Below average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Asbury Health Center during CMS and state inspections, most recent first.
Failure to supervise a resident at risk for elopement led to repeated exit-seeking and wandering events, including being found off the unit and near exterior areas. The resident had dementia with cognitive impairment, hemiplegia, and diabetes, and staff notes described missing documentation of several wandering episodes, an incomplete care plan intervention, and incidents involving a broken alarmed door, a Wanderguard, and an unknown visitor letting the resident off the unit.
Unsanitary Main Kitchen Conditions: Surveyors observed leaking water under kettle pan heaters, an ice machine drainpipe sitting on the floor with a black substance around it and water leaking onto the floor, ice buildup in an ice cream cooler, and wall cooler issues including a leak and a broken hinge that prevented proper closure. The CDM confirmed the facility failed to maintain sanitary conditions in the kitchen.
Inaccurate MDS coding led to incomplete BIMS and mood interviews for seven residents. Several residents were documented as rarely/never understood, which prevented completion of the BIMS and mood interviews, even though surveyor interviews and observations showed they had clear speech and could answer questions about their names, birthdays, food, care, and staff treatment. The RN assessment nurse confirmed that residents who are at least somewhat understood should not be coded as rarely/never understood, and the NHA and DON acknowledged the assessments were not fully completed.
Failure to Complete Restorative Nursing Program for ADL Support: The DON confirmed that restorative nursing activities were not documented as completed daily for four residents with significant mobility and ADL needs. The affected residents had conditions including cognitive impairment, stroke with right-sided paralysis, anoxic brain damage with dementia, and muscle weakness, and their care plans and therapy recommendations included AROM, strengthening, transfers, and assisted walking.
Failure to provide timely assistance and required ADL care: A resident’s call light was left unanswered for 23 minutes and another for 18 minutes, both beyond the facility’s stated response time. Other residents did not receive ordered positioning or incontinent care as documented; one resident with diabetes, AFib, and skin damage was observed without the required wedge or with it placed incorrectly, and another resident with dementia and total toileting dependence was found in bed with urine-soaked linens and no documented bowel/bladder care for most of the day.
The facility failed to maintain documentation that 14 of 41 licensed nurses had current CPR certification for Healthcare Providers. CPR cards were not available for several RNs and LPNs, and the NHA and DON confirmed the facility did not ensure these nurses maintained current CPR certification in accordance with accepted national standards.
Failure to monitor weight and nutrition status: one resident did not have a required weight evaluation, and two residents had significant weight loss without reassessment or new nutritional interventions. One resident with neurologic disease and malnutrition developed a coccyx pressure area that worsened, while another resident with diabetes, anemia, and malnutrition lost weight despite a supplement order. The DON and NHA confirmed the failures.
A resident with dementia, anxiety, and osteoarthritis was observed sitting naked on the bed in full view of the hallway while a CNA assisted with dressing. The care plan directed staff to assist with dressing, and the CNA stated the curtain had not been pulled after returning the resident from the bathroom. The ED confirmed the facility failed to maintain the resident's dignity.
A facility failed to ensure grievance forms available at one of the grievance information locations included wording that a grievance could be filed anonymously. Although the grievance policy stated complaints may be submitted orally or in writing and may be filed anonymously, the policy/procedure was not posted at the Willow Unit location, and the grievance forms there did not mention anonymous filing. The NHA confirmed the omission.
The NHA and DON failed to manage the facility effectively to protect a resident known to be at risk for elopement. A resident exited the assigned nursing unit unsupervised, and the report states this created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks. The NHA and DON confirmed the administrative failure during interview.
Incomplete and inaccurate resident clinical documentation: A resident with hemiplegia, DM, and dementia had inconsistent behavior monitoring and a new order for a Wanderguard, but no progress note was entered on the day of the order. The chart also included a physician note stating the resident had been found wandering outside on the curb, which the NHA later said was inaccurate; the facility’s review found the statement was entered based on word of mouth staff information and that no elopement occurred.
Failure to Provide Bed-Hold Notice at Transfer: The facility failed to ensure that written bed-hold policy notice was given to the resident and/or representative at the time of hospital transfer for four residents. The affected residents had diagnoses including dementia, CKD, diabetes, HTN, AFib, anxiety, and depression, and were transferred for issues such as abdominal pain, coughing up blood, altered mental status, elevated BP, UTI, and pneumonia. The NHA confirmed Medicaid residents were not provided bed-hold information upon transfer, and the DON and NHA confirmed the lapse.
