Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bradford Hills Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Missed Documentation of Ordered Wound Treatments: The facility failed to complete and document multiple physician-ordered wound and skin treatments for three residents. TARs showed blank entries for ordered care such as wound cleansing, topical medications, dressings, and Interdry use, including repeated missed documentation for one resident with several wound/skin orders and missed treatment entries for two other residents.
A resident with severe cognitive impairment had a court-appointed guardian as responsible party. After the resident, who required assistive device and one-person assistance, fell while attempting to self-transfer, staff assessed the resident with no injuries and notified the guardian by phone. Later, the guardian called 911 requesting that the resident be checked and potentially transferred to the hospital. When 911 contacted the facility, staff reported the resident was being monitored and denied pain, and no EMS dispatch or hospital transfer occurred. There was no documented follow-up communication with the guardian to discuss the resident’s condition or the guardian’s expressed wish for emergency services, and the guardian was not given the opportunity to exercise the right to request hospital transfer.
A resident with pain related to a femur fracture reported daily pain that was sometimes severe. Her MAR showed a buprenorphine patch, PRN Tylenol, and PRN hydromorphone for moderate to severe pain, yet staff documented frequent moderate-to-severe pain on routine assessments and the resident received hydromorphone many times over two months. The facility failed to ensure pain management was provided consistent with professional standards of practice.
Medication administration errors caused the facility’s error rate to reach 23%. An RN failed to give several scheduled meds to one resident, including a nasal spray that was documented as self-administered even though it was not in the room and there was no evidence the resident was assessed for self-administration; an unlabeled-for-use nasal spray was also found in an unlocked bedside drawer. For another resident, the RN gave incorrect doses of Tylenol Arthritis, sodium bicarbonate, and ferrous sulfate, and administered antihypertensives without the required BP check.
A resident’s confidential medication information was left visible in a regular trash receptacle on a wound care cart near the nurse’s station. The discarded silver sulfadiazine box still had the pharmacy label attached, showing the resident’s name and order instructions. A nurse aide said the bins were used for regular garbage and was unsure if the box belonged there, and the NHA stated the labeled medication should not have been in the trash and the label should be shredded.
Failure to investigate and report alleged resident-to-resident sexual abuse. A resident with severe cognitive impairment was documented making out with two other severely cognitively impaired residents, including in his room and in a back lounge, and became upset when redirected. Facility policy required immediate separation, investigation, social services involvement, and reporting to the state, but the NHA and DON confirmed no investigation, witness statements, law enforcement notification, or DOH report were completed.
MDS assessments did not accurately reflect resident status for three residents. One resident was coded as having bed rails used as a restraint despite no restraint order in the chart, another was coded as receiving insulin despite no active insulin order, and a third was coded as receiving an anticoagulant despite no evidence of anticoagulant use in the assessment period. The RN assessment coordinator confirmed the coding errors.
Failure to Develop Care Plan for Dental Needs: A resident had broken natural teeth and blackened tooth fragments observed in the mouth, while nursing documentation also described the resident as edentulous. The MDS and oral/dental inspection identified obvious or likely cavities or broken natural teeth, but the care plan did not address the dental concern until after surveyor questioning.
A resident’s MDS showed a decline from needing only set-up help to requiring one-person limited physical assistance for bed mobility and transfers, but the clinical record had no documentation that the decline was identified or assessed. During the 7-day look-back period, the resident needed staff physical assistance multiple times for bed mobility and transfers, and the facility could not provide further documentation of assessment or measures to mitigate the decline.
Failure to Follow Ordered Bowel Management Plan: A resident admitted with PRN bowel management orders had no documented BM for 5 consecutive days, yet staff did not document offering the ordered MOM or Dulcolax suppository, and there was no record that the resident refused either medication. The issue was reviewed with the DON.
Failure to provide comprehensive pressure ulcer assessments. A resident with cognitive impairment had a sacral/right buttock pressure ulcer with ongoing treatment orders and TAR documentation, but the record lacked routine comprehensive wound assessments. Intermittent skin checks noted a small open area, while wound care center notes documented a Stage 2 sacral pressure injury with serial measurements, serous exudate, and later erythematous, macerated peri-wound skin; the NHA and RN confirmed there was no further documentation of routine comprehensive assessment.
A resident with hemiplegia, hemiparesis, and cognitive impairment was observed smoking in the designated area without the required smoking apron, despite a care plan and policy requiring it. The smoking area also had cigarette butts scattered around the receptacle, and the receptacle was blocked by plastic with partially smoked cigarettes sitting on top.
Hand hygiene was not performed between glove changes during medication administration for a resident. An employee administered eye drops, nasal spray, and artificial tears while repeatedly removing and donning new gloves without cleaning hands, and later confirmed she knew hand hygiene should have been done between glove changes.
Surveyors observed multiple live and dead cockroach-appearing insects, winged insects, and unsanitary conditions in the kitchen, including unsealed openings, greasy surfaces, and accumulated debris. Staff confirmed ongoing pest sightings, and documentation showed pest control visits but no evidence of follow-up or notification after continued pest activity.
Four dependent residents did not consistently receive bathing assistance as per their documented preferences and care needs, with missed showers not attributed to resident refusal and staff citing occasional shortages as a reason for lapses.
The facility failed to protect residents' property from loss, affecting three residents. The facility's policy required a documented inventory of belongings upon admission, but this was not consistently followed. For one resident, some items were inventoried, but clothing was not included, and there was no documentation of property disposition upon discharge. Another resident's belongings were not properly inventoried or acknowledged upon discharge. A third resident's belongings were not inventoried upon admission, and there was no documentation of property disposition upon discharge. Interviews confirmed these findings, highlighting a lack of adherence to the facility's policy.
A facility failed to ensure that properly certified personnel provided CPR to a resident in an emergency. The resident experienced a medical crisis, and although CPR was initiated, the AED was not applied by facility staff before EMS arrival. The registered nurse supervisor involved did not complete the necessary skills portion of CPR/AED training, as confirmed by the Nursing Home Administrator. This deficiency highlights the facility's failure to maintain current CPR certification for its staff.
A resident's preference for showers was not honored by the facility, despite being documented in their care plan and task list. The resident, who had no cognitive impairment, was consistently given bed or towel baths instead. The facility could not provide a rationale for this failure, as confirmed by interviews with the resident and the DON.
A resident with Type Two Diabetes Mellitus had incomplete clinical documentation due to missing blood sugar values. The MAR/TAR indicated measurements were taken, but only one value was recorded. Interviews revealed the facility could not provide documentation for the missing values, resulting in an incomplete clinical record.
A resident with Alzheimer's was physically abused by another resident, leading to a serious injury. Despite initial interventions, the facility failed to maintain adequate monitoring or separate the residents, resulting in further aggression and harm. The aggressive resident, who was cognitively intact, continued to threaten and harm the victim, culminating in a fracture that required hospital admission.
The facility failed to maintain a sanitary environment in its main kitchen and two nursing units. Observations revealed dirty handwashing sinks, trashcans, and kitchen equipment, along with debris and food buildup in floor drains. The Second-Floor East and Third-Floor West nourishment rooms had dirty microwaves, countertops, and refrigerators, despite check sheets indicating they were clean. These deficiencies were reviewed with the Nursing Home Administrator.
