Carnegie Park Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1848 Greentree Road, Pittsburgh, Pennsylvania 15220
- CMS Provider Number
- 395743
- Inspections on file
- 37
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Carnegie Park Post Acute during CMS and state inspections, most recent first.
A resident with multiple medical conditions received the incorrect TPN due to staff errors, including mixing and administering the wrong solution and setting the infusion pump at an incorrect rate. The error was discovered when another resident's TPN was being prepared, and it was confirmed that the resident did not receive the complete prescribed dose. Facility leadership acknowledged the failure to prevent significant medication errors for multiple residents.
The facility did not conduct annual performance evaluations for five nurse aides, as required by regulations. This was confirmed through personnel record reviews and an interview with the Nursing Home Administrator, revealing a lapse in adhering to staff development protocols.
The facility failed to provide timely assistance to three residents, affecting their dignity and quality of life. A resident with heart conditions reported sitting in a soiled brief for over an hour, while another with seizure and bipolar disorders experienced similar delays after an accident. A third resident with heart failure and sepsis was observed without pants, expressing dissatisfaction. The facility's failure to maintain an environment that promotes dignity was confirmed by the administration.
The facility failed to provide timely ADL assistance and personal care to 15 residents, with reports of prolonged call light response times and inadequate personal hygiene care. Residents expressed frustration over waiting an hour or longer for assistance, and some experienced neglect in personal grooming and clothing care. The facility's policy of responding to calls within five minutes was not followed, leading to dissatisfaction and complaints.
The facility failed to properly store and dispose of medications and biologicals, as expired items were found in an unused dining room and an unlocked treatment cart in a utility room contained improperly labeled and expired items. These deficiencies were confirmed by staff, including the DON.
The facility did not follow its preplanned menu and failed to accommodate residents' food preferences. Residents were served different meals than expected without prior notification, and specific food preferences were not honored. The Dietary Services Director acknowledged challenges in tracking preferences, and the Nursing Home Administrator confirmed these failures.
The facility failed to provide mandatory infection control training to seven staff members, including nurse aides, a registered nurse, a medical records employee, and a therapy employee. The deficiency was confirmed by the Nursing Home Administrator and identified through a review of facility policy, training records, and staff interviews.
The facility failed to provide required behavioral health training to eight staff members, including nurse aides and registered nurses, as per the facility's policy and regulatory requirements. The deficiency was confirmed by the Nursing Home Administrator during an interview.
A facility failed to notify a resident's representative of changes in appointment and transportation times, despite policy requirements. The resident, with diabetes and multiple fractures, had a son as the emergency contact and medical power-of-attorney. The son was not informed of an appointment with a plastic surgeon or a change in transportation time, leading to the resident attending appointments alone. The Nursing Home Administrator confirmed the oversight.
The facility failed to maintain a homelike environment in one of its dining rooms, as a bed, mattress, and treatment carts were stored there, contrary to the facility's policy. This was confirmed by staff interviews and observations, indicating a violation of residents' rights to a safe and comfortable environment.
The facility did not have a qualified professional to direct the activities program for one month. The Activities Director position required a certificate, which was not fulfilled during this time. The NHA confirmed the deficiency.
A resident with anemia, chronic kidney disease, and osteomyelitis did not receive proper post-hospitalization care. Despite instructions to only reinforce a dressing on the resident's right lower extremity, staff changed the dressing without an order and used a soiled bandage. The facility failed to adhere to the care plan and professional standards.
A facility failed to ensure the availability of prescribed medications for a resident with chronic pain and other conditions. Despite having the necessary medications in the automated dispensing machine, the resident did not receive oxycodone and methocarbamol as prescribed, resulting in consistently high pain levels. The facility's policy required accurate provision of pharmaceutical services, but this was not met, leading to a deficiency in pharmacy services.
The facility's resident call bell system on the Second Floor Nursing Unit was not fully operational, as central call bells in the A, B, and C halls failed to illuminate when activated. This was confirmed by the DON, who noted that the issue was due to the ceiling bulkhead obstructing visual communication.
The facility failed to maintain a safe and clean environment for two residents when a wall section was removed, exposing wires and insulation. This occurred because the wall pulled away due to a heavy television. Residents' belongings were scattered, allowing debris to fall onto them. The Maintenance Director and Nursing Home Administrator confirmed the issue.
The facility failed to provide mandatory training on the Prevention of Abuse and Neglect for a staff member, Employee E18, as required by their policy. Despite the policy mandating education on preventing abuse, neglect, and exploitation, Employee E18 did not receive this training within the specified period. The Nursing Home Administrator confirmed this oversight, indicating a gap in compliance with training requirements.
The facility failed to provide the required 12 hours of annual in-service training for two nurse aides, Employees E11 and E15, within 12 months of their hire date anniversary. Both employees only completed approximately four hours of training, contrary to the facility's policy and federal regulations.
The facility failed to ensure the Department of Health's most recent survey results were accessible to residents and visitors in four locations, including the lobby and nursing units on multiple floors. The Nursing Home Administrator confirmed the deficiency during an interview.
The facility failed to provide a means for residents to file grievances anonymously, as required by policy. Observations revealed no grievance boxes in five locations, and signage directed forms to be submitted to social services. The Nursing Home Administrator confirmed the absence of anonymous filing options.
The facility failed to provide mandatory effective communication training for seven direct care staff members, as required by regulations. This deficiency was identified through a review of training records and confirmed by the Nursing Home Administrator. The lack of training violates facility policy and regulatory requirements related to staff development and management.
The facility failed to provide mandatory Resident Rights training to eight staff members, including nurse aides, RNs, a medical records employee, and a dietary employee. Despite the facility's policy requiring such training, documentation showed these employees did not receive the necessary education within the specified time frames. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to provide mandatory QAPI training to ten staff members, including nurse aides, RNs, and other personnel, as required by federal regulations. The deficiency was confirmed through a review of training records and staff interviews, revealing a systemic issue in compliance with training requirements.
The facility failed to provide required Compliance and Ethics training for four staff members, as per its policy. Documentation showed that a Nurse Aide and three RNs did not receive the necessary in-service education within the specified timeframes, which was confirmed by the Nursing Home Administrator.
The facility failed to prominently display nurse staffing information on one of the surveyed days. The NHA could not locate the staffing data at the receptionist desk, as required by regulations, which was confirmed during an interview.
The facility failed to provide accident prevention training for three nurse aides, as required by their policy. Despite the policy mandating education and training for all personnel, Nurse Aides E11, E13, and E15 did not receive the necessary in-service education within the specified timeframes. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide training on restorative nursing techniques for two nurse aides, as required by facility policy. Employee E11 and Employee E15 did not receive the necessary in-service education within the specified timeframes. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to provide emergency preparedness training for two nurse aides, as required by their policy. Employee E11 and Employee E15 did not receive the necessary training within the specified timeframes. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to provide required fire safety training to three nurse aides, as mandated by regulations. A review of training records revealed that these staff members did not receive documented fire safety education within the specified timeframe. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility failed to meet the required staffing levels for nurse aides on 12 out of 21 days, providing fewer hours than mandated for day, evening, and night shifts. This deficiency was confirmed by the Nursing Home Administrator after a review of nursing schedules and census information.
The facility failed to provide the required 3.2 hours of direct resident care per resident in a 24-hour period on six days. A review of nursing schedules and census information showed that the hours per patient day (PPD) were below the mandated requirement, with the lowest being 2.97 PPD. The Nursing Home Administrator confirmed this deficiency.
The facility did not meet the required nurse aide staffing levels during the day shift on two occasions. With a census of 150 residents, only 6.53 nurse aides were available instead of the required 15. Similarly, with 145 residents, only 9.6 nurse aides were present instead of 14.5. No additional staff were available to cover these shortages, as confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels during a night shift, with only one LPN available for 146 residents, instead of the required 3.65 LPNs. This staffing shortage was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct resident care per resident on two days. With a census of 146 and 150 residents, the facility provided only 3.10 and 2.64 hours respectively. This was confirmed by the Nursing Home Administrator.
The facility failed to provide appropriate treatment and care for five residents, as observed and confirmed through interviews and record reviews. A resident had ACE wraps applied incorrectly, another had them applied in a manner inconsistent with the physician's order, and others did not have them on as ordered. The Director of Nursing confirmed the facility's failure to ensure residents received appropriate treatment and care, as required by physician orders and resident care policies.
The facility failed to provide sufficient staffing, resulting in residents experiencing long wait times for assistance and being left in unsanitary conditions. Residents reported excessive delays in call light responses and missed showers, with some left in soiled clothing or bedding. The administration confirmed the staffing inadequacies.
The facility's QAPI program failed to correct previously cited deficiencies related to the improper use of elastic bandages, affecting 16 residents. Despite a plan of correction that included audits and staff education, a recent survey found repeated issues with the application or absence of ACE wraps for several residents. The Nursing Home Administrator and DON confirmed the facility's failure to maintain an effective Quality Assurance Committee.
