Spring Hill Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 2170 Rhine Street, Pittsburgh, Pennsylvania 15212
- CMS Provider Number
- 395666
- Inspections on file
- 44
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 38 (3 serious)
Citation history
Health deficiencies cited at Spring Hill Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its own policies for one resident transferred to the hospital when it failed to document that required clinical and care-plan information, including diagnoses, status, medications, and special instructions, was communicated to the receiving provider. In addition, for two residents sent to the hospital, the clinical records lacked evidence that the residents or their representatives received the required written notice of the facility’s bed-hold policy at the time of transfer or within the specified timeframe, and the Assistant DON confirmed these failures.
Surveyors found that medications on three medication carts were not stored and labeled according to facility policy and professional standards. On two first-floor carts, multiple Lispro and Basaglar insulin pens were not kept in required bags, and a Stioloto Respimat inhaler lacked a date opened. On a second-floor cart, a Novolog insulin pen was not bagged, was labeled as house stock, and did not include a resident name. These issues were confirmed by involved LPNs and the DON.
A resident with chronic pain and multiple comorbidities, including DM, heart failure, and depression, had a PRN order for Oxycodone 5 mg PO every eight hours. Over three consecutive days, the resident reported requesting this medication for breakthrough pain but did not receive it, leading to increased pain, poor sleep, and reduced ability to perform usual ADLs. Review of the MAR showed no documentation of Oxycodone administration on those days, and the controlled substance record for the medication was missing. Nursing and clinical staff confirmed the absence of documentation and records, and that effective pain management was not provided, resulting in harm.
The facility failed to protect residents from misappropriation of property when multiple discrepancies were found in the controlled substance records for narcotic pain medications. Several residents with conditions such as heart failure, COPD, osteoarthritis, neuropathy, depression, and spina bifida had orders for MS Contin and Oxycodone, but pill counts did not reconcile with documented administrations, and in one case there was no controlled substance record for a dispensed PRN narcotic. Nursing staff reported that an agency RN on an overnight shift appeared shaky and could not account for missing Oxycodone tablets, and later review showed documentation inconsistencies, including records of narcotics given to a resident who reportedly slept all night. The NHA and DON confirmed that an agency RN allegedly took multiple residents’ narcotics and that the facility failed to ensure residents were free from misappropriation of their medications.
The facility failed to report and investigate allegations of misappropriation of resident property involving controlled medications for multiple residents. Despite policies requiring protection against exploitation and strict recordkeeping for controlled substances, staff identified repeated discrepancies between narcotic counts and documented administrations for several residents receiving MS Contin and Oxycodone for chronic pain and other conditions. An agency RN who worked the relevant overnight shifts appeared shaky and emotional, could not fully explain missing tablets, and staff discovered incorrect counts and documentation after shift change. The DON later confirmed that no formal investigation was completed and that the incident involving missing narcotics and suspected diversion was not reported to the Department of Health.
The facility failed to investigate multiple discrepancies in controlled substance counts and documentation involving five residents receiving MS Contin and Oxycodone for chronic pain and other conditions. Despite policies requiring protection against misappropriation of resident property and special recordkeeping for controlled drugs, narcotic records showed unexplained reductions in tablet counts, missing controlled substance records for a PRN medication, and documentation of doses that conflicted with resident status reports. Staff reported that an agency RN on an overnight shift appeared shaky and emotional, gave inconsistent explanations for missing tablets, and left after writing a statement. The DON and NHA acknowledged awareness of missing narcotics and alleged diversion but confirmed that no thorough investigation was conducted and the missing narcotics were not reported to the state health department.
The DON failed to timely and effectively manage and investigate five allegations of misappropriation of resident belongings, including narcotic diversion, affecting multiple residents. Although the DON’s job description required oversight of nursing operations, monitoring for potential abuse or neglect, and participation in investigations, no investigations were completed for these incidents. In interviews, the DON first indicated an investigation existed but later admitted there was none, and the NHA confirmed the DON’s failure to manage these allegations. These failures were cited under applicable Pennsylvania regulatory codes.
A resident with diabetes, heart failure, and depression had a physician order for a low air loss mattress with functioning checks every shift, but the motor controlling the foot portion of the bed broke and the resident was unable to raise or lower their legs in bed. Observation confirmed the bed made a loud noise and the lower portion did not move when the control was used. The Maintenance Director acknowledged being notified that the bed was broken and needing a new motor, had taken specifications to order the part, but did not know if it had been ordered, and the DON confirmed the facility failed to maintain the resident’s rights to a safe and comfortable environment by not ensuring the bed was in working order.
The facility failed to follow its own abuse prevention and credentialing policies by allowing an agency RN to work two shifts before verifying the nurse’s license status. Facility policies required pre-employment screening for abuse, neglect, exploitation, and misappropriation, as well as license verification for all licensed nurses upon employment, with documentation maintained. However, the RN’s license verification was completed and documented several days after the nurse had already worked, as confirmed by the DON and HR staff.
A resident with diabetes, heart failure, and depression had a physician order for Singulair 10 mg, two tablets daily, but the pharmacy supplied and staff administered only one tablet per day. The resident reported receiving only one tablet, and review of the medication supply confirmed that the pharmacy was dispensing a single 10 mg tablet instead of the ordered two. The pharmacist acknowledged the pharmacy cycle order was incorrect, and facility staff confirmed that the pharmacy did not provide the medication in the correct dose as ordered.
Surveyors found that facility leadership failed to provide access to an investigation into narcotic diversion and misappropriation of resident property. During a complaint survey, the NHA and DON were informed that multiple complaints would be investigated, and staff disclosed that a nurse had taken narcotics and police had been notified. When the SA requested the complete investigation, the DON initially stated it was in his office and could be copied, but later admitted that no investigation existed for the misappropriation incidents involving five residents. The NHA and DON acknowledged that the absence of an investigation and the time surveyors spent waiting for it caused a delay in the survey.
Surveyors found that the facility failed to follow its own abuse, neglect, and mistreatment policy by not providing required annual abuse/neglect training to nearly all staff, including several individuals later identified as alleged perpetrators in a neglect incident where 12 residents on one floor received no morning care due to lack of staff assignment. Review of personnel files showed that multiple staff, including NAs, RNs, the DON, and an LPN, lacked documented pre-employment criminal background checks, required FBI checks for out-of-state employment, or had expired or missing licenses, and the NHA admitted not knowing how to check for expired licenses. Staff interviews and training records confirmed that abuse/neglect education had not been conducted for an entire year, and some staff reported only receiving such training at other jobs or not for a long time at this facility, leading to an Immediate Jeopardy determination for all residents.
The facility failed to reassign staff when an NA did not report for duty, leaving an entire hall of 12 residents without direct care coverage for a full shift. Despite the supervisor being informed and nurses being told they would need to assist, residents remained in bed in disheveled condition and reported receiving no morning care, incontinence care, repositioning, or assistance getting out of bed. Several residents with conditions such as diabetes, hemiplegia, paraplegia, heart failure, Parkinson’s disease, osteomyelitis, PVD, COPD, and difficulty walking stated their briefs had not been changed since the prior night and that they remained soiled after episodes of diarrhea. Multiple staff, including an RN, an LPN, and NAs, confirmed that no care had been provided to that section and that the assignment was not redistributed after the NA’s absence. The administrator and DON acknowledged that the facility failed to ensure residents were free from neglect and did not timely or effectively manage the 12 neglect allegations, resulting in Immediate Jeopardy for those residents.
The facility failed to ensure adequate nursing staff coverage when an NA assigned to one hall did not report for work, and the assignment for that hall was not reallocated to other staff. As a result, twelve residents on that hall, many with conditions such as DM, hemiplegia, CHF, COPD, paraplegia, and depression, remained in bed in nightgowns into midday without morning care, incontinence care, repositioning, or assistance out of bed. Multiple residents reported being soiled with urine or diarrhea since early morning without brief changes or application of protective creams, and no baths, showers, dressing, or oral care were provided. Staff interviews confirmed that no NA was assigned to the section, that nurses were told they would need to help but did not consistently provide ADL care, and that residents in that hall had not been cared for since the overnight shift. The administrator and DON acknowledged that the facility did not have sufficient nursing staff to provide necessary nursing services, resulting in an Immediate Jeopardy situation for all residents on that hall.
The facility failed to maintain its main elevator in safe operating condition for an extended period, leaving it nonfunctional and posted with a "Do not use" sign. According to facility policy, the elevator was intended to ensure safe and efficient access for residents, staff, visitors, and others. Documentation and staff interviews showed that residents and visitors needing to access the second floor had to use the stairs while the elevator was out of service, and the NHA reported difficulty obtaining responsive service from the original elevator vendor despite prior payment.
The facility failed to accommodate resident needs and preferences when its only elevator was out of service for several days, leaving residents on an upper floor unable to access desired areas and activities on the main floor. The Maintenance Director acknowledged that residents on the second floor had to remain there and that repair efforts had stalled. Several residents with conditions such as HTN, DM, depression, cerebral palsy, cerebral infarction, muscle weakness, and fractures reported feeling confined and unable to go downstairs to visit friends, use vending machines, attend the community room for coffee, watch TV, play games, obtain snacks, or socialize. The NHA confirmed that the facility did not accommodate these residents' needs.
The facility did not follow its policy requiring annual written performance evaluations for all employees, resulting in two nurse aides going more than 12 months without a documented evaluation by their department supervisor. Review of personnel files showed missing evaluations within the required annual timeframes, and the HR Director confirmed that these evaluations were not completed as required by facility policy and state regulations.
The facility did not ensure that direct care staff received required training on effective communication. Policy required all employees to complete designated trainings within set time frames, and HR reported that education is organized by calendar year. Review of education records showed that two NAs and two RNs lacked any documented communication training for the year reviewed. The NHA confirmed that communication training had not been provided to these direct care staff, resulting in noncompliance with staff development requirements.
The facility did not provide required Resident Rights education to multiple direct care staff members. Review of the continuing education policy showed that all employees were expected to complete mandatory trainings within set time frames, and HR reported that education is organized by calendar year. However, review of 2025 training records revealed that a NA, two RNs, and another NA lacked documented Resident Rights training. The NHA confirmed that Resident Rights training had not been provided to these direct care staff, resulting in noncompliance with state staff development and license responsibility requirements.