The facility failed to maintain a clean and safe environment in two nursing units, with issues such as damp odors, fecal material, and black substances in shower rooms, as well as peeling paint and stained curtains in a resident's room. Several chairs in the patient lounge were also found with stains, debris, and frayed cushions. These deficiencies were observed and reported to facility management.
The facility failed to address grievances from four residents in a timely manner. Grievances filed by a resident in August and another in September were not investigated or addressed until November. This delay was confirmed by the Nursing Home Administrator and violated residents' rights as per state codes.
The facility failed to document and complete essential nursing rehab tasks for five residents, leading to a decline in their ability to perform activities of daily living (ADLs). Staff did not consistently document or complete tasks for dressing, grooming, eating, and walking, as required, across multiple shifts. These omissions were discussed with the Nursing Home Administrator and the Director of Nursing, highlighting a systemic issue in care practices.
The facility failed to provide appropriate respiratory care for three residents. A resident's oxygen was set above the prescribed level, and monitoring was not documented. Another resident's nasal cannula was found unprotected and unlabeled in a hallway. A third resident's respiratory equipment was improperly stored, with a nebulizer mask and suction tubing left uncovered. These issues were discussed with the facility's administration.
A facility's medication error rate reached 16% due to errors by two LPNs. One LPN administered Insulin Lispro after a resident's meal and failed to provide proper instructions for Dulera and Flonase use. Another LPN gave Glipizide after a resident's meal, contrary to instructions. Both LPNs confirmed their actions.
The facility failed to maintain accurate clinical documentation for four residents receiving restorative nursing services. Staff recorded providing nursing rehab for eating and swallowing before the scheduled delivery of breakfast trays, indicating discrepancies in the documentation. This issue was identified during a surveyor's interview with the Nursing Home Administrator and the DON.
The facility failed to provide the highest practicable care for three residents by not adhering to physician-ordered treatments and medications. A resident with sepsis missed several doses of an antibiotic, and their care plan lacked comprehensive assessment for PICC line complications. Another resident reported inconsistent tracheostomy care, and their treatment record showed incomplete documentation for skin tear care and a requested multivitamin. A third resident's treatment for foot blisters was not documented as completed, indicating a lack of communication and documentation regarding physician orders.
The facility failed to serve meals at scheduled times, with significant delays observed on multiple nursing units. A resident on the Second-Floor East unit received lunch over an hour late, and another resident on the Third Floor East unit reported similar delays for supper. Observations confirmed that meal trays consistently arrived late, affecting residents' meal times.
A facility failed to establish clear advance directives for a resident, resulting in a discrepancy between the resident's documented wishes and physician orders. The resident was initially listed as Full Code, but facility documentation indicated a DNR status, signed by the resident and medical provider. After review, it was clarified that the resident wished to be Full Code, but staff had entered the order as DNR.
The facility did not investigate a resident's rib fracture to rule out abuse and failed to complete a state police background check for a newly hired LPN. The resident complained of rib pain, and an x-ray confirmed a fracture, but no investigation was conducted. The LPN worked for over a month without the required background check.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis. The resident, who had a right chest tunnel catheter, did not have an emergency kit in their room containing essential items like sterile gauze and hemostat. This deficiency was confirmed during a review with the Nursing Home Administrator and DON.
A facility failed to provide trauma-informed and culturally competent care for a resident with PTSD. The resident, who is triggered by arguing, fighting, screaming, and doors slamming, had no identified triggers or individualized interventions in her care plan. The facility did not collaborate with the resident, her family, or mental health professionals to develop a personalized care plan.
A facility failed to ensure a physician responded to a pharmacist's recommendation for a resident's medication regimen. The resident had orders for Oxycodone and Acetaminophen, and the pharmacist suggested changes to improve pain management. However, the facility did not document a note to the physician, and the recommendation was not completed, as confirmed by the Nursing Home Administrator.
The facility failed to serve food at a palatable temperature on one nursing unit, affecting a resident. During a meal service, the oven fried chicken and rice were found to be lukewarm, with temperatures of 111.2°F and 119.2°F, respectively. A resident had previously expressed concerns about food temperatures, which was also noted in Food Committee meeting minutes.
The facility failed to implement enhanced barrier precautions (EBP) for three residents with indwelling medical devices, as required by CMS guidelines. A resident with a PICC line, another receiving dialysis via a central line, and a third with a foley catheter were observed without necessary EBP measures, such as signage or PPE. This deficiency was confirmed through observations and interviews with facility staff.
A facility failed to honor a resident's preferences for daily routines, such as waking and sleeping times. The resident preferred to wake at 7:00 AM and sleep between 7:00 PM and 7:30 PM, but was often still in bed at noon and delayed in going to bed due to late meal deliveries. This inconsistency was observed and confirmed through interviews.
A resident who required two-person assistance for bed mobility fell out of bed when a nurse aide attempted to reposition her alone, resulting in minor injuries. The facility failed to identify the staff involved, recognize the potential for neglect, and report the incident to state and local agencies. The incident was not thoroughly investigated, and the deficiency was confirmed during an interview with the NHA and DON.
A facility failed to secure medication properly on a nursing unit, as a resident was found with an unsecured bottle of Povidone-Iodine solution on her tray table. The resident, who shared a room, indicated she used the solution for a mole, but there was no clinical order or authorization for self-administration. The Nursing Home Administrator and DON confirmed the unsecured access to the solution.
A facility failed to maintain the privacy of resident records on the 2 [NAME] Nursing Unit. Employee 1 repeatedly left a resident's clinical record open and unattended on the medication cart, accessible to non-licensed staff and residents. The Nursing Home Administrator observed and confirmed the breach, which violated resident rights under 28 Pa. Code 201.29 (c.3)(4).
A medication cart on a nursing unit was repeatedly left unlocked and unattended by an LPN, despite being near residents and non-licensed staff. The cart was unsecured for 43 minutes, with the LPN lacking direct visualization for 23 minutes, violating medication security protocols.
The facility failed to assist two residents with activities of daily living, including bathing, repositioning, and toileting care. One resident, requiring extensive assistance, was not repositioned every two hours as ordered, and another resident did not receive regular bathing assistance. These issues were confirmed through interviews and documentation review.
A facility failed to maintain a resident's mobility as per her care plan, which included a walking program requiring staff assistance. The resident reported that staff did not follow her prescribed ambulation program, and documentation confirmed missed assistance on several occasions. The resident believed staffing changes, which removed dedicated restorative nursing aides, contributed to this deficiency. These concerns were discussed with the Nursing Home Administrator and the DON.
