Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aventura At Creekside during CMS and state inspections, most recent first.
Failure to Identify Authorized Decision Makers and Advance Directive Documentation: Three residents with severe cognitive impairment had medical decisions documented as signed or approved by themselves despite records showing they could not make decisions independently. POLST forms were completed for these residents without clear evidence of a legally authorized representative, and one record lacked a physician signature while another lacked documentation of who reviewed the treatment decisions. The records also did not show advance directive documentation or evidence that the residents were offered information about the right to formulate one.
Resident Council concerns about call bell response times were not adequately documented, communicated, or followed up on. Although a grievance about delayed call bell response was reviewed and marked resolved, eight cognitively intact residents later reported ongoing inconsistent response times, and the facility could not show that residents were re-interviewed or that the Council was informed of the actions taken or the outcome of the concern.
Housekeeping failed to maintain a clean and sanitary environment for two residents. One resident’s room had dried tube feeding residue on the tube feeding pole, fall mat, and privacy curtain, while another resident’s Broda chair had debris, stains, hair, and crumbs on the seat, footrest, and Dycem. The NHA and DON reviewed the findings and acknowledged the lapse in maintaining resident care equipment and room cleanliness.
A resident with cerebral palsy and intact cognition was observed seated in a wheelchair with a buckle belt secured across the waist. The record showed long-term use of the belt for positioning, but the facility did not identify it as a restraint or document interdisciplinary review, a medical symptom, informed consent, least-restrictive analysis, or ongoing monitoring. The ADON, NHA, and DON stated the belt was used for fall risk and safety, and acknowledged the resident could not remove it and that it restricted movement.
Failure to Verify Prior Employment for New Hires: The facility did not fully screen three of five new hires, including an LPN, an RN, and another LPN, because there was no documentation that former employers were contacted even though each application listed prior employment. The facility’s abuse prohibition policy required screening potential employees and obtaining references from previous and current employers, but the NHA could not provide evidence that this was done.
Inaccurate MDS coding occurred for three residents. One resident with cerebral palsy was observed in a wheelchair with a buckled belt attached for safety, yet the MDS did not code a restraint. Two other residents had documented falls in the clinical record, but their quarterly MDS assessments recorded no falls. The MDS Coordinator acknowledged the assessments did not accurately reflect the residents’ conditions.
A facility failed to ensure a comprehensive person-centered care plan was implemented consistently for two residents. One resident with cerebral palsy had conflicting transfer directions in the care plan, listing both 2-person assist and a Hoyer lift for all transfers without clear guidance. Another resident with COPD and fall risk had a care plan calling for Dycem above and below the wheelchair cushion, but observation showed Dycem only on top of the cushion and not below it as written. The NHA and DON were interviewed about the issue.
The facility failed to verify that two LPNs had the required IV therapy education, training, and competency to administer IV Meropenem through a PICC line. A resident with a surgical site infection had a PICC line and an order for Meropenem IV q8h, and the eMAR showed two LPNs documented administering the medication via the PICC line. The facility could not produce IV training, competency validation, or supervision documentation for either LPN, and the DON and NHA confirmed the missing records.
A resident with hyperkalemia and moderate cognitive impairment had an order for Midodrine with specific BP hold parameters. Nursing staff administered the medication multiple times without documenting a BP reading beforehand and later held doses when only the systolic BP exceeded the ordered limit, even though the diastolic BP did not meet the hold criteria. The DON acknowledged the MAR did not match the physician’s order.
A resident with heart failure and muscle weakness had Tramadol orders for pain, but staff administered the opioid outside the ordered pain scale parameters multiple times and, after the order was revised to require nonpharmacological interventions first, gave two doses without documenting those interventions. The DON reviewed the record and confirmed staff did not follow the physician orders for pain management.
A resident with bipolar disorder had a consultant pharmacist MRR that identified Mirtazapine 15 mg and recommended consideration of a GDR. The record included a psych NP note that the resident had previously failed a GDR of Seroquel and was stable on the current regimen, but there was no documentation that the attending physician reviewed the pharmacist’s recommendation or documented a clinical rationale for continuing Mirtazapine without a GDR. The ADON stated the facility had an ongoing issue obtaining physician documentation in response to consultant pharmacist recommendations.
A resident with dementia and muscle weakness was given Ceftriaxone for a UTI even though the facility’s McGeer's Criteria checklist documented no fever, leukocytosis, acute mental status change, or acute functional decline. The clinical record did not show signs or symptoms of infection before the antibiotic was started, and the urine culture later identified E. coli that was resistant to Ceftriaxone. The DON reviewed the findings during interview.
The facility did not obtain food from approved sources or ensure that food was stored, prepared, distributed, and served according to professional standards, resulting in a deficiency related to food safety and handling.
The facility did not maintain an effective pest control program, as evidenced by the presence of live and dead cockroaches in the kitchen and food preparation areas. Staff and management confirmed ongoing pest sightings, and pest control services were not provided at the increased frequency requested. Documentation of pest monitoring was lacking, and a pest control inspection identified active infestations and structural vulnerabilities.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility did not ensure adequate safeguards against physical, mental, sexual abuse, physical punishment, or neglect by any person.
Surveyors identified unsanitary conditions in the dietary department, including dirty meal carts stored near food prep areas, soiled ceiling tiles and light fixtures, a sticky and contaminated juice dispenser, and improper storage of wire racks and debris in the dry storage area. These findings indicated a failure to maintain food storage, preparation, and service areas in a clean and sanitary condition as required by facility policy and federal guidelines.
Three residents with chronic respiratory conditions did not receive supplemental oxygen at the flow rates ordered by their physicians. Observations found that oxygen concentrators were set below the prescribed levels, and staff confirmed the discrepancies. The facility's policy requires licensed nurses to administer and monitor oxygen therapy as ordered, but this was not followed for these residents.
Surveyors found that multi-dose insulin pens, including Insulin Degludec, Insulin Glargine, and Insulin Aspart, were opened and in use without proper labeling of the date opened, and one pen was used past its expiration date. An LPN and the DON confirmed these practices did not follow facility policy or manufacturer guidelines.
Facility administration failed to immediately remove a nurse aide accused of physical abuse from resident contact, and did not report or investigate additional abuse allegations involving two other residents and two nurse aides. These failures resulted in Immediate Jeopardy and placed all residents at risk.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with Parkinson's Disease experienced significant unplanned weight loss, and the facility failed to document the provision of recommended nutritional interventions, notify the physician and representative, or conduct timely follow-up assessments and monitoring as required.
Nursing staff did not consistently follow procedures for verifying and documenting controlled substance counts at shift change on two medication carts. Facility policy requires both oncoming and outgoing nurses to count and sign off on controlled medications at each shift change, but multiple instances were found where the oncoming nurse failed to sign the narcotic count sheets. Interviews confirmed staff awareness of the policy, and the administrator acknowledged the lack of consistent implementation.
A resident with intact cognition and a history of frequent falls and pneumonia experienced a monthly rate increase without receiving the required advance written notice. The facility's admission agreement mandated a 60-day written notification for financial changes, but billing records and staff interviews confirmed that neither the resident nor his representative was notified before the higher charges were applied.
The facility did not post its smoking policy in required areas, failed to provide fire safety equipment in the designated smoking patio, and did not assess a cognitively intact resident with nicotine dependence for safe smoking practices. Staff confirmed these lapses, and documentation showed the resident became agitated and verbally aggressive when denied access to smoke without assessment.
