Avalon Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Castle, Pennsylvania.
- Location
- 3410 W. Pittsburgh Rd, New Castle, Pennsylvania 16101
- CMS Provider Number
- 396075
- Inspections on file
- 26
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Avalon Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including respiratory failure and difficulty swallowing, had a verbal order for staff supervision during meals that was not based on practitioner consultation or Speech Therapy recommendations. The order was entered in error, and staff did not provide the required supervision, allowing the resident to eat alone despite the documented order.
Multiple residents and families reported excessive delays in call bell responses, with some waiting up to an hour or more for assistance, especially on weekends. Staff often failed to respond promptly or stated they were not the assigned aide, leaving residents' needs unmet. These issues were consistently documented in resident council meetings and grievance logs, and facility leadership acknowledged awareness of the ongoing concerns.
Surveyors found that food items in a resident refrigerator and freezer were not labeled with names or use by dates, and several items were expired or lacked identifying information. Additionally, the refrigerator was observed to be dirty, with spilled and dried liquids present. The Medical Records / Admissions Coordinator confirmed these deficiencies, which were not in accordance with facility policy or food safety standards.
The facility did not ensure that all necessary information, such as care plan goals and advanced directives, was communicated to the receiving health care provider when two residents with complex medical needs were transferred to the hospital. Clinical records lacked documentation of this required information prior to transfer, as confirmed by staff interview.
The facility did not ensure that all required QAPI committee members, including the Infection Preventionist, attended quarterly meetings as mandated by policy, with the Infection Preventionist absent from two meetings during the review period.
A resident was observed sitting in a bedside chair without access to a call bell, and no call bell was found plugged in or present in the room. An LPN confirmed that the resident had no way to alert staff for assistance, which was not in accordance with facility policy requiring all residents to have a means to call for help.
Two residents with complex medical conditions were found living in a room with broken closet doors, chipped and peeled paint, and an exposed, soiled toilet plunger in their shared bathroom. These unsanitary and uncomfortable conditions were confirmed by the residents, a family member, and the Infection Control Nurse, indicating a failure to provide a clean and homelike environment as required by facility policy.
A resident with multiple medical conditions and nicotine dependence was able to leave the facility unsupervised to purchase cigarettes, despite the facility's non-smoking policy. The resident accessed the door release button and exited without staff awareness, and there was no evidence of a safe smoking assessment, updated care plan, or elopement prevention interventions prior to the incident. Staff interviews confirmed that cigarettes and a lighter were kept in a locked cart, but supervision and monitoring were insufficient to prevent the elopement.
The NHA and DON did not effectively manage the facility to ensure proper supervision and implementation of safety interventions for elopement prevention and safe smoking, as required by their job descriptions and regulatory standards. This failure was identified through review of records and staff interviews, which showed that necessary safety measures were not consistently maintained.
Two residents did not receive prescribed medications as ordered, resulting in delays of several days before administration. One resident with multiple health conditions did not receive an ordered antibiotic for three days after returning from the hospital, while another with CHF, kidney disease, and respiratory failure experienced a four-day delay in receiving a new medication. The DON confirmed that medications were not administered according to physician orders.
The facility was found to be using portable space heaters in twelve resident sleeping rooms, which is a violation of NFPA 101 standards. This was observed and confirmed during an interview with the maintenance director and the administrator. The use of portable space heaters is prohibited in sleeping areas of health care occupancies.
Avalon Care Center failed to maintain an adequate emergency preparedness plan when their air handler heat exchanger failed, affecting twelve resident rooms. The facility used space heaters and provided blankets but did not implement additional safety measures while waiting for a replacement. The deficiency was confirmed during a survey through interviews with the maintenance director and administrator.
A facility failed to provide sufficient nursing staff, resulting in delayed care for several residents. One resident was awakened at inappropriate hours for showers, while another waited hours for call bell responses, leading to incontinence. Observations showed multiple residents left in bed without timely assistance for transfers, confirmed by the Interim DON.