The facility failed to properly clean and disinfect glucometers, as an LPN used a 70% isopropyl alcohol pad instead of an EPA-approved disinfecting wipe, contrary to the manufacturer's instructions. The LPN was unaware of the correct procedure, and the deficiency was confirmed by the Nursing Home Administrator and DON.
A resident with a full code status was found unresponsive and not breathing, but CPR was not initiated by the nursing staff. Despite the resident's POLST and care plan indicating resuscitation should be attempted, the RN did not start CPR due to the presence of an upset family member. This failure to follow the resident's code status and physician orders resulted in immediate jeopardy.
The facility's main laundry room was found to be deficient due to non-functional equipment, with only one of three washing machines and two of three dryers operational. The soiled linen area was overcrowded with bags and emitted a strong odor. Staff interviews revealed that the washers had been out of service since December 2023, and the issue had persisted since February. The NHA confirmed the equipment's status and mentioned pending repairs and replacements.
A resident with high blood pressure and obesity left the facility with her son around 1:00 a.m. without signing AMA papers or taking medications. The night shift staff did not report the departure, and the absence was only discovered the following morning. Interviews confirmed that the staff were unaware of the resident's departure, indicating a lack of adequate supervision and communication.
The facility failed to follow proper sanitation and temperature procedures for the dish machine, leading to potential cross-contamination in the main kitchen over seven out of nine months. Logs revealed multiple instances of wash temperatures not reaching the required 120 degrees and missing or incomplete documentation of sanitation levels.
The facility failed to respond to grievances for five residents during the annual survey. Residents were unaware of the grievance officer and how to file anonymous grievances, and staff did not follow up on their concerns. The Nursing Home Administrator confirmed she was the grievance officer but was unaware of these issues.
The facility failed to provide the opportunity to formulate an advance directive for eight of the twelve residents reviewed, despite having a policy in place to inform and provide written information about this right. The Director of Nursing confirmed the lack of documentation in the clinical records for residents with various diagnoses.
The facility failed to provide residents access to grievance forms, the ability to file grievances anonymously, and did not post the name of the Grievance Official. Several residents were unaware of how to file a grievance, and the Nursing Home Administrator and DON confirmed the lack of available forms and posted information.
The facility failed to investigate potential abuse and/or neglect for three residents. One resident did not receive required wound treatments, another was left in a soiled brief, and a third reported continued pain after an incident but was not investigated due to a brain injury. The facility did not follow its Abuse Prohibition policy, which mandates timely investigations and reporting to state agencies.
The facility failed to provide appropriate treatment and care for four residents, including incorrect application of ACE wraps, failure to apply ACE wraps, and not replacing soiled compression stockings, as confirmed by staff and resident interviews.
The facility failed to properly store and dispose of medications and medical supplies on the Second-Floor Nursing Unit. Numerous expired items and opened, undated prescription creams were found in treatment carts and storage areas, some associated with discharged residents. The facility did not adhere to its own policies or regulatory standards, as confirmed by staff interviews.
The facility failed to provide a safe and sanitary environment to prevent potential cross-contamination for two medication carts. Multiple residents' medications were co-mingled and not stored in individual bags, with some medications found without resident names or room numbers, and some opened and undated. The Unit Manager and the Nursing Home Administrator confirmed these observations, acknowledging the potential for cross-contamination.
A facility failed to identify and address significant weight loss and the need for increased nutrition for a resident with dysphagia and malnutrition. Despite multiple assessments indicating high risk for malnutrition, the facility did not implement required weekly weight assessments or complete a dietary screening, resulting in a 16.20% weight loss over 35 days.
Failure to Prevent Significant Medication Errors in TPN Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of the incorrect Total Parenteral Nutrition (TPN) to a resident. The resident, who had diagnoses including peritoneal abscess, colitis, and high blood pressure, was prescribed a specific TPN regimen to be administered over a twelve-hour cycle. On the date in question, the resident received the wrong TPN, which was discovered an hour later when another resident was to have their TPN prepared. The infusion was stopped and the provider was notified. Interviews with staff confirmed that the wrong TPN was administered and that the infusion pump had been set at an incorrect rate, resulting in the resident not receiving the complete dose of TPN. Further review revealed that the TPN products were stored in dedicated, labeled bins for each resident, but a staff member confirmed mixing the incorrect TPN. The Assistant Director of Nursing and the Nursing Home Administrator acknowledged that the facility failed to prevent significant medication errors for two of three residents reviewed. The resident involved reported no ill effects or concerns with the TPN infusions at the time of interview.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for its nursing staff, specifically for five nurse aides identified as Employees E11, E12, E13, E14, and E15. This deficiency was discovered through a review of personnel records and confirmed during an interview with the Nursing Home Administrator. The evaluations were not completed based on the date of hire, as required by the regulations, which stipulate that a performance review must be conducted at least once every 12 months for each nurse aide. This oversight indicates a lapse in adhering to the mandated staff development protocols.
Plan Of Correction
As a newly established company, we acknowledge this deficiency and view it as an opportunity to build a comprehensive and sustainable performance management system from the ground up. Recognizing the importance of staff development and regulatory compliance, we are committed to thoroughly evaluating all existing personnel and creating a robust framework for performance evaluations that supports both accountability and professional growth. To allow for a thoughtful and fair assessment of our current workforce, we have established a corrective action date of June 17, 2025. This extended timeline provides the necessary window to evaluate all nursing personnel, review existing training and evaluation protocols, and implement a standardized annual review system that aligns with each employee's hire date. During this period, Human Resources will work closely with the Director of Nursing and department heads to build a tracking system that ensures timely evaluations moving forward. A performance evaluation template based on job-specific competencies and core values will be finalized and implemented by the corrective date. All nurse aide personnel files will be audited and updated, and a schedule will be created to complete all outstanding evaluations by June 17. Training for supervisors on conducting effective and compliant evaluations will also be completed prior to that date. Addendum to Ensure Compliance with 60-Day Requirement: The facility is committed to completing all outstanding performance evaluations for current nurse aide personnel by the regulatory deadline of June 17, 2025. Human Resources, in collaboration with the Director of Nursing, has begun auditing personnel files and will implement a tracking system by May 31 to support timely completion. A standardized evaluation template will be finalized, and supervisors will receive in-service training to ensure evaluations are conducted appropriately. While every effort will be made to meet the June 17 target, if additional time is needed to ensure thorough and meaningful evaluations, the facility will continue working diligently to complete all evaluations as soon as possible. A long-term evaluation schedule based on hire dates will be implemented beginning July 1, 2025, to support ongoing compliance.
Failure to Provide Timely Assistance and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide prompt assistance to meet the care needs of three residents, compromising their dignity and quality of life. Resident R67, who has coronary artery disease and heart failure, reported sitting in a soiled brief for over an hour, with delays in response to call lights being a regular occurrence. Resident R63, diagnosed with seizure disorder and bipolar disorder, experienced similar delays, having to wait over an hour for assistance after an accident in bed. This resident also expressed discomfort with being woken up at 2:00 a.m. to change briefs, which they found disruptive. Resident R8, who has heart failure and sepsis, was observed without pants, wearing only a shirt and a brief, which they expressed dissatisfaction with. The facility's failure to provide timely assistance and maintain an environment that promotes dignity was confirmed by the Nursing Home Administrator and the Director of Nursing. These incidents highlight a lack of adherence to the facility's policy on resident rights, which mandates treating residents with kindness, respect, and dignity.
Plan Of Correction
Immediate Intervention: Staff for residents identified R67, R63, and R8 were notified that residents' rights were violated in the stated manor. Immediate counseling on resident rights to CNAs was provided. R67 and R63 were provided with immediate hygiene care and R8 was given hygiene care and lower body dressing provided. Identification of other residents who potentially can be affected: All residents residing in the building could potentially be affected by this violation of resident rights. Prevention of future occurrence: Educate all nursing staff on the call light response policy. Corrective Action to be monitored: DON/designee will complete the following audits. Call light response time will be monitored using an audit tool. DON/designee will interview 3 residents of each unit to determine if resident's rights are being violated. Audits for call-bell response times and interviews will be completed: 5 times per week for three weeks. Weekly for three weeks and then monthly for three months. QA Program: Call light response and maintaining Residents' rights will be added to Monthly QAPI meeting review.
