Beaver Valley Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaver Falls, Pennsylvania.
- Location
- 257 Georgetown Road, Beaver Falls, Pennsylvania 15010
- CMS Provider Number
- 395266
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Beaver Valley Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure that three residents with Stage 3 and Stage 4 pressure ulcers consistently received and had documented their ordered daily wound treatments. Physician orders directed daily cleansing with NSS, application of collagen or hydrofera blue, and coverage with bordered dressings, but multiple treatment dates were missing from the TARs for each resident. An LPN reported that wound treatments are only documented on the TAR and that there is no other way to verify completion without directly viewing the wound, and the ADON could not provide proof that the missed-date treatments were performed, resulting in a cited failure to provide necessary services to promote pressure ulcer healing.
A resident with multiple medical conditions reported to a CRNP that another male resident with dementia entered her room and fondled her breast. Although administration and nursing leadership were made aware, there was no evidence that the incident was reported to authorities or that a formal abuse investigation was conducted, in violation of required protocols.
A resident with multiple medical conditions reported being inappropriately touched by another resident with dementia. Despite facility policy requiring prompt and thorough investigation of abuse allegations, there was no evidence of a completed investigation, documentation, or actions taken to ensure resident safety. Staff interviews confirmed awareness of the incident but did not provide supporting documentation.
The facility failed to meet the required nurse aide staffing levels on three days, resulting in a deficiency. On one night shift, only 48 hours of care were provided instead of the required 56 hours for 105 residents. On another day, the daylight shift required 84.80 hours, but only 56 hours were provided, and the evening shift required 77.09 hours, with only 53.25 hours provided for 106 residents. On a subsequent day, the daylight shift required 84.80 hours, but only 71.58 hours were provided for 106 residents.
The facility failed to provide the required staffing levels for nurse aides on three days and did not meet the mandated 3.2 hours of direct resident care per resident on one day. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to assess a resident's ability to self-administer medications, as required by their policy. A resident with acute kidney failure, anemia, and hypertension was found with Ivizia eye drops on the bedside stand without orders for self-administration. An LPN confirmed the lack of orders and removed the medication.
The facility failed to communicate necessary information to receiving health care providers for two residents transferred to the hospital. The required documentation, including care plan goals and specific instructions for ongoing care, was not provided, as confirmed by the Nursing Home Administrator.
The facility failed to provide written notification of its bed-hold policy to two residents or their representatives upon hospital transfer. Despite policy requirements, there was no documented evidence of notification for a resident with anxiety and high blood pressure, and another with Alzheimer's and wheelchair dependence. The Nursing Home Administrator confirmed the oversight.
A facility failed to include necessary interventions for skin sleeves in a resident's care plan, despite the resident's diagnoses of heart failure, hypertension, and diabetes. The omission was confirmed by the DON, highlighting a lapse in adhering to the facility's policy for comprehensive, person-centered care planning.
The facility failed to obtain physician orders for treatments for two residents. One resident with heart failure, hypertension, and diabetes was observed with skin sleeves without a physician order. Another resident with dementia, heart failure, and dysphagia had an NPO diet due to choking risks, but lacked a physician order for this status. The DON confirmed these deficiencies.
Two residents with urinary catheters experienced deficiencies in care at the facility. A resident with a history of hypertension and neurogenic bladder was found with a Foley catheter bag lacking a dignity/privacy cover, contrary to facility policy. Another resident with dementia and heart failure had a Foley catheter inserted without a physician order, as confirmed by an LPN. These incidents highlight failures in adhering to catheter care and documentation policies.
A facility failed to maintain sanitary conditions for a resident's respiratory equipment. The nebulization machine was not stored in a labeled bag, and the oxygen concentrator's humidifying jar was empty. An LPN confirmed these deficiencies, which did not comply with the facility's policies for respiratory care.
The facility failed to provide trauma-informed care for two residents with PTSD by not identifying or mitigating triggers in their care plans. Despite the facility's policy on trauma-informed care, the care plans lacked specific strategies to prevent re-traumatization, as confirmed by the Social Service Director.
The facility failed to conduct ongoing assessments for two residents using bed rails, as required by federal regulations and facility policy. Despite having conditions like anemia, hypertension, parkinsonism, and diabetes, the residents' bed rail evaluations were outdated, with the last assessments recorded months prior. This oversight was confirmed by the DON and NHA, highlighting a lapse in ensuring resident safety and compliance with care standards.
A facility failed to properly store medications and biologicals in a medication cart. Items found included unlabeled vials and bottles, personal drinks, and a medicine cup with various tablets. An RN confirmed these observations, noting the medicine cup belonged to a sleeping resident and the drinks were personal.