A resident with multiple health issues experienced a worsening cough over ten days without timely assessment or physician notification. Despite complaints and ineffective medication, the facility delayed contacting the physician until a chest X-ray revealed pneumonitis. The resident and family expressed concerns about the lack of urgency and communication.
The facility failed to provide adequate nursing staff, resulting in delayed assistance with ADLs and personal care for residents. Observations and interviews revealed that residents requiring extensive assistance were not repositioned or transferred as needed, leading to prolonged periods in bed or discomfort. Residents reported long wait times for call bell responses and inadequate incontinence care, particularly during night shifts. These issues were exacerbated by recent management changes and insufficient staff training.
The facility failed to label a multi-dose vial of Tubersol and three insulin pens with the date they were opened, as required by manufacturer's instructions and facility policy. This was confirmed by staff during observations, making it impossible to determine if the medications were within the safe usage period.
The facility did not properly dispose of garbage and refuse, as observed with three outside dumpsters having open and damaged lids, leading to garbage accumulation on the ground. The Dietary Manager confirmed that the lids should be closed and the area kept clean to prevent pest attraction.
The facility did not develop baseline care plans or provide written summaries to two residents within 48 hours of admission, as required by policy. One resident had diagnoses including muscle wasting and heart disease, while another had Type 2 Diabetes and dementia. The Nursing Home Administrator confirmed the absence of these documents.
A resident with pneumonia had a follow-up chest x-ray that showed limited improvement and a pleural effusion. The facility failed to notify the physician of these results in a timely manner, as required by their policy, resulting in a delay of two days before the physician was informed.
A resident with a suprapubic catheter was found with the catheter bag improperly positioned in bed, entangled with bed linen, and not below the bladder as required by facility policy. This was confirmed by staff interviews and observed multiple times, indicating a failure to maintain unobstructed urine flow as per the facility's catheter care protocol.
A resident with a history of osteoporosis and repeated falls, requiring a two-person assist for transfers, was injured when a nurse aide transferred them alone. This resulted in rib fractures and required medical treatment at a hospital. The facility's failure to follow the prescribed transfer protocol led to the resident's harm.
A resident with a history of multiple health issues reported rib pain after being transferred by a CNA. An x-ray revealed minimal buckle fractures. The facility's investigation was incomplete, lacking statements from all relevant staff members. The DON confirmed the investigation should have been more thorough.
Failure to Implement Resident-Directed Care and Treatment per Professional Standards
Penalty
Summary
The facility failed to provide resident-directed care and treatment consistent with professional standards of practice for one resident. A verbal physician's order was entered into the clinical record for a staff member to be present with the resident during meals, and for the resident to take small bites and sips. However, there was no evidence that this order was based on a conversation with the practitioner, nor was it supported by recommendations from Speech Therapy or included in the hospital discharge orders. The DON confirmed that the order was entered in error and not based on appropriate consultation. Observations revealed that the resident was left alone during meals, feeding themselves without staff supervision, contrary to the order in the clinical record. The DON confirmed that staff did not follow the order for supervision during meals. The resident's diagnoses included respiratory failure, pneumonia, difficulty swallowing, an artificial right knee, and altered mental status. The failure to implement care according to orders and professional standards was confirmed through record review, staff interview, and direct observation.
Failure to Provide Sufficient Nursing Staff and Timely Call Bell Response
Penalty
Summary
The facility failed to provide sufficient nursing staff and services to meet the needs of all residents, as evidenced by multiple sources including policy review, job descriptions, resident council minutes, grievances, and interviews with residents, families, and staff. Residents and their families reported excessive delays in call bell responses, with some call bells going unanswered for up to an hour or more, particularly on weekends. Residents described situations where staff would respond to call bells only to state they were not the assigned aide and would not assist, or would promise to return but failed to do so. These concerns were consistently documented in resident council meetings and grievance logs over several months, with repeated reports of long wait times for assistance, including while on the toilet or waiting to be put to bed. Facility policies and job descriptions require prompt response to call lights and assistance to residents regardless of staff assignment, but these procedures were not followed. Eight alert and oriented residents interviewed confirmed ongoing issues with delayed responses and lack of assistance, corroborated by family observations and documented grievances. During interviews, facility leadership acknowledged awareness of these concerns as reflected in council minutes and grievance logs, but did not provide additional information to address the staffing-related issues.
