use, but this trauma history was not documented in the clinical record or care plan, and no trauma-informed interventions or trigger identification were in place. The DON and Administrator acknowledged that trauma-informed care and trigger mitigation were not provided for these trauma survivors.
Surveyors found that a resident with schizophrenia, bipolar disorder, and paralytic syndrome had a physician order and care plan for bilateral bed grab bars to assist with self-positioning, and therapy had recommended their use, but the bed did not have the ordered grab bars in place. The nursing portion of the enabler bar assessment was left blank, and the resident reported that promised side rails had not been provided. An RN confirmed both the absence of the grab bars and that accurate assessments regarding bed rail use and associated risks had not been completed.
A resident with COPD, heart failure, and hypertension was admitted with a physician’s order for Xanax 0.5 mg TID for anxiety, but review of the MAR showed the medication was not administered as ordered. A provider note indicated the resident initially did not have medications available while awaiting pharmacy and was sent back to the hospital the same day with crushing chest pain and tachycardia before returning later that night. On observation, the resident complained of nausea and feeling shaky, and an RN reported the ordered Xanax had not been given as prescribed, believing the resident was experiencing withdrawal after long-term use. The resident stated they had only received the Xanax twice since admission, and the DON confirmed the failure to ensure the resident was free from significant medication errors.
Surveyors found that one medication cart contained multiple opened medications that were not dated as required by facility policy, including budesonide inhalation suspension, ipratropium bromide, Trelegy Ellipta, and a Lantus insulin pen. An RN confirmed the medications were opened and undated, and the DON acknowledged that medications on this cart were not being stored properly.
Surveyors found that the facility did not provide or document required written bed-hold notices to residents and/or their representatives at the time of multiple hospital transfers. Several residents with complex conditions such as CAD, COPD, CKD, heart failure, ALS, diabetes, seizure disorders, and prior stroke were sent to the ED or hospital for issues including pneumonia, neurologic changes, lethargy, cellulitis-related leg swelling, and respiratory decline. Although progress notes showed that family or POA were verbally informed of the transfers, the clinical records lacked completed Transfer/Discharge/Bed Hold Forms or any notation that written bed-hold information was given, and in one case the form was present but incomplete. The NHA and DON acknowledged that written notice of the bed-hold policy was not ensured for these hospitalizations.
The facility failed to ensure MDS assessments accurately reflected the use of non-invasive mechanical ventilation for two residents with diabetes, obstructive sleep apnea, and other chronic conditions. For both residents, MDS Section O0110 G1 indicated no use of a non-invasive mechanical ventilator, despite physician orders for CPAP/BiPAP at bedtime, care plans specifying CPAP/BiPAP with oxygen bleed and settings, and treatment administration records documenting BiPAP use over multiple days. One resident reported using CPAP every night, while the other stated she tried to use BiPAP but could not apply the mask independently and did not receive sufficient staff assistance. The DON confirmed the discrepancy between the documented treatments and the MDS coding.
The facility failed to ensure accurate completion of BIMS assessments in the MDS, resulting in four alert and oriented residents being incorrectly documented as rarely/never understood and coded as having severe cognitive impairment, despite a history of prior BIMS scores in the cognitively intact or mildly to moderately impaired range. An LPN later acknowledged completing these assessments incorrectly, and facility leadership confirmed that resident clinical records were not complete and accurate as required.
The facility did not provide the required minimum number of LPNs on several day and night shifts, as shown by a review of staffing schedules and census data. The Nursing Home Administrator confirmed that LPN staffing levels fell below regulatory requirements on these occasions.
The facility did not return personal funds to the responsible parties of two residents within the required 30-day period after the residents' deaths. One resident's family had not received a $385 refund despite repeated inquiries, and another resident's $2,530 refund could not be verified as returned, with no supporting documentation provided. Staff confirmed both cases of delayed fund return.
Over a 21-day period, the facility did not provide the required minimum number of nurse aides for the resident census on 20 days, as confirmed by review of staffing schedules and by the DON. The number of nurse aides scheduled for day, evening, and night shifts was repeatedly below the regulatory minimums, resulting in a deficiency in nurse aide staffing coverage.
Administrative staff did not ensure the minimum required 3.2 hours of direct nursing care per resident per day on multiple occasions, as confirmed by review of staffing schedules and by the DON.
A resident with a history of sexually inappropriate behavior and severe cognitive impairment repeatedly engaged in non-consensual sexual contact and touching of other residents, including those who were cognitively impaired or physically unable to defend themselves. Despite staff and resident reports of ongoing incidents, facility management failed to implement effective interventions or respond appropriately, resulting in multiple residents being subjected to unwanted sexual contact and harassment.
The facility did not follow required procedures to report multiple allegations of sexual abuse by a resident with a history of inappropriate behavior. Staff and family members observed and reported incidents involving several residents, including those with dementia and severe cognitive impairment, but administration failed to notify authorities as mandated by law and policy. This led to ongoing unreported abuse and placed vulnerable residents at risk.
A resident with severe cognitive impairment and a history of sexual offenses was not properly supervised, leading to repeated incidents of sexually inappropriate behavior toward other residents, many of whom were cognitively or physically impaired. Staff and resident interviews revealed that these behaviors were ongoing, widely known, and not consistently reported or documented. The facility failed to implement and document care plan interventions, resulting in direct harm and distress to multiple residents.
The facility did not properly document, investigate, or follow up on grievances submitted by residents and staff, including concerns about aggressive resident behavior. Residents and staff reported being threatened with retaliation for filing grievances, and grievance forms were sometimes unavailable, compromising anonymity. Facility leadership confirmed these failures.
A male resident was repeatedly observed wandering into female residents' rooms and engaging in inappropriate behavior. Multiple staff, including LPNs and CNAs, reported these incidents to management but were instructed not to discuss them, not to file grievances, and were threatened with termination if they did. The NHA and DON confirmed that no investigations or grievances were documented and that staff did not feel safe from retaliation.
The facility did not follow its abuse investigation policies after multiple staff reported a resident with a history of sexually inappropriate behavior touching non-consenting residents. Despite repeated reports to administration and the DON, the facility failed to document or investigate these incidents, and only a portion of relevant staff were interviewed. This inaction allowed the behavior to continue without proper intervention.
The NHA and DON failed to prevent resident-to-resident sexual abuse when a resident with a known history of sexually inappropriate behavior touched a non-consenting resident, resulting in Immediate Jeopardy for five residents. Both leaders acknowledged they did not effectively manage the facility to protect residents, in violation of regulatory requirements.
The facility failed to maintain an effective QAPI program, resulting in repeated incidents of sexual abuse involving multiple residents. Despite previous corrective actions, inappropriate sexual contact and behavior continued, with staff and guardians confirming that these incidents were not properly identified or managed.
The facility did not post complete and current contact information for the Grievance Officer, Adult Protective Services, and the State Long-Term Care Ombudsman in three common areas, as confirmed by the Administrator and DON during staff interviews.
The facility did not include the needs of residents involved in consensual romantic relationships in their care plans, despite evidence of such relationships and guardian awareness. Care plans for several residents with cognitive and medical complexities lacked interventions or objectives related to their psychosocial needs in this area, as confirmed by documentation and staff interviews.
A resident with severe dementia and a history of hypersexual behaviors repeatedly engaged in sexually inappropriate conduct with other residents, including kissing, touching, and wandering into rooms, without timely or adequate care planning or monitoring by staff. Despite staff awareness and multiple incidents, the facility did not implement a care plan for sexually inappropriate behavior until months after the behaviors began, and documentation of monitoring was infrequent and incomplete. This failure to provide necessary psychosocial services resulted in resident-to-resident sexual abuse.
A review of staffing records and staff interview confirmed that the facility did not provide the required number of nurse aides on multiple day and night shifts, with actual nurse aide hours falling short of regulatory minimums. The DON acknowledged the staffing shortfalls on the identified shifts.
The facility did not provide the required minimum number of LPNs on several day, evening, and night shifts, as confirmed by a review of staffing schedules and census data. The DON acknowledged that LPN staffing levels were below regulatory requirements on multiple occasions.
A facility failed to protect a cognitively impaired resident from sexual abuse, resulting in the resident contracting an STI. Despite staff awareness of the resident's relationship with another resident, no care plan or interventions were implemented to address the situation. The facility did not follow up on the resident's diagnosis or revise her care plan, leading to a deficiency in ensuring the resident's right to be free from abuse.
The facility failed to maintain the automatic sprinkler system, with deficiencies including missing documentation for the three-year Full Flow Trip Test and multiple missing ceiling tiles in various rooms. These issues were confirmed by the Facility Administrator and Maintenance Director.
The facility did not conduct five of the twelve required fire drills over a year, impacting the entire facility. Missing documentation included a drill for the third shift in the second quarter, all shifts in the third quarter, and the third shift in the fourth quarter. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the emergency generator, lacking documentation for weekly visual inspections and monthly conductance testing. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director, affecting the entire facility.
A facility failed to report an allegation of abuse within the required timeframe for a resident with severe cognitive impairment. The resident, diagnosed with Trichomoniasis, mentioned a consensual relationship with another resident but was unreliable in determining when the intercourse occurred. Despite the facility's policy requiring immediate reporting of such incidents, the Nursing Home Administrator and DON confirmed the failure to report in a timely manner.
The facility failed to maintain hazardous area enclosures as the doors to the Condensing Room could not close and latch properly, affecting one of five smoke compartments. This was confirmed by the Facility Administrator and Maintenance Director.