Missed Documentation of Ordered Wound Treatments
Penalty
Summary
The facility failed to provide the highest practical care regarding physician-ordered treatments for three residents. For Resident 1, a physician order dated May 19, 2026 directed staff to use Acetic Acid Irrigation Solution for wound care, cleanse the right hip wound with acetic acid, pat dry, apply Santyl to the base of the wound, and secure with a bordered dressing. The treatment administration record for May 2026 showed that the ordered treatment was not completed on one of the three days reviewed, with no documentation on May 21, 2026. For Resident 2, multiple wound and skin treatment orders were reviewed and several were not documented as completed on the treatment administration record. Orders included cleansing the left lower posterior thigh with normal saline, applying collagen, and securing with an abdominal pad; cleansing the right buttock with normal saline, applying calcium alginate and zinc oxide paste; placing Interdry in the abdominal folds every day and night shift; applying Triamcinolone Acetonide Cream to the left posterior thigh and wound base; cleansing the left abdomen with normal saline, applying zinc and nystatin, and leaving open to air; and applying Nystatin external cream to the abdomen. The May 2026 TAR showed missed documentation on multiple days for these treatments, including several blank entries on May 10, May 18, May 19, May 20, and May 21, 2026, depending on the order reviewed. For Resident 3, an order for left ischium wound care was in place from April 28 through May 4, 2026, requiring cleansing with normal saline, patting dry, applying Silvasorb gel and zinc oxide, and securing with bordered gauze dressing every day shift. A revised order beginning May 4, 2026 required the same wound care every day and night shift. The May 2026 TAR showed missed documentation for the ordered treatment on one of four days reviewed for the first order and on two of 23 days reviewed for the revised order, with blank documentation on May 3, May 20, and May 21, 2026. The findings were reviewed with the Nursing Home Administrator and the DON on May 27, 2026 at 2:21 PM.
Failure to Honor Guardian’s Right to Decide on Hospital Transfer After Fall
Penalty
Summary
Facility staff failed to honor the right of a resident’s court-appointed guardian to make decisions regarding transfer to the hospital. The resident had an MDS completed showing a BIMS score of seven, indicating severe cognitive impairment, and a court order documented that the resident was an incapacitated person with the son designated as permanent guardian and responsible party. After the resident, who required an assistive device and one-person assistance, attempted to self-transfer and was found on the floor, staff completed assessments and documented no injuries. Staff left a message for the responsible party about the fall and later documented that the responsible party returned the call and had no questions at that time. Subsequently, 911 dispatch contacted the facility to report that the resident’s responsible party had called 911, stating the resident had fallen and needed to be checked. Facility staff reported to 911 that the resident was being monitored per protocol and that the resident denied pain, and no EMS dispatch or hospital transfer occurred. There was no documentation of any follow-up or attempted communication from facility staff to the resident’s responsible party after the 911 call to discuss the resident’s condition or the guardian’s expressed desire for emergency services or hospital transfer. The record contained no evidence that staff provided the resident’s responsible party the opportunity to exercise the right to have the resident transferred to the hospital as requested.
Inadequate pain management for resident with daily severe pain
Penalty
Summary
The facility failed to ensure that pain management was provided consistent with professional standards of practice for one resident who had daily pain related to a right lower extremity femur fracture. The resident was admitted on February 27, 2025, and the care plan identified pain related to the fracture. The facility policy required pain assessment on admission, quarterly, with significant change, and with new or worsening pain, and it directed the physician to order appropriate interventions and reassess pain when pain relief was not acceptable. The resident told the surveyor that she had pain daily and that it could be severe at times. Her July and August 2025 MARs showed a weekly buprenorphine patch, Tylenol as needed for mild pain, and hydromorphone 4 mg every 12 hours as needed for moderate to severe pain. During July, the resident received hydromorphone 50 times for moderate to severe pain, and staff’s routine 12-hour pain assessments showed 32 of 62 assessments rated her pain as moderate to severe. During August, she received hydromorphone 48 times for moderate to severe pain, and 37 of 62 routine assessments rated her pain as moderate to severe. The facility failed to ensure her pain was managed consistent with professional standards of practice.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure its medication error rate remained below five percent. Surveyors determined a 23 percent medication error rate based on 38 medication opportunities with nine medication errors, involving Residents 13 and 17. The errors were identified through observation of medication administration, clinical record review, and interviews with staff and residents. For Resident 17, the RN did not have artificial tears or Lidocaine patches available in the medication cart during the 9:00 AM medication pass. The RN also did not administer four scheduled medications: Pyridoxine HCL, Loratadine, Fluticasone Propionate nasal spray, and Fluticasone-Umeclidin-Vilant inhalation powder. The RN stated the electronic medication administration system automatically entered U-SA for Flonase because it was listed as self-administered and kept at the bedside, but the resident stated she did not take Flonase that morning and it was not in her room. The RN also found Ipratropium Bromide nasal spray in an unlocked drawer in the resident’s bedside stand, although there was no physician order for the resident to self-administer that medication. The DON later confirmed there was no evidence of an assessment showing the resident was capable of self-administration, and maintenance staff had supplied the resident a key to the lockable drawer after the observation. For Resident 13, the RN prepared and administered medications incorrectly during the morning pass. The resident received two tablets of Tylenol Arthritis instead of one, one tablet of Sodium Bicarbonate instead of two tablets to equal the ordered 650 mg dose, and five tablets of Ferrous Sulfate instead of one tablet. The RN also administered Amlodipine and Carvedilol without obtaining the required blood pressure assessment specified in the physician orders. The RN stated she believed five iron tablets were needed to equal 325 mg and acknowledged she did not review the bottle labeling showing the ordered tablet strength. The RN and the DON reviewed these medication errors with the surveyor.
Confidential Medication Label Left Visible in Trash Receptacle
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical information when a discarded medication box with the resident’s name and order instructions remained visible in a regular trash receptacle on a wound care cart near the nurse’s station. Clinical record review showed the resident had an order for silver sulfadiazine cream one percent for bilateral lower extremity wound care, and a nursing progress note later documented a new order for the same medication to be applied to the bilateral lower extremities for wound care and rashes. During observation on the Nursing Unit Two East, two wound care carts were seen near the nurse’s station with trash receptacles attached to the side and partially filled clear garbage bags inside. One cart’s trash receptacle lid was mostly open, and a discarded silver sulfadiazine box with the pharmacy label attached was visible, showing the resident’s name and order instructions. A nurse aide confirmed the bins were used for regular garbage and was unsure whether the medication box belonged there, while the NHA stated the labeled medication should not have been in the regular garbage receptacle and that the label should be shredded.
Failure to Investigate and Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of potential resident-to-resident sexual abuse involving Resident 43 and two other residents, Residents 26 and 49. Facility policy required immediate separation of the alleged perpetrator from access to the alleged victim, initiation of an investigation by nursing leadership, notification of social services, and reporting of alleged abuse to the Pennsylvania Department of Health and other agencies as required. However, the Nursing Home Administrator and Director of Nursing confirmed that the facility did not complete an investigation, obtain witness statements, notify law enforcement, or notify the Department of Health regarding the allegation. Clinical record review showed Resident 43 was admitted on March 17, 2025, and was assessed as severely cognitively impaired on the most recent MDS. Nursing documentation on July 28, 2025, noted Resident 43 was making out with Resident 26. Records for Resident 26 also showed severe cognitive impairment on the most recent MDS. Nursing documentation on September 24, 2025, stated Resident 43 had Residents 26 and 49 in his room making out with them, and later that day Resident 43 and Resident 26 were in the back lounge making out and became upset when redirected. Social service documentation the next day noted Resident 43 may exhibit sexual advances described as making out with female residents on his unit, and he was placed on 15-minute checks. Nursing documentation also noted Resident 43 was reported with behaviors of making sexual advances toward others and placed on every 15-minute checks.