Failure to Provide Timely ADL Assistance and Personal Care
Penalty
Summary
The facility failed to provide adequate Activity of Daily Living (ADL) assistance to 15 out of 22 residents, as evidenced by prolonged response times to call lights and insufficient personal care. Residents reported waiting an hour or longer for assistance, which was corroborated by a resident group interview and confirmed by the Director of Nursing. The facility's policy mandates that calls for assistance should be answered within five minutes, but this was not adhered to, leading to resident frustration and complaints during resident council meetings. Additionally, residents expressed dissatisfaction with agency staff, citing inattentiveness and lack of care. Specific instances of neglect included a resident waiting for their laundered clothes, resulting in wearing ill-fitting facility clothing, and another resident having long, unkempt fingernails and being malodorous. One resident was observed without pants, expressing discomfort, while another reported receiving only two showers since admission, despite being scheduled for regular showers. These observations and interviews highlight the facility's failure to meet the necessary ADL care requirements, as confirmed by the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
Immediate Intervention: Call light box was inspected and found to have a burnt-out bulb and bulb was replaced immediately. R68 clothes were discovered in laundry and returned to R68 and nail care and hygiene were provided. R125 nail care provided. R08 lower body was dressed. R69 shower was provided. Identification of other residents who potentially can be affected: All residents were identified to potentially be affected. Prevention of further occurrence: Education to resident rights as it pertains to resident ADL care. Educate staff about ADL resident rights and call light system. Corrective Action to be monitored: Audit tool created and DON or designee to assess residents' hygiene and shower schedule for compliance. QA Program: 3 residents on each unit will be audited (to assess residents' hygiene and shower schedule for compliance) daily for five days, weekly for three weeks, and monthly for three months. The identification of non-compliance staff will result in a performance improvement plan with potential for corrective action and discipline. Results of shower compliance added to monthly QAPI.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals, as evidenced by observations and staff interviews. During an inspection of the unused dining room on the first floor, expired items were found, including a box of Midline blood glucose test strips and an adult manual resuscitator, both past their expiration dates. The Unit Manager confirmed these findings, indicating a lapse in adherence to the facility's policy on medication storage and disposal. Further inspection of the ground floor clean utility room revealed additional deficiencies. The room, which had a keypad lock, was found with the door open, and an unlocked treatment cart inside contained open tubes of medical honey ointment without proper labeling or individual packaging. Additionally, expired wound dressing packages were discovered. These observations were confirmed by an LPN and later acknowledged by the Director of Nursing, highlighting the facility's failure to maintain proper storage and disposal practices for medications and biologicals.
Plan Of Correction
Immediate Intervention: Treatment cart was used for education and stored on units in common areas. The treatment cart was discarded, and its contents were destroyed. How to identify residents who can be affected: No further residents can be affected because the cart was removed, and contents were destroyed. Prevention of further occurrence: Facility assessment to determine if there are any other carts that need labeled or disposed. Corrective Action to be monitored: DON or designee to do weekly checks around the facility for carts and its contents being labeled, dated, and locked appropriately for one month and monthly for three months. QA Program: Performance Improvement plan added to monthly QAPI meetings to evaluate employee education progress.
Failure to Follow Menu and Resident Preferences
Penalty
Summary
The facility failed to adhere to its preplanned cycle menu and did not accommodate residents' food preferences and standing orders. On a specific date, residents were served pot pie for lunch instead of the expected chicken tenders, as indicated on the menu. The residents were not informed of this menu change in advance. Additionally, the facility's policy on menus and resident food preferences, which was last reviewed in March, outlines that menus should meet resident choices while following national nutritional guidelines and that individual food preferences should be assessed and communicated to the interdisciplinary team. Two residents were directly affected by these failures. One resident, who had a standing order for two cups of coffee, orange juice, and a boiled egg, received toast, a bagel, and only one cup of coffee, with no protein included. Another resident, who had a preference for a boiled egg and a dislike for scrambled eggs, was served a scrambled egg instead. The Dietary Services Director acknowledged making menu changes to gauge resident preferences but admitted difficulty in tracking these preferences due to limitations in the computer system. The Nursing Home Administrator confirmed the facility's failure to follow the preplanned menu and provide residents with their preferred food choices.
Plan Of Correction
The Dietary Director will ensure all menu changes are reviewed and approved at least 24 hours in advance by the Dietitian and Administrator. To notify residents in a simple and effective manner, the facility will implement a "Daily Menu Notice Board" in the facility, updated each morning by dietary staff. Any changes to the published menu will be clearly highlighted, and a brief explanation will be included. In addition, nursing aides will verbally inform residents of any substitutions at mealtime. To address errors in food preferences, the Dietary Services Director and Dietitian will jointly audit all resident food tickets for accuracy by June 9, 2025, and ensure corrections are entered into the dietary software. Staff responsible for tray preparation will receive re-training on reviewing food tickets and adhering to standing orders. A weekly audit of at least 10 meal trays will be conducted for 8 weeks to confirm compliance with resident preferences. The Administrator will monitor audit results and ensure follow-up for any deviations.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training to seven out of ten staff members, as required by their infection prevention and control program. The facility's policy, "In-Service Training, All Staff," mandates that all personnel receive education and training related to resident care, including infection control. However, a review of the facility's training records revealed that several employees, including nurse aides, a registered nurse, a medical records employee, and a therapy employee, did not have documented infection control training within the specified time frames after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of infection control training for these staff members. The deficiency was identified based on the review of facility policy, personnel in-service training records, and staff interviews. The failure to provide this essential training is a violation of the facility's infection prevention and control program standards, as well as state regulations regarding staff development and management responsibilities.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Infection Control training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and discovered that 0945 was not uploaded to the training platform. Infection Control training has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0945 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training to eight out of ten staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, "In-Service Training, All Staff," mandates that all personnel receive education and training related to resident care, including behavioral health. However, the training records revealed that Nurse Aides E11, E12, E13, and E15, Registered Nurses E16 and E19, Medical Records Employee E17, and Therapy Employee E18 did not have documented behavioral health training within the specified time frames after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency is a violation of the facility's policy and the regulatory requirements outlined in 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Behavior Health training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and discovered that 0949 was not uploaded to the training platform. Behavior Health Training has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0949 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Notify Resident Representative of Appointment Changes
Penalty
Summary
The facility failed to notify the resident representative of changes in appointment and transportation times for a resident, identified as Resident R69. The facility's policy, "Notification for Medical Appointments," requires that the responsible party be notified at least 48 hours in advance of a medical appointment, unless it is emergent. This notification should include details such as the date and time of the appointment, the healthcare provider's name and specialty, the purpose of the appointment, and any special instructions. However, the facility did not adhere to this policy for Resident R69, who was admitted on 4/2/25 and had a history of diabetes and multiple fractures. The resident's son, who is the emergency contact and medical power-of-attorney, was not informed of an appointment with a plastic surgeon, which led to a referral to an orthopedic surgeon. The resident's son expressed frustration over not being informed of the appointment in advance, a concern he had previously raised with the facility administration. Despite assurances that this issue would not recur, the son was not notified of a change in transportation time for another appointment, resulting in the resident departing the facility without him. The Nursing Home Administrator confirmed that the facility failed to notify the resident representative of these changes, acknowledging that the concern had been previously brought to their attention.
Plan Of Correction
Immediate Intervention: Resident and family were notified on all future appointments with dates and times including transportation times for pick up. Identification of other residents who potentially can be affected: All residents in the facility can be affected. Prevention of future occurrence: Education and policy review was provided to the scheduler on updating residents and families on upcoming appointments. The appointment scheduler/designee will print out all appointments and transportation for all residents in the facility. A copy will be given to the resident, and the family will be notified and documented in PCC. Corrective Action to be monitored: Audit tool created to assess resident and family notification of appointments and transportation. QA Program: Interview 3 residents with appointments daily for five days, then weekly for three weeks and monthly for three months. Notification of appointment compliance reviewed monthly at QAPI.
Failure to Maintain Homelike Environment in Dining Room
Penalty
Summary
The facility failed to maintain a homelike environment in one of its resident dining locations, specifically on the first floor nursing unit. This deficiency was identified during a review of the facility's "Homelike Environment Policy" and through observations and staff interviews. The policy, dated 3/14/25, mandates that residents are provided with a safe, clean, and comfortable environment, encouraging the use of personal belongings. However, during an observation on 4/14/25, it was noted that the first floor resident dining room was being used to store a bed, mattress, and two treatment carts, which is not in line with the policy's requirements. Interviews conducted with the unit manager and the nursing home administrator, along with the Director of Nursing, confirmed the presence of these items in the dining room. This situation was acknowledged as a failure to maintain a homelike environment in the specified dining location. The deficiency was documented as a violation of the residents' right to a safe, clean, comfortable, and homelike environment as per the regulatory requirements.
Plan Of Correction
The facility directed correct the deficient practice by removing the bed, mattress, and two treatment carts stored in the dining room. To prevent recurrence, staff have been reminded that dining rooms must not be used for storage. A new designated storage area has been established for extra equipment, and signage has been posted to reinforce this policy. Beginning June 9, 2025, the Unit Manager will conduct weekly inspections of all dining rooms for eight weeks, followed by monthly random checks. Any findings will be addressed immediately. The Administrator is responsible for ensuring the implementation and continued compliance with this plan.
Failure to Provide Qualified Activities Director
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program for a period of one month, from March 3, 2025, through April 14, 2025. This deficiency was identified based on staff interviews and a review of facility-provided documentation. The job description for the Activities Director required an Activity Director certificate, which was not met during the specified period. The Nursing Home Administrator confirmed this lapse during an interview conducted on April 16, 2025.
