Mon Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monongahela, Pennsylvania.
- Location
- 200 Stoops Drive, Monongahela, Pennsylvania 15063
- CMS Provider Number
- 396085
- Inspections on file
- 24
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Mon Valley Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not document that two residents or their representatives were invited to participate in care conferences, despite facility policies requiring resident-centered care planning and advance notice of conferences. One resident with HTN, diabetes, and post-amputation care needs had a discharge plan involving family support and home health, and a care conference note stated the resident and family declined the invite, yet no record of an actual invitation was found; the resident’s family member also reported never being invited and not receiving information on Medicare payment limits and length of stay. Another resident with HF, COPD, and a seizure disorder had a similar note indicating the resident and family declined the invite, but again there was no supporting documentation of an invitation. The DON acknowledged that the facility failed to document invitations for these two residents.
A resident with diabetes, hypertension, and a recent amputation was discharged home after rehab despite documentation that the resident lived alone and would not have supervision. The care plan called for discharge home with family support and home health, but progress notes repeatedly stated the resident lived alone, and the resident had requested an extended rehab stay with a new prosthesis. After an insurance appeal was denied, the resident was discharged home with borrowed DME and a sliding board intended for supervised use, but without the prosthetic leg, which remained at the facility. The DON acknowledged the expectation that the son would help, despite records showing the resident lived alone, and hospital records later documented the resident’s inability to ambulate or care for himself at home without the prosthesis.
A resident with diabetes, hypertension, and a recent amputation was discharged home after losing an insurance appeal, despite living alone and lacking funds for private pay. Although the care plan anticipated discharge with family support and home health, documentation showed that when the resident later wished to extend rehab with a new prosthesis, the SW was unavailable and nursing and rehab staff lacked updated insurance information. The family reported the resident was not offered help with Medicare/Medicaid or Social Security Disability applications, and the record contained no evidence of referrals or assistance with these benefits, reflecting a failure to provide required medically related social services and information on coverage and eligibility.
The facility did not maintain a fully operational call bell system on one nursing unit, as observed when central and room call lights failed to illuminate as expected. This issue was confirmed by the Maintenance Director, indicating residents could not reliably call for staff assistance.
Surveyors observed that several rooms on one nursing unit had soiled floors with black skid marks and cracked floor tiles, compromising the cleanliness and homelike environment required by facility policy. The NHA confirmed these deficiencies during the investigation.
Surveyors found that the facility did not post required Adult Protective Services (APS) contact information, including agency name, address, email, and phone number, in accessible areas for residents and their representatives. The DON confirmed the absence of this information, resulting in non-compliance with regulations requiring the posting of pertinent State agency and advocacy group contacts.
The facility did not display written information for residents or their responsible persons on how to apply for Medicare and Medicaid benefits or obtain refunds for payments covered by these programs, as confirmed by observation and the DON.
The facility did not consistently complete required dialysis communication forms for three residents with end stage renal disease, resulting in incomplete documentation of care and coordination with the dialysis center for multiple treatment dates, as confirmed by the DON.
The facility did not maintain required documentation for automatic sprinkler system inspections, with no records available for inspections in the last two quarters of the previous year. The Facility Maintenance Director confirmed the absence of these inspection records.
The facility did not complete one of the two required semi-annual kitchen exhaust hood cleanings, as documentation showed only one cleaning was performed and staff confirmed the lack of records for the second cleaning. This affected one smoke compartment.
The facility failed to maintain acceptable food storage practices, leading to potential contamination and microbial growth risks. Observations revealed black fuzzy material on the walk-in cooler's fans and ceiling, and significant ice buildup in the deep freezer, affecting stored food. These issues were confirmed by a dietary employee and the DON.
The facility failed to implement a Water Management Program to prevent Legionella and did not follow proper infection control during a dressing change. A nurse contaminated a clean dressing by not changing gloves after cleansing a wound and failed to wash hands before replacing a contaminated dressing.
A resident with COPD and heart conditions was not provided appropriate respiratory care as prescribed. The care plan lacked specific interventions for oxygen therapy, and observations revealed the resident's nasal cannula was not reapplied after a transfer, and the humidification cannister was repeatedly found empty. A nurse aide confirmed it was their responsibility to maintain the cannister, and the DON acknowledged the deficiency.
The facility did not inform residents or their representatives that signing the arbitration agreement was voluntary and failed to allow a 30-day rescission period. Instead, the agreement misleadingly stated a three-day revocation period and required immediate vacating if canceled. This affected all 20 admitted residents, as confirmed by the NHA.