MDS Assessments Did Not Match Resident Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for three residents reviewed. For Resident 150, a quarterly MDS dated June 26, 2025, indicated that bed rails were being used as a physical restraint, but the clinical record contained no evidence that any restraints had been ordered for this resident. The Nursing Home Administrator and DON reviewed this information on October 1, 2025, and again on December 10, 2025, and the RN assessment coordinator later stated that the facility does not utilize restraints and that the MDS entry for Resident 150 was an error. For Resident 17, a quarterly MDS indicated that insulin had been received on three days during the seven-day review period, but a physician order dated May 1, 2025, discontinued Humalog insulin injections before meals based on blood glucose assessments, and the record showed no active physician order for insulin in July or August 2025. For Resident 75, an annual MDS indicated that an anticoagulant medication had been received during the last seven days of the assessment period, but the clinical record showed no evidence that the resident received an anticoagulant during that period. The RN assessment coordinator confirmed that the coding for Resident 17 and Resident 75 was in error.
Failure to Develop Care Plan for Identified Dental Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 45’s dental needs that were identified in the comprehensive assessment. Resident 45 stated that she had only broken natural teeth left, and observation of her mouth showed several blackened pieces of teeth in her lower jaw. However, nursing documentation dated September 30, 2025, recorded that staff noted Resident 45 was edentulous, and the record reviewed by the surveyor did not show evidence that she received professional dental services or declined such services when requested by the surveyor during interview with the NHA and DON. The oral/dental inspection completed after the surveyor’s questioning assessed Resident 45 as having obvious or likely cavities or broken natural teeth. The admission MDS also indicated that the resident had obvious or likely cavities or broken natural teeth, and the dental concern triggered the facility to proceed to a care plan. Review of the resident’s plan of care showed no plan addressing the identified dental concern. The NHA later confirmed that the facility did not develop a plan of care to address Resident 45’s dental concerns until after the surveyor questioned the issue.
Failure to Assess Decline in Bed Mobility and Transfers
Penalty
Summary
The facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of four residents reviewed for ADL concerns, Resident 9. Clinical record review showed that an MDS assessment dated [DATE] identified Resident 9 as independent with set up help only for bed mobility and transfers, but a later MDS assessment dated [DATE] assessed the resident as requiring one person, limited physical assistance for both bed mobility and transfers. There was no documented evidence in the clinical record that the facility identified or assessed the resident’s decline in these ADLs. During the seven-day look-back period, Resident 9 required staff physical assistance on four occasions for bed mobility and five occasions for transfers. The surveyor reviewed these findings with the DON and NHA on December 12, 2025, at 9:42 AM, and the facility was unable to provide further documentation showing that the decline was assessed or that any measures were implemented to mitigate it.
Failure to Follow Ordered Bowel Management Plan
Penalty
Summary
The facility failed to provide the highest practical care related to bowel management for one resident who was admitted on February 21, 2025. The resident had physician orders for Milk of Magnesia 30 mL by mouth as needed for bowel management if no bowel movement occurred in two days, and Dulcolax suppository as needed for constipation if Milk of Magnesia was ineffective and as needed for bowel management on day three. Review of the bowel elimination record showed no documented bowel movements for five consecutive days, from July 5 through July 9, 2025. During that period, there was no indication that staff offered the ordered PRN medications, and no documentation that the resident refused them. These findings were reviewed with the DON during interview on December 11, 2025.
Failure to Provide Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide comprehensive skin assessments consistent with professional standards of practice to promptly identify and promote healing of a pressure ulcer for one resident. The resident had cognitive impairment, with a BIMS score of 7 on a quarterly MDS dated November 11, 2025, and the MDS also indicated the resident had a pressure ulcer. Current physician orders dated August 21, 2025 directed staff to treat the resident’s sacral wound every other day on the day shift, and the TAR for November 2025 showed the treatment was being documented as completed. The resident’s care plan identified actual skin breakdown related to a right buttock pressure ulcer/sacral wound that began on June 26, 2025. Review of the clinical record showed no documentation that the pressure ulcer was comprehensively assessed on a routine basis, including wound measurements, signs of infection, drainage, or appearance. Available wound-related documentation from August through November 2025 consisted of intermittent skin observations noting a small open area with treatment in place and wound care center assessments showing a Stage 2 sacral pressure injury with measurements and drainage. Those wound care center notes documented the wound as 2.5 cm by 1.6 cm by 0.1 cm with light serous exudate and intact peri-wound skin, then 1.7 cm by 1 cm by 0.1 cm with light serous exudate and intact peri-wound skin, then 1.5 cm by 0.5 cm by 0.1 cm with moderate serous exudate and erythematous, macerated peri-wound skin, and later 0.8 cm by 0.5 cm by 0.5 cm with moderate serous exudate and erythematous, macerated peri-wound skin. The Nursing Home Administrator stated the pressure ulcer should have been assessed weekly, and an RN confirmed there was no further documentation showing the wound was routinely and comprehensively assessed for the dates reviewed.
Failure to Follow Smoking Safety Requirements
Penalty
Summary
The facility failed to ensure an environment free from potential accident hazards for one resident who smoked. The resident had diagnoses including hemiplegia and hemiparesis, an order allowing smoking cigarettes with staff supervision, and a care plan noting the resident wished to smoke and was at risk of injury due to the desire to smoke. The care plan also included interventions to provide and review the smoking policy, reassess the resident after any smoking policy violation, and provide adaptive safety devices when applicable, including a smoking apron. The resident’s MDS noted a BIMS score of 8, indicating cognitive impairment, and upper and lower extremity impairment on one side. During observation in the designated smoking area, the resident was sitting in a wheelchair and smoking a cigarette without the smoking apron required by the facility policy and care plan. The smoking aprons were hanging on the wall of the shed. Outside the shed, multiple partially smoked cigarette butts were observed on the ground around the smoking receptacle, and the receptacle contained a piece of plastic that blocked cigarettes from entering it, with several partially smoked cigarettes sitting on top of the plastic. The facility policy stated that smoking aprons would be worn by all residents while smoking, and the administrator later stated the resident should have had a smoking apron and, if in violation of the smoking policy, should have been immediately reassessed and brought back into the building.
