Squirrel Hill Wellness And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 2025 Wightman Street, Pittsburgh, Pennsylvania 15217
- CMS Provider Number
- 395028
- Inspections on file
- 56
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Squirrel Hill Wellness And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, comfortable, and homelike environment across three nursing units. Surveyors observed an overwhelming urine odor in a hallway, dusty ceiling fan filters on one unit, and a loose floor strip in a dining room that created a potential tripping hazard. Multiple resident rooms were also found with broken blinds. The NHA confirmed these environmental issues and that the facility did not meet its own policy for providing a safe, clean, and homelike setting.
The facility did not employ a qualified Food Service Director to oversee the Dietary Department for an identified period. During a surveyor interview, the Corporate Dietary Manager reported that there was no certified dietary manager on staff and that dietitians were not employed full time. The Corporate Dietary Manager further confirmed that the facility lacked documentation showing that any staff member met the qualifications for the Food Service Director role, resulting in noncompliance with state dietary services and management requirements.
The facility failed to provide palatable, adequate, and timely meals, as shown by documentation and resident grievances describing subpar food quality, menu items not being served as listed, and tasteless meals except for a few specific dishes. Residents reported that trays were almost always late, and some male residents stated they did not receive enough food or extra portions when requested. Observation of meal cart delivery confirmed that meals were delivered about 20 minutes late. The Corporate Dietary Manager acknowledged that the facility lacked a dietary manager and that kitchen staffing was often inadequate to ensure proper food preparation and timely delivery, resulting in failure to meet dietary service requirements.
Surveyors found multiple sanitation breaches in the main kitchen, including a dietary aide eating in the dish machine room, a low-temp dish machine with nonfunctioning wash and rinse gauges, undated and unsealed food items stored in the cooler, and an ice machine drainpipe resting on the floor rather than properly draining into the floor drain. Personal items such as a staff neck cooling collar and an opened crate of cereal were stored on a prep table, and a cell phone was placed on a tray at another prep table near the tray line. The NHA confirmed these failures to maintain sanitary conditions and prevent potential cross-contamination or foodborne illness.
Surveyors found that the main kitchen’s low-temperature dish machine had non-functioning wash and rinse temperature gauges, and a dietary employee reported that the gauges had not worked consistently since installation. The Nursing Home Administrator confirmed that the facility failed to keep this essential equipment in proper working order, resulting in a deficiency related to the Administrator’s responsibility.
The facility failed to protect residents from misappropriation of property when controlled medications and personal funds went missing from a locked medication cart. One resident with severe cognitive impairment and another cognitively intact resident each had a tablet of their ordered controlled anti-anxiety medication missing after a narcotic count on a cart assigned to an LPN, despite documentation that counts had previously matched at shift change and that multiple staff, including an RN manager with an extra set of cart keys, had access to the cart. In a separate incident, a resident with cirrhosis and ESRD had a wallet, multiple cards, and $145 in cash stored in the cart’s locked narcotic drawer over a weekend; staff gave conflicting statements about whether the money was seen or counted, and the cash was later reported missing while the cart was under the control of an LPN, with concern for misappropriation of the resident’s property.
The facility failed to follow its abuse, neglect, and exploitation policy by not reporting suspected misappropriation of resident property, specifically controlled and other medications, for multiple residents to required authorities. Review of narcotic sign-out sheets and electronic MARs showed numerous extra doses of hydromorphone, Tramadol, oxycodone, oxycodone/acetaminophen, and alprazolam signed out on paper but not documented in the MAR, including doses signed out after orders were discontinued, illegible entries, and multiple doses signed out when only one was scheduled. A narcotic count discrepancy for oxycodone tablets was also identified for a resident, with no corresponding administration documented and an RN noted accessing the narcotic drawer shortly before the discrepancy. These events were not reported as possible misappropriation as required by facility policy and state regulations.
The facility failed to follow its abuse, neglect, and exploitation policy by not fully investigating potential misappropriation of controlled medications after two missing narcotic tablets were discovered on a medication cart overseen by an LPN. The internal review focused narrowly on the two affected residents and the involved nursing staff, including conflicting statements about narcotic counts and the later discovery that an RN had an extra set of cart keys. However, the facility did not initially audit other residents’ narcotic records. When additional controlled substance sign-out sheets were examined, numerous undocumented or illegible doses, doses signed out after orders were discontinued, and discrepancies between paper records and the electronic MAR were identified for multiple other residents receiving opioids, tramadol, and alprazolam. The DON and the administrator confirmed that the investigation did not include broader audits or resident interviews to determine whether misappropriation extended to these additional residents.
The facility failed to maintain required transmission-based precautions for numerous residents with active Covid-19 infections. Despite policies and state guidance requiring airborne and contact precautions, including closed room doors and appropriate PPE use, surveyors observed multiple open doors to rooms of Covid-19 positive residents across several nursing units. An LPN began closing doors only after noticing surveyor observations and confirmed that PPE caddies on one unit lacked N95 respirators. The administrator acknowledged that the facility did not ensure an environment free from potential infection spread for a substantial number of affected residents.
The facility failed to ensure that a resident's investigation records related to a possible misappropriation of property were readily accessible to the State Survey Agency. Surveyors made multiple requests to the former NHA and the DON, both in person and via telephone and electronic communication, for the investigation documents. Despite these repeated requests, the records were not provided until several days later, causing a delay in the survey process. The NHA ultimately confirmed that the facility did not maintain resident records in a manner that allowed timely access for surveyors, as required by clinical record regulations.
The facility did not provide clear information or accessible forms for filing grievances on multiple units. Grievance boxes were either not visible, not labeled, or lacked signage, and staff were sometimes unaware of their locations. Information about the Grievance Official and the grievance process was missing or posted separately, and grievance forms were not available for residents or visitors.
A resident with severe cognitive impairment and a history of anxiety and dementia was involved in two incidents where her roommate, also cognitively impaired and exhibiting behavioral issues, acted aggressively toward her. Despite facility policy requiring notification, there was no documentation that the resident's representative was informed of these abuse incidents, as confirmed by the DON and review of clinical records.
Surveyors observed that one nursing unit was not maintained in a clean and homelike manner, with refuse in a sink, partially used hygiene products left out, broken furniture, exposed electrical wires, and soiled items in drawers. A restroom was accessible without a call light system, and an electrical room with circuit breakers and loose wires was accessible due to a taped-over lock. The DON confirmed these deficiencies.
Two residents with dementia were involved in separate incidents where one displayed aggressive behavior toward her roommate, causing distress and fear. Despite documentation of these events, there was no evidence of an investigation, notification to the responsible party, or actions taken to prevent recurrence, as confirmed by the DON.
A resident with significant mobility impairments who required maximal assistance for bed mobility fell from bed during care, resulting in a forehead laceration requiring sutures. Two CNAs were present, but the fall occurred when one turned to retrieve a washcloth and the resident was unable to stop rolling. The incident happened despite care plans and facility policies requiring an assist of two for such activities, and staff confirmed knowledge of these requirements.
The facility did not maintain an effective pest control program, as evidenced by ongoing mouse activity in the kitchen, storage areas, and resident rooms. Mouse droppings were found on food packaging, and food items had to be discarded due to contamination. Staff and a resident confirmed ongoing pest issues, and pest control records documented repeated findings of mice and bait consumption throughout the facility.
The facility did not ensure that the Department of Health's most recent survey results were accessible to residents and visitors in key locations, including the lobby and nursing units. Observations showed that survey result books were either missing or contained outdated information, and residents were unaware of their location. The DON confirmed the deficiency.
The facility failed to provide the required 12 hours of in-service training for four nurse aides within 12 months of their hire date anniversary. Documentation was lacking or incomplete for the training period, and the Nursing Home Administrator confirmed this deficiency.
The facility failed to provide seven residents the opportunity to formulate or review advance directives, as required by regulations. Despite varying cognitive abilities and medical conditions, there was no documentation of advance directives or periodic reviews in their records. The Nursing Home Administrator confirmed this oversight during an interview.
The facility failed to provide timely Medicare non-coverage notices to two residents, preventing them from appealing the decision. The facility's policy requires issuing Advance Beneficiary Notices per CMS guidelines, but the necessary documentation was not provided, as confirmed by the NHA.
The facility failed to maintain a homelike environment on the 4th, 5th, and 6th floors, with issues such as broken vents, dusty debris, and damaged walls in resident rooms. Dining rooms had lifting vinyl flooring with holes. The DON confirmed these deficiencies.
The facility failed to complete MDS assessments within required timeframes for several residents, as per the RAI User's Manual. Delays were identified through clinical record reviews and staff interviews, indicating a systemic issue in meeting assessment deadlines.
The facility failed to complete quarterly MDS assessments within the required timeframe for ten residents, as mandated by the RAI User's Manual. The assessments were not completed within 14 days after the ARD, with delays noted for several residents. This issue was identified during a review of clinical records and staff interviews, highlighting a systemic problem in meeting assessment schedules.
The facility failed to ensure accurate and complete MDS assessments for several residents. Despite indications that assessments should have been conducted, sections related to cognitive patterns and mood were either inaccurately coded or marked as 'Not Assessed.' The Resident Nurse Assessment Coordinator confirmed these deficiencies.