Failure to Properly Store, Label, and Maintain Food in Resident Refrigerators
Penalty
Summary
The facility failed to store, label, and maintain food in accordance with professional standards and its own policy. Observations of the resident freezer and refrigerator in Building 1 revealed multiple food items that were not labeled with the resident's name or use by date, as required by facility policy. Items found included Stouffers Spaghetti with only a staff name and no date, a pie crust with no name and an expired date, and various other foods such as frozen vegetables, beverages, and desserts with no identifying information. Additionally, several perishable items in the refrigerator, such as containers of grapefruit, jello, yogurt, guacamole, and other foods, were either unlabeled or past their expiration dates. Sanitary conditions were also not maintained, as evidenced by a tipped-over cup with a creamy white liquid that had spilled and dried on the refrigerator door and shelf. The Medical Records / Admissions Coordinator confirmed that the resident freezer and refrigerator were dirty and contained numerous items that were not labeled as required or were expired. These findings indicate noncompliance with facility policy and state regulations regarding food storage, labeling, and sanitation.
Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that all necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two residents. According to facility policy, a transfer form should be prepared and sent with the resident during an emergency transfer or discharge. However, a review of the clinical records for two residents who were transferred to the hospital revealed that there was no documented evidence that specific information, such as care plan goals, advanced directive information, instructions for ongoing care, resident representative information, and other details necessary to meet the residents' needs, was communicated to the receiving provider. One resident had a history of high blood pressure, diabetes, and dementia, while the other had muscle wasting, muscle weakness, dysphagia, and difficulty walking. Both residents were transferred to the hospital, and their records lacked the required documentation prior to transfer. This deficiency was confirmed during an interview with the Corporate Compliance Registered Nurse, who acknowledged that the necessary information was not present in the clinical records before the residents were transferred.
Failure to Ensure Required QAPI Committee Attendance
Penalty
Summary
The facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all required committee members, as evidenced by a review of facility policy, QAPI meeting attendance records, and staff interviews. Specifically, the Infection Preventionist, who is a required member of the QAPI committee, was not present at the October 2024 and January 2025 meetings. The facility's policy states that the QAPI committee must include the Administrator or designee, Director of Nursing Services, Medical Director, Infection Preventionist, and representatives from various departments as requested, and that meetings must occur at least quarterly. The absence of the Infection Preventionist from two quarterly meetings was confirmed by the Corporate Nursing Home Administrator, and there was no evidence of their attendance during the specified periods.
Resident Lacks Access to Call Bell in Room
Penalty
Summary
The facility failed to ensure that all residents had access to a functioning call bell system as required by facility policy. During a medication pass observation in building two, one resident was found sitting in a bedside chair without a call bell available to alert staff for assistance. Further inspection of the room revealed that there was no call bell cord plugged into the wall for the resident's bed, nor was a call bell present anywhere in the room. This was confirmed by an LPN at the time of observation, who acknowledged that the resident had no means to alert staff if assistance was needed. Facility policy, reviewed and dated 1/20/25, specifies that each resident must be provided with a means to call staff directly for assistance from their bed, toileting/bathing facilities, and from the floor. The lack of a call bell for this resident was in direct violation of this policy.