Failure to Meet Minimum Nurse Aide Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet state-required minimum nurse aide (NA) staffing ratios on multiple shifts over a nine-day review period. Review of facility staffing documents from 4/20/26 through 4/28/26 showed that on the day shift, the facility did not provide at least one NA per 10 residents on four days, with census counts of 58–59 residents and actual NA hours falling below the required hours (for example, on 4/25/26 and 4/26/26, 29.91 and 31.38 actual hours were provided versus 44.25 required). On the evening shift, the facility failed to provide at least one NA per 11 residents on four days, again with census counts of 58–59 residents and actual NA hours (30.50–38.16) below the required 39.55–40.23 hours. On the night shift, the facility failed to provide at least one NA per 15 residents on one day, with 27.00 actual hours versus 29.50 required for 59 residents. During an interview, the Director of Nursing confirmed that the facility did not provide the required number of NAs on the identified shifts.
Plan Of Correction
The Facility submits this plan of correction under the procedures established by the Department of Health in order to comply with the department's directive to change conditions which the department alleges are deficient under date and/or federal long term care regulations. This plan of correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of state or federal regulatory requirements. 5520CNA The Nursing schedule is created to ensure CNA staffing ratios reflects the current census per shift. Each shifts CNA staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Failure to Meet Minimum LPN Staffing Requirements on Day and Evening Shifts
Penalty
Summary
Facility administrative staff failed to meet state-required minimum LPN staffing levels on specified day and evening shifts, as identified through review of nursing time schedules and census data. For the day shift on 4/25/26, with a census of 59 residents, the facility provided 15.92 hours of LPN coverage instead of the required 18.88 hours, resulting in an LPN staffing shortage. For the evening shift on 4/20/26, with a census of 62 residents, the facility provided 14.57 hours of LPN coverage instead of the required 16.53 hours, again resulting in an LPN staffing shortage. During an interview on 4/30/26 at 3:00 p.m., the Director of Nursing confirmed that the facility did not provide the minimum number of LPNs required by regulation on these identified shifts.
Plan Of Correction
Formatted text (without <text> tags or quotes): The Nursing schedule is created to ensure LPN staffing ratios reflects the current census per shift. Each shifts LPN staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts when needed. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assist with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing rations and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Completion Date: 06/15/2026 Status: APPROVED Date: 05/15/2026 Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Failure to Meet Minimum Direct Nursing Care Hours (PPD) on Multiple Days
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct nursing care per resident per day (PPD) on multiple days within the review period. Review of staffing documents and nursing staff schedules for 4/20/26 through 4/28/26 showed that on five of the nine days reviewed, the total general nursing care hours, when calculated per resident, fell below the required 3.20 PPD. Specifically, the PPD levels were 3.14 on 4/24/26, 2.94 on 4/25/26, 2.88 on 4/26/26, 2.97 on 4/27/26, and 3.19 on 4/28/26. During an interview, the DON confirmed that the facility did not provide the minimum required PPD hours of direct care on these dates as required by regulation. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency are provided in the report.
Plan Of Correction
The Nursing schedule is created to ensure staffing PPD reflects the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility will utilize agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, HR, the scheduler and RN Supervisors on the staffing ratios and PPD and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, HR and scheduler. Daily recruiting calls with the NHA, HR, and recruiter occur to update the status of new applicants and interviews. The 3 week DOH Staffing Calculator Tool will be updated daily to monitor hours. The Audits will be taken to QAPI for review.
Improper Freezer Temperature Control in Main Kitchen
Penalty
Summary
Facility staff failed to maintain proper freezer temperatures in the main kitchen in accordance with the facility’s Food Storage policy, which required freezer units to be maintained at 0°F or below. During a kitchen observation, surveyors noted the main kitchen freezer door was ajar and the external temperature gauge read 8°F. After the door was closed, subsequent temperature checks showed the freezer at 20°F on two separate readings, and the internal thermostat was observed to be set to turn on at 15°F and off at 10°F, settings inconsistent with the policy requirement. The freezer temperature did not return to 0°F until approximately one hour after the initial observation, indicating the freezer was out of the proper temperature range for that period. The Director of Maintenance confirmed that the freezer was not maintaining proper temperature ranges, and the Nursing Home Administrator confirmed that the facility failed to properly store food products in the main kitchen, which created the potential for foodborne illness. No specific residents or patient conditions were mentioned in the report, and the deficiency was cited under Pa. 28 Code: 211.6(c)(d)(f) Dietary services.
Insufficient Nursing Staff Leading to Poor Hygiene and Delayed Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs for activities of daily living (ADLs), hygiene, and timely response to call lights. Facility policies required timely responses to residents’ requests and provision of services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Observations on the same day showed multiple residents with poor hygiene: one resident had a large amount of brown substance under very long, curled fingernails; another had a large amount of dandruff and dry skin crusted on his hair; a third resident also had a large amount of brown substance under his fingernails; and a fourth resident had a large amount of brown substance under his fingernails and nodded affirmatively when asked if he wanted his facial hair shaved. Review of point-of-care documentation for these residents over approximately one month showed missed or inconsistently provided showers and bed baths, including multiple entries marked as “Not Applicable,” “No documentation,” or only occasional bed/towel baths, despite the residents being present in the facility on those dates. Multiple residents reported concerns about staffing and care responsiveness. One resident stated that call light response times could be excessive and depended on which staff were working. Other residents stated that the facility was short-staffed, very understaffed, and that this stressed the aides and was not good for the patients. Additional residents reported that staffing was sometimes adequate, that they could always use more help, and that there were delays in getting people dressed and out of bed in the morning, with call lights taking a long time because there was not enough staff. Staff interviews corroborated these concerns, with four employees describing staffing as poor, variable, and resulting in them working short on day shift and having to pick up on evenings and days off. The Nursing Home Administrator and DON confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for ten of fifteen residents reviewed.
Improper Kitchen Food Storage and Lack of Required Thermometers
Penalty
Summary
The facility failed to properly store food products in the main kitchen in accordance with its own “Food Storage” policy dated 8/27/25, which requires food to be stored to facilitate thorough cleaning and for areas to be maintained in a clean, safe, sanitary manner with thermometers available in storeroom, freezer, and refrigerator units. During an observation of the main kitchen on 1/20/26 between 8:50 a.m. and 9:15 a.m., surveyors noted that the drink/food line cooler did not contain an internal thermometer, contrary to policy requirements. In addition, the refrigerator and deep freezer were observed to have food stored approximately three inches from the ceilings. During an interview at 9:15 a.m. on the same day, the Dietary Supervisor (Employee E8) confirmed that the facility had failed to properly store food products in the main kitchen, creating the potential for foodborne illness, in violation of Pa. 28 Code: 211.6(c)(d)(f) Dietary services. No specific residents or patient conditions were mentioned in the report, and the deficiency was identified based on policy review, environmental observations in the kitchen, and staff interview.
Failure to Maintain Clean Shower Areas and Comfortable Temperatures in Resident Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a clean, safe, comfortable, and homelike environment in multiple common-use areas, including both resident shower rooms, two resident hallways, and both resident lounges. During a tour with the Nursing Home Administrator, the B/C shower room was observed to have a dark brown/black substance in the grout of the shower floor, cracked tiles at the base of the shower and wall, and shower chairs soiled with brown residue. The A/E shower room was observed to have a metal pin protruding from the rear wall of stall one, discolored shower grout, a brown substance on the third stall’s shower head handle, and a shower chair with brown residue and rust on all four wheels. The Nursing Home Administrator confirmed these observations. Residents participating in a resident council group interview reported that the resident lounges on both sides (B/C and A/E) were too cold during the winter months. During a subsequent tour and interview with the Nursing Home Administrator and the Maintenance Director, the B/C lounge was noted to be blowing cold air, with a measured temperature of 58.1°F. Several resident rooms in the B/C hallways were also found to have temperatures below the facility’s stated comfort range of 71–81°F, with readings of 68°F, 68.9°F, 65.6°F, 64.7°F, and 68.3°F. The Nursing Home Administrator confirmed that the facility failed to provide a clean, safe, comfortable, and homelike environment in the identified shower rooms, hallways, and lounges, contrary to the facility’s homelike environment policy and applicable state regulations.
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 two residents with diabetes, as well as the absence of clear provider notification parameters in policy, care plans, and physician orders. The facility’s policy on nursing care of older adults with diabetes, dated 8/27/25, stated that providers would order glucose monitoring frequency and establish glycemic targets, and that the facility would establish provider notification guidelines, but no specific facility protocol for notification was found. For one resident with dementia and diabetes, the care plan for potential hypo/hyperglycemia, revised on 9/26/24, did not include interventions related to physician notification for elevated blood sugars. A physician order dated 12/30/25 directed daily Basaglar insulin, but there were no orders for blood sugar checks or parameters for when to notify the physician. Review of this resident’s blood sugar records showed multiple markedly elevated CBG readings (ranging from 402.0 mg/dL to 524.0 mg/dL) on numerous dates and times without documentation that the provider was notified. For a second resident with epilepsy and diabetes, the care plan for potential hypo/hyperglycemia, initiated 10/19/23, referenced Accuchecks as ordered and to call the MD per order/facility protocol, but physician orders dated 12/30/25 only included Lantus insulin at bedtime and did not include blood sugar check orders or notification parameters. This resident’s blood sugar records also showed several elevated readings (ranging from 404.0 mg/dL to 482.0 mg/dL) without documentation of provider notification. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to notify physicians of increased and decreased CBG levels for two of five residents reviewed.
