Sherwood Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranberry Township, Pennsylvania.
- Location
- 100 Norman Drive, Cranberry Township, Pennsylvania 16066
- CMS Provider Number
- 395549
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Sherwood Oaks during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was able to leave the unit unsupervised after staff failed to maintain adequate supervision and the wander guard system was improperly disabled. Staff did not update the care plan in a timely manner to reflect the resident's increased elopement risk, and multiple staff were unaware of the resident's whereabouts during the incident, resulting in an elopement event.
The NHA and DON did not ensure proper supervision for a resident at high risk for elopement, resulting in the resident leaving the facility and creating an immediate jeopardy situation. Review of job descriptions, records, and staff interviews confirmed that required management and oversight were not provided, leading to noncompliance with professional standards and facility policies.
The facility did not comply with NFPA 101 requirements for self-closing doors, as observed in the basement library where a door was missing a closure arm. This was confirmed by the maintenance supervisor.
The facility was found to have deficiencies in smoke barrier doors on one of its building levels. Observations revealed large gaps in the doors next to the administration office and room 430, allowing air flow and compromising their effectiveness. The maintenance supervisor confirmed these deficiencies during the survey.
A facility was found to have an alcohol-based hand rub (ABHR) dispenser improperly mounted above an ignition source in a resident room, violating NFPA 101 safety standards. This deficiency was confirmed by the maintenance supervisor during a survey.
The facility failed to properly store medications in three of four medication carts, with opened multi-dose packages of Ipratropium/albuterol and Xdemvy eye drops found without dates. This was confirmed by nursing staff and the Director of Nursing, indicating a breach in the facility's medication disposition policy.
Sherwood Oaks failed to develop comprehensive care plans for two residents, omitting critical medical interventions. One resident's care plan did not address the use of a Dexcom G7 Receiver Device for diabetes management, while another's lacked goals for antiplatelet medication use for CVA prophylaxis. These omissions were confirmed by facility staff, indicating non-compliance with federal care planning requirements.
A facility failed to develop comprehensive care plans for two residents and did not follow physician orders for a lab test for a resident on anticoagulant therapy. The missed INR test led to the resident experiencing excessive anticoagulation symptoms, including bruising and nausea, and resulted in a dangerously high INR level. This oversight caused the resident to be sent to the emergency room and later readmitted after suffering a hemorrhagic stroke.
A resident with cognitive impairment and physical dependencies was left unsupervised in the bathroom, resulting in a fall and severe injuries, including a head laceration and a fractured shoulder. The incident highlighted a failure in ensuring proper supervision and assistance, as confirmed by the DON.
The facility failed to provide sufficient nursing staff, resulting in delayed call bell responses for several residents. Grievances and interviews revealed that residents experienced long wait times for assistance, with some instances exceeding 30 minutes. The Director of Nursing acknowledged challenges in meeting response expectations due to staffing shortages and high resident needs.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of three residents, as required. The residents, with various medical conditions, were transferred without the necessary notifications, which was confirmed by the Nursing Home Administrator.
A resident with dementia and recent joint replacement surgery eloped from the facility due to inadequate assessment and supervision. Despite documented confusion and independent ambulation, the resident's care plan was not updated to reflect elopement risk. Additionally, two other residents were not routinely assessed for wandering risk, contrary to facility policy.
The facility failed to ensure resident safety and adherence to care plans, resulting in incidents involving four residents. These included improper transfers and rough handling, indicating a failure to follow care plans and ensure resident safety.
The facility failed to disinfect a pulse oximeter between residents and did not use gloves during eye drop administration, as observed during medication passes for two residents. These actions were confirmed by staff interviews and violated the facility's infection control policies.
The facility failed to maintain the confidentiality of residents' medical information on one of three medication carts. A nurse left a computer screen open with resident information visible to anyone passing by, along with a report sheet and a binder labeled with a resident's name and fluid restrictions.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation of a resident. The resident, admitted with multiple diagnoses including heart failure and osteoporosis, suffered a fractured hip after a fall and later had an abrasion and a bruise. The DON confirmed the facility's failure to implement necessary policies.
