Vincentian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 111 Perrymont Road, Pittsburgh, Pennsylvania 15237
- CMS Provider Number
- 395034
- Inspections on file
- 28
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Vincentian Home during CMS and state inspections, most recent first.
A resident with multiple medical conditions and an order for one-person transfers with a wheeled walker was the subject of a grievance from the spouse alleging that a NA was rude, left the resident waiting for toileting assistance for an extended period after using the call bell, and grabbed the resident’s arm during toileting, causing a bruise. The facility’s policy required thorough investigation of all alleged abuse and neglect, but the DON’s review was limited to the involved NA’s account, and no additional residents or staff were interviewed. An RN reported not being informed of any abuse concerns, and the NHA acknowledged treating the matter as a grievance focused on the family’s dislike of the NA, confirming that a comprehensive investigation to rule out abuse or neglect was not conducted.
Surveyors found that the facility failed to document required communication of care plan goals, advance directives, and other essential information to a receiving provider for a resident sent to the hospital and expected to return, and also failed to provide written notice of its bed-hold policy to three residents or their representatives at the time of hospital transfers. Clinical records for residents with conditions such as hypertension, BPH, muscle wasting, muscle weakness, hyperlipidemia, and trigeminal neuralgia lacked evidence of written bed-hold notifications, and the DON confirmed these omissions during interview.
A resident with significant mobility impairments, requiring two-person assistance for transfers and bed mobility, was injured when a nurse aide provided care alone, contrary to care plan and physician orders. The aide did not seek help as required, resulting in the resident falling from bed and sustaining a head laceration. Facility staff and leadership confirmed that established protocols were not followed, leading to neglect.
A resident who was dependent on staff for transfers and positioning was found on the floor after rolling out of bed during care, and was transferred to the hospital. The facility did not report this incident of suspected neglect to the State Agency within the required 24-hour timeframe, as confirmed by facility leadership.
A resident with significant mobility impairments and orders for two-person assistance during bed mobility was left unattended by a single nurse aide, resulting in the resident rolling out of bed and sustaining a head laceration. Staff interviews and documentation confirmed that facility protocols and care plans requiring two-person assistance were not followed at the time of the incident.
A resident with multiple medical conditions was found self-applying Aquaphor ointment for skin irritation without a physician's order, care plan, or interdisciplinary assessment for self-administration. The ointment, brought in by family and lacking a pharmacy label, was not documented in the clinical record, and staff confirmed the absence of required orders and assessments.
A resident with an indwelling Foley catheter did not have physician orders specifying the catheter size or balloon inflation amount, as required by facility policy. The clinical record included instructions for catheter changes, use of a dignity cover, and irrigation, but omitted these key specifications. This deficiency was confirmed by the ADON during review.
Two residents did not receive proper respiratory care according to facility policy and physician orders. One resident's CPAP mask was repeatedly left out and not stored in a bag, and their care plan lacked CPAP interventions. Another resident's oxygen tubing was not labeled with a date as required. Staff and leadership confirmed these deficiencies.
A resident with anemia, kidney stones, and Alzheimer's Disease did not receive nine ordered doses of TheraLith XR because the medication was unavailable from the pharmacy. Staff and leadership confirmed the medication was out of stock, resulting in the resident not receiving the prescribed treatment.
Surveyors found that drugs and biologicals were not stored securely or in an orderly manner, including a resident keeping medications at the bedside, comingling of suppositories with oral medications in medication carts, unlabeled COVID-19 testing solution, unlabeled ice packs in a medication refrigerator, and expired insulin syringes in storage. These deficiencies were confirmed by nursing staff and the administrator.
The facility did not track or monitor residents who tested negative for COVID-19 during an outbreak, as required by policy, and failed to follow infection control procedures during a dressing change for a resident with multiple medical conditions. A nurse did not establish a clean field, placed a soiled dressing on the bed, and did not perform proper hand hygiene, resulting in a failure to prevent cross-contamination.