A resident with multiple medical conditions, who was cognitively intact, expressed a desire to transfer to a local facility that allowed smoking. Despite this, the resident was discharged to a facility several hours away without documentation explaining why local options were not pursued or why the resident's preferences were not honored. The facility also lacked documentation confirming guardianship status and did not demonstrate that the resident was involved in the discharge decision-making process.
Three residents experienced harm due to the facility's failure to provide adequate supervision, staff training, and individualized interventions to prevent accidents. One resident with severe cognitive impairment suffered multiple falls, including a head injury after being left unsupervised and another fall from a Broda chair transported by untrained staff. Another resident with dementia and Parkinson's disease had repeated falls and injuries due to insufficient care planning and lack of staff guidance. A third resident, at risk for wandering, exited the building unsupervised when the lobby was left unattended, resulting in an elopement event.
A resident, who was cognitively intact and responsible for his own care, experienced a daily room rate increase without receiving advance written notice. Billing records and facility documentation confirmed that neither the resident nor his representative was notified of the rate change before it took effect, and the NHA acknowledged the notice was not sent in a timely manner.
The facility failed to maintain sanitary food storage and service practices, risking food-borne illness for all residents. Observations included a sticky kitchen floor, buildup in juice machines, undated and uncovered food items, improper ice machine drainage, and expired food. The janitor's closet was cluttered, and dirty garbage cans were noted. These issues were confirmed by the Nursing Home Administrator.
A resident with contractures in both ankles and elbows did not receive prescribed therapeutic devices, including contracture boots and elbow splints, as required. Documentation showed multiple instances in August and September where these devices were not applied or removed as scheduled. Observations confirmed the absence of these devices, and staff interviews revealed unfamiliarity with the resident's care needs.
The facility failed to assess and manage bowel and bladder function for four residents, including a resident who became frequently incontinent without a new toileting plan, and another who did not receive a two-hour check and change program. Additionally, a resident with a catheter experienced inadequate care, with their catheter bag not emptied regularly, leading to excessive urine accumulation. These deficiencies were confirmed by staff and the Nursing Home Administrator.
The facility did not ensure monthly drug regimen reviews by a licensed pharmacist for two residents with dementia-related diagnoses. This was confirmed by the DON, who acknowledged the lack of documentation for the required reviews.
The facility did not follow the planned menus for residents on a pureed diet. During a lunch meal service, it was observed that essential items like pureed mixed vegetables and sugar cookies were missing from the tray line. An interview with the District Kitchen Manager confirmed the oversight, highlighting a failure to adhere to dietary service regulations.
The facility failed to serve meals at safe and palatable temperatures for a resident. Lunch trays were delayed, sitting for about 40 minutes before being delivered. A test tray showed food temperatures below the safe range, with a cheeseburger at 90°F, fries at 82°F, and coleslaw at 65°F. The District Kitchen Manager confirmed the deficiency.
The facility failed to accommodate meal preferences for four residents. During lunch, two residents did not receive the requested pasta salad, one did not receive fruit cocktail, and another was served a plain cheeseburger instead of a barbecue cheeseburger. The Nursing Home Administrator confirmed the dietary staff's failure to meet these preferences.
The facility failed to secure resident medical records, as observed on multiple occasions. A copier room in the front lobby was found unlocked and open, containing unsecured resident medical records accessible to non-medical staff. Additionally, an unlocked shed outside the facility contained a box of papers with resident medical records, also unsecured. An interview with the Nursing Home Administrator confirmed the facility's failure to maintain organized and secured resident medical records.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them, despite having a policy in place. During a survey, it was observed that no EBP were in use for residents with conditions such as tube feeding, foley catheters, and open wounds. The Director of Nursing confirmed the lack of EBP implementation, violating both facility policy and CMS/CDC guidance.
The facility failed to maintain essential equipment in a safe condition, with resident items stored in unsanitary conditions. Mattresses, bed bolsters, and air mattresses were placed directly on dirty floors, and wheelchairs had dirty wheels. An interview with the NHA confirmed the facility's failure to ensure safe equipment conditions.
The facility failed to maintain an effective pest control program, as small flies were observed around the juice machine in the food and nutrition services department. The pest control contract did not cover flies, and invoices from June to September did not show treatment for them. The NHA confirmed the lack of evidence for an effective program, noting a recent contract with a new pest management company.
The facility failed to ensure timely responses to resident requests, as reported by several residents who experienced delays exceeding 30 minutes, leading to soiling themselves. Despite raising these concerns in resident council meetings, no resolution was documented. The NHA and DON acknowledged the issue but could not explain the delays.
The facility failed to maintain a clean and safe environment, as observed in the main dining room and a resident's bathroom. Debris, food particles, and sticky floors were noted, along with dirty place settings and a resident breakfast tray left from meal service. A hole in a resident's bathroom wall was covered with plaster, and the floor was dirty with debris. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to develop comprehensive care plans for a resident with depression and two residents who smoke. One resident's care plan did not address his preference for bedtime, leading to frustration and agitation. The other two residents, identified as smokers, had no mention of smoking in their care plans. The Nursing Home Administrator and DON confirmed these deficiencies.
A facility failed to update and implement an individualized discharge plan for a resident with bipolar disorder, despite the resident having intact cognition. The resident's care plan, identifying them as a long-term placement, was not revised since December of the previous year, and there was no evidence of discussions about discharge plans in social service notes. The Nursing Home Administrator confirmed this oversight.
A resident with diabetes and muscle weakness experienced an unwitnessed fall. An LPN assessed the resident, noting no injuries and starting neuro checks, but there was no documented RN assessment as required by professional standards. The Nursing Home Administrator confirmed this deficiency.
A resident with a history of falls and high fall risk did not receive effective interventions to prevent further falls. Despite multiple falls, the facility failed to update the resident's care plan with new interventions for nearly two months. Observations showed the resident's call bell was out of reach, and alarms were not effectively preventing falls. Staff confirmed the facility's responsibility to implement the care plan.
A resident with Parkinson's disease had a nebulizer machine that was not properly maintained, with visible dirt and dried substances on the equipment. Despite multiple observations, the equipment remained unclean, and the facility's Director of Nursing confirmed the failure to maintain the nebulizer equipment according to policy.
A facility failed to consistently attempt non-pharmacological interventions before administering narcotic pain medication to a resident with neuropathy and hypertension. The resident's MARs for July, September, and October 2024 showed multiple instances where oxycodone was given without prior non-pharmacological attempts. Interviews confirmed the lack of evidence for such attempts before administering the medication.
A facility failed to ensure accurate accounting of controlled drugs for a resident discharged home. The facility's policy requires drug disposition records to be forwarded to medical records and a complete list of medications provided upon discharge. However, there was no record of the disposition of the resident's Alprazolam 0.5 mg. The NHA had no further information and expected compliance with the policy.
A resident received Ativan without proper documentation of behaviors or attempts at non-pharmacological interventions. The facility failed to monitor behaviors and potential adverse consequences of psychoactive drug use, as confirmed by the DON.
The facility failed to follow procedures for storing multi-dose medications, as observed when a registered nurse was present. Open vials of Lidocaine Hydrochloride Injection USP and Tuberculin Purified Protein Derivative were found undated and uninitialed, contrary to the facility's policy. Interviews with the Nursing Home Administrator and DON confirmed the non-compliance with storage and use by date requirements.
The facility failed to implement non-pharmacological interventions before administering psychotropic anti-anxiety medication to a resident. Despite having a plan of correction, the facility did not document attempts of non-pharmacological interventions for a resident who received multiple doses of Alprazolam, as confirmed by the DON.
