Asbury Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 700 Bower Hill Road, Pittsburgh, Pennsylvania 15243
- CMS Provider Number
- 395391
- Inspections on file
- 41
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Asbury Health Center during CMS and state inspections, most recent first.
Surveyors found that medications, including discontinued drugs for a current resident and medications for several discharged residents, were stored in an unsecured drawer within an unsecured office on one nursing unit. Despite a policy requiring drugs and biologicals to be kept in locked compartments accessible only to authorized staff, multiple oral, topical, and patch medications remained in this unsecured location. The NHA and DON confirmed that medications were not properly stored or disposed of as required.
Staff failed to follow sanitary food handling practices during meal service, including improper glove use and handling of food items without changing gloves or washing hands between tasks, leading to potential cross-contamination.
Surveyors identified multiple accident hazards, including exposed electrical outlets and unsecured hazardous materials, as well as an incident where a resident with dementia removed their elopement bracelet using nail clippers. Staff confirmed these hazards and that a required incident investigation was not conducted.
A resident with multiple medical conditions reported to a nurse that a CNA pushed her wheelchair hard and on purpose after instructing her to use it for the bathroom, which the resident did not want to do. The incident was reported internally to the DON and NHA, but the facility failed to report the allegation of abuse to the State Agency as required by policy and regulation.
A resident with multiple diagnoses, including dementia and diabetes, was admitted to hospice care, but the MDS assessments did not reflect the resident's hospice status as required. The RN Assessment Coordinator confirmed the assessment was inaccurate, resulting in incomplete documentation of the resident's care needs.
A resident with dementia did not have a comprehensive, person-centered care plan that included goals and interventions for their condition, as required by facility policy and federal regulations. This deficiency was confirmed by the DON after review of clinical records and staff interviews.
The facility did not assess, document, or notify physicians about significant changes in blood glucose levels for three residents with diabetes, despite repeated high CBG readings above physician-ordered thresholds. Staff failed to follow protocols for assessment and documentation, and care plans lacked person-centered interventions for diabetic care. Nursing staff interviews revealed inconsistent practices, and the DON confirmed these deficiencies.
Two residents with indwelling urinary catheters did not receive care in accordance with facility policy, including inadequate documentation of catheter removal procedures, lack of post-removal continence support, and failure to provide privacy by not covering catheter drainage bags with dignity bags. The DON confirmed these lapses in required treatment and services.
A resident with dementia, diabetes, and aphasia did not have required monthly Medication Regimen Reviews (MRRs) completed by the pharmacy for several months, as confirmed by review of clinical records and facility policy, and acknowledged by the NHA.
The facility did not provide timely access to requested employee files, annual education records, and other documentation to the State Agency, resulting in multiple delays during the survey process. Despite repeated requests, some records remained incomplete or were only provided after significant delay, impacting the surveyors' ability to complete their review efficiently.
A resident with dementia and high blood pressure was not properly documented as being offered influenza and pneumococcal immunizations, nor was there evidence that the resident or their legal representative received education about the benefits and side effects of these vaccines, as required by facility policy and federal regulations.
A resident with multiple chronic conditions experienced a discontinuation of insulin medications without any documentation explaining the change or indicating a change in condition. The lack of documentation was only discovered after the resident became hyperglycemic and required physician intervention to restart insulin. The DON and Nursing Home Administrator confirmed the incomplete medical record and failure to document the medication change.
The facility did not maintain a comprehensive infection prevention and control program from September 2023 to July 2024. Despite having an IC policy, there was no evidence of a system to track infections, analyze clusters, or monitor infection rates. The DON confirmed the lack of a functional infection control program during this period.
The facility did not implement an effective antibiotic stewardship program, as required by their policy. The infection control program lacked documentation of antibiotic use, and the tracking system failed to provide necessary feedback reports. The DON confirmed the absence of stewardship information for the specified period.
A facility failed to consistently provide showers to four residents, as required by their ADL policy. One resident, with kidney and heart failure, had not received a shower for eleven days after occupational therapy stopped assisting. Three other residents, with various medical conditions, also lacked shower documentation. The RN Unit Manager confirmed the deficiency, unable to explain the lack of consistent shower provision.
The facility's secured Dementia unit, Willow, was found to have potential accident hazards, including personal care items and cleaning supplies accessible to residents. Observations revealed unsecured items in residents' rooms and common areas, confirmed by staff interviews, indicating a failure to maintain a hazard-free environment.