The facility failed to communicate necessary resident information during transfers to the hospital for three residents, as required by policy. The deficiency was confirmed by the ADON, who stated that the facility did not document what information was sent with the residents. This affected residents with conditions such as multiple sclerosis, dementia, and Parkinson's Disease.
The facility failed to notify the LTC Ombudsman of hospital transfers for three residents, as required by federal regulations. The residents, who had conditions such as multiple sclerosis, dementia, and Parkinson's Disease, were transferred without documented notification. The DON confirmed the facility's usual practice of not sending such notifications.
The facility failed to obtain necessary hospice diagnoses and coordinate hospice services for three residents receiving end-of-life care. Physician orders lacked hospice-related diagnoses, and care plans did not include hospice contact information or access to a 24-hour on-call system, as confirmed by the DON.
A resident did not receive prescribed medication for COPD, and three residents did not have weekly skin assessments as ordered. Additionally, one resident did not have weekly labs conducted. These deficiencies were confirmed by the DON.
A resident with hypertension, osteoporosis, and anxiety was found with medication at her bedside without a physician's order or assessment for self-administration. The facility's policy prohibits leaving medication at the bedside, and the RN and DON confirmed the oversight, leading to a deficiency.
The facility failed to prevent accidents and ensure proper neurological assessments for residents after falls. A resident slid off the bed during care, resulting in a head injury, while two other residents did not receive complete neurological checks as required by facility policy. Staff interviews confirmed these deficiencies.
The facility failed to ensure proper physician orders and care for residents with urinary catheters. A resident lacked a physician's order specifying catheter details and a valid medical diagnosis. Additionally, two residents did not have dignity bag covers for their catheters, as confirmed by staff. The Director of Nursing acknowledged these deficiencies.
The facility failed to monitor and address significant weight changes in residents, including severe weight loss in a resident and missed daily weights for two residents. Additionally, a resident's weight gain was not reported to the physician as required.
A medication cart on the second floor of Building One was found unlocked and unattended, with the top drawer open, violating the facility's policy on secure medication storage. This was confirmed by a registered nurse and the Nursing Home Administrator.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to initiate a thorough investigation into alleged abuse and neglect involving a discharged resident. The resident, who had diagnoses including hypertension, benign prostatic hyperplasia, and muscle wasting/atrophy, had a physician order for one-person transfers with a wheeled walker. A grievance filed by the resident’s wife reported that a nurse aide was rude and sharp in tone when the resident used the call bell, asked “what do you want,” stated someone would help with toileting, then left and did not return for two hours after the call light was used. The grievance also alleged that during toileting the aide grabbed the resident’s right arm to reposition him, resulting in a visible bruise on the right forearm, and that the aide had been rude, disrespectful, impatient, inattentive, and scolding on several other occasions, including scolding him for being wet after he had waited an unreasonable amount of time for assistance. The facility’s own policy required thorough investigation of all alleged violations of abuse, neglect, exploitation, or mistreatment. However, the investigation was limited. The grievance log documented that the DON investigated and found the concerns unsubstantiated, and the aide’s written statement focused on transfer safety and the need for a two-person assist, with no acknowledgment of the alleged rude behavior or rough handling. The DON later confirmed that no other residents cared for by the aide were interviewed and no additional staff interviews were conducted, stating that the claim was only about this aide so they only looked at her. An RN reported not being informed of any abuse concerns and that no NA had reported abuse to her. The NHA acknowledged that the family’s complaint was investigated as a grievance and that they preferred not to have the aide, and when asked about broader interviews regarding physical/verbal abuse or neglect, questioned at what point the investigation should stop, confirming that a thorough investigation to rule out abuse or neglect was not initiated.