The facility failed to provide an adequate program of activities for residents, impacting their physical, mental, and psychosocial well-being. Following staff resignations, only one part-time activity aide remained, leading to a significant reduction in activities. Residents with various medical conditions reported dissatisfaction, and facility records showed minimal participation in group activities. The facility could not provide requested documentation, and the NHA confirmed the deficiency.
The facility did not provide a qualified professional to direct the activities program for two months. The job description required a qualified therapeutic recreation specialist or activities professional, but this requirement was not met, as confirmed by the NHA and DON.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three out of four quarters in 2024. The Director of Nursing confirmed the absence of meetings for the second, third, and fourth quarters, as required by the facility's policy.
The facility failed to maintain an effective training program for its staff, as required by §483.95. A review of training records revealed that four nurse aides had incomplete or missing documentation of training. Employee E1 had no documented training dates, Employee E3 had no education file, and Employees E4 and E5 had undated '12-hour in-service packets.' The Nursing Home Administrator confirmed the lack of training on infection prevention and control for six of nine staff members.
The facility failed to provide mandatory effective communication training for five staff members, including NAs and an LPN, as required by regulations. This deficiency was confirmed by the Nursing Home Administrator and was identified through a review of training records and facility policy.
The facility failed to provide required Resident Rights training to six staff members, including nurse aides, a dietary employee, an LPN, and the Maintenance Director. Despite a policy mandating such training, records showed these employees did not receive it within the specified timeframe. The Nursing Home Administrator confirmed this deficiency, which violates Pennsylvania Code regulations on staff development and management.
The facility failed to provide mandatory abuse and neglect prevention training to six staff members, including nurse aides, a dietary employee, an LPN, and the maintenance director. Despite the facility's policy requiring such training, documentation showed these employees did not receive the necessary education within the specified timeframes. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to provide mandatory QAPI training to six staff members, including NAs, a dietary employee, an LPN, and a maintenance director. Despite policy requirements, these employees did not receive the necessary training within the specified timeframe, as confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory infection prevention and control training to six staff members, including nurse aides, a dietary employee, an LPN, and the maintenance director. The deficiency was confirmed through a review of training records and an interview with the Nursing Home Administrator.
The facility did not provide required behavioral health training to seven staff members, including nurse aides and a maintenance director, as per their policy. The Nursing Home Administrator confirmed the deficiency, which was identified alongside a lack of infection prevention training for six staff members.
Squirrel Hill Wellness and Rehabilitation Center failed to honor the smoking rights of four residents after changing its policy to a smoke-free facility. Despite the residents' history of smoking and their expressed desire to continue, the facility did not provide acceptable alternatives, such as transferring them to a smoking facility. The residents, who were alert and able to communicate their needs, declined nicotine patches and expressed dissatisfaction with the new policy. The Director of Nursing confirmed the policy change and the resulting deficiency.
The facility failed to facilitate Resident Council meetings for three months due to staffing issues in the activities department. Residents reported that meetings were not arranged after the resignation of the activity director and another staff member, leaving only one part-time aide. The Nursing Home Administrator confirmed the deficiency, which violates residents' rights to organize and participate in groups.
The facility failed to provide accessible grievance forms and a grievance box on the fourth-floor nursing unit, as a trash bin blocked the grievance box and forms were missing. The DON confirmed these findings during an interview.
A facility failed to thoroughly investigate allegations of abuse involving a resident with intact cognition, who reported inappropriate comments from nursing staff regarding delayed pain medication. The investigation lacked documentation of an interview with the resident, and the facility dismissed the resident's credibility based on past behaviors. The deficiency was confirmed by the NHA and DON.
A resident with a history of diabetes, dysphagia, and hemiplegia required tube feedings, but the facility failed to date the formula container upon opening, contrary to guidelines. Observations showed the container was left hanging beyond the recommended time, risking use beyond 24 hours. Staff confirmed the oversight, acknowledging the failure to provide appropriate care.
Facility staff failed to maintain communication with the hemodialysis center for a resident requiring dialysis. The resident, with end-stage renal disease, was scheduled for dialysis three times a week. However, the 'Dialysis Hand Off Communication Report' forms were not completed for nine treatments, as confirmed by the DON. This failure violated the facility's policy on ensuring ongoing communication and collaboration with the dialysis facility.
The facility failed to provide culturally competent, trauma-informed care for three residents with histories of trauma. A resident with gunshot wounds and significant pain did not have a trauma-informed care assessment or PTSD interventions in their care plan. Two other residents with PTSD also lacked appropriate assessments and care plan interventions. The facility did not adequately address safety and privacy concerns, as acknowledged by the DON.
The facility did not complete the required annual performance evaluation for a nurse aide, Employee E3, hired in 2004. This deficiency was identified through a review of facility records and confirmed by the Nursing Home Administrator. The lack of evaluation violates the requirement for regular in-service education and performance reviews.
The facility failed to conduct monthly Medication Regimen Reviews (MRRs) for two residents, as required by policy. One resident's records lacked MRRs for multiple months in 2024, while another resident's records showed missing MRRs for the latter part of the year. The DON confirmed the oversight.
The facility failed to maintain complete and accurate medical records for two residents. One resident passed away, and another was discharged without the completion of required forms. The DON confirmed these findings, indicating a lapse in adhering to the facility's policy of completing records within 30 days of discharge.
The facility did not follow pre-employment TB screening procedures for two newly hired employees, as required by state regulations and CDC guidelines. Employee records showed incomplete TB testing, with one employee having only a one-step skin test and another having an outdated chest x-ray, contrary to the facility's policy.
A resident admitted with breast cancer, high blood pressure, and anxiety disorder did not receive the required Resident handbook or Facility Orientation materials upon admission. The Admission Director and DON confirmed the oversight, which was identified through staff interviews and record reviews.
The facility did not meet the required nurse aide staffing levels during a night shift, with only 2 NAs available for 67 residents, instead of the required 4.47 NAs. This deficiency was confirmed by the NHA.
The facility's Emergency Preparedness (EP) Plan was found lacking a communication plan that complies with federal, state, and local laws. This deficiency was confirmed during interviews with the Facility Administrator and Maintenance Director, who acknowledged the absence of a compliant communication plan.
The facility was found deficient in its Emergency Preparedness (EP) program due to a lack of specified training and testing requirements. A review revealed that the EP plan did not indicate the type and frequency of training needed to ensure staff knowledge of emergency procedures. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of these requirements in the EP plan.
The facility failed to maintain its fire alarm system, with multiple unresolved trouble codes on the main control panel affecting the entire facility. This deficiency was confirmed through documentation review, observation, and an interview with the Facility Administrator and Maintenance Director.
Failure to Maintain Safe, Clean, and Homelike Environment on Multiple Units
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment on all three nursing units (4th, 5th, and 6th floors). The facility’s policy titled “Safe and Homelike Environment” dated 2/14/25 stated that the facility will provide a safe, clean, comfortable, and homelike environment. During an observation on 4/21/2026 between 11:12 a.m. and 12:25 p.m., surveyors identified an overwhelming urine scent in the 4th floor hallway, indicating inadequate odor control and cleanliness. On the 5th floor, ceiling fans in the hallway had a white dusty substance covering the filtering area, and the dining room had a loose floor strip at the center of the room, creating a potential tripping hazard. Additional resident rooms were noted to have broken blinds, specifically in multiple rooms identified only by room number. In an interview later that day at 1:25 p.m., the Nursing Home Administrator confirmed these findings and acknowledged that the facility failed to provide a safe, clean, comfortable, and homelike environment on all three nursing units. No specific resident medical histories or conditions were described in the report, and the findings were based on environmental observations and staff interview rather than individual resident clinical events.
Lack of Qualified Food Service Director for Dietary Department
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for the period from March 19, 2026 through April 2026. During a staff interview on 4/8/26 at approximately 11:00 a.m., the Corporate Dietary Manager stated that the facility did not have a certified dietary manager in place and that dietitians were not employed full time in the facility. The Corporate Dietary Manager also confirmed that the facility could not provide documented evidence that any staff member met the qualifications required for the position of Food Service Director, resulting in noncompliance with PA Code 201.18(e)(6) Management and 211.6(c)(d) Dietary Services. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers on staffing qualifications and the absence of appropriately credentialed leadership for the food and nutrition service.
Failure to Provide Palatable, Adequate, and Timely Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature, as evidenced by multiple sources of information. Review of facility documentation on 4/7/26 identified that the food served was not adequate. The February 2026 grievance log included a complaint from a resident stating that the food was subpar and that items listed on the menu were not actually provided for lunch and dinner. During individual resident interviews on 4/8/26, conducted between 9:10 a.m. and 11:40 a.m., residents reported that meals were tasteless except for certain items such as orange chicken and sometimes spaghetti; male residents reported they often did not receive enough food and sometimes were denied extra portions even when requested, and that meal trays were almost always late. An observation of meal cart delivery on 4/8/26 from 12:00 p.m. through 12:45 p.m. showed that meal carts were delivered approximately 20 minutes late. In an interview on 4/8/26 at approximately 1:00 p.m., the Corporate Dietary Manager (Employee E1) stated that the facility did not have a dietary manager and that kitchen staffing was often inadequate to ensure that foods were prepared properly and delivered in a timely manner. She confirmed that the facility failed to serve food that was palatable and attractive, in violation of 28 Pa. Code 211.6(c)(d)(f) regarding dietary services.