The facility failed to notify physicians of significant changes in blood glucose levels and did not assess residents for hyperglycemia and hypoglycemia, affecting three residents receiving insulin. One resident did not receive prescribed insulin on multiple occasions, another did not have blood glucose checks completed as ordered, and a third had elevated blood glucose levels that were not addressed according to physician orders. These deficiencies were confirmed by facility staff.
The facility failed to secure a medication cart, specifically the Hickory Nursing Units back hall cart, which was found unlocked and unattended near the nurse's station. This was against the facility's policy requiring carts to be secured when out of view. An LPN confirmed the cart was unattended and unlocked, violating Pennsylvania Code sections on pharmacy and nursing services.
A resident with Atrial Fibrillation and a history of thrombosis did not receive their prescribed Rivaroxaban for three consecutive days. The physician was notified, and the DON confirmed the failure to administer the medication as ordered.
Improper Storage and Disposal of Medications in Unsecured Area
Penalty
Summary
Surveyors determined that the facility failed to ensure medications were properly stored and/or disposed of on the Hickory nursing unit. The facility’s policy dated 3/26/25 required that drugs and biologicals be stored in locked compartments under proper environmental controls, with access limited to authorized personnel. During an observation of the Hickory unit medication room on 1/21/26 at approximately 9:30 a.m., the Director of Nursing and the Nurse Manager (RN Employee E1) accompanied surveyors and observed multiple medications stored in an unsecured drawer within an unsecured office, contrary to the policy and regulatory requirements. The unsecured drawer contained medications for both current and discharged residents, including discontinued medications. Items observed included diclofenac gel and Vitamin D3 tablets for a current resident whose medications had been discontinued, as well as various vitamins, gastrointestinal medications (pantoprazole, omeprazole, senna), topical agents (hydrocortisone cream, Silvadene, Aquaphor, Medihoney), lidocaine patches, Tylenol tablets, Cepacol lozenges, and Vitamin D2 tablets for multiple residents who had been discharged on various prior dates. During an interview later that day at approximately 1:00 p.m., the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that medications were properly stored and/or disposed of.
Failure to Maintain Sanitary Food Handling During Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions during the lunch tray line, as evidenced by observations and staff interviews. Specifically, a dietary aide was seen leaning racks and trays of bowls over food items on the steam table while food was being plated, which could lead to contamination. Another dietary aide was observed wearing gloves while touching the outer surfaces of bags of buns, removing a bun, plating it, and then, with the same gloved hands, picking up lettuce and tomatoes to place on burgers. This aide also opened packages of buns and cheese and returned to placing them on burgers without changing gloves or washing hands between tasks. The facility's own policy on food preparation and service prohibits bare hand contact with food and requires gloves to be worn and changed between tasks to prevent the spread of foodborne illness. The interim dietary manager confirmed that these practices were not followed, resulting in a failure to maintain sanitary conditions and prevent potential cross-contamination during meal service.
Plan Of Correction
E13 was immediately educated on proper food handling procedures on tray line and infection control standards. The bread bags and bowls were removed from the tray line after discovery. CDM or designee will educate all kitchen staff on proper food handling procedures. CDM or designee will audit tray line during meal service 3 times a week for 4 weeks, then twice a month for 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Maintain Safe Environment and Supervision on Memory Care Unit
Penalty
Summary
The facility failed to maintain an environment free from potential accident hazards on the Memory Care Unit. Observations revealed three electrical outlets in a hallway without covers, exposing wiring, and an unsecured activity room containing accessible hazardous materials such as wipes, food items, hand sanitizer packs, sugar packs, sharp metal file holders, tape, paperclips, binding clips, electrical extension cords, and a coiled wire. These items were accessible to residents, including one resident observed attempting to wheel through the hallway during the inspection. A registered nurse confirmed the presence of these hazards. Additionally, a resident with dementia, anxiety, insomnia, and kidney disease, who was admitted to the secured memory care unit, was found to have removed their elopement (wanderguard) bracelet using nail clippers. The nurse took the clippers and replaced the bracelet, but the incident was only documented on an incident statement form without a full investigation. The Nursing Home Administrator confirmed that no investigation was conducted, and the facility did not ensure an environment free from potential accident hazards.
