Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Concordia At Villa St Joseph during CMS and state inspections, most recent first.
A resident with multiple medical conditions experienced a fall while preparing for bed. Two nurse aides, without notifying or obtaining an assessment from an RN, used a mechanical lift to return the resident to bed, contrary to facility policy requiring RN evaluation after a fall. The DON confirmed the lack of RN assessment prior to the transfer.
A resident with diabetes, heart failure, and obstructive uropathy had a suprapubic catheter, but the physician order and care plan did not specify the catheter size or balloon inflation amount as required by facility policy. This omission was confirmed by the DON during review.
The facility failed to ensure nursing staff had the necessary competencies to care for residents with Life Vests, placing two residents in immediate jeopardy. Staff were not adequately trained on the device's operation, and care plans lacked instructions for the Life Vest. The facility was unaware of the presence of a second Life Vest, highlighting a communication gap with hospitals.
A facility failed to provide a dignified dining experience for a resident, as an employee stood while feeding her. Additionally, two residents' privacy was compromised when a nurse aide entered their rooms without knocking, and an LPN did not close the door during a wound dressing change.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in person-centered care. A resident with heart failure did not have a care plan for a Life Vest, another resident's dietary needs were not reflected in their care plan, and a third resident's care plan lacked interventions for a Life Vest. These issues were confirmed by facility staff.
The facility failed to maintain three crash carts in safe operating condition. Observations revealed missing documentation on checklists for the Ebensburg, Fontbonne, and Carondelet crash carts. Additionally, the Carondelet cart contained an expired bag valve mask. These issues were confirmed by an LPN, an RN, and the Nursing Home Administrator.
The facility failed to develop baseline care plans that included necessary interventions for two residents wearing a Life Vest, a wearable defibrillator. One resident's care plan did not mention the Life Vest despite having heart-related diagnoses, while another's plan acknowledged the Life Vest but lacked person-centered goals and safety measures. This deficiency was confirmed by a Corporate Clinical Coordinator.
The facility failed to update care plans for two residents, resulting in inaccuracies regarding their medical needs. One resident's care plan did not include a fluid restriction and allergy, while another's did not reflect current tube feed orders. These deficiencies were confirmed by staff interviews.
The facility failed to clarify physician orders for four residents, leading to deficiencies in care. Two residents were admitted with Life Vests, but the facility did not have physician orders for their care. Another resident had a fluid restriction order without specified fluids, and a fourth resident had an enteral feeding order lacking administration details. These omissions were confirmed by staff interviews.
A resident with an enteral feeding tube was inappropriately administered oral medications despite being NPO. The facility's policy allowed enteral feedings for those unable to take food orally, yet the resident received oral medications, confirmed by the DON. This oversight led to a deficiency in care.
The facility failed to obtain complete physician orders and develop care plans for two residents requiring respiratory care. One resident with a tracheostomy lacked specific orders for the tracheostomy tube, while another resident using a CPAP machine had no physician order or care plan for its use. These deficiencies were confirmed by facility staff.
A facility failed to maintain consistent communication with a dialysis center for a resident with end-stage renal disease. The resident, who required dialysis three times a week, had incomplete communication forms for two out of four days. This issue was confirmed by a registered nurse during an interview.
A facility failed to act on a pharmacist's recommendations in the MRR for a resident with high blood pressure, GERD, and hyperlipidemia. Despite the physician agreeing to change Prilosec to Protonix due to a potential interaction with Clopidogrel, no changes were made in the EMR. Additionally, recommendations to taper Omeprazole based on Beer's Criteria were not implemented, leading to a deficiency in timely action on medication irregularities.
The facility failed to properly store medications in the Ebensburg Second Hall Med Cart. The narcotic lock box was found unlocked, and the cart contained an expired Humalog Insulin Pen and an Insulin Glargine Pen without an opened date. These issues were confirmed by an RN and the DON, highlighting a breach in medication storage protocols.
The NHA and DON failed to ensure nursing staff had the necessary skills to care for residents with Life Vests, leading to an immediate jeopardy situation for two residents. The facility did not provide adequate training, resulting in a violation of Pennsylvania Code regulations.
The facility did not implement a complete facility-wide assessment to identify necessary resources for its resident population, failing to include the management of Life Vests for two residents with cardiac conditions. Both residents were observed with Life Vests and charging stations, but the facility's assessment did not account for this complex medical care requirement.