Failure to Maintain Sanitary Conditions in Main Kitchen
Penalty
Summary
Surveyors identified that the facility failed to maintain sanitary conditions in the main kitchen, creating the potential for cross-contamination or foodborne illness. During an observation of the kitchen, a dietary aide was seen eating food in the dish machine room. The dish machine, which is a low-temperature machine using chemicals, had wash and rinse temperature gauges that were not functioning, and a dietary employee reported that the gauges had not worked consistently since the machine was installed. In the cooler, surveyors observed a cart containing undated fruit cups, unsealed bread cubes, and undated cooked carrots. The ice machine drainpipe was resting directly on the floor and draining approximately four inches away from a covered floor drain. On a prep table, a pink staff neck cooling collar was found on top of the work surface and an opened crate of cereal was on the second shelf, with a dietary aide acknowledging the items were hers. Another prep table near the tray line area had a cell phone placed on a tray, also identified by a dietary aide as her property. The Nursing Home Administrator confirmed that the facility failed to maintain sanitary conditions in the main kitchen. No residents or their medical conditions were mentioned in the report.
Failure to Maintain Properly Functioning Dish Machine in Main Kitchen
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the main kitchen dish machine, was in proper working order. During an observation of the main kitchen, surveyors noted that the dish machine’s wash and rinse cycle temperature gauges were not functioning, even though the machine is a low-temperature unit that relies on chemicals. A dietary employee reported that these gauges had not worked consistently since the machine was installed. The Nursing Home Administrator confirmed that the facility had not ensured the dish machine was maintained in proper working condition, in violation of 28 Pa Code 207.2(a) regarding the Administrator’s responsibility. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the malfunctioning dish machine gauges and the facility’s failure to maintain this essential equipment.
Misappropriation of Resident Medications and Funds from Secured Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property, including controlled medications and personal funds, for three residents. Facility policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Resident R1, with diagnoses including peripheral vascular disease and dementia and a BIMS score of 1 (severe cognitive impairment), had an order for lorazepam 0.5 mg three times daily. Resident R2, with schizophrenia and an anxiety disorder and a BIMS score of 15 (cognitively intact), had an order for clonazepam 1 mg twice daily. During a routine narcotic count reconciliation on the 6th floor medication cart, one tablet of lorazepam belonging to Resident R1 and one tablet of clonazepam belonging to Resident R2 were found to be missing/unaccounted for. The medications had been stored in a secured, locked medication cart assigned to LPN Employee E1 at the time the discrepancy was discovered. Statements obtained during the investigation revealed conflicting accounts regarding the narcotic count and access to the cart. In an initial verbal statement, LPN Employee E1 reported that the count was wrong that morning when she counted with another LPN and stated she did not have her reading glasses and did not know the count was wrong. In a later written statement, she corrected the name of the nurse she counted with but maintained that the Ativan and Klonopin counts were not correct. However, LPN Employee E2 stated that when she counted the narcotic drawer with LPN Employee E1 at shift change, all counts matched the records and no discrepancies were noted or questioned. Facility documentation indicated that both nurses reported the narcotic count was accurate at the time of shift change, and that the discrepancy was later identified through review of narcotic count sheets and MAR documentation. During the course of the investigation, RN Employee E3, the Assistant Director of Nursing, was found to be in possession of an extra set of medication cart keys and was working in the facility during the timeframe of the discrepancy, indicating that more than one staff member had access to the locked narcotic drawers. The deficiency also involved misappropriation concerns related to Resident R3’s personal property. Resident R3, with cirrhosis of the liver, end stage renal disease, and a BIMS score of 9 (moderate cognitive impairment), had personal items including a wallet, multiple credit/debit and insurance cards, state ID, and $145 in cash stored in a locked narcotic drawer of the 6th floor medication cart. Staff statements conflicted regarding awareness and handling of this property. One LPN stated that on the morning of December 27, while counting off the cart, there was a stack of cards with rubber bands around it that were said to belong to the resident, and that money was never seen or mentioned and therefore never counted. Another LPN reported last seeing the resident’s money in a clear plastic bag in the narcotic drawer on the morning of December 26, noting a visible hundred-dollar bill, and later noticing that the money was no longer visible when counting the drawer the night of December 27, prompting notification of the acting supervisor. A third LPN stated that on December 27, she specifically informed another nurse that the resident had a wallet, a stack of different credit cards, and $145 in cash in a plastic bag labeled with the resident’s name in the narcotic box, and that she picked up and showed the bundle to ensure the other nurse knew it was there. Facility documentation indicated that the resident’s credit/debit cards, ID, insurance cards, and $145 in cash were being stored in the locked drawer over the weekend to be taken to the business office, and that on December 28 the money was reported missing while the cart was under the control of LPN Employee E1, with concern for loss or possible misappropriation of resident property. The facility’s investigation report later noted that, because more than one nurse had access to the locked narcotic drawer during the relevant timeframe, the investigation into the missing funds was inconclusive and could not be substantiated or unsubstantiated.
Failure to Report Suspected Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to report suspected misappropriation of resident property, specifically controlled substances and other medications, for 12 of 14 residents as required by its Abuse, Neglect, & Exploitation policy and state regulations. The facility’s policy dated 2/14/25 required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, depending on whether abuse or serious bodily injury was involved. Despite this, documentation submitted to the State Survey Agency did not include reports of possible misappropriation for the affected residents, and the Nursing Home Administrator later confirmed that the facility failed to implement its policies and procedures for reporting possible misappropriation of resident property. Surveyors’ review of narcotic sign-out sheets and the electronic MARs for multiple residents showed numerous additional doses of controlled and other medications signed out on paper but not documented in the electronic MAR. For one resident, extra doses of hydromorphone were recorded on paper on several dates without corresponding MAR entries. Other residents had undocumented paper sign-outs for Tramadol, oxycodone, oxycodone/acetaminophen, and alprazolam, including instances where multiple doses were signed out in a short time frame, illegible entries, and doses signed out after the physician’s order had been discontinued. One resident’s record showed three doses signed out between 12:20 a.m. and 5:00 a.m. when only one dose was scheduled, and another resident’s record showed wasted doses and multiple undocumented administrations. Further review showed that for one resident, a narcotic inventory discrepancy was identified, with 4½ tablets of oxycodone 5 mg unaccounted for between two documented counts, and no medication administration recorded during that interval. Activity records indicated that an RN accessed the narcotic drawer shortly before the discrepancy was noted. Despite these discrepancies and the facility’s own policy requiring prompt reporting of alleged violations, the facility did not report these possible misappropriations for 12 residents to the State Survey Agency or other required authorities, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(5) and 201.29(j).
Failure to Fully Investigate Misappropriation of Controlled Medications for Multiple Residents
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy to fully investigate potential misappropriation of resident property, specifically controlled medications, for multiple residents. The policy required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, preserving potential evidence, investigating all types of alleged violations, interviewing all involved persons, and providing complete documentation. An incident was identified in which one tablet of lorazepam 0.5 mg prescribed to a resident with peripheral vascular disease and dementia (BIMS score 1, on scheduled lorazepam) and one tablet of clonazepam 1 mg prescribed to a resident with schizophrenia and anxiety (BIMS score 15, on scheduled clonazepam) were found missing during a narcotic count. The missing medications were stored in a locked medication cart on the sixth floor, and the discrepancy was discovered during routine narcotic count reconciliation while an LPN was in charge of the cart. Following discovery of the two missing controlled substances, the facility’s investigation focused on the LPN assigned to the cart and the nurse who handed off the cart, including obtaining statements about the narcotic count at shift change and the LPN’s report of not having reading glasses and being unaware of an incorrect count. Narcotic count sheets and the MAR were reviewed for the two residents whose medications were missing, and statements were obtained from the involved LPNs. During the course of this focused inquiry, a RN who served as the Assistant DON was later found to be in possession of an extra set of medication cart keys and had been working in the facility during the time frame of the discrepancy. However, the investigation documentation provided did not show that the facility broadened its review beyond the two initially identified missing doses to determine whether misappropriation extended to other residents. When additional narcotic sign-out sheets were reviewed with the DON, numerous discrepancies were identified for twelve other residents, including extra doses of hydromorphone, tramadol, oxycodone, oxycodone/acetaminophen, alprazolam, and other controlled medications signed out on paper but not documented in the electronic MAR, illegible entries, doses recorded after orders had been discontinued, and multiple doses signed out in time frames inconsistent with the physician’s orders. These discrepancies involved residents with various pain and anxiety medication regimens and included instances where orders were no longer active or where extra or wasted doses were recorded without corresponding MAR documentation. The DON confirmed that the facility’s investigation into misappropriation did not include audits of other residents’ medication records, narcotic sign-out sheets, or resident interviews to determine whether misappropriation involved additional residents. The Nursing Home Administrator also confirmed that the facility failed to implement policies and procedures to investigate misappropriation of resident property for 12 of 20 residents, resulting in a deficiency under 28 Pa. Code 211.12(d)(1)(5) Nursing services and 28 Pa. Code 201.29(j) Resident rights.
