Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ann's Choice during CMS and state inspections, most recent first.
A resident with dementia, hypertension, and atrial fibrillation experienced a fall after a private 1:1 aide, who was only supposed to sit with the resident, attempted a transfer without proper authorization. The facility only provided verbal, not written, information to residents and their representatives about the rule prohibiting private aides from providing direct care.
A quarterly Minimum Data Set (MDS) assessment was not completed within the required timeframe for a resident. The RNAC confirmed that the assessment was not done as mandated by the RAI User's Manual, resulting in noncompliance with assessment regulations.
A resident's discharge MDS assessment contained an incorrectly coded social security number, as confirmed by the RN Assessment Coordinator during record review and staff interview.
Three CNAs did not receive required QAPI training as mandated by facility policy and state regulations. Review of records and staff interviews confirmed the absence of QAPI in-service education for these employees during the review period.
The facility did not notify the State Long-Term Care Ombudsman of emergency transfers and discharges for three residents, as required by policy. A resident was readmitted after hospitalization for hypotension and heart failure, another was hospitalized with septic shock, and a third was admitted with osteopenia and a hip fracture. Staff confirmed the failure to provide the required notices.
A facility failed to create a comprehensive care plan for a resident's respiratory needs, despite a physician's order for oxygen. The resident, with multiple health issues, did not have a care plan addressing their respiratory care, confirmed by the RN Unit Manager. This deficiency was noted during a survey, showing non-compliance with care policies.
A resident with a history of elopement behaviors eloped from the facility due to inadequate supervision. The resident, previously identified as an elopement risk and equipped with a WanderGuard, was admitted to the Skilled Nursing Unit without the device after a hospitalization. The facility's assessment failed to recognize the resident's risk, leading to the elopement incident.
A resident with severe cognitive impairment and multiple medical conditions, including a urinary tract infection, was found to have an indwelling urinary catheter without a physician's order. Facility staff confirmed the absence of the order, indicating a failure in obtaining necessary medical documentation.
A resident with multiple health conditions was prescribed 2L/min oxygen via nasal cannula at night. However, the resident was observed receiving 4L/min, a discrepancy confirmed by the RN Unit Manager and acknowledged by the facility's Administrator and DON, indicating a failure to follow the physician's order.
Failure to Provide Written Notice of Facility Rules Regarding Private Companions
Penalty
Summary
The facility failed to provide residents or their representatives with written information regarding facility rules about private companions not being permitted to provide direct care to residents. Although the facility's policy states that a written description of resident rights will be provided upon admission and upon request, interviews confirmed that only verbal information was given about the restriction on private aides providing direct care. This omission was identified during a review of facility documentation and staff interviews. This deficiency was identified in the context of a resident with dementia, hypertension, and atrial fibrillation who experienced a fall in their room. The incident report revealed that a private 1:1 aide, who was present to sit with the resident, attempted to transfer the resident from bed to wheelchair and subsequently lowered the resident to the floor. The nurse later informed the aide that the resident required a two-person transfer due to their condition. The lack of written communication regarding the facility's rules for private aides contributed to the incident.
Failure to Complete Quarterly MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for one resident. According to the Resident Assessment Instrument (RAI) User's Manual, a quarterly MDS assessment must have an assessment reference date (ARD) no more than 92 days after the ARD of the most recent assessment, and must be completed within 14 days after the ARD. For one resident, the admission MDS assessment had an ARD of March 31, 2025, but there was no evidence that the subsequent quarterly MDS assessment was completed within the required 90-day period. This was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview, who acknowledged that the quarterly MDS assessment was not completed as required.
Incorrect Coding of Resident Information in MDS Assessment
Penalty
Summary
The facility failed to accurately complete a resident assessment for one of sixteen residents reviewed. Specifically, a review of the clinical record and the discharge Minimum Data Set (MDS) assessment for a resident revealed that the resident's social security number was incorrectly coded in the MDS. This error was confirmed during an interview with the Registered Nurse Assessment Coordinator. The deficiency was identified through both record review and staff interview.