The facility failed to coordinate hospice services for two residents receiving end-of-life care. For one resident with Alzheimer's, the care plan lacked hospice contact information and access instructions. Another resident with cancer had no hospice provider identified in physician orders, and the care plan also lacked coordination details. These deficiencies were confirmed by facility staff.
A facility failed to implement proper infection control practices during a dressing change for a resident with an unhealed pressure ulcer. The LPN did not use a gown as required by enhanced barrier precautions and failed to clean the stand used after the procedure, despite multiple handwashing and glove changes. This deficiency was identified as a failure to follow the facility's infection control policies.
The facility failed to provide necessary treatment for pressure ulcers for two residents. One resident did not receive prescribed wound care on multiple occasions, while another resident's care plan lacked interventions for multiple pressure wounds. These deficiencies were confirmed by facility staff.
The facility failed to protect a resident with high blood pressure, hemiplegia, and Multiple Sclerosis from verbal abuse by a Nurse Aide (NA). The NA admitted to yelling at the resident during care, causing emotional distress. The incident was reported by an RN, and the Director of Nursing confirmed the facility's failure to ensure a safe environment.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked goals and interventions for catheter care and dementia, while another resident's care plan lacked goals and interventions for dementia. These deficiencies were confirmed by the LPNAC, RNAC, and DON during interviews.
The facility failed to maintain sanitary conditions of respiratory equipment for two residents. One resident's nebulizer machine was not labeled with a date, and another resident's nasal cannula was also not labeled with a date. These lapses were confirmed by RNs during interviews.
The facility failed to properly store and secure medications and biologicals for two residents, with items found on an overbed table and window sill. Additionally, an unlabeled open tube of antifungal cream was found in a medication cart. These actions were confirmed and corrected by nursing staff.
The facility failed to properly disinfect reusable equipment between residents and did not implement proper infection control practices during a dressing change for a resident with multiple medical conditions. Staff inconsistencies and improper training were observed and confirmed, highlighting lapses in adherence to infection control policies.
A facility failed to provide appropriate treatment for a resident with an indwelling catheter. An RN flushed the catheter multiple times without verifying a physician's order, and the Director of Nursing confirmed the deficiency.
Failure to Assess Resident by RN After Fall Prior to Transfer
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care following a fall. According to the facility's policy, any injuries resulting from incidents or accidents are to be assessed by a licensed nurse or practitioner, and the affected individual should not be moved until it is deemed safe. However, after a resident with diagnoses including diabetes, heart failure, and obstructive uropathy experienced a fall, two nurse aides used a mechanical lift to return the resident to bed without first notifying or obtaining an assessment from a Registered Nurse (RN) or practitioner. The nursing notes and investigative report confirmed that the RN was not notified prior to moving the resident. The resident described the fall as occurring while preparing for bed, using a walker, and slowly slumping to the left side. The aide present ensured the resident was alright and, with another aide, used a lift to return the resident to bed. There was no documentation of an RN assessment prior to this transfer, which was contrary to both facility policy and the re-education provided to staff. The Director of Nursing confirmed that the required assessment was not completed before the resident was moved.
Lack of Specific Physician Order and Care Plan for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure that a physician order and care plan for a resident with a suprapubic catheter included specifications for the catheter size and balloon inflation amount. According to the facility's policy, catheter care must be provided in accordance with current professional standards and resident care policies. However, review of the clinical record for a resident admitted with diagnoses including diabetes, heart failure, and obstructive uropathy showed that the physician order only directed the suprapubic catheter to be changed every four weeks, without specifying the required size or balloon inflation amount. Additionally, the resident's care plan, which was revised during their stay, noted the use of a suprapubic catheter but also failed to include the necessary specifications for catheter size and balloon inflation. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required details were missing from both the physician order and the care plan for this resident.