Failure to Maintain Sanitary and Homelike Environment for Two Residents
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for two residents, as evidenced by direct observations and interviews. Both residents were found to have broken closet doors in their shared room, and the wall behind one resident's bed and chair had peeled and chipped paint. Additionally, an exposed and soiled toilet plunger was observed in their shared bathroom, resting on a wet bag with a brown substance, and had been left uncovered and exposed for an extended period. These conditions were confirmed by the residents, a family member, and the Infection Control Nurse, who acknowledged that the issues had persisted for some time. The residents involved had significant medical histories, including recent fractures, post-surgical symptoms, high blood pressure, atrial fibrillation, cerebral infarction, COPD, and diabetes mellitus. Despite the facility's policy requiring a safe, clean, and comfortable environment, the observed deficiencies in room maintenance and sanitation were not addressed, resulting in a failure to provide a homelike and sanitary environment for the affected residents.
Failure to Prevent Elopement and Ensure Smoking Safety
Penalty
Summary
The facility failed to implement sufficient monitoring interventions and supervision to prevent an elopement incident involving a resident. The resident, who had a history of traumatic subdural hemorrhage, mild cognitive impairment, COPD, type 2 diabetes, repeated falls, anxiety, depression, and nicotine dependence, was able to exit the facility without staff awareness. The resident left the premises by unlocking the door and leaving the property to purchase cigarettes, despite the facility's status as a tobacco-free, non-smoking environment. Staff interviews and documentation confirmed that the resident was able to access the door release button and leave the facility unsupervised. Prior to the elopement, there was no evidence that the facility had conducted a safe smoking assessment or implemented any safety interventions related to the resident's smoking habits. Progress notes indicated that the resident had previously been caught smoking inside the facility and had expressed frustration about not being able to smoke, but no additional safety measures or care plan updates were documented. The resident's care plan and progress notes lacked any interventions or updates addressing elopement risk or smoking safety from the time of the incident until the investigation several days later. Staff interviews revealed that the resident's cigarettes and lighter were kept in a locked medication cart, and when the resident requested a cigarette, staff would provide them and allow the resident to smoke on the porch. However, there was no supervision or monitoring in place to prevent the resident from leaving the property. The facility was unable to provide a smoking policy when requested, and there was no documentation of the elopement in the progress notes until the investigation began. At the time of the investigation, no elopement prevention interventions had been implemented for the resident.
Removal Plan
- Resident will have a smoking assessment completed. Resident will have supervised smoking three times per day until discharged to a smoking facility, or until discharged to his residence.
- All residents will be assessed for elopement risk by the director of nursing or designee.
- All care plans for residents identified with elopement risks will be reviewed and updated if needed with interventions to prevent elopement by the Director of Nursing or designee.
- A facility care feed message will be sent to families reminding them that the facility is a non-smoking facility and resident smoking is prohibited.
- Education will be completed by all staff on elopement risks, assessments, and supervision of residents by the director of nursing or designee.
- Education will be provided to all staff on facility smoking policy. Facility is a non-smoking facility for residents.
- Elopement books with identified resident photos will be placed on all nurses stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- A protective device will be placed over the exit door button to prevent residents from access.
- Audits will be implemented to ensure residents are adhering to the facility smoking policy by the Director of nursing or designee.
- New admissions will be audited for elopement and smoking risks at morning stand up meeting by the director of nursing or designee to ensure appropriate interventions are in place as needed.
- An Ad Hoc Quality Assurance and Process Improvement Meeting will be held by the Administrator or designee.
- This part of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met.
Failure to Ensure Effective Supervision and Elopement Prevention
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure proper supervision and implementation of safety interventions related to elopement prevention and safe smoking practices. Review of facility records, job descriptions, and staff interviews revealed that the NHA and DON did not fulfill their essential job duties as outlined in their job descriptions, which require adherence to federal, state, and local regulations and the consistent application of facility policies. The deficiency was identified based on findings that the facility did not consistently supervise residents or maintain all necessary safety interventions to prevent elopement, thereby failing to meet regulatory requirements for resident safety and care.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to follow physician's orders for medication administration for two residents. One resident, with a history of a broken right lower leg, stroke, dementia, and muscle wasting, was hospitalized for rectal bleeding and upon return had a physician's order for Azithromycin to be administered daily for four days to treat Respiratory Syncytial Virus. However, review of the Medication Administration Record (MAR) showed that the antibiotic was not started until three days after the order was written. Another resident, diagnosed with congestive heart failure, kidney disease, heart disease, and respiratory failure, was identified in a complaint as not having received a newly ordered medication for four days. Facility documentation indicated that the medication was expected to arrive within a day or two, but the MAR confirmed that administration did not begin until four days after the order. The DON confirmed during an interview that both residents' medications were not administered as ordered and were given late.
