Beaver Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Aliquippa, Pennsylvania.
- Location
- 616 Golf Course Road, Aliquippa, Pennsylvania 15001
- CMS Provider Number
- 395109
- Inspections on file
- 37
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Beaver Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents were unable to access their trust account funds on weekends and holidays due to inconsistent implementation and staff confusion regarding the facility's policy for after-hours fund access. Staff interviews revealed a lack of clarity about the process, and the administrator confirmed that residents were not provided access to their funds as required.
The facility did not serve the approved dinner menu, substituting minestrone soup and carrot raisin salad with other items due to lack of supplies. Staff confirmed that menu changes were made without RD review or approval, resulting in non-compliance with the displayed menu.
Surveyors identified several deficiencies in the Main Kitchen, including failure to monitor food expiration dates, maintain clean food equipment, ensure proper beard restraint for staff, uphold sanitary conditions during tray line, and verify dish machine sanitizing temperatures. These lapses were confirmed by the Dietary Manager and Administrator, with observations of undated or expired food, grime buildup, improper use of dropped plate lids, and lack of temperature checks for dish sanitation.
For a full year, the facility did not conduct or document required floor mapping as part of its infection surveillance program, as confirmed by record review and staff interview.
The facility did not maintain an effective pest control program, resulting in a persistent gnat infestation in the kitchen and dry food storage areas. Staff and pest control documentation confirmed ongoing issues, with observations of gnats throughout the kitchen and contributing factors such as water damage and inaccessible areas for treatment.
The facility did not complete admission agreements in a timely manner for four residents and failed to ensure that three cognitively impaired residents had the capacity to understand the agreements they signed. Some agreements were completed well after admission, and residents with severe or moderate cognitive impairment signed their own agreements without proper assessment of their understanding.
The facility did not complete required annual performance evaluations for three nurse aides, as shown by a review of personnel records and confirmed by the administrator. This failure was not in accordance with the facility's policy, which mandates yearly performance reviews for nurse aides.
The facility did not ensure that three residents with cognitive impairments, including dementia and stroke, had the capacity to understand the terms of binding arbitration agreements before signing. Facility policy requires clear explanation and understanding, but documentation and staff interviews confirmed that these residents lacked the necessary capacity at the time of signing.
The facility did not ensure that crash carts in both the Front and Back hallways were checked and documented daily as required, with one cart missing an entire month's checklist and the other lacking documentation for 14 days. This was confirmed by an LPN, an RN, and the DON, indicating a failure to maintain essential emergency equipment in safe operating condition.
The facility did not provide mandatory QAPI training to three nurse aides and an LPN, as required by its own policies for orientation and annual education. This lapse was confirmed by the DON and identified through document review and staff interviews.
Four staff members, including three nurse aides and an LPN, did not receive required annual compliance and ethics training as mandated by facility policy. This lapse was confirmed by the DON and identified through review of training records and staff interviews.
Staff took and shared unauthorized photos and videos of two residents, both with significant medical conditions, without their knowledge or consent. The images were transmitted between staff and then to another resident, constituting mental abuse facilitated by technology. Facility leadership confirmed the failure to protect residents from this form of abuse.
Two residents received PRN orders for Hydroxyzine, a psychotropic medication, for anxiety without the required 14-day stop dates or physician-documented rationale for extending use beyond 14 days, contrary to facility policy and regulatory requirements. The DON confirmed the lack of compliance with psychotropic medication management protocols.
A nurse aide was permitted to begin working before a criminal background check was completed, as required by regulations. Review of personnel records and administrator confirmation showed the background check was conducted after the nurse aide's start date, indicating noncompliance with mandated employee screening procedures.
Two residents requiring oxygen therapy did not receive appropriate respiratory care, as oxygen equipment was not maintained or labeled according to facility policy. Staff confirmed that humidifiers and tubing were not dated as required, and physician orders lacked clear instructions for oxygen maintenance.
A resident with multiple chronic conditions did not have required monthly Medication Regimen Reviews (MRR) completed or documented by the consultant pharmacist for several months. The DON confirmed the absence of MRR documentation, citing lack of computer access for the pharmacist and inability to locate records, in violation of facility policy.