The facility failed to provide adequate protection from hazards for hot pack use, resulting in a reddened area on a resident's knee that required monitoring until it healed. The incident occurred when a Nurse Aide applied hot packs, contrary to the facility's policy that only nurses should handle hot/cold packs. Interviews and a review of policies confirmed the lapse in adherence to established protocols.
A facility failed to properly secure medications when an RN left a Trelegy Ellipta inhaler unattended on top of a medication cart outside a resident's room, making it accessible to anyone passing by in the hallway.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including altered mental status, encephalitis, and unspecified lack of coordination, was assessed as having severe cognitive impairment and required partial to moderate assistance with mobility. Initial elopement risk assessments did not identify wandering behaviors, but subsequent assessments documented wandering, confusion, and exit-seeking behaviors. Despite these findings, the resident's care plan was not updated to reflect the increased risk for wandering and elopement until twenty days after the risk was identified. On the day of the incident, the resident independently left the skilled unit and navigated to another area of the facility without staff knowledge. Multiple staff statements indicated that the resident was seen in various locations prior to the elopement, but staff did not maintain adequate supervision or respond to the resident's movements. The wander guard system, which was intended to prevent such incidents, was disabled by a staff member for another resident without confirming that other at-risk residents were not in the vicinity. As a result, the resident was able to exit the unit undetected, and the alarm did not sound when the resident left the area. Staff interviews and documentation confirmed that the alarm system was not properly monitored and that staff were unaware of the resident's whereabouts during the incident. The failure to provide adequate supervision and to ensure the effectiveness of the wander guard system resulted in the resident's elopement, creating an immediate jeopardy situation. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not meet the required standard of supervision for residents at risk for wandering and elopement.
Failure to Supervise High-Risk Resident Resulting in Elopement and Immediate Jeopardy
Penalty
Summary
The facility failed to ensure effective management and supervision for residents identified as high risk for elopement, resulting in an actual elopement event that created an immediate jeopardy situation. Review of job descriptions for the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed their responsibilities to manage the facility and nursing services in accordance with federal, state, and local regulations, and to ensure the highest degree of quality care. However, based on facility and clinical records, as well as staff interviews, it was determined that the NHA and DON did not fulfill these responsibilities, as proper supervision was not provided for residents at high risk for elopement. This failure led to a resident elopement and demonstrated noncompliance with professional standards of practice and facility policies.
Missing Closure Arm on Basement Library Door
Penalty
Summary
The facility failed to meet the requirements for doors with self-closing devices on one of its three building levels. During an observation on March 11, 2025, at 10:01 a.m., it was noted that the basement library door was missing a closure arm. This deficiency was confirmed through an interview with the maintenance supervisor, who acknowledged the absence of the arm from the door closure device.
Plan Of Correction
Work order #192926 added to our computerized work order system to replace door closer for Medical Suite Entrance to one which complies with Life Safety Code 7.2.1.8.2. The device has been replaced and will be monitored every week for 4 weeks and reported in quarterly QAPI meeting.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to meet the smoke barrier requirements on one of its three building levels. During an observation conducted on March 11, 2025, between 11:00 a.m. and 11:24 a.m., it was noted that the smoke barrier doors had large gaps that would allow air flow, compromising their effectiveness. Specifically, the smoke barrier doors next to the administration office and those next to room 430 were identified as having these deficiencies. An interview with the maintenance supervisor at 11:24 a.m. on the same day confirmed the presence of these deficiencies at the time of the survey.
Plan Of Correction
Work order # 192928 added to our computerized work order system to replace the astragals of smoke barrier doors between West and Lake halls on our Skilled Nursing Unit limiting the gap of the doors to 1/8 of an inch or less. The astragal have been replaced and will be monitored monthly for 4 months and reported at our quarterly QAPI meeting.