Failure to Maintain Comprehensive, Current Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans to reflect the current clinical status and needs of two residents. For one resident with diagnoses including diabetes, obstructive sleep apnea, and renal insufficiency, the clinical record and current physician orders showed multiple active conditions and medications, such as glargine insulin and Jardiance for diabetes, Eliquis as an anticoagulant, Bumex for fluid management, Flomax and finasteride for BPH, Lyrica for neuropathy, oxycodone for pain, and metoprolol for hypertension. However, the resident’s care plan did not include goals or interventions for management and monitoring of diabetes, anticoagulant therapy, fluid status, BPH, neuropathy, pain, hypertension, or potential constipation related to oxycodone use. The MDS also did not indicate CPAP use in Section O0110 G3. The DON confirmed that the care plan was lacking the required medications and disease processes. For another resident with documented traumatic brain dysfunction, anxiety, depression, and PTSD, the MDS, facility diagnosis list, and multiple psychiatry notes described a history of severe trauma, a traumatic brain injury, a long hospital stay, and ongoing symptoms including mood swings, depression, hypervigilance, increased anxiety, and feeling nervous around other people. Despite this documented PTSD diagnosis and related symptoms, the resident’s current care plan did not include goals or interventions that accounted for the resident’s past experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization. The DON confirmed that the facility failed to update this resident’s care plan to accurately reflect the resident’s current status.
Failure to Implement and Follow Audiology Consults and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received proper treatment and services to maintain hearing abilities, as required by its own consult policy and physician orders. The facility’s Consults Policy and Procedures dated 8/27/25 requires nursing staff to notify the attending provider of consulting providers’ recommendations, review the provider’s acceptance, and monitor compliance with recommended treatment. Multiple residents had physician orders authorizing or directing audiology services, but their clinical records either lacked evidence that audiology assessments were completed or that recommended treatments were implemented. One resident admitted with traumatic brain injury, obesity, stroke, and atrial fibrillation had an order allowing audiology services in place since 12/20/16, yet no audiologist assessment was documented from admission through the current review period. Another resident with autism, intellectual disabilities, obesity, and visual disabilities had an order for audiology services from admission, but no audiologist assessment was found in the record. For several other residents, audiology assessments were completed but the recommended treatment was not carried out. A resident with quadriplegia, seizures, dementia, glaucoma, and kidney disease had audiology assessments on two occasions identifying impacted cerumen in the left ear and recommending Debrox ear drops, but the MAR for the corresponding months did not show any Debrox order. Another resident with anoxic brain damage and dementia had an audiology assessment identifying impacted cerumen in the left ear with a recommendation for Debrox drops, yet the MAR did not include an order for Debrox. A further resident with stage IV kidney disease, schizophrenia, and unspecified psychosis had two audiology assessments identifying impacted cerumen in both ears and recommending Debrox drops, but the MAR for both months reviewed did not show any Debrox orders. In an interview, the DON confirmed the facility failed to ensure these residents received proper treatment and services to maintain hearing abilities.
Failure to Provide Safe Tracheostomy and Respiratory Equipment Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory and tracheostomy care in accordance with its own policies and professional standards for multiple residents. One resident with COPD, anxiety, hip fracture, and a tracheostomy was receiving tracheostomy care, but the clinical record and care plan did not include the type and size of the tracheostomy tube as required. Observation showed a suction canister at the bedside dated over a month prior, half full of white/light yellow substance, and an RN confirmed there was no order or care plan specifying the trach tube type/size and that the suction canister had not been changed since the earlier date. Another resident with anemia, hypertension, and depression had physician orders to change oxygen tubing weekly, label it with the date, and apply and date a humidifying water bottle weekly. Observation found this resident sleeping in bed with oxygen equipment in use, but the oxygen bottle and tubing were not dated as ordered, which the RN verified. A third resident with diabetes, obstructive sleep apnea, and renal insufficiency had an order for CPAP with oxygen bleed and a care plan for oxygen at 4 L/min to the CPAP device; however, the CPAP mask was observed hanging off the bedside stand and not stored in a bag when not in use, contrary to facility policy. The RN confirmed the mask was not stored appropriately. A fourth resident with atrial fibrillation, heart failure, and hypertension had an order for CPAP with oxygen bleed at night and a care plan for compliance with CPAP use. Observation showed the CPAP mask on the bedside stand and not stored in a bag when not in use, again inconsistent with policy. A fifth resident with diabetes, obstructive sleep apnea, and COPD had an order for BiPAP at bedtime and a care plan including BiPAP settings and assistance with BiPAP. The treatment record showed BiPAP use earlier in the month, but during interview the BiPAP mask was found on the floor next to the bed. This resident reported trying to use the BiPAP but being unable to apply the mask independently, stated that staff did not come in often to assist with the mask, and reported discomfort with the current mask and not being offered alternative mask options. The DON confirmed the facility failed to provide tracheostomy care consistent with professional standards and failed to provide appropriate respiratory care and equipment maintenance for all five identified residents.
Failure to Employ a Qualified Food Service Director for Dietary Management
Penalty
Summary
The deficiency involves the facility’s failure to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for a continuous 12‑month period from February 2025 through January 2026. During an interview on 1/20/26 at approximately 9:00 a.m., the Dietary Supervisor (Employee E8) stated that she was not certified and that the facility’s Dietitian only worked two days per week in the facility and another two days in a different facility. In a separate interview on 1/20/26 at 11:20 a.m., the Nursing Home Administrator confirmed that the Registered Dietitian was not employed full time and only came to the facility two times per week, and further confirmed that the facility could not provide documented evidence that Dietary Supervisor Employee E8 met the qualifications required for the position of Food Service Director. These findings reflect noncompliance with Pa Code: 201.18(e)(6) regarding management requirements for the food and nutrition service. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Failure to Ensure Informed Consent for Binding Arbitration Agreements
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to make informed decisions regarding a binding arbitration agreement at admission. The facility’s admission packet included an “Alternative Dispute Resolution Agreement Between Resident and Facility” stating that, with the exception of payment disputes, all other disputes are governed by the agreement and that binding arbitration waives the right to a court trial, jury trial, trial by judge, and most appeals. For two residents, all admission documents, including this arbitration agreement, were signed by the residents themselves despite significant cognitive impairment documented at the time of admission. One resident was admitted with an admission assessment indicating alert and oriented to person only, a baseline care plan noting the resident could not communicate easily with staff and had cognitive needs, and a BIMS score of 3, indicating severe cognitive impairment. Another resident was admitted with an admission assessment also indicating alert and oriented to person only, a baseline care plan describing the resident as very confused, agitated, and yelling out, and a BIMS score of 2, also indicating severe cognitive impairment. In both cases, the residents personally signed the arbitration agreement, and there is no indication in the report that a representative was involved or that the agreement was explained in a form and manner the residents could understand. During interview, the Nursing Home Administrator and DON confirmed the facility failed to ensure residents understood the conditions of the binding arbitration agreement and that it was explained in a way, and in a language, they could understand for two of five sampled residents.
Infection Control and Food Safety Lapses Involving Wound Care, Ice Machines, and Personal Refrigerators
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices and food safety monitoring. For one resident with a stage four pressure ulcer, two LPNs performed a wound dressing change without wearing gowns, despite facility policy and a physician’s order for Enhanced Barrier Precautions (EBP) related to the presence of a wound and a catheter. During this dressing change, the resident, who had diagnoses including peripheral vascular disease, heart failure, and diabetes, was noted to have a cloth underpad on the bed that was soiled with wound drainage. After the dressing change was completed, the resident was rolled back onto the soiled underpad, and one LPN did not perform hand hygiene after removing soiled gloves before donning clean gloves. The Nursing Home Administrator and Director of Nursing confirmed that infection control practices were not maintained during this wound care. The facility also failed to maintain two ice machines in a sanitary manner. Policy required that ice machines and ice storage/distribution containers be used and maintained to assure a safe sanitary supply of ice. Observations of the A/E and B/C pantries showed each ice machine drainpipe coiled directly into the drain without an air gap, and used small heaters, paper towels, gloves, and wash basins stored underneath the ice machines. Debris such as gloves, paper towels, and dust was present within and around the drain and ice machine drainpipe. The Maintenance Director confirmed that the facility failed to maintain both ice machines in a sanitary condition. Additional deficiencies were identified in monitoring personal refrigerator temperatures and adherence to EBP. Two residents with diagnoses including heart failure, anxiety, depression, atrial fibrillation, and high blood pressure had personal refrigerators in their rooms, but the temperature logs for both refrigerators were last documented in October 2025, indicating the facility failed to properly monitor these temperatures. For another resident with a history of MDRO and a wound, a physician’s order required EBP every shift. During morning care that included personal hygiene, brief change, and dressing, a nurse aide provided high-contact care without wearing a gown. The nurse aide stated that staff did not have to wear a gown despite the EBP sign on the door, while the Infection Preventionist confirmed the resident was currently on EBP and required a gown during high-contact care activities.