Surveyors found that drugs and biologicals were not stored securely or in an orderly manner in a medication room. Items such as a personal cell phone, food, and backpacks were present on the counter, while an unlocked tackle box under the sink contained various injectable medications. Unlabeled medication samples were also found in a brown paper bag on a shelf. An LPN confirmed the improper storage and labeling practices.
The facility failed to obtain a physician order for hospice services and did not ensure proper coordination of hospice care with facility services for two residents with serious medical conditions. In both cases, the care plans lacked essential information such as hospice agency contact details and instructions for accessing 24-hour hospice support, and one resident's record did not include a hospice-related diagnosis or order.
Two nurse aides did not receive required in-service training on effective communication, as confirmed by a review of training records and facility policy. The DON acknowledged that these staff members lacked documented training on this topic during the review period.
Two staff members, an LPN and a nurse aide, did not receive the required annual behavioral health training as outlined in the facility's assessment. The DON confirmed the lapse in training during an interview, and review of records showed the training was not completed within the expected timeframe.
A resident was observed with medications at her bedside without a physician's order for self-administration, contrary to the facility's policy. The resident, diagnosed with diabetes, atrial fibrillation, and high blood pressure, did not have care plan interventions for self-administration. A nurse confirmed the medications were left without an order, and the NHA acknowledged the oversight.
Beaver Healthcare and Rehabilitation Center failed to meet state-mandated nurse aide-to-resident ratios on several occasions. The facility was understaffed during the day, evening, and night shifts, as confirmed by a review of staffing documents and census data. The Nursing Home Administrator acknowledged these deficiencies, which occurred over a period of three weeks.
The facility failed to implement COVID-19 infection control policies, affecting ten residents. Staff did not use PPE correctly, with an LPN improperly disposing of a gown and two NAs entering COVID-19 rooms without PPE. Isolation signage was incorrect or missing, and resident records lacked necessary isolation orders. The facility also failed to track COVID-19 exposures adequately.
The facility failed to document consent and education for vaccinations and did not administer the influenza vaccine in a timely manner for two residents. One resident declined both vaccines without proper documentation, while another consented to the influenza vaccine but did not receive it, and their pneumococcal vaccination status was not updated.
The facility failed to document COVID-19 vaccine offers and education for two residents and did not offer vaccines to seven staff members. A resident's record lacked evidence of a booster offer, and another's record lacked vaccination documentation. Staff interviews confirmed no vaccine offers, which the DON acknowledged.
A facility failed to document a physician's discharge order and medication orders for a resident with a fracture, hypertension, and diabetes. The resident requested discharge to home, but the clinical record lacked a physician's discharge order, and inhalers were provided without documented orders. This was confirmed by the Nursing Home Administrator.
The facility failed to provide written notice and document reasons for room changes for two residents, violating their rights. One resident with high blood pressure and muscle weakness, and another with diabetes and dementia, were moved without proper notification or documentation, as confirmed by the Nursing Home Administrator.
A facility failed to provide a comprehensive review of admission rights and maintain proper documentation for a resident. The facility's policy requires an orientation of policies, programs, and services, including resident rights. However, the admission record for a resident with anorexia nervosa, low potassium, and muscle weakness lacked necessary signatures and evidence of rights review. This deficiency was confirmed by the Nursing Home Administrator.
Failure to Provide Resident Fund Access on Weekends and Holidays
Penalty
Summary
The facility failed to ensure that resident funds were accessible on holidays and weekends, as required by facility policy and state regulations. Review of the facility's procedures indicated that residents should be able to access their trust account funds even when the business office is closed, with a process in place for RNs to issue cash from a locked bank bag. However, interviews with residents revealed that requests for funds on weekends were not fulfilled, with one resident stating she was unable to access her money on a Saturday and another reporting a delay in receiving requested cash. Multiple staff members, including RNs and nurse aides, confirmed that they either directed residents to the business office or informed them that funds were not available outside regular hours, indicating a lack of awareness or implementation of the established process. Further interviews with staff and temporary business office personnel revealed confusion and inconsistency regarding the process for accessing resident funds when the business office was closed. Some staff believed cash should be available in a cart or locked box, while others stated that no such system was in place or that they were unaware of it. The Nursing Home Administrator confirmed that the facility did not provide residents with access to their funds on weekends and holidays as required, resulting in noncompliance with state regulations regarding management and resident rights.