Plan Of Correction
All items cited on the Willow unit were removed from the shelving/drawers and outlet covers were installed immediately. R225 did not sustain any injury due to removing their security bracelet with nail clippers. Nurse statement revealed family member admitted to bringing the clippers and they were immediately removed, warranting no further investigation. Rounds were completed in each room of the Willow unit to ensure no hazardous items were present. No further items were discovered. NHA or designee will educate memory care staff on maintaining a hazard-free environment. Unit Manager or designee will audit the unit for potential hazards twice weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency as required by federal and state regulations. According to the facility's own policy, any suspicion of abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately to the administrator and to other officials, including the State Agency. In this case, a resident with diagnoses including high blood pressure, diabetes, muscle weakness, and cognitive communication deficit reported to a registered nurse that a certified nursing aide had pushed her wheelchair hard and on purpose after telling her to use the wheelchair to go to the bathroom instead of walking. The resident requested that the aide not be assigned to her again and wanted the incident addressed in writing. The Director of Nursing and Nursing Home Administrator were made aware of the situation, and it was decided that two aides would be required to provide care to the resident going forward. Despite the facility's policy and the seriousness of the allegation, documentation provided to the State Agency did not include this incident. During an interview, the Director of Nursing confirmed that the facility failed to report the allegation of abuse to the State Agency for this resident. This omission constitutes a failure to comply with both federal and state requirements for reporting alleged violations involving abuse or neglect.
Plan Of Correction
F 0609 R325 was interviewed by management immediately after discovering this nurse's note. Resident recalled the comment and stated she didn't like the aide taking her to the bathroom in a wheelchair as she preferred the walker. A grievance form was completed for not following resident preference and resolved to the resident's satisfaction. Allegation of abuse was reported upon receipt of survey results. A review of the last 30 days of grievances was conducted to ensure no other grievance was reported as an allegation of abuse that should have been, with no negative findings. DON and unit managers will be educated by the NHA to review the 24-hour progress note report daily for any notes triggering an allegation of abuse and report accordingly. NHA or designee will audit 24-hour progress notes for the same weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed. F 0609
Failure to Accurately Document Hospice Care in Resident Assessment
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one of five residents reviewed. Specifically, a resident with diagnoses including diabetes, dementia, and a history of repeated falls was re-admitted to the facility and later admitted to hospice services per a physician order. However, review of the Minimum Data Set (MDS) assessments dated after the hospice admission showed that the resident's hospice care status was not accurately documented in Section O: Special Treatments, Procedures, and Programs. Both the MDS dated 12/14/24 and 3/16/25 failed to indicate that the resident was receiving hospice care, despite the active physician order for hospice services. During an interview, the Registered Nurse Assessment Coordinator confirmed that the facility did not complete an accurate assessment for the resident. Facility policy requires comprehensive and accurate assessments, including the completion of the MDS and documentation of all special treatments and services, but this was not followed in this case, resulting in an inaccurate record of the resident's care status.
Plan Of Correction
R71's MDS assessments were modified to reflect hospice care. MDS assessments for all residents on hospice were reviewed to ensure they indicated the residents were receiving hospice care. No other inaccuracies noted. NHA or designee will educate the MDS department on routine auditing of residents on hospice to ensure it is captured in their assessments. MDS Coordinator or designee will audit resident assessments for hospice care weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Develop Comprehensive Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident diagnosed with dementia. According to the facility's own policy, each resident should have a care plan that includes measurable objectives and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. However, a review of the resident's clinical record and care plan revealed that there were no documented goals or interventions specifically addressing the resident's dementia. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan for the resident was incomplete and did not address the resident's care needs related to dementia. The lack of a comprehensive care plan for this resident was identified through a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
R57 care plan was updated to reflect the diagnosis of dementia with appropriate interventions. All residents with dementia were audited to ensure it was reflected appropriately in their care plans. NHA or designee will educate the RNAC department on the need for a dementia diagnosis to be care planned and reviewed with each MDS assessment to ensure care plans are person-centered. RNAC or designee will audit care plans for dementia diagnoses weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Assess, Document, and Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to assess, document, and notify physicians of significant changes in capillary blood glucose (CBG) levels for three residents with diabetes. Despite having policies in place that required documentation of assessment data, notification of physicians for significant changes, and person-centered care planning, the facility did not follow these protocols. Specifically, multiple instances were identified where residents had elevated CBG readings well above the thresholds specified in physician orders, yet there was no evidence of assessment for hyperglycemia, monitoring for effectiveness of treatment, or physician notification. For one resident with dementia, diabetes, and aphasia, repeated CBG readings above 350 mg/dL were recorded, some exceeding 400 mg/dL. The physician's order required notification for CBG levels above 331 mg/dL, but there was no documentation of physician notification, assessment, or follow-up in the clinical record or eMAR. Similar failures were observed for two other residents with diabetes and other comorbidities, where CBG levels exceeded the notification threshold set by their physicians, but no corresponding documentation or notification was found. Additionally, care plans for these residents lacked person-centered interventions specific to their diabetic care needs. Interviews with nursing staff revealed inconsistent understanding and application of the facility's protocols regarding when to notify physicians and how to document interventions for abnormal blood glucose levels. Staff responses varied on the thresholds for physician notification and the steps to take in response to abnormal CBG readings. The Director of Nursing confirmed that the facility did not notify physicians of changes in condition, failed to document assessments or interventions related to blood glucose, and did not follow physician orders for the affected residents.
