Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Canterbury Place during CMS and state inspections, most recent first.
A cognitively intact resident with cancer and malnutrition was left without an accessible, functioning call bell after an RN unplugged the call system from the wall in an attempt to stop persistent TV sound. The call bell was left on the floor and no alternative call method was provided, despite facility policy requiring call lights to be plugged in and functioning at all times. Staff statements indicated awareness that the call light was not working and that no one ensured the resident had another way to summon help, even as the resident later experienced emesis and could not call for assistance. Documentation also showed a gap in MAR entries during the overnight hours, and the NHA confirmed the failure to provide a fully functioning call bell system, which was cited as immediate jeopardy.
Staff disconnected a malfunctioning call bell for a trach‑dependent, cognitively intact resident and left it on the floor, out of reach, without providing any alternative means to summon help. The resident, who could not speak due to a tracheostomy and had diagnoses including cancer and malnutrition, later experienced emesis and was unable to call for assistance, ultimately walking to the nurse’s station to obtain help. Facility documentation and interviews confirmed that the call bell was unplugged and no backup system or checks were implemented, resulting in the resident being left without a functional way to contact staff.
A resident with spinal stenosis, obesity, and muscle weakness who required a Hoyer lift for transfers developed significant left thigh pain and bruising during care, after reporting that staff held her legs open to clean her. She was transferred to the hospital, where imaging showed a large hematoma of the left medial thigh with active bleeding. Facility records indicated that an incorrect Hoyer pad had been used, and surveyors determined that inadequate supervision and improper use of mechanical lift equipment led to the injury.
The facility failed to ensure that a resident had access to a fully functioning call bell system, resulting in an immediate jeopardy situation. The NHA, whose role includes overseeing overall operations and resident safety, and the DON, responsible for directing nursing services and coordinating care to maintain quality, did not effectively manage the facility to provide this essential safety measure. Consequently, the facility did not uphold fundamental principles of treatment and care or ensure that care was delivered in accordance with professional standards of practice and facility policy.
Care plans were not updated to match the current needs of three residents. One resident with dysphagia choked on a hamburger, but the care plan still showed no need for a modified diet despite the resident being offered pureed food and refusing it. Another resident on Eliquis for PE had no care plan goal or interventions for anticoagulant monitoring, and a third resident’s care plan still listed fluid restriction concerns even after the MD discontinued the restriction. The DON and RD confirmed the omissions.
The facility failed to complete quarterly AIMS assessments for three residents receiving antipsychotic meds. Records showed residents with diagnoses including dementia, HTN, A-fib, HF, and Parkinsons disease, and the MDS indicated antipsychotic use. The DON confirmed the AIMS reviews were supposed to be done every 3 months and that the facility did not meet that requirement for the residents.
A facility failed to coordinate hospice services with facility services for five residents receiving end-of-life care and did not have a current hospice agreement that included the vendor’s name. The residents had hospice orders and diagnoses including DM, dementia, OA, HTN, A-fib, CAD, HF, hyperlipidemia, and Parkinson’s disease, but their hospice binders did not contain hospice plans of care. An RN said she was not aware of what belonged in the binder, and the hospice RN confirmed the care plans were missing.
Failure to Maintain Resident Dignity With Exposed Catheter Bag: A resident with an indwelling catheter for obstructive uropathy was observed walking in a public area with the catheter drainage bag fully visible and without a privacy cover. An employee confirmed the bag was uncovered and that the resident's dignity was not maintained.
A resident with HTN, ESRD, and anemia had no documented advance directive or record that the facility offered the opportunity to formulate one. The resident’s MDS and social service assessment did not show any advance directive documentation, and the DON confirmed the missing documentation for the resident reviewed.
A resident with polyneuropathy, edema, obesity, and IDDM had multiple blood glucose readings above the ordered call-provider threshold, but the chart showed no physician notification. The DON confirmed the elevated blood sugars were not reported as required.
Failure to Post Required Grievance Information: A resident council reported that residents were not aware of the grievance officer or the location of grievance boxes and forms. Observations on multiple unit bulletin boards found missing grievance officer contact information, instructions for filing a grievance, and business address/email details, and the NHA confirmed the required grievance process information was not displayed.
Failure to properly treat and monitor pressure ulcers. The facility did not ensure proper PU/PI care for two residents. One resident with dementia, depression, and anxiety had a DTI to the left heel with a physician order for daily wound care, while another resident had an unstageable left heel PI with slough, but the wound was not measured weekly as required and the care plan lacked a goal and interventions for monitoring and management. An RN and the DON confirmed the deficiencies.
A resident with a trach, COPD, anemia, and schizophrenia was ordered daily and PRN trach care, monitoring for infection or dislodgement, and oxygen via trach mask. Although the admission assessment noted a spare trach kit at bedside, surveyors observed the resident with oxygen connected and no backup Shiley uncuffed #6 trach present; an RN confirmed the backup trach was missing, and the DON confirmed the facility failed to provide trach care consistent with professional standards of practice.
The facility failed to provide trauma informed care for a resident with PTSD. The resident’s care plan noted trauma but did not identify triggers or how to avoid them, and the DON confirmed the deficiency during interview. The resident also had heart failure, HTN, dementia, CAD, and hyperlipidemia.
Improper Medication Storage and Unsecured Medication Cart: The facility failed to store drugs and biologicals securely in a medication room and multiple med carts. An ice pack was kept in the wrong refrigerator, several opened meds were undated, one eye drop medication was not stored in a box or bag, and insulin pens were opened and undated. A med cart was also observed unlocked and unattended near the nursing station, and an LPN confirmed it was accessible to residents.
The facility failed to hold QAA meetings at least quarterly with all required committee members for two of four quarters. Review of policy and QAPI sign-in sheets showed the Medical Director was absent from the committee meetings during those quarters, and the NHA confirmed the failure during interview.
Failure to provide required PPE for Covid airborne isolation. A resident with positive Covid was ordered to remain in a private room under contact and airborne precautions, with care provided in the room. Observation showed the room had masks, N95 respirators, gloves, gowns, and hand sanitizer available, but no eye protection. Staff interviews showed an NA and an RN were unsure eye protection was required, and the IP confirmed eye protection was needed in the positive Covid room.
Two residents did not receive treatment and care in accordance with professional standards due to inaccurate transcription of physician orders on admission. One resident received Hydroxyurea at twice the prescribed frequency, and another received Omeprazole at a lower frequency than ordered, with both errors confirmed by facility leadership.
A resident with diabetes experienced multiple episodes of blood glucose levels above 400 mg/dL, which required physician notification according to orders. Facility staff did not notify the physician as required, despite repeated abnormal readings, as confirmed by review of records and staff interview.
A resident with chronic respiratory conditions did not receive Bipap therapy as ordered due to repeated device malfunctions and lack of timely staff response. Staff noted the Bipap would turn off or stop working, but did not always notify the physician or family. The resident experienced respiratory distress and was ultimately hospitalized with elevated CO2 levels, requiring ICU care.
A resident with severe cognitive impairment and multiple medical conditions was recorded by a nurse aide, who then posted the video on social media while laughing at the resident's comments. The resident's identity was partially obscured but still recognizable, and the video was shared among staff. This incident was reported by another staff member, and facility leadership confirmed the failure to protect the resident from mental abuse facilitated by technology.