Improper Use of Portable Space Heaters in Resident Rooms
Penalty
Summary
The facility failed to comply with NFPA 101 standards regarding the use of portable space heaters in health care occupancies. During an observation and interview conducted on December 6, 2024, between 12:00 p.m. and 3:00 p.m., it was found that the facility was using portable space heaters to heat twelve resident sleeping rooms, specifically rooms #101-112. This was confirmed in an interview with the maintenance director and the administrator, who acknowledged the use of portable space heaters at the time of the survey. The use of these heaters in sleeping areas is a violation of the requirement that prohibits portable space heating devices in health care occupancies, except in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius).
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 or Federal regulatory requirements. On December 6, 2024, the facility removed portable space heaters from all resident rooms. Space heaters on December 6, 2024, were placed at approximately 3pm in nonsleeping staff and employee areas. Also, elements did not exceed the 212 degrees Fahrenheit per regulations. On December 6, 2024, at approximately 10pm the failed air exchanger was replaced with a new unit. Within 30 minutes of the installation, the building established an appropriate temperature range for the entire building.
Deficiency in Emergency Preparedness Plan for Heating/Cooling
Penalty
Summary
Avalon Care Center was found to have deficiencies in its emergency preparedness plan, specifically related to maintaining appropriate heating and cooling conditions in resident rooms. On November 30, 2024, the facility's air handler heat exchanger failed, affecting twelve out of twenty-four resident rooms. The facility consulted an HVAC vendor who determined that parts needed to be ordered, which would take twenty-one days. In the interim, the facility used space heaters and provided blankets and coats to residents but did not implement additional emergency action plans to ensure resident safety. The vendor later offered a full replacement option that could be completed within a week, and the facility chose to wait for this solution. However, there were no additional interim safety measures implemented while waiting for the replacement. The replacement was completed on December 6, 2024, but the facility's failure to maintain an adequate emergency preparedness plan was confirmed through interviews with the maintenance director and administrator. This deficiency was noted during an emergency preparedness survey conducted on December 6, 2024.
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 or Federal regulatory requirements. Facility will review and revise emergency preparedness plan as needed to ensure that the building can maintain/provide heating and cooling in resident rooms per requirements.
Insufficient Staffing Leads to Delayed Care and Assistance
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, impacting their ability to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This deficiency was observed in seven residents, who experienced delays in receiving necessary care and assistance. For instance, Resident R2, who requires extensive assistance for transfers, reported being awakened at 3 a.m. for showers, which they refused due to the inappropriate timing. The resident's family member confirmed that hospice staff often provided showers instead, and the facility staff marked these as refusals. Additionally, Resident R2 expressed discomfort from prolonged periods in a chair due to insufficient staff to assist with timely transfers back to bed. Resident R1 and their roommate, Resident R7, also experienced significant delays in receiving assistance. Resident R1 reported that their roommate sometimes waited up to two hours for call bell responses, necessitating Resident R1 to seek help from the nurse's station. Both residents confirmed that the lack of staffing led to delays in receiving showers and assistance with transfers, with Resident R7 expressing frustration over waiting two hours to use the bathroom, resulting in incontinence. Further observations revealed that Residents R3, R4, R5, and R6, all of whom require extensive assistance for transfers, were left in bed for extended periods without being repositioned or offered opportunities to get out of bed. Interviews with these residents highlighted their reluctance to get out of bed due to the risk of prolonged discomfort in chairs, as staff were often too busy to assist with timely transfers. The Interim Director of Nursing confirmed these observations, acknowledging that residents should be repositioned frequently and offered opportunities to get out of bed.