Failure to Communicate Transfer Information and Provide Bed-Hold Policy Notices
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required information was communicated to a receiving health care provider and that residents or their representatives were notified in writing of the facility’s bed-hold policy at the time of hospital transfers. Facility policy on Resident Notice of Transfer or Discharge required that, before transfer or discharge, the admission coordinator or designee notify the resident or representative in writing of the transfer or discharge and the reason for the move, and record the reasons in the medical record. Policy on Notice of Bed Hold and Return required that written information about the bed-hold policy be provided to the resident and family or legal representative before a hospital transfer or therapeutic leave, or within 24 hours in the case of an emergency transfer. For one discharged resident admitted with diagnoses including high blood pressure, BPH, and muscle wasting, the clinical record for a hospital transfer showed no documentation that the facility communicated necessary information to the receiving provider, such as care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs. The same discharged resident’s record, as well as the records of two additional residents, showed no documented evidence that the residents or their representatives were provided written information about the facility’s bed-hold policy at the time of their respective hospital transfers. One discharged resident admitted with muscle weakness, high blood pressure, and hyperlipidemia was transferred to a local hospital without documentation of written bed-hold policy notification. Another resident admitted with trigeminal neuralgia and high blood pressure was also transferred to a local hospital without documented written notice of the bed-hold policy. During an interview, the Director of Nursing confirmed that the facility failed to ensure necessary resident information was communicated to the receiving health care provider for one resident and failed to notify three residents or their representatives of the facility’s bed-hold policy at the time of hospital transfers.
Failure to Follow Two-Person Assist Protocol Resulting in Resident Fall
Penalty
Summary
The facility failed to protect a resident from neglect when a nurse aide provided care without following the required two-person assist protocol for a resident with significant mobility impairments. The resident, who had diagnoses of muscle wasting, muscle weakness, and abnormal gait, was care planned and had physician orders for a full body mechanical lift and two-person assistance for all transfers, hygiene, and bed repositioning. Despite these documented requirements, the nurse aide attempted to provide care alone, resulting in the resident rolling out of bed and sustaining a head laceration. The incident was reported by the nurse aide, who admitted to not seeking help as typically required, and was corroborated by the resident's statement and facility documentation. Facility policies reviewed emphasized the necessity of using appropriate transfer techniques and ensuring two-person assistance for residents with such needs. Staff interviews confirmed that aides are expected to reference the Kardex and report sheets for transfer status and to wait for assistance when required. The incident was acknowledged by facility leadership as a failure to protect the resident from neglect, as the established protocols and care plan directives were not followed, directly leading to the resident's fall and injury.
Failure to Timely Report Suspected Neglect to State Agency
Penalty
Summary
The facility failed to report an incident of neglect involving a resident within 24 hours to the local state field office, as required by both facility policy and regulatory standards. The incident involved a resident with diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, who required a full body mechanical lift and two-person assistance for all transfers, hygiene, and repositioning. According to the care plan and physician orders, the resident was dependent on staff for bed positioning and movement. On the day of the incident, a nurse aide reported that the resident rolled out of bed while care was being provided, resulting in the resident being found on the floor and subsequently transferred to the hospital for further evaluation. Despite the facility's policies mandating immediate or within 24-hour reporting of suspected neglect to the State Agency, the incident was not included in the information submitted to the State Agency on the days following the event. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the required report of neglect was not made within the specified timeframe for this resident.
Failure to Provide Required Two-Person Assistance for Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, was not provided with the required assistance for bed mobility. The resident's care plan, physician orders, and Minimum Data Set all indicated a need for a full body mechanical lift and assistance from two staff members for transfers, hygiene, and repositioning in bed. Despite these documented requirements, a nurse aide attempted to provide care and reposition the resident alone. During this process, the aide lost balance, and the resident rolled out of bed, sustaining a partial head laceration and a headache, which required hospital evaluation. Facility policies required staff to use appropriate transfer techniques and to assess and provide the necessary assistance for each resident. Staff interviews confirmed that aides are expected to follow the care plan and obtain help when two-person assistance is required. The nurse aide involved admitted to typically seeking help but failed to do so on this occasion. The incident was confirmed by the resident, staff, and facility leadership, who acknowledged that the appropriate assistance was not provided, resulting in the resident's fall.