Failure to Identify Authorized Decision Makers and Document Advance Directives
Penalty
Summary
The facility failed to ensure that residents who lacked the ability to make medical decisions had an identified authorized representative and failed to ensure documentation of advance directives or evidence that residents were offered information about the right to formulate an advance directive. This involved three residents whose records showed severe cognitive impairment, yet medical decisions were still documented as being made or signed by the residents themselves, and POLST forms were completed without clear evidence of a legally authorized decision maker. Resident 13 was admitted with rheumatoid arthritis and bipolar disorder and had an admission MDS showing severe cognitive impairment with a BIMS score of 3, which remained unchanged on the most recent quarterly MDS. The record showed consents for psychotropic medications, nutritional supplements, and a vaccination refusal signed by the resident despite documentation that the resident lacked the ability to independently make medical decisions. The resident also had a POLST completed that documented do not attempt resuscitation, comfort measures, antibiotics if life prolonging, and a trial period of artificial hydration and nutrition by feeding tube, but the POLST was documented as reviewed with the resident despite severe cognitive impairment and there was no advance directive or documentation that the resident was offered information about formulating one. Resident 27 was admitted with malnutrition and schizophrenia and had a quarterly MDS showing severe cognitive impairment with a BIMS score of 7. The record contained no documentation identifying a legally authorized representative for medical decision making, yet ongoing treatment decisions included psychotropic medications and a POLST signed by the resident despite the cognitive impairment. The POLST indicated attempted resuscitation, full treatment, antibiotics, and refusal of artificial tube feeding, but it lacked a physician signature and included signatures from the resident and the Social Services Director. Resident 51 had diagnoses including intellectual disabilities and depression, a quarterly MDS with a BIMS score of 4, and ongoing medical decision-making documentation such as vaccination consents and psychotropic medication authorizations completed by the resident despite inability to make medical decisions independently. A POLST uploaded to the record was signed by the resident but not signed or dated by the physician, and it lacked documentation identifying who the treatment decisions were reviewed with.
Resident Council Concerns Not Addressed or Communicated
Penalty
Summary
The facility failed to make reasonable efforts to address concerns raised by the Resident Council and failed to keep residents informed regarding the status and outcome of identified concerns. A grievance submitted by a resident regarding extended call bell response times was reviewed by the facility, staff were interviewed, the concern was documented as resolved, and staff received re-education with call bell response audits initiated. However, during a resident group meeting with eight cognitively intact residents, all residents reported continued concerns that call bell response times remained inconsistent. Residents stated that call bell response times had been discussed during Resident Council meetings in January, February, and March 2026, but the meeting minutes did not document those concerns. The facility could not provide documented evidence that residents were re-interviewed after corrective actions were implemented to determine whether they perceived improvement, and it could not provide documented evidence that the Resident Council was informed about actions taken or the outcomes of the concerns raised. During interview, the Nursing Home Administrator was unable to provide documented evidence showing resident satisfaction with the facility's response to grievances or Resident Council concerns.
Housekeeping Failed to Maintain Clean Resident Environment and Equipment
Penalty
Summary
The facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment, including resident care equipment, for two residents. In one resident’s room, dried tube feeding residue was observed in multiple locations, including on the base of the tube feeding pole, on the fall mat positioned on the floor to the right side of the bed, and on the privacy curtain to the right side of the bed. The resident was receiving tube feeding, and the observations showed dried nutritional formula present in the room during two separate observations. In another resident’s room, a Broda chair was observed unoccupied and not maintained in a clean condition. The chair contained multiple pieces of debris on the seat and footrest, the cushion had stains from an unknown substance, multiple strands of hair were adhered to the Dycem on the chair surface, and crumbs were observed throughout the seating area. The NHA and DON reviewed these findings and acknowledged that housekeeping services had not ensured a clean and sanitary environment and resident care equipment, consistent with a safe, comfortable, and homelike environment.
Failure to Recognize Wheelchair Buckle Belt as a Restraint
Penalty
Summary
The facility failed to identify a wheelchair buckle belt as a physical restraint and failed to follow its restraint policy for one resident with cerebral palsy who was cognitively intact with a BIMS score of 15. The resident’s care plan included a wheelchair with a buckle belt for positioning and directed staff to release the belt every two hours, and physician orders had included the buckle belt since 2013, with the order later revised to a wheelchair with a pressure-relieving cushion and buckle belt for positioning. However, the clinical record did not show that the interdisciplinary team evaluated whether the device met the definition of a restraint, whether it was clinically necessary to treat a medical symptom, or whether it was the least restrictive intervention. An observation found the resident seated in a wheelchair at the nurses’ station with a belt secured across the waist using a buckle attached to the wheelchair. The resident was unable to verbalize the purpose of the belt and did not demonstrate movement of the upper extremities during the observation. The record also lacked documentation of periodic reassessment of the continued need for the device, attempts to reduce its use, evaluation of alternative positioning interventions, informed consent, or evidence of ongoing monitoring, release of the device, range of motion, or use for the least amount of time necessary. During interviews, the ADON, NHA, and DON stated the buckle belt was used to reduce fall risk and maintain safety while seated, and they acknowledged the resident could not remove it independently and that it restricted movement. The facility stated it had not identified the wheelchair buckle belt as a restraint and could not provide documentation showing the restraint policy was implemented, including interdisciplinary assessment, identification of a medical symptom, consent, care plan interventions to reduce or eliminate restraint use, or ongoing monitoring while the buckle belt was in use.
Failure to Verify Prior Employment for New Hires
Penalty
Summary
The facility failed to fully screen three of five newly hired employees to determine their eligibility for employment in a nursing care facility. A review of the Resident Abuse policy, last reviewed by the facility on September 25, 2025, showed that the facility required screening of potential employees, including obtaining references from previous and current employers to determine appropriateness for working with individuals with specific conditions and needs. Review of personnel files showed that Employee 1, an LPN hired on February 26, 2026; Employee 2, an RN hired on February 20, 2026; and Employee 3, an LPN hired on March 9, 2026, all listed previous employers on their applications, but there was no documentation that the facility contacted any former employer for screening. During an interview on April 2, 2026, at 1:15 PM, the NHA was unable to provide evidence that previous employers were contacted regarding the employees' past work history. The facility did not follow its abuse prohibition policy by not verifying previous employment for three of five new hires.
Inaccurate MDS Assessments for Restraint Use and Fall History
Penalty
Summary
The facility failed to complete accurate MDS assessments for three residents. The RAI Manual requires the assessment to accurately reflect the resident’s status and to include direct observation and communication with the resident and direct care staff on all shifts. For Resident 10, who was admitted with cerebral palsy, the annual MDS dated March 1, 2026, coded that the resident did not use a restraint when in a chair. However, an observation on April 1, 2026, found the resident seated in a wheelchair at the nurses’ station with a belt attached to the wheelchair and secured in front of the waist with a buckle. The resident could not verbalize the purpose of the belt or demonstrate movement in the upper extremities, and the DON and NHA confirmed the resident could not release the belt and that it was intended for safety and limited movement. For Resident 11, admitted with COPD, the quarterly MDS documented no falls since admission or the prior assessment, but the clinical record showed falls on November 16, 2025, January 4, 2026, and January 14, 2026. For Resident 23, admitted with dementia, the quarterly MDS also documented no falls since admission or the prior assessment, but the clinical record showed a fall on November 24, 2026. The MDS coding for these three residents was reviewed with the MDS Coordinator, who acknowledged the assessments did not accurately reflect the residents’ health conditions, and the information was then communicated to the NHA and DON.