The facility failed to implement proper infection control measures during a COVID-19 outbreak for a resident who was not tested promptly despite symptoms. Additionally, an LPN did not adhere to infection control practices during a dressing change for another resident, leading to potential cross-contamination.
The facility failed to notify the Office of the LTC Ombudsman Division about the hospital transfers of two residents, as required by policy. Both residents, one with vascular dementia and another with end-stage renal disease, were transferred without the necessary notification. Interviews with staff revealed a lack of awareness about this requirement.
A resident with Vascular Dementia and other conditions was not readmitted to the facility after hospitalization due to increased behaviors and the need for a secure unit. The facility failed to provide formal discharge notice or evidence that they could not meet the resident's needs, as confirmed by staff interviews and the Nursing Home Administrator.
The facility failed to provide sufficient staffing, resulting in delayed call light responses and inadequate personal hygiene care for several residents. Residents reported long wait times for assistance, with some waiting over an hour. Observations showed residents in nightgowns or hospital gowns, and shower records indicated missed or undocumented showers. The Nursing Home Administrator confirmed the staffing inadequacy.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary pressure ulcer treatments in accordance with physician orders and facility wound care policy for three residents with pressure injuries. The facility’s wound care policy required documentation in the medical record of the type of wound, date and time wound care was given, changes in condition, resident complaints, and refusals with reasons. One resident with spinal stenosis, diabetes, hypertension, and peripheral vascular disease had a documented Stage 4 coccyx wound, with physician orders to cleanse with normal saline, apply collagen with silver, and cover with bordered gauze every day on the day shift. Review of the February Treatment Administration Record (TAR) showed no documented wound treatments on three specific dates, despite the standing daily order. A second resident with diabetes, general weakness, and hyperlipidemia had a Stage 3 coccyx pressure area with orders to cleanse with normal saline, apply hydrofera blue, and cover with bordered gauze every day on the day shift; the February TAR lacked documentation of wound treatments on four specified dates. A third resident with diabetes, COPD, morbid obesity, and hyperlipidemia had a Stage 3 sacral pressure area with orders to cleanse with normal saline, apply collagen particles, and cover with a bordered dressing every day on the day shift; the February TAR showed missing wound treatments on three dates. During interviews, an LPN stated that wound treatments are documented on the TAR and that, unless the area is directly assessed, there is no other way to know if treatments were done. When asked, the ADON could not provide proof of wound treatments for the three residents, and surveyors informed facility leadership that the facility failed to ensure residents received necessary treatment and services consistent with professional standards to promote healing of pressure ulcers.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, as required by its abuse investigation and reporting policy. The policy mandates prompt reporting of all abuse allegations to local, state, and federal agencies, as well as thorough investigation and documentation. In this case, a resident with multiple medical conditions, including diabetes, hypothyroidism, and congestive heart failure, reported to a Certified Registered Nurse Practitioner (CRNP) that another male resident with dementia entered her room and fondled her breast. The CRNP documented the incident and noted that the administration was aware and investigating. However, there was no evidence in the resident's clinical records or facility documentation that an abuse investigation was conducted or that the incident was reported to the appropriate authorities. Further review of facility records from December 2024 to March 2025 confirmed the absence of required notifications to the local State field office, police department, or Department of Aging regarding the allegation. Staff interviews corroborated that the incident was discussed with administration and nursing leadership, but no formal report or investigation documentation was found. This failure to report and document the allegation of sexual abuse constitutes a violation of state regulations regarding the responsibility of management to ensure timely reporting and investigation of abuse allegations.
Failure to Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported that another male resident with dementia entered her room and fondled her breast. The resident, who had diagnoses including an injury to the right Achilles tendon, diabetes, hypothyroidism, and congestive heart failure, was upset by the incident but denied physical injury. Although the facility's policy requires prompt reporting and thorough investigation of all abuse allegations, there was no evidence in the clinical or social services records, or in the facility's abuse investigation documents, that an investigation was conducted or reported as required. Specifically, the documentation lacked a signed statement from the resident, identification of the alleged perpetrator, staff statements, actions to prevent recurrence, measures to ensure resident safety, interviews with other residents, and an assessment of the other resident involved. Interviews with facility staff confirmed awareness of the allegation but did not provide evidence of a completed investigation or appropriate documentation, as required by facility policy and state regulations.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on three specific days, resulting in a deficiency. On December 13, 2024, during the night shift, the facility provided only 48 hours of nurse aide care when 56 hours were required for a census of 105 residents. On December 14, 2024, the daylight shift required 84.80 hours of nurse aide care, but only 56 hours were provided, and the evening shift required 77.09 hours, with only 53.25 hours provided, for a census of 106 residents. On December 15, 2024, the daylight shift required 84.80 hours of nurse aide care, but the facility provided only 71.58 hours for a census of 106 residents. These deficiencies were identified through a review of nursing schedules and census information, indicating that the facility administrative staff failed to ensure adequate staffing levels as per the regulatory requirements effective July 1, 2024.