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.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident elopement for a resident who was identified as at risk for elopement and did not reside on a secured unit. The resident had diagnoses including hemiplegia, diabetes, and dementia, and the MDS indicated cognitive impairment. The record showed multiple elopement evaluations with changing results, including several assessments that identified the resident as at risk for elopement in July 2026, while earlier assessments had indicated not at risk or were incomplete. The care plan identified the resident as an elopement risk/wanderer related to impaired safety awareness, but the record contained only one incomplete intervention related to wandering, and no resident preferences were included. Behavior monitoring documented exit-seeking and wandering behaviors on multiple occasions in May, June, and July 2026, but progress notes did not document the behaviors noted on 5/21/26, 6/21/26, and 7/14/26. A physician order for a Wanderguard was created after the resident was found wandering outside on the curb, and staff notes described discussions with family and assessments after the resident was returned to the unit. The resident was later involved in additional elopement-related events. Staff statements and progress notes described the resident being found near a door, in the front hall, in the assisted living area, and off the unit near common areas, with staff searching for her after she was reported missing. One note stated the resident could escape through a security door because the alarm was broken and had not been fixed yet. Another investigation note stated the resident was found off the unit in a common area adjacent to the unit after being let off by an unknown visitor. The facility determined that the resident was cognitively unable to recognize the door requiring a code and would be physically unable to open it without assistance. The report states the facility was out of compliance with resident safety and supervision since 4/12/26.
Unsanitary Main Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the Main Kitchen during survey observation. Surveyors observed leaking water under kettle pan heaters, one of two ice machines with a drainpipe sitting on the floor and a black substance around the pipe, with the pipe not positioned over a drain and water leaking onto the floor. They also observed an ice cream cooler with ice buildup, wall cooler units with a leaking area on the first unit, and a fourth unit with a broken hinge that would not allow the unit to close without force; the thermometer inside that cooler read 50 degrees and the inside of the unit felt warm. During interview, the Certified Dietary Manager confirmed the facility failed to maintain sanitary conditions in the Main Kitchen.
Inaccurate MDS coding led to incomplete BIMS and mood interviews
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were accurate and fully completed for seven residents. The cited issue involved Section B coding for hearing, speech, and vision, where residents were documented as rarely or never understood, which then led to Section C BIMS interviews and Section D mood interviews not being completed. The RAI User’s Manual instructions cited in the report stated that if a resident is at least sometimes understood, the BIMS and mood interviews should be conducted. For Resident R19, the MDS listed kidney disease, Alzheimer’s disease, and malnutrition, and coded the resident as rarely/never understood in Section B, with BIMS and mood interviews not completed. During surveyor interview, however, R19 had clear speech, provided her name and birth month, and answered questions about meals; the birth month matched the clinical record. Resident R21’s MDS listed diabetes, osteoporosis, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed. During interview, R21 was confused but had clear speech and was able to be understood. Resident R58’s MDS listed kidney disease, diabetes, and dementia and similarly omitted the BIMS and mood interviews after coding the resident as rarely/never understood; during interview, R58 had clear speech, gave her name and birthday, and answered questions about food, staff treatment, and care, with the birthday confirmed by the record. Resident R22’s MDS listed heart failure, diabetes, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed; during interview, R22 provided his preferred name, had clear speech, answered questions about food and care, and stated his birthdate correctly. Resident R93’s MDS listed osteoporosis, malnutrition, and dementia and coded the resident as rarely/never understood, with BIMS and mood interviews not completed. During interview, R93 had clear speech, provided her full name, answered questions about food, staff respect, and ADL care, and was able to discuss assistance in and out of bed. Resident R51’s MDS listed anxiety, depression, and dementia and also coded the resident as rarely/never understood, with no BIMS or mood interview completed; during observation, R51 had clear speech, held a simple conversation, and answered questions about the prior day’s food activity. Resident R118’s MDS listed kidney disease, malnutrition, and Alzheimer’s disease and likewise coded the resident as rarely/never understood, with no BIMS or mood interview completed; during observation, R118 had clear speech, answered questions appropriately, and shook her head when asked if she had concerns about her care. The RN assessment nurse confirmed that if a resident is at least somewhat understood, the resident should not be coded as rarely/never understood and the BIMS and PHQ-9 assessments should be attempted, and the NHA and DON confirmed the facility failed to ensure the MDS assessments were accurate and fully completed for seven residents.