Plan Of Correction
Residents R58, R64, and R111. Doctors were notified of blood sugars out of parameters. A one-week review of 24-hour reports was conducted to assess the need for physician notification. The DON or designee will educate nurses on the need to notify the MD for all blood sugars out of range per order. The DON or designee will audit five diabetic residents for blood sugar MD notification weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Provide Appropriate Catheter Care and Privacy for Residents
Penalty
Summary
The facility failed to provide appropriate treatments and services for residents with indwelling urinary catheters, as required by both federal and state regulations. Specifically, two residents with complex medical histories, including chronic kidney disease, urinary tract infections, and obstructive and reflux uropathy, did not receive care in accordance with facility policies. Documentation was lacking regarding catheter removal procedures, including assessment data, resident tolerance, and post-removal monitoring. For one resident, after a foley catheter was discontinued, there was no evidence that staff offered frequent toileting attempts or documented assistance with continence or incontinence, despite orders for bladder scans and fluid intake. This resident ultimately required re-insertion of the catheter due to incomplete bladder emptying. Observations revealed that both residents with indwelling catheters did not have their catheter drainage bags covered with dignity bags for privacy, as required by facility policy. On multiple occasions, the catheter bags were visible and not shielded from view, either hanging on a wheelchair, walker, or bed frame. Staff interviews confirmed that the required privacy measures were not consistently implemented. The Director of Nursing acknowledged that the facility did not ensure appropriate treatment and services for the two residents with indwelling urinary catheters. The deficiencies were also found to be in violation of several Pennsylvania state codes related to management, resident care policies, and nursing services.
Plan Of Correction
R331's MD was notified of concern having orders for output, measuring and recording of urinary output for resident's catheter management. R51 was provided with a Foley privacy bag. All residents with Foley catheters were audited for privacy bags and Foley management orders reviewed to ensure output documentation within a 24-hour period is inclusive. DON or designee will educate nurses on proper Foley catheter management including documentation of output for all residents with a Foley catheter and proper placement of catheters in a dignity bag. Facility IP or designee will audit all Foley catheter residents for appropriate chart documentation and privacy bags 1 time a week for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a monthly Medication Regimen Review (MRR) was completed by the pharmacy for one resident. According to facility policy, the consultant pharmacist is required to perform an MRR for every resident upon admission and at least monthly thereafter, with copies of the reports and physician responses maintained as part of the permanent medical record. However, a review of the clinical record for a resident admitted with diagnoses including dementia, diabetes, and aphasia showed that there was no documentation of an MRR for the months of February, March, and May. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required monthly pharmacy MRRs were not completed for the resident in question. The absence of these reviews was identified through examination of the resident's clinical record and facility policy documentation.
Plan Of Correction
R58 will have a pharmacy review completed and reviewed by MD. An audit of all other residents was conducted to identify those out of compliance with pharmacy reviews, and all identified residents will have a pharmacy review completed and reviewed by MD. Unit Managers will be educated on the need for monthly pharmacy review compliance and assisting with physician follow-up until completion is documented in resident charts. Unit Managers or designee will audit monthly pharmacy reviews weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.