Failure to Follow Approved Menu for Dinner Meal
Penalty
Summary
The facility failed to follow the approved dinner menu for one of three observed meals. On the specified date, the menu approved by the Registered Dietician included minestrone soup and carrot raisin salad, but instead, residents were served either beef vegetable or chicken noodle soup and 3 bean salad. The rest of the meal components matched the approved menu. This deviation was observed during a dining observation and confirmed through staff interviews. Staff interviews revealed that the substitutions were made because the facility did not have the required menu items available. The dietary staff member responsible for meal preparation stated that they substituted the items due to lack of supplies. The Dietary Manager confirmed that while the menus are created and approved by the RD, changes are sometimes made without RD review or approval. This resulted in the facility not adhering to the displayed and approved menu for the observed meal.
Multiple Food Safety and Sanitation Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to properly monitor food expiration dates in the Main Kitchen, as evidenced by multiple opened food items in the freezer and walk-in cooler that were either undated or expired. These included half a bag of bacon pieces, ham slices, a container of sour cream, pineapple salad, mayonnaise, and mixed fruit, all of which were either missing dates or had expired. The Dietary Manager confirmed these findings and acknowledged the lack of monitoring for food expiration dates. Additionally, observations revealed that the walk-in cooler fans, ceiling, and walls, as well as the main kitchen ceiling vents, had grime buildup, indicating a failure to maintain food equipment in a clean and sanitary condition. During tray line observation, two employees with beards were not wearing beard nets, and the Dietary Manager confirmed that beard nets were not available. Furthermore, seven plate lids fell onto the floor and were picked up and reused by a staff member until a surveyor intervened, demonstrating a failure to maintain sanitary conditions and prevent cross-contamination. In the dish room, it was observed that the facility did not verify the final rinse temperature of the dish machine using temperature test strips, and the Dietary Manager stated that this practice was not in place. The Nursing Home Administrator confirmed all these deficiencies, which were found to be in violation of facility policies and state regulations.
Failure to Implement Infection Surveillance with Floor Mapping
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as required by its own policy and state regulations. Specifically, for a period of twelve consecutive months, the facility did not conduct or document floor mapping as part of its monthly infection surveillance activities. This omission was confirmed during a review of the facility's infection control records and through an interview with the Infection Preventionist, who was unable to provide documentation of the required surveillance, including floor mapping, for the specified period. The deficiency was identified through policy review, clinical record review, observation, and staff interview.
Failure to Maintain Effective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its policy, resulting in a persistent gnat infestation in the main kitchen and dry food storage areas. Observations during a kitchen tour revealed a significant number of gnats on boxes, cans, and flying throughout the kitchen, including above the prep table, around the dish machine, and near the microwave. Mounted bug lights were present, but the infestation persisted. Staff interviews confirmed the ongoing issue, with one employee stating efforts had been made to address the problem over the past three months, and another noting the gnats were widespread and problematic. Documentation from the pest control log indicated that fungus gnats were observed alive in both the dry food storage and kitchen areas, and that previous conditions contributing to the infestation still existed. The pest control inspection also noted that certain service areas were not accessible for treatment and recommended repairs or drying out of water-damaged walls or wood. Staff interviews further revealed that water damage and improper repairs to the ceiling may have contributed to the moisture problem, which was identified as a source of the gnat infestation.
Failure to Timely Complete Admission Agreements and Assess Resident Capacity
Penalty
Summary
The facility failed to maintain timely documentation of admission agreements for four residents and did not ensure that three of these residents had the capacity to understand the terms of the admission agreement. Specifically, records showed that admission agreements were not completed at the time of admission, and in some cases, were only completed much later. For example, one resident's agreement was completed on the same day as the surveyor's interview, rather than at admission. Additionally, the facility did not complete a new admission agreement for each separate admission for a resident with multiple admissions and discharges. Three residents who signed their own admission agreements were found to have significant cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. Two residents had severe impairment (BIMS score of 5), and one had moderate impairment (BIMS score of 11), raising concerns about their ability to understand the terms of the agreement. Interviews with the Nursing Home Administrator confirmed that these residents did not have the capacity to comprehend the admission agreements at the time they were signed.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three nurse aides, as required by its own policy. Review of personnel records for three nurse aides, each with varying hire dates, showed that none had annual performance evaluations documented based on their respective dates of hire. The facility's policy specifies that a performance review for nurse aides must be conducted at least every 12 months. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required annual evaluations had not been completed for the identified nurse aides. No information regarding the medical history or condition of any residents was included in the report, and the deficiency pertains solely to staff performance evaluation procedures.