A resident with multiple diagnoses, including a history of cancer and dizziness, exhibited slurred speech and nonsensical talking after receiving Lorazepam. An LPN noted the change but failed to notify the physician or document further assessment, contrary to facility policy. The DON confirmed the lack of notification, highlighting a deficiency in adhering to professional standards.
A facility failed to ensure a medication regime was free from unnecessary medications for a resident. Despite the facility's policy requiring clinical indications for psychotropic medication use, a resident was administered Haloperidol and Lorazepam without documented symptoms such as anxiety or nausea. The Director of Nursing confirmed the lack of documentation, and the MAR showed multiple administrations of these medications without corresponding symptom documentation.
A resident with hypertensive heart disease and macular degeneration continued to receive an ineffective antibiotic, Nitrofurantoin, despite lab results showing bacterial resistance. The facility's failure to act on these results and modify the treatment was confirmed by the DON and Nursing Home Administrator, highlighting a deficiency in monitoring antibiotic use.
The facility failed to provide training on Resident Rights to its staff, as revealed by a review of policy documents and staff interviews. The policy on in-service training, dated March 2024, aimed to ensure staff competency in enhancing residents' quality of life and care. However, no evidence of training on Resident Rights was found. The Nursing Home Administrator confirmed this deficiency, violating several Pennsylvania Codes related to licensee responsibility, management, and staff development.
The facility failed to provide effective communication training for two staff members, a Nurse Aide and an LPN, as required by their in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory QAPI training to four staff members, including a Nurse Aide, an administrative employee, an LPN, and a dietary employee, as required by the facility's in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide required behavioral health training for three staff members, including two nurse aides and a dietary employee, as per the facility's in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
Failure to Document Resident/Representative Invitations to Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to document that residents or their representatives were invited to participate in care conferences for two of five reviewed residents. Facility policies titled “Care Planning - Interdisciplinary Team” and “Care Plans, Comprehensive [NAME]-Centered,” both dated 4/14/25, state that residents, families, and/or legal representatives are encouraged to participate in care plan development and revisions, and that residents are informed of their right to participate and provided advance notice of care planning conferences. For one resident, admitted on an unspecified date with diagnoses including hypertension, diabetes, and post-surgical amputation care needs, the plan of care dated 1/14/26 included discharge planning to home with family support and home health services. A care conference note dated 12/23/25 stated that a care conference was held and that the resident and family declined the invite, but review of the clinical and paper records did not show documentation that the resident or family member had actually been invited. For a second resident, admitted on an unspecified date with diagnoses including heart failure, COPD, and a seizure disorder, a care conference note dated 12/2/25 similarly documented that a care conference was held and that the resident and family declined the invite. However, review of this resident’s clinical record also failed to show documentation that the resident or family member had been invited to the care conference. During an interview, a family member of the first resident reported that the facility did not provide information related to Medicare payment limitations and allowed time in the facility and stated that he was never invited to a care plan conference. In a separate interview, the DON confirmed that the facility failed to document the invitation of the resident or their representative to care conference meetings for two of five residents reviewed, in violation of cited Pennsylvania regulatory codes regarding resident rights, resident care policies, and nursing services.
Inappropriate Discharge of Resident Without Prosthesis and Adequate Support
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to remain in the facility and not transfer or discharge the resident unless the transfer or discharge was appropriate based on the resident’s health status. Facility policy stated that discharge planning must ensure a safe transition to a post-discharge setting that meets the resident’s health and safety needs and preferences. The resident had diagnoses including hypertension, diabetes, and a need for care following a surgical amputation, and the care plan identified discharge home with family support and home health services. However, multiple progress notes documented that the resident lived alone in an apartment and planned to discharge home after rehab, with no indication of consistent in-home supervision. Care conference documentation showed that a care conference was held, but the resident and family declined the invitation, and the plan of care was reviewed only with the IDT. Progress notes repeatedly recorded that the resident lived alone, and one note indicated the resident expressed a desire to extend the rehab stay with a new prosthesis, while staff lacked updated insurance information. Another note documented that the resident lost an insurance appeal and that the family chose to take the resident home that day, with arrangements for transportation and some DME (wheelchair cushion and sliding board) to be borrowed until ordered items were delivered. Interviews and hospital records further described that the resident was discharged home without his prosthetic leg and was instead provided a sliding board intended for use with supervision/assistance, despite documentation that he would be alone at home. The DON acknowledged that it was thought the resident’s son would help, but could not explain this expectation in light of the record showing the resident lived alone. The resident’s family member reported that the appeal for continued care was denied, that the resident was discharged only hours before a major snowstorm, that the resident was sent home without his prosthesis despite pleas not to discharge him without it, and that he lacked funds to pay out of pocket. Hospital documentation indicated the resident presented requesting placement, reporting inability to ambulate and care for himself at home without his prosthesis, and that the facility still had the prosthetic leg. The DON confirmed that the facility failed to permit the resident to remain in the facility and not transfer or discharge him unless the transfer or discharge was appropriate because his health had improved sufficiently so he no longer needed facility services.