Delayed Physician Notification for Resident's Acute Condition Change
Penalty
Summary
The facility failed to assess and notify a resident's physician in a timely manner regarding a change in the resident's condition. The resident, who was admitted with diagnoses including muscle wasting, dysphagia, lack of coordination, and cognitive communication deficit, began experiencing a harsh, moist, productive cough on 10/06/24. Despite the resident's complaints and the ineffectiveness of the prescribed cough medication, the facility did not conduct a timely respiratory assessment or notify the physician promptly. It was not until 10/16/24, ten days after the onset of symptoms, that the facility refaxed the physician and received new orders for a chest X-ray and additional treatments. Interviews with the resident and a family member revealed dissatisfaction with the lack of urgency and communication regarding the resident's condition. The resident expressed feeling unwell and weak, and the family member noted the physician had not visited as promised. The clinical record lacked evidence of timely assessment and physician notification, which was confirmed by the Regional Clinical Director. The chest X-ray ordered on 10/16/24 revealed right lower lobe pneumonitis, indicating a significant delay in addressing the resident's acute condition change.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, affecting their physical, mental, and psychosocial well-being. Observations and interviews revealed that several residents, including those with cognitive impairments and mobility issues, were not receiving adequate assistance with activities of daily living (ADLs) such as transferring from bed to chair, repositioning, and being out of bed for meals. For instance, Resident R20, who requires extensive assistance for transfers, was observed in bed during meal times over several days, contrary to physician orders. Similarly, Resident R61, who is cognitively intact but requires assistance for transfers, expressed reluctance to get out of bed due to prolonged periods in a chair causing back pain, indicating insufficient staff to assist with timely repositioning. Interviews with residents highlighted concerns about long wait times for call bell responses and inadequate assistance with personal care. Resident R29 reported waiting over an hour for restroom assistance, while Resident R57 experienced delays in incontinence care, resulting in prolonged exposure to urine. These issues were attributed to insufficient staffing, particularly during night shifts, and inadequate training for newer staff members. The facility's management change was noted as a contributing factor to the staffing challenges. The Resident Council meetings and minutes from previous months corroborated these concerns, with multiple residents voicing dissatisfaction with the timeliness of staff responses and assistance. The facility's failure to maintain adequate staffing levels and ensure timely care and support for residents' ADLs and personal needs was a significant deficiency, as confirmed by the Director of Nursing and other staff members during interviews.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to properly label medications, specifically one multi-dose vial of Tubersol tuberculin purified protein derivative (PPD) and three insulin pens, with the date they were opened. This deficiency was identified during observations in one of two medication storage rooms and two of two medication carts. The manufacturer's instructions for Tubersol indicate that a vial should be discarded 30 days after being opened, while Lantus insulin pens should be used within 28 days at room temperature. However, these medications were found without the required opened or use-by dates, making it impossible to determine if they were still within the safe usage period. During the observations, it was confirmed by various staff members, including an LPN, an RN, and the Director of Nursing, that the medications were in use daily but lacked the necessary labeling. The facility's policies on medication storage and labeling, which were reviewed, require that all drugs and biologicals be stored safely and securely, with proper labeling in accordance with state and federal guidelines. The failure to adhere to these policies resulted in the deficiency noted in the report.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per their policy dated 4/24/24. Observations on 6/30/24 and 7/01/24 revealed that three outside dumpsters had open and damaged lids, allowing garbage to hang over the dumpsters and accumulate on the ground. This condition was confirmed by the Dietary Manager, who acknowledged that the dumpster lids should always be closed and tightly fitted, and the surrounding area should be free from garbage to prevent attracting insects and rodents.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and a written summary was provided to the resident and/or the resident's representative within 48 hours of admission for two residents. According to the facility's policy, a baseline care plan should be created to address the resident's immediate health and safety needs within this timeframe. Resident R62, who was admitted with diagnoses including muscle wasting, high blood pressure, Type 2 Diabetes, pancytopenia, and heart disease, did not have evidence of a baseline care plan or a written summary provided. Similarly, Resident R126, admitted with Type 2 Diabetes, stroke, heart disease, kidney disease, and dementia, also lacked evidence of a baseline care plan and a written summary. The Nursing Home Administrator confirmed the absence of these documents for both residents during an interview.
