William Penn Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jeannette, Pennsylvania.
- Location
- 2020 Ader Road, Jeannette, Pennsylvania 15644
- CMS Provider Number
- 396056
- Inspections on file
- 42
- Latest survey
- May 8, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at William Penn Care Center during CMS and state inspections, most recent first.
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.
The facility failed to conduct a thorough investigation of an elopement-related incident involving a cognitively intact resident with cardiomegaly, hyperlipidemia, and anxiety. Policy required staff to report, investigate, and review all incidents on facility property involving residents. A RN was notified by rehab staff that the resident was outside in a wheelchair; the RN found the resident outdoors with a newspaper and wallet, stating he was trying to go to an appointment, and redirected him back to his room. Facility documentation included only one witness statement from the DON, and the Nursing Home Administrator acknowledged that a complete elopement investigation was not performed as required.
A resident with cardiomegaly, hyperlipidemia, and anxiety, assessed as cognitively intact and not at risk for elopement, was able to leave the building unsupervised after obtaining a newspaper at the front area while the receptionist was briefly distracted by a phone call. The resident was later found outside in a wheelchair with a newspaper and wallet, stating an intent to go to an appointment. Facility records also described a separate prior incident in which another resident was found outside in a power wheelchair after forcing sliding doors off their hinges to exit. The DON acknowledged that the facility failed to provide adequate supervision, resulting in an elopement.
Three residents with complex medical conditions did not have documented monthly medication regimen reviews by a licensed pharmacist, as required by facility policy. Care plans specified monthly pharmacy reviews, but for the month in question, no evidence of these reviews was found in clinical notes or medication records. The DON confirmed the lack of documentation.
Kitchen equipment, specifically the walk-in cooler's cold air condenser unit, was observed to have a build-up of dust, grime, and dark debris around the fan covers and ceiling. The Certified Dietary Manager confirmed the unsanitary condition, which created the potential for cross contamination in the kitchen.
A resident with traumatic brain injury, aphasia, and heart disease experienced significant weight loss, but the facility did not accurately assess the nutritional status or update the care plan to address this issue. The dietary assessment lacked details on the weight loss, and the care plan did not include specific goals or interventions, as confirmed by staff interviews.
A resident with moderate cognitive impairment and multiple medical conditions was able to exit the facility unsupervised by forcing open a malfunctioning front door in a motorized wheelchair. The door alarm was not functioning, and staff were unaware of the resident's departure until the individual was found outside. The resident was assessed as not at risk for elopement, and staff interviews confirmed no prior history of such behavior.
A resident with dementia, anxiety disorder, and Alzheimer's disease was discharged after death, and a law firm requested the resident's medical records. The facility failed to provide access to these records for several months, citing equipment issues, despite policy requirements and available alternatives. This resulted in noncompliance with regulations regarding resident rights to access records.
A facility failed to adhere to physician orders for a resident who was on a Nothing by Mouth (NPO) diet due to their medical condition. Despite the NPO status, the resident was prescribed oral medications, Oxycodone HCl and Claritin, which were not appropriate. The Nursing Home Administrator confirmed the discrepancy, highlighting a failure in following the prescribed care plan.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about hospital transfers for three residents, as required by regulations. The residents, with various medical conditions, were transferred to the hospital and returned without documented evidence of notification. This deficiency was confirmed by the Nursing Home Administrator.
The facility, with a capacity of 145 beds, failed to employ a qualified full-time social worker as required. The previous social worker left, and although a new hire is pending, there is currently no social worker employed, as confirmed by the NHA.
The facility failed to pay bills in a timely manner, leading to service disruptions from Vendor 1. The Kitchen Manager reported that Vendor 1 had cut off services multiple times, requiring reliance on an alternative vendor. The Accounts Payable Ledger showed outstanding balances with both Vendor 1 and Vendor 2. The Nursing Home Administrator confirmed the facility's failure to adhere to state regulations requiring timely payment of bills.
A resident with a history of falls and other medical conditions suffered a tibial fracture due to neglect during a transfer. Despite clear care plans and physician orders requiring a sit-to-stand lift with two staff, aides manually transferred the resident without the lift, leading to injury. The aides admitted to not reviewing the care plan and relying on assumptions, resulting in harm to the resident.
The facility failed to properly store food and verify dish machine temperatures, risking foodborne illness. An employee's lunch was stored with residents' food, and dishwashing temperatures were not checked before use. Incorrect test strips were used, and the machine's temperature was below the required level.