Failure to Ensure Resident Capacity for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement prior to signing. Facility policy requires that the terms and conditions of such agreements be explained in a manner that ensures the resident or their representative understands, including the fact that signing may waive the right to litigation. However, for three residents, documentation and staff interviews confirmed that the residents signed the Grievance Procedure and Voluntary Arbitration Agreement despite having cognitive impairments. Specifically, two residents with diagnoses of dementia and severe cognitive impairment, as indicated by a BIMS score of five, and a third resident with moderate impairment (BIMS score of eleven) and a history of stroke, signed the agreements. The Nursing Home Administrator confirmed that these residents did not have the capacity to understand the terms of the agreements at the time of signing. This failure was identified through review of clinical records, facility documents, and staff interviews.
Failure to Maintain Emergency Crash Carts in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that emergency crash carts were maintained in safe operating condition as required by facility policy. Observations and review of documentation revealed that the Back hallway crash cart did not have a checklist initiated for the current month, and this was confirmed by an LPN. Additionally, the Front hallway/Dining room crash cart's checklist was missing documentation for 14 days, indicating that the required daily checks for emergency readiness were not performed or recorded. These findings were verified through staff interviews and review of the crash cart binders. The Director of Nursing confirmed that both crash carts, located in the Front and Back hallways, were not properly checked and documented as required. The facility's policy mandates that crash carts be checked every 24 hours and after each use, with missing or expired items replaced as needed. The lack of documentation and failure to perform these checks resulted in the facility not ensuring that essential emergency equipment was in safe operating condition.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to four out of five reviewed employees, including three nurse aides and one LPN. According to the facility assessment, staff training on QAPI is required during general orientation upon hire, annually, and as needed. Document review showed that Nurse Aide Employees E10, E11, and E12, as well as LPN Employee E8, did not receive QAPI in-service education within the specified annual periods. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged that the required QAPI training had not been provided to these staff members.
Failure to Provide Annual Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required annual compliance and ethics training to four out of five reviewed staff members, including three nurse aides and one LPN. According to the facility's own assessment and in-service training policy, all personnel are mandated to participate in regular education sessions covering topics such as compliance and ethics. Document review showed that Nurse Aide Employees E10, E11, and E12, as well as LPN Employee E8, did not receive compliance and ethics in-service education during their respective annual review periods. This deficiency was confirmed by the Director of Nursing during an interview, who acknowledged the lapse in providing the mandated training to these staff members.
Failure to Prevent Mental Abuse via Unauthorized Photography and Sharing
Penalty
Summary
Facility staff failed to protect two residents from mental abuse, specifically abuse facilitated through the use of technology. An activities employee took a photo and video of two residents in the dining room without their knowledge or consent, while they were looking at items left over from an Alzheimer's sale. The staff member then sent these images to another staff member, who subsequently transmitted them to another resident. The stated reason for taking and sharing the images was to check on items allegedly being taken by the residents, but at no point was permission obtained from the residents involved. Both residents had significant medical histories, including dementia, coronary artery disease, hypertension, peripheral vascular disease, anemia, and diabetes. Interviews with the residents confirmed they were unaware that photos or videos were being taken and had not given permission for such actions. The Nursing Home Administrator and Director of Nursing acknowledged that the facility failed to ensure residents were free from mental abuse, including abuse enabled by technology, as required by federal and state regulations.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications for two residents. According to the facility's policy, psychotropic medications such as anti-psychotics, anti-depressants, anti-anxiety agents, and hypnotics should only be prescribed when clinically indicated and, if ordered on a PRN (as needed) basis, should be limited to 14 days unless a physician provides a documented rationale for extending the order. For one resident with diagnoses including anxiety, hypokalemia, and spina bifida, a physician's order for Hydroxyzine 10 mg every four hours PRN for anxiety did not include a 14-day stop date or a documented rationale for continuation beyond 14 days. Similarly, another resident with anxiety, high blood pressure, and COPD had a physician's order for Hydroxyzine 10 mg every six hours PRN for anxiety, also lacking a 14-day stop date and physician justification for extension. These findings were confirmed through clinical record review and staff interview, specifically with the Director of Nursing, who acknowledged the failure to comply with requirements for psychotropic medication management. The absence of appropriate stop dates and physician documentation for PRN psychotropic medications resulted in non-compliance with both facility policy and regulatory requirements.