Failure to Timely Notify Physician of Diagnostic Results
Penalty
Summary
The facility failed to adhere to professional standards of care by not notifying the physician in a timely manner regarding the results of a diagnostic test for a resident. The facility's policy on radiology requires that all positive x-ray or diagnostic results be immediately communicated to the medical provider. However, in the case of a resident with a history of anxiety, depression, muscle wasting, atrophy, and pneumonia, the facility did not follow this protocol. The resident had a follow-up chest x-ray ordered on June 25, 2024, to monitor pneumonia and dyspnea, which showed only limited improvement and a residual pleural effusion. Despite the x-ray being conducted on June 25, 2024, the physician was not informed of the results until June 27, 2024. This delay was confirmed through interviews with the resident's representative and a registered nurse, as well as the nursing home administrator, who acknowledged that the nursing staff was unaware of the delay in communication. The deficiency was identified as a failure to notify the physician promptly, as required by the facility's policy and professional standards of care.
Inadequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident R14, who was admitted with diagnoses including depression, benign prostatic hyperplasia (BPH), chronic kidney disease (CKD), and required a suprapubic catheter. The facility's policy on catheter care, dated 4/24/24, outlined the need to maintain unobstructed urine flow by ensuring the catheter and tubing were free of kinks and the drainage bag was positioned lower than the bladder. However, observations on 7/01/24 revealed that Resident R14 was lying in bed with the catheter bag entangled with the bed linen and positioned near the resident's feet, which was not in compliance with the facility's policy. Interviews with Registered Nurse Employee E2 and the Regional Clinical Director confirmed that the catheter bag was not positioned safely below the bladder, as required to prevent urine from flowing back into the urinary bladder. This deficiency was noted during multiple observations throughout the day, indicating a failure to adhere to the established catheter care protocol. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in actual harm. The resident, who had a history of osteoporosis, high blood pressure, anxiety, depression, and repeated falls, was identified as requiring a two-person assist for transfers. However, a nurse aide transferred the resident alone, leading to the resident experiencing rib pain and later being diagnosed with rib fractures. The incident report and subsequent medical evaluations confirmed the injuries, and the resident required medical treatment at a hospital for the fractures. The facility's policy and the resident's care plan clearly indicated the need for a two-person assist during transfers. Despite this, the nurse aide did not follow the prescribed transfer protocol, resulting in the resident's injury. The nurse aide admitted to not checking the transfer status and stated that other staff had transferred the resident with only one person. The Nursing Home Administrator confirmed that the staff person should not have transferred the resident alone, acknowledging the failure to adhere to the care plan and facility policies, which led to the resident's harm.
Incomplete Investigation of Resident Injury
Penalty
Summary
The facility failed to fully investigate an incident involving Resident R1, who sustained injuries. According to the facility's policy on abuse, neglect, and exploitation, incidents where a resident is injured should be promptly and thoroughly investigated. This includes compiling a list of all witnesses and individuals with knowledge of the event and obtaining statements from them. However, the investigation into Resident R1's injury was incomplete. The only statements obtained were from the LPN who documented the resident's pain and the NA who cared for the resident during the day shift. There were no statements from other staff members who were on duty during the timeframe when the alleged incident occurred until the resident first complained of pain at 6:00 p.m. Resident R1, who has a history of breathing issues, osteoporosis, high blood pressure, anxiety, depression, and repeated falls, reported rib pain after being transferred by a CNA. An x-ray revealed minimal buckle fractures of the lateral right third and fifth ribs. The Director of Nursing confirmed that the investigation was incomplete and should have been more thorough. The deficiency was identified based on the review of facility policy, clinical records, documentation, and staff interviews.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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