Surveyors found that two residents did not receive proper respiratory care, including undated and unchanged oxygen tubing, and respiratory equipment such as BiPAP masks and nebulizer masks not being stored in bags as required by facility policy and physician orders. An LPN and the DON confirmed these deficiencies during interviews.
The facility failed to maintain its automatic sprinkler system, as the sprinkler gauges were dated 2019 and lacked documentation of replacement or testing within the last five years. This deficiency was confirmed by the Facility Administrator and Maintenance Director, affecting the entire facility.
The facility did not perform required criminal history background checks before hiring five staff members, including RNs, NAs, and an LPN, as per their policy. This failure was confirmed by the Nursing Home Administrator and identified through personnel records and deployment documents.
The facility failed to include necessary details in physician orders for urinary catheters for three residents and did not cover catheter bags as required for two residents, impacting their care and dignity. This was confirmed through staff interviews and observations.
The facility failed to maintain consistent communication with the dialysis provider and accurate care plans for residents requiring dialysis. Incomplete communication forms were found for four residents, and two residents had care plans lacking necessary monitoring instructions for dialysis access sites. Staff interviews confirmed these deficiencies, violating facility policy and state regulations.
The facility did not complete annual performance evaluations for three nurse aides as required by federal regulations. The personnel records for these aides lacked the necessary evaluations based on their hire dates, which was confirmed by the Nursing Home Administrator.
A resident with renal insufficiency and diabetes was found with two cups of medication at their bedside, but the facility failed to conduct a thorough investigation. The Director of Nursing confirmed the investigation was incomplete, lacking documentation and staff interviews to determine the origin and nature of the medications.
The facility failed to update care plans for two residents, omitting necessary interventions for a Continuous Glucose Monitoring system and a Wound Vac. This was confirmed by the DON, indicating a lack of adherence to policy and state regulations.
A facility failed to notify a physician of abnormal glucose readings for a resident with diabetes, as per the physician's order. The resident had multiple glucose readings above the threshold requiring physician notification, yet no documentation of such notification was found. The Director of Nursing confirmed the oversight, which violated facility protocols and state regulations.
The facility failed to prevent and treat pressure ulcers for two residents. One resident with a Stage 3 pressure injury lacked a care plan for injury management and preventative measures. Another resident had an injury on the toe with no documented follow-up. Staff confirmed the lack of care plans and preventative measures.
A facility failed to provide appropriate care for a resident with an enteral feeding tube, as observed when the resident's feeding and water flush bags were found undated. The resident, with diagnoses including cerebral infarction and aphasia, had specific physician orders for enteral feeding and water flushes, which were not properly managed, potentially leading to complications.
A facility failed to coordinate hospice services for a resident with heart failure, dysphagia, and high blood pressure. The facility's policy requires collaboration with hospice representatives, but the resident's records lacked appropriate physician orders and a comprehensive care plan for hospice services. Interviews confirmed the facility's failure to ensure proper coordination of hospice care.
The facility failed to follow enhanced barrier precautions for two residents and did not implement proper interventions for a Covid-positive resident. A resident with renal failure did not have EBP orders for indwelling devices, and a nurse improperly donned a gown. Another resident under isolation-contact and droplet precautions was assisted by a nurse aide without proper PPE, and the signage was incorrect. A Covid-positive resident's room was left open, and a nurse aide was observed without appropriate PPE.
A facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to a newly hired nurse aide on the date of orientation, as required by policy. The nurse aide began working without this training and only received it two months after her hire date. This deficiency was confirmed by the NHA.
The facility's Infection Control Committee meetings in 2024 lacked required multidisciplinary members, specifically laboratory personnel, for two quarters. This non-compliance with the MCARE Act was confirmed through attendance logs and an administrative assistant's interview, which also noted the absence of pharmacy staff in a previous quarter.
The facility failed to maintain complete personnel records for an RN, missing documentation such as job description, educational background, employment history, and reference checks. Despite the facility's policy requiring these documents before employment, the RN began working without them, as confirmed by the NHA.
The facility failed to conduct pre-employment TB screening for a newly hired RN, Employee E2, as required by their TB infection control program policy. The RN's pre-employment health questionnaire had an unanswered TB section, yet the RN was hired and began working without the necessary screening. This was confirmed by the Nursing Home Administrator during an interview.
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for 30 months, from April 2022 through September 2024. This was confirmed through a review of facility documents, an audit by the State Ombudsman Office, and an interview with the DON. The facility did not provide evidence of compliance with the notification requirement, as required by PA Code: 201.29(f)(g) on resident rights.
Resident Left Without Functioning Call Bell After RN Unplugs System
Penalty
Summary
The deficiency involves the facility’s failure to ensure a fully functioning and accessible call bell system for a cognitively intact resident, resulting in the resident being without an active call system in the room and bathroom/bathing area for an extended period. The resident had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx, and was assessed as cognitively intact with a BIMS score of 15. Facility policy required that call lights be plugged in and functioning at all times and that residents unable to use call lights be checked frequently. Despite this policy, the resident’s call bell was disconnected from the wall and left inaccessible on the floor, leaving the resident unable to summon assistance. According to facility documentation and witness statements, during a night shift an RN attempted to address a problem with the television sound that was controlled through the call system remote. The resident requested that the TV sound be turned off, and when the RN could not silence the sound using the available controls, the RN removed the call system cord from the wall to stop the noise. The RN acknowledged that this action disconnected the call system and that no alternative call method (such as a hand bell or backup cord) was provided to the resident. The resident later reported that the call bell was left on the floor and was not accessible, and that she experienced an episode of emesis and was unable to call for assistance because the call bell had been disconnected. Additional staff statements indicated that other staff were aware the call light was not working and did not ensure that the resident had an alternative means to call for help. A nurse aide reported being told by the RN that the call light was not working and that she did not know how to fix it. Another undated/unsigned witness statement described a staff member seeing the call light going off at 2 a.m., being told by the assigned nurse that the light had been broken that shift and that it was fine with no need to enter the room, and therefore not checking on the resident. Facility documentation also showed a gap in the resident’s MAR documentation between 1:25 a.m. and 4:00 a.m. The Nursing Home Administrator later confirmed that the facility failed to provide a fully functioning call bell system for this resident, which was determined to be an immediate jeopardy situation.
Removal Plan
- Tested Resident R1's call bell to ensure proper functioning and verified the resident had access to a functioning call system positioned appropriately to meet the resident's needs.
- Completed an assessment of Resident R1 to ensure no adverse outcomes occurred as a result of the call bell being unplugged; no injuries found.
- Educated staff from all departments on call bell accessibility and what to do if the call bell stops working.
- Inspected and tested all resident rooms and common areas with call bell access for functionality and accessibility; no issues identified.
- Had an outside vendor examine the nurse call system and test all activation points; all found in good working condition.
- Conducted a root cause analysis regarding the call bell issue and performed an audit of the call bell system in all resident rooms and common areas where residents may initiate a call.
- Implemented a preventative maintenance schedule for ongoing monitoring of the call bell system.
- Re-educated staff on daily visual checks of call bell accessibility and reporting procedures for any identified functionality issues.
- Implemented Maintenance Director/designee audits of call bell functionality and maintained documentation, reviewed results at QAPI, and corrected and reported any deficiencies immediately.
- Updated the TELS maintenance tracking system to include conducting a test of the nurse call system.