Improper Placement of ABHR Dispenser
Penalty
Summary
The facility failed to comply with the alcohol-based hand rub dispenser requirements as outlined by NFPA 101. During an observation on March 11, 2025, at 10:40 a.m., it was noted that a resident room, specifically room 440, had an alcohol-based hand rub dispenser mounted above an ignition source. This placement is in violation of the safety standards that prohibit dispensers from being installed within 1 inch of an ignition source. The deficiency was confirmed through an interview with the maintenance supervisor at the time of the survey.
Plan Of Correction
Work order #192927 added to our computerized work order system to address and relocate any/all alcohol-based hand rubbing stations which may be located above any electrical devices throughout the Skilled Nursing Unit. All sanitizing stations have been relocated and will be monitored weekly for 4 weeks and reported at our quarterly QAPI meeting.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to properly store medications in three of four medication carts, specifically the West cart, Founder Cart, and Lake Cart. During an observation, it was noted that the West medication cart contained an opened multi-dose foil package of Ipratropium/albuterol without a date. This was confirmed by RN Employee E2, who acknowledged that the medication should have been dated when opened. Similarly, the Founder's medication cart also had an opened multi-dose foil package of Ipratropium/albuterol without a date, confirmed by LPN Employee E3. Additionally, the Lake medication cart was found to have an opened Xdemvy eye drop container without a date, which was confirmed by RN Employee E4. The Director of Nursing later confirmed that the facility failed to properly store medications in these three medication carts. The facility's policy on the disposition of medications, which requires that expired or no longer required medications be properly dispositioned, was not adhered to, leading to this deficiency.
Plan Of Correction
1. Undated multidose foil package breathing treatments and the eye drops were disposed of on 03/03/2025 and 03/04/2025. 2. Following the findings, the medication carts were audited for other undated multidose foil package breathing treatments or eye drops. None were found. 3. DON/designee educated RNs and LPNs on the need to date multidose foil package breathing treatments and eye drop containers when they are opened. 4. DON/designee will audit med cart three times a week for 2 weeks and weekly thereafter until substantial compliance is achieved. 5. Results of the audits will be reported at the quarterly QA meeting.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
Sherwood Oaks was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically in the development and implementation of comprehensive care plans for residents. The facility's policy mandates that care plans be individualized and reviewed regularly, yet deficiencies were identified for two residents. The care plans failed to address specific medical interventions and goals related to their conditions, as required by federal regulations. Resident R13, admitted with diagnoses including diabetes, high blood pressure, and stroke, did not have a person-centered care plan addressing the use of a Dexcom G7 Receiver Device for continuous glucose monitoring. Despite a physician's order for the device, the care plan lacked goals and interventions related to its use. This oversight was confirmed by the Director of Nursing during an interview, highlighting a gap in the facility's adherence to its own care planning policy. Similarly, Resident R23, with diagnoses of Parkinsonism, chronic pain syndrome, and polyneuropathy, was receiving antiplatelet medication for CVA prophylaxis. However, the care plan did not include goals and interventions related to this medication. The Registered Nurse Assessment Coordinator confirmed this omission, indicating a failure to incorporate critical aspects of the resident's medical treatment into the care plan. These deficiencies demonstrate a lack of comprehensive care planning for residents with complex medical needs.
Plan Of Correction
1. The care plan for R13 and R23 have been updated to include Dexcom use and anti-platelet medication. 2. All resident care plans were evaluated for the need to add interventions related to Dexcom use and anti-platelet medication. No other issues were found. 3. All RNs and LPNs will be educated by the Director of Nursing or designee regarding the need to care plan Dexcom use and anti-platelet medication. 4. The Director of Nursing/designee will audit care plans weekly for one month or until substantial compliance is achieved to ensure residents with Dexcom monitors and anti-platelet medication are addressed on the comprehensive plan of care. 5. Results will be reviewed at the Quarterly QA Meeting.