Failure to Assess and Document Resident's Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and authorized to self-administer medications. According to facility policy, residents must be evaluated for competency to self-administer medications, and the results must be documented in the resident's record and care plan. Additionally, a specific order for self-administration must be present in the medical record. In this case, a resident with diagnoses including irritable bowel syndrome, overactive bladder, and dysphagia was observed to be self-applying Aquaphor ointment and desitin cream for skin irritation and incontinence-related issues. The ointment was found in the resident's bathroom without a pharmacy label, and staff confirmed it was brought in by the family. Review of the resident's clinical record revealed there were no physician orders for the Aquaphor ointment, no orders or care plan for self-administration of medications, and no interdisciplinary assessment to determine the resident's competency for self-administration. The Director of Nursing confirmed that the required documentation and assessment were not present for this resident. These findings indicate the facility did not follow its own policies or regulatory requirements regarding self-administration of medications for one of five residents reviewed.
Lack of Physician Order Specifications for Foley Catheter
Penalty
Summary
The facility failed to obtain and document physician order specifications for the size of the indwelling Foley catheter and the balloon inflation amount for one resident. According to the facility's Foley Catheter Care policy, physician orders for catheter use must include the bulb and catheter size, frequency of catheter changes, and catheter care instructions. However, a review of the clinical record for a resident admitted with diagnoses including dysphagia, chronic kidney disease, and urinary retention revealed that the physician orders only specified the frequency of catheter changes, use of a dignity cover, and irrigation instructions, but did not include the required catheter size or balloon inflation amount. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the clinical record lacked the necessary specifications for the indwelling catheter. The deficiency was identified for one of three residents reviewed for catheter care, indicating noncompliance with both facility policy and regulatory requirements regarding proper documentation and physician orders for catheter use.
Failure to Provide Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents as required by facility policy and physician orders. For one resident with diagnoses including anemia, heart failure, and dysphagia, the physician order specified nightly use of a CPAP machine, with instructions for cleaning and storage. However, the order did not include the CPAP settings or a diagnosis, and the resident's baseline care plan lacked interventions related to CPAP use. Observations over several days showed the resident's CPAP mask was repeatedly left out on the bed or dresser, not stored in a bag as required by policy. Staff interviews confirmed the improper storage and the absence of a baseline care plan for CPAP care. For another resident with pneumonia, congestive heart failure, and emphysema, the oxygen tubing in use was not labeled with a date, contrary to facility policy that requires dating and weekly changing of such equipment. This was confirmed by staff during interviews. Facility leadership acknowledged the failure to provide appropriate respiratory care for both residents.
Failure to Provide Ordered Medication Due to Pharmacy Out-of-Stock
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate provision of medications for one resident. According to the facility's policy, pharmacy services are to be provided routinely and in a timely manner. However, a review of the clinical record for a resident admitted with diagnoses including anemia, kidney stones, and Alzheimer's Disease revealed that a physician's order for TheraLith XR, to be administered twice daily, was not followed. The resident did not receive nine doses of the medication between 4/24/25 and 4/28/25, as documented in the Medication Administration Record. Progress notes and staff interviews confirmed that the medication was unavailable from the pharmacy during this period. On 4/29/25, during a medication pass, the medication was still not in stock, and both a registered nurse and the Director of Nursing verified that the pharmacy was out of TheraLith, resulting in the resident not receiving the medication as ordered. The Nursing Home Administrator also confirmed the failure to implement pharmaceutical services to ensure accurate medication provision for the resident.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner across multiple nursing units and medication storage areas. On one unit, a resident was observed to have several medications, including eye drops and an inhaler, stored on their bedside table inside a tissue box on two separate occasions. This improper storage was confirmed by both a registered nurse and the nursing home administrator. Additionally, during reviews of medication carts, suppositories were found comingled with oral medications, and a vial of COVID-19 testing solution was not labeled with an open date. These issues were confirmed by nursing staff during interviews. Further deficiencies were identified in medication storage rooms, where two unlabeled cold brick ice packs were found in a medication refrigerator, and a box of insulin safety syringes with an expired use-by date was discovered in a cupboard. These findings were also confirmed by nursing staff. The facility's policies require that medications and biologicals be stored securely and according to manufacturer recommendations, and that only authorized personnel have access, but these procedures were not followed in the instances cited.