Care Plan Not Consistently Implemented or Clearly Written
Penalty
Summary
The facility failed to ensure the comprehensive person-centered care plan was implemented consistently and accurately reflected resident-centered measures for two residents. One resident, admitted in 2011 with cerebral palsy, had an annual MDS dated March 1, 2026 showing intact cognition with a BIMS score of 15. The resident’s comprehensive care plan, initiated in 2011, identified a need for assistance with ADLs, including transfers. The plan listed two staff for transfers beginning May 19, 2021, and also stated that as of November 8, 2024, the resident required a Hoyer lift for all transfers. The care plan contained both transfer methods without clear direction about which intervention was to be used. A second resident, admitted with COPD and assessed on a quarterly MDS as cognitively intact with a BIMS score of 11, was identified in the care plan as at risk for falls related to weakness and arthritis. The fall prevention interventions included Dycem above and below the wheelchair cushion to reduce movement and improve positioning safety. During an observation, the wheelchair contained a blue piece of Dycem on top of the cushion, but Dycem was not present below the cushion as written in the care plan. The NHA and DON were interviewed regarding the facility’s failure to ensure the care plan accurately reflected resident needs and was implemented consistently for transfers and fall prevention interventions.
LPN IV Therapy Competency Not Verified
Penalty
Summary
The facility failed to ensure nursing services met professional standards of quality by not verifying that two LPNs had the required education, training, and demonstrated competency to administer an IV medication through a PICC line. Pennsylvania nursing standards cited in the report state that an LPN may perform IV therapy functions only after completing the required education and training and only when the LPN has the knowledge, skill, and ability to perform the procedure safely under appropriate supervision. Resident 5 was admitted with diagnoses including a surgical site infection and had a PICC line in place. The physician ordered Meropenem 1 gram IV every eight hours via the PICC line for treatment of the infection. The eMAR showed that Employee 5, an LPN, documented administration of Meropenem via PICC line on March 21, 2026, and Employee 6, an LPN, documented the same medication administration on March 29, 2026. The facility was unable to produce evidence that either LPN completed IV therapy education and training, competency validation, supervision documentation, or other training specific to administering IV medications through a PICC line. During interview, the DON and NHA confirmed the facility could not provide documentation showing the required IV therapy education or competency validation for these employees.
Medication Administered and Held Without Following BP Parameters
Penalty
Summary
Nursing services were not provided in accordance with physician orders for Resident 20, who was admitted with hyperkalemia and was moderately cognitively impaired with a BIMS score of 8. The resident had an order for Midodrine HCl 5 mg by mouth three times daily for orthostatic hypotension, with instructions to hold the medication only if both the systolic blood pressure was greater than 145 mm/Hg and the diastolic blood pressure was greater than 95 mm/Hg. The facility policy stated that medications are to be administered as prescribed and that required vital signs are to be verified before giving medications when parameters are ordered. The MAR showed Midodrine was administered 11 times without documentation of a blood pressure reading before administration, so nursing staff did not have the required clinical information to determine whether the medication met the ordered parameters. The February 2026 MAR also showed the medication was held four times when the documented blood pressures were 148/90, 152/62, 158/76, and 161/84 mm/Hg, even though the physician’s order required both systolic and diastolic values to exceed the hold parameters. The DON acknowledged that the medication was administered without obtaining required blood pressure readings and was withheld when the ordered criteria to hold it were not met.
Pain medication given outside ordered parameters and without required nonpharmacological interventions
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who had orders for Tramadol 50 mg for pain. The resident was admitted with diagnoses including heart failure and muscle weakness. A physician order dated January 9, 2026, directed Tramadol 50 mg by mouth every 12 hours as needed for severe pain rated 8-10. Review of the January 2026 MAR showed Tramadol was administered 16 times, including 3 doses given outside the ordered pain parameters: one dose for pain rated 3 and two doses for pain rated 0. Review of the February 2026 MAR showed Tramadol was administered 13 times, including 1 dose given for pain rated 3. The physician order was then revised on February 25, 2026, to Tramadol 50 mg every 6 hours as needed for moderate shoulder pain, with nonpharmacological interventions attempted prior to administration. Review of the clinical record showed two Tramadol administrations after the revised order without documentation that nonpharmacological interventions were attempted first. Review of the March 2026 MAR showed Tramadol was administered 88 times, including 16 doses given outside ordered parameters, with doses documented for pain ratings of 8, 3, and 0. During an interview on April 3, 2026, the DON reviewed the findings and stated the facility failed to ensure staff administered the opioid pain medication according to physician orders, including adherence to ordered pain scale parameters and implementation of ordered nonpharmacological interventions prior to administration.
Physician Did Not Document Response to Pharmacist Medication Review
Penalty
Summary
The facility failed to ensure the attending physician acted upon and documented a clinical rationale for a consultant pharmacist-identified medication regimen irregularity for one resident. Resident 4 was admitted with a diagnosis that included bipolar disorder. In the November 2025 consultant pharmacist Medication Regimen Review, the pharmacist identified the resident’s order for Mirtazapine 15 mg and recommended consideration of a gradual dose reduction. The clinical record showed documentation from the facility’s contracted psychiatric services Nurse Practitioner stating the resident had previously failed a gradual dose reduction of Seroquel and was stable on the current medication regimen. However, the record did not contain documentation that the attending physician reviewed the pharmacist’s recommendation regarding Mirtazapine or documented a clinical rationale for not attempting a gradual dose reduction or for why it was clinically contraindicated. During an interview on April 3, 2026, the ADON stated the facility had an ongoing issue obtaining documentation from the attending physician in response to consultant pharmacist recommendations.