Inaccessible Bathroom Call Bell Systems for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of a fully functioning resident call bell system in resident bathrooms and bathing areas. The facility’s policy dated 8/27/25 stated that each resident must be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor. ADA Standards for Accessible Design require that emergency call system pull cords be accessible to individuals with disabilities, reachable from a seated or fallen position, with operating mechanisms within a reach range of 15 to 48 inches from the floor. During the survey, the call systems in certain resident restrooms did not meet these accessibility expectations. On 1/20/26, observations revealed that the bathroom call lights for two residents, identified as R10 and R46, consisted only of a short chain of approximately three inches extending from the wall, with no attached string or call pendant. This configuration did not provide residents with an accessible means to activate the call system from typical positions of need. In a subsequent interview on 1/23/26, the Nursing Home Administrator and the DON confirmed that the facility failed to maintain a fully functioning resident call bell system that allows residents to call for staff assistance through a communication system relaying the call directly to staff or a centralized work area in two of five rooms reviewed. The deficiency was cited under 28 Pa Code 207.2(a) (Administrator’s responsibility) and 28 Pa Code 205.28(c)(1)(4) (Nurses station).
Failure to Ensure Continuity of Behavioral Health Therapy Services
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident received necessary behavioral health services as outlined in its Behavioral Health Services policy dated 8/27/25, which states that behavioral health services are to be provided as needed as part of an interdisciplinary, person-centered approach to care. The resident, identified as R33, was admitted on an unspecified date and had documented diagnoses including heart failure, anxiety, and depression per the MDS dated 1/14/26. The resident’s care plan noted a behavior problem involving requests for staff to purchase gift cards for an online friend and to take the resident to the store to buy gift cards, related to intellectual disability and poor safety awareness. During an interview, the resident reported that their Legal Guardian had taken their personal cell phone a few weeks prior and that they had not had their private therapy call for two weeks. The DON confirmed that the resident had a standing private therapy call every Monday at 1:00 p.m. for as long as the DON had worked at the facility, and that the resident had missed two therapy appointments because the facility did not have the therapist’s name or phone number after the Legal Guardian took the phone for repairs and did not return it. Further interview with the DON revealed that the facility did not have the therapist’s contact information documented elsewhere and had not contacted the Legal Guardian to obtain it so that the resident’s weekly therapy calls could continue using a facility phone. The DON confirmed that the resident missed two therapy treatment calls and that the facility failed to ensure the resident received appropriate behavioral health services to maintain the highest practicable well-being.
Failure to Provide Required Two-Person Assistance and Positioning Safety During Incontinence Care
Penalty
Summary
The facility failed to protect a resident from neglect when a nurse aide provided incontinence care alone to a resident who required the assistance of two staff for bed mobility. The resident had diagnoses including Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right hip ORIF, and the MDS documented that the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning in bed. Multiple staff, including nurse aides and an LPN, confirmed that substantial/maximal assistance meant two staff were required to perform the task. The resident also had an order for bilateral enabler bars for positioning. A progress note documented that the nurse was called to the resident’s room early in the morning and found the resident on the floor on her left side. Facility documentation showed that the nurse aide had entered the room alone to provide incontinence care, turned the resident onto her side, and then left the resident in that position while going into the bathroom to wet a towel, during which time the resident rolled out of bed. The documentation did not show that the resident was protected from neglect, did not address whether the ordered enabler bars were in use, and indicated that the physician was called and X‑rays were ordered to rule out possible injury or fracture after the resident complained of pain. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to protect the resident from neglect, resulting in pain and the need for X‑rays.
Failure to Promptly Investigate Fall and Rule Out Neglect After Resident Rolled From Bed
Penalty
Summary
The deficiency involves the facility’s failure to promptly conduct a thorough investigation into a fall incident to rule out neglect and to complete and submit the investigation results to the State Survey Agency within five working days. Facility policies on Abuse and Neglect and on Reporting and Investigating Abuse, Neglect, Exploitation or Misappropriation require that all reports of possible abuse, neglect, and injuries of unknown origin be thoroughly investigated, documented, and reported to appropriate agencies. Resident R11 had diagnoses including Alzheimer’s dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right ORIF, and the most recent MDS showed the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning in bed. Multiple staff (NAs and an LPN) confirmed that substantial/maximal assistance meant two staff were required to perform the task. Clinical record review showed an order for bilateral enabler bars for positioning. A progress note documented that at 5:10 a.m. the nurse was called to the resident’s room and found the resident on the floor on her left side. Facility documentation indicated that a single NA entered the room alone to provide incontinence care, turned the resident onto her side, noted a bowel movement, and then left the resident on her side while going into the bathroom to wet a towel, during which time the resident rolled out of bed. The documentation did not indicate whether the enabler bar was in use at the time of the fall, nor did the facility-provided documentation show that the facility ensured the resident was protected from neglect while the physician was called and X-rays were ordered after the resident complained of pain. In an interview, the Nursing Home Administrator and DON confirmed the facility failed to promptly conduct a thorough investigation to rule out neglect and to submit the completed investigation results to the State Survey Agency within the required timeframe.
Failure to Provide Required Two-Person Assistance During Incontinence Care Leading to Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for one resident, identified as R11. The resident was admitted with multiple diagnoses including Alzheimer's dementia, obstructive uropathy, glaucoma, obesity, lack of coordination, and a history of right hip ORIF. An MDS dated 10/24/25 documented that these diagnoses remained current, and another MDS indicated that the resident required total assistance of two staff for bed mobility and substantial/maximal assistance for turning left and right in bed. Multiple staff interviews confirmed that substantial/maximal assistance meant two staff were required to perform the task. The resident also had an order dated 1/16/19 for bilateral enabler bars for positioning. A progress note dated 8/22/25 documented that at 5:10 a.m. a nurse was called to the resident’s room and found the resident on the floor on her left side. Facility documentation showed that a nurse aide (Employee E9) had entered the room alone to provide incontinence care, turned the resident onto her side, and then left the resident in that position while going into the bathroom to wet a towel. During this time, the resident rolled out of bed and fell. The documentation did not state whether the ordered enabler bars were in use at the time of the fall, and there was no documented investigation into why the nurse aide attempted to provide care alone when the resident had been identified as requiring the assistance of two staff. The Nursing Home Administrator and DON confirmed that the facility failed to ensure the resident received proper assistance and supervision, resulting in pain and the need for X‑rays to rule out injury or fractures.
Failure to Follow Venous Port and TPN Administration Policies
Penalty
Summary
The facility failed to follow its policies for care of an implanted venous port for one resident. The facility’s policy required that when a port is accessed, the needle and access site be covered with a transparent sterile dressing labeled with the date, time, and initials of the person performing the procedure. One resident with COPD, heart failure, and hypertension had a physician order to change the venous port dressing weekly, but the baseline care plan did not include instructions for care and management of the venous port. During observation, the resident was seen in bed with a venous port in the left upper chest, and the dressing covering the port was not labeled or dated as required. An RN confirmed that the dressing lacked the required labeling. The facility also failed to properly manage TPN administration for another resident. Facility policy required nursing staff to check the TPN label against the physician order, verify pump delivery settings, and document all. The resident, who had atrial fibrillation, heart failure, and hypertension, had specific physician orders for TPN infusion rates and times. The resident’s care plan noted potential for fluid volume changes related to TPN as the primary hydration source. During observation, the resident was lying in bed with TPN actively infusing via an IV pump, but the TPN bag did not have verification checks of the TPN content, a date it was hung, or the initials of the person who administered it, as required. An RN confirmed the absence of these required verifications and labeling, and the DON acknowledged the failures related to both the venous port and TPN care.
Failure to Provide Trauma-Informed Care for Identified Trauma Survivors
Penalty
Summary
The facility failed to provide trauma-informed care to residents identified as trauma survivors, as required by its policy "Trauma Informed Care and Culturally Competent Care" dated 8/27/25. This policy states that the purpose is to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident R7’s admission record showed admission to the facility and a Minimum Data Set (MDS) dated 11/10/25 documented diagnoses of PTSD, dementia, and high blood pressure, with Section I6100 indicating PTSD is present. Resident R7’s current care plan noted use of psychotropic medications related to vascular dementia and PTSD, but the care plan did not include a trauma-informed care plan addressing PTSD or identifying potential triggers and strategies to prevent re-traumatization. The DON confirmed that the care plan lacked a trauma-informed component addressing PTSD and triggers. Resident R33’s admission record showed admission to the facility and an MDS documenting diagnoses of anemia, heart failure, and high blood pressure. During an interview, Resident R33’s legal guardian reported that the resident had a history of being victimized by predators involving cellular phone usage, indicating a past trauma. Review of Resident R33’s care plan and clinical record did not identify this traumatic history. The DON stated that the facility was unaware of this trauma history and did not have a trauma-informed care plan in place to address it or to identify potential triggers and prevention for re-traumatization. The Nursing Home Administrator confirmed that the facility failed to provide trauma survivors with trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization for two of four residents reviewed (R7 and R33).
Failure to Implement Ordered Bed Rails and Complete Bed Rail Assessment
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to conduct accurate assessments and ensure appropriate use of bed rails for one resident. Facility policy dated 8/27/25 stated that bed rail use is prohibited unless specific criteria are met, including attempts to use alternatives, an interdisciplinary evaluation, resident assessment, and informed consent. The resident involved was admitted with diagnoses including schizophrenia, bipolar disorder, and paralytic syndrome. A physician order dated 1/19/26 directed the use of bilateral grab bars on the bed to assist the resident with self-positioning, and the resident’s care plan dated the same day also specified bilateral grab bars. Despite these orders and care plan directives, an observation on 1/20/26 showed that the resident’s bed did not have the ordered bilateral grab bars. Review of the resident’s Enabler Bar assessment indicated that therapy had recommended bilateral grab bars, but the nursing portion of the assessment was left blank. During an interview, the resident reported that the facility had promised to provide side rails to assist with self-positioning in bed and that they still had not been provided. A registered nurse confirmed that the bed lacked the ordered bilateral grab bars and acknowledged that the facility failed to conduct accurate assessments to ensure bedrails were used to meet the resident’s needs and to address the risks associated with bedrail usage.