Delayed Provision of Facility Information and Employee Records
Penalty
Summary
The facility failed to provide the State Agency with timely access to requested facility information, which resulted in delays during the survey process. During the entrance conference, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were asked to provide a list of new hires, contracted employees, and an all-house employee list with hire dates. Requested new hire personnel files were not received until several hours after the initial request, and additional information regarding employee licensure, physicals, reference checks, and orientation was delayed further. Some documentation remained incomplete, requiring the surveyors to search through other files, which added more time to the review process. Additionally, the facility did not promptly provide complete annual educational records for employees, including the required 12 hours of annual training for nurse aides. Multiple requests were made for this information, and some records for nurse aides, therapy staff, and a registered nurse were still missing or incomplete after repeated follow-ups. The NHA asserted compliance but did not provide the requested documentation. There were also delays in providing an investigation for a resident and a staffing deployment sheet, with the requested documentation being provided an hour after the request. These repeated delays in providing readily available information hindered the survey process.
Plan Of Correction
F 0836 Facility will maintain new hire lists and training records in a central location monthly to ensure information is readily available. Copies of resident investigations will be maintained in the NHA office for ease of access during survey moving forward. NHA or designee will educate the HR Director on the new hire file checklist and maintaining employee lists. NHA or designee will educate the DON on maintaining annual education centrally and accurately for all staff for ease of review. ED or designee will educate the NHA on maintaining resident investigations. For auditing the timely provision of requested information to the surveyor team, the facility will audit the following areas: HR or designee will audit new hire files weekly for 4 weeks, then monthly for 2 months for compliance. Facility staff educator or designee will audit employee education weekly for 4 weeks, then monthly for 2 months for compliance. NHA will audit resident investigations weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Document Immunization Offer and Education
Penalty
Summary
The facility failed to document that a resident was offered influenza and pneumococcal immunizations and that the resident or their legal representative received education regarding the benefits and potential side effects of these vaccines. Facility policies required that all residents be offered these vaccines in accordance with CDC recommendations and that education be provided and documented in the medical record. However, a review of the clinical record for a resident admitted with dementia and high blood pressure showed no documentation that the influenza or pneumococcal vaccines were offered or declined, nor that education was provided to the resident or their representative. The Minimum Data Set assessment indicated the resident had severely impaired cognition, did not receive the influenza vaccine, and was not offered the pneumococcal vaccine. While a nurse's progress note recorded a refusal of the flu vaccine, there was no evidence that the resident's legal representative was informed or educated about the vaccines. The Director of Nursing confirmed these findings, acknowledging the lack of required documentation for both the offer and education regarding immunizations for this resident.
Plan Of Correction
R53's POA will be contacted to offer a pneumococcal vaccine. During next flu season, facility will ensure the POA is notified if resident refuses a flu vaccine. A full house audit of all residents will be conducted to ensure all residents are offered appropriate vaccines and educated accordingly. If residents are not capable of making their own decisions, their legal representative will be notified to offer the vaccines and education. DON or designee will educate the facility IP on maintaining documentation of offering the influenza and pneumococcal vaccines on admission and annually. Facility IP or designee will audit all new admissions for documentation of the influenza and pneumococcal vaccine being offered weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.
Failure to Document Medication Changes and Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, as required by facility policy and professional standards. Specifically, a resident with diagnoses including Alzheimer's disease, diabetes, dysphagia, and heart failure was admitted and later readmitted to the facility. Upon review, it was found that the resident's insulin medications (Lantus and Humalog) were discontinued without any documentation explaining the reason for the stoppage or indicating a change in condition that prompted this action. The clinical record did not contain any notation regarding the discontinuation of these medications, and the omission was not addressed until the resident became hyperglycemic and the physician had to be notified to restart insulin orders. Further review of the progress notes revealed that the physician acknowledged the previous discontinuation of insulin orders without documentation and confirmed that the medications were immediately reordered with no issues to care. During interviews, both the Director of Nursing and the Nursing Home Administrator confirmed the lack of documentation regarding the change in the resident's medication regimen and the incomplete medical record. This failure to document changes in the resident's condition and medication orders constituted a deficiency under the applicable clinical records regulation.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program over an 11-month period from September 2023 through July 2024. A review of the facility's Infection Control (IC) Policy and Procedure, last reviewed on April 1, 2024, indicated a commitment to identifying and reducing the risk of infections among residents, staff, and visitors. However, the facility's infection control documentation during this period did not show evidence of an infection prevention system that tracked infections, analyzed clusters, or monitored changes in prevalent organisms and infection rates. During an interview on July 17, 2024, the Director of Nursing confirmed the absence of a functional infection control program for tracking infections within the facility. This deficiency was noted in the context of several Pennsylvania Code regulations related to nursing services, resident care policies, licensee responsibility, management, and staff development.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required by their policy. The policy, reviewed on two occasions, indicated that antibiotics should be prescribed and administered under the guidance of the program to monitor their use. However, the facility's infection control program lacked documentation of antibiotic use from September 2023 through July 2024. The tracking system did not provide feedback reports on specific antibiotic use, including criteria for active infection, recommended duration, appropriateness, and resistance patterns. During an interview, the Director of Nursing confirmed the absence of antibiotic stewardship information for the specified period.