- Completed immediate corrective action for Resident R1 and completed facility-wide call bell testing, with ongoing preventative maintenance and monitoring to continue.
Resident Left Without Functional Call System After Call Bell Disconnected
Penalty
Summary
Facility staff failed to ensure that a cognitively intact, trach‑dependent resident had a functional means to contact staff after the resident’s call bell system malfunctioned. The resident, who had diagnoses including cancer, malnutrition, and malignant neoplasm of the larynx and was unable to speak due to a tracheostomy, reported that during the night shift a nurse removed the call bell from the wall because of a technical issue and left it on the floor, out of the resident’s reach. Facility documentation and staff statements indicated that the call system’s TV volume function was malfunctioning, and the RN disconnected the call bell from the wall to stop the noise. At that time, there were no alternative call systems, backup cords, or other devices provided to the resident to summon assistance. The resident stated that after the call bell was disconnected and left inaccessible, she experienced an episode of emesis and was unable to call for help. She reported that staff did not come in to check on her and that, without a working call bell, she had to walk out to the nurse’s station to obtain assistance. Facility documentation confirmed that the resident’s call bell was unplugged and that no other way to contact staff was provided, despite the resident’s trach dependence and inability to speak. This sequence of actions and inactions resulted in the resident being left without necessary means and services to request help, constituting neglect as defined in the facility’s abuse and neglect policy.
Improper Hoyer Lift Pad Use and Inadequate Supervision Resulting in Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe use of mechanical lift equipment during care for one resident, resulting in a significant injury. The resident had diagnoses including spinal stenosis, obesity due to excess calories, and muscle weakness, and required the use of a Hoyer lift for transfers. During care, the resident complained of left leg pain while care was being performed, cried out, and reported tightness in her legs and a loose stool overnight. She stated that no one hit her but that her legs had been held open to clean her, after which her left leg developed a bruise and became painful. Vital signs were within normal limits and respirations were easy at the time, but the resident’s daughter requested hospital transfer. Hospital documentation later identified a 9 x 7 x 16.6 cm hematoma within the soft tissue of the left medial thigh with a small spot of active bleeding. Facility documentation indicated that the resident required a Hoyer lift and that an incorrect Hoyer pad had been used during the incident. Based on policy review, clinical and facility record review, hospital records, and staff and resident interviews, surveyors determined that the facility did not ensure the area was free from accident hazards and did not provide adequate supervision and proper use of assistive devices for this resident, leading to the hematoma and transfer to the hospital.
Failure to Ensure Functioning Call Bell System Resulting in Immediate Jeopardy
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility so that it provided a fully functioning call bell system for one resident (R1), resulting in an immediate jeopardy situation. The NHA’s job description specified responsibility for overseeing overall operations, including resident care, customer service, and the welfare and safety of residents, while the DON’s job description specified responsibility for planning, organizing, developing, and directing the overall operation of the nursing services department and coordinating nursing services with other departments to maintain quality of care. Despite these defined responsibilities, the facility did not ensure that one resident had access to a fully functioning call bell system. As a result, the facility failed to provide fundamental principles that apply to treatment and care, and failed to ensure that residents receive treatment and care in accordance with professional standards of practice and facility policy.
Care plans not revised to reflect residents’ current needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents’ specific care needs for three residents. Resident R29, who had diagnoses including pulmonary hypertension, glaucoma, and dysphagia, was documented as choking on a hamburger on 12/12/25. The progress note stated the resident had difficulty coughing the piece of hamburger up, then recovered and returned to baseline. The resident was offered a pureed diet and refused it, and the daughter present stated, “That will never happen.” The care plan reviewed on 1/13/26 still indicated no need for a modified diet, and the Registered Dietitian confirmed the care plan had not been revised as required. Resident R22’s MDS dated 12/10/25 identified diagnoses of high blood pressure, diabetes, and falls, and also indicated use of anticoagulants. A physician order dated 12/6/25 showed Eliquis 5 mg twice daily for pulmonary emboli, but the current care plan did not include a goal or interventions for management and monitoring of anticoagulant use; the DON confirmed this omission. Resident R31, with diagnoses including end stage renal disease, anemia, and diabetes, had a physician order dated 12/16/25 discontinuing fluid restriction because the resident refused to comply. However, the care plan reviewed on 1/13/26 still stated the resident had potential for dehydration or fluid deficit related to dialysis and fluid restriction, and the DON confirmed the care plan had not been updated to remove the discontinued restriction.
Failure to Complete Quarterly AIMS Assessments
Penalty
Summary
The facility failed to provide AIMS assessments at least quarterly for three residents who were receiving antipsychotic medications. Facility policy stated that AIMS assessments are to be completed prior to initiation of any antipsychotic medication and every three months thereafter for all residents receiving antipsychotics. Review of the clinical records showed that Resident R30 had diagnoses of hypertension, atrial fibrillation, and dementia, and the MDS indicated antipsychotic use; the last AIMS evaluation was completed on 7/8/25. Resident R36 had diagnoses of heart failure, hypertension, and dementia, with antipsychotic use also indicated on the MDS; the last AIMS evaluation was completed on 9/20/25. Resident R102 had diagnoses of Parkinsons disease, atrial fibrillation, and dementia, with antipsychotic use indicated on the MDS; the last AIMS evaluation was also completed on 9/20/25. During an interview on 1/16/26 at 11:40 a.m., the DON confirmed that AIMS assessments should be completed quarterly and acknowledged that the facility failed to provide an AIMS assessment at least quarterly for these three residents. The deficiency was cited under 28 Pa. Code 201.14(a), 211.5(f), and 211.12(d)(1)(3)(5).
Hospice care plans missing from resident binders and vendor agreement incomplete
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the needs of five residents receiving end-of-life care, and it also failed to have a current hospice agreement that included the vendor’s name. The facility’s Hospice Program stated that hospice services were available to residents at the end of life and that contracted hospice providers must have a written agreement with the facility outlining responsibilities. However, the agreement reviewed on 1/15/26 did not provide a current hospice agreement with the vendor’s name. Review of five residents’ records showed each had an order for outside vendor hospice services, but their hospice binders did not contain a hospice plan of care. Resident R21 had diagnoses including diabetes, dementia, and osteoarthritis and had hospice services ordered on 10/16/25. Resident R30 had hypertension, atrial fibrillation, and dementia and had hospice services ordered on 12/26/25. Resident R33 had CAD, hyperlipidemia, and dementia and had hospice services ordered on 12/26/25. Resident R36 had heart failure, hypertension, and dementia and had hospice services ordered on 10/18/25. Resident R50 had CAD, hypertension, and Parkinson’s disease and had hospice services ordered on 12/26/25. During interview, the RN stated she was not aware of what should be in the binder, and the hospice RN confirmed the five binders did not have care plans and stated she could get them sent over and put them in. The Nursing Home Administrator confirmed the facility failed to ensure coordination of hospice services and lacked a current hospice agreement with the vendor’s name.