Plan Of Correction
The facility will continue to take measures to adequately staff nurses' aides to meet the staffing requirement. The Nursing Home Administrator or designee will conduct a daily labor meeting and audit the nurses' aide schedule to ensure the nurses' aide to resident ratio is met. The Department of Health staffing worksheet will be utilized at this meeting. Re-education will be completed by the Nursing Home Administrator or designee, on the nurses' aide to resident ratio with the Director of Nursing and the Assistant Director of Nursing. The Facility will continue to post open positions on hiring forums. The facility will continue to interview and hire nurses' aides to meet the facility needs.
Staffing and Care Hours Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on three specific days, namely 12/13/24, 12/14/24, and 12/15/24. During these days, the facility did not provide the minimum number of nurse aides per resident during the day, evening, and night shifts as mandated. Additionally, on 12/14/24, the facility did not meet the required 3.2 hours of direct resident care per resident in a 24-hour period, providing only 2.94 hours per resident with a census of 106. This deficiency was confirmed by the Nursing Home Administrator during an interview on 12/19/24.
Plan Of Correction
The facility will continue to take measures to adequately staff to meet the minimum of 3.2 hours of direct care for each resident. The Nursing Home Administrator will conduct a daily labor meeting and audit the staffing schedule to ensure the minimum hours of direct care for each resident is met. The Department of Health staffing worksheet will be utilized at this meeting. Re-education will be completed by the Nursing Home Administrator or designee with the Director of Nursing and the Assistant Director of Nursing, on the state mandate for minimum hours of direct care for each resident in a 24-hour period. The Facility will continue to post open positions on hiring forums. The facility will continue to interview and hire nurses' aides to meet the facility needs.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine the ability of a resident, identified as Resident R96, to self-administer medications. According to the facility's policy dated 8/1/24, residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team. However, it was observed on 9/3/24 that Resident R96 had a box of Ivizia eye drops on the bedside stand, which should not have been there as the resident did not have orders for medication self-administration. This was confirmed by LPN E4, who removed the eye drops and acknowledged the lack of orders for self-administration. Resident R96 was admitted to the facility with diagnoses including acute kidney failure, anemia, and hypertension. The failure to assess and document the resident's ability to self-administer medications led to the presence of unauthorized medication in the resident's room, which was against the facility's policy.
Failure to Communicate Necessary Information During Resident Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. The facility's policy on transfer or discharge documentation requires that specific information, such as the basis for transfer, medication disposition, care plan goals, and other necessary details, be documented and communicated to the receiving facility. However, for Resident R21, who was admitted with diagnoses including anxiety, weakness, and high blood pressure, and was transferred to the hospital due to shortness of breath and weakness, there was no documented evidence that the required information was communicated. Similarly, Resident R60, who had diagnoses of high blood pressure, Alzheimer's disease, and dependence on a wheelchair, was transferred to the hospital and later returned to the facility. The clinical record for Resident R60 also lacked evidence of communication of necessary information to the receiving health care provider. During an interview, the Nursing Home Administrator confirmed the absence of documentation for both residents, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital or during therapeutic leave. This deficiency was identified for two residents, R21 and R60, during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 8/1/24, mandates that residents or their responsible parties be informed of bed-hold options and associated financial liabilities at admission and each time a resident is absent from the facility. However, the clinical records for both residents lacked documented evidence of such notifications. Resident R21, who was admitted with diagnoses including anxiety, weakness, and high blood pressure, was transferred to the hospital on 3/10/24 without receiving the required bed-hold policy notification. Similarly, Resident R60, with diagnoses of high blood pressure, Alzheimer's disease, and wheelchair dependence, was transferred to the hospital on 6/2/24 without documented evidence of notification. The Nursing Home Administrator confirmed during an interview that the facility was not completing bed-hold notifications, acknowledging the absence of written notifications for both residents.
Failure to Include Skin Sleeves in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R28, which included necessary interventions for maintaining the resident's highest practicable physical well-being. The resident, who had re-entered the facility with diagnoses of heart failure, hypertension, and diabetes, was observed wearing bilateral skin sleeves. However, the care plan did not include any interventions related to the use of these skin sleeves. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the omission in the care plan. The facility's policy, dated 8/1/24, mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs. Despite this policy, the care plan for Resident R28 lacked specific goals and interventions for the skin sleeves, which are essential for the resident's care.