The facility did not provide required abuse and neglect training to multiple direct care staff, including NAs, RNs, and the DON, despite a policy requiring all employees to complete mandatory education within set time frames. Facility education records for the year reviewed showed no documented abuse and neglect training for several direct care employees, and the HR Director confirmed that education is organized by calendar year. The NHA acknowledged that direct care staff had not received this required training, resulting in noncompliance with state regulations on licensee responsibility and staff development.
The facility did not provide mandatory Quality Assurance and Performance Improvement (QAPI) training to multiple direct care staff, including NAs, an LPN, and RNs, despite a policy requiring all employees to complete designated education within set time frames. Review of annual education records showed no documented QAPI training for these staff members, and leadership confirmed that QAPI education had not been provided, resulting in noncompliance with state requirements for licensee responsibility and staff development.
The facility did not provide required infection control training to multiple direct care staff members, despite a policy stating that all employees must complete mandatory education within set time frames. Review of annual education records showed that two NAs and two RNs lacked documented infection control training, and the HR director confirmed that education is organized by calendar year. The NHA acknowledged that the facility failed to ensure these direct care staff received infection control education as required by state regulations.
The facility did not provide required Compliance and Ethics training to multiple direct care staff, despite a policy stating all employees must complete mandatory education within set time frames. Review of education records showed that several NAs and RNs lacked any documented Compliance and Ethics training for the year, and leadership confirmed that this training had not been provided, resulting in noncompliance with state staff development and licensee responsibility regulations.
Surveyors found that the facility did not ensure two nurse aides received the required minimum of 12 hours of annual in‑service education, including dementia care and abuse prevention. Facility policy required all employees to complete designated trainings within a calendar year, but review of 2025 education records and personnel files showed that these nurse aides did not meet the 12‑hour requirement, and the facility could not produce documentation to show otherwise. The HR Director confirmed education is tracked by calendar year, and the NHA acknowledged the lack of evidence that the required yearly in‑service training had been completed, resulting in noncompliance with state staff development regulations.
The facility did not provide required Behavioral Health training to multiple direct care staff members, including NAs and RNs, despite a policy stating that all employees must complete required education within set time frames. The HR Director reported that staff education is organized by calendar year, but review of education records showed that four direct care staff lacked any documented Behavioral Health training. The NHA confirmed that Behavioral Health training had not been provided as required by the facility assessment and state staff development regulations.
The facility did not ensure that all nurse aides maintained active certification as required by its personnel policies and state regulations. A review of the Employee Handbook showed that professional staff must maintain a valid current license or certification. An audit of licensed employees found that most had active licenses, but two NAs were discovered to have expired nurse aide registrations and had continued working until they were sent home. The NHA confirmed that the facility failed to ensure renewal of nurse aide registrations for these staff members.
The NHA and DON failed to carry out their responsibilities for overseeing operations, nursing services, and abuse prevention, including not timely or effectively managing 12 allegations of resident neglect and not maintaining sufficient nursing staff to provide needed care and treatment, resulting in Immediate Jeopardy for all residents. Required annual abuse and neglect prevention training was not completed or documented for multiple staff, and no training records were available for the entire workforce over a full year. Additionally, at least one LPN was hired without a pre-employment criminal background check, and several staff, including NAs, RNs, and the DON, were employed without verification of current, valid licenses or review of possible disciplinary actions with licensing boards.
Surveyors found that the facility failed to coordinate and document hospice services for two residents receiving end-of-life care. One resident with heart failure and depression had been on hospice, but the record contained no hospice documentation for an extended period despite an LPN confirming hospice staff were still actively providing care. Another resident with traumatic brain injury and a seizure disorder was on hospice, yet there was no hospice care plan in the clinical record, which an RN confirmed. These issues showed that hospice services were not properly integrated into facility care and documentation as required by facility policy.
Surveyors found that the facility failed to follow its clean linen handling policy on one nursing floor. Staff were using a clean linen cart to transport meal trays to residents’ rooms, and clean linens were stored uncovered on bedside tables in the corridor and on tables in a common room. The Environmental Director stated that use of clean linen carts for meal trays was not authorized and that linens should not be left uncovered, and the DON confirmed that proper infection control practices for clean linen care were not maintained, creating potential for cross-contamination on the second floor.
The facility's governing body did not respond to vendor invoices or requests for payment, leading to unpaid bills with multiple service providers. As a result, essential services such as transportation for medical appointments and laboratory testing were unavailable, causing three residents to be sent to the hospital and preventing lab work for others.
The facility did not follow physician orders for medical appointments and lab work for four residents, including missed drug treatment appointments, dialysis sessions, and required blood tests. This resulted in residents not receiving necessary care as ordered, with some experiencing distress or requiring hospital admission due to missed treatments. Facility leadership confirmed lapses in completing lab work and difficulties in arranging transportation for external appointments.
A resident with liver cell carcinoma receiving hospice care did not have documented assistance with activities of daily living, such as bathing and eating, as required by facility policy. Review of clinical records revealed gaps in documentation, and facility leadership confirmed the absence of evidence that ADL care was provided.
Surveyors found that multiple residents with complex medical conditions did not receive appropriate respiratory care due to improper cleaning, dating, and storage of nebulizer and CPAP equipment, undated or overdue oxygen tubing, and an empty humidifier bottle. Staff confirmed these lapses, which were not in accordance with facility policy.
The facility did not ensure proper hand hygiene for enhanced barrier precautions in eight rooms with EBP signage, as soap, paper towels, and hand sanitizer were missing or unavailable. Staff reported bringing their own supplies and using resident wipes to dry hands, while hand sanitizer was only accessible at nursing desks. Facility leadership confirmed the lack of accessible hand hygiene resources in the affected rooms.
A resident who was cognitively intact and had requested to self-administer medications was not afforded this right, despite facility policy allowing it with proper assessment and a prescriber's order. The DON confirmed that no residents were permitted to self-administer medications, and no documentation was found indicating the required assessment or process was followed.
During a facility tour, multiple resident rooms were found without functional hand soap dispensers, and some unoccupied rooms had stained and damaged mattresses. Additionally, a resident common area was cluttered with equipment and had dirty floors. These conditions were confirmed by nursing staff and the administrator, indicating a failure to maintain a clean, safe, and homelike environment.
Two residents did not receive care according to physician orders: one did not receive a scheduled Adalimumab injection and neither the physician nor family were notified, while another had a necessary Colo-Rectal surgery appointment cancelled by the facility despite a physician order and confirmation from the CRNP that the appointment should have occurred.
Two residents did not receive the required level of supervision and assistance during transfers and bed mobility, as staff failed to follow care plans specifying two-person assistance and proper bed positioning. In both cases, residents were left at risk, resulting in one resident sustaining a minor injury after a fall and another being lowered to the floor without injury.
Surveyors found that the facility did not provide enough towels and washcloths for several residents, resulting in some having to use paper towels or dirty linens for personal hygiene. Staff confirmed the shortage, stating they had to prioritize which residents received care due to limited supplies. The issue was compounded by laundry equipment problems, and the administrator acknowledged the failure to meet residents' linen needs.
Staff failed to follow established protocols for tube feeding care, including improper storage and cleaning of syringes, dirty feeding pumps, and failure to change a G-tube dressing as ordered. These deficiencies were confirmed by the DON and involved multiple residents with complex medical needs.
Multiple deficiencies were observed on the first floor, including a hole in the wall, dust buildup on bathroom vents, peeling plaster and wallpaper, brown stains on ceilings, a shower room with a duct-taped ceiling and hanging light fixture, and an unsecured fire pull station with unpainted plaster. These issues were confirmed by an RN and acknowledged by the administrator, indicating a failure to maintain a safe, clean, and homelike environment as required by policy and regulation.
A resident without a diabetes diagnosis was given a long-acting insulin injection by an RN after verbally refusing the medication, despite facility policy requiring notification and documentation of refusals. The resident, who primarily spoke French, did not have an order for insulin, and staff interviews revealed inconsistent resident identification practices. The DON confirmed the failure to protect the resident from neglect and mistreatment.
A resident with a history of stroke, diabetes, and hypertension, who relied on a feeding tube, was transferred to a hospital for a gastrostomy tube replacement. The facility did not provide the required written information—including care plan goals, advanced directives, and ongoing care instructions—to the receiving provider, as confirmed by the DON.
A resident with renal insufficiency, sepsis, and lymph edema, but no diabetes diagnosis or insulin order, was mistakenly given a long-acting insulin by a nurse. Facility policy prohibits administering medications ordered for one resident to another, but this was not followed. The error was identified after the resident's family reported the incident, and the DON confirmed the medication error.
Surveyors found that personal care items such as deodorant, body wash, shampoo, and toothpaste were unlabeled and stored in shared bathrooms, making them accessible to multiple residents. Staff interviews confirmed that toiletries should be labeled and not shared, but acknowledged that items are sometimes shared when supplies run low. The administrator confirmed the failure to prevent cross contamination in two shared bathrooms.
A resident experienced an unwitnessed fall resulting in a lumbar compression fracture, which was not reported to the Department of Health. The DON stated the incident was not reported as the resident did not go to the hospital. Both the Nursing Home Administrator and DON confirmed the failure to notify the Department of Health.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as unclean utility rooms, broken soap dispensers, and inadequate linen supplies. Observations revealed brown substances on equipment, strong odors in shower rooms, and a shortage of essential linens, which were confirmed by the Director of Maintenance.
The facility failed to provide appropriate treatment and care for several residents. A resident with a diabetic foot ulcer did not have their dressing changed as ordered, and another with a vascular wound also missed daily dressing changes. A third resident was given antibiotics without a physician's signature and experienced a change in condition without timely care. Additionally, a resident with severe malnutrition and acute kidney injury was not properly assessed or treated, leading to hospital transfer.
The facility failed to provide required annual in-service education for three nursing staff members, as evidenced by missing documentation in their personnel records. The training program, which should cover essential topics like infection control and resident rights, was not effectively implemented, as confirmed by Human Resources. This deficiency highlights a lapse in ensuring nursing staff possess necessary competencies to meet residents' needs.
The facility failed to provide adequate pharmaceutical services, resulting in medication delays for two residents. A resident's Zoloft was unavailable due to a discrepancy in the Pyxis machine, and another resident experienced multiple instances of unavailable medications, including eye drops and patches for glaucoma and depression. Interviews revealed a lack of effective communication and coordination with the pharmacy, contributing to the issue.
Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to a receiving health care provider during a facility-initiated transfer and failed to provide required written bed-hold policy notices during hospital transfers. Facility policy on transfers required that contact information for the responsible practitioner, resident representative information, advance directives, resident status (including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs), diagnoses, allergies, medications with last administration times, recent labs and diagnostics, immunizations, and special instructions or precautions be provided to the receiving provider. For one resident with diabetes, hyperlipidemia, and aphasia whose G-tube became dislodged and who was transferred to a local hospital ED for G-tube replacement, the clinical record did not contain documented evidence that this specific information, including care plan goals and all information necessary to meet the resident’s specific needs, was communicated to the receiving provider. The facility’s bed-hold policy required that written information regarding bed-hold practices be provided to the resident and/or representative both in advance and at the time of transfer for hospitalization or therapeutic leave, or within 24 hours in the event of an emergency transfer, with documentation of multiple attempts if the representative could not be reached. For the resident transferred for G-tube replacement and another resident with high blood pressure, hyperlipidemia, and diabetes who was transferred to the hospital via EMS for low sodium level, the clinical records contained no documented evidence that the residents or their representatives were provided written information about the facility’s bed-hold policy at the time of transfer. During interview, the Assistant DON confirmed that the facility failed to ensure necessary information was communicated to the receiving provider for one resident and failed to notify two residents or their representatives of the facility bed-hold policy during hospital transfers.
Improper Storage and Labeling of Insulin Pens and Inhaler on Multiple Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices, specifically related to labeling and storage of insulin pens and an inhaler on three of four medication carts. Review of the facility’s “Medication Storage” policy, last reviewed on 3/26/26, showed that all medications were to be stored according to manufacturer recommendations with appropriate sanitation, temperature, light, ventilation, moisture control, segregation, and security. However, during an observation of the first-floor [NAME] medication cart on 4/1/26 at 11:30 a.m., two Lispro insulin pens were found not stored in a bag as required. An LPN (Employee E7) confirmed at 11:35 a.m. that these two Lispro insulin pens were not stored in a bag as required. Further observations on 4/1/26 revealed additional issues on other carts. At 11:42 a.m., the first-floor East medication cart contained two Basaglar insulin pens that were not stored in a bag as required, and a Stioloto Respimat inhaler that was not labeled with a date opened as required; an LPN (Employee E8) confirmed these findings. At 12:08 p.m., the second-floor [NAME] medication cart contained one Novolog insulin pen that was not stored in a bag, was labeled as “house stock,” and did not have a resident name as required; an LPN (Employee E4) confirmed at 12:11 p.m. that the Novolog pen was not bagged and lacked a name, stating it must have been pulled prior to receiving the one sent by the pharmacy. At 3:05 p.m., the Director of Nursing confirmed that the facility failed to properly store medications on three of the four medication carts reviewed, in violation of state code requirements for pharmacy and nursing services.
Failure to Administer PRN Oxycodone and Maintain Controlled Substance Records
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain, resulting in excessive pain, poor sleep, and decreased ability to perform activities of daily living. The resident had diagnoses including diabetes, heart failure, and depression, and was care planned for chronic pain with an intervention to administer medications per physician orders. A physician order dated 12/23/25 directed staff to administer Oxycodone 5 mg by mouth every eight hours as needed. The resident reported requesting Oxycodone for breakthrough pain and not receiving it on three consecutive days, stating that this caused significantly increased pain, poor sleep, reduced time out of bed, and inability to complete usual activities such as doing laundry. Review of the resident’s Medication Administration Record for the relevant days showed blank entries for the as-needed Oxycodone, indicating it was not administered. Additionally, when the resident’s chart was reviewed, the controlled substance record for Oxycodone was missing, preventing verification of whether any doses had been given. A registered nurse confirmed that the controlled substance record could not be located and that they were unable to identify if the resident had received Oxycodone as requested. The clinical consultant later confirmed that the MAR entries for the three days in question were blank and acknowledged that the facility failed to provide effective pain management, causing harm to the resident, in violation of 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Misappropriation and Poor Control of Residents’ Narcotic Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property by not ensuring accurate control, documentation, and safeguarding of multiple residents' controlled medications. Facility policies on Abuse, Neglect & Exploitation and on Medication Ordering and Receiving from Pharmacy required protection of resident property and special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, controlled substance records for several residents showed discrepancies between documented administration and remaining pill counts, and in one case, the absence of any controlled substance record for a prescribed PRN narcotic. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed for pain. Review of the controlled substance record for MS Contin 15 mg showed that on a specific date the resident was documented as receiving two tablets, with a starting count of 25 and an ending count of 21, which did not reconcile. For MS Contin 30 mg twice daily, the record showed that on two dates the resident was documented as receiving three tablets, with a starting count of 18 and an ending count of 11, again not reconciling. Additionally, there was no controlled substance record for the resident’s Oxycodone 5 mg PRN from the date of order initiation through the date of review, even though the pharmacy confirmed dispensing 18 tablets. Another resident with coronary artery disease, COPD, and osteoarthritis had an order for Oxycodone 7.5 mg every eight hours as needed; the controlled substance record showed that on two dates the resident was documented as receiving one tablet, with a starting count of 40 and an ending count of 36, which did not match the documented usage. A third resident with high blood pressure, depression, and spina bifida had an order for MS Contin 15 mg three times daily. The controlled substance record indicated that on two dates the resident was documented as receiving two tablets, with a starting count of 38 and an ending count of 32, reflecting a discrepancy. A fourth resident with high blood pressure, depression, and neuropathy had an order for Oxycodone 5 mg every 12 hours as needed; the record showed that on one date the resident was documented as receiving one tablet, with a starting count of 12 and an ending count of 9, which did not reconcile. A fifth resident with heart failure, COPD, and muscle spasms had an order for Oxycodone 10 mg three times daily; the controlled substance record showed that on two dates the resident was documented as receiving four tablets, with a starting count of six and an ending count of two, while the resident was reported to have slept all night. Staff interviews further described events surrounding these discrepancies. A RN supervisor reported working a double shift while an agency RN worked the overnight shift; the oncoming RN identified that one resident’s Oxycodone count was four tablets short. The agency RN stated she might have given a double dose and could not account for the remaining tablets. The RN supervisor notified the DON and adjusted the narcotic count so the oncoming nurse could begin medication administration. Another RN later noted that while her narcotic counts were correct at shift change, the controlled substance records contained documentation discrepancies, including inconsistent count changes for one resident’s MS Contin and documentation of Oxycodone administration to another resident who had reportedly slept all night. The Nursing Home Administrator and DON acknowledged that an agency RN allegedly took multiple residents’ narcotics and confirmed that the facility failed to ensure residents were free from misappropriation of property. The facility did not provide documentation showing that the missing narcotics were reported to the Department of Health.
Failure to Report and Investigate Alleged Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures prohibiting misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, review of clinical records and controlled substance records on multiple residents revealed discrepancies in narcotic counts and missing documentation, and the facility did not report these issues to the Department of Health as required. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed. Review of the controlled substance records showed that on specific dates, the documented doses and the beginning and ending counts for MS Contin 15 mg and 30 mg did not reconcile. Additionally, there was no controlled substance record for the ordered Oxycodone 5 mg as needed over more than a month, even though the pharmacy confirmed dispensing 18 tablets. Similar discrepancies were identified for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg as needed count decreased from 40 to 36 tablets over two days while documentation indicated only two tablets were administered. Further review showed that a resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily with count discrepancies over two days, and another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg as needed with a count that dropped from 12 to 9 tablets while only one tablet was documented as given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily, with records indicating four tablets given over two days while the count decreased from six to two tablets, and this resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and could not adequately account for missing tablets. The RN supervisor and oncoming RN identified incorrect counts and documentation, notified the DON, and obtained a statement from the agency RN. However, the DON later acknowledged that no investigation of the alleged narcotic diversion was completed and that the incident was not reported to the Department of Health, confirming the facility’s failure to report allegations of misappropriation of resident belongings for the five affected residents.
Failure to Investigate Alleged Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures to prohibit misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, multiple discrepancies were identified in narcotic counts and documentation for several residents’ controlled medications, and the facility did not complete an investigation into these discrepancies or the alleged diversion by an agency RN. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed. Review of the controlled substance records showed that for MS Contin 15 mg, the record documented two tablets given with a starting count of 25 and an ending count of 21, and for MS Contin 30 mg, three tablets were documented as given over two days with a starting count of 18 and an ending count of 11. No controlled substance record was found for the resident’s Oxycodone 5 mg PRN from 1/18/26 through 2/25/26, although the pharmacy confirmed that 18 tablets had been dispensed. Similar discrepancies were found for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg PRN count decreased from 40 to 36 while documentation indicated only two tablets were given. Additional residents were affected. One resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily ordered; the controlled substance record showed the count going from 38 to 32 while documentation indicated only two tablets were given over two days. Another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg every 12 hours PRN ordered; the count went from 12 to 9 while documentation indicated one tablet given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily ordered; the record showed four tablets documented as given over two days, with the count going from six to two, while the resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and gave inconsistent explanations for missing tablets. The DON and NHA acknowledged that missing narcotics from those dates were known, that police were present, and that the DON had not conducted or produced an investigation into the alleged narcotic diversion or misappropriation, and the missing narcotics were not reported to the Department of Health.