Lack of Staff Competency in Managing Life Vests
Penalty
Summary
The facility failed to ensure that nursing staff had the specific competencies and skill sets necessary to provide care for residents with a Life Vest, a wearable defibrillator designed to protect residents from sudden cardiac death. This deficiency placed two residents, identified as R314 and R49, in immediate jeopardy, impacting their health and safety. The report highlights that the facility did not have a care plan or physician orders for the Life Vest for these residents, and staff were not adequately trained or informed about the device's operation and care requirements. Resident R314 was admitted to the facility with a Life Vest, as confirmed by a discharge form from the hospital. However, interviews with various staff members, including nurse aides and nurses, revealed a lack of knowledge and training regarding the Life Vest. Staff members were unaware of the device's alarms, how to care for the batteries, and the specific needs for bathing residents wearing the Life Vest. The care plan for Resident R314 did not include instructions for the Life Vest, and there were no physician orders for its use. Similarly, Resident R49 was admitted with a Life Vest, but the facility's clinical record did not include orders or a care plan for the device. Interviews with staff members assigned to Resident R49 indicated that they had not received education on the Life Vest and were unaware of its presence and requirements. The Director of Nursing acknowledged that the facility was unaware of the second Life Vest and that hospitals did not notify them about such equipment needs. This lack of communication and training led to the immediate jeopardy situation for the residents involved.
Removal Plan
- Clinical staff will complete education on the care and operation of Life Vests that includes but is not limited to what the different alarms mean, the dangers of electrical shock, the care of the batteries, the care of the garment for laundering, and special needs for bathing.
- The facility will demonstrate competency of all clinical staff through completion of a test following the education.
- A resident centered comprehensive care plan outlining the care of Resident R314, and R49 related to the Life Vest has been completed.
- A care plan addressing the Life Vest, and the management of the Life Vest has been completed for Resident R314, and R49.
- The facility obtained physician orders for the implementation of the Life Vest.
- Clinical staff will be educated on the policies and procedures related to the use of the Life Vest.
- Resident R314's physician's orders and care plan were updated.
- Resident R49's physician's orders and care plan were updated.
- The facility will produce a policy related to the Life Vest and will provide in an education to staff.
- The facility will provide a policy/procedure related to the admission of residents with anticipated equipment needs that will be provided to clinical staff and admissions team.
- Audits will be conducted of five clinical staff for one day to demonstrate competency of caring for a resident with a Life Vest.
- Audits will continue to include five staff weekly to demonstrate competency of caring for a resident with a Life Vest for 2 weeks or until substantial compliance is achieved.
- Education and initial audit results will be reviewed with the Quality Assurance and Quality Improvement Committee for analysis and further recommendation.
Failure to Ensure Dignified Dining and Privacy for Residents
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident in the Carondelet dining room. During an observation, it was noted that a resident was being assisted with lunch by an employee who was standing beside her while feeding her, which was confirmed by the employee as not providing a dignified dining experience. Additionally, the facility did not protect and value residents' private space. On the [NAME] Unit, a nurse aide was observed entering two residents' rooms without knocking or requesting permission, which the aide confirmed. Furthermore, on the Fontbonne Unit, an LPN was observed performing a wound dressing change without closing the door for privacy, which the LPN acknowledged.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed specific needs for three residents, leading to deficiencies in person-centered care. Resident R49, who was diagnosed with high blood pressure, septicemia, and heart failure, did not have a care plan that included goals and interventions for a Life Vest, a critical component of their care. This oversight was confirmed by the Nursing Home Administrator during an interview. Similarly, Resident R228, with a history of fractures and falls, had a physician's order for a gluten-free and lactose-restricted diet, but the care plan did not reflect this dietary requirement. This was confirmed by the Registered Dietitian. Additionally, Resident R314, who was wearing a Life Vest, did not have a care plan that included goals and interventions for its use, as confirmed by the Nursing Home Administrator. These deficiencies indicate a failure to ensure that care plans were updated and comprehensive for the residents' specific needs.
Crash Cart Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that equipment was in safe operating condition for three crash carts. During observations, it was found that the Ebensburg crash cart's checklist lacked documentation for checks on specific dates in February 2025. Similarly, the Fontbonne crash cart's checklist was missing entries for other dates in the same month. The Carondelet crash cart not only had missing checklist entries but also contained a bag valve mask with an expiration date of November 13, 2023. These deficiencies were confirmed through interviews with LPN Employee E9 and RN Employee E8, as well as the Nursing Home Administrator, who acknowledged the failure to maintain the crash carts as required.