The facility failed to assess the nutritional status of three residents, resulting in incomplete dietary clinical notes and missing nutritional assessments. This deficiency was confirmed by the Dietary Manager, who acknowledged the lack of essential information such as height, weight, and diet orders in the records.
The facility failed to follow enhanced barrier precautions for two residents and did not implement proper transmission-based precautions for a resident with COVID-19. A resident with a Stage 4 pressure ulcer received care without the required gown, and another resident with a wound vacuum lacked a physician order for EBP. Additionally, there was no signage for a COVID-19 positive resident, and staff were uncertain about isolation protocols. These deficiencies were confirmed by the Director of Nursing.
The facility did not have a designated Infection Preventionist (IP) with specialized training for six months. The Director of Nursing was covering the IP role since the previous IP left in February 2024, as confirmed by the Nursing Home Administrator. This was a violation of management and nursing services regulations.
The facility failed to maintain an effective training program for staff, as five employee files lacked documentation of required annual in-service training in critical areas such as resident rights, abuse, QAPI, and fire safety. This deficiency was confirmed by a Human Resource employee, indicating non-compliance with regulatory requirements.
A resident's funds totaling $5,251.83 were misappropriated by a former Business Officer Manager (BOM) at the facility. The resident's daughter reported the issue when the funds were not reflected in the trust account, despite a receipt being issued. The facility's investigation failed to locate the money or the employee, leading to a police report.
A facility failed to implement its policies to prevent abuse and misappropriation of property when a nurse aide, under police investigation for theft from a resident, was not suspended. The resident, with medical conditions including high blood pressure and renal insufficiency, was allegedly stolen from, but the aide continued working without separation from residents, violating the facility's policy.
A facility failed to report an alleged misappropriation of property involving a resident, who was under investigation for possible theft by a nurse aide. Despite being contacted by local police, the facility did not report the incident to the Department of Health or law enforcement within the required timeframe, violating their policy and state regulations.
A facility failed to investigate an allegation of misappropriation of property involving a resident with high blood pressure, renal insufficiency, and atrial fibrillation. Despite being informed by local police about a possible theft by a nurse aide, the facility did not initiate an investigation, contrary to its policy requiring thorough investigation of all abuse or neglect allegations.
The facility failed to maintain proper admission documentation for two cognitively impaired residents. Despite severe cognitive impairments indicated by BIMS scores, both residents signed their admission packets. An admission coordinator confirmed that these residents should not have signed the paperwork, highlighting a deficiency in adhering to the facility's admissions policy.
The facility failed to communicate necessary information during transfers for two residents, including care plan goals and advanced directives. This deficiency was confirmed by the DON, highlighting a lapse in following the facility's emergency transfer policy.
A facility failed to follow physician orders and conduct weekly assessments for a resident with a surgical wound. The resident had a history of falling, a fracture, hypertension, and an infection requiring a wound vacuum. The facility did not perform weekly wound assessments and lacked a contingency plan for wound vacuum malfunction. Observations showed the wound vacuum machine was off, and staff confirmed the oversight.
The facility failed to maintain respiratory equipment for two residents. A resident's CPAP mask was not stored properly, risking contamination, while another resident's nasal cannula lacked a required date label. These deficiencies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to provide trauma-informed care for two residents with PTSD, as their care plans did not identify or address specific triggers. Despite the facility's policy requiring staff training on trauma assessment and trigger identification, the care plans lacked necessary details, which was confirmed by a social worker.
The facility failed to properly date medications after opening, as required by its policy, in two of three medication carts in the East Hall. Observations revealed that several residents' medications, including albuterol inhalers and Trelegy, were opened without a date. Staff interviews confirmed these deficiencies, and the DON acknowledged the failure to store medications properly and securely.
The facility failed to ensure that two residents with severe cognitive impairment had a representative sign their binding arbitration agreements. Both residents, with BIMS scores indicating severe impairment, signed the agreements themselves, which was confirmed as inappropriate by the Admission Coordinator.
A facility failed to update and implement a comprehensive person-centered care plan for a resident with dementia, diabetes, and bipolar disorder. Despite a wandering risk assessment indicating moderate risk, the care plan was not updated to reflect this. The Nursing Home Administrator confirmed the oversight.