Failure of DON to Investigate Multiple Allegations of Misappropriation and Narcotic Diversion
Penalty
Summary
The deficiency involves the DON’s failure to timely and effectively manage and investigate five allegations of misappropriation of resident belongings, including narcotic diversion, involving five residents (R1, R2, R3, R4, and R5). The DON’s job description dated 12/9/24 required him to plan, organize, develop, and direct the overall operations of the nursing services department, establish facility policies and procedures, ensure appropriate care and services, perform rounds to observe residents, and monitor for allegations of potential abuse or neglect while participating in the investigative process. Despite these defined responsibilities, the facility did not have investigations completed for the reported misappropriation incidents that included diversion of narcotic medications. During an interview on 2/25/26 at 3:15 p.m., the DON initially stated that he had the investigation of the incident in his office and would provide a copy to the state agency. Later that same day at 4:45 p.m., when asked directly if he had an investigation concerning the narcotic diversion, the DON replied that he did not and confirmed he had failed to have an investigation for the misappropriation of resident belongings that included narcotic diversion for all five residents. On 2/26/26 at 3:00 p.m., the NHA confirmed that the DON failed to timely and effectively manage these five allegations of misappropriation of resident belongings, which included narcotic diversion. These failures were cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Failure to Maintain Resident Bed in Safe Working Condition
Penalty
Summary
The facility failed to maintain a resident’s right to a safe, comfortable, and homelike environment by not ensuring that a bed was in proper working order. The facility’s Resident Rights policy dated 9/22/25 stated that residents have the right to a safe, clean, comfortable environment and to receive treatment and support for daily living safely. One resident, admitted on the documented admission date, had an MDS dated 1/10/26 reflecting diagnoses of diabetes, heart failure, and depression, and a physician order dated 9/29/25 for a low air loss mattress with instructions to check placement and functioning every shift. During an interview on 2/25/26 at 1:50 p.m., the resident reported that on 2/22/26 the motor for the foot portion of the bed broke, and since then they had been unable to raise or lower their legs while in bed. An observation on 2/25/26 at 1:55 p.m. showed that when the resident used the bed control to move the leg area, the bed made a loud noise and the bottom portion did not move. In a 2/25/26 interview at 2:07 p.m., the Maintenance Director stated that his department had been notified that the bed was broken and needed a new motor, that he had taken the specifications from the bed to place an order, but he did not know if the motor had actually been ordered. At 3:15 p.m. on the same day, the DON confirmed that the facility failed to maintain resident rights by not having the bed in working condition for this resident.
Failure to Verify RN License Prior to First Shift
Penalty
Summary
The facility failed to follow its own policies for preventing abuse, neglect, exploitation, and misappropriation of resident property by not completing required pre-employment screening and license verification for a registered nurse before the nurse began working. The facility’s Abuse, Neglect, and Exploitation policy required that potential employees be screened for a history of abuse, neglect, exploitation, and misappropriation of resident property, with documentation maintained as proof of screening. The Licensed Nurse Credentialing and License Verification policy required that all licensed nurses have their credentials and license verified upon employment. An agency RN (Employee E1) worked in the facility on two consecutive days, but review of the personnel file showed that the nurse’s license verification was not conducted until three days after those shifts. In interviews, the DON confirmed the RN’s work dates, and the HR staff member confirmed there was no documented evidence of license verification prior to the RN’s first working shift.
Failure to Ensure Pharmacy Supplied Correct Singulair Dose per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its contracted pharmacy provided medications in accordance with the physician’s order for one resident. Facility policy on “Medication Ordering and Receiving from Pharmacy” dated 9/22/25 states that medications are to be administered in an organized and safe manner, including pouring the correct number of tablets or capsules into the medication cup and administering them to the resident. Resident R1’s admission record showed admission on an unspecified date, and the MDS dated 1/10/26 documented diagnoses including diabetes, heart failure, and depression. A physician’s order dated 1/25/26 directed that Singulair 10 mg be given as two tablets every day. During an interview on 2/25/26 at 11:45 a.m., the resident reported that he should be receiving two Singulair 10 mg tablets daily but had only been receiving one tablet. On 2/26/26 at 11:20 a.m., observation of the resident’s medication with Clinical Consultant Employee E9 showed that the pharmacy was supplying Singulair 10 mg in a quantity of one tablet to be administered. In a phone interview at 11:41 a.m. the same day, Pharmacist Employee E10 confirmed that the resident had been receiving only one 10 mg tablet and acknowledged that the pharmacy cycle order was incorrect. Later that day at 3:00 p.m., Clinical Consultant Employee E9 confirmed that the facility failed to ensure the pharmacy provided medications timely and correctly for this resident, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
Failure to Provide Investigation of Narcotic Diversion and Misappropriation to Surveyors
Penalty
Summary
The deficiency involves the facility’s failure to provide the State Agency (SA) with access to a facility investigation related to narcotic diversion and misappropriation of resident property, which caused a delay in the survey process. During a complaint survey, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed that the SA team would be investigating five complaints. Later that day, the SA was informed that a nurse over the weekend had been taking narcotics and that the police had been notified. In an interview, the DON confirmed that a nurse had taken narcotics and that law enforcement had been contacted several days earlier. When the SA requested the facility’s complete investigation of this incident, the DON stated that the investigation was in his office and that he could retrieve it, and the SA requested a copy of the full investigation at that time. Subsequent interviews with the Interim Assistant DON and the NHA documented that they were made aware the SA was waiting for the DON’s complete investigation. Later that afternoon, the DON confirmed that he did not have an investigation for the misappropriation of resident belongings that included narcotic diversion involving five residents. When questioned by the SA about his earlier statement that the investigation was in his office and would be copied for review, the DON admitted that no such investigation existed. The NHA and DON then confirmed that the facility did not have an investigation for five instances of misappropriation of resident property involving narcotic diversion, and they were made aware that the extended time the SA spent waiting for an investigation that did not exist resulted in a delay in the survey. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility for licensee and 28 Pa. Code 201.18(d)(e)(1) Management.
Systemic Failure in Abuse/Neglect Training, Screening, and Licensing Leading to Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures to prevent abuse, neglect, and mistreatment, specifically through required screening and training of staff. The facility’s written Abuse, Neglect, & Mistreatment policy stated that all potential employees would be screened for a history of abuse, neglect, or mistreatment through inquiries to state licensing authorities or nurse aide registries and criminal background checks, and that abuse, neglect, and misappropriation education would be completed upon hire and at least annually for all employees. Despite this, review of employee files showed that one LPN had no documentation of a pre-employment background check, and an out-of-state scheduler had only a state background check with no evidence of the required FBI background check. Further review revealed that 26 facility employees had no pre-employment background check documented in their files until checks were completed later. The facility also failed to ensure that staff held current, valid licenses and that these were verified prior to and during employment. File reviews showed that multiple staff members, including two NAs, two RNs, and the DON, had expired licenses or no license on file. Additional audits identified two NAs who had been working with expired licenses. The NHA acknowledged not knowing the process for checking expired licenses. These lapses occurred despite the policy requirement that screening include inquiries into state licensing authorities and nurse aide registries to identify any disciplinary actions. In addition, the facility did not provide required annual abuse and neglect prevention training to its staff. Review of training records and staff files showed that five of seven staff members later identified as alleged perpetrators in a reported neglect incident had no documentation of annual abuse and neglect education for the current year. A broader review confirmed that none of the 90 current facility employees had documentation of annual abuse and neglect training for a 12‑month period. The Human Resources Director stated that no annual education had been completed from January through the date she started working at the facility, and the list of 2025 education topics did not include abuse and neglect. Staff interviews corroborated that while some employees had recently received abuse and neglect education, several indicated it had been a long time since they received such training at this facility or that they received it only at other jobs. These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all residents. The neglect incident that triggered identification of alleged perpetrators involved 12 residents on the second floor who did not receive any morning care because no staff were assigned to rooms 209-A through 217-B. A NA reported that these residents had not received morning care, and surveyors informed the NHA and DON twice during the same day that the 12 residents still had not received any morning care. The NHA confirmed that seven staff members, including NAs, an LPN, RNs, the DON, and the NHA, were identified as alleged perpetrators of neglect related to this incident. The facility’s own policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, including when staff are aware or should be aware of residents’ care needs but do not meet them due to factors such as lack of training, insufficient staffing, lack of supplies, or lack of knowledge of resident needs. The survey findings linked the lack of required abuse/neglect training, incomplete background checks, and unverified or expired licenses to this neglect event and the resulting Immediate Jeopardy for all residents. Surveyors confirmed through interviews with successive NHAs that the facility failed to ensure annual abuse and neglect prevention training for the majority of staff, failed to complete required pre-employment criminal background checks for multiple employees, failed to conduct an FBI background check for an out-of-state employee, and failed to verify current, valid licenses and any disciplinary actions prior to employment for several staff members. These findings were cited under Pennsylvania regulatory provisions related to the responsibility of the licensee, management, and personnel policies and procedures. The Immediate Jeopardy was based on these systemic failures in screening, training, and oversight, combined with the documented incident in which 12 residents did not receive morning care due to lack of staff assignment.
Removal Plan
- Facility has reviewed current policy on abuse and neglect.
- All current facility staff including agency will receive training on current facility policy for abuse and neglect.
- Those who do not complete education will not be permitted to work until education is completed.
- All current facility employee files, including agency, will be reviewed to ensure that they have education on facility policy for abuse and neglect, a current and active license on file, and a background check present in their file.
- Missing items that are identified in audit will be immediately corrected.
- Facility will audit all new hire and all new agency staff files to ensure that files contain evidence of abuse education, a current and active license, and a background check.
- Results of the audit will be reported to the Ad Hoc Quality Assurance Performance Improvement Committee.
Failure to Reassign Staff Leads to Widespread Resident Neglect on One Hall
Penalty
Summary
The deficiency involves the facility’s failure to protect 12 residents from neglect when an entire hall (rooms 209-A through 217-B) was left without a nursing assistant (NA) for the day shift, and no reassignment of staff was made to cover those residents. During a tour of the second floor, an NA reported that only two NAs were on the floor because the third did not show up, and that residents down one hall had not been “touched” since the overnight shift. Review of the daily assignment sheets confirmed that the West assignment (rooms 209-A through 217-B) was assigned to an NA who failed to report to work and that this assignment was not reassigned to another staff member. A licensed practical nurse (LPN) stated that when she learned there was no third NA, she informed the supervisor and was told nurses would need to help the NAs, but she said she could not help due to difficulty walking and confirmed that no care had been provided since the overnight shift. Subsequent observations and resident interviews showed that all 12 residents in rooms 209-A through 217-B, who required assistance with activities of daily living, remained in bed in disheveled condition and had not received morning care, incontinence care, repositioning, or assistance getting out of bed. Multiple residents reported that no one had come in to clean them, change their briefs, or help them get up, despite some having conditions such as diabetes, hemiplegia, paraplegia, heart failure, Parkinson’s disease, osteomyelitis, peripheral vascular disease, COPD, depression, and difficulty walking. Several residents specifically stated that their briefs had not been changed since the previous night, that they had experienced diarrhea and remained soiled, and that they usually received skin cream but had not received it that day. One resident reported having to seek out staff to request to see the nurse practitioner because no one had checked on them. Staff interviews corroborated that residents in the affected section did not receive care. An RN stated she offered to help but that the LPN refused, saying she did not want to help with care and was functioning as a cart nurse. The LPN acknowledged that no care, including incontinence care and repositioning, had been provided to the residents in that section and that the whole section had been without an NA all day. NAs confirmed that no morning care, baths, showers, dressing, getting residents out of bed, teeth brushing, or incontinence care had been done for that section. A supervising RN reported being aware that one NA did not show up, notifying the DON and scheduler, and informing nurses that they would have to assist, but stated that the two NAs did not help by splitting the floor into two sections instead of three, resulting in residents not receiving care. The administrator and DON confirmed that the facility failed to ensure residents were free from neglect and failed to timely and effectively manage 12 allegations of neglect, creating an Immediate Jeopardy situation for all 12 residents. The facility’s own abuse, neglect, and mistreatment policy stated that the facility prohibits neglect and is responsible for providing a safe environment, preventing and reporting suspected or alleged neglect, and ensuring that incidents are investigated by the administrator and DON. Neglect was defined in the policy as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Despite this policy, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not ensure that nurses and NAs provided necessary care to the residents in the unstaffed section. The State Agency notified the nursing home administrator and DON twice on the same day about the 12 allegations of neglect and the ongoing lack of care in the affected section before Immediate Jeopardy was called due to resident neglect of the 12 residents.