Failure to Include Life Vest Interventions in Baseline Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary interventions for residents wearing a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified for two residents, R49 and R314, out of ten reviewed. Resident R49, admitted on an unspecified date, had a baseline care plan dated 2/9/25 that did not mention the Life Vest, despite having diagnoses of high blood pressure, septicemia, and heart failure. Similarly, Resident R314, admitted on an unspecified date, had a baseline care plan completed on 2/13/25 that acknowledged the presence of a Life Vest and heart failure but failed to provide person-centered initial goals or address specific health and safety concerns related to the Life Vest. The deficiency was confirmed during an interview with the Corporate Clinical Coordinator, Employee E7, on 2/28/25. The facility's failure to include Life Vest interventions in the baseline care plans for these residents indicates a lack of effective and person-centered care planning. This oversight could potentially impact the residents' health and safety, as the care plans did not address the necessary interventions to prevent decline or injury associated with the use of a Life Vest.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, resulting in deficiencies in accurately reflecting their current medical needs. Resident R70, who was admitted with diagnoses including sepsis, bacterial pneumonia, and dysphagia, had a physician's order for a 1500cc fluid restriction and an allergy to fish/shellfish. However, the care plan dated 2/3/25 did not include these critical details. This oversight was confirmed by a Registered Dietetic Technician during an interview. Similarly, Resident R90, who was admitted with difficulty swallowing, malnutrition, and aphonia, had a physician's order for Glucerna 1.2 via a feeding tube, with specific instructions for administration and water flushes. Despite these orders, the care plan dated 12/20/24 did not reflect the resident's current tube feed and flush orders. This deficiency was confirmed by a Registered Dietitian during an interview. Both cases highlight the facility's failure to update care plans to ensure they are person-centered and reflective of the residents' current medical needs.
Failure to Clarify Physician Orders for Residents
Penalty
Summary
The facility failed to clarify physician orders for four residents, leading to deficiencies in care. Resident R49 was admitted with a Life Vest, a wearable defibrillator, but the facility did not have a physician's order for its care. Despite the presence of a charging station and confirmation from the resident that they were wearing the Life Vest, the clinical record lacked the necessary orders. Similarly, Resident R314 was admitted with a Life Vest, confirmed by both the resident and the presence of a charging station, yet there was no physician order documented for its care. Additionally, Resident R70 had a physician order for a 1500cc fluid restriction, but the order did not specify which fluids were to be provided by nursing or dietary staff. Resident R57 had an order for enteral feeding with Nepro at 45 ml/hr, but the order did not specify the administration route or what the tube was providing. These omissions were confirmed by staff interviews, indicating a failure to clarify physician orders as required, which is a deficiency in the facility's responsibility to provide appropriate treatment and care according to orders and resident needs.
Inappropriate Administration of Oral Medications to NPO Resident
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services, as evidenced by the administration of oral medications despite the resident being NPO (nothing by mouth). The facility's policy on enteral feeding, dated 1/2/25, states that enteral feedings may be prescribed for individuals unable to take food by mouth in sufficient amounts. However, a review of Resident R90's clinical record revealed that the resident, who was admitted with diagnoses including high blood pressure, cancer, and diabetes, had a feeding tube and was ordered to be NPO. Despite this, current physician orders for Resident R90 included medications to be administered orally, such as Amoxicillin-Pot Clavulante, Levsin, and Synthroid. During an interview, the Director of Nursing confirmed that the facility failed to ensure the resident received appropriate treatment and services, as the medications were ordered to be taken by mouth, contrary to the resident's NPO status. This oversight was identified as a deficiency in the care provided to Resident R90.
Failure to Provide Complete Respiratory Care Orders and Plans
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, Resident R90 and Closed Resident Record CR264. For Resident R90, the facility did not obtain a complete physician order for the tracheostomy care, as the physician orders and care plan did not specify the correct kind and size of the tracheostomy tube used. Additionally, the care plan lacked appropriate respiratory care instructions for the resident, who had a tracheostomy and required specific care procedures. This deficiency was confirmed by the Director of Nursing during an interview. For Closed Resident Record CR264, the facility did not obtain a physician order for the use of a CPAP machine, nor did it develop a care plan with goals and interventions related to the resident's CPAP usage. The resident had diagnoses of high blood pressure, respiratory failure, and obstructive sleep apnea, which necessitated the use of a CPAP machine. The absence of a physician order and a care plan for CPAP usage was confirmed by the Corporate Clinical Coordinator. These deficiencies indicate a failure to adhere to the facility's policy on noninvasive ventilation and to ensure proper respiratory care for residents.