A resident with dementia, diabetes, and bipolar disorder was found outside after the facility's door was locked for the evening. The resident, assessed as low risk for wandering, was assisted back inside without injury. The facility failed to provide adequate supervision, as confirmed by the Nursing Home Administrator.
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.
Failure to Conduct Thorough Investigation of Elopement-Related Incident
Penalty
Summary
The facility failed to initiate a thorough investigation of an elopement-related incident involving one resident. Facility policy dated 1/28/25 required staff to report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve a resident. The resident, admitted on 10/18/24, had diagnoses including cardiomegaly, hyperlipidemia, and anxiety, and an MDS dated 1/18/26 showed a BIMS score of 13, indicating cognitive intactness. A progress note dated 2/17/26 at 11:36 a.m. documented that a RN was informed by rehab staff that the resident was outside in a wheelchair; upon assessment, the nurse found the resident outside with a newspaper and wallet in hand, stating he was trying to go to an appointment, and the resident was redirected back inside. Facility-provided documents contained only one witness statement from the DON, and during an interview on 3/20/26, the Nursing Home Administrator confirmed that the facility did not conduct a thorough elopement investigation for this incident as required by policy. This deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1)(3) Management, 28 Pa. Code: 211.10(d) Resident care policies, and 28 Pa. Code: 211.12(d)(3) Nursing services, based on the lack of a complete investigation into the resident’s elopement-related event despite policy requirements.
Failure to Adequately Supervise Resident Leading to Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident. Facility policy on Elopements and Wandering Residents requires a systemic approach to identifying and managing residents at risk for elopement, including assessment of risk, implementation of interventions, and vigilant staff response to alarms, with the understanding that alarms are not a substitute for necessary supervision. The resident involved was admitted in October 2024 and had diagnoses including cardiomegaly, hyperlipidemia, and anxiety. A BIMS score of 13 on the MDS indicated the resident was cognitively intact, and an elopement/wandering risk assessment completed in January 2025 documented that the resident was not at risk for elopement and not at safety risk for wandering, or wandered but was easily redirected. On the date of the incident, a progress note documented that a nurse was informed by rehab staff that the resident was outside in a wheelchair. When the nurse went outside, the resident was found sitting in the wheelchair with a newspaper and wallet in hand, stating he was trying to go to an appointment, and had exited the building without staff knowledge. Facility documentation indicated that the receptionist saw the resident get his newspaper, then turned away to take a phone call and obtain a phone number, and when she turned back, the resident had left through the front door. The record also included a prior employee statement describing a different resident found outside in a power wheelchair in the back parking lot after having pushed sliding doors off their hinges to exit the building. During interview, the DON confirmed that the facility failed to provide adequate supervision resulting in an elopement for one resident.
Lack of Documented Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to provide documentation of monthly medication regimen reviews (MRR) by a licensed pharmacist for three sampled residents. According to the facility's policy, a licensed pharmacist is required to conduct a thorough monthly review of each resident's medication regimen, including a review of the medical chart. For each of the three residents reviewed, their care plans indicated that pharmacy reviews were to occur monthly as per protocol. However, for the month of April 2025, there was no documentation in the clinical progress notes or medication regimen review records to show that these reviews had been completed. The residents involved had complex medical histories, including diagnoses such as dementia, heart disease, diabetes, chronic kidney disease, hyperlipidemia, emphysema, hypertension, and cirrhosis of the liver. Despite these conditions and the facility's stated policy, there was no evidence that a licensed pharmacist had performed or documented the required monthly medication reviews for these residents during the specified period. The Director of Nursing confirmed the absence of this documentation during an interview.
Failure to Maintain Sanitary Conditions in Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition, specifically in the main kitchen's walk-in cooler. During an observation conducted with the Certified Dietary Manager, the cold air condenser unit was found to have a build-up of dust, grime, and dark colored debris around the fan covers and on the ceiling immediately forward of the fans. The Certified Dietary Manager confirmed the unsanitary condition of the equipment and acknowledged that this failure to maintain cleanliness created the potential for cross contamination in the kitchen. The facility's policy required adherence to all local, state, and federal standards to ensure a safe and sanitary food and nutrition department, which was not followed in this instance.