Failure to Provide Medically Related Social Services and Benefits Assistance
Penalty
Summary
The facility failed to provide medically related social services to assist a resident in understanding and accessing insurance and public benefits needed to continue necessary care. Federal regulations at 42 CFR 483.10(g)(4) require that residents receive notices and information regarding Medicare and Medicaid eligibility and coverage in a format and language they understand, and the facility’s Director of Social Services job description included assisting discharged residents and families with placement options. The resident, who had diagnoses including hypertension, diabetes, and a need for care after a surgical amputation, was admitted for rehabilitation and had a care plan goal for discharge home with family support and home health services. A progress note documented that the resident lost an insurance appeal, the family chose to take the resident home that day, and arrangements were made for transportation and durable medical equipment, with the facility temporarily lending a wheelchair cushion and sliding board. Subsequent documentation showed that the resident later expressed a desire to extend the rehab stay with a new prosthesis, but the social worker was not available and nursing and rehab staff did not have updated insurance information. Another note indicated that personal care and continued stay at the SNF level without insurance coverage were offered to the resident’s son, who declined. During interview, the resident’s family member stated that the facility had been informed the resident lived alone without supervision upon discharge and lacked funds to remain as a private pay resident, and further stated the resident was not offered assistance with completing Medicare/Medicaid or Social Security Disability applications. Review of the clinical record confirmed there was no documentation of referrals or assistance with such applications, and the DON acknowledged that the facility failed to provide medically related social services to this resident.
Failure to Maintain Fully Functioning Resident Call Bell System
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system on the second-floor nursing unit, as required by facility policy. Observations revealed that when the central call light was activated in the North Hall, no resident room lights were illuminated above the doors. Additionally, in multiple instances, individual resident room call lights were illuminated above the doors, but the corresponding central hall lights for the South Hall and another hall were not illuminated. The Maintenance Director confirmed that the call bell system was not fully operational, preventing residents from reliably calling for staff assistance through the communication system.
Failure to Maintain Safe and Homelike Environment Due to Damaged and Soiled Flooring
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the second floor nursing unit. Observations revealed that one room had black skid marks and soiled floor tiles, another room had cracks in the tiles at the entrance, and a third room had multiple cracked floor tiles. These conditions were confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to maintain the required environment as outlined in the facility's housekeeping policy.
Failure to Post Required APS Contact Information
Penalty
Summary
The facility failed to post the required contact information for Adult Protective Services (APS) in areas accessible and understandable to residents and their representatives. Observations conducted in the first-floor lobby and the second-floor nursing unit revealed that no elements of the APS contact information, including agency name, address, email, or phone number, were posted or accessible. This omission was confirmed during an interview and rounds with the Director of Nursing, who acknowledged that the required information was not displayed in the building. The deficiency was identified during a survey, which found that the facility did not comply with regulations mandating the posting of a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups. This list must include the State Survey Agency, State licensure office, APS, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit, along with a statement informing residents of their right to file complaints. The lack of posted APS contact information constituted non-compliance with state code requirements.
Failure to Display Required Medicare and Medicaid Information
Penalty
Summary
The facility failed to display written information for residents and/or their responsible persons regarding how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs. During observations of the first-floor lobby and the second-floor nursing unit posting locations, it was noted that this required information was not posted. In an interview, the Director of Nursing confirmed that the facility did not have the necessary written information displayed as required by regulations. No specific residents or medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for three residents with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, licensed nurses are required to communicate with the dialysis center using a designated communication form or other written/telephonic means, documenting information such as medication administration, treatment orders, laboratory values, vital signs, advanced directives, nutrition/fluid management, treatments provided, adverse reactions, changes in condition, injuries, and transportation concerns. However, review of the clinical records and dialysis communication forms for the three residents revealed multiple instances where these forms were incomplete on several treatment dates. The affected residents had complex medical histories, including diagnoses of end stage renal disease, hypertension, diabetes, heart disease, and bladder cancer, and were scheduled for dialysis at specific times and days each week. Despite these needs, the required communication forms were not fully completed for numerous dialysis sessions, as confirmed by the Director of Nursing. This failure to ensure ongoing and thorough communication with the dialysis center was identified through review of facility policy, clinical records, and staff interviews.