Removal Plan
- All residents will be assessed and a full body head to toe skin check will be performed for any indications of skin concerns; any identified concerns will be immediately addressed; findings will be documented in resident medical records and attending physician and responsible parties will be notified of adverse findings.
- Facility Medical Director, attending physician for resident (if different from Medical Director), and responsible party for resident will be notified of the neglect that was identified, as well as any potential indications of skin concerns or ill effects secondary to alleged neglect.
- Report will be called into Adult Protective Services.
- Department of Health event report will be completed and applicable PB22's.
- Resident care plans will be updated as applicable to reflect changes as identified.
- Facility NHA, DON, Scheduler and/or Designee will review the current schedule and ensure adequate staff are scheduled to ensure that care is provided to avoid neglect.
- All current nursing staff, including agency, will be educated on facility policy for abuse and neglect and sign the education prior to their next working shift.
- DON/Designee will conduct audits for resident care needs to ensure that no abuse or neglect is identified.
- Results of the audit will be reported to Ad Hoc Quality Assurance Performance Improvement (QAPI) committee.
Failure to Reassign Staff After NA No-Show Leaves Entire Hall Without ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs on the West Hall (rooms 209-A through 217-B), resulting in 12 residents not receiving required ADL care for an entire morning and into the afternoon. On the day of the survey, only two NAs were present on the second floor because the NA assigned to the West Hall did not report for work, and the assignment was not reallocated to other staff. Staff reported that management, including the administrator, DON, and supervisor, had been informed of the staffing shortage. Despite this, no NA coverage was arranged for the affected section, and nurses on the unit did not consistently assume ADL care responsibilities for the unassigned residents. Surveyors observed that all 12 residents in rooms 209-A through 217-B remained in bed around midday with disheveled appearances and still in nightgowns. Multiple residents reported that no one had come in to clean them, change their briefs, assist them out of bed, or provide incontinence care since the overnight shift. One resident stated that only a nurse had come in to administer medications and that they had to seek out someone to request to see the nurse practitioner. Several residents with conditions such as diabetes, hemiplegia, cerebral infarction, heart failure, paraplegia, COPD, and other chronic illnesses reported being soiled with diarrhea or urine since early morning, with no brief changes or application of protective creams, and no assistance with bathing, showering, dressing, or repositioning. Interviews with staff confirmed that no morning care, incontinence care, repositioning, or assistance out of bed had been provided to the residents in the unstaffed section. An LPN stated that when informed there was no third NA, the supervisor said nurses would need to help, but the LPN reported she could not assist with care and that no care had been done since the overnight shift. An RN on the unit stated that she had offered to help but that the LPN refused, and that residents had been left without care. NAs and nursing staff consistently acknowledged that the entire section had no NA coverage, that residents did not receive basic ADL services, and that this constituted neglect. At one point, surveyors observed the RN, LPN, and NA at the nurse’s station talking while residents in the affected section remained without care. The NHA and DON later confirmed that the facility failed to have sufficient nursing staff to provide nursing-related services necessary to attain or maintain residents’ highest practicable well-being, creating an Immediate Jeopardy situation for all 12 residents on the West Hall. The facility’s own Resident Rights policy stated that residents have the right to reside and receive services in a safe, clean, comfortable, and homelike environment, including treatment and support for daily living. The Facility Assessment Tool indicated that the facility was to identify specific staffing needs, including nights, holidays, and weekends, and to implement a proactive and systematic approach to staffing, including cross-training and use of on-call and agency staff. Despite these policies and tools, the facility did not ensure that all residents were assigned to working staff when the scheduled NA failed to report, and did not implement effective contingency measures to cover the West Hall. This failure to follow its own staffing and resident care expectations directly led to the lack of ADL and incontinence care, lack of repositioning, and lack of assistance out of bed for the 12 residents in rooms 209-A through 217-B on the day of the survey. The surveyors determined that this failure to provide sufficient nursing staff and to ensure that residents received necessary care created an Immediate Jeopardy situation by potentially putting residents at risk of harm or injury. The NHA and DON acknowledged that the facility failed to have sufficient nursing staff to provide nursing-related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 12 affected residents on the West Hall.
Removal Plan
- Facility DON, NHA, Scheduler, and Designee will review current staffing sheets to ensure that adequate staff are present to meet the residents' needs.
- Facility will prepare and review the current emergency staffing policy and procedures to determine appropriate actions in case of emergency staffing needs.
- Facility will review all agency staffing contracts and obtain additional agency staffing contracts as a back-up to current existing agency contracts.
- NHA, DON, Scheduler or Designee will be educated on how to staff the facility to meet the needs of the facility residents.
- Facility NHA, DON, Scheduler or Designee will review the current schedule to ensure adequate staff are scheduled to ensure adequate care is provided and neglect is avoided.
- Facility nursing staff, including agency, will be educated on meeting staffing needs for each nursing unit and sign the education prior to their next working shift.
- The facility will re-align nurse aide assignments to ensure that all residents are taken care of when a shortage is identified.
- The facility will maintain the projected weekend ratios.
- The facility will hold admissions to ensure that adequate staffing is maintained for the current census.
- The facility will maintain the following staffing pattern to meet the needs of the residents: First floor - First shift = 2 nurses/4 nurse aides; First floor - Second shift = 2 nurses/3 nurse aides; First floor - Third shift = 1 nurse/3 nurse aides; Second floor - First shift = 2 nurses/3 nurse aides; Second floor - Second shift = 2 nurses/3 nurse aides; Second floor - Third shift = 1 nurse/2 nurse aides; One RN Supervisor for each shift.
- Facility DON/Designee will perform audits to ensure that the facility staffing meets the care needs for the residents to ensure that no abuse or neglect is identified.
- Results of the audit will be reported to an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee.
Failure to Maintain Main Elevator in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the main elevator in safe operating condition for an 11-day period, during which it remained nonfunctional and posted with a "Do not use" sign. The facility’s Elevator Use and Out-of-Service policy, dated 9/22/25, was intended to ensure safe and efficient elevator use, maintain accessibility for residents and staff, and provide clear procedures when the elevator was out of service. Documentation showed that the Nursing Home Administrator was notified by the Plant Operations Director that the elevator was not functioning, and an elevator service call was placed the same day. The facility documented that there was no disruption to resident appointments or meal service and that EMS would use transport devices on the stairs in the event of an emergency. Staff interviews confirmed that, while the elevator was out of service, residents on the second floor who needed to exit the building would have to use the stairs, and visitors going to the second floor would also need to use the stairs. The Nursing Home Administrator stated that she was attempting to find another elevator company to repair the elevator because the original company, which had already received a payment, was not responding to calls. The elevator remained out of service throughout the identified period, and the facility acknowledged that it failed to maintain the main elevator in safe operating condition for those 11 days.
Failure to Accommodate Resident Needs Due to Inoperable Elevator
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of multiple residents when the only elevator in the building became nonfunctional and remained out of service. Upon surveyor entrance, the main floor elevator was observed with a sign stating "Do not use," and the Maintenance Director reported that the elevator had been broken for several days and that residents on the second floor would need to stay on that floor. The Maintenance Director also stated that the repair company had not returned calls. Facility policy on Accommodation of Needs required that residents be treated with respect and dignity and that reasonable accommodations be made for individual needs and preferences to help them maintain independent functioning, dignity, and well-being. Four residents with various medical conditions reported feeling confined to their floor and unable to access preferred activities and areas on the first floor due to the broken elevator. One resident with diagnoses including hypertension, diabetes, and depression stated feeling confined and unable to get off the floor, noting they liked to go downstairs. Another resident with depression, cerebral palsy, and cerebral infarction reported not having been on the first floor recently and missing visits to vending machines and a friend whose room was downstairs. A third resident with depression, hypertension, and diabetes, who used a wheelchair, stated they liked to go to the first-floor community room for free coffee, which was not available on their floor. A fourth resident with hypertension, muscle weakness, and a fracture stated they would go downstairs if the elevator worked to watch a big TV, play games, get snacks from vending machines, and mingle with others. The Nursing Home Administrator confirmed that the facility failed to accommodate the needs of these residents.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance evaluations for two nurse aides in accordance with its own Employee Handbook, which states that all employees will receive a written annual rating and evaluation by their department supervisor based on their anniversary date. Review of the personnel record for one nurse aide, hired on 10/25/21, showed no performance evaluation was conducted between 10/1/24 and 10/1/25. Review of the personnel record for a second nurse aide, hired on 11/23/21, showed no performance evaluation was conducted between 11/23/24 and 11/23/25. During an interview, the Human Resources Director confirmed that the facility did not complete annual performance evaluations at least every 12 months for these two nurse aides, in violation of 28 Pa Code: 201.14(b) and 201.18(b)(1)(3). No residents or specific patient conditions were mentioned in the report, and the deficiency pertains solely to staff performance evaluation practices and documentation.
Failure to Provide Required Communication Training to Direct Care Staff
Penalty
Summary
Surveyors found that the facility failed to provide required training on effective communication to most of the direct care staff reviewed. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education records showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented training on effective communication. During an interview, the Nursing Home Administrator confirmed that the facility did not provide communication training to these direct care staff members, resulting in noncompliance with staff development and licensee responsibility requirements under 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of documented communication training for direct care staff within the established education period.