Unnecessary Antibiotic Use Without Supporting Clinical Criteria
Penalty
Summary
The facility failed to ensure Resident 8’s drug regimen was free from unnecessary antibiotics when Ceftriaxone was initiated for a urinary tract infection without sufficient clinical evidence of an active infection. Resident 8 was admitted with diagnoses including dementia and muscle weakness. The facility policy on Antibiotic Stewardship stated antibiotics are to be prescribed only when there is sufficient clinical evidence of an active infection and that orders should include the medication name, dose, duration, and clinical indication. The facility also used a McGeer's Criteria Checklist to determine whether antibiotics should be started. A physician order dated January 20, 2026, directed Ceftriaxone 1 gram IM at bedtime for three days for a UTI. However, the McGeer's Criteria Checklist dated January 17, 2026 documented that Resident 8 did not have symptoms consistent with a UTI, including no fever, leukocytosis, acute mental status change, or acute functional decline, even though the checklist indicated the UTI criteria had been met. A urinalysis with culture report dated January 21, 2026 showed E. coli, and the organism was resistant to Ceftriaxone. The clinical record did not contain documentation of clinical signs or symptoms consistent with infection before the antibiotic was started. During an interview on April 3, 2026, the DON reviewed these findings.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Effective Pest Control Program in Food Service Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy and regulatory standards. Despite having a policy that mandates ongoing pest control and contracted services, observations in the kitchen revealed the presence of both dead and live cockroaches, particularly in the food preparation and dishwasher areas. Staff interviews confirmed sightings of cockroaches and water bugs, and the food service director acknowledged that the administrator had been informed of the issue about a month prior. Although the facility requested an increase in pest control service frequency from monthly to every two weeks, records showed that the pest control company did not provide service as scheduled during one of the biweekly intervals. Additionally, pest control reports documented heavy treatment for roaches, but the interval between services did not align with the requested schedule. Further investigation revealed that the facility lacked documentation of ongoing monitoring for cockroach activity, as required by policy. The maintenance director was unable to provide evidence of monitoring or identification of potential entry points and hiding places for pests. A licensed pest control inspector's inspection confirmed active cockroach infestations around kitchen walls, behind appliances, and under the dishwasher, and identified structural vulnerabilities such as gaps around pipes and the need for door sweeps. The nursing home administrator confirmed the facility's failure to maintain an effective pest control program and acknowledged the responsibility to keep the facility free of pests.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all individuals in their care.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's dietary department during an initial tour. Dirty breakfast meal carts with soiled resident trays were stored near food preparation areas, clean utensils, and cooking equipment. Ceiling tiles and light fixtures above the dishwashing machine were found with brown discoloration, splattered residue, and visible dirt and debris inside the light covers throughout the kitchen. The juice station's thickened juice dispenser contained a gelatinous substance inside the nozzle and was sticky to the touch, with staff reporting that cleaning was performed only weekly. Further inspection of the dry storage area revealed wire racks stored directly on the floor, debris under shelving, and an accumulation of dirt and debris behind the door. These findings were reviewed with the Nursing Home Administrator, who acknowledged the requirement for the dietary department to be maintained in a clean and sanitary condition. The facility's policies and federal guidelines require all food storage, preparation, and service areas to be kept clean and sanitary, but these standards were not met as evidenced by the observed conditions.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen therapy was administered according to physician orders for three residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, the physician ordered continuous supplemental oxygen at 4 liters per minute (LPM) via nasal cannula. However, observation revealed the oxygen concentrator was set at 0 LPM while the resident was awake and upright, and the Director of Nursing confirmed the resident should have been receiving oxygen as ordered. Another resident with chronic obstructive pulmonary disease (COPD) had a physician's order for continuous oxygen at 3 LPM, but was observed with the flowmeter set at 2.5 LPM; this was confirmed by an LPN. A third resident, also with COPD, was prescribed continuous oxygen at 3 LPM but was observed with the concentrator set at 2 LPM, and the resident reported not feeling oxygen from the cannula, though not in distress. The DON confirmed the setting was incorrect. These findings were based on clinical record reviews, facility policy review, direct observations, and staff and resident interviews. The facility's policy requires licensed nurses to initiate and monitor oxygen therapy per physician orders, but in these cases, the prescribed flow rates were not maintained, resulting in deviations from the required oxygen administration for all three residents.
Failure to Properly Label and Discard Multi-Dose Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to comply with its own policy and accepted professional standards regarding the labeling and storage of multi-dose medications. During an inspection of a medication cart on the Lilac Hall unit, one multi-dose insulin pen of Insulin Degludec and one multi-dose pen of Insulin Glargine were found to be opened and in use without being labeled with the date they were first accessed. Additionally, a multi-dose insulin pen of Insulin Aspart was found with a date indicating it had been opened on July 1, 2025, but was still available for use past its manufacturer-recommended discard date of July 28, 2025. Interviews with an LPN and the DON confirmed that these insulin pens were opened, available for resident use, and not properly dated or discarded according to facility policy and manufacturer guidelines. The facility's policy requires that all multi-use medication vials or bottles be labeled with the date they are opened to ensure proper tracking for expiration, which was not followed in these instances.
Failure to Remove Accused Staff and Report Abuse Allegations
Penalty
Summary
Facility administration failed to use its resources effectively and efficiently to ensure resident safety and maintain the highest practicable physical and mental functioning of residents. Specifically, after an allegation of physical abuse by a nurse aide against a resident, the facility did not immediately remove the accused employee from resident contact while the allegation was unresolved. This allowed the employee continued access to residents, placing them at risk. The failure to implement immediate protective measures resulted in Immediate Jeopardy cited at F600. Further review revealed that the facility did not fulfill mandatory reporting obligations for additional abuse allegations involving two other residents and two nurse aides. The facility failed to report these allegations to the State Survey Agency and other required officials, and did not conduct investigations into these incidents. The lack of timely reporting and investigation prevented the facility from determining whether abuse had occurred, identifying and removing potential perpetrators, and implementing protective measures to prevent further harm.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Address and Document Significant Unplanned Weight Loss
Penalty
Summary
A resident with Parkinson's Disease experienced a significant unplanned weight loss, dropping from 133.5 lbs to 111 lbs over a 37-day period, representing a 16.9% decrease. Meal intake records showed variable consumption, and although a dietary note confirmed the weight loss and recommended providing nutritious dessert cups twice daily, there was no documentation that these were offered or consumed. The clinical record also lacked evidence that the resident's physician and representative were notified of the significant weight loss, as required by professional standards and regulatory guidance. Further review revealed that after the significant weight loss was identified, the facility did not obtain weekly weights or conduct a nutritional assessment between the time of the weight loss and a later date. Interviews with facility staff, including the Registered Dietician and the DON, confirmed that the weight loss was not addressed in a timely manner, and the facility could not provide a written policy for monitoring and managing residents' nutritional status. No documentation was available to show that any interventions were implemented to address the resident's weight loss.
Failure to Consistently Document Controlled Substance Counts at Shift Change
Penalty
Summary
Nursing staff failed to consistently follow established procedures for verifying and documenting the count of controlled substances at shift change on two medication carts. Facility policy requires that both the oncoming and outgoing nurses count controlled medications together at the end of each shift, document the count, and report any discrepancies to the director of nursing services. However, a review of narcotic count records revealed multiple instances where the oncoming nurse did not sign off to confirm the count was completed and correct on both the green and lilac nursing unit medication carts. Specifically, on several dates, the required signatures were missing from the narcotic count sheets for both day and night shifts. Staff interviews confirmed that it is the expectation for nursing staff to review and sign off on narcotic count sheets at each shift change. The nursing home administrator acknowledged that the facility did not consistently implement procedures to ensure accurate controlled drug records, as required by facility policy and state regulations.
Failure to Provide Advance Written Notice of Rate Increase
Penalty
Summary
The facility failed to provide advance written notice of a private pay rate increase to a resident who was cognitively intact and responsible for his own financial matters. The resident, who had a history of frequent falls and pneumonia, was admitted with his daughter listed as the emergency and HIPAA contact. According to the facility's admission agreement, a minimum of 60 days' written notice is required before any financial rate increase is implemented. However, billing records showed that the resident's monthly charge increased from $1,200 to $1,567.18 without documented evidence of advance written notification to the resident or his representative. The deficiency was further substantiated when the resident's daughter contacted the Business Office Manager to inquire about the increased charges, and it was confirmed during a staff interview that no written notification had been provided prior to the rate increase. This failure was identified through a review of billing records, clinical documentation, facility policies, and staff interviews, and it was cited as a violation of resident rights under 28 Pa Code 201.29(c)(1).