Failure to Maintain Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by missing documentation for sprinkler system inspections in two instances. During a documentation review, it was found that there was no verification of any sprinkler inspections being performed in the last two quarters of the previous twelve months. The last recorded inspection was on October 15, 2024. This lack of documentation was confirmed in an interview with the Facility Maintenance Director, who acknowledged the absence of records for the required inspections.
Plan Of Correction
The quarterly sprinkler inspection will be scheduled by the Maintenance Director with completion expectation sprinkler inspection vendor by 8-8-25. I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Missed Semi-Annual Kitchen Hood Cleaning
Penalty
Summary
The facility failed to complete one of the two required semi-annual cleanings of the kitchen exhaust hood, as mandated by NFPA 101 and NFPA 96 standards for cooking facilities. Documentation and observation on July 2, 2025, revealed that the last hood cleaning was performed on December 22, 2024, and there was no documentation available for the subsequent required cleaning. This deficiency affected one of nine smoke compartments within the facility. During interviews, both the Facility Administrator and Maintenance Director confirmed the absence of documentation for the missed semi-annual hood cleaning. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission and or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. The semi-annual hood cleaning will be scheduled by the Maintenance Director with completion expectation from hood cleaning vendor by 8-8-25.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to maintain acceptable practices for food storage, which increased the risk of food-borne illness in the main kitchen. During an observation, the walk-in cooler was found to have black fuzzy material throughout the fans and on the ceiling, with a cart of several trays of food stored underneath. Additionally, the deep freezer had abundant ice buildup on the ceiling, fan areas, and shelving, with several boxes of frozen food having blocks of ice buildup. These conditions were confirmed by a dietary employee and the Director of Nursing and Director of Maintenance during interviews.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement an effective Water Management Program to prevent and control water-borne contaminants, such as Legionella. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged that the facility had not had a Water Management Program in place since 2023. The absence of this program poses a risk of exposure to water-borne bacteria, which can lead to serious health conditions like Legionnaires' Disease. Additionally, the facility did not adhere to proper infection control practices during a dressing change for a resident. During an observation, a registered nurse placed wound care items on a resident's overbed table alongside personal items, potentially contaminating the clean field. The nurse then failed to change gloves after cleansing the wound and placed a clean dressing with the same soiled gloves, contaminating it. After leaving the room to obtain a new dressing, the nurse did not wash hands before donning new gloves and replacing the contaminated dressing. This lapse in infection control was confirmed by the nurse involved.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R1, who was admitted with diagnoses including hypertensive heart disease, heart failure, and COPD. The resident was prescribed continuous oxygen therapy at 3 LPM via nasal cannula. However, the care plan did not include specific interventions for oxygen therapy, such as maintenance of humidification cannisters, changing of tubing, monitoring for skin breakdown, and recognizing signs and symptoms related to oxygen therapy that should be reported to a provider. During observations, it was noted that the resident's nasal cannula was removed during a transfer and not reapplied, and the humidification cannister on the oxygen concentrator was empty. Despite the presence of a water jug next to the concentrator, the cannister remained unfilled. A nurse aide confirmed that maintaining water in the humidification cannister was part of their responsibilities, yet it was found empty on multiple occasions. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for the resident.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to uphold residents' rights regarding binding arbitration agreements. Specifically, the facility did not inform residents or their representatives that signing the arbitration agreement was voluntary, nor did it allow them the right to rescind the agreement within 30 calendar days of signing. Instead, the agreement misleadingly stated that residents had only a three-day revocation period and required them to make immediate arrangements to vacate the facility if they chose to cancel the agreement. This deficiency affected all 20 residents admitted to the facility, as confirmed by the Nursing Home Administrator during an interview.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for Resident R21, who was admitted with multiple diagnoses including a history of colon cancer, aneurysm of the aorta, cancer of the parotid gland, dizziness, and unsteadiness on feet. On a specific date, a progress note by an LPN indicated that Resident R21 exhibited slurred speech and nonsensical talking after being administered Lorazepam. The LPN documented that the oncoming shift should monitor the resident due to the medication administration but did not document any further assessment or notification of the physician regarding the resident's change in condition. The facility's policy on changes in a resident's condition requires staff to notify the attending physician of any significant changes, such as adverse reactions to medication or changes in mental status. However, the clinical record lacked documentation of any notification or further assessment following the observed change in Resident R21's condition. During an interview, the Director of Nursing confirmed that the LPN did not notify anyone about the resident's condition change, which is a failure to adhere to the facility's policy and professional standards of practice.