Plan Of Correction
The facility will ensure that all activity assessments are reviewed and signed off by a licensed Occupational Therapist (OT) under the supervision of the Director of Rehabilitation. This temporary oversight measure will remain in place until our current Activities director has completed her licensure for the state. The Director of Rehab and RDCS will also provide guidance and ensure compliance with all regulatory standards for activity assessments and care planning. Staff involved in activity programming will be educated on the interim procedure and documentation expectations. Weekly reviews will be conducted by the Director of Rehab to confirm that all assessments are completed and signed appropriately.
Failure to Follow Post-Hospitalization Care Instructions
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident R68, following their hospitalization. The resident was admitted with diagnoses including anemia, chronic kidney disease, and osteomyelitis. Hospital discharge instructions specified that the dressing on the resident's right lower extremity should only be reinforced and not changed until a follow-up appointment. However, a progress note indicated that the dressing was changed without an order, and a soiled bandage was used to wrap the wound, which was against the physician's instructions. Staff interviews revealed that the dressing was removed and replaced with a dirty ace wrap, despite orders to only reinforce the dressing and notify the doctor in case of excessive drainage. The Unit Manager and Nursing Home Administrator confirmed that the dressing was changed without an order, and the facility failed to provide the necessary care and services for the resident after hospitalization. This incident highlights a deficiency in adhering to professional standards of practice and the resident's care plan.
Plan Of Correction
Immediate Intervention: Surgeon was notified that dressing was removed. Orders received from surgeon for dressing. Immediate education for all nurses involved in dressing change was given. Education on following doctor's orders. How to Identify residents who can be affected: All residents can potentially be affected. Prevention of further occurrence: Immediate education for all nurses was started. All nursing staff will be trained in following doctors' orders using policy 7.1 medication administration. Corrective Action to monitor: Audit tool created to review staff compliance to review physician orders against completion. The wound nurse or designee will audit new wounds five days a week for three weeks, weekly for three weeks, and monthly for three months. QA Program: Identification of staff noncompliance will result in a performance improvement plan with potential for corrective action and discipline. Treatment compliance added to monthly QAPI for review.
Failure to Ensure Availability of Prescribed Medications
Penalty
Summary
The facility failed to implement procedures to ensure the availability of prescribed medications for a resident, identified as R244. The resident was admitted with chronic obstructive pulmonary disease, spinal stenosis, and chronic pain syndrome. Physician's orders indicated the resident was to receive oxycodone, methocarbamol, and ketorolac tromethamine for pain management. However, the Medication Administration Record (MAR) showed no documentation of oxycodone being provided on the day of admission, and methocarbamol was noted as on order from the pharmacy. The resident's pain levels were consistently high, ranging from 7 to 10 on a scale of 0 to 10, indicating severe pain. The facility's policy, "Pharmacy Services Overview," required the accurate and safe provision of pharmaceutical services, including routine and emergency medications. Despite this, the facility's automated medication dispensing machine inventory included the necessary medications, but they were not administered as prescribed. The Director of Nursing was informed of the failure to ensure the availability of prescribed medications for the resident, highlighting a deficiency in the facility's pharmacy services.
Plan Of Correction
Immediate Intervention: Immediate education for all nurses was given on medicating residents for pain and discomfort when pain is assessed. Education provided to all nurses by DON on medication availability in pyxis and process of obtaining new scripts. How to Identify residents who can be affected: All residents can potentially be affected. Prevention of further occurrence: Education for medicating for pain and discomfort along with medication availability in pyxis and process of obtaining new scripts will be done in orientation. Corrective Action to be monitored: DON/designee will audit documented pain scale against pain medications administered of 5 residents on each unit daily for five days, then weekly for three weeks, then monthly for three months. QA Program: Performance improvement plan using Plan do Study Act and root cause analysis for proper medication administration for PRN pain medication administration and availability of routine medications to be presented monthly at QAPI.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call bell system was fully operational on the Second Floor Nursing Unit. The facility's policy, dated 3/14/25, requires that the call system be both audible and visual, and functional at all times. However, during an observation, it was noted that the central call bells in the A, B, and C halls did not illuminate when resident call bells in their rooms were activated. This issue was confirmed during an interview with the Director of Nursing, who acknowledged that the central call bells were not providing unobstructed visual communication due to the ceiling bulkhead.
Plan Of Correction
This error was corrected within the survey time and the deficient practice has been fixed. Staff will be re-educated by DON on the importance of promptly responding to call bells and reporting any malfunctions immediately. Weekly maintenance checks of the call system will be conducted for eight weeks, with findings reported to the QAPI committee. The DON or designee will complete the weekly checks.
Unsafe and Unclean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, functional, and clean environment for two residents on the Third Floor B wing nursing unit. During an observation, it was noted that a section of the wall behind one resident's bed had been removed, exposing wires and insulation. This was due to the wall pulling away because of a heavy television. The residents' belongings were scattered throughout the room, allowing debris to fall onto them and into their personal items. The Maintenance Director confirmed the issue, and the Nursing Home Administrator acknowledged the failure to provide a safe and functional environment for the residents involved.
Plan Of Correction
The facility noted the incorrect practices and the situation was addressed immediately. Maintenance staff began repairs as soon as the damage was discovered, and both residents were temporarily relocated to another room to ensure their safety and comfort during the repair process. Their personal belongings were cleaned and restored, and the room was returned to a clean, functional condition upon completion of the repairs. To prevent recurrence, all maintenance projects involving occupied resident rooms will now require advance coordination with nursing and housekeeping staff to ensure resident relocation and item protection prior to work beginning. The TELS system will be the means by which all maintenance repairs are used, including confirming that rooms are vacated and resident property is secured. On April 17, 2025, the Maintenance Director provided in-service education to all maintenance staff on the new protocol for repairs in occupied resident rooms, including the requirement for coordination with nursing and housekeeping, proper resident relocation, and protection of personal items. All work orders will continue to be processed through the TELS system, which now includes confirmation that rooms are vacated and belongings secured prior to any work. To ensure compliance, the Administrator or designee will conduct weekly audits of 2 random maintenance work orders for eight weeks beginning April 21, 2025. Audit results will be reviewed during QAPI meetings, with monthly spot checks continuing thereafter as part of the facility's environmental safety program.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to provide mandatory training on the Prevention of Abuse and Neglect for one of its staff members, identified as Employee E18. This deficiency was discovered through a review of the facility's policy on in-service training and personnel training records. The policy, last reviewed on March 14, 2025, mandates that all staff receive education on various topics, including preventing abuse, neglect, exploitation, and misappropriation of resident property. However, it was found that Employee E18, who was hired on February 9, 2009, did not receive the required in-service education on Prevention of Abuse and Neglect between February 9, 2024, and February 9, 2025. During an interview conducted on April 18, 2025, the Nursing Home Administrator confirmed the oversight, acknowledging that the facility did not provide the necessary training to Employee E18. This lapse in training is a violation of the facility's policy and the regulatory requirements set forth in §483.95(c), which stipulate that all staff must be educated on activities that constitute abuse, neglect, and exploitation, as well as procedures for reporting such incidents. The deficiency highlights a gap in the facility's compliance with training requirements, potentially impacting the quality of care and safety of residents.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Abuse/Neglect and Exploitation on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Abuse and Neglect is part of annual training on the electronic platform. Nurse Educator has identified employees who need to complete Abuse/Neglect education. Employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0943 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to meet the required in-service training hours for nurse aides, as mandated by federal regulations. Specifically, two nurse aides, identified as Employees E11 and E15, did not receive the minimum 12 hours of in-service education within 12 months of their hire date anniversary. Employee E11, hired on March 26, 2023, only completed approximately four hours of in-service education between March 26, 2024, and March 26, 2025. Similarly, Employee E15, hired on April 14, 2014, also completed only about four hours of in-service education between April 14, 2024, and April 14, 2025. The deficiency was confirmed during an interview conducted on April 18, 2025, at approximately 1:00 p.m., where it was acknowledged that the facility did not provide the required annual in-service education for these two nurse aides. The facility's policy, "In-Service Training, All Staff," which was last reviewed on March 14, 2025, indicates that all personnel should receive education and training related to resident care, yet this was not adhered to in the cases of Employees E11 and E15.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Staff Development training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0947 was not uploaded to the training platform. Staff Development training has since been added to the electronic platform and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0947 training completed. Corrective action required: Nurse educator to review all nurse aide staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Survey Results Not Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors. This deficiency was observed across four locations within the facility: the first floor lobby, and the nursing units on the ground, second, and third floors. During observations conducted on April 14, 2025, at various times in the morning, survey result books were not found in any of these locations. The Nursing Home Administrator confirmed during an interview on February 12, 2025, that the facility did not have the Department of Health's most recent survey results accessible in the specified areas. This lack of accessibility to survey results is a violation of the residents' rights to examine the results of the most recent survey and the facility's obligation to post these results in a place readily accessible to residents, family members, and legal representatives.
Plan Of Correction
Regional Director of Clinical Services educated the Administrator about the survey binder and its importance of locating the Survey results binder. Administrator will have large postings on every floor of the location the survey results binder that that floor. Administrator will do a weekly audit for 4 weeks to ensure that survey binder is updated.
Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to ensure that grievance or concern forms could be filed anonymously by residents and their representatives. This deficiency was identified across five locations within the facility, including four nursing units and the lobby, where grievance or complaint forms are provided. The facility's policy, last reviewed on March 14, 2025, stated that grievances could be submitted orally or in writing and could be filed anonymously. However, during an observation on April 14, 2025, it was noted that there were no grievance boxes available in the facility. Instead, posted signage instructed individuals to provide completed grievance or complaint forms to social services, or to slide the document under the door if the office was closed. During an interview on the same day, the Nursing Home Administrator confirmed the absence of grievance boxes and acknowledged the facility's failure to ensure that grievance or concern forms could be filed anonymously. This lack of anonymous filing options was consistent across all five locations where grievance or complaint forms were available. The deficiency was noted under the regulation 28 PA Code: 201.18(e)(4) Management, indicating a failure to comply with the requirement to provide a means for residents to file grievances without fear of reprisal or discrimination.
Plan Of Correction
The facility will install secure, locked grievance boxes in each of the five locations where forms are provided (four dining rooms and the lobby). Each box will be clearly labeled and placed in a visible, accessible location. New signage will also be posted to inform residents and representatives that grievance/concern forms may be submitted anonymously through these boxes. A facility-wide check confirmed that no such boxes currently exist. Staff will be re-educated on the grievance policy, including the right to file anonymously, by the Social Services Director. The Social Services Department will check the boxes weekly to collect submissions and ensure functionality. Random monthly audits will continue thereafter. The Nursing Home Administrator is responsible for ensuring the implementation of this correction and compliance. Secure, locked grievance boxes will be installed in all five designated locations (four dining rooms and the lobby). Each box will be placed in a location that is visible and accessible to residents and representatives but positioned to maintain privacy, such as near unit entrances or in recessed wall areas obscured from direct staff oversight. Boxes will be clearly labeled and signage will be updated to inform residents and families that grievances may be submitted anonymously. On June 7, 2025, the Social Services Director provided an in-service training to the Administrator and Social Services staff responsible for grievance management. The training covered: - The policy and resident rights regarding grievance filing - The importance of maintaining anonymity - Protocols for monitoring and responding to submissions Training documentation is retained in the education file. To ensure timely attention to grievances, the Social Services Department will check each box daily, beginning June 9, 2025. A log will be maintained to document daily checks and response actions. Additionally, monthly audits will be conducted to confirm: - Each box remains secure and in proper working condition - Signage is in place and clear - Daily check logs are complete and up to date Audit results will be reviewed in the QAPI meeting each month to support continued compliance.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for seven out of eight direct care staff members, as required by §483.95(a). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care, including effective communication with residents and family. However, documentation revealed that Nurse Aides E11, E12, E13, E14, and E15, as well as Registered Nurses E16 and E19, did not receive the required training within the specified time frames after their hire dates. During an interview on April 18, 2025, the Nursing Home Administrator confirmed the lack of effective communication training for these staff members. This failure to provide the necessary training is a violation of the facility's policy and regulatory requirements, as outlined in 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with communication training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0941 was not uploaded to the training platform. Effective communication has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0941 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Resident Rights Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Resident Rights to eight out of ten staff members, as required by §483.95(b). This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care, including resident rights and responsibilities. However, documentation revealed that several staff members, including nurse aides, registered nurses, a medical records employee, and a dietary employee, did not have documented training on Resident Rights within the specified time frames. The staff members who lacked the required training included Nurse Aides with hire dates ranging from 1995 to 2023, Registered Nurses hired in 2007 and 2022, a Medical Records employee hired in 2010, and a Dietary employee hired in 2017. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the necessary training on Resident Rights for these employees. This deficiency is in violation of the facility's policy and the regulatory requirements set forth in 28 Pa Code sections related to staff development and management responsibilities.
Plan Of Correction
All nursing staff were provided with Resident Rights training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0941 was not uploaded to the training platform. Resident Rights has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0942 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for ten staff members, as required by §483.95(d). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, "In-Service Training, All Staff," which was last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care, including the elements and goals of the facility's QAPI program. However, documentation revealed that none of the ten staff members, including nurse aides, registered nurses, a medical records employee, a therapy employee, and a dietary employee, received the required QAPI training within the specified timeframes. During an interview, the Nursing Home Administrator confirmed the lack of QAPI training for these staff members. The staff members had various hire dates ranging from 1995 to 2023, and the failure to provide QAPI training occurred between 2023 and 2025, depending on each employee's hire date. This oversight indicates a systemic issue in ensuring compliance with mandatory training requirements, as outlined in the facility's policy and federal regulations.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with QAPI training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 0944 was not uploaded to the training platform. QAPI training has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0944 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide required training on Compliance and Ethics for four out of ten staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on March 14, 2025, mandates that all personnel receive education and training on various topics, including the compliance and ethics program standards, policies, and procedures. This training is required annually for organizations operating five or more facilities. However, documentation revealed that Nurse Aide Employee E11, Nurse Aide Employee E15, Registered Nurse Employee E16, and Registered Nurse Employee E19 did not receive the necessary in-service education on Compliance and Ethics within the specified timeframes. During an interview on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the required training for these staff members. The deficiency was identified based on the absence of documented training records for the specified employees, despite the facility's policy requiring such training. This oversight indicates a lapse in the facility's adherence to its compliance and ethics training program, as outlined in the regulatory requirements.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Compliance and Ethics training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and Compliance and Ethics training discovered that 0946 was not uploaded to the training platform. It has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0946 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Display Nurse Staffing Information
Penalty
Summary
The facility failed to meet the requirement of prominently displaying nurse staffing information on one of the five days surveyed. On April 14, 2025, during an observation at 11:05 a.m., the Nursing Home Administrator (NHA) was unable to locate the current nurse staffing information at the facility's receptionist desk. This indicates a lapse in the facility's compliance with the regulation that mandates the posting of nurse staffing data in a clear and readable format in a prominent place accessible to residents and visitors. During an interview conducted on the same day at 11:30 a.m., the NHA confirmed the facility's failure to display the required nurse staffing information for that day. This deficiency was noted under the regulatory requirements of 28 Pa Code 211.12 (d)(1)(3)(4) Nursing services, which emphasize the importance of maintaining transparency and accessibility of staffing information to ensure adequate nursing services are provided to residents.
Plan Of Correction
The administrator educated the Staffing Coordinator, who will be responsible for preparing and updating daily nurse staffing information using a standardized Excel sheet. This sheet will be printed and placed at the receptionist desk in a clearly marked and visible location each morning. The Staffing Coordinator will receive training on this new process, and a backup designee will be assigned to ensure coverage on weekends or in the coordinator's absence. The Nursing Home Administrator will conduct random weekly checks for four weeks to ensure staffing information is consistently posted and visible. Results will be reviewed with the Quality Assurance Committee.
Failure to Provide Accident Prevention Training
Penalty
Summary
The facility failed to provide necessary training on accident prevention for three out of five nurse aides, as required by their policy. The policy, last reviewed on March 14, 2025, mandates that all personnel receive education and training related to resident care. However, a review of the facility's documents and training records revealed that Nurse Aide Employee E11, hired on March 26, 2023, did not receive accident prevention in-service education between March 26, 2024, and March 26, 2025. Similarly, Nurse Aide Employee E13, hired on March 8, 2022, lacked this training between March 8, 2024, and March 8, 2025. Additionally, Nurse Aide Employee E15, hired on April 14, 2014, did not receive the required training between April 14, 2024, and April 14, 2025. This deficiency was confirmed by the Nursing Home Administrator during an interview on April 18, 2025.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Accident Prevention training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 1550 was not uploaded to the training platform. Accident Prevention has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1550 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Restorative Nursing Techniques Training
Penalty
Summary
The facility failed to provide training on restorative nursing techniques for two nurse aides, Employee E11 and Employee E15. According to the facility's policy, all personnel are required to receive education and training related to resident care. However, a review of the facility's documents and training records revealed that Employee E11, hired on March 26, 2023, did not receive the required in-service education on restorative nursing techniques between March 26, 2024, and March 26, 2025. Similarly, Employee E15, hired on April 14, 2014, did not receive the necessary training between April 14, 2024, and April 14, 2025. During an interview on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the required training for these two nurse aides. This deficiency was identified based on the review of facility policy, personnel in-service training records, and staff interviews.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Restorative Nursing Techniques on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and discovered that 1560 was not uploaded to the training platform. Restorative Nursing Techniques has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1560 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Emergency Preparedness Training
Penalty
Summary
The facility failed to provide required training on emergency preparedness for two nurse aides, identified as Employee E11 and Employee E15. According to the facility's policy titled 'In-Service Training, All Staff,' which was most recently reviewed on March 14, 2025, all personnel are required to receive education and training related to resident care, including emergency preparedness. However, a review of the facility's documents and training records revealed that Employee E11, hired on March 26, 2023, did not receive emergency preparedness training between March 26, 2024, and March 26, 2025. Similarly, Employee E15, hired on April 14, 2014, did not receive the required training between April 14, 2024, and April 14, 2025. During an interview conducted on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the necessary emergency preparedness training for these two nurse aides. This deficiency was identified based on the review of facility policy, personnel in-service training records, and staff interviews.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Emergency Preparedness on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 1570 was not uploaded to the training platform. Emergency Preparedness has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1570 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Failure to Provide Fire Safety Training to Nurse Aides
Penalty
Summary
The facility failed to provide mandatory fire safety training to three out of five nurse aides, as required by 42 CFR 483.90. The deficiency was identified through a review of the facility's policy on in-service training, personnel training records, and staff interviews. Specifically, Nurse Aide Employee E11, hired on 3/26/23, did not receive fire safety training between 3/26/24 and 3/26/25. Similarly, Nurse Aide Employee E13, hired on 3/14/05, and Nurse Aide Employee E15, hired on 4/14/14, also lacked documented fire safety training for the period between 3/14/24 and 3/14/25, and 4/14/24 and 4/14/25, respectively. The Nursing Home Administrator confirmed the absence of this essential training during an interview conducted on 4/18/25.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Fire Prevention and Safety on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed training platform and discovered that 1580 was not uploaded to the training platform. Fire Prevention and Safety has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 1580 training courses completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides across multiple shifts over a period of 12 out of 21 days. Specifically, the facility did not provide the mandated minimum of one nurse aide per 10 residents during the day, one per 11 residents in the evening, and one per 15 residents overnight. This deficiency was identified through a review of nursing schedules and census information, which revealed consistent shortfalls in the number of nurse aide hours provided compared to what was required. The shortfalls in staffing were documented on specific dates, with discrepancies ranging from minor to significant. For instance, on several occasions, the facility provided fewer hours of nurse aide care than required, such as providing only 67.50 hours when 73.00 were needed on a night shift. The Nursing Home Administrator confirmed these staffing deficiencies during a follow-up communication, acknowledging the failure to meet the regulatory staffing requirements on the specified days.