Hand Hygiene Not Performed Between Glove Changes During Medication Administration
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection related to hand hygiene for one of 27 residents reviewed, Resident 13. The facility policy on handwashing/hand hygiene, last reviewed without changes on April 2, 2025, stated that personnel are to follow handwashing/hand hygiene procedures to help prevent the spread of infections and that hand hygiene is the final step after removing and disposing of PPE. The policy also stated that hand hygiene should be performed before applying non-sterile gloves and after removing gloves. During observation of the medication administration pass for Resident 13 on December 10, 2025, Employee 1 prepared and administered Olopatadine Hydrochloride eye drops, artificial tears, and Flonase nasal spray. Employee 1 donned gloves to administer the right eye dose, removed the gloves, and then donned a new pair without performing hand hygiene before administering the left eye dose. Employee 1 again removed gloves without performing hand hygiene, donned another pair to administer the nasal spray, then removed those gloves and did not perform hand hygiene before obtaining the artificial tears. Employee 1 donned gloves to administer the right eye dose of artificial tears, removed them, and donned another pair without hand hygiene before administering the left eye dose. In interview, Employee 1 confirmed she was aware of the steps for disposable glove use and that she should have performed some kind of hand hygiene between glove changes, but did not do so.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the main kitchen area, as evidenced by multiple direct observations of pest activity and unsanitary conditions. During a survey, multiple live and dead cockroach-appearing insects were found in both the dishwashing and cook areas, including inside overhead cupboards, under splash guards, and behind cooking appliances. The dishwashing area also had multiple smaller winged insects flying around, and there was a thick, black, greasy, and sticky substance coating the bottom of a stainless-steel table. Openings between the wall and splash guard were not sealed, allowing for visible insect activity. Additionally, there was an extensive build-up of dirt and debris along the perimeter of the wall and significant dust accumulation in air vents above the kitchen doors. Staff interviews confirmed sightings of cockroaches under floor mats in the cook area, and pest control documentation showed that while pest control services had been performed and areas treated, there was no evidence that the pest control service was notified of continued cockroach activity after their last visit. The facility did not provide documentation of further pest control actions in response to ongoing pest sightings, nor did it demonstrate that it had removed dead insects, sealed openings, or ensured a clean and sanitary environment in the affected areas.
Failure to Provide Bathing Assistance According to Resident Preferences
Penalty
Summary
The facility failed to provide bathing assistance to dependent residents in accordance with their documented preferences and care needs. Review of clinical records and electronic task documentation for four residents revealed that staff did not consistently assist with or document showers as required. For example, one resident who was dependent on staff for bathing missed a scheduled shower, with no documentation of refusal. Another resident, requiring setup and clean-up assistance, missed two scheduled showers, and reported that staff shortages sometimes prevented assistance. A third resident, needing partial to moderate assistance, also missed a scheduled shower without documentation of refusal. A fourth resident, dependent on staff and preferring two showers per week, only received one shower per week, contrary to her stated preference, with no documentation of refusal. Facility policy requires nursing staff to obtain and honor residents' bathing preferences, including frequency and timing. The documentation reviewed did not indicate that any of the residents refused their scheduled showers, suggesting that the missed care was due to staff inaction or lack of documentation. Interviews with residents confirmed that assistance was not always provided as scheduled, and staff acknowledged the findings during interviews with surveyors.
Failure to Protect Residents' Property from Loss
Penalty
Summary
The facility failed to implement procedures to protect residents' property from loss, affecting three of five residents reviewed. The facility's policy required a documented inventory of residents' personal belongings upon admission, but this was not consistently followed. For Resident CR1, the facility inventoried some items but failed to include clothing on the Disposition of Resident's Personal Effects form. Additionally, there was no documentation of the disposition of Resident CR1's property upon discharge, and a grievance was filed regarding a missing phone. For Resident CR3, the facility initially recorded no property on the Disposition of Resident's Personal Effects form, but later inventoried clothing on a separate form not acknowledged by the resident or their representative. Upon discharge, there was no evidence that Resident CR3 or their representative signed the form to confirm the collection of belongings. Similarly, for Resident CR4, there was no inventory of personal effects upon admission, and no documentation of property disposition upon discharge, despite confirmation from the responsible party that belongings were collected. Interviews with the Director of Nursing confirmed these findings, highlighting a lack of adherence to the facility's policy for inventorying and documenting residents' personal property. The facility's failure to ensure proper documentation and acknowledgment of residents' belongings upon admission and discharge led to deficiencies in safeguarding residents' property, as evidenced by missing items and incomplete records.
Failure to Provide Certified CPR in Emergency
Penalty
Summary
The facility failed to ensure that properly certified personnel provided basic life support, including CPR, to a resident who required emergency care. The facility's policy stated that CPR-certified staff should be available at all times, and staff must maintain current CPR certification through a provider that includes hands-on practice and in-person skills assessment. However, Employee 1, a registered nurse supervisor, did not complete the skills portion of the CPR/AED training to obtain certification, which was confirmed by the Nursing Home Administrator. On February 22, 2025, Resident CR2 experienced a medical emergency with decreased respirations and a thready pulse. Despite the facility's policy that residents without a completed POLST are considered Full Code, the documentation indicated that the AED was not applied by facility staff but only after EMS personnel arrived. CPR was initiated by the staff at 8:31 AM, and the AED was delivered at 8:45 AM, but there was no evidence that the AED was applied by the facility staff before EMS arrival. The Nursing Home Administrator confirmed that Employee 1 did not have CPR/AED certification and that the facility had an AED machine on each floor. The facility did not provide evidence that the AED was applied timely by the staff, which contributed to the deficiency. The report highlights the failure of the facility to ensure that licensed nursing staff maintained current CPR certification, which is crucial for providing timely and effective emergency care.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not adhering to their shower preference for bathing. Resident 1, who was admitted to the facility and assessed with no cognitive impairment, expressed a preference for showers on specific days. Despite this, the facility's records showed that the resident was consistently given bed or towel baths instead of showers over a 30-day period. There was no documentation indicating that the resident refused showers or had any medical condition preventing them from receiving a shower. Interviews with the resident and the Director of Nursing confirmed that the facility did not provide any evidence or rationale for not honoring the resident's shower preference. The care plan and task list both indicated the resident's preference for showers, yet this was not reflected in the care provided. The deficiency was noted during a survey, and the facility's administration was informed of these findings.
Incomplete Clinical Documentation for Diabetic Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident who was admitted with Type Two Diabetes Mellitus. The resident was required to have their blood sugar levels monitored four times a day as per a physician's order. On the day in question, the Medication Administration Record and Treatment Administration Record (MAR/TAR) indicated that blood sugar measurements were taken at three specified times, but only one value was documented. The facility's Weights and Vitals Summary recorded a blood sugar level of 210 mg/dL at one of these times, but there was no evidence of the other two blood sugar values that were marked as obtained. Interviews with the Nursing Home Administrator and a licensed practical nurse (Employee 1) revealed that the facility could not provide documentation for the missing blood sugar values. Employee 1 confirmed that they had documented the blood sugars as measured with a checkmark on the MAR/TAR but was unable to retrieve the actual values. This lack of documentation resulted in an incomplete and inaccurate clinical record for the resident, which was acknowledged by the Nursing Home Administrator and Director of Nursing.