Failure to Maintain Resident Dignity With Exposed Catheter Bag
Penalty
Summary
The facility failed to ensure that care was provided in a manner that maintained resident dignity for Resident R64. Facility policy on dignity stated that each resident shall be cared for in a manner that promotes well-being, satisfaction with life, and self-worth, and that demeaning practices compromising dignity are prohibited, including helping residents keep urinary catheter bags covered. Resident R64 was admitted to the facility with diagnoses including benign prostatic hyperplasia, obstructive uropathy, and depression, and the MDS indicated an indwelling catheter was present. A physician order directed catheter care every shift, and the care plan identified the resident as having an indwelling catheter due to obstructive uropathy. During an observation, Resident R64 was walking with Therapy Employee E2 in the foyer at the top of the public stairwell with the urinary catheter bag in full view of passersby and without a privacy or dignity cover over the bag. During an interview at the time of the observation, Therapy Employee E2 confirmed that the catheter draining bag did not have a privacy cover and that the facility failed to ensure care was provided in a way that maintained Resident R64's dignity.
Missing Documentation of Advance Directive Opportunity
Penalty
Summary
The facility failed to provide documentation that one resident, R48, was given the opportunity to formulate an advance directive. Review of the facility policy indicated that prior to or upon admission, the social services director or designee is to inquire about the existence of any written advanced directives and, if none exist, offer assistance in establishing them, with the offer and the resident’s decision documented in the medical record. Resident R48 was admitted to the facility and had diagnoses of high blood pressure, end stage renal disease, and anemia. Review of the resident’s MDS dated 1/6/26 and the Social Service Initial Assessment and Social History dated 1/6/26 failed to reveal an advance directive or documentation that the resident was given the opportunity to formulate one. During interview on 1/13/26 at 2:55 p.m., the DON confirmed that the facility failed to provide documentation that residents were given the opportunity to formulate an advance directive for one of four residents reviewed, R48.
Failure to Notify Physician of Elevated Blood Glucose
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident R41, who was admitted with diagnoses including polyneuropathy, edema, and obesity. The resident’s physician orders for insulin lispro included instructions to call the provider if blood glucose was greater than 340. Review of the blood sugar summary showed multiple elevated readings, including 423.0 mg/dL, 424.0 mg/dL, 399.0 mg/dL, and 388.0 mg/dL. Review of the resident’s progress notes from 12/1/2025 through 1/8/2026 showed no indication that these elevated blood sugars were reported to the physician. During interview, the DON confirmed there was no physician notification for the elevated blood sugar as required.
Failure to Post Required Grievance Process Information
Penalty
Summary
The facility failed to display the required grievance process information for residents and family members throughout the building. Review of facility policies showed that residents, family members, or appointed resident representatives may file grievances or complaints about care, treatment, staff behavior, theft of property, or other concerns, and that the facility will post grievance information in prominent locations, including the grievance officer’s contact information, the expected time frame for review, the right to a written decision, and contact information for independent entities. During the resident council on 1/13/26, residents stated they were not aware of the grievance officer and did not know where the grievance boxes and forms were located. Observations on 1/12/26, 1/14/26, and 1/16/26 found that the first-floor bulletin board, second-floor nursing unit bulletin board, third-floor nursing unit bulletin board, and first-floor secure nursing unit bulletin board did not display the grievance officer information, how to file a grievance, or the business address and email. The Nursing Home Administrator confirmed on 1/16/26 that the facility failed to display the required grievance process information for residents and family members.
Failure to Properly Treat and Monitor Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing. The facility failed to make certain that residents received proper treatment for pressure ulcers/injuries for two residents. One resident with diagnoses including non-Alzheimer's dementia with behavioral disturbance, depression, and anxiety had a deep tissue injury to the left heel, and a physician order dated 11/21/25 directed cleansing with normal saline, application of xeroform to the wound bed, application of 4x4 gauze, wrapping with kerlix, and daily dressing changes. The facility wound policy required a full assessment of a pressure sore, including location, stage, length, width, depth, and the presence of exudates or necrotic tissue. Another resident had an unstageable pressure injury to the left heel measured on 12/24/25 at 1.2 cm long by 1.1 cm wide, with slough filling 50% of the wound bed. The clinical record showed the left heel pressure injury was not measured on 12/17/25, 12/31/25, or 1/7/26 as required for monitoring wound progress or deterioration, and the care plan did not include a goal or interventions for management and monitoring of the left heel pressure injury. During interview, an RN confirmed the wound was not measured weekly as required and the care plan lacked a goal and interventions, and the DON confirmed the facility failed to make certain that residents received proper treatment for pressure ulcers/injuries for two of four residents.
Missing Backup Trach at Bedside
Penalty
Summary
The facility failed to provide tracheostomy care consistent with professional standards of practice for one resident receiving oxygen. The resident had diagnoses of anemia, COPD, and schizophrenia, and the MDS indicated that tracheostomy care was being provided. Physician orders directed daily and as-needed trach care, monitoring of the trach site for infection, increased secretions, and dislodgement, use of a size 6.0 cuffless trach, and oxygen at 4 liters via trach mask. The care plan identified that the resident had a Shiley uncuffed #6 trach and was to have no abnormal drainage around the trach site through the review date. The resident’s admission assessment documented clear lungs, no difficulty breathing, head of bed elevated, and a spare trach kit at bedside. However, during observation the resident was sitting in a stationary chair with a trach mask connected to an oxygen concentrator, and a backup Shiley uncuffed #6 trach was not present. An RN confirmed there was not a backup trach in the room as required, and the DON confirmed the facility failed to provide tracheostomy care consistent with professional standards of practice for the resident.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma informed care for Resident R36, a resident with a history of PTSD. Review of the admission record showed the resident was admitted to the facility, and the MDS dated 10/23/25 listed heart failure, hypertension, and dementia. Physician progress notes dated 8/19/25 documented past medical history including CAD, hypertension, hyperlipidemia, and PTSD. The resident’s care plan, revised on 10/20/25, indicated the resident had trauma but did not identify the resident’s triggers or how to avoid them. Review of the facility policy stated care plans shall incorporate goals and objectives that lead to the resident’s highest obtainable level of independence. During an interview on 1/15/25 at 2:39 p.m., the DON confirmed the facility failed to provide trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Improper Medication Storage and Unsecured Medication Cart
Penalty
Summary
The facility failed to store medications properly and securely in one of two medication rooms, four of four medication carts, and failed to ensure medication carts were secured when not in the presence of the nurse. In the Renaissance unit medication room, an ice pack was found stored in the refrigerator, and an LPN confirmed it belonged in the laboratory refrigerator instead. The facility policy stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner. Multiple medication carts contained opened medications that were not dated as required. The First Floor Cart A contained undated albuterol nebulizers, and First Floor Cart B contained moxifloxacin eye drops that were opened, undated, and not stored in a box or bag. The Renaissance front cart contained opened, undated bottles of Miralax and Geri-tussin, and the Renaissance back cart contained Humalog and Lantus insulin pens that were opened and undated. In addition, a medication cart on the first-floor nursing care unit was observed unlocked and unattended in front of the nursing station, and an interim unit manager confirmed it was accessible to residents.
QAA Committee Failed to Meet Quarterly With Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for two of four quarters, specifically January 2025 through March 2025 and July 2025 through September 2025. Review of the facility’s Quality Assurance and Performance Improvement Program Guidelines and Quality Assurance and Performance Improvement policy showed that the QAPI committee was to include the Administrator, DON, Medical Director, Infection Preventionist, Pharmacy, Social Services, Activity Service, Environmental Services, Human Resources, Medical Records, and Diagnostics. Review of QAPI Committee meeting sign-in sheets from January 2025 through December 2025 showed that the Medical Director did not attend during those two quarters. During interview, the Nursing Home Administrator confirmed that the facility failed to conduct QAA meetings at least quarterly with all required committee members for those two quarters.