Failure to Administer Ordered Anti-Anxiety Medication as Prescribed
Penalty
Summary
Surveyors identified a deficiency in ensuring residents are free from significant medication errors when a resident with COPD, heart failure, and hypertension did not receive a prescribed anti-anxiety medication as ordered. The facility’s policy defined a medication error to include omission of an ordered drug. The resident was admitted with a physician’s order for Xanax 0.5 mg three times daily for anxiety, but review of the MAR showed the medication was not administered as ordered. A provider note documented that upon initial admission the resident did not have their medications at the facility while awaiting pharmacy, and the resident was sent back to the hospital the same evening with crushing chest pain and tachycardia, treated, and then returned to the facility later that night. On subsequent observation, the resident was noted to be complaining of nausea and feeling shaky. During an interview, an RN stated that the resident had not received the ordered Xanax as prescribed and expressed the belief that the resident was experiencing withdrawal symptoms after a long history of receiving Xanax three times daily. The resident reported having received the Xanax only twice since being at the facility. The DON later confirmed that the facility failed to ensure residents were free from significant medication errors for this resident.
Improper Storage and Dating of Opened Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to improper storage and labeling of medications on one of two medication carts (the A side medication cart). Review of the facility’s “Storage of Medications” policy dated 8/27/25 indicated that all drugs and biologicals are to be stored in a safe, secure, and orderly manner. During an observation on 1/20/26 at 2:58 p.m., surveyors found multiple medications on the A side cart that had been opened and were not dated as required, including budesonide inhalation suspension, two boxes of ipratropium bromide, Trelegy Ellipta, and a Lantus insulin pen. At the time of the observation, an RN (Employee E2) confirmed that these medications were opened and not dated as required, and at 3:00 p.m. the Director of Nursing confirmed that the facility failed to store medications properly on this medication cart. No specific residents or their medical histories were mentioned in the report, and the deficiency focused solely on the handling and storage of these medications on the A side medication cart.
Failure to Provide Required Bed-Hold Notices at Time of Hospital Transfers
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice of the facility’s bed-hold policy at the time of transfer to the hospital, as required by 42 CFR §483.15(d) and the facility’s own bed-hold policy. Federal regulation requires two written notices: one at or before admission and another at the time of transfer (or within 24 hours for emergency transfers), explaining the duration of any bed-hold, reserve bed payment policy, and return-to-bed provisions. The facility’s policy dated 8/27/25 stated that residents or their representatives would be informed of the bed-hold and return policy prior to transfers and therapeutic leaves. Surveyors determined, through policy review, clinical record review, and staff interviews, that this requirement was not met for five of six residents reviewed for hospitalization. For one resident with coronary artery disease, diabetes, and hemiplegia, a progress note documented that the resident was sent to the hospital per MD order and that the spouse was made aware, but the clinical record contained no notation that written bed-hold information was provided at the time of transfer. The electronic medical record’s Forms section also lacked a completed Transfer/Discharge/Bed Hold Form for this hospital discharge. Another resident with CAD, diabetes, and a seizure disorder had multiple documented hospital transfers for pneumonia, transfer from dialysis to the hospital, lethargy and change in mental status, and worsening condition requiring ER evaluation. In each of these instances, progress notes showed that family or POA were notified of the transfers, but there was no documentation that written bed-hold notices were provided, and no corresponding Transfer/Discharge/Bed Hold Forms were found in the Forms section. A resident with COPD, CKD, hypertension, and a history of stroke was transferred to the ED for a possible neurologic event after slurred speech and tremors were observed during a video assessment; the record lacked any notation of written bed-hold notification and no Transfer/Discharge/Bed Hold Form was present. Another resident with COPD, heart failure, and arthritis requested hospital transfer due to increased lower leg swelling related to cellulitis; the MD ordered the transfer and EMS transported the resident, but again there was no documentation of written bed-hold notice or a completed Transfer/Discharge/Bed Hold Form. A further resident with ALS, hypertension, and a seizure disorder was sent to the hospital after a hospice RN noted significantly decreased respirations and apnea and contacted the resident’s husband, who requested hospital evaluation. For this transfer, a Transfer/Discharge/Bed Hold Form existed but was incomplete, with the section documenting the method of resident or representative notification left blank. In an interview, the Nursing Home Administrator and DON confirmed that the facility did not ensure written bed-hold notice at the time of transfer for five of six residents reviewed for hospitalization.
Inaccurate MDS Coding for Non-Invasive Ventilator Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the actual use of non-invasive mechanical ventilation for two residents. For one resident with diagnoses including diabetes, obstructive sleep apnea, and renal insufficiency, the MDS section O0110 G1 documented that a non-invasive mechanical ventilator was not in use. However, the clinical record showed a physician’s order for CPAP with 4 liters of oxygen every evening and night for obstructive sleep apnea, a care plan specifying oxygen at 4 liters per minute to the CPAP device, and a treatment administration record indicating BiPAP use over a specified period. During an interview, this resident reported using the CPAP machine every night, and the Director of Nursing confirmed that the MDS did not indicate CPAP or BiPAP use as required. For the second resident, who had diagnoses of diabetes, obstructive sleep apnea, and COPD, the MDS section O0110 G1 also documented that a non-invasive mechanical ventilator was not in use. In contrast, the clinical record contained a physician’s order for BiPAP use at bedtime for obstructive sleep apnea, a care plan describing BiPAP settings and oxygen bleed, and a treatment administration record showing BiPAP administration over a specified period. During an interview, the resident’s BiPAP mask was observed on the floor next to the bed, and the resident stated she tried to use her BiPAP but could not put the mask on herself and that nursing staff did not come in often to assist with applying the mask. The Director of Nursing confirmed that the facility failed to ensure MDS assessments accurately reflected these residents’ status, in violation of 28 Pa. Code 211.12(c)(d)(5) Nursing services.
Inaccurate BIMS Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medical records were complete and accurately documented for four of nine sampled residents, specifically in the completion of the Brief Interview for Mental Status (BIMS) section of the Minimum Data Set (MDS). The Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual requires that Section C0100 be coded as 0 only if a resident is rarely/never understood, and coded as 1 with the BIMS completed if the resident is at least sometimes understood. Review of prior BIMS scores for these residents showed that they had consistently scored in the cognitively intact or mildly to moderately impaired ranges, with scores between 11 and 15 on multiple assessments throughout the previous year. On 1/19/26, an LPN (Employee E6) completed BIMS assessments for four residents and documented each as rarely/never understood, coding them as 0.0, indicating severe impairment, despite their prior documented BIMS scores of 11–15. Specifically, Resident R8 had prior BIMS scores of 14 and 15; Resident R18 had repeated scores of 15; Resident R46 had scores ranging from 11 to 15; and Resident R57 had repeated scores of 15. During an interview, the LPN confirmed that these residents were alert and oriented and acknowledged that the BIMS assessments completed on that date were done incorrectly. In a subsequent interview, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that medical records for these residents were complete and accurately documented, in violation of 28 Pa. Code 211.5(f)(g)(h) regarding clinical records.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for licensed practical nurses (LPNs) as mandated by regulation. Specifically, on two days during the reviewed period, the facility did not provide at least one LPN per 25 residents on the day shift, and on two separate days, did not provide at least one LPN per 40 residents on the night shift. This was determined through a review of the facility's census data and nursing time schedules, which showed that the actual LPN hours worked were less than the required hours for the number of residents present. The Nursing Home Administrator confirmed during an interview that the minimum LPN staffing requirements were not met on these days. No information was provided regarding the specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. --- Date of POC Updated to reflect reason for previous rejection: 1. The facility cannot correct that the LPN staffing ratio was not met on one LPN per 25 residents on the morning shift on two of five days (9/27/25 and 9/28/25) and one LPN per 40 residents on the night shift on two of five days (9/25/25, and 9/30/25). There were no adverse effects to residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. A Daily staffing meeting with scheduler will be held by administration to monitor staffing ratios. Staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off duty personnel or call extra support staff. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Timely Return Resident Personal Funds After Discharge or Death
Penalty
Summary
The facility failed to comply with federal and state regulations regarding the timely return of resident personal funds following discharge or death. Specifically, for two residents, the facility did not return the funds within the required 30-day period. One resident, who had diagnoses including cancer, high blood pressure, and diabetes, was admitted and subsequently passed away. Despite multiple inquiries from the family, the responsible party had not received the refund of $385.00 as of several months after the resident's death. The business office confirmed that billing is managed by a third-party company and acknowledged the delay in refunding the personal funds. A second resident, with medical conditions including diabetes, cerebral infarction, and high blood pressure, also passed away while at the facility. The responsible party for this resident was due a refund of $2,530.00. Although the business office stated that the refund was processed by the third-party company, the facility was unable to provide documentation, such as a copy of the check or a bank statement, to confirm that the funds were actually returned. Staff interviews confirmed that the personal funds for both residents were not refunded to the families within the required timeframe.