Incomplete Dialysis Communication for Resident
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident receiving hemodialysis. Resident R165, diagnosed with end-stage renal disease, diabetes mellitus, and abnormalities of gait and mobility, had physician orders for dialysis on Mondays, Wednesdays, and Fridays. However, a review of the resident's dialysis binder revealed that the dialysis communication forms were incomplete for two out of four days, specifically on 2/19/25 and 2/24/25. This deficiency was confirmed during an interview with Registered Nurse Employee E15, who acknowledged the incomplete communication forms.
Failure to Act on Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action on irregularities identified in the medication regimen reviews (MRR) for one resident. The facility's policy requires that recommendations from the pharmacist regarding drug therapy be communicated and acted upon in a timely manner. However, for a resident with diagnoses including high blood pressure, GERD, and hyperlipidemia, the pharmacist's recommendations to change the medication from Prilosec to Protonix due to a potential drug interaction with Clopidogrel were not implemented despite the physician's agreement. This issue persisted over several months, with multiple MRRs indicating the same recommendation without any change being made in the electronic medical record. Additionally, the pharmacist recommended considering the tapering and discontinuation of Omeprazole based on the Beer's Criteria, which identifies potentially inappropriate medications for older adults. Despite the physician agreeing to this recommendation, no action was taken. The Corporate Clinical Coordinator confirmed that the facility did not ensure that the irregularities submitted in the MRRs were acted upon in a timely manner, as required by the facility's policies and state regulations.
Improper Storage of Medications in Medication Cart
Penalty
Summary
The facility failed to properly store medical supplies in one of its medication carts, specifically the Ebensburg Second Hall Med Cart. During a medication cart review, it was observed that the narcotic lock box on this cart was not locked, which is a violation of the facility's policy requiring narcotics to be stored under double lock. Additionally, the cart contained a Humalog Insulin Pen that was expired and an Insulin Glargine Pen that did not have an opened date on it. These findings were confirmed by a Registered Nurse and the Director of Nursing during interviews, indicating a lapse in adherence to medication storage protocols.
Failure to Ensure Staff Competency for Life Vest Care
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to ensure that the nursing staff possessed the necessary competencies and skills to care for residents equipped with a Life Vest, a wearable defibrillator designed to protect against sudden cardiac death. This deficiency was identified through a review of job descriptions, clinical records, and staff interviews. The job descriptions for both the NHA and DON outlined their responsibilities to lead and manage the facility's operations and nursing services to ensure high-quality care. However, the facility did not provide adequate training or ensure that staff had the specific skills required to care for residents with Life Vests. This oversight resulted in an immediate jeopardy situation for two residents, identified as Resident R49 and Resident R314, who were at risk due to the staff's lack of training and competency in handling Life Vests. During an interview, both the NHA and DON acknowledged their failure to manage the facility effectively in this regard. The report cites specific Pennsylvania Code regulations that were violated, highlighting the responsibility of the licensee and management to ensure proper nursing services.
Facility Fails to Include Life Vest Management in Assessment
Penalty
Summary
The facility failed to implement and document a complete facility-wide assessment to determine the necessary resources for caring for its specific resident population. The facility's policy, dated 1/2/25, requires a comprehensive assessment to identify the resources needed for both day-to-day operations and emergencies. However, the facility's assessment did not include the use of Life Vests, which are wearable defibrillators for residents with specific cardiac conditions, as a condition requiring complex medical care and management. Two residents, identified as R49 and R314, were admitted to the facility with Life Vests, which were not accounted for in the facility's assessment. Resident R49 had a history of high blood pressure, septicemia, and heart failure, and was observed wearing a Life Vest with a charging station in his room. Similarly, Resident R314, with diagnoses of heart failure, diabetes, and high blood pressure, was also observed with a Life Vest and charging station. The facility's failure to include the management of Life Vests in their assessment was confirmed by the Nursing Home Administrator.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to properly coordinate hospice services for two residents, R59 and R90, who were receiving end-of-life care. For Resident R59, the facility did not include the hospice provider's contact information or instructions on accessing the hospice's 24-hour on-call system in the comprehensive care plan. This oversight was confirmed by the Corporate Clinical Coordinator during an interview. Resident R59 had been diagnosed with Alzheimer's Disease, malnutrition, and depression, and was receiving hospice care as indicated in the Minimum Data Set (MDS). Similarly, for Resident R90, the facility did not identify a hospice provider in the physician orders and failed to include necessary hospice coordination details in the care plan. Resident R90 had diagnoses of cancer, high blood pressure, and diabetes, and was also receiving hospice care. The Director of Nursing confirmed the lack of coordination and identification of hospice services for Resident R90 during an interview. These deficiencies indicate a failure to ensure the coordination of hospice services with facility services to meet the residents' needs for end-of-life care.