Failure to Assess and Address Resident's Significant Weight Loss
Penalty
Summary
The facility failed to accurately assess the nutritional status of a resident and did not update the individualized care plan to address specific nutritional concerns. The facility's policy requires a comprehensive nutritional assessment, including current status and risk factors, to be conducted upon admission and as indicated by changes in condition. For one resident with diagnoses of traumatic brain injury, aphasia, and heart disease, the Minimum Data Set (MDS) indicated significant weight loss. However, the clinical dietary assessment note did not identify the parameters of this weight loss, such as prior weights or specific time frames. Additionally, the resident's nutritional plan of care was not updated to reflect a focus on the significant weight loss, nor did it include goals or interventions to address the issue. Staff interviews confirmed that the assessment and care plan failed to address the resident's nutritional concerns as identified in the MDS. This deficiency was found during a review of four resident records.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with moderate cognitive impairment. The resident, who had diagnoses including heart disease, chronic kidney disease, and diabetes, was assessed as not being at risk for elopement or unsafe wandering on multiple occasions. Despite these assessments, the resident was able to exit the facility unsupervised by using a motorized wheelchair to force open the front lobby doors, which were found to be off their tracks and not properly alarmed at the time of the incident. Staff discovered the resident outside in the parking lot after a staff member returning from a break noticed the individual in their wheelchair. The resident was confused, had a pile of belongings in their lap, and required assistance to return to their room. Upon investigation, it was determined that the door alarm was not functioning, and no alarm had sounded during the event. The resident had no recollection of leaving the building and did not sustain any injuries. Interviews with staff confirmed that the behavior was new for the resident and that there were no prior indications of elopement risk. The facility's policy required vigilant supervision and timely response to alarms, as well as a systemic approach to monitoring residents at risk for elopement. However, the failure of the door alarm and lack of adequate supervision directly contributed to the resident's unsupervised exit from the facility.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for one resident, as required by both facility policy and state and federal regulations. According to the facility's policy, medical records should be released upon a valid request, with proper legal documentation and notification of associated costs. In this case, a law firm submitted a request for a resident's medical records, and the facility acknowledged receipt of the request several months prior to the survey. Despite this, the records were not provided due to issues with the facility's copier and the volume of the records. The Nursing Home Administrator confirmed that the facility had not fulfilled the request and that alternative means, such as using an off-site scanner, were available but not utilized. The resident in question had diagnoses of dementia, anxiety disorder, and Alzheimer's disease, and had been discharged from the facility after passing away. The deficiency was identified through staff interviews and review of facility documentation, which confirmed that the facility did not provide access to the requested medical records for this resident, in violation of resident rights under 28 Pa. Code 201.29(a).
Failure to Follow NPO Orders for a Resident
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with diagnoses including malignant neoplasm of the upper lobe, right bronchus or lung, cyst of kidney, and ischemic cardiomyopathy. The resident was ordered to be on a Nothing by Mouth (NPO) diet with enteral feeding every shift by j-port. However, the resident's physician orders for January included two medications, Oxycodone HCl and Claritin, to be administered orally, which contradicted the NPO status. During an interview, the Nursing Home Administrator confirmed that the resident should not receive medication by mouth, indicating that the orders were inappropriate for an NPO resident.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three residents. Resident R2, who was admitted with diagnoses including diabetes, anxiety disorder, and fibromyalgia, was transferred to the hospital and returned to the facility without documented evidence of a written transportation notification to the Ombudsman. Similarly, Resident R1, with diagnoses of protein-calorie malnutrition, chronic kidney disease, and cardiomegaly, was transferred to the hospital and returned without the required notification. Resident R3, admitted with anemia, respiratory disorders, and spinal stenosis, was also transferred to the hospital on two occasions without the necessary notification to the Ombudsman. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to provide the required transfer notices for these residents. The report highlights that the facility did not comply with the regulation requiring timely notification to the Ombudsman, as outlined in 28 Pa. Code 201.29(a)(c.3)(2) regarding resident rights. This oversight affected three out of nine residents reviewed, indicating a lapse in the facility's adherence to regulatory requirements for resident transfers.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker, which is required for facilities with more than 120 beds. The facility assessment indicated the need for a full-time Social Services Director, and the facility has a capacity of 145 beds, necessitating a full-time social worker. An interview with the Nursing Home Administrator revealed that the previous social worker left on September 6, 2024, and although a new social worker has been hired, they have not yet started. As of September 17, 2024, the Nursing Home Administrator confirmed that there is currently no social worker employed at the facility, which is a requirement.