Failure to Ensure Medication Regime Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure a medication regime was free from potentially unnecessary medication for a resident, identified as Resident R21. The facility's policy on psychotropic medication use requires that residents do not receive medications that are not clinically indicated to treat a specific condition. However, a review of Resident R21's clinical records and interviews with staff revealed that there was no documentation of diagnoses or symptoms such as anxiety, hallucinations, or nausea that would justify the use of psychotropic medications. Despite this, Resident R21 was administered Haloperidol and Lorazepam without proper documentation of the symptoms these medications were intended to treat. The Director of Nursing confirmed the lack of documentation for Resident R21's symptoms, and it was noted that the facility had to contact the Hospice office to obtain relevant notes. The Medication Administration Record (MAR) indicated that Haloperidol and Lorazepam were administered multiple times without corresponding documentation of the symptoms they were prescribed for. This oversight was further confirmed during interviews with the Nurse Practitioner and the Director of Nursing, highlighting a failure in the facility's medication management practices.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to monitor antibiotic use for a resident, identified as Resident R8, which led to the continuation of an ineffective antibiotic treatment. The facility's policy on Antibiotic Stewardship, dated March 2024, mandates that lab results and the current clinical situation be communicated to the provider to determine appropriate antibiotic therapy. However, this protocol was not followed for Resident R8. The resident, who had diagnoses of hypertensive heart disease and macular degeneration, was initially prescribed Nitrofurantoin for a urinary tract infection. A urine culture and sensitivity report later revealed that the bacteria causing the infection were resistant to Nitrofurantoin, but the resident continued to receive this medication until the original end date of the order. The failure to act on the lab results was confirmed during interviews with the Director of Nursing and the Nursing Home Administrator. They acknowledged that the facility did not respond to the lab results indicating resistance to the prescribed antibiotic and did not modify the treatment to an effective antibiotic. This oversight was identified as a deficiency in the facility's monitoring of antibiotic use, as per the facility's policy and state regulations.
Failure to Provide Training on Resident Rights
Penalty
Summary
The facility was found to have a deficiency due to its failure to provide training on Resident Rights to its staff. This was determined through a review of the facility's policy and documents, as well as staff interviews. The policy titled 'Inservice Training, All Staff,' dated March 2024 and previously reviewed in March 2023, stated that the primary objective of in-service training is to ensure staff can interact in a manner that enhances residents' quality of life and care, demonstrating competency in training topics. However, the review of the facility's education documents did not show any evidence that training on Resident Rights was offered. During an interview conducted on June 17, 2024, the Nursing Home Administrator confirmed the facility's failure to provide this essential training. This deficiency is in violation of several Pennsylvania Codes, including 28 Pa Code: 201.14 (a) regarding the responsibility of the licensee, 28 Pa Code: 201.18 (b)(1) concerning management, and 28 Pa Code: 201.20 (a)(c) related to staff development.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for two staff members, Nurse Aide Employee E7 and Licensed Practical Nurse Employee E10. The facility's policy on in-service training, last reviewed in March 2023, mandates that all staff participate in training to enhance residents' quality of life and care. However, a review of training records revealed that Employee E7, hired on May 21, 2019, did not receive effective communication training between May 21, 2023, and May 21, 2024. Similarly, Employee E10, hired on May 11, 2008, lacked documented training in effective communication between May 11, 2023, and May 11, 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on June 11, 2024.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, specifically Employees E7, E9, E10, and E11. According to the facility's policy on in-service training, all staff are required to participate in training to ensure they can enhance residents' quality of life and care. However, a review of the training records revealed that these employees did not have documented QAPI training within the specified time frames. Employee E7, a Nurse Aide, did not receive QAPI training between May 21, 2023, and May 21, 2024. Employee E9, an administrative staff member, lacked training between February 12, 2023, and February 12, 2024. Employee E10, an LPN, did not have training between May 11, 2023, and May 11, 2024. Lastly, Employee E11, a dietary staff member, was not trained between March 1, 2023, and March 1, 2024. The Nursing Home Administrator confirmed this deficiency during an interview.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for three staff members, identified as Employees E7, E8, and E11. The facility's policy on in-service training, last reviewed in March 2023, mandates that all staff participate in training to enhance residents' quality of life and care. However, a review of training records revealed that Nurse Aide Employee E7, hired on 5/21/19, did not receive behavioral health or dementia training between 5/21/23 and 5/21/24. Similarly, Nurse Aide Employee E8, hired on 1/23/08, and Dietary Employee E11, hired on 3/1/18, also lacked documented training in these areas for the specified periods. The Nursing Home Administrator confirmed this deficiency during an interview on 6/17/24.
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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