Failure to Maintain Transmission-Based Precautions for Covid-19 Positive Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program during a period when 41 of 109 current residents had active Covid-19 infections. Facility policy on Isolation – Notices of Transmission-Based Precautions required the use of notices to alert personnel and visitors of transmission-based precautions while protecting resident privacy, and the Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit directed that masking and appropriate transmission-based precautions, including airborne and contact precautions for SARS-CoV-2, be used. These precautions included keeping doors to rooms of residents with suspected or confirmed respiratory viral infections closed, using fit-tested N95 or higher-level respirators, and following contact precautions such as gloves, gowns, and dedicated or disinfected equipment. On multiple nursing units, surveyors observed that room doors for numerous residents with active Covid-19 infections were open, contrary to airborne precaution requirements that doors remain closed. On the Five South unit, doors were open for several rooms housing residents with active Covid-19, and an LPN began closing doors only after noticing the surveyor documenting room numbers. The same pattern of open doors for Covid-19 positive residents was observed on the Sixth Floor, Fifth Floor, and Fourth Floor nursing units. Additionally, the LPN confirmed that none of the three PPE caddies on the Five South unit contained N95 masks for staff who chose to wear them. The Nursing Home Administrator confirmed that the facility failed to ensure an environment free from the potential spread of infection for 27 of 41 residents, in violation of multiple cited Pennsylvania regulatory codes.
Failure to Provide Timely Access to Resident Investigation Records
Penalty
Summary
The facility failed to ensure that a resident's records were readily accessible to the State Survey Agency, resulting in a delay in the survey process for one of three reviewed residents (Resident R3). Surveyors repeatedly requested investigation documents related to a possible misappropriation of Resident R3's property from both the former Nursing Home Administrator and the Director of Nursing. These requests were made during an in-person interview with the former Nursing Home Administrator on 12/30/25, an in-person interview with the Director of Nursing on 12/31/25, and a telephone interview with the former Nursing Home Administrator on 1/2/26. Additional requests for the same investigation documents were made via electronic communication to the Director of Nursing on 1/5/26 and again on 1/7/26. The investigation documents related to the possible misappropriation of Resident R3's property were not received by the surveyors until the evening of 1/7/25. During an interview on 1/8/26, the Nursing Home Administrator confirmed that the facility failed to ensure residents' records were readily accessible to the State Survey Agency, which caused a delay in the survey process for Resident R3, in violation of 28 Pa. Code: 211.5(f)(g)(h) regarding clinical records.
Failure to Provide Accessible Grievance Process Information and Forms
Penalty
Summary
The facility failed to provide adequate information and access regarding the grievance process on multiple nursing units. Specifically, on two of three nursing units, there was no information posted about how to file a grievance or about the designated Grievance Official. Observations revealed that grievance boxes were either not easily visible or not clearly labeled as being for grievances. Staff interviews indicated that some employees were unaware of the location of the grievance box, and when located, the boxes lacked appropriate signage. Additionally, on all three nursing units reviewed, grievance forms were not available for residents or their representatives to fill out. In some areas, information about the Grievance Official was posted in a separate location, not near the grievance box. The Director of Nursing confirmed these deficiencies, acknowledging the lack of accessible grievance forms and insufficient information about the grievance process and official on the affected units.
Failure to Notify Resident Representative After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to notify the representative of a resident following incidents of resident-to-resident abuse. Specifically, there were two documented occasions where one resident, who had a diagnosis of dementia and a BIMS score indicating severe cognitive impairment, was subjected to distressing behavior by her roommate, who also had dementia and exhibited behavioral symptoms such as combativeness and wandering. In both incidents, the roommate was observed standing over the resident, yelling and causing the resident to cry and express fear. Despite these events, there was no documentation in the resident's clinical record indicating that her representative was notified of the incidents. Review of facility policy and interviews confirmed that the facility's procedures require notification of a resident's representative in such situations. The Director of Nursing acknowledged that the required notifications were not made. The clinical records and progress notes for the affected resident did not contain any evidence of incident documentation or representative notification, which is inconsistent with both facility policy and regulatory requirements.
Failure to Maintain Clean and Homelike Environment on Nursing Unit
Penalty
Summary
The facility failed to maintain a clean and homelike environment on one of its nursing units, as evidenced by multiple observations during a survey. In the Fourth Floor dining room/lounge, surveyors found refuse in the sink, partially used bottles of shampoo and lotion on a shelf above the sink, and a drawer with a broken handle containing a sock, a soiled Ziploc bag, and a soiled disposable cup lid. The sink only had a hot water handle, and an electrical outlet near the television was missing a faceplate, exposing wires. Additionally, a resident reclining chair was missing an arm cushion, exposing the metal frame, and had dried brown and food substances on its surface, with a broken footrest. Further observations revealed that a restroom door, not designated for staff, visitors, or residents, was unlocked and accessible to residents but lacked a call light system. Personal hygiene items were stored on top of the paper towel dispenser in this restroom. An interior door covered with duct tape over the locking mechanism led to an electrical room with accessible circuit breakers and loose wires. The DON confirmed these findings, indicating the facility did not provide a clean and homelike environment as required by policy.
Failure to Investigate Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate two separate resident-to-resident abuse incidents involving a resident with severe cognitive impairment and another resident with moderate impairment. On two occasions, one resident was observed standing over her roommate, exhibiting aggressive and threatening behavior, including yelling and causing the roommate to cry and express fear. Despite these incidents being documented in progress notes, there was no evidence in the clinical records that an investigation was initiated, nor was there documentation of notification to the affected resident's representative. Additionally, the clinical records did not show any actions taken to prevent recurrence of these incidents, such as offering to move the resident to a different room. Staff interviews confirmed that the facility did not complete an investigation into the incidents, as required by facility policy. The residents involved had significant medical histories, including dementia, heart failure, diabetes, and recent stroke, and both had their children listed as emergency contacts and responsible parties. The lack of investigation and follow-up was confirmed by the Director of Nursing during interviews.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a fall that resulted in actual harm to a resident. The resident, who had a history of paraplegia, hemiplegia following a CVA, and other significant medical conditions, required substantial or maximal assistance for bed mobility and an assist of two for activities of daily living (ADLs). During a bed change, two CNAs were present and the resident was rolled onto his side, but was unable to stop rolling and fell from the bed, sustaining a large laceration on the forehead that required sutures. The incident report and staff statements indicated that while one CNA turned to grab a washcloth, the resident slipped out of bed and staff were unable to prevent the fall due to the resident's weight and loss of balance. The resident's care plan and facility policies required an assist of two for bed mobility and ADLs, and staff were expected to follow these instructions as documented in the Kardex and care orders. Despite these requirements, the fall occurred during routine care, and the resident suffered a significant injury. Staff interviews confirmed knowledge of the care requirements and the use of the Kardex for safety measures, but the incident still resulted in harm. Clinical documentation showed that the resident was alert and oriented at the time of the incident, and after the fall, was assessed and transferred to the hospital for treatment. The facility's failure to ensure adequate supervision and safe handling during bed mobility directly led to the resident's fall and injury. The deficiency was confirmed by review of facility policies, clinical records, incident reports, and staff interviews.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy and state regulations. Observations in the Main Kitchen revealed mouse droppings and mouse traps in the kitchen storage area, as well as an open box of brown sugar with mouse droppings on top and tortilla shells that had to be discarded due to mice eating through the packaging. The Assistant Kitchen Manager confirmed ongoing concerns with mice in the Main Kitchen and reported keeping a detailed list of food that needed to be discarded and replaced due to pest contamination. Additionally, multiple mouse traps were observed in resident rooms on several nursing unit floors, and a resident reported that while the mouse problem had improved, mice were still seen running around. Review of pest control records showed repeated findings of bait being eaten and mice being caught in glue traps in various areas of the facility, including the kitchen, dining rooms, breakrooms, and resident areas, over several weeks. Despite regular inspections and interventions by pest control, evidence of active pest infestation persisted. The Nursing Home Administrator and Director of Nursing confirmed that the facility had not maintained an effective pest control program, resulting in the continued presence of pests in the facility.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors in three key locations: the first-floor lobby, and the nursing units on the fourth and sixth floors. During an interview, four residents expressed that they were unaware of where the survey results were located. Observations revealed that signage in the lobby, fourth floor, and sixth floor indicated that survey results could be found on the 1st, 4th, and 6th floors, but the survey result book was not found in the lobby or the sixth floor. On the fourth floor, the survey result book was found behind empty folders and contained outdated survey results from 2023, despite the most recent survey being conducted on 2/12/24. The Director of Nursing confirmed the facility's failure to make the Department of Health's most recent survey results readily accessible to residents and visitors. This deficiency was identified through observations and interviews, highlighting a lack of compliance with the requirement to post survey results in a place that is easily accessible to residents, family members, and legal representatives. The facility did not meet the regulatory requirement to ensure transparency and accessibility of survey results, as evidenced by the inability of residents and visitors to locate the necessary information in the designated areas.
Plan Of Correction
No residents were affected by not having access to the survey results. Previous years surveys have been printed and placed in the survey binders. The Director of nursing was educated on Access to survey results. The Director of nursing will audit the binders monthly for up-to-date 2567 information. Findings will be reported in quality assurance and process improvement meetings.