Plan Of Correction
The facility will implement a corrective staffing plan led by the Staffing Coordinator and overseen by the Director of Nursing and Administrator. The Staffing Coordinator will use a facility software to verify projected ratios tracking tool to calculate required hours per shift daily based on resident census and will ensure adequate staffing coverage is planned in advance. A float pool and an on-call list of PRN staff will be developed to cover unexpected absences or shortfalls. Additionally, the facility will continue the recruitment effort to increase the availability of certified nurse aides. Starting June 9, daily staffing compliance reports will be submitted to the Administrator and reviewed in QAPI meeting. In-service training will be conducted for administrative staff on regulatory staffing requirements and the importance of maintaining minimum staffing ratios. To ensure sustained compliance, the Administrator or designee will conduct weekly audits of the staffing schedules to: - Compare projected vs. actual staffing per shift - Verify adherence to required ratios - Ensure appropriate documentation and use of PRN/on-call staff when needed Audit results will be discussed in weekly QAPI meetings beginning June 9, 2025. After the initial 30-day audit period, the facility will continue with monthly audits through the remainder of the calendar year to ensure ongoing compliance.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility administrative staff failed to provide the minimum required 3.2 hours of direct resident care per resident in a 24-hour period on six specific days between April 3, 2025, and April 11, 2025. This deficiency was identified through a review of nursing schedules and census information, which revealed that the provided hours per patient day (PPD) fell short of the mandated requirement on these dates. Specifically, the PPD was 3.16 on April 3 and 4, 3.14 on April 5, 3.19 on April 8, 2.97 on April 10, and 3.13 on April 11. The Nursing Home Administrator confirmed this shortfall during a follow-up communication on April 21, 2025.
Plan Of Correction
The Staffing Coordinator will implement a daily tracking process in the facility software program to monitor projected and actual nursing hours PPD. This tool will calculate staffing requirements based on daily census and will be reviewed by the Administrator each morning to ensure adequate coverage. If staffing levels are projected to fall below the minimum threshold, the Coordinator will call-in procedure to utilize PRN staff, float pool personnel, or approved agency staff. The facility will also continue recruiting methods to bring more staff in. Administrative staff will be re-educated on minimum nursing hour requirements and their role in meeting them. Daily staffing logs will be audited for 30 days beginning June 9, and results will be reviewed weekly in QAPI meetings. To ensure sustained compliance, the DON or designee will conduct weekly audits of the prior week's staffing logs for accuracy and completeness. These audits will confirm that the 3.2 PPD minimum is met, verify proper documentation of census and hours, and confirm any corrective actions taken if shortfalls occur. Results of these audits will be reviewed weekly during QAPI meetings. Following the initial 30-day audit period, the facility will transition to monthly staffing audits for the remainder of the calendar year to monitor long-term compliance.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the day shift on two specific days. On January 16, 2025, the facility had a census of 150 residents, necessitating 15 nurse aides, but only 6.53 nurse aides were available. Similarly, on January 20, 2025, with a census of 145 residents, 14.5 nurse aides were required, yet only 9.6 were present. There were no additional higher-level staff available to compensate for these shortages. This deficiency was confirmed by the Nursing Home Administrator during an interview on February 5, 2025.
Plan Of Correction
DON will educate Administrator and Staffing Coordinator on the staffing ratios. Staffing meetings will be held 5 days per week to review ratios from the prior day(s) and the projected staffing to the upcoming week to ensure appropriate staffing levels are planned. Identified staffing needs will be offered to existing staff and contracted agencies, as needed, by the Administrator/designee. The facility will continue to recruit staff through use of company platforms and recruiter representatives. Audits of staffing ratios will be completed by the NHA/designee to ensure that the facility meets daily hours requirements and nurse aid staffing ratio requirements. Audits will be completed by the administrator during the staffing meetings.
LPN Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one Licensed Practical Nurse (LPN) per 40 residents during the night shift. On January 21, 2025, the facility had a census of 146 residents, necessitating 3.65 LPNs for adequate coverage. However, the nursing time schedules revealed that only one LPN was available to provide care during the night shift, resulting in a staffing shortage. The Nursing Home Administrator confirmed this deficiency during an interview conducted on February 5, 2025, acknowledging the failure to meet the required staffing levels.
Plan Of Correction
DON will educate Administrator and Staffing Coordinator on the staffing ratios. Staffing meetings will be held 5 days per week to review ratios from the prior day(s) and the projected staffing to the upcoming week to ensure appropriate staffing levels are planned. Identified staffing needs will be offered to existing staff and contracted agencies, as needed, by the Administrator/designee. Should additional staff be needed during the after hours shifts, the administrator/designee should provide more shifts on agencies platforms. The facility will continue to recruit staff through use of company platforms and recruiter representatives. Audits of staffing ratios will be completed by the NHA/designee to ensure that the facility meets daily hours requirements and LPNS staffing ratio requirements. Audits will be completed by the administrator during the staffing meetings.
Deficiency in Minimum Nursing Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on two specific days. On January 15, 2025, with a census of 146 residents, the facility provided only 3.10 hours per resident. On January 16, 2025, with a census of 150 residents, the facility provided only 2.64 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 5, 2025, who acknowledged the shortfall in nursing hours on these two days.
Plan Of Correction
DON will educate Administrator and Staffing Coordinator on the PPD state requirements. Staffing meetings will be held 5 days per week to review ratios from the prior day(s) and the projected staffing to the upcoming week to ensure appropriate staffing levels are planned. Identified staffing needs will be offered to existing staff and contracted agencies, as needed, by the Administrator/designee. The facility will continue to recruit staff through use of company platforms and recruiter representatives. Audits of PPD requirements will be completed by the NHA/designee to ensure that the facility meets daily hours requirements. Audits will be completed by the administrator during the staffing meetings.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for five residents, as observed and confirmed through interviews and record reviews. Resident R1 had ACE wraps applied incorrectly, with no active order to place them on, and they were not removed at the hour of sleep as ordered. Resident R2 had ACE wraps applied in a manner inconsistent with the physician's order, reversing the direction from knees to toes. Resident R3 did not have ACE wraps on as ordered, and during an interview, it was revealed that the wrap was removed due to pain from being too tight, with significant swelling observed. Resident R4 was noted not to have ACE wraps on during a scheduled time, and Resident R5 was observed without ACE wraps despite having swollen lower legs, as confirmed by a Licensed Practical Nurse. The Director of Nursing confirmed the facility's failure to ensure residents received appropriate treatment and care, as required by physician orders and resident care policies. The deficiencies were identified under several Pennsylvania Code regulations, including the responsibility of the licensee, resident rights, resident care policies, and nursing services. These observations and interviews highlight a pattern of non-compliance with prescribed care protocols, affecting the residents' health and well-being.
Plan Of Correction
Residents R1, R2, R3, R4 and R5 had no ill effects from F0684. Any residents with compression stockings, ted hose and ace wraps will be audited for correct application. Identified deficient practice will be corrected upon notation with 1:1 education and return demonstration competency as indicated. To prevent future occurrences, nurses will receive education on maintenance and use of compression stockings, ted hose and ace wraps. Director of Nursing and/or designee will complete audits of maintenance and use of compression stockings, ted hose and ace wraps at random with 4 A/O residents 2x a week x 1 month; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.