Failure to Protect Resident from Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in actual harm. Resident 399, diagnosed with Alzheimer's Disease, was kicked by Resident 90, who claimed self-defense. Despite the initial intervention of separating the residents and implementing 15-minute checks, the facility did not maintain adequate monitoring or take further preventive measures. The one-to-one monitoring for Resident 90 was discontinued verbally by the Nursing Home Administrator, and the residents remained in the same room. Subsequent incidents of aggression by Resident 90 were documented, including threats and physical aggression towards Resident 399 and staff. Resident 90 was sent for a psychiatric evaluation but returned without new orders and continued to share a room with Resident 399. On a later date, Resident 399 was found on the floor with a serious injury, a left femoral neck fracture, after being pushed by Resident 90, who admitted to the act. The facility's investigation revealed that Resident 90 had a history of aggression and was cognitively intact, as indicated by a BIMS score of 13. Despite this, the facility did not implement effective interventions to prevent further abuse, resulting in significant harm to Resident 399. The failure to separate the residents or utilize additional resources to manage Resident 90's behavior contributed to the deficiency.
Deficiencies in Kitchen and Nourishment Room Sanitation
Penalty
Summary
The facility was found to have significant deficiencies in maintaining a safe and sanitary environment in its main kitchen and two nursing units. Observations revealed that handwashing sinks in the kitchen were stained and surrounded by dust, dirt, and debris. Trashcans and walls near these sinks were also dirty, with dried liquid spills and food splatter. The kitchen's large trash bins, flooring, and equipment such as the fryer, stove, and steamers were covered in dust, dirt, and food debris. The pot and pan shelving unit was corroded, and floor drains were clogged with food debris. Additionally, the interior of a portable cooler and a microwave contained old food and debris, indicating poor cleaning practices. On the Second-Floor East nursing unit, the nourishment room was observed to have brown stains in the sink, white buildup on the faucet, and crumbs and stains on the countertop. The microwave was dirty, and the refrigerator/freezer contained a frozen red substance and debris. A cabinet labeled not to store items contained an empty soda can, and the interior was dirty. A check sheet indicated that the area was marked as clean, despite the visible dirt and debris. Similarly, the Third-Floor West nourishment room had a microwave with blackened vents and dried food debris inside. Cabinets under the sink and for storing plasticware were dirty with spills and debris. The refrigerator and freezer also contained dried spills and a black/brown substance. Despite these conditions, a check sheet indicated that the area was marked as clean. These findings were reviewed with the Nursing Home Administrator, highlighting the facility's failure to maintain cleanliness and prevent potential food contamination.
Inadequate Housekeeping and Maintenance in Nursing Units
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unclean and unsafe environment in two of its nursing units, 2E and 2W. Observations on the 2E Nursing Unit revealed a damp odor in the shower room, while the 2W Nursing Unit had a damp odor, fecal material, and a black substance in the grout lines of the tile in the shower room. Additionally, there were missing and cracked tiles near the sink and entry door. These conditions were confirmed during an interview with the Nursing Home Administrator and Director of Nursing. Further observations included issues in Resident 15's room, where the bathroom ceiling had peeling paint and cobwebs, and the exhaust fan made a loud noise. The wall behind the bed had missing paint, and the privacy curtain was stained. In the patient lounge, several chairs, including those labeled for Residents 73, 84, 134, and 32, were found with stains, debris, and frayed cushions. These findings were communicated to the housekeeping staff and facility management.
Failure to Address Resident Grievances Timely
Penalty
Summary
The facility failed to address resident grievances in a timely manner for four residents. Resident 24 filed grievances on August 6 and August 13, while Resident 95 filed a grievance on August 7. Resident 65 raised a concern on September 24, and Resident 22 filed a grievance on September 15. However, there was no documentation indicating that the facility investigated and addressed the concerns of Residents 24, 65, and 95 until November 13. Similarly, Resident 22's grievance was not addressed until November 13, as confirmed by the Nursing Home Administrator during an interview on November 21. This delay in addressing grievances violated the residents' rights as outlined in the relevant state codes.
Failure to Document and Complete Nursing Rehab Tasks
Penalty
Summary
The facility failed to provide adequate care and services to prevent the decline in activities of daily living (ADLs) for five residents. The clinical record reviews and staff interviews revealed that the staff did not consistently document or complete the required nursing rehabilitation tasks for dressing, grooming, eating, and walking. These tasks were essential for maintaining the residents' abilities in ADLs, yet there were numerous instances where the staff either did not document the completion of these tasks or marked them as not applicable. For Resident 47, the staff failed to document or complete the nursing rehab tasks for grooming and eating on multiple occasions across both day and evening shifts. Similar patterns of neglect were observed for Residents 66, 73, 80, and 108, where the staff did not document or complete the required tasks for dressing, grooming, eating, and in some cases, walking. These omissions occurred over several days and shifts, indicating a systemic issue in the facility's care practices. The surveyor discussed these findings with the Nursing Home Administrator and the Director of Nursing, highlighting the facility's failure to adhere to resident care policies and nursing services regulations. The lack of documentation and completion of essential nursing rehab tasks contributed to the residents' decline in their ability to perform ADLs, which should have been prevented unless there was a medical reason for such decline.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents. For Resident 73, the clinical record indicated a physician's order for oxygen to be administered at 4 liters per minute (LPM) via nasal cannula, with oxygen saturation to be monitored every shift. However, observations revealed that the oxygen concentrator was set at higher levels of 6 LPM and 6.5 LPM on multiple occasions, and the resident was unable to adjust the settings independently. Additionally, there were several instances where staff failed to document the monitoring of the resident's oxygen levels as required. For Resident 122, a nasal cannula attached to a portable oxygen cylinder was found unprotected and unlabeled in a wheelchair in the hallway, with staff unable to identify its owner or ensure its proper storage. It was later identified as belonging to Resident 122. In the case of Resident 300, respiratory equipment, including a nebulizer mask and suction tubing, was observed uncovered and improperly stored in the resident's room on consecutive days. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 16 percent error rate based on 25 medication opportunities with four errors. During a medication administration pass, an LPN administered Insulin Lispro to a resident 90 minutes after breakfast, contrary to the physician's order to administer it before meals. Additionally, the same LPN did not instruct the resident to rinse her mouth after using a Dulera inhaler, as per the manufacturer's guidelines, nor did she instruct the resident to blow her nose or hold the opposite nostril closed when using Flonase nasal spray. Another LPN administered Glipizide to a different resident after breakfast, despite the medication label indicating it should be given before meals. Both LPNs confirmed their actions during interviews. The Nursing Home Administrator and Director of Nursing were informed of these medication administration concerns during a meeting.