Failure to Provide Resident Rights Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Resident Rights training to most of the direct care staff reviewed, contrary to its own continuing education policy and state regulations. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented training on Resident Rights. During a subsequent interview, the Nursing Home Administrator confirmed that the facility had failed to provide Resident Rights training to these direct care staff members, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c). No specific residents, medical histories, or clinical conditions were described in the report in connection with this deficiency.
Failure to Provide Required Abuse and Neglect Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required abuse and neglect training to the majority of its direct care staff during the 2025 calendar year. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a January-through-December calendar-year basis. However, review of 2025 facility education documents showed that a nurse aide (E1), a registered nurse (E3), another nurse aide (E4), another registered nurse (E6), and the Director of Nursing all lacked documented training on abuse and neglect. During a subsequent interview, the Nursing Home Administrator confirmed that the facility did not provide abuse and neglect training to these direct care staff, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c) regarding responsibility of the licensee and staff development. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the absence of required staff education on abuse, neglect, and exploitation and how to report such incidents.
Failure to Provide Required QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Quality Assurance and Performance Improvement (QAPI) training to direct care staff, as identified through review of policies, education records, and staff interviews. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), an LPN (Employee E2), an RN (Employee E3), another nurse aide (Employee E4), and another RN (Employee E6) had no documented QAPI training. In a subsequent interview, the Nursing Home Administrator confirmed that the facility did not provide QAPI training to these direct care staff, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c) regarding responsibility of the licensee and staff development. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of required QAPI education for the identified direct care employees.
Failure to Provide Required Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required infection control training to most of the direct care staff reviewed as part of its infection prevention and control program. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented infection control training. In a subsequent interview, the Nursing Home Administrator confirmed that the facility failed to provide infection control training to these direct care staff members, in violation of 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of mandatory infection control education for direct care personnel as required by facility policy and state regulations.
Failure to Provide Compliance and Ethics Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to most of the direct care staff reviewed, contrary to its own Continuing Education policy dated 9/22/25, which states that all levels of employees are expected to complete required trainings within designated time frames. The Human Resources Director reported that education is conducted on a calendar-year basis from January through December, yet review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented Compliance and Ethics training. During a subsequent interview, the Nursing Home Administrator confirmed that the facility did not provide Compliance and Ethics training to these direct care staff, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of required Compliance and Ethics education for direct care personnel as identified through policy review, education record review, and staff interviews.
Failure to Provide Required Annual In‑Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that two sampled nurse aides received the required minimum of 12 hours of annual in‑service education, including dementia care and abuse prevention, as required by facility policy and state regulations. Review of the written policy titled “Continuing Education” dated 9/22/25 showed that all employees are expected to complete required trainings within designated time frames, and the Human Resources Director stated that education is tracked by calendar year from January through December. Review of 2025 facility education documents and personnel records revealed that nurse aide employees E1 and E4 did not receive 12 hours of in‑service training in the last year, and the facility was unable to provide documentation that these staff met the annual in‑service requirement. In an interview, the Nursing Home Administrator confirmed the facility could not provide evidence that these nurse aides received the required yearly in‑service training, constituting noncompliance with 28 Pa. Code 201.14(a) and 201.20(c). No information was provided in the report about specific residents, their medical histories, or their conditions at the time of the deficiency.
Failure to Provide Required Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to direct care staff as identified through policy review, education records, and staff interviews. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented Behavioral Health training. During an interview, the Nursing Home Administrator confirmed that the facility did not provide Behavioral Health training to these direct care staff members, in violation of state requirements and the facility assessment. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of Behavioral Health training for the identified staff members, contrary to 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(c) Staff Development.
Failure to Ensure Nurse Aides Maintained Active Certification
Penalty
Summary
The facility failed to ensure that nurse aides maintained current, valid certification as required by facility policy and state regulations. Review of the Employee Handbook showed that professional staff are required to have and maintain a valid current license or certification. A facility audit of licensed employees revealed that 64 of 66 licensed employees had an active, valid license, leaving two nurse aides with inactive licenses. During an interview, the Nursing Home Administrator (NHA) stated that two nurse aides, identified as Employees E15 and E16, were sent home due to inactive licenses. Further review showed that NA Employee E15’s nurse aide registration had expired, and this aide continued working until their last day at the facility, and NA Employee E16’s nurse aide registration had also expired, with that aide likewise working until their last day at the facility. NHA 3 confirmed that the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as nurse aides for two of the nurse aides reviewed, in violation of 28 Pa. Code 201.19(3) regarding personnel policies and procedures. No specific resident conditions, medical histories, or direct resident care events related to these uncertified work periods were described in the report.
Failure of Administration, Staffing, and Abuse-Prevention Systems Creating Immediate Jeopardy
Penalty
Summary
The deficiency involves the Nursing Home Administrator (NHA) and Director of Nursing (DON) failing to fulfill their essential job duties related to resident safety, staffing, and abuse prevention. According to their job descriptions, the NHA was responsible for leading and directing facility operations in accordance with regulations and facility policies, performing rounds to observe residents, and promoting an environment of trust focused on resident safety and abuse prevention. The DON was responsible for planning, organizing, and directing nursing services, ensuring adequate staff coverage, performing rounds to ensure nursing needs were met, and monitoring for allegations of potential abuse or neglect and participating in investigations. Surveyors determined that the NHA and DON failed to timely and effectively manage 12 allegations of resident neglect and failed to maintain sufficient nursing staff to provide resident care and treatment, resulting in an Immediate Jeopardy situation for 12 of 12 identified residents (R1–R12). These failures were identified through review of job descriptions, clinical records, observations, and staff interviews. The facility also failed to ensure required abuse and neglect prevention measures and staff screening processes were in place and documented. Annual abuse and neglect prevention training was not completed for five of seven reviewed staff members (two NAs, two RNs, and the DON), and the facility could not provide documentation of annual abuse and neglect training for all 90 current employees for an entire 12‑month period. In addition, the facility failed to complete a pre‑employment criminal background check for one LPN and failed to verify current, valid licenses and check for disciplinary actions with licensing and registration boards for five of seven reviewed employees (two NAs, two RNs, and the DON). These combined failures in training, background checks, and license verification resulted in an Immediate Jeopardy determination for all 66 residents in the facility. The NHA and DON were formally notified by surveyors that their failures created Immediate Jeopardy conditions affecting both the 12 residents associated with neglect allegations and the entire resident population.
Failure to Coordinate and Document Hospice Services for Residents on End-of-Life Care
Penalty
Summary
The deficiency involves the facility’s failure to coordinate hospice services with facility services and to maintain required hospice documentation and care planning for residents receiving end-of-life care. Facility policy dated 9/29/25 states that when a resident elects hospice, the facility will coordinate care with hospice staff, maintain written agreements, communicate necessary information, and develop a coordinated plan of care that identifies which services each entity will provide. The policy also requires the facility to communicate with hospice, identify, follow, and document all interventions put into place by hospice and the facility. For one resident with heart failure and depression who was admitted to hospice on 10/29/25, the clinical record showed that hospice staff were last documented as providing care on 11/20/25, with no subsequent hospice documentation in the record. On 1/19/26, an LPN confirmed that this resident continued to receive hospice services and that hospice staff were present that day, but also confirmed there was no hospice clinical documentation past 11/20/25. For a second resident with traumatic brain injury and a seizure disorder who was admitted to hospice on 12/16/25, review of the clinical record and care plans showed there was no hospice care plan implemented. A RN confirmed during interview that this resident remained on hospice and was receiving care from the hospice service, and also confirmed that the facility had failed to implement a care plan addressing the resident’s hospice needs. These findings demonstrate that, for both residents on hospice, the facility did not ensure coordination and documentation of hospice services in accordance with its own policy and did not incorporate hospice needs into the resident’s care planning process.
Improper Handling and Storage of Clean Linen on Second Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling and storage of clean linen on the second floor. The facility’s policy "Handling Clean Linen" dated 9/22/25 stated that clean linen would be handled, stored, processed, and transported in a safe and sanitary manner to prevent contamination. During a tour of the second floor, an empty clean linen cart was observed positioned by the exit stairwell door. A nurse aide reported that staff were using this clean linen cart to transport meal trays to residents’ rooms and showed surveyors where linen was being kept. Additional observations on the second floor showed clean linen stored in multiple uncovered and inappropriate locations. Bedside tables in the corridor were observed with uncovered clean linen placed on them. In the resident common room, stacks of uncovered clean linen, including towels, washcloths, and gowns, were found on a table. The Environmental Director stated that they had not authorized staff to use clean linen carts for meal trays and affirmed that linens should not be left uncovered anywhere. The DON confirmed that the facility failed to maintain proper infection control practices related to the care of clean linen on the second floor, creating the potential for cross-contamination.
Failure to Manage Vendor Payments Resulting in Service Disruptions
Penalty
Summary
The governing body failed to implement and enforce policies for the management and operation of the facility, specifically by not responding to vendor invoices and not addressing facility requests for payment of outstanding bills. This resulted in significant unpaid balances to multiple vendors, including transportation companies, laboratory services, utility providers, and medical suppliers. As a direct consequence, the facility was unable to secure necessary services for residents, such as transportation to physician and medical appointments and laboratory testing, due to vendors refusing service over unpaid invoices. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that three residents had to be sent to the hospital because the facility could not provide transportation for their required medical appointments. Additionally, the DON confirmed that laboratory services could not be obtained for residents because of outstanding bills. Review of the facility's accounts payable ledger showed substantial overdue payments to a wide range of vendors, with many accounts having received no payments for several months.
Failure to Follow Physician Orders for Appointments and Lab Work
Penalty
Summary
The facility failed to follow physician orders regarding doctor's appointments and lab work for four out of five residents reviewed. Facility policy requires that residents receive treatment and care in accordance with professional standards, care plans, and resident choices. However, documentation and interviews revealed that residents did not receive scheduled medical appointments or required laboratory tests as ordered by their physicians. One resident with anxiety disorder and depression was unable to attend scheduled drug and alcohol treatment center appointments, resulting in the facility sending her to the hospital for medication, which caused her distress and embarrassment. Another resident with renal insufficiency and dementia missed scheduled hemodialysis sessions, leading to a hospital admission due to missed dialysis. A third resident with dementia and lung cancer had physician orders for blood tests (CMP and CBC) that were not completed, and a fourth resident with hyponatremia, Parkinson's disease, and hyperlipidemia had orders for weekly sodium level monitoring and lab results to be faxed to nephrology, but the clinical record did not show that these labs were performed. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that lab work had not been completed for approximately four weeks, following the cessation of services from a contracted lab provider. The facility also acknowledged difficulties in sending residents to required external appointments, such as dialysis and drug treatment programs, resulting in non-compliance with physician orders for multiple residents.