Failure to Implement Smoking Policy and Ensure Resident Safety
Penalty
Summary
The facility failed to implement its established smoking policy to ensure resident safety and regulatory compliance. Observations revealed that the smoking policy was not posted in a conspicuous and legible manner in the designated smoking area or elsewhere in the facility, as required by the facility's own policy. Additionally, the designated smoking patio lacked necessary fire safety equipment, such as a fire extinguisher or fire blanket, and there was no signage indicating it was a designated smoking area. The only available fire extinguisher was kept inside a locked cabinet within the facility, not accessible in the smoking area where residents regularly smoked. Further review showed that the facility did not conduct required assessments for safe smoking practices for all residents who smoke. Specifically, one cognitively intact resident with a diagnosis of Wernicke's encephalopathy and nicotine dependence was not assessed for safe smoking, despite documented incidents where the resident attempted to light a cigarette using a lighter taken from a staff member and became agitated and verbally aggressive when denied access to the smoking patio. Documentation indicated that the resident was told he could not participate in smoking until assessed by nursing, but this assessment was not completed. Interviews with the DON and NHA confirmed that the facility did not follow its own smoking policy regarding resident assessment, posting of the policy, and provision of fire safety equipment in the designated smoking area. These failures were observed during the survey and corroborated by staff interviews and clinical record reviews.
Failure to Honor Resident's Discharge Preferences and Goals
Penalty
Summary
The facility failed to ensure that the discharge process for a resident with diagnoses including Wernicke's Encephalopathy, alcohol-induced psychotic disorder, alcoholic cirrhosis, and nicotine dependence honored the resident's preferences and goals. The resident, who was cognitively intact, expressed a clear desire to be transferred to a local skilled nursing facility that permitted smoking. Documentation showed that the social worker communicated this preference to the resident's guardian, who authorized the release of records to two local facilities. However, the resident was ultimately transferred to a facility several hours away, contrary to his stated wishes. There was no documentation provided to justify why a local placement was not pursued or why the facility could no longer meet the resident's needs. The social worker was unable to explain the decision to transfer the resident to a distant facility and there was no evidence that the resident was meaningfully involved in the discharge decision-making process. Additionally, the facility could not produce documentation confirming the resident's guardianship status during the survey.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for three residents, resulting in multiple incidents of harm. One resident with severe cognitive impairment, a history of falls, and physical limitations experienced several falls, including one where the resident was left unsupervised while agitated and attempting to climb out of bed. During this incident, the resident fell and struck her head on a nightstand that had been improperly returned to the head of the bed, resulting in a laceration and a subdural hematoma. The same resident later fell from a Broda chair during transport by an untrained staff member who did not adjust the chair to the safe position, resulting in additional lacerations and a hematoma. Another resident with dementia and Parkinson's disease, also severely cognitively impaired, experienced repeated falls and injuries, including abrasions, skin tears, and a laceration requiring staples. The care plan for this resident did not specify the level of assistance required for bed mobility or toileting, and staff were not provided with clear guidance. Despite multiple incidents, the care plan was not updated to address the resident's behavioral triggers or need for increased assistance, and interventions were not individualized or revised to prevent recurrence. A third resident, who was cognitively intact but at risk for wandering, was able to exit the facility unsupervised when the front lobby was left unattended. The resident was found outside the building in the parking lot by a passerby and was returned to the facility without injury. The lapse in supervision occurred because the designated staff member assigned to monitor the lobby was away from the desk, leaving the area unmonitored and allowing the resident to leave the building.
Failure to Provide Timely Written Notice of Room Rate Increase
Penalty
Summary
The facility failed to provide advance written notice of a daily room rate increase to a resident and/or his representative prior to the effective date of the increase. The resident, who was admitted with diagnoses including diabetes and was cognitively intact, was his own responsible party, with his sister listed as an emergency and HIPAA contact. Billing records showed that the daily room rate increased from $350.00 to $550.00, but there was no documented evidence that the resident or his representative received written notification of this change before it took effect. The deficiency was confirmed through review of billing statements, facility documentation, and staff interviews. The resident's sister contacted the Nursing Home Administrator (NHA) via email, stating that neither she nor her brother had seen the notification letter regarding the rate increase until it was provided to her on a later date. The NHA confirmed during an interview that the notice of the rate increase was not sent in a timely manner to the resident or his representative.
Unsanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness for all 78 residents. During a kitchen tour, several unsanitary conditions were observed, including a sticky floor with food, dirt, and debris, and juice machine guns with a buildup of juice. The counter had dried sticky juice, and multiple fruit flies were noted near the juice machine. Opened juice was not dated, and the dry storage room was improperly propped open. On the prep counter, there were uncovered and undated food items, including biscuits, shredded cheese, and light cream that felt warm to the touch. Dried food particles were found on the steam table and plate warmer, and the plate warmer covers were broken. Additional issues included an ice machine not draining properly, resulting in a puddle of water underneath. Expired and undated food items were found, such as cereal, breadcrumbs, marinated vegetables, cut potatoes, tuna fish, mushrooms, lemons, rice, hotdogs, apple sauce, cake, and peanut butter and jelly sandwiches. The janitor's closet was cluttered with boxes, preventing proper storage of cleaning equipment, and dirty garbage cans with sticky lids were noted. These observations were confirmed by the Nursing Home Administrator, indicating a failure to store, prepare, and serve food under sanitary conditions.
Failure to Apply Therapeutic Devices for Resident with Contractures
Penalty
Summary
The facility failed to ensure that therapeutic devices were applied to a resident to maintain proper positioning and support. Resident 48, who was admitted with contractures in both ankles and elbows, was prescribed restorative nursing care that included the use of ankle plantar flexion contracture boots and elbow splints. These devices were to be applied in the morning and removed at night. However, documentation revealed that the contracture boots were not applied or removed as prescribed 29 times in August and 31 times in September. Similarly, the elbow splints were not applied or removed as prescribed 31 times in August and 30 times in September. Observations conducted on October 1, 2, and 3, 2024, confirmed that the resident's contracture boots and elbow splints were not in place. An interview with a nursing assistant on October 2, 2024, revealed that the boots were found in the resident's closet, but the elbow splints were missing. The nursing assistant was unfamiliar with the resident as she did not usually work in that area. The Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to apply the therapeutic devices as required.
Deficiencies in Bowel, Bladder, and Catheter Care
Penalty
Summary
The facility failed to thoroughly assess and evaluate bowel and bladder function and implement individualized approaches for four residents. Resident 20, who was initially continent of bowel, became frequently incontinent, but the facility did not assess this change or develop a specific toileting plan. Resident 48, always incontinent of bowel and bladder, had not been assessed since February 2024, and the facility did not document maintenance care frequency or initiate a two-hour check and change program. Resident 3, always incontinent, had a care plan that failed to identify urinary incontinence and lacked documentation of care plan implementation. Resident 22, with acute cystitis and urine retention, reported that their catheter bag was not emptied regularly, sometimes containing up to 1500 ml of urine. This was confirmed by staff observations. The facility's failure to maintain routine catheter care was acknowledged by the Nursing Home Administrator. These deficiencies indicate a lack of proper assessment and care planning for residents' bowel and bladder needs, as well as inadequate catheter care for Resident 22.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly drug regimen reviews for two residents, as required by their policies and procedures. Resident 42, who was admitted with a diagnosis of dementia, did not have evidence of monthly drug regimen reviews from December 2023 to March 2024. Similarly, Resident 54, diagnosed with Pick's Disease and Alzheimer's disease, also lacked evidence of monthly reviews during the same period. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation for the required monthly medication regimen reviews for both residents.