Inaccurate Documentation of Nursing Rehab Services
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for four out of five residents reviewed for restorative nursing services. Specifically, the clinical records for Residents 47, 66, 80, and 108 showed discrepancies in the documentation of nursing rehabilitation services for eating and swallowing. Staff documented that they provided these services before the breakfast meal trays were delivered to the 2W Nursing Unit, which was scheduled for 7:50 AM and 8:00 AM. This inconsistency suggests that the documentation was not accurately reflecting the actual time the services were provided. The review of task documentation for the residents revealed that staff recorded providing nursing rehab for eating and swallowing on multiple dates in October and November 2024, all before the scheduled delivery time of the breakfast trays. This issue was identified during a surveyor's interview with the Nursing Home Administrator and the Director of Nursing, indicating a failure to maintain accurate medical records in accordance with accepted professional standards. The deficiency was noted under the regulations 28 Pa. Code 211.5 (f) Medical records and 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Failure to Adhere to Physician-Ordered Treatments and Medications
Penalty
Summary
The facility failed to provide the highest practicable care for three residents by not adhering to physician-ordered treatments and medications. Resident 131, diagnosed with sepsis and resistance to multiple antimicrobial drugs, was observed with a PICC line for intravenous antibiotic administration. However, the Medication Administration Record (MAR) showed missed doses of Meropenem on several occasions, with no documentation of administration, refusal, or unavailability. Additionally, the care plan for Resident 131 lacked comprehensive assessment for potential complications related to the PICC line. Resident 300, who required daily inner cannula changes for a tracheostomy, reported that the task was only performed sometimes. The treatment record lacked evidence of completed changes on specific dates, with no documentation of refusal or other reasons for non-completion. Furthermore, Resident 300 had a physician's order for daily application of xeroform gauze to a skin tear on the right elbow, but the treatment record showed no evidence of completion on a particular date. Additionally, despite a family request and physician's note for a daily multivitamin following the transition from enteral feeding to oral intake, there was no evidence of the multivitamin being ordered or administered. Resident 52 had a physician's order for daily betadine application to blisters on the right foot, but the treatment record showed no evidence of the night shift treatment being completed on specific dates. A family member had previously inquired about the treatment, indicating a lack of communication and documentation regarding the physician's order. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to ensure proper documentation and adherence to physician orders for resident care.
Delayed Meal Service Across Multiple Nursing Units
Penalty
Summary
The facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on three of five nursing units. Observations and interviews revealed that meals were consistently served late, with lunch trays being delayed by over an hour on multiple occasions. For instance, on the Second-Floor East nursing unit, Resident 9 was served lunch at 12:40 PM, despite the scheduled time being around noon. The delay was further compounded when the resident requested an alternate entree, which was not served until 1:01 PM. Similarly, on the Third Floor East Nursing Unit, lunch trays arrived over 45 minutes late, causing residents to wait in the dining room. Interviews with residents confirmed the issue of delayed meal service, with Resident 108 reporting that supper trays often arrived almost an hour late. The facility's meal schedule and observations of the tray line in the main kitchen corroborated these delays, as carts were observed leaving the kitchen later than scheduled. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting a systemic issue in meal service timing across multiple units.
Discrepancy in Resident's Advance Directive
Penalty
Summary
The facility failed to establish clear advance directives for a resident, leading to a discrepancy between the resident's documented wishes and the physician's orders. The resident was admitted to the facility with physician orders indicating a Full Code status, meaning resuscitation and CPR should be attempted if the resident had no pulse and was not breathing. However, facility documentation titled 'Code Status' for the resident indicated a Do Not Resuscitate (DNR) status, which was signed by both the resident and the medical provider. This discrepancy was identified during a review with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Despite the resident's signed wishes indicating a DNR status, nursing documentation initially listed the resident as Full Code. After further discussion, it was clarified that the resident wished to be Full Code, but staff had entered the order as DNR. This inconsistency in the resident's code status documentation was reviewed again with the NHA and DON.
Failure to Investigate Injury and Conduct Background Check
Penalty
Summary
The facility failed to implement its abuse policy regarding the investigation of an unknown injury for a resident and the completion of a background check for a newly hired employee. The policy on Resident Abuse and Neglect Prevention Program, last reviewed in May 2024, requires the investigation of bruises and marks of unknown origin, but does not specify how other injuries, such as fractures, should be investigated to rule out abuse. Resident 118 complained of left rib pain, and an x-ray revealed a fracture of the left 10th rib. Despite the absence of documented evidence of a fall, the facility did not conduct an investigation to rule out potential abuse or neglect. Additionally, the facility failed to complete a state police criminal background check for Employee 4, a licensed practical nurse hired in September 2024, who worked until October 18, 2024. The facility's policy requires a criminal background check to be completed within 30 days of hiring, but this was not done for Employee 4. Interviews with the Nursing Home Administrator confirmed these deficiencies, as the required investigation and background check were not completed as per the facility's policies.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. Clinical record review revealed that the resident was admitted to the facility and was receiving hemodialysis three days a week through a right chest tunnel catheter. An observation of the resident's room did not reveal any emergency supplies for the central line, such as sterile gauze, hemostat, needleless connector, or tape. The absence of an emergency kit was confirmed during a review with the Nursing Home Administrator and Director of Nursing, who initially suggested the kit might be in the resident's closet, but a subsequent observation confirmed it was not present.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, admitted on November 2, 2015, had an active diagnosis of PTSD, as noted in the Minimum Data Set Assessment dated June 15, 2024. During an interview on November 19, 2024, the resident disclosed that she is triggered by arguing, fighting, screaming, and doors slamming, which causes her to become anxious and pick at her fingernail beds. The clinical record review revealed that the facility did not identify the resident's history of trauma or her specific triggers. Additionally, the care plan lacked any identified triggers or individualized interventions to address her PTSD. There was no evidence of collaboration with the resident, her family, or mental health professionals to develop a personalized care plan. These findings were discussed with the Nursing Home Administrator and Director of Nursing on November 21, 2024.
Failure to Address Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to ensure an appropriate physician response to a consultant pharmacist's recommendation for a resident who was reviewed for potentially unnecessary medications. Resident 122 had current physician orders for Oxycodone HCL, an opioid analgesic, to be administered as needed for moderate to severe pain, and Acetaminophen for mild pain. A consultant pharmacist recommended a change in the medication regimen, suggesting Tylenol XR for daily pain management and a reduced dosage of Oxycodone at bedtime for a limited period. However, the facility did not provide documentation of a note written to the physician regarding the pharmacist's recommendation, indicating a lack of follow-through on the suggested changes. During an interview, the Nursing Home Administrator acknowledged that the recommendation was not completed and stated that it would be followed up on. This deficiency was identified through clinical record review, facility documentation, and staff interviews, highlighting a lapse in the facility's process for addressing pharmacist recommendations.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature on the Third Floor East nursing unit, affecting Resident 15. During a meal service observation, it was noted that food trays arrived on the unit and were immediately served to residents. However, the oven fried chicken and plain white rice were found to be at temperatures of 111.2 degrees Fahrenheit and 119.2 degrees Fahrenheit, respectively, which were confirmed by a nurse aide. These temperatures were not hot enough, as the food felt lukewarm and lacked steam. Resident 15 had previously expressed concerns about the food sometimes being cold, which was also noted in the Food Committee meeting minutes from September and October 2024, where residents indicated that hot food was not always hot and cold food was not always cold.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions (EBP) for three residents, as required by the CMS memo released on March 20, 2024. This memo mandates the use of EBP, including gown and glove use, for residents with chronic wounds or indwelling medical devices during high-contact care activities. Resident 131, diagnosed with sepsis and resistant to multiple antimicrobial drugs, had a PICC line but was observed without any EBP measures in place, such as signage or personal protective equipment (PPE). Similarly, Resident 52, who was receiving dialysis via a central line, and Resident 83, who had a foley catheter since 2022, were also found without EBP measures, including the absence of signage and PPE near their rooms. The facility's Infection Control Plan, last reviewed in September 2023, outlines the necessity of EBP for residents at higher risk of acquiring or spreading multidrug-resistant organisms (MDROs). However, observations and interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of EBP implementation for these residents. The deficiency was identified through clinical record reviews and direct observations, revealing a gap between the facility's policy and its execution, as no EBP measures were in place for the residents with indwelling devices or wounds, contrary to the CMS guidelines.