Failure to Pay Bills Timely
Penalty
Summary
The facility failed to pay bills in a timely manner, as evidenced by a review of financial documents and interviews with staff and vendors. According to the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, a facility owner is required to pay bills incurred in the operation of a facility in a timely manner, especially those that are not in dispute and are essential for the residents' health and safety. The Nursing Home Administrator's job description emphasizes the importance of adhering to federal, state, and local standards to ensure quality care for residents. During an interview, the Kitchen Manager revealed that Vendor 1 had cut off services multiple times due to unpaid bills, forcing the facility to rely on an alternative vendor. The Accounts Payable Ledger showed an outstanding balance with Vendor 1 and Vendor 2, with Vendor 1's credit manager confirming a significant overdue amount. The Nursing Home Administrator acknowledged the facility's failure to pay bills promptly, which is a violation of the management's responsibilities as outlined in the state code.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R27, was free from neglect, resulting in actual harm evidenced by fractures to her right tibia. The deficiency occurred when two nurse aides, despite being trained on the proper use of mechanical lifts, transferred Resident R27 without using the required sit-to-stand lift. The aides, unable to locate the lift, decided to perform a manual two-person assist transfer, contrary to the resident's care plan and physician orders, which specified the use of a sit-to-stand lift with the assistance of two staff members. Resident R27 had a medical history that included a history of falling, chronic kidney disease, spinal stenosis, an artificial hip joint, and a history of other fractures. Her care plan and physician orders clearly indicated the need for a sit-to-stand lift with two staff members for transfers. On the day of the incident, the aides lifted Resident R27 manually, which led to her experiencing discomfort and subsequently being found with a significant bruise on her right shin. An X-ray confirmed an acute to sub-acute proximal right tibial fracture, and further hospital evaluation revealed a non-displaced comminuted proximal tibial fracture. Interviews with the staff involved revealed that they were aware of the requirement to use a sit-to-stand lift but proceeded with a manual transfer due to the unavailability of the lift. The aides admitted to not reviewing the resident's transfer status in the care plan or Kardex before the transfer, relying instead on assumptions and verbal communication. This neglect in following established protocols and care plans directly led to the resident's injury, highlighting a significant lapse in ensuring resident safety and adherence to care procedures.
Improper Food Storage and Dish Machine Temperature Verification
Penalty
Summary
The facility failed to properly store food products and verify the washing temperature of the dish machine in the Main Kitchen, which created the potential for foodborne illness. During an observation, an employee's lunch was found stored among the residents' food supply in the walk-in refrigerator, and it remained there for at least two days. The Dietary Manager confirmed the improper storage of food products. Additionally, the facility utilized a high-temperature dishwashing machine, but the staff did not verify the machine's operating temperature before washing dishes. Instead, they attempted to use test strips after the dishes were washed, which would not identify any issues beforehand. The test strips used were not appropriate for measuring the temperature of the dish machine. The first strip was intended for the three-compartment sink, and the second strip was for measuring chemical concentration, not temperature. The Temperature and Sanitizer Log indicated consistent entries of 160 degrees for the wash temperature, but an observation showed the gauge at 145 degrees, below the required minimum of 150 degrees. The Dietary Manager confirmed the failure to verify the washing temperature, which posed a risk of foodborne illness.
Failure to Assess Nutritional Status of Residents
Penalty
Summary
The facility failed to adequately assess the nutritional status of three residents, leading to a deficiency in providing sufficient food and fluids to maintain their health. For Resident R3, the facility's dietary clinical note did not include essential information such as height, weight, and diet order, which were documented in the Minimum Data Set (MDS). This omission was confirmed by the Dietary Manager, who stated that she was instructed to provide only a brief note. Similarly, Resident R67's dietary clinical note also lacked the necessary details captured in the MDS, including height, weight, and diet order. Additionally, Resident R35 did not receive a nutritional assessment during significant change and quarterly assessments, as required. The Certified Dietary Manager confirmed the absence of these assessments. These failures indicate a lack of adherence to the facility's policy and state regulations, which require comprehensive nutritional assessments to ensure residents' dietary needs are met.