Plan Of Correction
The facility cannot correct the past. Resident refunds for R1 who expired 5/5/25 and R2 who expired 5/21/25. The facility will ensure all resident funds for residents who expired/discharged are refunded within the 30-day requirement. Business Office Manager and Wellsky Representative will be re-educated by the Administrator on ensuring resident funds are refunded within 30 days of discharge/expiration. Daily Business Office Meetings will be held by administration to review discharges and confirm if refund has been processed by the facility and Wellsky. The Nursing Home Administrator/designee will audit resident fund accounts for discharges daily for one month, then monthly for 3 months to ensure requirements are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing levels as mandated by regulation, which specifies a minimum of one nurse aide per 10 residents during the day, one per 11 residents during the evening, and one per 15 residents overnight. Review of nursing time schedules, census data, and deployment sheets revealed that, over a 21-day period, the facility did not provide the required number of nurse aides on 20 days. Specific shortfalls were documented for both day and evening shifts, as well as overnight shifts, with the number of nurse aides consistently falling below the required ratios for the resident census on multiple occasions. During an interview, the DON confirmed the facility's failure to provide the mandated minimum nurse aide coverage on these days. The report details the exact census and staffing numbers for each shift, showing repeated instances where the number of nurse aides scheduled was insufficient according to the regulatory requirements. No information is provided regarding the impact on individual residents or their medical conditions at the time of the deficiency.
Plan Of Correction
The facility cannot correct that the nurse aide staffing ratio was not met on the day shift on seventeen of twenty-one days (8/26/25 thru 9/15/2025). The ratio was one NA per 11 residents on the evening shift on twelve of twenty-one days (8/29/25 thru 9/1/25 and 9/5/25 thru 9/15/25). On the night shift, the ratio was one NA per 15 residents on six of twenty-one days (9/6, 9/9, 9/10, 9/12, 9/13, and 9/15/25). These staffing issues occurred as required. There were no adverse effects to the residents on the identified dates. The facility will ensure that staffing ratios are met every shift. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. A daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler or designee will call off-duty facility staff and will utilize external staffing support resources. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
Facility administrative staff failed to provide the required minimum of 3.2 hours of direct general nursing care per resident in a 24-hour period on 13 out of 21 reviewed days. Review of nursing time schedules from 8/26/25 through 9/15/25 showed that on multiple dates, the provided nursing care hours per patient day (PPD) fell below the regulatory minimum, with PPDs ranging from 2.43 to 3.15. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the facility did not meet the mandated nursing care hours on the identified dates. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facility cannot correct that the PPDs were not met on 8/29, 8/30, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/12, 9/13, 9/14, and 9/15. There were no adverse effects to the residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring PPDs are met for the day. A daily staffing meeting will be held by administration to monitor PPD levels. Nursing supervisors will monitor on weekends. If the facility is projected to not meet PPD, the scheduler/or designee will call off-duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure PPDs are met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Protect Residents from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, resulting in multiple incidents involving a resident with a known history of sexually inappropriate behavior. This resident, who was a registered sexual offender with severe cognitive impairment and diagnoses including dementia and a history of stroke, was documented to have engaged in inappropriate sexual contact and touching of non-consenting residents. Despite the resident's care plan identifying the risk and outlining interventions such as monitoring whereabouts and providing counseling, there was no evidence that these interventions were consistently implemented or documented. Staff interviews and clinical records revealed that the resident repeatedly wandered into other residents' rooms and engaged in inappropriate behaviors, including touching, kissing, and fondling other residents, some of whom were severely cognitively impaired or physically unable to defend themselves. Multiple staff members and residents reported ongoing incidents of inappropriate sexual behavior by the resident, with some staff expressing frustration that their concerns were dismissed or not acted upon by facility management. Staff accounts indicated that the behavior was widely known throughout the facility, with some staff being told by management that such actions were permissible or not considered inappropriate. There were also reports that management failed to investigate or take action on complaints, and that the resident's behavior had been escalating over several months. Documentation in the clinical records for affected residents did not reflect that concerns were reviewed or addressed by clinicians, and there was a lack of timely updates to care plans or implementation of effective interventions to prevent further incidents. The deficiency resulted in at least five residents being subjected to unwanted sexual contact or harassment, including one incident where a resident with severe cognitive impairment was found in a vulnerable state in an unoccupied room with the offending resident. Observations and interviews confirmed that the resident's actions were non-consensual and caused distress to the victims, some of whom were unable to communicate or defend themselves. The facility's failure to implement and document effective interventions, respond appropriately to staff and resident reports, and protect residents from abuse created an Immediate Jeopardy situation.
Removal Plan
- Resident R1 will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.
- Facility will provide 1:1 to Resident R1 to ensure safety of Residents R3, R4, R5, and R6 from resident initiated sexual abuse.
- Resident R1 and R2 will be separated.
- Resident R2 will be assessed for injuries and sent to the hospital for further evaluation.
- Current female residents who are cognitively intact will be interviewed. Current female residents who are cognitively impaired will have a skin assessment completed.
- All staff will be educated on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Resident R1 will remain on 1:1.
- Resident R1 will be evaluated by psychiatry services in conjunction with the facility medical director.
- Audits will be completed on female residents who are cognitively intact to ensure residents safety. These audits will be completed by Social Services or designee.
- Audits will be completed on female residents who are cognitively impaired to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator.
- Affected residents will be seen by facility contracted psychiatry/psychology provider if they request to do so to address their emotional trauma.
- This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Report Alleged Sexual Abuse of Multiple Residents
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of abuse, neglect, or theft for four residents. Despite state law and facility policy requiring immediate reporting of suspected abuse to appropriate authorities, including the state survey agency, local ombudsman, and law enforcement, the facility did not report multiple incidents of alleged sexual abuse involving a resident with a known history of sexually inappropriate behavior. Staff interviews and documentation revealed that the behaviors of this resident, which included touching, kissing, and other inappropriate contact with non-consenting residents, were widely known among staff and had been ongoing for months. Specific incidents included a resident's family reporting that their relative had been harassed and touched by the male resident on multiple occasions, with the facility failing to report this to the state survey agency. Staff members described witnessing the resident being sexually inappropriate with several other residents, including those who were cognitively impaired and unable to defend themselves. Despite these observations and verbal reports to facility administration, no formal reports were made to the required authorities as mandated by law and facility policy. Interviews with staff further confirmed that management was aware of the ongoing behaviors but did not take appropriate action to report the incidents. Some staff were told by administration that the behaviors were not inappropriate or were dismissed with comments minimizing the seriousness of the incidents. The failure to report these allegations resulted in a situation where residents, including those with severe cognitive impairments and limited ability to communicate, were left unprotected from further abuse.
Removal Plan
- Resident R1 was placed on 1:1 supervision and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.
- Residents R3, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1.
- Resident R1 and R2 were immediately separated.
- Resident R2 was assessed for injuries and no injuries noted.
- Resident R2 was sent to the hospital for further evaluation and remains at hospital.
- Current female residents who were cognitively intact were interviewed.
- Current female residents who were cognitively impaired had a skin assessment completed.
- Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Resident R1 will remain on 1:1.
- Resident R1 will be evaluated by psychiatry services in conjunction with the facility medical director.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively intact daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively impaired daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator.
- Affected residents will be seen by facility contracted psychiatry/psychology provider if they request to do so to address their emotional trauma.
- This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Supervise Resident with Sexually Inappropriate Behaviors Creates Immediate Jeopardy
Penalty
Summary
The facility failed to provide necessary supervision for a resident with a known history of sexually inappropriate behaviors, resulting in an immediate jeopardy situation for multiple residents. The resident in question had severe cognitive impairment, a history of sexual offenses, and was identified as a registered sexual offender. Despite these known risks, the care plan interventions designed to monitor and manage the resident's behaviors were not implemented or documented as completed. Staff interviews and clinical record reviews revealed that the resident frequently wandered into other residents' rooms, engaged in inappropriate touching, and was not consistently monitored as required by the care plan. Multiple incidents were reported where the resident was observed engaging in sexually inappropriate behaviors with other residents, many of whom were cognitively impaired or physically unable to defend themselves. Staff and resident interviews indicated that these behaviors were ongoing and widely known among staff, yet there was a lack of formal reporting and documentation. Staff described instances of the resident touching, kissing, and following female residents, with some staff expressing discomfort and concern over the lack of action taken by facility management. In several cases, staff reported being discouraged from filing incident reports or were told by management that such behaviors were permissible among older adults. The facility's failure to follow its own policies for behavior management and resident supervision, as well as the lack of consistent documentation and reporting, allowed the resident's inappropriate behaviors to continue unchecked. This resulted in direct harm and distress to at least five residents, including incidents where residents were found in vulnerable positions and unable to recall or defend against the inappropriate actions. The deficiency was further compounded by the lack of timely intervention, inadequate monitoring, and insufficient staff education on handling residents with sexually aggressive behaviors.
Removal Plan
- Resident R1 is placed on 1:1 supervision and continues to remain on 1:1 supervision.
- Resident R1 care plan will be updated to individualized interventions regarding supervision based on his sex offender status.
- Resident R1 behavior is monitored by the 1:1 supervisor.
- Facility will identify and address any allegations of inappropriate touching/behaviors via facility policy and investigative process.
- Follow-up and follow-through of interventions will be monitored by the Director of Nursing and Nursing Home Administrator.
- Any affected residents identified, reporting will be completed, notifications will be made, and support will be offered to residents and family.