Failure to Provide Required PPE for Covid Airborne Isolation
Penalty
Summary
The facility failed to manage airborne isolation for a resident with a positive Covid infection in one of seven rooms. The facility policy for Covid-19 identification and management stated that newly identified Covid-19 infections and symptomatic residents, regardless of vaccination status, are to be restricted to their rooms and cared for by staff using a NIOSH-approved N95 or equivalent or higher level respirator, eye protection, gloves, and a gown. Resident R37 was admitted to the facility on 8/11/25 and had diagnoses including hypertension, renal insufficiency, and depression. A physician order dated 1/8/25 directed staff to assess lungs and apical heart rate every shift for Covid for ten days and to use Covid isolation with contact and airborne precautions in a private room due to positive Covid, with care and services provided in the resident's room for ten days. On 1/12/26 at 11:00 a.m., observation of Resident R37's room showed a sign for airborne precautions and a door holder containing masks, N-95 respirators, gloves, gowns, and hand sanitizer, but no eye protection for staff. During interviews, a nurse aide stated staff were to wear a gown and gloves in the resident's room and did not think eye protection was required, and an RN stated they were unaware if eye protection was needed. The Infection Preventionist confirmed eye protection was needed in a positive Covid room and said the nurse aide would be re-educated on eye protection requirements. The DON later confirmed the facility failed to manage airborne isolation for Covid positive infections in one of seven rooms.
Failure to Accurately Transcribe Physician Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders were transcribed accurately upon admission for two residents. For one resident with diagnoses including encephalopathy, COPD, and dementia, the medication Hydroxyurea was ordered at 1000 mg by mouth daily, but was incorrectly transcribed and administered as 1000 mg by mouth twice daily throughout the resident's stay and included in discharge instructions. This error was identified after the resident was hospitalized, and the facility administrator confirmed the transcription failure. For another resident admitted with a history of elbow fracture, benign prostatic hyperplasia, and heart disease, the medication Omeprazole was ordered at 20 mg by mouth twice daily per hospital discharge summary, but was initially transcribed and administered as 20 mg by mouth once daily. The discrepancy was noted in physician progress notes, and the order was later adjusted to match the hospital discharge instructions. Both the Nursing Home Administrator and Director of Nursing confirmed the failure to accurately transcribe physician orders on admission for these two residents.
Failure to Notify Physician of Abnormal Glucose Readings
Penalty
Summary
The facility failed to notify a physician of abnormal blood glucose readings for a resident with diabetes, as required by physician orders and facility policy. The resident had multiple documented blood glucose levels exceeding 400 mg/dL, which, according to the physician's sliding scale insulin order, required immediate notification of the physician or CRNP. Despite these elevated readings occurring on several occasions, there was no evidence in the resident's progress notes that the physician was notified as directed. The resident in question had a medical history including diabetes, anemia, and hypertension, and was receiving insulin therapy with specific parameters for monitoring and reporting abnormal glucose levels. The facility's policy and the resident's care plan both emphasized the importance of maintaining blood glucose within the desired range and following physician orders for reporting. Staff interviews confirmed that the required notifications were not made, resulting in a failure to provide care and treatment according to orders and the resident's clinical needs.
Failure to Follow Physician Order and Address Malfunctioning Bipap Device
Penalty
Summary
The facility failed to follow a physician's order for the use of a Bipap device and did not act in a timely manner when the device was reported as malfunctioning for a resident with significant respiratory conditions. The resident had diagnoses including COPD, acute and chronic respiratory failure, and heart failure, and was ordered to use Bipap nightly with specific settings. Documentation and staff interviews revealed that the Bipap device was not consistently functioning as ordered, with multiple staff noting that the machine would turn off or stop blowing air, and that these issues were not always communicated to the physician or the resident's family. Progress notes indicated that the resident experienced episodes of shortness of breath and complaints of discomfort, with staff at times substituting oxygen via nasal cannula when the Bipap was not working. Despite ongoing issues with the Bipap, there was a lack of timely escalation to the physician or respiratory company, and the care plan did not specify steps to follow in the event of equipment malfunction. The resident's family ultimately provided a backup Bipap device, but the resident continued to exhibit symptoms consistent with hypercapnia and respiratory distress. The resident was eventually transferred to the hospital in respiratory distress, where elevated carbon dioxide levels were confirmed, and ICU admission for Bipap was required. Staff interviews confirmed that the Bipap malfunction was known but not always reported or addressed promptly. The facility's failure to follow the physician's order for Bipap use and to respond appropriately to equipment malfunction resulted in actual harm to the resident, including dyspnea, hypoxemia, and hypercapnia.
Failure to Prevent Mental Abuse via Social Media
Penalty
Summary
The facility failed to protect a resident from mental abuse, specifically abuse facilitated through the use of technology. A nurse aide recorded a video of a resident, who had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of six, and posted it on a social media platform. The video showed the resident in bed, making inappropriate comments, while the staff member recording the video laughed at her. The resident's face was partially obscured by an emoji, but at one point, the face became recognizable. The video was shared within a group of staff members on social media, and another staff member reported the incident to nursing management after viewing the video. The resident involved had multiple medical diagnoses, including dementia, atrial fibrillation, and diabetes, and was dependent on staff for care. The facility's own policy emphasized the importance of maintaining a culture of compassion and caring, especially for residents with behavioral, cognitive, or emotional problems. Despite this, the actions of the staff member who recorded and shared the video constituted a failure to ensure the resident was free from mental abuse, as confirmed by the facility's administration during interviews.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required oxygen therapy and respiratory equipment. For one resident with diagnoses including heart failure, COPD, and respiratory failure, surveyors observed that the oxygen nasal cannula in use was not dated, and two BiPAP masks were left on the bedside nightstand without being stored in a bag as required by facility policy. The LPN confirmed these deficiencies during an interview. Physician orders specified that oxygen tubing should be changed weekly, and the facility policy required proper storage and dating of respiratory equipment. For another resident with heart failure, hypertension, and dementia, surveyors found that the oxygen tubing in use was dated beyond the weekly change interval specified in physician orders, and the nebulizer tubing was not dated. Additionally, the nebulizer mask was not stored in a bag when not in use, contrary to facility policy. The LPN confirmed that the oxygen tubing was not changed as ordered and that the nebulizer was not properly stored. The DON also confirmed the facility's failure to provide appropriate respiratory care for both residents.
Failure to Maintain Automatic Sprinkler System
Penalty
Summary
The facility failed to maintain its automatic sprinkler system, as evidenced by an observation on January 13, 2025. The sprinkler gauges were found to be dated 2019, and the facility was unable to provide documentation that these gauges had been replaced or tested against a calibrated gauge within the last five years. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director, indicating a lapse in the required maintenance and testing of the sprinkler system, which affects the entire facility.
Plan Of Correction
The automatic sprinkler gauges dated 2019 were replaced by an outside vendor on January 20, 2025. The Director of Maintenance and the maintenance staff were educated by the Administrator on the importance of ensuring that the fire sprinkler gauges need to be tested or replaced every five years. The Director of Maintenance or designee will pre-schedule with the outside vendor to ensure the five-year test and/or replace regulation.