Failure to Provide Documented ADL Care for Hospice Resident
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care and assistance to a resident who was unable to perform these tasks independently. According to the facility's policy, care and services should be provided for bathing, dressing, grooming, oral care, toileting, transfer and ambulation, and eating. The resident in question was admitted with a diagnosis of liver cell carcinoma and was receiving hospice services due to increased care needs. Review of the clinical record showed documentation of care during the overnight shift, but there was no documentation of bathing or eating assistance for the resident, and the next entry was a physician note in the afternoon. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that they could not locate additional documentation to show that the resident received required ADL care and services during their stay.
Failure to Maintain and Store Respiratory Equipment per Policy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for five of six residents, as evidenced by multiple deficiencies in the handling and maintenance of respiratory equipment. Observations revealed that nebulizer equipment was not cleaned, dated, or stored in bags as required by facility policy for several residents. Additionally, CPAP masks were found not stored in bags, and oxygen tubing was either not dated or not changed according to policy. In one instance, a humidifier bottle was found completely empty, and the back of an oxygen concentrator was covered in dust at the filter area. These findings were confirmed through staff interviews and direct observation. The residents involved had significant medical histories, including hypertension, renal insufficiency, heart failure, diabetes, chronic obstructive pulmonary disease, and hyperlipidemia. The deficiencies were identified through a review of facility policies, clinical records, and direct observation of resident rooms and equipment. Staff, including the DON and an LPN, confirmed the failures to adhere to established protocols for respiratory care equipment maintenance and storage.
Failure to Provide Hand Hygiene Supplies for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene practices for enhanced barrier precautions (EBP) in eight resident rooms with EBP signage. Facility policy required gowns and gloves to be available near or outside resident rooms and access to alcohol-based hand rub in every resident room. During a tour and interviews, it was observed and confirmed that soap and paper towels were missing from dispensers in several resident bathrooms, and wall-mounted hand sanitizers were empty throughout the first and second floors. Staff reported bringing in their own soap and using resident dry wipes to dry their hands due to the lack of supplies. The Environmental Manager confirmed that hand sanitizer was only available at nursing desks and not readily accessible to staff or residents in the rooms, and that paper towels were awaiting delivery. The Director of Nursing acknowledged the failure to provide proper hand hygiene resources for EBP in all eight affected rooms. These findings were based on direct observation, staff interviews, and review of facility policy and documentation.
Failure to Honor Resident's Right to Self-Administer Medication
Penalty
Summary
The facility failed to honor a resident's right to self-administer medication as outlined in both its own policies and regulatory requirements. According to the facility's Resident Rights and Self-Administration by Resident policies, residents who wish to self-administer medications may do so if deemed clinically appropriate by the interdisciplinary team and with a prescriber's order. A review of one resident's clinical record showed that the resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including hypertension, anxiety, and irritable bowel syndrome, had repeatedly requested to self-administer his medications. The resident also indicated understanding of the facility's requirements and had a locked drawer available for medication storage. Despite these requests and the resident's cognitive capability, there was no documentation that the facility followed the necessary steps to assess or facilitate the resident's right to self-administer medication. Interviews with the DON confirmed that the facility did not allow any residents to self-administer medications, citing paperwork and a lack of precedent as reasons. This resulted in the resident not being afforded the right to self-administer medication, as required by facility policy and state regulation.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for residents, as evidenced by multiple deficiencies observed during a facility tour. Specifically, 12 out of 15 resident rooms were found to have bathrooms without working and functional hand soap dispensers. Additionally, in several unoccupied resident rooms, mattresses were observed to be stained, discolored, and ripped. These findings were confirmed by both nursing staff and the Nursing Home Administrator during the survey. Further observations revealed that one of the two resident common rooms on the second floor contained three empty medication carts, a Hoyer lift, two wheelchairs, and had dirt and debris scattered throughout the floor. Staff interviews confirmed these conditions. The facility's own policy requires maintaining a safe, clean, and homelike environment, but the observed conditions did not meet these standards, as confirmed by staff and administration.
Failure to Follow Physician Orders and Provide Appropriate Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate treatment and care for two residents. For one resident with diagnoses including hypertension, renal insufficiency, and heart failure, a physician order for Adalimumab injections every fourteen days was not followed, as the medication was omitted on one scheduled date. Additionally, neither the physician nor the resident's family were notified of this omission, as confirmed by the Director of Nursing. Another resident, who was cognitively intact and had diagnoses of hypertension, anxiety, and irritable bowel syndrome, had a physician order for a follow-up appointment with a Colo-Rectal surgery center. This appointment was cancelled by the facility, and all other appointments were placed on hold, despite the physician order. The Certified Registered Nurse Practitioner confirmed that only physical therapy appointments should have been cancelled, and the resident should have attended the Colo-Rectal appointment as ordered. The Director of Nursing acknowledged that the facility failed to ensure the resident received appropriate treatment and care.
Failure to Provide Adequate Supervision and Assistance During Resident Transfers
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, as required by facility policy and resident care plans. For one resident with a history of hypertension, stroke, and hemiplegia, the care plan specified bed mobility assistance from two staff members and that the bed should remain in a low position. However, a nurse aide raised the bed, left it in a high position, and left the resident unattended while retrieving linens, resulting in the resident falling from the bed and sustaining a minor skin tear. The nurse aide did not follow the prescribed two-person assist protocol or maintain the bed in the required low position. Another resident, dependent for transfers due to diagnoses including hypertension, renal insufficiency, and heart failure, had physician orders and a care plan requiring transfer with a walker and assistance from two staff members, with a Hoyer lift as needed. Despite this, a nurse aide attempted to transfer the resident with only one staff member, leading to the resident losing balance and being lowered to the floor. No injuries were noted in this incident. In both cases, the Director of Nursing confirmed that staff failed to provide the required level of supervision and assistance as outlined in the residents' care plans.
Failure to Provide Adequate Linen Supplies for Resident Care
Penalty
Summary
The facility failed to provide adequate linen supplies to meet the needs and preferences of three out of five residents reviewed. Facility policy requires a safe, clean, and homelike environment, including reasonable accommodation of individual resident needs. During a facility tour, surveyors observed that clean linen racks on both floors were inadequately stocked, with some racks having no towels or washcloths, and others having only a few or torn items. Staff interviews confirmed that there were not enough towels and washcloths available, forcing nursing assistants to prioritize which residents would receive hygiene care. One nursing assistant reported having to choose who to wash due to the shortage, while another stated that only a limited number of towels and washcloths were available for a large number of residents. Resident interviews further substantiated the deficiency. One resident reported having to use paper towels for personal hygiene due to the lack of linens, while another used dirty towels from the previous day because no clean ones were available. A third resident expressed concern about the ongoing shortage and resorted to using disposable wipes. Observations in the laundry room revealed that only one dryer was operational, further limiting the facility's ability to provide sufficient clean linens. The Nursing Home Administrator confirmed the shortage and the facility's failure to accommodate the proper linen needs for the affected residents.
Failure to Provide Proper Tube Feeding Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate care and services to residents receiving tube feedings, as evidenced by multiple observations and record reviews. For four residents with feeding tubes, staff did not follow facility policies regarding the care and maintenance of feeding equipment and supplies. Specifically, feeding tube pumps and poles were found to be dirty with dried feeding substances, and syringes used for tube feeding were not stored properly—some were left in cups with unknown fluids, not air drying, and not placed in plastic bags as required by policy. Additionally, feeding bags and tubing were left connected to residents even when pumps were turned off, and there was a lack of proper labeling and dating of equipment. One resident with a G-tube had a drain dressing that had not been changed according to physician orders, with the dressing dated two days prior to observation. The same resident's room was found with spilled tube feeding and water on the floor, dirty pumps, and cups on the floor. These findings were confirmed by the Director of Nursing, who acknowledged the failure to adhere to established protocols for tube feeding care and site dressing changes. The deficiencies were cited under relevant state codes for management, nursing services, and resident care policies.
Failure to Maintain Homelike Environment on First Floor
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on the first floor, as required by its own policy and state regulations. During a tour of the unit, multiple deficiencies were observed, including a hole in the wall by an air conditioner unit, dust buildup on several bathroom vents, peeling plaster on bathroom ceilings, patched but unfixed bathroom ceilings with brown stains, and peeling bathroom wallpaper. Additionally, one bathroom had brown stains on the ceiling, and a shower room had a sign indicating it was not to be used, with plastic duct-taped to the ceiling to cover an opening and a light fixture hanging improperly. The fire pull station in one wing was not secured to the wall and had unpainted plaster behind it. These findings were confirmed by a Registered Nurse during the tour and later acknowledged by the Nursing Home Administrator. The observations were documented as affecting one of two floors in the facility, specifically the first floor, and were found to be in violation of 28 Pa. Code: 201.18(b)(3) regarding management's responsibility to provide a homelike environment.
Resident Administered Wrong Medication After Refusal
Penalty
Summary
A resident with diagnoses including renal insufficiency, sepsis, and lymphedema was admitted to the facility and did not have a diagnosis of diabetes nor an order for insulin. Despite this, a registered nurse administered a long-acting insulin injection to the resident after the resident verbally refused the medication. The resident primarily spoke French and had limited English proficiency, which may have contributed to communication barriers. The nurse later admitted to the medication error, and documentation confirmed that the insulin was given against the resident's wishes. Facility policy required that if a medication dose is refused, the physician and responsible party must be notified, and the reason documented in a progress note. However, these procedures were not followed. Staff interviews revealed inconsistent practices for resident identification, with some staff unsure if all residents had ID bands and relying on photos in the computer or names on doors. The Director of Nursing confirmed that the facility failed to ensure residents were free from neglect and mistreatment by administering the wrong medication after refusal.
Failure to Communicate Required Resident Information During Hospital Transfer
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during a transfer for one of three residents reviewed. Specifically, the facility's policy required that, for any transfer to another provider, information such as the resident's care plan goals, advanced directive information, specific instructions for ongoing care, and all information necessary to meet the resident's specific needs be provided to the receiving provider. However, a review of the clinical record for a resident who was transferred to a local hospital for a gastrostomy tube replacement revealed no documented evidence that this information was communicated in writing to the receiving health care provider. The resident involved had a medical history including stroke, diabetes, and high blood pressure, and was dependent on a feeding tube for the majority of caloric and fluid intake. Despite these complex care needs, the facility did not provide the required written information to the hospital at the time of transfer. This deficiency was confirmed by the DON during an interview, who acknowledged the failure to communicate the necessary resident information as outlined in facility policy.