Failure to Complete Restorative Nursing Program for ADL Support
Penalty
Summary
The facility failed to complete a restorative nursing program for four residents reviewed for ADL concerns. Facility policy stated residents were to receive restorative nursing care as needed to promote optimal safety and independence, and the DON stated restorative activities were documented on the daily ADL documentation report. However, review of the daily documentation reports for July and August 2026 did not show that restorative tasks were completed daily as required for the affected residents. Resident R23 had cognitive impairment, lack of coordination, and a history of falls, and the care plan called for dependent assistance with all ADLs and restorative exercises for the upper and lower extremities. Therapy recommendations indicated the resident had been discharged from therapy and required AROM to both upper and lower extremities. Resident R26 had stroke and right-sided paralysis, with care plan interventions for assistance with all ADLs, restorative exercises to the upper extremities, ROM, and lifting weights; therapy recommendations included AROM to both upper and lower extremities, weight strengthening, and assisted walking up to 90 feet. Resident R91 had anoxic brain damage, dementia, and difficulty with walking and mobility, with restorative interventions for strengthening, transfers, and walking; therapy recommendations included AROM to both upper and lower extremities, weight strengthening, and sit-to-stand exercises. Resident R99 had diabetes, high blood pressure, muscle weakness, and lack of coordination, with restorative interventions for AROM and walking; therapy recommendations included assisted walking with a wheeled walker up to 100 feet. The DON confirmed the facility failed to complete the restorative nursing program for these residents.
Failure to Provide Timely Assistance and Required ADL Care
Penalty
Summary
The facility failed to provide necessary care and services for residents who were unable to complete activities of daily living independently. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, and that call lights should be answered as soon as possible, but no later than 5 minutes. During observation, Resident R3’s call light was illuminated for 23 minutes before being answered, and the resident stated she needed to be changed. During another observation, Resident R124’s call light remained illuminated for 18 minutes before a nurse aide entered the room and assisted the resident. The Nursing Home Administrator and DON were informed of the delayed response times and confirmed they would review call bell response with staff. The facility also failed to provide ordered positioning and incontinent care for other residents. Resident R62 had diagnoses including diabetes and atrial fibrillation, required substantial/maximal assistance to roll in bed, had moisture associated skin damage at the base of the spine, and had a physician order for a wedge in bed at all times. Observations showed the resident lying on the back without a wedge present, and later with the wedge placed under the fitted sheet at the same level as the head rather than at torso level as confirmed by the wound nurse. Resident R128 had diagnoses including diabetes, chronic kidney disease, and dementia, was dependent on staff for toileting hygiene, and was always incontinent of urine and frequently incontinent of stool. The resident was observed in bed with a strong odor of urine and wet, saturated linens and blanket; although staff stated the resident sometimes refused care, the record did not document a refusal, and the point-of-care record showed no bowel or bladder care documented from early morning until late evening that day.
Missing Current CPR Certification for Licensed Nurses
Penalty
Summary
The facility failed to maintain documentation that its nursing personnel had current education and certification to provide basic life support, including CPR, prior to the arrival of emergency medical personnel and subject to physician orders and residents’ advance directives. A review of the facility’s CPR policy showed it was intended to ensure timely and appropriate initiation of CPR by licensed nursing staff in accordance with facility policy, resident rights, and federal and state regulations. During the survey, the facility provided a list of 41 currently employed licensed nurses and copies of CPR certification cards for review. CPR certification cards were not available for RN Employees E3, E4, E5, E6, and E7 and LPN Employees E8 through E16, totaling 14 of 41 licensed nurses. In an interview, the Nursing Home Administrator and the DON confirmed that the facility failed to ensure these nursing personnel maintained current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting in accordance with accepted national standards.
Failure to Monitor Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor residents’ weight and nutrition status. Review of the facility policy indicated that any weight change of 5% or more since the last weight assessment was to be retaken the next day for confirmation and, if verified, nursing was to notify the dietician in writing. For Resident R6, the clinical record showed a physician order for weekly weights, but the weight record from 6/28/26 through 8/4/26 did not include a weight evaluation, and the facility failed to obtain a monthly weight. For Resident R97, the record showed diagnoses including Progressive Supranuclear Palsy, stroke history, cognitive deficit, and malnutrition. The resident lost 7.5 pounds, or 6.05%, from 7/5/26 to 8/1/26, and developed a 1 cm x 1 cm open area on the coccyx on 7/1/26 that worsened by 7/28/26. The dietician had last assessed the resident on 5/15/26 and did not reassess after the pressure ulcer developed or identify nutritional interventions. For Resident R9, the record showed diagnoses including diabetes, anemia, and malnutrition, with Glucerna ordered for weight stabilization. The resident lost 11.3 pounds, or 8.29%, in one month and 17.5 pounds, or 12.28%, in three months, but the dietician confirmed no reassessment or new interventions were put in place to address the weight loss.