- Staff and consultants' failure to report any allegations timely will be addressed through the disciplinary process up to and including termination of employment or contracted services.
- An audit on all female residents will be completed by the Director of Nursing, or designee, to identify any documented inappropriate touching or sexually inappropriate behaviors.
- If any are found, facility policy and protocol of investigation, notification, and reporting will be followed.
- Current female residents who are cognitively intact are being interviewed five days per week.
- Current female residents who are cognitively impaired are having a complete skin assessment five days per week.
- With resident remaining on 1:1 supervision, female residents are being kept safe from Resident R1 inappropriate touching/sexual behaviors.
- Education was completed with all staff on Abuse/Neglect, Reporting of Incident and Accidents, and providing direct supervision with Resident R1 by the Director of Nursing.
- Education of all new hires will include supervision of handling residents with history of sexual aggression and behaviors. This will be updated into the new hire packet.
- Mandatory education will be sent to all staff to inform staff of updates to Resident R1 care plan interventions to successfully redirect sexual aggression and behaviors.
- Resident R1 will remain on 1:1.
- Resident R1 is being followed by facility contracted psychiatric provider in conjunction with the facility medical director.
- Referrals are being made to alternate care facilities that can better meet Resident R1's needs.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively intact daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- While Resident R1 remains in the facility, audits will be completed on female residents who are cognitively impaired daily for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.
- An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator or designee to address supervision of handling residents with sexual aggression and behaviors, including adding of this education to new hire orientation.
- This plan of correction will be monitored through facility Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Address and Document Resident and Staff Grievances Without Retaliation
Penalty
Summary
The facility failed to honor residents' and staff members' rights to voice grievances without discrimination or reprisal, as required by federal and state regulations. Review of facility documentation and interviews revealed that grievances and concerns submitted by both residents and staff were not properly documented, investigated, or followed up on. Specifically, two residents reported filing both verbal and written grievances regarding aggressive behavior by another resident, but no action was taken, and they did not receive written confirmation of any investigation or resolution. Additionally, these residents reported being threatened by staff to stop filing grievances and noted that grievance forms were sometimes unavailable, forcing them to submit concerns verbally and compromising their anonymity. Staff interviews further revealed that employees who attempted to file grievances were threatened with job loss if they continued, leading them to stop submitting grievances on behalf of residents out of fear of retaliation. The facility's grievance log for the past six months showed only a few grievances, with some being misclassified or not properly investigated. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to address concerns raised by staff and residents.
Failure to Protect Residents and Prevent Retaliation
Penalty
Summary
Staff interviews revealed that a male resident was observed wandering into female residents' rooms and engaging in inappropriate touching. Multiple staff members, including LPNs and CNAs, reported witnessing this behavior and having to redirect the male resident away from female residents. Staff also reported that families had inquired about the male resident entering their family members' rooms. Despite these observations and concerns, staff were instructed by facility management not to discuss the incidents, not to talk to families, and not to file grievances. Some staff reported being threatened with termination if they spoke about the situation or reported it. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to protect female residents from the male resident's wandering and inappropriate behavior. There were no grievances or investigations available to indicate that the facility was aware of or addressing the situation. Additionally, staff did not feel safe from retaliation, as they were threatened with termination if they discussed the incidents, filed grievances, or communicated with families about the male resident's behavior.
Failure to Investigate Allegations of Abuse and Inappropriate Sexual Behavior
Penalty
Summary
The facility failed to implement its policies and procedures for investigating allegations of abuse involving four residents. Despite having a policy that requires all allegations to be thoroughly investigated, the facility did not conduct comprehensive interviews or document investigations after multiple reports of inappropriate sexual behavior by a resident with a known history of such actions. For example, only a subset of nurse aides and licensed nurses who provided care to one of the affected residents were interviewed, and there was no evidence of interviews or observations with other potentially affected residents. Multiple staff members reported witnessing or hearing about the resident's sexually inappropriate behaviors, including touching, kissing, and entering other residents' rooms without consent. These behaviors were reported to facility administration and the DON, but the facility's incident logs did not include documentation or investigations related to these reports. Staff interviews revealed that the behaviors were ongoing, widely known among staff, and that some staff were told by management to disregard or minimize the incidents. The clinical records and incident lists reviewed showed a lack of documentation for several reported incidents involving different residents, including those who were unable to communicate. Staff expressed concerns that the administration was aware of the behaviors for months but failed to act according to policy. The deficiency resulted in a resident with a known history of sexually inappropriate behavior continuing to touch non-consenting residents without proper investigation or intervention.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to protect residents from resident-to-resident sexual abuse, as evidenced by a resident with a known history of sexually inappropriate behavior inappropriately touching a non-consenting resident. This incident resulted in Immediate Jeopardy for five out of 67 residents. The facility's job descriptions for both the NHA and DON require them to manage the facility and nursing services in accordance with federal, state, and local regulations to ensure the highest degree of quality care and resident safety at all times. Despite these responsibilities, the NHA and DON confirmed during interviews that they did not effectively manage the facility to prevent the incident of sexual abuse. The failure to follow established policies and regulations directly led to the occurrence of resident-to-resident sexual abuse, impacting multiple residents and violating state regulatory requirements for management and nursing services.
Failure to Prevent and Address Repeated Sexual Abuse Incidents
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies related to sexual abuse. Despite having a QAPI policy and a plan of correction from a previous survey, the facility did not ensure that concerns related to sexual abuse were properly identified or addressed. During the survey, it was found that multiple residents experienced incidents involving inappropriate sexual contact or behavior from another resident. Specific incidents included a resident being found in bed with her pants down and a perpetrator standing over her, another resident's guardian reporting unwanted touching and disturbances in her room, and additional residents being subjected to inappropriate physical contact in common areas. Staff interviews confirmed that these incidents were not effectively managed or prevented by the facility's quality assurance systems. The repeated nature of these incidents, affecting five residents, demonstrates that the facility's QAPI committee did not adequately monitor, evaluate, or correct the issues related to sexual abuse. The documentation review showed that the facility had previously identified similar problems and developed corrective actions, but these measures were not successful in preventing recurrence. The failure to implement and sustain effective quality assurance processes allowed the same types of abuse to continue, as confirmed by both staff and guardian interviews during the survey.
Incomplete Posting of Grievance and Advocacy Contact Information
Penalty
Summary
The facility failed to post complete and current contact information for the Grievance Officer, Adult Protective Services, and the Office of the State Long-Term Care Ombudsman program in three nursing units, specifically in the Bird Room (main area near the dining room), Solarium C, and Solarium E. Observations conducted over two days revealed that the Bird Room lacked the address and email contact information for Adult Protective Services and the Ombudsman program, as well as for the facility's Grievance Officer. Additionally, Solarium C and Solarium E did not display the correct contact information for the Grievance Officer. During an interview, the Nursing Home Administrator and DON confirmed these deficiencies, acknowledging the absence of required postings in the identified common areas.
Failure to Address Resident Romantic Relationships in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing the needs of residents involved in consensual romantic relationships. Specifically, for four residents with varying degrees of cognitive impairment and complex medical histories—including dementia, Alzheimer's, Parkinsonism, bipolar disorder, heart failure, and other conditions—there was no evidence in their care plans that their desire or involvement in romantic relationships with other residents was assessed or addressed. Documentation showed that while some guardians were informed and expressed no objection to the relationships, the care plans did not reflect any interventions, objectives, or timetables related to supporting or monitoring these relationships as part of the residents' psychosocial needs. Review of clinical records, progress notes, and staff interviews confirmed that the facility's interdisciplinary care planning team did not include the residents' romantic relationships in their care plans, despite clear evidence of such relationships and, in some cases, guardian awareness and approval. The deficiency was acknowledged by facility leadership, who confirmed that care plans for these residents did not address this aspect of their care, as required by facility policy and regulatory standards.
Failure to Address and Monitor Hypersexual Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to provide necessary services to meet the psychosocial needs of a resident diagnosed with severe dementia and a history of hypersexual behaviors, resulting in resident-to-resident sexual abuse. The resident, who was a registered sexual offender with a BIMS score indicating severe cognitive impairment, exhibited sexually inappropriate behaviors as early as March, including kissing, touching, and wandering into other residents' rooms. Despite these behaviors being observed and reported by multiple staff members, the facility did not initiate a care plan addressing the potential for sexual inappropriateness until several months later. Behavior monitoring for the resident was limited and did not specifically include sexually inappropriate behaviors, focusing instead on general mood and adjustment issues. Documentation of behavior monitoring was infrequent, with only three recorded instances over approximately six months, and did not reflect the frequency or severity of the inappropriate behaviors described by staff. Additionally, the resident's known relationship with another resident was not care planned, and there was a lack of timely documentation regarding notification or acceptance of this relationship by responsible parties. Staff interviews revealed that the resident's sexually inappropriate behaviors were widely known among employees, with reports of daily incidents involving multiple residents, including those unable to communicate. Despite this, interventions and care planning were delayed, and there was insufficient monitoring and documentation of the resident's behaviors. The facility administrator confirmed these failures, acknowledging that the necessary services to address the resident's psychosocial needs were not provided, resulting in the occurrence of resident-to-resident sexual abuse.
Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum nurse aide staffing levels as mandated by regulation. Specifically, staffing documents reviewed for the period from 7/3/25 through 7/7/25 showed that the facility did not provide at least one nurse aide per 10 residents during the day shift on all five days reviewed, with actual nurse aide hours consistently falling short of the required hours. Additionally, on one night shift, the facility did not provide the required one nurse aide per 15 residents, with actual hours again below the mandated level. These findings were confirmed by the Director of Nursing during an interview, who acknowledged the facility's failure to meet the nurse aide staffing requirements on the identified shifts.
Plan Of Correction
1. The facility cannot correct that the nurse aide staffing ratio was not met on the day shift on five of five days (7/3/25 through 7/7/25) and one NA per 15 residents on the night shift on one of five days (7/4/25) as required. There were no adverse effects to the residents on the identified dates. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the nursing scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. A daily staffing meeting will be held by administration to monitor staffing ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/designee will call off-duty facility staff and will utilize external staffing support resources. 4. The Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum LPN Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for LPNs on multiple shifts over several days. Specifically, the facility did not provide at least one LPN per 25 residents during the day shift on four out of five days, one LPN per 30 residents during the evening shift on two out of five days, and one LPN per 40 residents during the night shift on three out of five days. Review of the facility's census data and nursing time schedules confirmed that the actual LPN hours worked were consistently below the required hours for each shift on the identified days. The Director of Nursing confirmed during an interview that the facility did not meet the minimum LPN staffing requirements on these occasions.
Plan Of Correction
1. The facility cannot correct that the LPN staffing ratio was not met on day shift on four of five days (7/4/25 through 7/7/25), one LPN per 30 residents on the evening shift on two of five days (7/5/25 and 7/6/25), and one LPN per 40 residents on the night shift on three of five days (7/4/25 through 7/6/25). There were no adverse effects to residents on the identified date. 2. The facility will ensure that staffing ratios are met every shift. 3. Nursing administration and the scheduler will be re-educated by the Nursing Home Administrator/designee on ensuring staffing ratios are met each shift. Daily shift staffing ratios will be reviewed at Standup and Stand down. The Nursing Supervisors will review shift staffing ratios on the weekends. If the facility projects not to meet staffing ratios on a shift, nursing administration/designee will be responsible to call off-duty personnel or call extra support staff to assist. 4. The Nursing Home Administrator/designee will audit staffing daily for four weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R29, was free from sexual abuse, resulting in the resident contracting a sexually transmitted infection (STI). The deficiency was identified through a review of facility policy, clinical records, observations, and interviews with residents and staff. Resident R29, who was admitted to the facility with severe cognitive impairment and a court-appointed guardian, was found to be in a relationship with another resident, Resident R67. Despite the known cognitive limitations of Resident R29, the facility did not have a care plan addressing her sexual behaviors or the relationship with Resident R67. Resident R29 was diagnosed with Trichomoniasis, a sexually transmitted infection, after a gynecological exam. The facility's records did not show any follow-up by social services, medical services, or management to assess the relationship between Resident R29 and Resident R67 or to revise her care plan to address her sexual behavior. Interviews revealed that staff were aware of the relationship and had reported it to management, but no interventions were implemented to manage the situation or prevent further incidents. The facility's failure to supervise and implement necessary interventions for Resident R29, who has severe cognitive impairment, allowed her to enter a relationship with Resident R67, who is cognitively intact. This lack of action resulted in harm to Resident R29, as evidenced by the STI diagnosis. The facility did not develop or implement interventions after the suspected sexual abuse occurred, nor did it prevent further incidents, leading to a deficiency in ensuring the resident's right to be free from abuse and neglect.
Plan Of Correction
1. R29, R67 charts have been reviewed and updated to reflect current status. R67 and R29 are currently followed by psych services. R29 gynecological follow up is 3/5/2025. Guardian has been updated. R29 and R67 visitations will only be allowed in common areas. 2. House review has been completed to ensure no other residents identified. 3. All Facility staff will be in-serviced via directed in-service LW Consulting on 2/27/25 for F600 freedom from abuse/neglect with focus on sexual abuse. 4. Director of Nursing/designee will educate all staff on facilities policy and procedure of abuse/neglect. 5. Director of Nursing/designee will monitor 24-hour report, progress notes for any instances that fall into this category at clinical meeting. 6. Director of Nursing/designee will audit weekly x2, monthly x2 progress notes and 24-hour report. 7. Results of in-service, monitoring and audits will be submitted to the Quality Assurance Performance Improvement Committee.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in six instances, affecting the entire facility. During an observation and document review, it was found that the facility did not provide documentation for the three-year Full Flow Trip Test of the dry pipe sprinkler system. Additionally, there were multiple instances of missing ceiling tiles in various rooms, including the Laundry room, Staff Development/Medical records room, kitchen, A-Wing utility room, and a gap larger than 1/8 inch in a ceiling tile inside the C-Wing Electrical Room. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
1. The Facility will schedule the three-year Full Flow Trip Test of the dry pipe sprinkler system. 2. The facility will replace the missing ceiling tiles in the laundry room, in the staff development/medical records room, in the kitchen and in the A-wing utility room. 3. The gaps in the ceiling tile in the C-Wing Utility closet greater than 1/8 inch will be repaired/replaced as needed. 4. The maintenance staff will be in-serviced on Sprinkler system Maintenance and Testing. 5. The Maintenance staff/designee will do facility rounds to ensure all ceilings tiles are intact and that there are no gaps that are greater than 1/8 inches and will report any concerns to the Quality Assurance Performance improvement committee. 6. The Safety Committee will review the repairs to ensure all corrections are made.
Failure to Conduct Required Fire Drills
Penalty
Summary
The facility failed to conduct five out of the twelve required fire drills over a twelve-month period, affecting the entire facility. Specifically, there was no documentation for a fire drill conducted in the second quarter for the third shift, and for the first, second, and third shifts in the third quarter, as well as the third shift in the fourth quarter. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, who acknowledged the lack of documentation for these fire drills.
Plan Of Correction
1. Facility cannot retroact fire drills from those that were missing from the second quarter of the year for third shift, the first, second and third shifts in the third quarter and the third shift in the fourth quarter. 2. Facility will create a yearly plan for fire drills for every shift for every quarter. 3. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure all fire drills are being conducted. 4. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the emergency generator as required, which was identified during a documentation review and interview. Specifically, the facility did not provide documentation for the weekly visual inspection of the emergency generator. This deficiency was noted at 8:50 a.m. on February 10, 2025. Additionally, the facility failed to provide documentation for the monthly conductance testing of the emergency generator, as noted at 8:52 a.m. on the same day. These deficiencies were confirmed during an interview with the Facility Administrator and Maintenance Director at 12:30 p.m. on February 10, 2025, affecting the entire facility.
Plan Of Correction
1. The Maintenance Director/designee will conduct the weekly visual inspection to ensure the facility is in compliance. 2. The Maintenance Director/designee will conduct the monthly conductance testing to ensure the facility is in compliance. 3. The Nursing Home Administrator/designee will educate the maintenance staff on visual inspection and conductance testing on the generator to ensure the facility is in compliance. 4. The maintenance staff/designee will audit weekly for two months and then monthly for two months to ensure all generator testing is completed. 5. Any concerns will be brought to the Quality Assurance Performance Improvement Committee for review.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident. The facility's policy mandates that all allegations of abuse, including those of unknown source, must be reported immediately to the Administrator, Director of Nursing, and the applicable State Agency. However, the facility did not adhere to this policy for one resident, identified as Resident R29, who was diagnosed with Trichomoniasis during a routine gynecological exam. The resident, who has severe cognitive impairment as indicated by a BIMS score of 6, mentioned being in a consensual relationship with another resident, but due to her cognitive issues, she was unreliable in determining when the intercourse might have occurred. The clinical record review and staff interviews revealed that the facility did not report the incident involving Resident R29 to the appropriate authorities within the required timeframe. The Nursing Home Administrator and Director of Nursing confirmed this failure during an interview. The resident's medical history includes diagnoses of encephalopathy, alcoholic cirrhosis, depression, and muscle weakness, which contribute to her cognitive impairment. Despite the resident's denial of intercourse, she admitted to physical contact with the other resident, which should have prompted an immediate report according to the facility's policy.
Plan Of Correction
1. Event report was submitted on 2/6/2025. 2. 24-hour report, progress notes, grievance reports will be reviewed at morning clinical meeting to ensure investigation is completed for any incidents, accidents or grievances if warranted. 3. The Interdisciplinary Team will be educated by the Regional Clinical Director on Reporting and investigating allegations of abuse and neglect. 4. Administrator/designee will audit weekly x2, monthly x2 any allegations for proper investigation and reporting. 5. Findings will be submitted to Quality Assurance Performance Improvement Committee.
Failure to Maintain Hazardous Area Enclosures
Penalty
Summary
The facility failed to maintain hazardous area enclosures, as evidenced by an observation on February 10, 2025, at 10:10 a.m. The doors to the Condensing Room, which is classified as a hazardous area, were found to be unable to close and latch properly. This deficiency affected one of the five smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director later confirmed that the door in the hazardous area enclosure failed to latch, indicating a lapse in maintaining the required safety standards for hazardous areas.
Plan Of Correction
1. The doors to the condensing room will be repaired/replaced to ensure positive latching and resistance to passage of smoke. 2. The maintenance staff will be in-serviced on positive latching and resistance to passage of smoke. 3. The maintenance staff/designee will audit the facility to ensure doors are positive latching to the frame and are resistant to the passage of smoke and report any concerns to the Quality Assurance Performance Improvement committee. 4. The Safety Committee will review the repairs to ensure all corrections are made.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