Staffing Deficiencies Lead to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of ten out of thirteen residents, as evidenced by multiple resident interviews and observations. Residents reported excessive wait times for call light responses, with some waiting up to six hours. Confidential residents expressed distress over being left in soiled conditions, with one resident stating they were told to have a bowel movement in their brief due to staff unavailability. Observations confirmed that residents were left in unsanitary conditions, such as being in wet clothing or having soiled bedding, indicating a lack of timely assistance from staff. Additionally, documentation revealed inconsistencies in the provision of showers and bathing for residents. For instance, one resident's bathing record showed multiple instances of missed or undocumented showers over a period of several weeks. Interviews with residents further highlighted the inadequacy of staffing, with some residents stating they had to wash themselves due to missed showers. The facility's administration acknowledged the staffing deficiencies, confirming the inability to meet resident needs adequately.
Plan Of Correction
Social services reviewed the grievance log and found no unaddressed care concerns. Social services interviewed twenty alert and oriented residents, who at the time did not express any delay of care or overall care issues. Social services additionally walked the entire building performing visual audits to include any residents who are not alert and oriented to ensure timely care was provided. At this time, there are no active grievances related to delay in care due to staffing. Any residents who have a shower report that is identified as refusing and/or N/A identified, the assigned staff will have 1:1 education from the nurse educator/designee. To prevent future occurrences, nurses and aides will receive education by the Nurse Educator/designee on the importance of timely call bell response as well as the importance of showers/hygiene. The aides and nurses will also be educated by the Nurse Educator/designee on completion of ADLs, emptying urinals, making beds, etc. The Director of Nursing and/or designee will complete audits of call bells and shower/bathing records at random with 4 residents on each unit 2x a week for 1 month; then monthly thereafter with reporting through the Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.
QAPI Program Fails to Correct Elastic Bandage Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the improper use of elastic bandages, affecting 16 of 140 residents. A review of the facility's documentation and staff interviews revealed that the QAPI program did not effectively correct the issues identified in a prior survey conducted on 3/22/24. The plan of correction from the previous survey included audits and education for staff on the proper application of compression stockings, ted hose, and ACE wraps. However, during the current survey ending on 12/19/24, repeated deficiencies were identified, indicating that the corrective measures were not successfully implemented. The survey findings showed that five out of ten residents had issues with the application or absence of ACE wraps. Specifically, two residents had their ACE wraps applied incorrectly, with the wraps being reversed from the knees to the toes. Three other residents did not have ACE wraps on at all. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee to address these concerns, which had the potential to affect 16 residents.
Plan Of Correction
After notation, the facility conducted a QAPI meeting to review the facility policy regarding the Quality Assurance and Performance Improvement program. All residents with compression stockings, ted hose, and ace wraps will be identified monthly during QAPI to ensure proper monitoring. The Director of Nursing/designee will observe nurses apply/remove compression stockings and report findings to the administrator. The Director of Nursing/Designee will monitor residents ordered compression stockings, ted hose, and ace wraps for proper application and removal daily. The Director of Nursing/designee will report findings to the administrator monthly at the QAPI meeting. To prevent future occurrences from happening, the Administrator will educate the Director of Nursing to ensure that those identified with an order for compression stockings, ted hose, and ACE wraps are being reviewed monthly during QAPI. The Director of Nursing/designee will educate all nursing staff on following orders as it relates to compression stockings, ted hose, and ace wraps. The Administrator/designee will complete an initial whole house audit, then weekly audit x 4 weeks, then monthly audit of all residents with compression stockings, ted hose, and Ace wrap orders. Then monthly thereafter with reporting through the Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.
Inadequate Cleaning of Glucometers
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the cleaning and disinfecting of glucometers, which are used to test blood sugar levels. The deficiency was observed on the third-floor medication cart, where a Licensed Practical Nurse (LPN) used a 70% isopropyl alcohol pad to clean the glucometer after use. This practice was contrary to the manufacturer's instructions, which required the use of an EPA-approved disinfecting wipe. The LPN stated that she used alcohol pads because she did not have any disinfecting wipes and was unaware that alcohol wipes were unacceptable for cleaning glucometers. The deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to consistently implement the infection prevention and control program. The report references guidance from the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention, which emphasize the importance of proper cleaning and disinfecting of shared blood glucose meters to prevent cross-contamination and the spread of infectious agents.
Plan Of Correction
Upon notation, Employee E2 was immediately removed from the unit to be educated by the Director of Nursing of the proper procedure for infection control protocols. All residents that require blood glucose reading within the facility will be identified by the Director of Nursing/designee, and 1:1 education will be provided by the Director of Nursing/designee to all nursing staff. To prevent future occurrences, nurses will receive education by the Director of Nursing/designee on the proper infection control protocols as they relate to blood glucose readings. The Director of Nursing/designee will complete audits on each medication cart to ensure each cart has appropriate cleaning materials (disinfecting wipes containing bleach). The Director of Nursing/designee will shadow the nurse as the task is being performed to ensure proper infection control protocols are being followed at random with 4 Nurses 2x a week x 1 month; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardio Pulmonary Resuscitation (CPR) for a resident who was unresponsive and had ceased to breathe, despite the resident being a full code. The resident, identified as Resident R1, had a Physician Order for Life Sustaining Treatment (POLST) form indicating that resuscitation should be attempted if there was no pulse and no breathing. The resident's clinical record and care plan also confirmed the full code status, yet CPR was not administered when the resident ceased to breathe. The incident occurred when the family of Resident R1 arrived and found the resident unresponsive. A Registered Nurse (RN) was called to evaluate the resident, but CPR was not initiated because the RN did not want to start in front of the upset family member. The RN pronounced the resident ceased to breathe without attempting resuscitation, despite the clear directive in the resident's POLST and care plan. This failure to act according to the resident's code status and physician orders resulted in an immediate jeopardy situation, as it placed all residents at risk if they became unresponsive and pulseless. The facility's policy required CPR to be initiated unless there were obvious clinical signs of irreversible death, which were not present in this case.
Removal Plan
- Whole house audit was conducted on all code status of all residents to ensure all orders are in medical record, care planned and POLST forms are uploaded into the medical record and the original form placed in the physical chart.
- Any POLST forms not uploaded into the chart will be uploaded to the electronic record.
- All primary staff will be educated on code status and recognition of signs of death and proper procedure of notification to nursing staff if there is an occurrence. All agency and PRN staff will be instructed to complete education prior to the start of their next shift.
- All primary Nurses will be educated on signs of irreversible death, proper documentation in medical records of the occurrence and Policy NSG208 Cardiopulmonary Resuscitation (CPR) and Procedure: Cardiac and/or Respiratory Arrest. All agency and PRN staff will be instructed to complete education prior to starting next shift.
- Primary Licensed staff will be educated to facilitate CPR on residents who have elected such services until EMS arrives and assumes responsibility for the residents. All agency and PRN staff will be instructed to complete education prior to their next scheduled shift.
- All new admissions will be audited to ensure code status orders are entered into the medical record accurately, care planned, and uploaded into the medical chart. They will also ensure the physical copy of the advance directive is placed in the physical chart weekly.
- Mock codes will be conducted every shift then randomly daily, then weekly.
- QAPI completed.
- Audit completed for nurses CPR cards.
- AED/Crash carts verified with stocked and expiration dates of PADS.
- Education related to change in condition and notifications NSG122 will be completed. Entering Advance Directives orders are put in the medical record, care planned and Advance Directives are uploaded in the medical record and the original form placed in the physical chart.
Laundry Room Deficiency Due to Non-Functional Equipment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and functional environment in the main laundry room. During an observation, it was noted that only one out of three commercial-sized washing machines was operational, and two out of three dryers were functional. The soiled linen holding area was overcrowded with approximately eight bags of soiled linen in the laundry chute, over 15 bags of soiled linen, and a large bin overflowing with soiled linen waiting to be laundered, accompanied by a strong odor of feces and urine. Interviews with the Director of Housekeeping and a laundry aide revealed that the washers had been out of service since December 2023, and the situation had persisted since February. The Nursing Home Administrator confirmed the non-functional status of the machines and mentioned that one washing machine was awaiting repairs while another was pending replacement quotes.
Failure to Supervise Resident Departure
Penalty
Summary
The facility failed to provide adequate supervision to be aware of a resident's departure from the facility. Resident R1, who had diagnoses of high blood pressure and obesity, was admitted to the facility and had an Elopement Risk Assessment completed, which indicated no risk for elopement. Despite this, Resident R1 left the facility with her son around 1:00 a.m. without signing AMA papers or taking her medications. The departure was not reported by the night shift staff, and the absence was only discovered the following morning during a medication pass by RN Employee E1. The Unit Manager and other staff were unaware of Resident R1's departure until the morning meeting, and the police were asked to do a wellness check after the incident was discovered. Interviews with staff and the roommate of Resident R1 confirmed that the resident left the facility without notifying the staff. The roommate observed Resident R1 leaving with her son but did not inform the staff. The night shift staff, including NA Employee E4, were not aware of the resident's departure, indicating a lack of adequate supervision and communication among the staff. The Nursing Home Administrator was informed of the incident, highlighting the facility's failure to ensure proper supervision and awareness of resident movements, which is a violation of several state codes related to resident care and management.