Failure to Conduct Background Checks Before Hiring
Penalty
Summary
The facility failed to implement its written procedures to prohibit and prevent abuse, neglect, and exploitation of residents by not performing criminal history background checks prior to the date of hire for five employees. These employees included two Registered Nurses (RNs), two Nurse Aides (NAs), and one Licensed Practical Nurse (LPN). The facility's policy, dated May 1, 2022, and last reviewed on January 3, 2024, required obtaining criminal and FBI background checks before an employee's first day of employment. However, the personnel records for these employees did not include the required State background checks. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to adhere to the facility's procedures. The employees in question were already working and no longer on orientation, indicating that the background checks were not completed in a timely manner as per the facility's policy. This oversight was identified through a review of personnel records and nurse deployment documents, which showed that the employees continued to work without the necessary background checks being documented.
Plan Of Correction
The facility obtained satisfactory criminal records checks (state background checks, PATCH) on new employees hired in the last four months including employees E-2, E-17, E-18, E-19, and E-20. Human Resources and the In-service coordinator have been re-educated on the importance of securing a satisfactory criminal records check (state background checks, PATCH) on all new employees prior to the employees' first day at the facility. All new hire paperwork including the satisfactory criminal records check (state background checks, PATCH) will be audited by the administrator or designee every two weeks for two months prior to the start of orientation to ensure that all new employees have a satisfactory criminal records check (state background checks, PATCH). Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Deficiencies in Catheter Management and Resident Dignity
Penalty
Summary
The facility failed to ensure that physician orders for urinary catheters included necessary details such as the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed for balloon inflation for three residents. This omission was confirmed through staff interviews and a review of clinical records. Specifically, the orders for Residents R53, R58, and R316 lacked these critical details, which are essential for proper catheter management and resident care. Additionally, the facility did not adhere to its policy on maintaining resident dignity by failing to cover catheter bags as required. Observations revealed that the catheter drainage bags for Residents R58 and R316 were not covered with dignity bags and were positioned facing the door entrance, contrary to the facility's dignity policy. This was confirmed by interviews with registered nurses who acknowledged the oversight. The deficiencies were identified during a review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the facility's failure to include necessary catheter details in physician orders and to ensure catheter bags were covered, impacting the care and dignity of the residents involved.
Plan Of Correction
The size of the suprapubic catheter, the balloon size and the proper fluid amount were obtained for residents R53, R58, and R316. Also, the catheter drainage bags were covered for residents R58 and R316. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee on adding the size of the suprapubic catheter, the balloon size and the proper fluid amount urinary catheter type and size when entering a suprapubic order. RNs, and LPNs, and CNAs will be educated by the Director of Nursing, In-Service Director and/or designee on covering all the urinary drainage bags with dignity bags. An audit of all residents with a suprapubic catheter will be conducted by the Director of Nursing or designee to ensure the order contains the size of the catheter, the balloon size and the fluid requirements weekly for three weeks and then biweekly for three weeks. An audit of all residents with a foley will be conducted by the Director of Nursing or designee to ensure that their catheter drainage bags are covered will be conducted weekly for three weeks and then biweekly for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Deficiencies in Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to ensure consistent communication between the dialysis provider and facility staff for four out of five residents requiring dialysis services. Specifically, the clinical records for these residents lacked complete communication forms, which are essential for maintaining continuity of care. For Resident R14, there were nine incomplete communication sheets and four missing sheets for December 2024. Similarly, Resident R22's records showed multiple instances of incomplete communication forms over several months. Resident R58 also had incomplete communication forms for several dates, and Resident R314's record was missing a communication sheet for a specific date. Additionally, the facility did not maintain accurate care plans for dialysis access sites for two residents. Resident R22's care plan failed to include monitoring instructions for the AV fistula, which is crucial for ensuring the fistula's functionality and preventing complications. Resident R314's care plan lacked a nursing plan of care for dialysis monitoring of the access device and communication with the dialysis center, only noting the days the resident attended dialysis. Interviews with facility staff, including registered nurses and the Director of Nursing, confirmed the deficiencies in maintaining complete dialysis communication forms and accurate care plans. These lapses in documentation and care planning are in violation of the facility's policy and state regulations, which require comprehensive care plans and consistent communication for residents undergoing dialysis.
Plan Of Correction
The facility cannot go backward and re-create documentation (i.e. blood pressures) from the past. Therefore, all RNs and LPNs will be educated by the Director of Nursing and/or designee on completely completing the dialysis communication log (example: vital signs, medical changes, status of access site including possible thrill and bruit, and nurse sign off) and having a care plan for the access site/fistula. The facility will audit all dialysis communication logs for all residents for completeness by both the facility and the dialysis center. Additionally, the care plans of the dialysis residents will be audited to ensure the access site/fistula is addressed. This will be completed weekly for three weeks and then three random dialysis residents weekly for three weeks. If a deficient practice is noted in the bottom half of the form completed by the dialysis center, it will be returned to them for completion. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of four nurse aides, specifically NA Employee E10, NA Employee E11, and NA Employee E12. According to the Code of Federal Regulations S483.35(d)(7), the facility is required to conduct a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on these reviews. However, a review of the personnel records for these employees showed that the facility did not conduct the required annual performance evaluations based on their respective dates of hire. During an interview on January 10, 2025, the Nursing Home Administrator confirmed the facility's failure to complete these evaluations. This deficiency is in violation of the federal regulation and the Pennsylvania Code, which outlines the responsibility of the licensee and management requirements.
Plan Of Correction
The facility will complete annual performance evaluation for all those nurse aide staff employed at the facility for a year. This includes nurse aides E10, E11 and E12. The Administrator will re-educate the Director of Nursing and Human Resources that evaluations are a requirement annually for nurse aide staff. A master list of current nurse aide employees will be viewed weekly for six weeks to determine who qualifies for this annual performance review. The Director of Nursing or designee will complete these evaluations. The evaluation period for all employees will be June 2025.
Incomplete Investigation of Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to conduct a thorough investigation regarding an incident involving a resident, identified as Resident R77, who was found with two cups of medication at their bedside. The facility's policy on abuse, neglect, and exploitation requires thorough investigation and reporting of such incidents, but the investigation was incomplete. The clinical record of Resident R77, who has diagnoses of renal insufficiency and diabetes mellitus, indicated that the medications were found on an unspecified date, and the facility's documentation did not include necessary details such as the identification of the pills, their origin, or whether they were documented as taken by the resident. The Director of Nursing confirmed that the investigation was incomplete, acknowledging the lack of documentation and interviews with staff from various shifts. The facility did not determine what the medications were, where they came from, or if they were part of the resident's prescribed regimen. This failure to conduct a thorough investigation is a violation of the facility's responsibility to ensure resident safety and comply with regulatory requirements.