Deficiency in Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to meet the required in-service training standards for nurse aides, as mandated by §483.95(g). Specifically, the facility did not ensure that four nurse aides received at least 12 hours of in-service education within 12 months of their hire date anniversary. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on 10/20/24, stated that an effective training program would be developed and maintained for all staff, but this was not adhered to. The review of training records revealed that Nurse Aide Employee E1, hired on 10/9/22, had no documented evidence of education between 10/9/23 and 10/9/24. Similarly, Nurse Aide Employee E3, hired on 10/11/04, had no documentation of completed education from 10/11/23 to 10/11/24. Nurse Aide Employee E4, hired on 10/11/05, and Nurse Aide Employee E5, hired on 11/12/13, both had education files with a "12-hour in-service packet," but no dates confirmed that the education occurred within the required timeframe. The Nursing Home Administrator confirmed the facility's failure to conduct the necessary in-service education during an interview on 2/14/25.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services provided education to the Administrator, Director of Nursing, and Human Resources Director regarding the need to track 12 hours of annual training for certified nursing assistants. The facility has developed a tracking form to track these education hours for each nurse's aide. The Human Resources Director will complete a monthly audit on all employees due to complete their 12 hours of training that month to ensure they have received the required 12 hours of training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to comply with the requirements for advance directives as outlined in 28 Pa. Code 201.14(a) and 483.10(c)(6)(8)(g)(12)(i)-(v). Specifically, the facility did not provide the opportunity for seven residents to formulate an advance directive or conduct periodic reviews of existing directives. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The residents involved in this deficiency included individuals with various medical conditions such as anxiety, depression, dementia, coronary artery disease, stroke, and schizoaffective disorder. Despite having cognitive abilities ranging from intact to severely impaired, as indicated by their BIMS scores, there was no documentation in their clinical records of advance directives or evidence of periodic reviews. This lack of documentation suggests that the facility did not adhere to its policy of supporting and facilitating residents' rights to make decisions about their medical treatment. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the opportunity for these residents to formulate or review advance directives. This deficiency affected seven out of the twenty-two residents reviewed, highlighting a significant oversight in the facility's compliance with federal and state regulations regarding resident rights and advance directives.
Plan Of Correction
Residents R11, R35, R41, R45, R52, and R55 have been provided the opportunity to formulate an advance directive. Residents electing to execute advance directives have been provided assistance. The facility has determined that current residents have the potential to be affected. An audit was completed on current residents to ensure each has been given the opportunity to formulate an advance directive. The facility reviewed with each resident their decision regarding advance directive status and provisions. The Nursing Home Administrator, or designee, has re-educated the interdisciplinary team members responsible for advance directives on the facility's "Advance Directives." The facility will offer residents on admission/readmission the opportunity and assistance to formulate an advance directive. The facility will review during the annual care conference with the resident and responsible party the decisions made regarding advance directives. The Director of Social Services, or designee, will review care conference summary notes to ensure each resident has been provided the opportunity to formulate an advance directive and review any previously made decisions regarding advance directives weekly for 2 months. Results of audits will be reviewed by the Quality Assurance Committee quarterly until the committee determines consistent substantial compliance.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notice of Medicare non-coverage for two residents, identified as R217 and R218, which is a requirement under federal regulations. The facility's policy, last reviewed on 10/20/24, mandates that appropriate Advance Beneficiary Notices (ABNs) be issued in accordance with CMS guidelines. However, the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) to these residents at least two calendar days before the end of their Medicare-covered services, as required. This failure prevented the residents from having the opportunity to appeal the non-coverage decision. Specifically, the SNF ABN form for Resident R218 indicated that payment for skilled nursing services would end on 8/2/24, but the facility did not provide the necessary documentation or time for appeal. Similarly, for Resident R217, the SNF ABN form indicated that payment would end on 10/21/24, yet the facility again failed to provide the document and appeal time. During an interview, the Nursing Home Administrator confirmed the absence of the NOMNC form for Resident R217 and the SNF ABN for both residents, highlighting a lapse in compliance with the required notification process.
Plan Of Correction
Resident 217 and 218 have been discharged on 10/22/2024 and 8/2/2024 respectively. The facility has determined that residents with a qualifying hospital stay and Medicare Part A benefit days available have the potential to be affected. An audit was conducted on current residents who were admitted in the past six months, and corrective actions were completed on 3/21/2025. The Administrator educated the following personnel on the facility's Advance Beneficiary Notices policy: Business Office Manager, Social Services Director and Assistant, MDS Coordinator, Director of Nursing, and Rehabilitation Program Manager. Copies of the relevant forms were placed in a binder in the offices of the Business Office Manager and Social Services Director. The Social Service Director, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks to verify that notices were issued timely. This plan of correction will be monitored at the Quality Assurance meeting until such time consistent substantial compliance has been met.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment across three nursing units, specifically on the 4th, 5th, and 6th floors. Observations revealed multiple deficiencies in resident rooms, including broken vents and dusty debris inside air conditioning/heating units in rooms 409 W, 410 W, 421 W, 423 W, and 424 W. Additionally, room 409 W had missing molding and holes around the night light, while rooms 401 and 425 had exposed tubing and black cables not in use. Dining rooms on these floors had brown vinyl flooring that was lifting and had worn black holes throughout. Further issues were noted in the form of walls with holes and scratches behind beds in rooms 511, 512, and other unnumbered rooms on the 5th floor, as well as room 607 on the 6th floor. These observations were confirmed by the Director of Nursing during an interview, acknowledging the facility's failure to maintain a homelike environment as required by regulations.
Plan Of Correction
By March 27th, 2025, the Maintenance Supervisor fixed the identified area noted in the 2567. All residents have the potential to be affected by this practice. The maintenance director will complete a house audit to ensure no other areas of the facility are affected. The Maintenance director will perform room inspections monthly and as needed to identify and address any needed repairs. Staff will report any identified concerns to the maintenance supervisor upon observation. Results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.
Delayed MDS Assessments for Residents
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframes for seven residents. According to the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in delayed assessments for several residents. Specifically, the report highlights that residents had MDS assessments completed beyond the stipulated deadlines. For instance, one resident had an ARD of November 13, 2024, but the MDS was completed on November 28, 2024. Another resident had an admission date of January 13, 2025, with the MDS due by January 27, 2025, but it was not completed on time. These delays were identified during a review of clinical records and confirmed through staff interviews, indicating a systemic issue in meeting the required assessment timelines.
Plan Of Correction
By time of the annual survey, the MDS Team completed the Comprehensive Assessment for Resident 1, 23, 45, 49, 52, 57, and 58. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure that comprehensive assessments were completed timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant will review the assessment schedule monthly to ensure timely completion. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for ten residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 days after the Assessment Reference Date (ARD). However, the facility did not meet this requirement for residents R12, R14, R20, R30, R34, R35, R41, R43, R44, and R55. The completion dates for these residents' MDS assessments exceeded the 14-day requirement, with delays ranging from a few days to several weeks. During an interview on February 14, 2025, the Nursing Home Administrator and the Director of Nursing were informed of the facility's failure to complete the quarterly MDS assessments within the required timeframe for six of the 25 residents reviewed. This deficiency was identified based on a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews, indicating a systemic issue in adhering to the mandated assessment schedule.
Plan Of Correction
By the time of the Annual Survey, the MDS Team completed the Quarterly Review for Resident 12, 14, 20, 30, 34, 35, 41, 43, 44, and 55. All residents of this facility have the potential to be affected by this practice. A house wide audit was completed to ensure quarterly assessments were done timely. The facility's MDS Team attended an in-service presented by the MDS Nurse Consultant. The Nurse Consultant or designee will review the assessment schedule monthly to ensure timely completion. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.
Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for seven out of ten residents. The deficiencies were identified through a review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews. The manual specifies that certain sections of the MDS, such as Section C: Cognitive Patterns and Section D: Mood, should be completed based on the resident's ability to be understood. However, for several residents, these sections were either inaccurately coded or marked as 'Not Assessed,' despite indications that assessments should have been conducted. For instance, Resident R8 was noted as 'sometimes understood' in Section B: Hearing, Speech, and Vision, yet Sections C and D were marked as 'rarely understood,' and the necessary assessments were not completed. Similarly, other residents, such as R10, R13, R29, R36, R40, and R54, had incomplete or inaccurately coded assessments, with critical sections left unassessed. The Resident Nurse Assessment Coordinator confirmed these findings, acknowledging the facility's failure to complete the MDS assessments accurately.
Plan Of Correction
Resident 8, 10, 13, 29, 36, 40, and 54 was reassessed to include Section C and BIMS be conducted. The facility has determined that all residents have the potential to be affected. A house audit has been completed to ensure that section C and BIMS were completed appropriately. An in-service education program was conducted by the Director of Nursing Services or designee with MDS Coordinator(s) and Social Service to addressing the importance of making certain that the comprehensive minimum data set assessments were accurate and fully completed. The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents per week on their MDS for four (4) consecutive weeks. These residents and their medical records will be assessed to ensure that the BIMS section is completed correctly in the MDS. This plan of correction will be monitored at the monthly Quality Assurance meeting until such a time consistent substantial compliance has been met.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of eight out of ten residents. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The residents reported a significant reduction in activities following the resignation of the activity director and another staff member, leaving only one part-time activity aide to manage the program. Several residents, including those with diagnoses such as anxiety, depression, dementia, coronary artery disease, and schizoaffective disorder, expressed dissatisfaction with the lack of activities. Their preferences, as documented in their care plans, included reading, music, group activities, and going outside. However, the facility's records showed minimal participation in group activities, with some residents not participating at all during the review period. Interviews with residents revealed a consistent theme of reduced activities and a lack of updated activity calendars. The facility was unable to provide requested documentation, including activity calendars for several months and the personnel file of the activity staff. The Nursing Home Administrator confirmed the facility's failure to meet the residents' activity needs, as required by regulations.