Failure to Follow Planned Menus for Pureed Diets
Penalty
Summary
The facility failed to adhere to the planned menus for residents requiring a pureed diet on October 1, 2024. The planned menu for the lunch meal included a pureed barbecue cheeseburger, pureed mixed vegetable salad, mashed potatoes, and a pureed sugar cookie. However, during the lunch meal service, it was observed that there were no pickles, pureed marinated mixed vegetables, or pureed sugar cookies available on the tray line as indicated on the menu. Additionally, the meals for four residents were missing the pureed hamburger bun, mixed vegetables, and sugar cookie. An interview with the District Kitchen Manager confirmed that all planned items should have been prepped on the tray line prior to the meal service, indicating a failure to follow the planned menus. This deficiency was identified under 28 Pa. Code 211.6 (a)(f) Dietary Services.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve foods at safe and palatable temperatures for one out of five residents, as observed during a survey. According to the federal regulation 483.60(i)-(2), food temperatures should not be in the danger zone, which is above 41 degrees Fahrenheit and below 135 degrees Fahrenheit, to prevent the rapid growth of pathogenic microorganisms. The scheduled lunch time for dining room cart one was 12:20 PM and for dining room cart two was 12:25 PM. However, dining room cart one left the kitchen at 12:35 PM and dining room cart two at 12:48 PM. By approximately 1:15 PM, staff were observed pushing a cart of meal trays out of the dining room to the nursing unit, indicating that the trays had been sitting for about 40 minutes before being delivered to residents who did not go to the dining room. A test tray conducted with the District Kitchen Manager revealed that the food temperatures were not within the safe range. The cheeseburger was at 90 degrees Fahrenheit, the French fries at 82 degrees Fahrenheit, and the coleslaw at 65 degrees Fahrenheit, all of which were below the minimum safe temperature of 135 degrees Fahrenheit. The coffee was at 125 degrees Fahrenheit. The cheeseburger bun appeared soggy, the fries were soggy and limp, and the coleslaw appeared watery. The District Kitchen Manager confirmed that the facility failed to ensure palatable temperatures for the residents' meals, which is a violation of 28 Pa. Code 211.6(a)(f) Dietary services.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated residents' preferences for four out of nine residents reviewed. During an observation of the lunch meal tray line, it was noted that Resident 8 and Resident 60 did not receive the pasta salad they requested, as it was not available. Similarly, Resident 58 did not receive the fruit cocktail they requested, and Resident 49 was served a plain cheeseburger instead of the requested barbecue cheeseburger. An interview with the Nursing Home Administrator confirmed that the dietary staff did not accommodate these residents' meal preferences, which is a violation of dietary services and resident rights regulations.
Failure to Secure Resident Medical Records
Penalty
Summary
The facility failed to ensure the security and organization of resident medical records, as observed on multiple occasions. On October 1, 2024, at both 10:00 AM and 2:00 PM, a copier room in the front lobby was found unlocked and open, containing multiple resident medical records that were not secured, allowing potential access by non-medical staff. Similar observations were made on October 2, 2024, at 11:00 AM, with the copier room again found unlocked and open with unsecured resident medical records. Additionally, on October 3, 2024, at approximately 9:15 AM, an unlocked shed outside the facility was observed to contain a box of papers with resident medical records on the floor, also unsecured and accessible to non-medical staff. An interview with the Nursing Home Administrator on October 4, 2024, confirmed the facility's failure to maintain systematically organized, readily accessible, and secured resident medical records.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents requiring such measures. The facility's policy, reviewed in March 2024, mandates that personal protective equipment (PPE) should be stored near residents' rooms and accessible to staff, with EBP employed during high-contact resident care activities. However, during an environmental tour on October 1, 2024, it was observed that there was no evidence of EBP for any of the five residents who required them, despite their medical conditions necessitating such precautions. The residents involved included those with conditions such as tube feeding, foley catheters, and open wounds, which require EBP to prevent the spread of infections. The Director of Nursing confirmed that no EBP were implemented for these residents at the time of the survey. This lack of implementation was in violation of the facility's own policies and the guidance issued by the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) regarding the use of EBP in nursing homes.
Unsanitary Storage Conditions for Resident Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe operating condition within its storage area. During a tour of the storage area, two sheds were found to contain resident equipment in unsanitary conditions. Dirt and debris were present on the floor, and mattresses were placed directly on the shed floor, accumulating dirt and dust. Pails for bedside commodes were also on the floor, with one containing a dried white and brown substance. Bed bolsters were uncovered and lying on the floor, and boxes of air mattresses were placed directly on the dirty floor. Additionally, wheelchairs were observed with dirty wheels and dust. An interview with the Nursing Home Administrator confirmed the facility's failure to ensure the safe operating condition of essential equipment, as the administrator could not provide an explanation for the poor storage conditions of the residents' items.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by their policy. During an observation of the food and nutrition services department, small flies resembling fruit flies were seen around the juice machine. The facility's pest control contract, initiated in June 2024, covered treatment for roaches, ants, mice, rats, and common spiders, but did not include services for flies. Despite monthly treatments by the pest control company, invoices from June to September 2024 did not indicate any identification or treatment for flies in the kitchen. The Nursing Home Administrator confirmed the lack of evidence for an effective pest control program, noting that the facility had recently signed a contract with a new pest management company and could not provide information on pest management prior to June 2024.
Failure to Respond Timely to Resident Requests
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life and ensures they are treated with dignity. This deficiency was identified through resident and staff interviews, where it was reported that staff did not respond timely to residents' requests for assistance. During a group interview with alert and oriented residents, five residents expressed concerns about long wait times for staff assistance, often exceeding 30 minutes. This delay resulted in residents soiling themselves and having to remain in soiled briefs while waiting for staff. Despite raising these concerns multiple times during resident council meetings, no resolution was documented in the meeting minutes or grievances over the past three months. The Nursing Home Administrator and Director of Nursing acknowledged that residents should be treated with dignity and respect but could not explain the untimely staff responses.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unclean and unsafe environment for residents. On October 1, 2024, observations in the main dining room revealed debris, food particles, and sticky floors, with dirty place settings and a resident breakfast tray left from the morning meal service. Additionally, a resident's bathroom in a specific room had a hole in the wall covered with plaster, and the floor was dirty with debris near the hole. Further observations on October 3, 2024, showed similar issues in the main dining room, with debris and dried sticky spills on the floor. An interview with the Nursing Home Administrator confirmed the facility's failure to maintain a clean and sanitary environment for residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for three residents, leading to deficiencies in addressing individual needs and preferences. Resident 56, who was admitted with a diagnosis of depression, exhibited increased behaviors when his wife, also a resident, would push him back to his room early in the evening, asking staff to put him to bed. Resident 56's personal preference for bedtimes and the resulting frustration and agitation were not addressed in his care plan, as noted during the survey ending on October 5, 2024. Additionally, the care plans for Residents 58 and 60, both identified as smokers, did not address their smoking habits. Resident 58, admitted with a diagnosis of Bipolar disorder and muscle weakness, had a care plan last updated on May 24, 2024, which failed to include smoking. Similarly, Resident 60, admitted with Chronic Obstructive Pulmonary Disease and End Stage Renal Disease, also had no mention of smoking in their care plan. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to ensure comprehensive care plans were developed.
Failure to Update Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement an individualized discharge plan for a resident, identified as Resident 47, who was part of a sample of 18 residents. The facility's policy on discharge planning, last reviewed in July 2024, mandates that each resident's discharge needs be evaluated and the plan updated based on any changes in the resident's condition or needs. Resident 47, who was admitted with a diagnosis of bipolar disorder, had an intact cognitive status as indicated by a BIMS score of 15 from an assessment conducted in July 2024. Despite this, the resident's comprehensive care plan, which identified them as a long-term placement since December 2023, was not revised or updated by the time of the survey in September 2024. Additionally, there was no documented evidence in the social service notes from September 2023 to October 2024 that the resident's discharge plans and desires were discussed. The Nursing Home Administrator confirmed the facility's failure to revise and implement a discharge plan based on the resident's desires.