Lack of Physician Orders for Resident Treatments
Penalty
Summary
The facility failed to ensure that a resident had a physician order for treatments they were receiving, affecting two of five residents. Resident R28, who had diagnoses of heart failure, hypertension, and diabetes, was observed wearing bilateral skin sleeves without a corresponding physician order. This was confirmed by the Director of Nursing during an interview, indicating a lapse in obtaining necessary physician orders for the resident's treatment. Additionally, Resident R260, diagnosed with dementia, heart failure, and dysphagia, was noted to have a diet order of NPO (nothing by mouth) due to choking incidents and failed swallow studies. However, the physician order for this diet was missing from the resident's records. Interviews with a Nurse Aide and an LPN confirmed that the resident did not take anything by mouth, and the Director of Nursing acknowledged the absence of a physician order for the NPO status. This deficiency highlights the facility's failure to provide care and services needed for the resident to maintain the highest practicable physical well-being.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services for two residents with urinary catheters. Resident R37, who has a history of hypertension, neurogenic bladder, and orthostatic hypotension, was observed with a Foley catheter bag hanging from the bedframe without a dignity/privacy cover. This was confirmed by an LPN, indicating a lack of adherence to the facility's catheter care policy, which requires the catheter bag to be covered for privacy and dignity. Resident R260, diagnosed with dementia, heart failure, and dysphagia, had a Foley catheter inserted, but there was no physician order for the catheter in the resident's clinical record. This was confirmed by an LPN during an interview. The absence of a physician order for the catheter indicates a failure to follow the facility's medication and treatment order policy, which mandates that all treatments must be consistent with safe and effective order writing.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions of respiratory equipment for a resident, identified as Resident R51. The facility's policy on oxygen administration requires that the humidifying jar on the oxygen concentrator contains water and that the water level is sufficient for bubbling as oxygen flows. Additionally, the policy for administering medications through a nebulizer mandates that the equipment be rinsed, disinfected, and stored in a labeled plastic bag after use. However, during an observation, it was noted that the nebulization machine for Resident R51 was not stored in a bag, nor was it labeled with the date. Furthermore, the humidifying jar on the oxygen concentrator was found to be void of water. Resident R51, who has diagnoses of anemia, hypertension, and chronic bronchitis, was observed in bed with the nebulization machine improperly stored and the oxygen concentrator's humidifying jar empty. The resident's physician orders included the use of Ipratropium-Albuterol Solution for nebulization every four hours as needed and oxygen at two liters per minute via nasal cannula, with a directive to change the oxygen tubing and canister weekly. An LPN confirmed the deficiencies in the storage and labeling of the nebulizer equipment and the lack of water in the humidifying jar, indicating a failure to adhere to the facility's respiratory care policies.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy on Trauma Informed Care, dated 8/1/24, outlines the importance of recognizing and responding to trauma to avoid re-traumatization. However, the care plans for both residents did not identify specific PTSD triggers or strategies to avoid them, which is a critical component of trauma-informed care. Resident R36, who was admitted to the facility with diagnoses including PTSD, high blood pressure, and chronic pain, had a care plan that acknowledged the PTSD diagnosis but did not specify the triggers or how to mitigate them. Similarly, Resident R84, admitted with PTSD, muscle weakness, and difficulty walking, also had a care plan lacking identification of PTSD triggers. The Social Service Director confirmed the facility's failure to identify and address these triggers, which is necessary to prevent re-traumatization.
Failure to Conduct Ongoing Bed Rail Assessments
Penalty
Summary
The facility failed to conduct ongoing assessments to ensure that bed rails were used appropriately to meet the needs of two residents, R51 and R79, and to evaluate the risks associated with their usage. According to Title 42 CFR S483.25(n), facilities must assess residents for the risk of entrapment from bed rails before installation and perform ongoing evaluations. However, the facility did not adhere to these regulations. For Resident R51, who was admitted with conditions such as anemia, hypertension, and chronic bronchitis, the last documented evaluation of the assist rails was on 3/12/24, despite the facility's policy requiring quarterly, annual, and condition-change evaluations. The Director of Nursing confirmed the lack of ongoing assessments for this resident. Similarly, Resident R79, diagnosed with parkinsonism, diabetes, and an overactive bladder, had enabler bars ordered for positioning and participation in care. The most recent evaluation for these assist rails was also dated 3/12/24. The Nursing Home Administrator confirmed that the facility did not conduct the necessary ongoing assessments for this resident. These findings indicate a failure to comply with both federal regulations and the facility's own policies regarding the use of bed rails, potentially compromising resident safety.