Failure to Complete Pre-Employment Background Check for Nurse Aide
Penalty
Summary
The facility failed to conduct a criminal background check prior to allowing a nurse aide to begin working on the nursing unit. Review of personnel records showed that the nurse aide started employment on 3/17/25, but the criminal background check was not completed until 5/28/25. This was confirmed by the Nursing Home Administrator during an interview. The deficiency was identified in one out of five personnel records reviewed, indicating that the required screening procedures for abuse, neglect, exploitation, or misappropriation of resident property were not followed as mandated by federal and state regulations.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including heart failure and coronary artery disease, a physician order directed oxygen use at 3 liters per minute for shortness of breath, but did not include instructions for oxygen maintenance. During observation, the resident's oxygen concentrator was not in use, the humidifier was labeled with a date over two months old, and the oxygen tubing was not labeled with a date. An LPN confirmed these findings, which did not meet facility policy requirements for equipment maintenance and infection control. For another resident with COPD, anemia, and hypertension, physician orders specified oxygen administration and required changing the oxygen tubing and canister weekly. However, during observation, the resident was using oxygen via nasal cannula, and the tubing was not labeled with a date as required. An RN confirmed the lack of labeling. The Nursing Home Administrator acknowledged that the facility did not provide appropriate respiratory care for these residents, as required by facility policy and state regulations.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were completed and documented by the consultant pharmacist for one of four residents. According to facility policy, the consultant pharmacist is required to review each resident's medication regimen at least monthly and document the findings in the resident's medical record. For the resident in question, who had diagnoses including high blood pressure, coronary artery disease, and diabetes, there was no documentation of MRRs in the clinical record for multiple months spanning from April 2024 through April 2025. During the review, it was confirmed that the facility could not provide evidence of completed MRRs for the specified months. The Director of Nursing stated that the lack of documentation was due to the consultant pharmacist not having computer access and an inability to locate any MRRs for the relevant dates. This failure was verified through clinical record review, facility policy review, and staff interviews.
Improper Storage and Labeling of Medications in Medication Room
Penalty
Summary
The facility failed to store all drugs and biologicals in a safe, secure, and orderly manner in one of its two medication rooms, specifically the back hall medication room. During an observation, surveyors found a blue tote bag containing a personal cell phone and food items, as well as a green backpack, on the medication room counter. Under the sink, there was an unlocked green tackle box containing various injectable medications, including Benadryl, Glucagon, Lasix, Narcan, and a bottle of nitroglycerin tablets, all with visible expiration dates. Additionally, a bag of lock out tags was present in the same area. On a shelf above the sink, a brown paper bag was found containing unlabeled medication samples, including multiple boxes of Vraylar and Nuplazid capsules. An LPN confirmed these findings, stating that the tackle box was intended to be returned to the old pharmacy and that the medication samples were provided by a psychiatrist for a resident returning from the hospital, to be used until insurance authorization was obtained. These observations demonstrated that the facility did not adhere to its own policies or accepted pharmaceutical practices regarding the secure and proper storage and labeling of medications and biologicals.
Failure to Obtain Hospice Orders and Coordinate Hospice Services
Penalty
Summary
The facility failed to obtain a physician order for hospice services and did not ensure proper coordination of hospice care with facility services for two residents. For one resident with diagnoses including heart failure, depression, and dementia, the clinical record did not contain a physician order for hospice services, lacked a diagnosis related to the need for hospice, and the care plan did not include essential information such as the hospice agency's contact details, access to the 24-hour on-call system, or the name of the hospice agency. For another resident with heart failure, coronary artery disease, and anxiety, although there was documentation of hospice admission in the physician orders, the comprehensive care plan similarly failed to include the hospice agency's contact information and instructions for accessing the hospice's 24-hour on-call system. The Director of Nursing confirmed these deficiencies, indicating a lack of coordination and documentation necessary to meet the end-of-life care needs of these residents.