Inconsistent Shower Provision for Residents
Penalty
Summary
The facility failed to consistently provide showers to four out of eight residents, as required by their policy on Activities of Daily Living (ADLs). The policy, dated April 1, 2024, mandates that residents receive care and services to maintain or improve their ability to perform ADLs, including hygiene care, which should be documented in the medical record. However, during a Resident Council meeting, one resident expressed that he had not received a shower since occupational therapy stopped assisting him, despite his preference for daily showers. This resident, admitted with kidney failure, heart failure, and a pacemaker, had no shower documented for eleven days. Similarly, three other residents also lacked documentation of showers. One resident with a traumatic brain injury had not received a shower in eleven days, while another resident with shoulder and foot fractures had no showers documented since admission. The fourth resident, admitted with a fractured lower extremity, also had no shower documentation for eleven days. The Registered Nurse Unit Manager confirmed the lack of shower documentation and could not provide additional information on why these residents were not consistently provided showers, indicating a failure in the facility's adherence to its own policies.
Failure to Maintain Hazard-Free Environment in Dementia Unit
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on the secured Dementia nursing unit, known as Willow. During an observation, it was noted that residents' rooms contained personal care items such as body creams, hair and body cleansers, mouthwash, and soaps on their sinks. Additionally, the resident lounge/dining room had a bottle of hand soap by the sink, an unlocked cabinet with a bottle of skin cream, Clorox wipes, and a drawer containing a bag of hand sanitizer. Under the sink, there was a soiled gown, a cup, and a brown substance spilled. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the presence of these potential hazards. The facility's policies on accidents and incidents, as well as safety and supervision of residents, were reviewed and indicated compliance with current rules and regulations. However, the observations and staff confirmations highlighted a failure to adhere to these policies, resulting in an environment that was not free from potential accident hazards.
Failure to Manage Diabetes Care and Notify Physicians
Penalty
Summary
The facility failed to notify physicians of significant changes in capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, leading to a deficiency in care for three residents receiving insulin. Resident R93, who was admitted with a diagnosis of diabetes, did not receive prescribed insulin on multiple occasions, and there was no documentation to explain the omission. This failure was confirmed by the Nursing Home Administrator during an interview. Resident R7, also diagnosed with diabetes, did not have blood glucose checks completed as ordered on specific dates. The Director of Nursing confirmed that the facility did not follow the physician's orders for blood sugar checks, which is a critical component of managing diabetes effectively. Resident R58, with a diagnosis of diabetes, had multiple instances of elevated blood glucose levels that were not addressed according to the physician's orders. The resident's care plan required monitoring and documentation of blood sugar levels, but the facility failed to assess for hyperglycemia, recheck blood sugar, or notify the physician of abnormal results. This was confirmed by the Director of Nursing, who acknowledged the lack of documentation and physician notification regarding changes in the resident's condition.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to properly secure one of the four medication carts reviewed, specifically the Hickory Nursing Units back hall medication cart. According to the facility's policy on the Security of Medication Cart, which was last reviewed on April 1, 2024, the medication cart should be secured at all times when out of the nurse's view. However, during an observation on July 14, 2024, at 9:10 a.m., the medication cart was found unlocked and unattended near the nurse's station. This observation was confirmed during an interview with an LPN, identified as Employee E3, at 9:16 a.m. on the same day. The LPN acknowledged that the medication cart was indeed unattended and unlocked, indicating a failure to adhere to the facility's policy for securing medication carts. This deficiency is in violation of the Pennsylvania Code sections 211.9(a)(1)(h)(k)(l)(1) regarding pharmacy services and 211.12(d)(1)(2)(3)(5) concerning nursing services.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for one resident. The resident, who was admitted with diagnoses including Atrial Fibrillation, a history of venous thrombosis, and a heart stent, had a physician's order for Rivaroxaban 20mg to be given in the evening for Atrial Fibrillation. However, the Medication Administration Record indicated that the medication was not provided on three consecutive days. The physician was notified of the missed doses, and the Director of Nursing confirmed the failure to administer the medication as ordered.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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