Deficiencies in Infection Control and Precautionary Measures
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for two residents, as well as proper signage and staff knowledge for a resident with a positive COVID-19 diagnosis. Resident R33, who had a Stage 4 pressure ulcer, was observed receiving incontinence care from a nurse aide who did not wear a gown as required by EBP. This was confirmed by a registered nurse who acknowledged the failure to follow the necessary precautions during high-contact care activities. Additionally, Resident R74, who had a wound vacuum and a PICC line, did not have a physician order for EBP, and there was no signage indicating the need for such precautions. A nurse aide providing care to Resident R74 was unaware of the requirement to wear a gown, and the resident's clinical record lacked the necessary documentation for EBP. The facility also failed to implement proper transmission-based precautions for Resident R180, who was in isolation for COVID-19. There was no signage at the facility entrance or on the resident's door to indicate the presence of an active COVID-19 infection. A registered nurse was uncertain about the resident's isolation status, and the Director of Nursing confirmed that the appropriate precautions were not in place. The facility's failure to follow EBP and transmission-based precautions was acknowledged by the Director of Nursing, highlighting deficiencies in infection prevention and control practices.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) with specialized training in infection prevention and control for six months, from February 2024 to July 2024. During the annual survey on July 15, 2024, it was found that the Director of Nursing was also serving as the current Infection Preventionist. The Nursing Home Administrator confirmed in interviews on July 15 and July 19, 2024, that the Director of Nursing had been covering the IP role since the previous IP's last day of work on February 5, 2024. This lack of a qualified IP was a violation of the facility's management and nursing services regulations as outlined in 28 Pa. Code 201.18(b)(3), 28 Pa. Code 201.14(a), and 28 Pa. Code 211.12(d)(1)(3).
Deficient Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the review of personnel records and staff interviews. Specifically, five out of ten employee files reviewed showed deficiencies in annual in-service training. These employees included Nurse Aides (NA) and a Licensed Practical Nurse (LPN). The personnel records of these employees lacked documentation of required training in areas such as resident rights, abuse, quality assurance performance improvement (QAPI), behavioral health, dementia care, infection control, communication, falls/incident accident, restorative care, emergency preparedness, and fire safety. The deficiencies were confirmed during an interview with Human Resource Employee E10, who acknowledged the facility's failure to provide the necessary training. The lack of training was noted across various critical areas, which are essential for ensuring the safety and well-being of residents. The report highlights the facility's non-compliance with the regulatory requirements set forth by 28 Pa. Code 201.18(b)(3) Management and 28 Pa. Code: 201.14(a) Responsibility of licensee.
Misappropriation of Resident Funds
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, specifically $5,251.83, which was entrusted to the previous Business Officer Manager (BOM), Employee E8. The incident involved Resident R5, who was admitted to the facility with diagnoses including high blood pressure, renal insufficiency, and heart failure. The resident's daughter reported that the cash given to Employee E8 was not reflected in the resident's trust account, despite a receipt being issued. The money was also not found in the facility's safe. The facility conducted a lengthy investigation and made multiple attempts to contact Employee E8, but was unable to locate either the money or the employee. Consequently, the findings were reported to the police. The Nursing Home Administrator confirmed the facility's failure to ensure residents were free from misappropriation of funds, as evidenced by the incident involving Resident R5.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of property for a resident. The policy, dated January 30, 2024, stated that the facility would take all reasonable measures to protect residents during an abuse investigation, including suspending any employee alleged to be involved. However, this policy was not followed in the case of a resident who was allegedly a victim of theft by a nurse aide. The resident, who had been diagnosed with high blood pressure, renal insufficiency, and atrial fibrillation, was allegedly the victim of theft by Nurse Aide Employee E9, who was under investigation by local police for stealing between $18,000 and $20,000. Despite the ongoing investigation, the nurse aide continued to work at the facility and was not suspended or separated from residents, as confirmed by the Human Resource Employee E10 and the Nursing Home Administrator. This failure to act according to the facility's policy resulted in a deficiency related to the protection of residents' rights and property.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged misappropriation of property involving a resident, identified as Resident CR1, who was admitted with diagnoses including high blood pressure, renal insufficiency, and atrial fibrillation. The incident came to light when local police contacted the facility on June 18, 2024, regarding an investigation into Nurse Aide Employee E9 for the possible theft of $18,000 to $20,000 from Resident CR1. Despite this notification, the facility did not report the allegation to the Department of Health or any law enforcement entity within the required 24-hour timeframe, as stipulated by their policy. The facility's records of state reportable abuse allegations from August 27, 2023, to July 11, 2024, did not include any report related to the misappropriation allegations concerning Resident CR1. An interview with the Nursing Home Administrator on July 17, 2024, confirmed that the facility failed to report the alleged misappropriation to the local State field office. This oversight is a violation of the facility's responsibility and management regulations, as well as resident rights under the specified Pennsylvania codes.