Failure to Provide Effective Communication Training to Nurse Aides
Penalty
Summary
The facility failed to provide required in-service training on effective communication to two nurse aides, as evidenced by a review of facility policy, training records, and staff interviews. The facility's policy mandates regular in-service education for all personnel, including training on communication. However, documentation showed that two nurse aides, one hired in 1989 and another in 2021, did not receive effective communication training during the specified review period. This was confirmed by the Director of Nursing during an interview, who acknowledged the lack of documented training for these staff members.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health training to staff members as required by its Facility Assessment. Specifically, two employees, an LPN and a nurse aide, did not receive annual mandatory behavioral health in-service education within the designated timeframes. Review of facility documents confirmed that the Facility Assessment required annual behavioral health training for staff. The Director of Nursing verified during an interview that these two employees had not completed the required training. This deficiency was identified through review of facility policy, training records, and staff interviews.
Failure to Obtain Physician Orders for Medication Self-Administration
Penalty
Summary
The facility failed to obtain physician orders and care plan interventions for medication self-administration for one of the residents. The facility's policy on administering medications requires that residents may self-administer their medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determines that the resident has the decision-making capacity to do so safely. However, during an observation, it was noted that a resident was holding a medication cup with several pills, and there was no physician order for self-administration in the resident's records. The resident, who was admitted with diagnoses of diabetes, atrial fibrillation, and high blood pressure, was observed with medications at her bedside. A registered nurse confirmed that the medications were left at the bedside without an order for self-administration. The Nursing Home Administrator also confirmed the lack of physician orders and care plan interventions for the resident's medication self-administration. This deficiency was identified as a failure to comply with the facility's policies and state regulations regarding medication administration and resident care.
Staffing Deficiencies at Beaver Healthcare
Penalty
Summary
Beaver Healthcare and Rehabilitation Center was found to be non-compliant with the 28. Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to meet the required nurse aide-to-resident ratios on multiple occasions. During the daylight shift, the facility did not provide one nurse aide per 10 residents on four separate days. Similarly, during the evening shift, the facility failed to maintain the required ratio of one nurse aide per 11 residents on two days. Additionally, the night shift was understaffed on six days, not meeting the requirement of one nurse aide per 15 residents. The staffing shortages were confirmed through a review of the facility's census data and nursing time schedules from December 3, 2024, to December 24, 2024. The Nursing Home Administrator acknowledged these deficiencies during an interview. The report details specific dates and the corresponding census, actual hours worked, and the required hours, highlighting the shortfall in staffing levels. These deficiencies indicate a failure to adhere to state regulations for adequate staffing, which is crucial for maintaining the quality of care in the facility.
Plan Of Correction
NHA has educated Scheduler on minimum staffing hours/regulations on new staffing guidelines effective 07/01/2024. Facility has advertised for open CNA positions. Interviews will be conducted as applicants apply. Scheduler will meet with NHA/DON twice daily to review staffing schedule for a period of 1 week to ensure CNA ratios are being met. NHA/DON/Scheduler will continue to monitor CNA ratios to ensure facility has sufficient staff. Findings will be reported to QAPI for further review and monitoring. Date of compliance 01/06/2025.
Inadequate COVID-19 Infection Control and PPE Use
Penalty
Summary
The facility failed to implement its infection prevention and control monitoring policies for COVID-19, affecting ten residents. Observations revealed that staff did not adhere to the required use of Personal Protective Equipment (PPE) when entering and exiting rooms of COVID-19 positive residents. Specifically, an LPN was seen improperly disposing of a gown and not wearing a face shield, while two nursing assistants entered COVID-19 positive rooms without any PPE and failed to change their masks upon exiting. These actions were confirmed by the Regional Director of Nursing and other staff members. Additionally, the facility did not have appropriate isolation signage for residents with COVID-19, with several rooms either lacking signs or displaying incorrect isolation precautions. This lack of proper signage was acknowledged by the Regional Director of Nursing, who confirmed that the residents were not in the correct type of isolation. Furthermore, the clinical records for several residents did not include orders for COVID-19 infection and droplet isolation requirements, nor did they document the maintenance of droplet isolation precautions. The facility also failed to adequately track residents exposed to COVID-19. The Infection Preventionist admitted to not having a formal tracking system in place, relying instead on handwritten notes. This lack of tracking was confirmed by the Regional Director of Nursing. The facility's failure to monitor respiratory symptoms and fever beyond three days during a COVID-19 outbreak was also noted, with the Infection Preventionist acknowledging the need for ongoing monitoring.