Failure to Provide QAPI Training to CNAs
Penalty
Summary
The facility failed to provide required training on Quality Assurance and Performance Improvement (QAPI) to three Certified Nursing Assistants (CNAs), as identified through a review of facility documents and staff interviews. According to the facility's own policies, all health services employees are required to complete continuing education topics, including QAPI, at the time of hire, annually, or more frequently as required by state or federal regulations. The policy also specifies that education regarding QAPI should be provided to appropriate personnel as needed, with ongoing training determined by supervisors or managers. Despite these requirements, documentation showed that three CNAs did not receive QAPI in-service education during the specified review period. This was confirmed during an interview with the Assistant Nursing Home Administrator, who acknowledged the lack of QAPI training for these employees. The deficiency was cited under state regulations related to the responsibility of the licensee, management, and staff development.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of initiated emergency transfers and discharges for three residents. The policy titled 'skilled nursing initiated transfer/discharge' dated June 2021 requires facility staff to send a timely copy of the notice of facility-initiated resident transfers or discharges to the Ombudsman or other State-required agencies. However, during a review, it was found that the facility did not provide such notifications for three residents. Resident R60 was readmitted to the facility after hospitalization for hypotension and heart failure. Resident R59 was hospitalized with septic shock, and Resident R111 was admitted to the hospital with osteopenia and a fracture involving the left femoral neck. Interviews with the social worker and the director of nursing confirmed the facility's inability to provide the required notices to the Ombudsman upon request.
Failure to Develop Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for a resident's respiratory care needs. The facility's policy requires individualized care plans that include resident preferences, strengths, routines, personal and cultural preferences, and clinical needs. However, upon review, it was found that the care plan for a resident with multiple diagnoses, including hypertension, chronic kidney disease, congestive heart failure, and paroxysmal atrial fibrillation, did not address the resident's respiratory care needs, despite a physician's order for oxygen administration. Interviews with the RN Unit Manager confirmed the absence of a comprehensive care plan with measurable objectives and timetables for the resident's respiratory care. The resident was receiving oxygen at a level different from the physician's order, indicating a lack of proper documentation and implementation of care plans. This deficiency was identified during a survey, highlighting non-compliance with the facility's resident care policies and nursing services regulations.
Failure to Supervise Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision, resulting in the elopement of a resident identified as R161. The resident, who had a history of elopement behaviors and had previously worn a WanderGuard in the Assisted Living Program, was admitted to the Skilled Nursing Unit without the device. Despite having a documented history of exit-seeking behaviors, the facility's holistic assessment upon admission did not identify the resident as an elopement risk, and thus, a specific Elopement Risk Assessment was not completed. This oversight led to the resident eloping from the facility and being found in the parking lot shortly after. Interviews with staff revealed that the resident's WanderGuard was removed during a prior hospitalization and was not reapplied upon their return to the facility. The receptionist on duty at the time of the elopement was unaware that the resident should have been wearing a WanderGuard, as the resident was not listed as requiring one. The facility's failure to recognize the resident's elopement risk and ensure appropriate safety measures were in place directly contributed to the incident.
Failure to Obtain Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for a resident, identified as Resident R45. The resident was admitted with multiple diagnoses, including tubule-interstitial nephritis, aftercare following joint replacement surgery, and urinary tract infection, among others. The resident's Admission MDS indicated severe cognitive impairment with a BIMS score of 3. During an observation on October 8, 2024, it was noted that the resident had an indwelling urinary catheter in place, but the clinical record lacked a corresponding physician's order. Further interviews with facility staff, including a licensed nurse and the Unit Manager, confirmed the absence of a physician's order for the catheter. Despite the resident's ongoing use of the catheter, the staff could not provide an explanation for the oversight, indicating a failure in the facility's process to obtain necessary medical orders. This deficiency was noted under 28 Pa Code 211.12(d)(5) Nursing services.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders for a resident. The resident, who was admitted with multiple diagnoses including hypertension, chronic kidney disease, congestive heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease, and mild cognitive impairment, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula at night. However, during an observation, the resident was found to have an oxygen level set at 4 liters. This discrepancy was confirmed by the RN Unit Manager and later acknowledged by the facility's Administrator and Director of Nursing, indicating a failure to ensure the resident received the appropriate oxygen rate as per the physician's order.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christ's Home Retirement Community | 0.7 mi | ★★★★★ | 3 | 0 |
| Majestic Oaks Rehabilitation And Nursing Center | 1 mi | ★★★★★ | 15 | 0 |
| Luther Woods Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 13 | 0 |
| Willowbrooke Court-southampton | 1.9 mi | ★★★★★ | 2 | 0 |
| Masonic Village At Warminster | 1.9 mi | ★★★★★ | 1 | 0 |
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