Inadequate Infection Control During Dressing Change
Penalty
Summary
The facility failed to implement proper infection control practices during a dressing change for Resident R8, who was diagnosed with coronary artery disease, diabetes, and Alzheimer's disease. The resident had an unhealed pressure ulcer, and a physician's order required enhanced barrier precautions (EBP) every shift, which includes the use of gown and gloves during high-contact care activities. However, during a wound care observation, the LPN did not use a gown and failed to clean the surface of the stand used after completing the dressing change. The LPN washed hands and changed gloves multiple times during the procedure but did not adhere to the EBP protocol by omitting the use of a gown. Additionally, the LPN confirmed during an interview that she did not implement the necessary infection control practices to prevent cross-contamination. This deficiency was identified as a failure to follow the facility's policy on enhanced barrier precautions and wound treatment management, which are designed to prevent the transmission of multidrug-resistant organisms.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, as per professional standards of practice. Resident R35, who was admitted with diagnoses including high blood pressure, diabetes, and heart failure, had stage 3 pressure ulcers on the left and right ischium. Despite a physician's order to cleanse the wounds and apply specific dressings daily, the Treatment Administration Record indicated that the prescribed treatment was not administered on several occasions. This was confirmed by the Director of Nursing during an interview. Additionally, the facility did not develop a care plan with goals and interventions for Closed Resident Record CR265, who had multiple pressure wounds and deep tissue injuries, including stage 4 and unstageable wounds. The resident's care plan lacked documentation of necessary interventions for these conditions. This oversight was confirmed by the Corporate Clinical Coordinator, highlighting a failure to adhere to the facility's policies on wound treatment management and pressure injury prevention.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving Resident R50. The resident, who has diagnoses of high blood pressure, hemiplegia, and Multiple Sclerosis, reported feeling verbally abused by Nurse Aide (NA) Employee E5. During care, NA Employee E5 yelled at Resident R50 and used inappropriate language, causing the resident emotional distress. This incident was reported by Registered Nurse (RN) Employee E4, who noticed signs of fearfulness in Resident R50 and immediately informed the unit nurse manager and facility administrator. The Nursing Home Administrator (NHA) conducted an interview with Resident R50, who confirmed the verbal abuse and expressed that her feelings were hurt by the interaction. NA Employee E5 admitted to yelling at the resident during a telephone interview, citing frustration and a bad night as reasons for the outburst. Further interviews revealed that Resident R50 continued to feel unsafe and dissatisfied with the care provided at the facility. The Director of Nursing confirmed that the facility failed to protect Resident R50 from verbal abuse. The facility's policy on abuse, neglect, and exploitation clearly defines verbal abuse and mandates protection for residents, but this policy was not effectively enforced in this case. The incident highlights a significant lapse in ensuring a safe and respectful environment for residents, particularly those with complex medical conditions like Resident R50.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans to meet the needs of two residents, R76 and R80. For Resident R76, the Minimum Data Set (MDS) assessment indicated diagnoses of dementia, obstructive uropathy, and renal insufficiency. The Care Area Assessment (CAA) Summary revealed that the Urinary Incontinence and Indwelling Catheter care area was triggered, and a decision was made to include it in the care plan. However, the care plan dated 1/16/24 did not include goals and interventions related to catheter care. Additionally, the Cognitive Loss/Dementia care area was also triggered, but the care plan failed to include goals and interventions for dementia. This was confirmed by the Licensed Practical Nurse Assessment Coordinator (LPNAC) during an interview on 3/14/24. Similarly, for Resident R80, the MDS assessment indicated diagnoses of dementia and high blood pressure. The CAA Summary revealed that the Cognitive Loss/Dementia care area was triggered, and a decision was made to include it in the care plan. However, the care plan initiated on 9/22/23 and revised on 1/26/24 did not include goals and interventions related to dementia. This deficiency was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview on 3/14/24. The Director of Nursing (DON) also confirmed that the facility failed to develop comprehensive care plans for these two residents during an interview on the same day.