Failure to Maintain Resident Dignity During Dressing Assistance
Penalty
Summary
The facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. Resident R23 had diagnoses including dementia, anxiety, and osteoarthritis. The MDS dated [DATE] indicated the resident had mild cognitive impairment and required assistance with dressing. The care plan identified a self-care performance deficit related to dementia and directed staff to assist the resident with dressing. During observation on 8/4/2026 at 10:15 a.m., Resident R23 was sitting on the bed naked in full view of anyone walking by in the hallway while a CNA was assisting with dressing. During interview, the CNA stated that the curtain had not been pulled after bringing the resident back from the bathroom, and the Executive Director confirmed the findings and that the facility failed to provide care and services to maintain the resident's dignity.
Grievance Information Missing Anonymous Filing Option
Penalty
Summary
The facility failed to ensure that grievance forms could be filed anonymously in one of four locations where grievance information was available, specifically on the Willow Unit. The facility policy on grievances, last reviewed 3/1/26, stated that grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. However, during an observation on 8/4/26 at 8:04 a.m., the grievance policy/procedure was not posted at the location on the [NAME] Unit, and the grievance forms available at the grievance box location did not include wording stating that a grievance form can be filed anonymously. During an interview on 8/6/26 at 3:30 p.m., the Nursing Home Administrator confirmed that the facility grievance policy and procedure failed to provide information on residents' right to file a grievance anonymously.
Failure to Protect a Known Elopement Risk
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to protect residents from elopement. Review of the facility’s job descriptions showed that the NHA was responsible for supervising department heads, ensuring compliance with regulatory guidelines, and reviewing complaints and trends, while the DON was responsible for directing nursing services, coordinating care, overseeing staffing, and investigating and reporting incidents and complaints. Despite these responsibilities, the facility failed to prevent and protect residents from exiting their assigned nursing unit unsupervised. The deficiency involved Resident R1, who was documented as an elopement risk. Survey findings showed that R1 exited the resident’s assigned nursing unit without supervision. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The report states that this failure created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks.
Incomplete and inaccurate resident clinical documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for one resident with hemiplegia, diabetes, and dementia. Review of the resident’s behavior monitoring showed inconsistent documentation from April through July 2026, including no wandering documented in April, exit-seeking behavior documented in May, exit-seeking and wandering documented in June, and additional exit-seeking, agitation, frustration, and threatening behaviors documented in July. The record also showed a new physician order on 4/12/26 for a Wanderguard to be placed, but there were no progress notes created that day. The clinical record contained a progress note on 4/13/26 stating the resident’s brother was informed about the Wanderguard, and another physician note on the same date stated the resident had been found wandering outside on the curb and now had a wander guard on. A later progress note repeated that statement, but the Nursing Home Administrator stated the note was inaccurate and that the resident was not found outside on the curb. The facility’s investigation found the physician note had been entered mistakenly based on word of mouth staff statements, that a staff member clarified the resident had been near the Hickory unit doorway rather than outside the facility, and that no elopement occurred. Surveyors determined the record therefore was not complete and accurately documented.
Failure to Provide Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that the resident and/or the resident representative received written notice of the facility bed-hold policy at the time of transfer for four of eight residents reviewed for hospitalization. Federal regulation S483.15(d) requires facilities to provide written information about bed-hold policies prior to and upon transfer, and the facility policy stated that residents are to receive this information well in advance of transfer and again at the time of transfer, or within 24 hours for an emergency transfer. Review of the clinical records for Residents R9, R58, R62, and R98 failed to reveal documentation that the written bed-hold notice was provided upon transfer to the hospital. Resident R9 had diagnoses of diabetes, cirrhosis of the liver, and dementia, with severe cognitive impairment, and was transferred to the hospital for abdominal pain. Resident R58 had diagnoses of high blood pressure, chronic kidney disease, and dementia, with severe cognitive impairment, and was transferred for coughing up blood. Resident R62 had diagnoses of atrial fibrillation, diabetes, and high blood pressure, and was transferred for increased altered mental status and elevated blood pressure. Resident R98 had diagnoses of anxiety, depression, and dementia, and was transferred and admitted to the hospital for a urinary tract infection and pneumonia. The Nursing Home Administrator confirmed that residents with Medicaid as a payer source were not provided bed-hold information upon transfer to the hospital, and the DON and Nursing Home Administrator confirmed the facility failed to ensure the required written notice was provided.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,323 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia Of The South Hills | 1.1 mi | ★★★★★ | 0 | 0 |
| Carnegie Park Post Acute | 1.1 mi | ★★★★★ | 21 | 0 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 1.6 mi | ★★★★★ | 6 | 0 |
| John J Kane Regional Center-sc | 1.7 mi | ★★★★★ | 3 | 0 |
| Providence Point Healthcare Residence | 1.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.