Resident Administered Insulin in Error
Penalty
Summary
A significant medication error occurred when a nurse administered a long-acting insulin to a resident who did not have a diagnosis of diabetes and was not prescribed insulin. Facility policy requires that medications be administered by licensed nurses as ordered by the physician, and that medications ordered for one resident are never administered to another. Despite these policies, the nurse gave the resident insulin at approximately 12:56 p.m., as later confirmed by the nurse's written statement and the Director of Nursing. The resident involved had a medical history including renal insufficiency, sepsis, and lymph edema, but no history of diabetes. The error was discovered after the resident's family reported the incident to nursing staff, and subsequent documentation confirmed the administration of insulin of an unknown amount. The Director of Nursing acknowledged that the facility failed to ensure residents are free from significant medication errors, as required by facility policy and state regulations.
Failure to Prevent Cross Contamination of Personal Toiletries
Penalty
Summary
The facility failed to prevent cross contamination of residents' personal toiletries in two of five shared bathrooms on the First Floor (Rooms 107 and 118). During a facility tour, surveyors observed multiple unlabeled personal care items, including deodorant, skin protectant, body wash, shampoo, toothpaste, and peri-wash cleanser, stored in shared bathrooms. These items were not marked with residents' names and were accessible to multiple residents, contrary to facility policy requiring personal toiletries to be labeled and not shared. Interviews with nursing assistants confirmed that residents are supposed to have their own labeled toiletries and that these items should not be kept in shared bathrooms. Staff acknowledged that, at times, supplies run out and items are shared among residents. The Nursing Home Administrator also confirmed the failure to prevent cross contamination of personal toiletries in the identified bathrooms. These findings were determined through policy review, clinical record review, direct observation, and staff interviews.
Failure to Report Resident Fall Resulting in Fracture
Penalty
Summary
The facility failed to notify the Department of Health of a reportable event involving a resident who experienced an unwitnessed fall. This incident occurred on April 19, 2025, and resulted in the resident sustaining a lumbar compression fracture, a type of spinal fracture where the vertebrae collapses. The clinical record review confirmed that the resident did not have a prior diagnosis of a lumbar compression fracture before the fall. During interviews, the Director of Nursing stated that the incident was not reported because the resident did not require hospitalization. Both the Nursing Home Administrator and the Director of Nursing acknowledged that the facility did not notify the Department of Health about this reportable event, which is a requirement under the regulations for events that seriously compromise quality assurance and patient safety.
Plan Of Correction
1. Reportable submitted and accepted for identified fall during complaint survey on 5/1/2025. 2. A 30 day look back audit was completed to ensure that no other falls experienced an injury of similar nature and went unreported. 3. NHA to educate DON/designee on events that require a report to be submitted. 4. DON/designee to audit falls and ensure reports are made for any falls with transfer and/or injury daily x 2 weeks, then 2x/week for 2 weeks, and 1x/week for 2 weeks. 5. Results to be submitted to QAPI for review and approval.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as required by regulations. During a tour, it was observed that the clean utility room on One-East had an ice machine with a brown substance on the water outlet and black spotted substance on the piping. The Director of Maintenance/Housekeeping confirmed that the tubing had been in place for a long time and acknowledged the failure to maintain cleanliness. Additionally, several residents reported broken soap dispensers in their bathrooms, which was confirmed through observations in multiple resident rooms. A resident was also heard complaining about the unclean state of a shower room, which was found to have a brown substance in the trash can and a strong odor. The facility also failed to maintain an adequate supply of linens, including washcloths, towels, and blankets, on the nursing units. Observations revealed that the linen carts were lacking these essential items, and the Director of Maintenance confirmed the shortage. These deficiencies were communicated to the Nursing Home Administrator, highlighting the facility's failure to provide a safe, clean, and homelike environment as required by regulations.
Plan Of Correction
1. Facility immediately cleaned ice machine in clean utility room, fixed soap dispensers in resident bathrooms, and emptied trash cans and cleaned shower rooms. 2. NHA/designee will educate Plant Ops manager on clean, homelike environment and correct par levels for facility. 3. Linen and bedding/blankets were purchased and dispersed into cycle. 4. NHA/designee will monitor linen supply for appropriate par levels. 5. Plant Operations Manager to audit clean, homelike environment within facility and linen supply 3x/week for 3 weeks, then 1x/week for 3 weeks. 6. Results to be submitted to QAPI for review and approval.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, as evidenced by the observations and interviews conducted. Resident R16, who had a diabetic left plantar foot ulcer, did not have their wound dressing changed daily as ordered. The dressing was observed to be dated two days prior, and both the LPN and the Director of Nursing confirmed the failure to adhere to the physician's orders. Similarly, Resident R23, who had a vascular wound on the left shin, did not receive the required daily dressing changes. Despite the treatment administration record indicating compliance, the dressing was found to be unchanged for several days. The resident expressed that staff had been asked to change the dressing, but it was not done, a fact confirmed by the LPN and the Nursing Home Administrator. Resident R52 was administered Cefpodoxime without a physician's signature on the order, and during a change in condition, the facility failed to provide timely care. The resident experienced acute gastrointestinal pain and repeatedly called 911 for hospital transport. Despite the resident's deteriorating condition, there was no evidence of physician notification until the resident was eventually transferred to the hospital. Additionally, Resident R128 experienced a significant change in condition, including severe malnutrition and acute kidney injury, but the facility did not initiate necessary lab tests or identify hydration as a concern, leading to the resident's transfer to the hospital.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were followed and a resident received treatment and care in accordance with professional standards of practice. 2. DON completed a whole house wound investigation and found no other residents with dressings not changed per physician order and that the identified wounds with outdated dressings were not worsening. 3. DON/designee will complete a 30-day lookback of all current physician's orders to ensure they have been signed off. 4. DON/designee to educate licensed staff on following treatment orders/physicians orders including pharmacy ordering and first dose machine, readmission orders, notifying physicians timely with change in conditions. 5. DON to audit physician's orders including readmission orders and timely notification of change in conditions, and medication availability via pharmacy delivery or first dose system 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 6. Results to be submitted to QAPI for review and approval.
Deficiency in Annual In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff received the required annual in-service education, as evidenced by the review of personnel records for three nursing staff members: RN Employee E16, LPN Employee E25, and RN Employee E26. The facility's policy on training requirements, last reviewed on December 9, 2024, mandates the development and maintenance of an effective training program for all staff, covering essential topics such as infection control, resident rights, and safety procedures. However, the personnel records for these employees did not include documentation of annual in-services on critical subjects like infection prevention, fire safety, disaster preparedness, resident abuse, and other key areas. During an interview, Human Resources Employee E5 confirmed the facility's failure to provide the necessary annual in-service education for the identified nursing staff. This deficiency indicates a lapse in the facility's compliance with regulatory requirements to ensure that nursing staff possess the competencies and skills necessary to meet residents' needs, as outlined in their individual care plans. The lack of documented training raises concerns about the facility's ability to maintain a safe and effective care environment for its residents.
Plan Of Correction
1. Employees Registered Nurse (RN) Employee E16, Licensed Practical Nurse (LPN) Employee E25, and Registered Nurse (RN) Employee E26 will receive mandatory education including infection prevention and control, fire prevention and safety, disaster preparedness, resident abuse, resident confidential information, Quality assurance, resident psychosocial needs, restorative nursing techniques, resident rights, cultural competency, and communication. 2. HR Director/designee to audit employee files to determine the mandatory education including infection prevention and control, fire prevention and safety, disaster preparedness, resident abuse, resident confidential information, Quality assurance, resident psychosocial needs, restorative nursing techniques, resident rights, cultural competency, and communication that needs to be completed by each employee. 3. Future mandatory education will be completed by employees annually. HRD/designee will audit employee files to ensure the annual mandatory education is completed monthly x12 months. Those employees not completing the education will be removed from the schedule. 4. Results to be submitted to QAPI for review and approval.
Inadequate Pharmaceutical Services Lead to Medication Delays
Penalty
Summary
The facility failed to implement adequate pharmaceutical services, resulting in the inaccurate provision of medications for two residents. For Resident R51, the issue was identified when a registered nurse was unable to locate the prescribed Zoloft medication in the Pyxis machine, which was supposed to contain four tablets but only had one. The nurse had to seek assistance to access the machine, and upon further investigation, it was found that the pharmacy had not been notified of the discrepancy, leading to a delay in medication delivery. Resident R128 experienced multiple instances of unavailable medications, including Dorzolamide HCl-Timolol Mal Ophthalmic Solution, Selegeline Transdermal Patch, and Clonidine HCl Oral Tablet, among others. These medications were not administered as ordered due to delays in delivery from the pharmacy. The progress notes indicated repeated instances of medications being on order or awaiting arrival, yet there was no documentation of follow-up actions to ensure timely delivery. Interviews with facility staff, including the Nursing Home Administrator, Director of Nursing, and Pharmacy Director, revealed a lack of effective communication and coordination with the pharmacy. The facility did not have a backup pharmacy plan, and there were inconsistencies in the restocking and monitoring of the Pyxis machine. The pharmacy director confirmed that the facility had not communicated the need for medication refills, contributing to the ongoing issue of unavailable medications for the residents.
Plan Of Correction
1. The facility is unable to go back and make certain physician orders were followed and a resident received treatment and care in accordance with professional standards of practice. Residents R51 and R128 had no adverse reactions. 2. DON completed whole house investigation on missing medication. MD was notified of any missed medication and discussed new orders received when medication is unavailable. Staff interviewed on medication re-ordering. Licensed staff educated on medication re-ordering. 3. DON/designee will complete a 30-day lookback of all current resident's medication list, and audit carts for medication availability. 4. DON/designee to educate licensed staff on emergency medication supply, access to emergency medication supply, physician notification requirements of meds not available, and documentation requirements. 5. DON/designee to audit RX NOW machine 1x/week for 3 weeks, then 1x/month for 3 months. 6. DON to audit cart medication availability 5x/week for 2 weeks, then 3x/week for 2 weeks, and 1x/week for 2 weeks. 7. Results to be submitted to QAPI for review and approval.
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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