Failure to Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to investigate a potential allegation of abuse/neglect related to the misappropriation of property for one resident. The facility's policy, dated 1/30/24, mandates that all allegations of abuse, neglect, exploitation, or mistreatment of residents be thoroughly investigated by the administrator and support staff. Resident CR1, who had diagnoses of high blood pressure, renal insufficiency, and atrial fibrillation, was admitted to the facility and resided there until 3/6/24. On 6/18/24, the facility was contacted by local police regarding an investigation into Nurse Aide Employee E9 for the possible theft of $18,000 - $20,000 from Resident CR1. Despite this notification, the Nursing Home Administrator confirmed on 7/17/24 that the facility did not initiate an investigation into the allegation, thus failing to adhere to their policy and potentially neglecting the resident's rights.
Failure to Maintain Proper Admission Documentation for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain proper admission documentation for two residents, both of whom were cognitively impaired. The facility's admissions policy, last reviewed on January 30, 2024, mandates fair and impartial admission practices. However, the review of resident records revealed that Resident R60, diagnosed with dementia, cardiomegaly, and chronic kidney disease, was admitted with a BIMS score of 7, indicating severe cognitive impairment. Despite this, the admission packet dated April 6, 2022, contained a signature from Resident R60. Similarly, Resident R2, diagnosed with chronic kidney disease and hypertensive heart disease, was admitted with a BIMS score of 2, also indicating severe cognitive impairment. The admission packet dated November 16, 2023, included a signature from Resident R2. During an interview, Admission Coordinator Employee E25 confirmed that both residents were cognitively impaired and should not have signed the facility paperwork. This failure to adhere to the admissions policy and ensure appropriate documentation was noted as a deficiency.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. According to the facility's policy on emergency transfers or discharges, a transfer form should be prepared and sent with the resident. However, for Resident R67, who was admitted with diagnoses including PTSD, cerebral vascular accident, and dysphagia, there was no documented evidence that specific information such as care plan goals, advanced directive information, and instructions for ongoing care were communicated to the hospital upon transfer. Similarly, Resident R72, who had diagnoses of high blood pressure, Alzheimer's disease, and hearing loss, was transferred to the hospital without documented evidence of communication of necessary information to the receiving health care provider. This included the resident's care plan goals, advanced directive information, and other essential details needed to meet the resident's specific needs. The Director of Nursing confirmed the lack of evidence for communication of necessary information for both residents during an interview.
Failure to Follow Physician Orders and Conduct Weekly Wound Assessments
Penalty
Summary
The facility failed to provide care according to physician orders and did not conduct weekly assessments for a resident with a surgical area. The resident, identified as R74, had a history of falling, a displaced trimalleolar fracture, hypertension, a dislocation to the left tarsometatarsal joint, an insertion of a left artificial ankle joint, and an infection. The hospital records indicated that the resident was hospitalized due to an infection in the left ankle surgical area, and a wound vacuum was ordered. The physician's orders specified the application of a wound vacuum and dressing changes every Monday, Wednesday, and Friday, with no need for a wound vac on the medial incision. However, the facility did not include actions to take if the wound vacuum was inoperable or unavailable. Observations and interviews revealed that the facility did not perform weekly assessments of the resident's surgical wound area from 7/4/24 to 7/16/24. During an interview, a registered nurse confirmed that there was no order for a wet-to-dry dressing change in case of wound vacuum malfunction. Additionally, the wound vacuum machine was found off during an observation, and the Assistant Director of Nursing stated it might have been shut off during therapy. The Director of Nursing confirmed the facility's failure to provide care as per physician's orders and to conduct the required weekly assessments.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide appropriate care of respiratory equipment for two residents, R70 and R71. Resident R70, who has diagnoses including high blood pressure, obstructive sleep apnea, and insomnia, was observed with a CPAP mask not stored in its designated storage bag, which is necessary to prevent contamination. This observation was confirmed by a registered nurse, indicating a lapse in following the facility's policy for storing respiratory equipment. Resident R71, diagnosed with hypertension, obstructive sleep apnea, and depression, was found to have a nasal cannula without a label indicating the date issued, contrary to the facility's policy requiring such labeling every two weeks. This was confirmed by an LPN, and the Director of Nursing acknowledged the facility's failure to adhere to the respiratory equipment care policy for both residents.