Failure to Honor Resident's Daily Routine Preferences
Penalty
Summary
The facility failed to ensure that residents could make choices about significant aspects of their lives, specifically regarding their daily routines. Resident 108 expressed a preference for waking up at 7:00 AM and going to bed between 7:00 PM and 7:30 PM. However, there were instances where the resident was still in bed at 12:00 PM and did not go to bed until 9:00 PM or 9:30 PM due to late supper meal delivery at 7:00 PM most nights. This was confirmed through an interview with Resident 108 and an observation made by the surveyor. The resident's initial MDS indicated the importance of personal choices, including waking and sleeping times, which were not consistently honored by the facility.
Failure to Investigate and Report Potential Neglect
Penalty
Summary
The facility failed to properly investigate and report an incident involving a potential neglect of a resident. Resident 65, who required assistance from two staff members for bed mobility, reported a fall that occurred when a nurse aide attempted to reposition her without the necessary assistance. This resulted in the resident rolling out of bed and sustaining minor injuries, including abrasions on her knees and a scratch on her elbow. The incident was not reported to the appropriate state and local agencies, and the facility's investigation did not identify the staff member involved or acknowledge the resident's care plan requirements. The incident was brought to the attention of the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing by Employee 9, who was informed by another nurse aide about the fall. Despite this, there was no documentation from the nurse aide who caused the fall, and the facility did not recognize the potential for neglect. The lack of timely reporting and thorough investigation of the incident was confirmed during an interview with the NHA and DON, highlighting a deficiency in the facility's management and reporting procedures.
Medication Security Lapse on Nursing Unit
Penalty
Summary
The facility failed to ensure appropriate medication security on one of its nursing units, specifically involving a resident on the Second Floor East. During observations on November 19 and 20, 2024, a bottle of Povidone-Iodine solution 10% was found unsecured on the resident's tray table. The resident, who shared a room with a roommate, indicated she was using the solution for a mole on her face, although she had not applied it recently. She mentioned purchasing the solution herself and that the facility staff was aware of its presence. However, a review of the clinical records showed no evidence of an order for the iodine solution, nor any authorization for the resident to self-administer or store it in her room. This situation was confirmed in an interview with the Nursing Home Administrator and Director of Nursing, highlighting the unsecured access to the solution by the resident and potentially other residents on the unit.
Resident Record Privacy Breach
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records on the 2 [NAME] Nursing Unit. During an observation on October 31, 2024, Employee 1 was seen repeatedly leaving a resident's clinical record open and unattended on the medication cart. This occurred multiple times between 12:21 PM and 12:44 PM, with the record being left in full view and accessible to non-licensed staff and residents who were nearby. Employee 1 was observed leaving the medication cart to attend to other tasks, such as pouring medications and administering them to residents, without securing the clinical record. At 12:44 PM, the Nursing Home Administrator (NHA) noticed the unattended clinical record and acknowledged the issue. The NHA found Employee 1 in a resident's room and informed them of the privacy breach. The observations and findings were confirmed during an interview with the NHA at the time of the incident. The deficiency was cited under 28 Pa. Code 201.29 (c.3)(4) regarding resident rights, highlighting the facility's failure to protect the confidentiality of resident records.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure appropriate medication security on the 2 [NAME] nursing unit, as observed by a surveyor. The medication cart was found unlocked and unattended near the nurse's station on multiple occasions. At 11:12 AM, the cart was left unlocked with no licensed staff in the vicinity, while several residents were nearby. Employee 1, an LPN, returned to the cart from down the hallway, out of view of the cart. This pattern continued, with the cart remaining unlocked and unattended at various times, including at 12:02 PM, 12:04 PM, 12:11 PM, 12:13 PM, 12:16 PM, 12:19 PM, 12:21 PM, 12:22 PM, 12:24 PM, 12:37 PM, and 12:38 PM. During these times, Employee 1 was observed leaving the cart to attend to residents or respond to call bells, often leaving the cart out of sight and unsecured. The Nursing Home Administrator (NHA) later observed the unlocked cart and acknowledged the issue, locating Employee 1 to inform them of the security lapse. The cart remained unlocked for a total of 43 minutes, with Employee 1 lacking direct visualization of the cart for 23 minutes. This failure to secure the medication cart violated the facility's obligation to store drugs and biologicals in locked compartments, as required by professional principles and state regulations.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance to two residents with their activities of daily living, specifically in bathing, repositioning, and toileting care. Resident 2, who requires extensive assistance from two staff members for bed mobility and transfers, reported discomfort from being left in the same position for extended periods. Despite having a physician's order and a care plan in place to turn and reposition her every two hours, documentation revealed that staff did not consistently follow these instructions on multiple occasions in May and June 2024. Additionally, the facility did not adhere to the bowel incontinence program for Resident 2, as evidenced by gaps in the task documentation for checking and changing her every two hours. Resident 7, who needs setup and cleanup assistance with bathing, reported receiving a shower approximately every other week. Task documentation confirmed that there were significant periods in May 2024 where no assistance with bathing was documented for Resident 7. These deficiencies were discussed with the Nursing Home Administrator and the Director of Nursing during an interview conducted by the surveyor.
Failure to Maintain Resident Mobility
Penalty
Summary
The facility failed to provide necessary services to maintain a resident's mobility, specifically for one resident who was part of a group of seven reviewed. The deficiency was identified through a clinical record review and interviews with the resident and staff. The resident, identified as Resident 6, reported that staff had not adhered to her prescribed walking program, which was part of her care plan to address deficits in self-care and activities of daily living. The care plan included a nursing rehabilitation program that required ambulation of 200-250 feet twice daily with one staff assist, using a roller walker and a wheelchair for support due to potential dizziness. Documentation from the facility's electronic system for nurse aide activities revealed that staff failed to assist Resident 6 with her restorative ambulation program on multiple dates in May and June 2024. The resident expressed concerns that the facility's restructuring of nurse aide staffing, which eliminated dedicated restorative nursing aides, contributed to the lack of assistance. These issues were discussed with the Nursing Home Administrator and the Director of Nursing during the surveyor's interview.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broad Acres Health And Rehabilitation | 18.7 mi | ★★★★★ | 1 | 0 |
| Wecare At The Green Home | 20.1 mi | ★★★★★ | 0 | 0 |
| Carleton Healthcare And Rehabilitation Center | 20.6 mi | — | 0 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 20.8 mi | ★★★★★ | 3 | 0 |
| Chemung County Health Center - Nursing Facility | 20.9 mi | ★★★★★ | 0 | 0 |
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