Plan Of Correction
Resident R5, R11, R26, R35, R41, R45, R52, and R55 were interviewed by Activities Staff to determine activity preferences. Structured activities were placed on the Activity Calendar and led by Activities Staff. Attendance and participation were documented and maintained in the Activities Office, to be filed with the resident's medical record by the 5th day of the following month. The facility has determined that all residents have the potential to be affected. The Activity Director reviewed activity attendance and participation records of residents for trends regarding activities. Follow-up interviews were conducted on 5 residents and completed to see if we are meeting their activity needs. The Activities Director provided education to Activities and Nursing Staff on their roles and responsibilities regarding activities. Attendance and participation in activities will be documented and maintained in the Activities Office during the current month and filed in each resident's medical record by the 5th day of the following month. The Activities Director will review activity attendance and participation records monthly for trends regarding activities. Activities Staff will interview five residents weekly to determine activity preferences and to guide activity planning for 3 months. Findings will be discussed with the Resident Council and at the monthly Quality Assurance meeting until such a time consistent satisfaction is reported by the Resident Council.
Failure to Provide Qualified Activities Director
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program for two months, from December 6, 2024, through February 14, 2025. This deficiency was identified based on staff interviews and a review of facility-provided documentation. The job description for the Activities Director required that the program be directed by a qualified therapeutic recreation specialist or an activities professional. However, during an interview on February 13, 2025, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility did not meet this requirement for the specified period.
Plan Of Correction
An activity director has been hired and is starting on March 17th, 2025. This has the potential to have a negative effect on the residents. The administrator will be educated by the clinical consultant on the policy of hiring a qualified Activity Director. The administrator will audit to ensure for 3 months there is a qualified activity professional on staff. Findings will be reported to the quality assurance and performance improvement committee.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for three out of four quarterly meetings in 2024. According to the facility's policy, the QAA committee is required to meet at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. However, the review of the Quality Assurance attendance records indicated that the facility only held a first-quarter meeting on February 22, 2024, and did not provide evidence of conducting meetings for the second, third, and fourth quarters of 2024. During an interview, the Director of Nursing (DON) confirmed the facility's failure to conduct the required QAA meetings with all necessary committee members for the specified quarters. This deficiency was identified based on the facility's policy review, attendance records, and staff interviews, highlighting a lapse in maintaining the mandated schedule and composition of the QAA committee meetings.
Plan Of Correction
Facility determined that not having quarterly quality assurance meetings could negatively affect the residents. Administrator and Director of nursing will be educated and educate all managers on the importance of regularly scheduled quality assurance meetings by regional clinical nurse. Administrator or designee will audit compliance with the quality assurance meetings. Findings will be reported at the quality assurance meetings.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as required by §483.95. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. Specifically, the facility's policy on 'Training Requirements,' last reviewed on October 20, 2024, mandates the development and maintenance of an effective training program for all staff. However, the facility did not adhere to this policy for four nurse aides, identified as Employees E1, E3, E4, and E5. The training records for these employees were either incomplete or missing, indicating a lack of documented training within the specified timeframe. Employee E1, hired on October 9, 2022, had no documented dates or times of training in their education file. Employee E3, hired on October 11, 2004, had no education file or documentation of completed education from October 11, 2023, through October 11, 2024. Employee E4, hired on October 11, 2005, had a '12-hour in-service packet' in their file, but no dates confirmed the training occurred within the required period. Similarly, Employee E5, hired on November 12, 2013, had a '12-hour in-service packet' without dates confirming the training occurred between November 12, 2023, and November 12, 2024. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide training on infection prevention and control for six of nine staff members.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Deficiency in Staff Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for five out of nine staff members, as required by §483.95(a). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on effective communication for direct care staff. However, documentation revealed that Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, and Licensed Practical Nurse Employee E8 did not receive the required training within the specified time frames. The Nursing Home Administrator confirmed during an interview that the facility did not provide the necessary training on effective communication for these staff members. The lack of training was in violation of the facility's policy and the regulatory requirements, as outlined in 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Plan Of Correction
No residents were affected by this deficiency. Residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide mandatory training on Resident Rights to six out of nine staff members, as required by §483.95(b). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on resident rights and facility responsibilities. However, documentation revealed that several staff members, including nurse aides, a dietary employee, an LPN, and the Maintenance Director, did not receive the required training within the specified timeframe. The staff members affected include Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, LPN Employee E8, and Maintenance Director Employee E9. Each of these employees had specific hire dates, and the review showed they did not receive resident rights training between their respective hire anniversaries in 2023 and 2024. The Nursing Home Administrator confirmed the lack of training during an interview, acknowledging the facility's failure to comply with the training requirements. This deficiency is in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide Abuse and Neglect Prevention Training
Penalty
Summary
The facility failed to provide mandatory training on abuse and neglect prevention to six out of nine staff members, as required by §483.95(c). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on abuse, neglect, and exploitation prevention. However, documentation revealed that several employees, including nurse aides, a dietary employee, a licensed practical nurse, and the maintenance director, did not receive the required in-service education on abuse and neglect prevention within the specified timeframes. The specific staff members who lacked documented training were identified as Employee E1, E3, E4, E7, E8, and E9. These employees had hire dates ranging from 2004 to 2018, and each failed to receive the necessary training between 2023 and 2024. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the required training. This deficiency is in violation of the facility's policy and the regulatory requirements set forth in §483.95(c), as well as Pennsylvania Code sections related to staff development and management responsibilities.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to six out of nine staff members, as required by federal regulations. The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on the elements and goals of the QAPI program. However, documentation revealed that Nurse Aides E1, E3, and E4, Dietary Employee E7, Licensed Practical Nurse E8, and Maintenance Director E9 did not receive the required QAPI training within the specified timeframe. The Nursing Home Administrator confirmed during an interview that the facility did not provide the necessary QAPI training to these staff members. The lack of training was noted for employees with hire dates ranging from 2004 to 2022, indicating a systemic issue in maintaining compliance with training requirements. This deficiency is a violation of the facility's responsibility to ensure staff are adequately trained in quality assurance and performance improvement, as outlined in the facility's policy and federal regulations.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory training on the Infection Prevention and Control program for six out of nine staff members, as required by §483.95(e). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including infection prevention and control. However, documentation revealed that several employees, including nurse aides, a dietary employee, a licensed practical nurse, and the maintenance director, did not receive the required training within the specified timeframe. Specifically, the training records showed that Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, Licensed Practical Nurse Employee E8, and Maintenance Director Employee E9 did not have documented in-service education on the infection prevention and control program. The Nursing Home Administrator confirmed the lack of training during an interview, acknowledging the facility's failure to comply with the training requirements. This deficiency was noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and staff development.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to seven out of nine staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including behavioral health training. However, documentation revealed that several employees, including nurse aides, environmental services, dietary staff, and a maintenance director, did not receive the necessary behavioral health in-service education within the specified timeframes after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency was identified in the context of the facility's broader training requirements, which also include communication, resident rights, infection prevention, and other critical areas. The failure to provide behavioral health training was noted alongside a separate issue regarding infection prevention and control training, which was also not provided to six of the nine staff members.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Honor Resident Smoking Rights
Penalty
Summary
Squirrel Hill Wellness and Rehabilitation Center was found to be non-compliant with resident rights as outlined in 42 CFR Part 483, Subpart B, and the 28 Pa. Code. The facility failed to honor the rights of residents to smoke, affecting four residents who were reviewed during the survey. The facility had a policy allowing supervised smoking in designated areas, but this was changed to a smoke-free policy, prohibiting smoking on the premises. The residents involved, who had a history of smoking and expressed a desire to continue, were informed of the new policy. Despite their wishes, the facility did not provide alternatives that were acceptable to the residents, such as transferring them to a facility that allows smoking. The residents, who were alert and able to make their needs known, declined the offer of nicotine patches and expressed their dissatisfaction with the inability to smoke or be transferred to a smoking facility. Interviews with the residents revealed their frustration and desire to either smoke or be moved to a facility that accommodates their smoking habits. The Director of Nursing confirmed the change in policy and acknowledged that the residents' rights to smoke were no longer honored. This change in policy and the facility's failure to accommodate the residents' rights led to the deficiency noted in the survey.