Failure to Follow Physician Orders Leads to Resident Harm
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as confirmed by the Director of Nursing. Additionally, the facility did not follow physician orders for a lab test for one resident, leading to a significant deficiency. The resident in question, who was admitted with diagnoses including anemia, high blood pressure, and atrial fibrillation, was on a regimen of Coumadin, an anticoagulant medication. The physician had ordered an INR test to be conducted on a specific date to monitor the resident's blood clotting levels, but this test was not transcribed into the electronic health record and was therefore missed. As a result of the missed INR test, the resident experienced symptoms consistent with excessive anticoagulation, including bruising and nausea, and was eventually found to have an extremely high INR level. This led to the resident being sent to the emergency room with a dangerously high INR and subsequently readmitted to the facility after suffering a hemorrhagic stroke. The Director of Nursing confirmed the failure to follow physician orders, which was identified as the root cause of the resident's high INR and subsequent medical complications.
Plan Of Correction
1 - The facility is unable to retroactively correct the INR testing order for 11/24/2024. 2 - The facility reviewed all residents with INR testing orders. No issues were found. 3 - The Director of Nursing/designee will educate RN, LPN, physicians, and CRNP on proper entry of an INR testing order. 4 - The Director of Nursing/designee will audit new orders for INR testing for new orders for meds requiring testing, 5 days a week for 3 weeks, weekly for 3 weeks, then monthly until substantial compliance is achieved. 5 - Results will be reviewed at the Quarterly QA Meeting.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, identified as Resident R6, leading to an accident. Resident R6, who was admitted to the facility in 2017, has a history of muscle weakness, macular degeneration, and allergic rhinitis, and is moderately cognitively impaired with a BIMS score of 12. The resident is dependent on assistance for activities such as toileting, transfers, and bathing, and requires supervision for personal hygiene tasks. On the day of the incident, the resident was left alone in the bathroom to brush her teeth, with the wheelchair's right lock not secured, despite being dependent on assistance for such activities. The incident occurred when the resident was found on the bathroom floor with a laceration on the right side of her head and a skin tear on her left forearm. The resident was not communicating with staff and was later diagnosed with a comminuted proximal humeral fracture. Staff statements indicated that the resident was left alone after being asked if she needed more time, and the bathroom call bell cord was draped around the sink faucet. The Director of Nursing confirmed the facility's failure to provide adequate supervision and assistance, contributing to the resident's fall and subsequent injuries.
Plan Of Correction
Resident R6 was re-evaluated by therapy for her ability to be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The plan of care has been updated. All residents will be re-evaluated to determine who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. This will be noted in the plan of care as indicated. Nurses, Nursing Assistants, and Therapists will be educated by the Director of Nursing and/or designee on who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. The details will be noted in the plan of care as indicated. Audits will be conducted by observing staff providing care and asking staff how to identify who can be left unsupervised at the bathroom sink to promote independent self-care such as but not limited to washing their face, brushing their teeth. Ten random audits will be completed weekly for 4 weeks or until substantial compliance is achieved. Results will be reviewed at the Quarterly QA meeting.
Insufficient Staffing Leads to Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by extended call bell response times for several residents. The facility's policy requires that all residents have a call light or alternative communication device within reach and that staff respond promptly to call lights. However, multiple grievances and interviews with residents revealed that call bells were not answered in a timely manner, leading to concerns about resident safety and well-being. Resident R2's son reported that his mother experienced delays in call bell responses, which he feared increased her risk of falls. The facility's device activity report confirmed prolonged response times, with some instances exceeding 30 minutes. Resident R4 also reported long wait times for assistance, resulting in accidents, and the device activity report corroborated these claims with several instances of delayed responses. Resident R5 expressed similar concerns, noting that staff shortages contributed to the delays, and the device activity report showed multiple instances of extended wait times. Interviews with other residents and staff further highlighted the issue of insufficient staffing, particularly during busy times such as after 7:00 p.m. The Director of Nursing acknowledged the challenges in meeting call bell response expectations due to competing demands and a high number of residents requiring assistance. Despite the facility's efforts to address these concerns, the report concluded that the facility failed to provide adequate nursing services to ensure the highest practicable well-being of the residents involved.