Plan Of Correction
An incident report will be filed in our internal risk master system regarding the medications being found at the bedside for resident R-77. The resident's provider was also made aware. If possible, it will be determined if the medications were facility based or were previously in the possession of the resident. The Medication administration record will be reviewed for accuracy and staff interviews conducted to possibly learn the origin of these medications. No untoward effects were demonstrated by the resident at the time of discovery. All incidents will be reviewed on an at least weekly basis by the DON and/or NHA to ensure timely and complete submission of all pertinent facts. Incidents will be reviewed more immediately if the situation is more acute. Nursing staff (RNs, LPNs and Unit Managers) will be educated by the Director of Nursing, Staff Educator or designee on the gathering of all pertinent information as part of the investigation of incidents including complete and accurate documentation of medication administration, and that nursing staff are not permitted to leave medication at the bedside unless directed by the provider and included as part of the care plan. Seven rooms will be checked for medications left in the resident's rooms per week for three weeks and then seven rooms will be checked every two weeks for a period of three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the care plans for two residents, resulting in deficiencies in accurately reflecting their current status and care needs. Resident R8, who was admitted with diagnoses of heart failure, mild cognitive impairment, and anxiety disorder, had a physician order for the use of a FreeStyle Libre 3 Continuous Glucose Monitoring system. However, the care plan did not include the use, care, and service interventions related to this device. This omission was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident R316, who was admitted with high blood pressure, Multiple Sclerosis, and diabetes, had a physician order for a Wound Vac to be applied to a sacral wound. The care plan for this resident also failed to include the necessary interventions for the Wound Vac, as confirmed by the DON. These deficiencies indicate that the facility did not update the care plans to reflect the residents' current medical needs and interventions as required by their policy and state regulations.
Plan Of Correction
The care plans of the affected residents (R8 and R316) were updated during survey to include the continuous glucose monitoring device and the wound vac. All the care plans of residents having either a continuous glucose monitoring device and/or a wound vac were reviewed and/or updated to ensure compliance. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee that care plans should be created and/or updated timely to reflect the current condition of the resident including their use of a continuous glucose monitoring device and/or a wound vac. The facility will audit the care plans of all residents with continuous blood glucose monitoring devices and/or wound vacs weekly for three weeks and then biweekly for three weeks to ensure that the care plans reflect the current needs of the residents utilizing these devices. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings for a resident, identified as Resident R108, as per the physician's order. The facility's policy on diabetes management required staff to incorporate physician-ordered parameters for monitoring and reporting blood sugar levels into the Medication Administration Record (MAR). Resident R108, who was admitted with diagnoses including diabetes, had specific physician orders for insulin administration based on a sliding scale, with instructions to notify the physician if glucose levels exceeded 340. However, the review of Resident R108's glucose log revealed multiple instances where glucose levels were significantly above 340, yet there was no documentation of physician notification in the progress notes. The Director of Nursing confirmed during an interview that the facility did not notify the physician of the abnormal glucose readings as required. The resident's care plan emphasized the importance of monitoring and reporting symptoms of hyperglycemia, yet the facility failed to adhere to these protocols. This deficiency was identified under the regulations 28 Pa. Code: 201.14(a) and 28 Pa. Code 211.12(d)(1)(2)(3)(5), which pertain to the responsibility of the licensee and nursing services, respectively.
Plan Of Correction
The resident has been discharged from the facility so provider notification was not accomplished. RNs, LPNs, and Unit Managers will be educated by the Director of Nursing, In-Service Director or designee on the necessity of timely provider notification of the resident's blood glucose level pursuant to the provider's order. The facility will audit five random residents' blood glucose levels weekly for three weeks and compare these levels with the provider's order to ensure compliance. Subsequently, the facility will audit five random residents' blood glucose levels for three weeks bi-weekly. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary services to prevent and treat pressure ulcers for two residents. Resident R317, who was admitted with a Stage 3 pressure injury, did not have a care plan that included management of the injury or the use of a low air loss mattress, despite being totally dependent on staff for repositioning. The resident's physician orders also lacked preventative measures such as a low air loss mattress and assistance with turning and repositioning. The facility's policy on pressure injury prevention was not followed, as the care plan did not address the resident's specific needs for pressure ulcer management. Resident R51, diagnosed with dementia and depression, had a noted injury on the right big toe, which was not adequately followed up. Progress notes indicated a red/purple area on the toe, but there was no documentation of the progression, cause, or resolution of the injury. Interviews with staff confirmed the lack of follow-up and the failure to develop a pressure ulcer care plan. The facility did not implement preventative measures or ensure that residents received necessary services to prevent and treat pressure ulcers, as confirmed by the Director of Nursing.
Plan Of Correction
The care plans of the affected residents (R51 and R317) were updated to reflect preventive measures for a stage III wound and a right great toe injury. RNs and LPNs will be educated by the Director of Nursing, In-Service Director, or designee on the importance of including in the clinical record how an injury occurred, its progression, treatment, and healing. The facility will audit the care plans of five random residents with wounds and skin issues weekly for three weeks and then bi-weekly for three weeks to ensure that documentation in the clinical record is complete and comprehensive (how the injury occurred, its progression, treatment, and healing). Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee, and the need for additional monitoring will be determined by the committee.
Failure to Ensure Appropriate Enteral Feeding Tube Care
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. The facility's policy on Enteral Nutrition, dated 1/2/25, mandates that adequate nutritional support through enteral nutrition is provided to residents as ordered, based on a comprehensive nutritional assessment and consistent with current standards of practice. However, during an observation on 1/7/25, it was noted that Resident R14's enteral feeding and water flush bag were hanging undated on a pole at the bedside. This was confirmed by Registered Nurse Employee E6, indicating a lapse in the facility's adherence to its policy and the provision of appropriate care. Resident R14, who was admitted to the facility with diagnoses including cerebral infarction, dependence on renal dialysis, and aphasia, had a Minimum Data Set indicating the presence of a feeding tube. The current physician orders specified a continuous enteral feed order with Nepro at 85 ml/hr for 19 hours, along with a 60 ml water flush every 4 hours. The failure to date the feeding and water flush bags could lead to potential complications, as the facility did not ensure the resident received the necessary treatment and services as per the physician's orders and facility policy.
Plan Of Correction
The tube feeding and water flush bag for resident R14 have been dated. RNs and LPNs will be educated by the Director of Nursing, In-Service director or designee on the importance of placing the date hung on both the tube feeding and water flush bag. An audit of all residents having a tube feeding will be conducted weekly for three weeks by the Director of Nursing or designee. Then the audit will be conducted biweekly of all residents receiving a tube feeding. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Coordinate Hospice Services for a Resident
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of a resident, identified as Resident R59, for end-of-life care. The facility's policy on hospice services, dated 1/2/25, requires collaboration with hospice representatives and coordination of facility staff participation in the hospice care planning process. However, a review of Resident R59's clinical records revealed that the facility did not provide appropriate physician orders for hospice care, which should have included the hospice diagnosis, the hospice provider, and contact information. Additionally, the current care plan for Resident R59 did not include a plan of care for hospice services by the facility. Resident R59 was admitted to the facility with diagnoses of heart failure, dysphagia, and high blood pressure. The MDS assessment indicated that hospice services were required, but the facility failed to document the necessary hospice information in the physician orders. Interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator confirmed these deficiencies, highlighting the facility's failure to coordinate hospice services effectively for Resident R59.