Plan Of Correction
A meeting regarding the facility's Non-Smoking Policy was conducted with residents #R11, R19, R28, and R53 (the "grandfathered residents"), each of whom had signed a smoking agreement prior to the non-smoking policy going into effect on February 5, 2025. The information discussed at that meeting included smoking times and rules for these grandfathered residents. The information was incorporated into the plan of care for these residents. The facility has determined that all residents have the potential to be affected. New residents are informed about the facility's Non-Smoking Policy prior to admission and are offered smoking cessation products. In-service education programs were conducted separately with licensed and non-licensed staff by the Director of Nursing Services (DON), or designee. In-service education regarding the Non-Smoking Policy included the grandfathered residents who are permitted to smoke. The Director of Nursing Services (DON), or designee, will conduct random observations to ensure that the smoking rights of the grandfathered residents are being met. Such observations will take place once per week for four weeks, then bi-weekly for one month, then monthly for one month. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
Failure to Facilitate Resident Council Meetings
Penalty
Summary
The facility failed to provide the Resident Council with the opportunity to hold meetings for three months, specifically September, October, and November of 2024. This deficiency was identified through a review of facility policy, documentation, and interviews with residents and staff. The facility's policy, titled "Resident Council Meetings," mandates that the council meets at least quarterly or as determined by the group. However, residents reported that meetings were not arranged during the specified months due to staffing issues in the activities department. The activity director and another staff member had resigned, leaving only one part-time activity aide to manage the department. During a Resident Group meeting attended by four alert and oriented residents and the Ombudsman, it was confirmed that the lack of meetings was due to the absence of sufficient staff to organize them. The Nursing Home Administrator acknowledged the facility's failure to provide the Resident Group with the opportunity for meetings during the specified months. This deficiency is in violation of the residents' rights to organize and participate in resident groups as outlined in the regulations.
Plan Of Correction
The Resident Council will be interviewed to see when they would like to have their meetings. No residents were affected by not having 3 months of resident council. Resident Council education was given to the Activity Director. A monthly review of resident council minutes will be completed by Administrator or designee. Findings will be discussed at quality assurance and process improvement meetings.
Inaccessible Grievance Forms and Box on Fourth Floor
Penalty
Summary
The facility failed to provide and make accessible grievance forms and a grievance box to residents and visitors on the fourth-floor nursing unit. During an observation, it was noted that a trash bin was placed in front of the grievance box, obstructing access. Additionally, grievance forms were not present on the fourth-floor nursing unit, which is a requirement for residents to voice their grievances effectively. The Director of Nursing confirmed these findings during an interview, acknowledging the facility's failure to comply with the requirement to make grievance forms and the grievance box accessible. This deficiency was identified based on a review of the facility's policy and observations made during the survey.
Plan Of Correction
No residents were affected by not having the forms and box accessible due to the trash in front of the box and no forms present. This does present a potential and the Grievance Officer was educated on the Grievance policy by the NHA and or designee. Trash bins removed and forms added. Grievance officer or designee will audit forms being present and no obstructions 3 times a week for 4 weeks in identified locations. Results will be reported to the quality improvement and process improvement.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one of the two residents reviewed, specifically Resident R46. The facility's policy on 'Abuse, Neglect, and Exploitation' requires complete documentation of investigations, including interviews with all involved parties. However, there was no documented evidence that Resident R46 was interviewed regarding the alleged incident of abuse. The incident involved RN Employee E14 and LPN Employee E15, who reportedly made inappropriate comments to Resident R46 when the resident inquired about delayed pain medication. Despite the facility's policy, the investigation report dismissed Resident R46 as a credible source based on past behaviors and medical history, without attaching any interview documentation. Resident R46, who was admitted to the facility with diagnoses including cerebrovascular accident, anxiety disorder, depression, and chronic osteomyelitis, was cognitively intact as indicated by a BIMS score of 14. The incident occurred when Resident R46 was reportedly given a hard time by the nursing staff, leading to an escalation. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing, highlighting a deficiency in adhering to the required investigative procedures.
Plan Of Correction
Resident R46 was discharged to another facility and unable to be interviewed. The facility has determined that all residents have the potential to be affected if allegations of abuse are not investigated in a timely manner. An in-service education program was conducted by the Director of Nursing Services and the Administrator with direct care staff addressing circumstances that require reporting for timely investigations, and their responsibilities related to investigations. Policy and education on Resident Abuse Prevention and Reporting: The Director of Nursing Services, or designee, will review nursing notes five days per week to identify any allegations of abuse weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
Failure in Tube Feeding Management
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings, as evidenced by observations and staff interviews. Resident R20, who has a history of diabetes, dysphagia, and hemiplegia following a stroke, was admitted to the facility with a requirement for tube feedings. The resident's care plan indicated the need for tube feedings due to dysphagia. A physician's order specified that the resident was to receive Glucerna 1.5 via peg-tube at a rate of 80 ml per hour from 8:00 p.m. to 8:00 a.m. However, during observations on two consecutive days, it was noted that the tube feeding formula container was not dated when opened, which is against the manufacturer's guidelines that require the formula to be used within 24 hours of opening. Interviews with staff, including a Registered Nurse and the Director of Nursing (DON), confirmed that the tube feeding container was left hanging beyond the recommended time without a date and time, increasing the risk of using the formula beyond the 24-hour limitation. The DON acknowledged that the formula should not be used after being opened for 24 hours and that the container should be removed when the feeding is stopped at 8:00 a.m. The Nursing Home Administrator and the DON confirmed the facility's failure to provide appropriate care and services to residents receiving tube feedings, as evidenced by the lack of adherence to the manufacturer's guidelines and facility policy.
Plan Of Correction
Resident R20's tube feeding was taken down and hung with the correct date on the next administration. The facility has determined that all residents receiving tube feeding have the potential to be affected if the tube feeding is not dated properly. All residents receiving tube feeding, bottle checked for proper dates and correct orders. In-service education programs regarding the Tube Feeding Policy were conducted separately with licensed staff by the Director of Nursing Services (DON), or designee. The Director of Nursing Services (DON), or designee, will conduct observations of dating tube feeding to take place three days per week for four weeks, then bi-weekly for one month, then monthly for one month. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility staff failed to maintain ongoing communication with the hemodialysis center for a resident who required dialysis services. The facility's policy on 'Hemodialysis' mandates that residents ordered for dialysis should have continuous communication and collaboration with the dialysis facility regarding their care and services. This communication is to be documented via a written format using a dialysis communication form. However, a review of the resident's 'Dialysis Hand Off Communication Report' forms revealed that the section to be completed by the dialysis center and returned with the resident was left blank for all nine scheduled treatments between January 14 and February 13, 2025. The resident in question, identified as Resident R18, was re-admitted to the facility with diagnoses including end-stage renal disease and low blood pressure. The resident was scheduled to receive dialysis three times a week, as indicated in the physician's order summary and nurse progress notes. Despite this, the necessary communication forms were not completed, as confirmed by the Director of Nursing during an interview. This lack of communication between the facility and the dialysis center constitutes a failure to meet the requirement of ensuring that residents who require dialysis receive services consistent with professional standards of practice and their care plan.
Plan Of Correction
Dialysis book of #R18 reviewed by the Director of Nursing Services, or designee, with the attending physician and dialysis provider. We are unable to correct uncharted documentation from the dialysis center. The facility has determined that residents who receive dialysis have the potential to be affected by poor communication between the nursing facility and the dialysis center. In-service education was conducted by the Director of Nursing Services or designee on dialysis communication to the licensed staff. The dialysis center was informed of the proper procedure as it relates to the nursing facility's documentation and communication. The Director of Nursing Services or designees will review the dialysis communication books of each resident receiving dialysis weekly for four weeks, then bi-weekly for one month to ensure the dialysis center's documentation is complete. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for three residents who are trauma survivors. Resident R58, admitted with a history of gunshot wounds and significant pain, did not have an assessment for trauma-informed care or PTSD in their evaluations. Despite experiencing anxiety and depression, their care plan lacked goals and interventions related to trauma-informed care. Additionally, Resident R58 expressed concerns about safety and privacy, which were not adequately addressed by the facility, as evidenced by the placement of their name outside their door against their wishes. Similarly, Residents R20 and R30, both diagnosed with anxiety, depression, and PTSD, did not have assessments for trauma-informed care or PTSD in their evaluations. Their care plans also failed to include goals and interventions related to their PTSD. The Director of Nursing acknowledged the facility's failure to provide trauma-informed care in accordance with professional standards, considering the residents' past experiences and preferences to prevent re-traumatization.
Plan Of Correction
Resident #58 continues to reside in the facility. Password for visitors has been added to her profile per resident request. Residents #20, 30 & 58 will have Trauma Informed Assessment and Care plan with interventions. Residents who have experienced Trauma in their lives have the potential to be affected. Social Services and Nursing will assess residents with Trauma Informed Assessment and develop care plans with interventions for the residents that require them. Facility administrator or designee provided education to Social Services Director and Licensed Nursing Staff regarding the need to assess residents for Trauma and develop care plans with interventions. Social Services will conduct weekly audit on all new admissions for 4 weeks, then monthly for 2 months to ensure that a Trauma Informed Care Assessment has been completed and if necessary, care plan with interventions has been developed. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Conduct Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete annual performance evaluations for one of its nurse aides, identified as Employee E3, who was hired on October 11, 2004. This deficiency was discovered through a review of the facility's policy, personnel records, and staff interviews. The absence of a performance evaluation for Employee E3 was confirmed during an interview with the Nursing Home Administrator on February 14, 2025. This failure to conduct the required annual performance review is a violation of the regulatory requirement for regular in-service education and performance evaluations for nurse aides.