Plan Of Correction
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. Residents will be educated on the grievance process, expectations for call bell response times, and the opportunity to share their concerns regarding staffing and call bell response times with the facility leadership anonymously, verbally, and/or in writing through resident council meetings. R2, R4, R5, R6, R7, and R8 will be interviewed to determine if improvements have been made. All residents have the potential to be affected by the deficient practice. Education for all nursing staff was completed regarding answering call bell times promptly (with a goal of less than 15 minutes), when rounding. An audit will be conducted by the Director of Nursing/designees on call light response times using the call light report five days a week for two weeks, then 4 times a week for an additional 2 weeks and then 3 times a week for an additional two weeks for a total of 6 weeks. The call bell report will be reviewed by DON/designees to track and trend peak call bell times to improve on timely response to resident needs. Any residents that do not have their call bell answered within the accepted time frame of less than 15 minutes will be interviewed and team members will be educated. At the next resident council meeting, we will discuss call bell response times and if they have improved. The results of these audits will be shared with the administrator and reviewed by the QAPI Committee.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of three residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. The records for three residents, who were transferred to the hospital, lacked documented evidence of written transportation notifications to the Ombudsman. The Nursing Home Administrator confirmed the absence of such notifications during an interview. Resident R1, diagnosed with hypertension, anemia, and atherosclerotic heart disease, was transferred to the hospital and returned to the facility without the required notification. Resident R2, with osteoporosis, obstructive sleep apnea, and dysphagia, was transferred and did not return, also without notification. Similarly, Resident R3, diagnosed with hypertension, arthritis, and a thyroid disorder, was transferred and did not return, with no notification provided. The failure to notify the Ombudsman was acknowledged by the Nursing Home Administrator.
Failure to Identify and Manage Elopement Risk
Penalty
Summary
The facility failed to identify and manage the elopement risk for a resident, leading to an incident where the resident left the skilled nursing unit without supervision. The resident, who had a history of non-Alzheimer's dementia and had undergone joint replacement surgery, was admitted to the facility and initially assessed as not being at risk for wandering or elopement. Despite this assessment, the resident demonstrated behaviors such as self-transferring and ambulating independently, which were documented in nursing progress notes. These behaviors, coupled with cognitive deficits and confusion, were not adequately addressed in the resident's care plan, resulting in the resident eloping from the facility. The incident occurred when the resident was last seen in her room at approximately 3:15 p.m. and was discovered missing at 3:30 p.m. A search was conducted, and the resident was found by security walking near an adjacent building. The resident had left the skilled nursing unit in an attempt to 'feed her fish,' indicating confusion and a lack of understanding of her surroundings. The facility's failure to reassess the resident's elopement risk, despite documented evidence of increased ambulation and confusion, contributed to the incident. Additionally, the facility did not conduct routine Wander Risk Assessments for two other residents, as required by their policy. These assessments are crucial for identifying residents at risk of wandering and ensuring appropriate measures are in place to prevent such incidents. The lack of routine assessments and failure to update care plans for residents with changing conditions highlight deficiencies in the facility's management of elopement risks.
Failure to Ensure Resident Safety and Adherence to Care Plans
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by incidents involving four residents. Resident R2, who required assistance from two staff members for transfers, was transferred by a single Nurse Aide using a pivot disc, resulting in the resident sliding off the bed and being lowered to the floor. Resident R134, who also required assistance from two staff members and a full-body lift for transfers, was transferred by two staff members using a walker, which was not in accordance with the care plan. Resident R134 had a history of falls and fractures, including a fractured right hip after a fall during a transfer. Resident R135, who had dementia and a history of falls, was subjected to rough handling by an LPN who kicked the resident's foot and was verbally rough. Resident R9, who required a sit-to-stand lift and assistance from two staff members for transfers, was transferred by a single Nurse Aide, resulting in the resident being lowered to the floor when their legs began to slide. None of these incidents resulted in injuries, but they indicate a failure to follow care plans and ensure resident safety. The Director of Nursing confirmed that the facility did not ensure residents were free from abuse and neglect for four of the six residents reviewed. The facility's policy aimed to provide a safe environment and prevent all forms of abuse and neglect, but the incidents involving Residents R2, R134, R135, and R9 demonstrate a failure to adhere to these policies. The facility's documentation and staff interviews revealed that the necessary care and services were not consistently provided, leading to these deficiencies.