Failure to Conduct RN Assessment After Resident Fall
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that a registered nurse (RN) conducted a thorough assessment of a resident following an unwitnessed fall. The incident involved a resident who was admitted with diagnoses including diabetes and muscle weakness. On the morning of September 3, 2024, the resident was found lying on his back on the floor by his bed. An LPN, identified as Employee 5, was called to the scene by the resident's roommate and conducted an initial assessment, noting no apparent injuries and initiating neuro checks and 15-minute checks. However, upon further review of the resident's clinical record, it was found that there was no documented evidence of an RN assessment following the fall, which is a requirement according to professional standards of practice. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that an RN had not completed the necessary assessment. The failure to document and maintain accurate records as required by the Pennsylvania Code was noted as a deficiency in the facility's nursing services.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to provide effective fall interventions for a resident who experienced repeated falls. The resident, who was admitted with diagnoses including schizophrenia, anxiety, and hypertension, had a documented history of falls on multiple occasions. Despite being identified as high risk for falls, the facility did not implement new interventions after a fall on July 29, 2024, until September 21, 2024, during which time the resident experienced seven additional falls. The care plan for the resident included interventions such as keeping the bed in the lowest position, using bilateral floor mats, a bed alarm, and ensuring the call bell was within reach, but these were not effectively implemented. An observation on October 3, 2024, revealed that the resident was attempting to get out of a wheelchair with the chair alarm sounding, and the call bell was not within reach. Interviews with facility staff, including a registered nurse and the Nursing Home Administrator, confirmed that the resident's call bell was not accessible and that the facility was responsible for implementing the care plan to mitigate fall risks. The deficiency was noted under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(c)(d)(5), which pertain to resident care policies and nursing services.
Failure to Maintain Clean Nebulizer Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a manner that promotes optimal functioning for a resident diagnosed with Parkinson's disease. The resident had a physician's order for nebulizer treatment with Ipratropium-Albuterol solution to be administered as needed for shortness of breath or coughing. Observations revealed that the nebulizer machine on the resident's nightstand had a dried brown substance and black spots on it. The tubing and mask were stored in a visibly dirty bag, which was not dated to indicate when the tubing was put into use. The mask inside the bag also had dried spots, indicating a lack of proper cleaning and maintenance. Despite multiple observations over three consecutive days, the nebulizer equipment remained in the same unclean condition. The Director of Nursing confirmed the facility's failure to maintain the resident's nebulizer equipment. This deficiency was identified under the 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services, highlighting the facility's non-compliance with its own policy for nebulizer therapy, which requires cleaning and proper maintenance of the equipment after each use.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to consistently attempt non-pharmacological interventions before administering narcotic pain medication to a resident with neuropathy and hypertension. The resident had a physician's order for oxycodone to be given as needed for moderate to severe pain. A review of the resident's Medication Administration Records (MAR) for July, September, and October 2024 revealed multiple instances where the pain medication was administered without prior attempts at non-pharmacological interventions. Specifically, in September 2024, out of 29 doses of oxycodone administered, 24 were given without trying non-pharmacological methods first. In October 2024, six out of eight doses were administered similarly, and in July 2024, two out of four doses were given without such attempts. An interview with the Nursing Home Administrator and Director of Nursing confirmed the lack of evidence for consistent attempts at non-pharmacological interventions before administering the as-needed pain medication.
Failure to Account for Controlled Drug Disposition
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure accurate accounting of controlled drugs, specifically for one resident. The facility's policy, titled Discharge Medications, requires nursing staff to forward completed drug disposition records to medical records and provide a complete list of the resident's medications upon discharge. However, upon review of the clinical record for a resident who was discharged home, it was found that there was no record of the disposition of the resident's remaining supply of Alprazolam 0.5 mg, an antianxiety medication. This oversight was identified during a review of the resident's closed record, indicating a failure to comply with the facility's policy. During an interview with the Nursing Home Administrator (NHA), it was revealed that there was no additional information available regarding the medication disposition, and the NHA expected that the medication disposition should have been completed according to the facility's policy. This deficiency was noted under the regulation 28 Pa. Code 211.12(d)(1)(3)(5) concerning nursing services.
Inadequate Monitoring and Intervention for Psychoactive Drug Use
Penalty
Summary
The facility failed to adequately monitor behaviors and potential adverse consequences of psychoactive drug use for a resident, identified as Resident 24. The resident was admitted with diagnoses including neuropathy and hypertension. A physician's order dated September 9, 2024, prescribed Ativan 1mg as needed for anxiety, but did not include a stop date for the medication. On multiple occasions, specifically on September 15, September 29, September 30, and October 1, 2024, the resident received doses of Ativan without documentation of the specific behaviors that warranted its administration. Additionally, there were no attempts to use non-pharmacological interventions before administering the medication. An interview with the Director of Nursing on October 4, 2024, confirmed that the nursing staff failed to record adequate monitoring for behaviors and did not consistently attempt non-pharmacological interventions prior to administering the as-needed antianxiety drug. This lack of documentation and intervention attempts led to the deficiency noted in the report.
Failure to Adhere to Multi-Dose Medication Storage Procedures
Penalty
Summary
The facility failed to implement and adhere to procedures for the proper storage and use by dates of multi-dose medications in the medication storage room. During an observation of the medication room, a registered nurse was present when it was discovered that a multi-dose vial of Lidocaine Hydrochloride Injection USP and a vial of Tuberculin Purified Protein Derivative were opened and available for use but were not dated or initialed as required by the facility's policy. The facility's policy, last reviewed on July 8, 2024, mandates that the expiration or beyond use date on the medication label must be checked prior to administering, and when opening a multi-use container, the nurse's initials and the date opened should be recorded on the container. An interview with the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to adhere to acceptable storage and use by dates for multi-dose medications. This deficiency is in violation of 28 Pa. Code 211.9(a)(1)(k) Pharmacy services and 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication
Penalty
Summary
The facility failed to effectively identify and address ongoing deficient practices related to the unnecessary administration of psychotropic anti-anxiety medications. During a survey ending November 26, 2024, it was found that the facility did not implement non-pharmacological interventions prior to administering as-needed psychotropic anti-anxiety medication to residents, as required by their plan of correction. Specifically, Resident 6 was administered Alprazolam 1.5 mg without documented attempts of non-pharmacological interventions, despite the facility's procedures to ensure such interventions were attempted first. The Director of Nursing confirmed that the nursing staff did not provide evidence of non-pharmacological interventions for Resident 6 before administering 15 doses of Alprazolam between November 16, 2024, and November 25, 2024. This oversight indicates that the facility failed to identify Resident 6 as at risk of noncompliance with the administration of psychotropic medications, leading to a recurrence of similar quality deficiencies in the area of unnecessary psychotropic medication use.
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.
Illustrative
What surveyors actually found near you
We read the 284 citations issued within 25 miles in the last 12 months — including the 3 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carbondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carbondale Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Wayne Woodlands Manor | 5.5 mi | ★★★★★ | 26 | 0 |
| Forest City Nursing And Rehab Center | 5.9 mi | ★★★★★ | 0 | 0 |
| Mid-valley Health Care Center | 7.4 mi | ★★★★★ | 19 | 0 |
| Aventura At Terrace View | 8 mi | — | 0 | 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 July 2026) and official state health department websites.