Plan Of Correction
A performance review was conducted with E3 by the Director of Nursing. Residents of the facility have the potential to be affected by this practice. The Human Resources Director will audit the Nurse Aide Employee files to ensure an annual performance review has been completed with Nurse Aides. Any Nurse Aide without an annual performance review will have one. A facility procedure regarding the annual performance review process was put into place 2/21/25. Director of Nursing and Human Resources Director received education from the Administrator, regarding the process of providing Nurse Aides Annual Performance Reviews. The Human Resources Director will review the schedule for each nurse's aides file that is due that month and corresponding documentation for (3) months to ensure compliance. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the pharmacy completed a Medication Regimen Review (MRR) at least once a month for two residents. According to the facility's policy, the drug regimen of each resident should be reviewed monthly by a licensed pharmacist to promote positive outcomes and minimize adverse consequences. However, the clinical records for two residents, one admitted with diagnoses including dementia, depression, and diabetes, and another with high blood pressure, diabetes, and dementia, showed that MRRs were not completed for several months in 2024. For the first resident, the clinical record lacked evidence of MRRs for February, April, May, June, July, September, October, and November 2024. Similarly, the second resident's record did not indicate MRRs for September, October, November, and December 2024. The Director of Nursing confirmed during an interview that the facility failed to complete the required monthly pharmacy MRRs, which is a violation of the facility's policy and federal regulations.
Plan Of Correction
Residents R 5 and R 56 medication regime review was completed by clinical pharmacist. Like residents have the potential to be affected. A house audit was completed by a clinical pharmacist to ensure current residents had a completed medication regime review. The Director of nursing and clinical pharmacist were educated on medication regime reviews by administrator of designee. The Director of nursing will audit the clinical pharmacist medication regime reviews monthly for compliance. Findings will be reported to quality assurance meetings.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurately documented. Resident R59 was admitted to the facility and passed away on December 2, 2024. However, the 'Interdisciplinary Discharge Summary' and 'Disposition of Medications' forms dated December 2, 2024, were not completed. Similarly, Resident R61 was admitted and discharged from the facility, but the same forms dated November 19, 2024, were also incomplete. During an interview, the Director of Nursing confirmed these findings, acknowledging that the facility did not maintain complete and accurate medical records for these residents. The facility's policy requires that clinical records be completed within 30 days of a resident's discharge, which was not adhered to in these cases.
Plan Of Correction
R 59 and R 61 have been discharged so we cannot update the discharge summary and disposition of medication. Like residents can be affected. Medical records and licensed staff have been educated by the director of nursing or designee on discharge medical records to include discharge summary and disposition of medications. Medical records will audit 5 discharge records a week for 4 weeks to ensure that discharge summaries and disposition of medications are completed. Findings will be reported to the quality assurance and process improvement committee meetings.
Failure to Implement Pre-Employment TB Screening
Penalty
Summary
The facility failed to implement pre-employment tuberculosis (TB) screening procedures for two of five newly hired employees, as required by Pennsylvania State regulations and CDC recommendations. The regulations stipulate that all healthcare personnel should undergo a TB screening upon hire, which includes a baseline individual TB risk assessment, TB symptom evaluation, and a TB test. The facility's policy also mandates that new staff receive two Mantoux TB Skin Tests given two weeks apart unless there is a documented history of a positive TB test. However, the personnel records for Environmental Services Employee E11 and Registered Nurse Supervisor Employee E12 did not meet these requirements. Employee E11's record showed only evidence of a one-step tuberculin skin test, which is insufficient according to the facility's policy. Additionally, Employee E12's record included documentation of a prior positive tuberculin skin test but had a chest x-ray that was over a year old, contrary to the requirement for a chest radiograph at the time of hire unless a recent one is documented. These oversights were identified during a review of personnel records and confirmed in an interview with the Nursing Home Administrator, indicating a lapse in adherence to the established TB screening protocols.
Plan Of Correction
No residents were affected by pre-employment tuberculosis testing issues. Residents may be affected if practice does not change. Human Resources will review employee files to ensure tuberculosis testing was completed on both employees. Human Resources was educated by the director of nursing or designee on the pre-employment tuberculosis policy. The director of nursing or designee will audit new hire charts for pre-employment tuberculosis testing weekly for 4 weeks for compliance. Findings will be reported to the quality assurance and process improvement meetings.
Failure to Provide Admission Orientation Materials
Penalty
Summary
The facility failed to ensure that a resident was sufficiently oriented to the facility upon admission, as required by their admission policy. The policy mandates that a Resident handbook and/or Facility Orientation material should be provided to the resident or family prior to or upon admission. However, a review of Resident R212's clinical record indicated that these materials were not provided upon their admission on February 9, 2025. Resident R212, who was admitted with diagnoses including breast cancer, high blood pressure, and anxiety disorder, confirmed during an interview that they did not receive the necessary orientation materials. Further investigation revealed that the Admission Director, Employee E13, confirmed the absence of evidence in Resident R212's clinical record regarding the provision of admission information. Additionally, the Director of Nursing (DON) acknowledged that the facility failed to ensure the resident was sufficiently oriented to the facility upon admission. This deficiency was identified through staff interviews and a review of facility policy and clinical records.
Plan Of Correction
The facility orientation handbook was developed for Squirrel Hill Wellness and Rehab. It was determined that not having the orientation could affect the new residents. The handbook was given to Resident 212. The Admissions Director was educated in giving the handbook to new residents. The Director of nursing will interview 2 new admissions per week to see if they have received a copy of the handbook. Once a week for 2 weeks, then every 2 weeks for 2 weeks, then monthly for 2 months. The findings will be reported to the quality assurance and performance improvement committee.
Nurse Aide Staffing Deficiency During Night Shift
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the night shift on one occasion. Specifically, on February 8, 2025, the facility had a census of 67 residents, which necessitated the presence of 4.47 nurse aides to meet the regulatory requirement of one nurse aide per 15 residents. However, only 2 nurse aides were available to provide care during that night shift. This staffing shortage was confirmed by the Nursing Home Administrator during an interview conducted on February 12, 2025.
Plan Of Correction
No residents were affected during the day identified in 2567. The Director of Nursing and Staffing Coordinator was re-educated regarding staffing ratios for nursing assistants by the Administrator. The facility has previously reviewed the staffing plan and has assessed wages, provided extra shift pick up bonuses to qualified staff, provided flexible scheduling, and has advertised in several ways for staff including on online help wanted sites. The facility will have each morning the administration staff meets to review the staffing for the day and any critical days in the future, weekly staffing meetings, staffing to include increased employees to cover for any call offs, progressive disciplinary action if necessary and weekly review of new staff that has been hired and will be joining the facility team in the future and any staff that has resigned or has been terminated. Corporate leadership included strategies and any needs of the facility. The Nursing Home Administrator, Director of Nursing, and Staffing Coordinator, or designees, will review the ratios daily and look ahead in the upcoming week schedule. The Director of Nursing or designee will monitor the ratios 5 times a week for 4 weeks then weekly times 4. Results of audits will be reviewed at the facilities quality assurance performance improvement meeting.
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. This deficiency was identified during a review of the facility's Emergency Preparedness (EP) Plan. On February 6, 2025, at 9:00 a.m., an interview and documentation review revealed that the EP Plan lacked a communication plan that met the required legal standards. This finding was confirmed during an interview with the Facility Administrator and Maintenance Director later that day at 1:00 p.m., who acknowledged the absence of a compliant communication plan in the EP Plan.
Plan Of Correction
Facility emergency preparedness plan will be updated to include communication plan that complies with local, state and federal laws by 3/21/2025. A review of policies and procedures will be conducted on an annual basis by the Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
Deficiency in Emergency Preparedness Training and Testing
Penalty
Summary
The facility was found to have a deficiency in its Emergency Preparedness (EP) program, specifically in the area of training and testing staff. During a review of the facility's EP Plan, it was discovered that the plan did not specify the type and frequency of training and testing required to ensure staff knowledge of emergency procedures. This lack of detail in the EP training and testing policy was identified during an interview and documentation review conducted on February 6, 2025. Further interviews with the Facility Administrator and Maintenance Director confirmed that the facility's EP plan was incomplete, as it did not include specific requirements for training and testing. This omission indicates that the facility failed to fully develop and maintain an EP program that meets regulatory standards, as it did not provide clear guidelines for staff training and testing to demonstrate their knowledge of emergency procedures.
Plan Of Correction
Facility trained staff on emergency procedures and tested staff on emergency procedures on March 21, 2025. Review of training and testing will be done on an annual basis by Administrator or designee. Findings will be reported to the Quality Assurance and Performance Improvement committee meeting.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, as evidenced by multiple unresolved trouble codes on the main fire alarm control panel. This deficiency was identified during a documentation review and observation conducted on February 6, 2025, at 8:30 a.m. The issue affected the entire facility. An interview with the Facility Administrator and Maintenance Director later that day confirmed the presence of the fire alarm system deficiency.
Plan Of Correction
Fire panel repairs will be completed by 3/21/2025 by a contracted vendor. Fire panel will be inspected weekly for 4 weeks by Maintenance Director or designee, then monthly to see if there are any troubles in the system. The administrator or designee will reeducate Maintenance Director on Fire Alarm System - K324. Findings will be reported to the Quality Assurance and Performance Improvement committee meetings.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