Failure to Implement Infection Surveillance and Infection Control Practices
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program as evidenced by two main deficiencies. First, during a COVID-19 outbreak spanning six months, the facility did not include residents who tested negative for COVID-19 on its case line listing, contrary to the requirements outlined in the Respiratory Virus Outbreak Toolkit. The Infection Preventionist and Director of Nursing confirmed that there was no surveillance plan in place to track and monitor residents who tested negative during the outbreak period, based on a misunderstanding of current guidance. Second, during a wound care observation for a resident with diagnoses of anemia, hypertension, and heart failure, a registered nurse did not follow established infection control practices. The nurse failed to establish a clean field, placed a soiled dressing on the bed, did not perform hand hygiene at required steps, handled a washcloth without gloves, and did not complete hand hygiene after the procedure. These actions were confirmed by the nurse during an interview, indicating a failure to prevent cross-contamination during a dressing change.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for three residents. The facility's policy required a comprehensive transfer and referral record to be completed and sent with the resident, including details such as the reason for transfer, physical and psychosocial status, care summary, treatment, progress towards goals, and other pertinent information. However, the clinical records for the three residents transferred to the hospital did not contain documented evidence that this information was communicated, including care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The deficiency was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the facility did not typically document in the progress notes what information was sent with the resident to the hospital. This lack of documentation and communication was identified for three residents with various medical conditions, including multiple sclerosis, dementia, muscle weakness, and Parkinson's Disease, who were transferred to the hospital and later returned to the facility. The failure to communicate necessary information to the receiving health care provider was a violation of resident rights as per 28 Pa. Code 201.29.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of three residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. Specifically, the facility did not document evidence of written transportation notifications for residents who were transferred to the hospital. The residents involved had various medical conditions, including multiple sclerosis, high blood pressure, dementia, muscle weakness, and Parkinson's Disease. During an interview, the Director of Nursing confirmed that the facility did not usually send notifications to the Ombudsman when residents were sent to the hospital. This oversight affected three out of four residents reviewed, indicating a failure to comply with the requirements outlined in Title 42 Code of Federal Regulations S483.15(c)(5), which mandates that such notifications include specific details about the transfer or discharge, including the resident's appeal rights and contact information for the Ombudsman.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services and ensure the coordination of hospice services with facility services for three residents receiving end-of-life care. The facility's policy on hospice services, dated 4/17/24, mandates a collaborative effort between the hospice provider and the facility staff, including obtaining hospice staff contact information and access to a 24-hour on-call system. However, the clinical records for Residents R17, R53, and R62 revealed that physician orders to admit them to hospice services did not include a diagnosis related to the need for hospice services. Additionally, the comprehensive care plans for these residents did not display the coordination of hospice services, as they lacked contact information for the hospice agency and details on accessing the hospice's 24-hour on-call system. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the facility's failure to meet the needs of the residents for end-of-life care. The report cites violations of 28 Pa. Code 211.2(a) regarding physician services and 28 Pa. Code 211.11(d) concerning resident care plans.
Medication and Assessment Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications as prescribed by the physician for one resident and did not perform weekly skin assessments as ordered for three residents. Specifically, Resident R174 did not receive the prescribed Trelegy Ellipta medication during their stay from April 18, 2024, to April 24, 2024, despite having orders from the hospital to administer it once daily. This oversight was confirmed by the Director of Nursing during an interview. Additionally, the facility did not conduct weekly skin assessments for Residents R50, R382, and R385 as per physician orders. Resident R50, who had diagnoses including anemia, dementia, and heart failure, was also supposed to have weekly lab work done, which was not completed. The failure to perform these assessments and obtain labs was confirmed by the Director of Nursing, highlighting a lapse in following physician orders and facility policy.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident to self-administer medications, which is a requirement for allowing residents to self-administer drugs if clinically appropriate. The facility's policy on medication administration specifies that medications should only be administered upon a physician's order and should not be left at the resident's bedside. However, during an observation, a medication cup with two pills was found on the overbed table of a resident, who stated she was not taking the pills. This indicates a lapse in following the facility's medication administration policy. The resident in question, who was admitted with diagnoses of hypertension, osteoporosis, and anxiety, did not have a physician's order for self-administration of medications, nor was there a self-administration assessment included in her clinical record. Additionally, her care plan did not address self-administration of medication management. The RN confirmed the presence of the pills at the bedside, and the Director of Nursing acknowledged the facility's failure to assess the resident's ability to self-administer medications, which contributed to the deficiency.