Infection Control Deficiencies in Equipment Disinfection and Eye Drop Administration
Penalty
Summary
The facility failed to properly disinfect reusable equipment between residents and did not implement infection control practices during the administration of eye drops. Specifically, a registered nurse (RN) used a pulse oximeter on a resident without disinfecting it before placing it back on the medication cart. This was confirmed by the RN during an interview. Additionally, another RN administered eye drops to a resident without wearing gloves, which was also confirmed during an interview. The deficiencies were observed during medication passes for two residents. The facility's policies on cleaning non-critical patient care equipment and medication administration for eye drops were not followed. The policies require proper disinfection of shared equipment and the use of gloves during eye drop administration to prevent the transmission of microorganisms. The failure to adhere to these policies was confirmed through staff interviews and direct observations by the surveyors.
Failure to Maintain Confidentiality of Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of three medication carts. During an observation, a registered nurse left a computer screen open with resident information visible to anyone passing by in the hallway. Additionally, a report sheet with resident information and a binder labeled with a resident's name and fluid restrictions were also visible on the medication cart. This was confirmed by the registered nurse during an interview, indicating a breach of privacy and confidentiality of resident health information.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically for Resident R134. The facility's policy on Abuse, Neglect, Exploitation, last reviewed on 2/21/24, indicated that residents should be protected from all forms of abuse, including injuries of unknown origin, and that such cases should be identified, investigated, and reported to state agencies as required. Resident R134, who was admitted with multiple diagnoses including heart failure, hallucinations, Myelodysplastic disease, heart disease, and osteoporosis, suffered a fractured right hip after a fall during a transfer. A subsequent skin assessment revealed an abrasion on the left hip and a dark purple bruise on the right lateral back. The Director of Nursing confirmed that the facility did not implement the necessary policies and procedures to prevent abuse, neglect, and exploitation for Resident R134.
Failure to Provide Adequate Protection from Hot Pack Hazards
Penalty
Summary
The facility failed to provide adequate protection from hazards for hot pack use for one of five residents, resulting in a reddened area that required monitoring until it healed 8 days later. Resident R18, who had a history of repeated falls and bilateral primary osteoarthritis of the knees, had a care plan that included the application of hot/cold packs to her knees. On the evening of the incident, a Nurse Aide (NA) placed hot packs on Resident R18's knees, which led to the development of a 3.5 cm x 2 cm area of erythema on her right knee. The hot packs were applied again later that night, contrary to the facility's policy that only nurses should handle hot/cold packs. The erythema was assessed by a Registered Nurse (RN) and treated with Calazime barrier cream, and later monitored until it healed. Interviews with multiple Nurse Aides confirmed that they were aware that only nurses were permitted to place and remove hot/cold packs. The Director of Nursing (DON) also confirmed the facility's failure to provide adequate protection from hazards related to hot pack use. The facility's policies on accidents and incidents, as well as the use of heated compresses, were reviewed and indicated that a safe environment should be promoted for all residents. Despite this, the incident occurred, highlighting a lapse in adherence to the established protocols.
Failure to Properly Secure Medications
Penalty
Summary
The facility failed to properly secure medications in one of three medication carts. During an observation, a Registered Nurse (RN) was seen administering medications to a resident and left a Trelegy Ellipta inhaler on top of the medication cart unattended while returning to the resident's room to complete the medication administration. The medication cart was placed outside the resident's room, making the inhaler accessible to anyone passing by in the hallway. The RN confirmed that the medication was left unattended and not properly secured.
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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