Plan Of Correction
The care plan and physician orders for R59 have been updated to include a diagnosis for hospice care, the provider and their contact information. Additionally, the care plan was reviewed/updated to ensure it was comprehensive to include hospice services. Staff including RNs, LPNs, and Unit Managers as well as providers will receive additional training on the needed components of hospice orders and the need for comprehensive care plans. Four residents receiving hospice care with a focus on those most recently admitted to hospice will be reviewed weekly for three weeks to ensure they have the proper provider order as well as a comprehensive care plan. Then two residents receiving hospice services will be reviewed weekly for three weeks to ensure complete hospice orders and comprehensive care plans. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Follow Infection Control Precautions
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for two residents, R22 and R315, and did not implement proper interventions for a Covid-positive resident, R34. Resident R22, who had renal failure and required dialysis, did not have EBP orders for indwelling medical devices as required. During an observation, a registered nurse failed to properly don a gown when checking the resident's AV fistula, indicating a lack of familiarity with the gowning procedure. Resident R315, diagnosed with breast cancer and secondary bone cancer, was placed under isolation-contact and droplet precautions due to respiratory symptoms. However, the care plan did not include necessary interventions for these precautions. An observation revealed that a nurse aide assisted the resident without wearing a gown or N95 respirator, as required by the physician's orders, and the signage on the resident's door was incorrect. Resident R34, who tested positive for Covid-19, was supposed to be under airborne contact isolation. However, the resident's door was left open, and a nurse aide was observed inside the room without the appropriate personal protective equipment (PPE), including an N95 mask, gloves, or gown. The signage on the door only indicated airborne precautions, and the infection preventionist confirmed the facility's failure to follow the required precautions for these residents.
Plan Of Correction
Residents R-22, R315, and R34 have all experienced resolution of their condition and are now not needing any precautions. All nursing staff (RNs, LPNs, CNAs, and Unit Managers) will receive additional training on the types and reasons for transmission-based precautions as well as the PPE required from the In-Service Director or designee. Additionally, staff will demonstrate their ability to effectively don and doff a gown. The Director of Nursing, In-Service Director, or designee will observe 10 random resident staff encounters weekly for three weeks to ensure proper PPE. This includes donning of gowns. Additionally, 5 random encounters will be observed for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Provide Timely Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to provide mandatory training on Abuse, Neglect, and Exploitation to a newly hired nurse aide, Employee E3, on the date of her orientation as required by the facility's policy. The policy, last reviewed on January 3, 2024, mandates that all employees receive education on these topics upon orientation, annually, and as needed. Employee E3 was hired on October 2, 2024, and began working on the floor on October 7, 2024, after completing her orientation. However, her personnel record indicated that she did not receive the required training until December 6, 2024, two months after her hire date. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 10, 2025.
Plan Of Correction
Nurse Aide (e-3) completed the educational material on abuse, neglect and exploitation. All new employees will be educated by Human Resources or the In-Service Director or designee during orientation on abuse, neglect and exploitation prior to starting their employment in the clinical areas. Human Resources and the In-Service Director were re-educated on the importance of completing all educational material while in orientation and prior to their employment in the clinical areas. The administrator or designee will review all employee training records after orientation but prior to the employee entering the clinical areas to ensure that abuse, neglect and exploitation education is complete. Audits will be conducted for each orientation class for two months. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Infection Control Committee Lacks Required Members
Penalty
Summary
The facility failed to meet the minimum standards for infection control as required by the Medical Care Availability and Reduction of Error (MCARE) Act. Specifically, the facility's Infection Control Committee did not include the required multidisciplinary members, such as laboratory personnel, during meetings for two of the four quarters in 2024. This deficiency was identified through a review of the facility's Infection Control Committee Attendance Log, which showed the absence of laboratory personnel in Quarters Three and Four of 2024. Additionally, during an interview, an administrative assistant confirmed the absence of both laboratory personnel and pharmacy staff in the attendance log for Quarter Four of 2023, further highlighting the facility's non-compliance with the infection control plan requirements.
Plan Of Correction
The laboratory member of the QAPI committee has been re-educated on attending the QAPI meetings at least quarterly. Email invitations are provided and a zoom option offered. The administrator will note if attendance is by zoom. Laboratory personnel did attend the QAPI meeting on January 16, 2025. On 1/28, all personnel sign in for the QAPI meetings including laboratory personnel. This sign in sheet serves to monitor attendance for all required personnel.
Personnel Record Deficiency for RN Employee
Penalty
Summary
The facility failed to ensure that personnel records for Registered Nurse (RN) Employee E2 included essential documentation such as a job description, educational background, employment history, and a reference check. This deficiency was identified during a review of the facility's policy, employee personnel records, and staff interviews. The facility's policy, "Safety-01 Abuse, Neglect, Exploitation general policy," mandates that reasonable efforts be made to obtain personal and professional reference information before an employee's first day of employment, with documentation of these attempts. However, RN Employee E2, who was hired on 9/3/24 and began working independently by 9/17/24, did not have the required documentation in her personnel file. The Nursing Home Administrator confirmed this oversight during an interview.
Plan Of Correction
The personnel record for registered nurse (E-2) has been updated to include the employee's job description, educational background, employment history and a reference check. Human Resources and the In-service director have been re-educated on the importance of ensuring that all pre-employment documentation including but not limited to the employee's job description, educational background, employment history and a reference check must be obtained prior to the first day of employment. All new hire paperwork including the employee's job description, educational background, employment history and a reference check will be audited every two weeks for two months by the administrator or designee to ensure all documentation is completed prior to their first day of employment. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.
Failure to Conduct Pre-Employment TB Screening for RN
Penalty
Summary
The facility failed to implement pre-employment screening procedures for Tuberculosis (TB) for a newly hired Registered Nurse (RN), identified as Employee E2. The facility's TB infection control program policy, reviewed on January 3, 2024, mandates screening of employees for latent TB infection and active TB as appropriate. However, upon review of RN Employee E2's pre-employment health questionnaire dated August 19, 2024, it was found that the TB section was unanswered. Despite this, RN Employee E2 was hired on September 3, 2024, and began working without the required TB screening. The nurse deployment documents confirmed that RN Employee E2 was no longer on orientation by September 17, 2024, and continued to work at the facility. The Nursing Home Administrator confirmed during an interview on January 10, 2025, that the facility did not conduct the necessary pre-employment TB screening for RN Employee E2 as required by their policy.
Plan Of Correction
Registered Nurse (E-2) has obtained a pre-employment screening test for Tuberculosis. The negative results are noted on the pre-employment health questionnaire. Human Resources and the In-service coordinator have been re-educated on the importance of securing a negative pre-employment screening test for Tuberculosis prior to the employees' first day at the facility. All new hire paperwork, including the pre-employment test for Tuberculosis, will be audited every two weeks for two months prior to orientation by the administrator or designee to ensure they have a recorded negative pre-employment screening for Tuberculosis. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee, and the need for additional monitoring will be determined by the committee.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period of 30 months, from April 2022 through September 2024. This deficiency was identified based on a review of facility documents, an audit conducted by the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. An audit conducted by the State Ombudsman Office on August 1, 2024, confirmed the lack of notifications since March 2022. During an interview on October 25, 2024, the Director of Nursing confirmed the facility's failure to report these transfers and discharges as required by the Pennsylvania Code: 201.29(f)(g) regarding resident rights.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,402 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ivy Park Post Acute | 1.9 mi | ★★★★★ | 10 | 1 |
| Spring Hill Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 78 | 3 |
| East End Health & Rehab Center | 2 mi | ★★★★★ | 15 | 0 |
| Upmc Magee-womens Hospital Tcu | 2 mi | ★★★★★ | 5 | 0 |
| Champion City Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 56 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.