Failure to Prevent Accidents and Complete Neurological Assessments
Penalty
Summary
The facility failed to prevent accidents and ensure proper neurological assessments following incidents involving falls for residents. Resident R13, who had a history of high blood pressure, muscle weakness, and dementia, was at risk of falls. During care, she slid off the bed and hit her head against the wall, resulting in a traumatic hematoma, head injury, and nasal laceration. The incident report indicated that the nurse aide was unable to prevent the fall due to the resident's weight. Additionally, the facility's policy required neurological checks after such incidents, but these were not completed as required for Resident R54 and Resident R81. Resident R54, diagnosed with osteoporosis, muscle weakness, and dementia, reported falling and bumping her head and arm. However, the neurological checklist for her did not include the required documentation of vital signs at specified intervals. Similarly, Resident R81, who had muscle weakness, overactive bladder, and dementia, was found on the floor in the bathroom. Although she denied hitting her head, only 15 out of the required 21 neurological checks were completed. Interviews with staff confirmed the failure to complete neurological assessments as per facility policy.
Deficiency in Urinary Catheter Care and Physician Orders
Penalty
Summary
The facility failed to ensure proper physician orders and appropriate care for residents with urinary catheters. Resident R385 did not have a physician's order specifying the size of the catheter, when to change it, or a valid medical diagnosis for its use. Additionally, the facility did not implement the use of a dignity bag cover for Resident R385's foley catheter, as observed during a survey. Registered Nurse Employee E7 confirmed the absence of necessary foley orders and the lack of a privacy bag. Resident R49, who was diagnosed with Parkinson's disease, obstructive uropathy, and muscle weakness, was observed with a urinary drainage bag hanging on the bed without a privacy cover. Registered Nurse Employee E8 confirmed the failure to use a privacy bag for Resident R49. The Director of Nursing acknowledged the facility's failure to ensure a physician order for a urinary catheter for Resident R385 and to provide appropriate treatments and services for the use of urinary catheters for both Resident R49 and R385.
Failure to Monitor and Address Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes in several residents, leading to deficiencies in care. Resident R78 experienced severe weight loss of 9.9% in one month and 10.4% over two months, yet there was no documentation from the dietary department addressing this issue. The Dietary Technician was aware of the weight loss but did not document any actions taken to address it. The Nursing Home Administrator confirmed that the facility did not identify and address the weight loss in a timely manner. Additionally, the facility failed to obtain daily weights for Residents R114 and R382 as per physician orders. Resident R114 also experienced a weight gain of 4.8 pounds in one day, but the facility did not notify the physician as required. The Director of Nursing confirmed these failures, indicating a lack of adherence to the facility's policies and physician orders regarding weight monitoring and management.
Medication Cart Security Breach
Penalty
Summary
The facility failed to properly secure one of the four medication carts reviewed, specifically the Building One Second Floor Low Side Med Cart. According to the facility's policy on Drug Acquisition, Storage, Inspection, and Dispensing, medications should be stored securely, and lockable medication carts must be used to store unit-of-use medications in the resident medication dose system. These carts are required to be locked when not attended. However, during an observation, the medication cart was found unlocked and unattended with the top drawer pulled open. This was confirmed by Registered Nurse Employee E2 and later by the Nursing Home Administrator, indicating a breach in the facility's protocol for securing medications.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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