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in one of its medication carts. During an observation, it was found that the medication cart contained several items that were not labeled with the date they were opened, including a vial of artificial tears, a vial of fluticasone nasal spray, a bottle of lactulose solution, and an Anora Ellipta inhaler. Additionally, the cart contained personal items such as an opened bottle of pure leaf tea and two cans of Arizona herbal tonic energy drink. A medicine cup labeled with the initial 'H' was also found, containing various tablets and capsules. A Registered Nurse (RN) confirmed these observations and stated that the medicine cup belonged to a resident who was sleeping, and the drinks were personal items.
Infection Control Deficiencies During COVID-19 Outbreak and Dressing Change
Penalty
Summary
The facility failed to implement proper infection control measures during a COVID-19 outbreak, specifically for Resident R6. Despite the facility's policy requiring immediate testing for COVID-19 symptoms, Resident R6, who had symptoms such as a headache and sore throat after a leave of absence, was not tested promptly. The resident was eventually tested and found positive for COVID-19, but the facility did not follow its own guidelines for outbreak management, including the lack of signage indicating an active outbreak and inconsistent testing protocols. Additionally, the facility did not adhere to infection control practices during a dressing change for Resident R13. The LPN involved in the procedure failed to establish a clean field, used a washable lift pad improperly, and did not maintain sterile technique. The LPN also placed contaminated items on the floor and returned used supplies to the medication cart, which could lead to cross-contamination. These deficiencies highlight lapses in the facility's adherence to its infection prevention and control policies, as confirmed by interviews with staff members, including the Infection Preventionist and the Nursing Home Administrator. The failure to implement these measures compromised the facility's ability to manage infections effectively and prevent cross-contamination during medical procedures.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two residents. The facility's policy requires that a written notice of transfer or discharge be sent to the resident or their representative, including a copy to the Ombudsman. However, for Resident R1, who was admitted with vascular dementia, urinary tract infection, and hypertension, and transferred to the hospital, there was no documented evidence of such notification. Similarly, Resident R9, admitted with end-stage renal disease, anemia, and diabetes, was also transferred to the hospital without the required notification to the Ombudsman. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman. The Social Service Director admitted to not notifying the Ombudsman of hospital transfers, stating unawareness of the necessity. The Director of Nursing confirmed that the facility did not send any notifications to the Ombudsman's Office, acknowledging the failure to comply with the notification requirement for the two residents. This deficiency was identified under 28 Pa. Code 201.29 (a) (c.3) (2) concerning resident rights.
Failure to Readmit Hospitalized Resident Without Proper Notification
Penalty
Summary
The facility failed to permit the readmission of a hospitalized resident, identified as Resident R1, without providing evidence that the facility was unable to meet the resident's needs. Resident R1, who was admitted with diagnoses including Vascular Dementia with agitation, Urinary Tract Infection, and Hypertension, exhibited increased behaviors such as exit-seeking and aggression towards staff. Despite these behaviors, there was no documentation indicating that the family or resident was informed of the need for a secure unit or transfer to another facility, nor was there a formal notice of discharge provided. Interviews with facility staff, including the Admission Coordinator and Social Service Director, revealed that the decision not to readmit Resident R1 was based on the resident's behaviors and the need for a locked-down unit. However, the Nursing Home Administrator confirmed that no formal discharge notice was given to the family, and the hospital was informed that the facility would not be taking Resident R1 back. This lack of communication and documentation led to the deficiency, as the facility did not follow proper procedures for transfer and discharge, failing to provide necessary notifications and evidence of inability to meet the resident's needs.
Insufficient Staffing Leads to Delayed Care and Hygiene Issues
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of eight out of twelve residents, as evidenced by resident interviews and observations. Residents reported long wait times for call light responses, with some waiting over an hour for assistance. Several residents were observed in nightgowns or hospital gowns, indicating they had not been assisted with personal hygiene or dressing. Additionally, residents expressed dissatisfaction with the frequency of showers, with some receiving only one shower per week or having showers scheduled during inconvenient hours. The facility's policy on answering call lights, dated 7/13/23, was not adhered to, as residents experienced delays in receiving care. Observations revealed residents with unkempt or greasy hair, and shower records indicated missed or undocumented showers. Residents also reported that staff often promised to return to assist them but failed to do so. The Nursing Home Administrator confirmed the facility's failure to provide sufficient staffing to meet the needs of the residents.
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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