Failure to Maintain Sanitary Conditions of Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for two residents. For Resident R2, the facility's policy required that nebulizer tubing and delivery devices be changed every seventy-two hours or as recommended by the manufacturer. However, during an observation, it was noted that Resident R2's nebulizer machine was not labeled with a date and was sitting on top of an unlabeled bag on a dresser. This was confirmed by a Registered Nurse (RN) during an interview. Resident R2 had multiple physician orders for inhalation medications, indicating a need for proper respiratory care and equipment maintenance. Similarly, for Resident R315, the facility's policy required that oxygen tubing and humidifiers be changed weekly if oxygen was used. During an observation, it was noted that Resident R315's nasal cannula was not labeled with a date. This was also confirmed by an RN during an interview. Resident R315 had a diagnosis of traumatic subarachnoid hemorrhage, hypertension, and multiple rib fractures, and was using oxygen via nasal cannula. The failure to label and date the respiratory equipment for both residents indicates a lapse in following the facility's policy and maintaining sanitary conditions.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in one of three medication carts and failed to properly secure medications and/or biologicals for two of six residents. Specifically, a tube of unlabeled Z-guard and peri-body cleanser was found on Resident R329's overbed table, and a Trelegy Ellipta inhaler was found on Resident R90's window sill. Both residents have diagnoses including COPD, hypertension, and diabetes. The items were confirmed and removed by Registered Nurse Employee E8 during the observation. Additionally, an unlabeled open tube of ciclopirox olamine cream was found in the bottom drawer of a medication cart on Hall 2 [NAME] unit. This was confirmed and removed by Registered Nurse Employee E9. The facility's policy on medication storage, which requires medications to be under direct observation or locked, and external products to be stored separately from internal and injectable medications, was not followed in these instances.
Infection Control Deficiencies in Equipment Disinfection and Wound Care
Penalty
Summary
The facility failed to properly disinfect reusable equipment between residents on one of the four nursing units observed. Specifically, a registered nurse was observed cleaning a glucometer with an alcohol prep pad instead of the approved disinfectant wipes as per facility policy and manufacturer's guidelines. This improper disinfection was confirmed by the nurse, who stated that she was trained to use the alcohol prep pad by the facility. Interviews with other staff members revealed inconsistencies in the understanding and implementation of the correct disinfection procedures for glucometers, further confirming the deficiency in infection control practices on the unit. Additionally, the facility failed to implement proper infection control practices during a dressing change for a resident with multiple medical conditions, including heart failure and hypertension. The licensed practical nurse did not clean the bedside table before placing clean supplies, used a pen from her pocket on the clean field, and handled the wound dressing supplies in a manner that risked contamination. The nurse also failed to set up a clean barrier field and did not follow proper hand hygiene and glove-changing protocols during the dressing change. These deficiencies were confirmed through staff interviews and direct observations, highlighting a failure to adhere to established infection control policies and procedures. The Director of Nursing acknowledged the lapses in proper disinfection and infection control practices, confirming the facility's failure to maintain a safe and sanitary environment for its residents.
Failure to Ensure Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an indwelling catheter. The resident, who had diagnoses of urinary tract infection, retention of urine, and diabetes, experienced issues with catheter blockage. A physician's order indicated that the catheter and catheter bag should be changed as needed for leakage or blockage. However, a Registered Nurse (RN) flushed the catheter multiple times with sterile water without verifying if there was a physician's order to do so. The RN later notified the Certified Registered Nurse Practitioner (CRNP) about the flushing but was unsure if it was in line with facility policy. Another RN stated that in such situations, they would check for a physician's order to flush the catheter or obtain one if it was not present. The Director of Nursing confirmed that the facility failed to provide appropriate treatment and services for the resident with the indwelling catheter. This deficiency was identified through a review of the facility policy, clinical records, and staff interviews.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 896 citations issued within 25 miles in the last 12 months — including the 16 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaver Healthcare And Rehabilitation Center | 4 mi | — | 1 | 0 |
| Rochester Residence And Care Center | 5 mi | — | 106 | 2 |
| Friendship Rehab And Health | 7 mi | — | 51 | 1 |
| Cedar Hill Healthcare And Rehabilitation Center | 7.1 mi | — | 2 | 0 |
| Sherwood Oaks | 7.4 mi | — | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.