Failure to Provide Trauma-Informed Care for PTSD Residents
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD), identified as Resident R1 and Resident R67. The facility's policy on Trauma Informed Care, dated January 30, 2024, mandates that nursing staff be trained on screening tools, trauma assessment, and identifying triggers associated with re-traumatization. However, the care plans for both residents did not identify specific PTSD triggers or strategies to avoid them, which is a critical component of trauma-informed care. Resident R1 was admitted with diagnoses including PTSD, high blood pressure, and dysphagia, while Resident R67 had PTSD, a cerebral vascular accident, and dysphagia. Despite these diagnoses, their care plans lacked the necessary details to address their PTSD triggers. This oversight was confirmed during an interview with Social Worker Employee E2, who acknowledged the facility's failure to identify and mitigate potential triggers for these residents, potentially leading to re-traumatization.
Medication Storage Deficiency in East Hall
Penalty
Summary
The facility failed to adhere to its medication storage policy, which requires that when the original seal of a manufacturer's container or vial is broken, the container or vial must be dated. During an observation of the East Hall medication carts A and B, it was found that several medications did not have a date opened as required. Specifically, Resident R10's albuterol inhaler and Resident R21's ipratropium albuterol were opened without a date on medication cart B. Similarly, on medication cart A, Resident R11's Trelegy and ipratropium albuterol, as well as Resident R23's fluticasone, were also opened without a date. Interviews with staff confirmed these deficiencies. LPN E18 confirmed the lack of date on the medications in cart B, while RN E20 confirmed the same issue for cart A. The Director of Nursing later confirmed that the facility failed to store medications properly and securely in two of the three medication carts. This failure to comply with the facility's medication storage policy was a violation of the relevant pharmacy and nursing services regulations.
Failure to Ensure Proper Representation for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that a representative signed a binding arbitration agreement on behalf of two residents who lacked the capacity to understand the agreement terms. This deficiency was identified for two residents, referred to as Resident R2 and Resident R60, both of whom were assessed with severe cognitive impairment. Resident R60, admitted with diagnoses including dementia, cardiomegaly, and chronic kidney disease, had a BIMS score of 7, indicating severe cognitive impairment. Despite this, the arbitration agreement dated 4/1/22 was signed by Resident R60. Similarly, Resident R2, admitted with chronic kidney disease and hypertensive heart disease, was assessed with a BIMS score of 2, also indicating severe cognitive impairment. The arbitration agreement for Resident R2, dated 11/4/23, was signed by the resident. During an interview, the Admission Coordinator confirmed that both residents were cognitively impaired and should not have signed the facility paperwork. This failure to ensure proper representation in signing the arbitration agreements constitutes a deficiency in the facility's admission policy and responsibility of the licensee.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as R1. According to the facility's policy dated 1/31/23, each resident should have a care plan that includes measurable objectives and timetables to meet their physical, psychosocial, and functional needs. Resident R1 was admitted with diagnoses of dementia, diabetes mellitus, and bipolar disorder. A Minimum Data Set (MDS) assessment dated 4/10/24 confirmed these diagnoses were current. Additionally, a wandering risk assessment indicated that Resident R1 was at moderate risk for wandering. However, the resident's care plan was not updated to reflect this risk. During an interview, the Nursing Home Administrator confirmed the facility's failure to update and develop a comprehensive care plan for Resident R1.
Failure to Provide Adequate Supervision for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident R1, who was identified as having a low risk for wandering. Resident R1, who has diagnoses including dementia, diabetes mellitus, and bipolar disorder, was found outside the facility after the receptionist locked the door for the evening. The resident was knocking on the door and was assisted back into the building by staff. A nurse assessed Resident R1 and found no injuries, and notifications were made to the resident's son, physician, and the Director of Nursing. However, no new orders were issued following the incident. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility failed to provide adequate supervision to prevent a potential accident for Resident R1. The facility's policy on incident/accident reporting emphasizes maintaining resident safety in the least restrictive manner, yet the lack of adequate supervision and a comprehensive care plan for Resident R1 led to this oversight. The incident highlights a lapse in ensuring the safety and supervision of residents, particularly those with cognitive impairments.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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