Deficiencies in Vaccination Documentation and Administration
Penalty
Summary
The facility failed to properly manage influenza and pneumococcal vaccinations for residents, as evidenced by incomplete consent documentation and untimely administration. Resident R4, who has diagnoses of high blood pressure, anemia, and atrial fibrillation, declined both the influenza and pneumococcal vaccines. However, the facility did not obtain R4's signature on the consent forms, nor did they document the education provided about the vaccines. Similarly, Resident R5, with diagnoses of high blood pressure, diabetes, and depression, consented to the influenza vaccine, but there was no record of the vaccine being administered. Additionally, R5's pneumococcal vaccination status was not up to date, and there was no documentation in the clinical record to confirm the administration of the vaccine. The Regional Director of Nursing confirmed these deficiencies during an interview, acknowledging the facility's failure to complete the necessary documentation and ensure timely vaccination. The facility's policies require that all residents be offered these vaccines, with proper documentation of consent and education. However, the review of clinical records and immunization records revealed lapses in following these protocols, leading to the identified deficiencies.
Failure to Document and Offer COVID-19 Vaccines
Penalty
Summary
The facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccine and providing education for two residents reviewed for immunizations. Resident R1's clinical record did not include documentation that the COVID vaccination booster was offered or that education was provided. Resident R5's clinical record indicated that he had already received the COVID-19 vaccine, but there was no documented evidence of the vaccination. The Regional Director of Nursing confirmed these documentation failures during an interview. Additionally, the facility failed to offer COVID-19 vaccines to staff members. Interviews with seven employees, including nursing assistants and registered nurses, revealed that none of them were offered COVID-19 vaccines or booster vaccines. The Regional Director of Nursing confirmed that the facility did not offer COVID-19 vaccines to these staff members. This deficiency was noted in the context of the facility's policy and CDC recommendations for COVID-19 vaccination.
Failure to Document Physician's Discharge Order and Medication Orders
Penalty
Summary
The facility failed to comply with its Discharge Medications policy by not acquiring and documenting a physician's discharge order and medication orders for a resident. The resident, who had been admitted with a nondisplaced fracture of the left ankle, hypertension, and diabetes, requested discharge to home along with her daughter. However, the clinical record lacked a physician's order for the discharge, and the physician orders did not include any for inhalers, despite them being provided at discharge. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor the residents' rights to receive written notice before a room change, as required by their own policy and regulations. The policy mandates that specific information, such as the date and time of the transfer, the individuals involved, assessment data, and the resident's response, should be documented in the resident's medical record. However, for two residents, R1 and R2, there was no documented evidence of the reasons for their room changes, nor any indication that they were notified or given the opportunity to refuse the move. Resident R1, who had diagnoses of high blood pressure, muscle weakness, and pain, was moved from one room to another without any documented notice or reason. Similarly, Resident R2, with diagnoses of diabetes, dementia, and high blood pressure, experienced a room change without proper documentation or notification. The Nursing Home Administrator confirmed the lack of documentation regarding written notice and reasons for the room changes during an interview, highlighting a deficiency in adhering to resident rights and facility policy.
Failure to Review Admission Rights and Maintain Documentation
Penalty
Summary
The facility failed to provide a comprehensive review of resident admission rights and maintain proper admission documentation for one of the sampled residents. The facility's policy on Admissions Orientation, last reviewed on 5/28/24, requires that each resident be given a tour and orientation of the facility's policies, programs, and services, including resident rights and responsibilities. However, the admission record for Resident R3, who was admitted on an unspecified date, lacked a signature from the resident or a representative, a date for the review of the admission packet, and evidence that resident rights were reviewed. Resident R3's MDS assessment dated 5/12/24 indicated diagnoses of anorexia nervosa, low potassium, and muscle weakness. Clinical nurse notes and admission documents also did not show that Resident R3 or her representative reviewed the resident rights and admission packet. This deficiency was confirmed during an interview with the Nursing Home Administrator on 6/6/24.
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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