Failure to Follow Dish Machine Sanitation and Temperature Procedures
Penalty
Summary
The facility failed to follow proper sanitation and temperature procedures for the dish machine operation, leading to potential cross-contamination in the main kitchen over a period of seven out of nine months. During an observation, the Assistant Dietary Manager admitted to not knowing the required temperatures or sanitation levels for the dish machine. A review of the dish machine temperature logs from January 2024 through March 2024, and previous logs from July 2023 through December 2023, revealed multiple instances where the wash temperatures did not reach the required 120 degrees, and sanitation levels were either not documented or not met. Specifically, in July 2023, the wash temperature did not reach 120 degrees on six days, and in August 2023, the sanitizer level was not documented for the entire month. Similar issues were found in October, November, January, February, and March, with missing or incomplete documentation of wash temperatures and sanitation levels. During an interview on March 19, 2024, the Dietary Manager confirmed the facility's failure to adhere to proper sanitation and temperature procedures for the dish machine. This lapse in protocol allowed for the potential for cross-contamination in the main kitchen, affecting the cleanliness and safety of dishes and items used by residents. The logs indicated inconsistent and often missing documentation of required wash temperatures and sanitation levels, highlighting a significant deficiency in the facility's dietary services.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to demonstrate a response to grievances for resident group meetings for five of six residents during the annual survey. The facility's grievance procedure policy indicated that concerns could be written and placed in a collection box or presented to the administration team, with a typical response time of 72 hours. However, during a Resident Council Meeting, residents expressed that they were unaware of who the grievance officer was and did not know how to file an anonymous grievance. They also reported that staff did not follow up on their concerns. The Nursing Home Administrator confirmed that she was the grievance officer but was unaware of the residents' issues related to grievance resolution and identification of the officer.
Failure to Provide Opportunity to Formulate Advance Directives
Penalty
Summary
The facility failed to provide the opportunity to formulate an advance directive for eight of the twelve residents reviewed. The facility policy on advance directives, reviewed on two separate dates, indicated that the facility would comply with requirements to inform and provide written information to all adult residents about their right to accept or refuse medical or surgical treatment and to formulate an advance directive. However, a review of the clinical records for residents with various diagnoses, including diabetes, high blood pressure, dementia, end-stage renal disease, cerebral palsy, depression, heart failure, Parkinson's disease, and chronic obstructive pulmonary disease, revealed no documentation that these residents were given the opportunity to formulate an advance directive. During an interview, the Director of Nursing (DON) confirmed that the clinical records did not include documentation that the residents were afforded the opportunity to formulate advance directives. This deficiency was identified for residents admitted to the facility on various dates, and it was confirmed that the facility did not comply with its policy to provide the necessary information and opportunity for residents to create advance directives, as required by 28 Pa. Code 201.29 (j) Resident rights.
Failure to Provide Access to Grievance Forms and Information
Penalty
Summary
The facility failed to provide residents access to grievance forms, the ability to file grievances anonymously, and did not post the name of the Grievance Official for residents to file a grievance orally. The facility's grievance procedure policy, last reviewed on 1/23/24, indicated that concerns could be written and placed in collection boxes at five identified locations or presented to the Administration team. However, during an observation on 3/19/24, no grievance forms were found in the identified areas. Additionally, the posted procedure listed the second previous Administrator as the grievance officer, and the facility's Resident Admission Packet indicated that residents had the right to file grievances, but this was not effectively communicated or facilitated in practice. During a group interview on 3/20/24, several residents indicated they did not know how to file a grievance, were never informed about the process, and were unaware of the availability of anonymous grievance filing. In an interview on the same day, the Nursing Home Administrator and Director of Nursing confirmed that the facility currently had no grievance officer information posted and that forms were not available for filing grievances. This failure affected all 155 residents at the facility, as it did not honor their right to voice grievances without discrimination or reprisal, as required by 28 Pa. Code: 201.18(e)(4) Management and 28 Pa. Code: 201.29(a)(j) Resident rights.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate potential abuse and/or neglect for three residents. Resident R209, who had multiple serious diagnoses including sepsis and breast cancer, did not receive required wound treatments for her chest port for six consecutive shifts. This lapse in care was not investigated by the facility. Resident R302, who had a fracture and other significant health issues, was left in a soiled brief for an extended period. Despite a grievance being filed, the facility did not identify this as neglect, failed to investigate, and did not report it to state agencies as required. Resident R37, who had a traumatic brain injury and other health conditions, reported continued neck pain and headaches after another resident fell on him. Although he had x-rays and a CT scan, the facility did not complete an incident report or investigation, dismissing his account due to his brain injury. The CT scan results were not communicated to the resident, and the facility failed to obtain the report in a timely manner. The Director of Nursing confirmed that the facility did not follow its Abuse Prohibition policy, which mandates that investigations begin within 24 hours and that all allegations be reported to state agencies. The facility's failure to investigate these incidents and report them as required demonstrates a significant lapse in adhering to regulatory requirements designed to protect residents from abuse and neglect.
Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for four residents, as observed and confirmed through interviews. Resident R20, diagnosed with coronary artery disease and a seizure disorder, had ACE wraps applied incorrectly from the knees to the toes, contrary to the physician's order. Resident R45, diagnosed with heart failure and high blood pressure, did not have ACE wraps applied at all during the observation. Resident R83, with coronary artery disease and high blood pressure, had ACE wraps applied incorrectly and too tightly, causing pain and significant swelling. Resident R145, diagnosed with malnutrition and high blood pressure, had fluid seeping through his compression stockings, indicating that new stockings were not applied when the previous ones were soiled. Interviews with staff and residents confirmed these deficiencies. Resident R83 reported pain due to the tightness of the ACE wrap, and Resident R145's condition was confirmed by the Unit Manager, who acknowledged the presence of seepage and dried fluid on the compression stockings. The Nursing Home Administrator confirmed that the facility failed to ensure appropriate treatment and care for these residents, violating several Pennsylvania Code regulations related to resident care policies and nursing services.
Improper Storage and Disposal of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were properly stored and/or disposed of on the Second-Floor Nursing Unit. During an observation, numerous expired medical supplies, including feeding pump bags, colostomy bags, wound dressings, and catheters, were found in the medication room and medical supply room. Additionally, several opened and undated prescription creams and ointments were found in treatment carts, some of which were not stored in bags and were associated with residents who had been discharged or no longer resided on the unit. The facility's policy on the storage and expiration dating of medications and biologicals was not followed, as evidenced by the presence of expired and improperly stored items. The CDC's NIOSH list of hazardous drugs was also not adhered to, as conjugated estrogen cream, a known human carcinogen, was found opened and undated without proper storage. The observations were confirmed by the Unit Manager and the Nursing Home Administrator during interviews. The deficiencies were noted in various sections of the treatment carts, with multiple instances of opened, undated, and improperly stored medications and supplies. These included prescription creams for specific residents, some of whom had been discharged, and other medical supplies that were not in their original packaging. The facility's failure to adhere to its own policies and regulatory standards resulted in the improper storage and disposal of medications and medical supplies on the Second-Floor Nursing Unit.
Failure to Prevent Cross-Contamination in Medication Carts
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent potential cross-contamination for two of four medication carts. The 2nd A/B Hall Treatment Cart and B/C Hall Treatment Cart were observed to have multiple residents' medications co-mingled and not stored in individual bags. Specific examples include tubes of prescription creams and ointments for various residents, some of whom had been discharged, stored together without proper separation. Additionally, some medications were found without resident names or room numbers, and some were opened and undated. During interviews, the Unit Manager and the Nursing Home Administrator, along with the Infection Preventionist, confirmed the observations and acknowledged that the co-mingling of medications and the improper storage created a potential for cross-contamination. The facility's policy on the storage and expiration dating of medications and biologicals was not followed, leading to this deficiency. The report cites specific Pennsylvania Code regulations that were violated, emphasizing the facility's responsibility to maintain a safe and sanitary environment.
Failure to Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to identify and address significant weight loss and the need for increased nutrition for a resident diagnosed with dysphagia following a cerebral infarction and malnutrition. The resident, who was admitted to the facility and required a feeding tube, experienced a weight loss of 16.20% over 35 days. Despite the resident's high risk for malnutrition, as indicated by multiple assessments and progress notes, the facility did not implement weekly weight assessments upon admission as required. Additionally, a dietary screening initiated on 3/1/24 was left incomplete, and the resident's significant weight loss was not addressed in a timely manner. Interviews with the Director of Nursing (DON) and the dietician confirmed that the resident should have been placed on weekly weight assessments upon admission. The facility's failure to monitor the resident's weight adequately and address the significant weight loss resulted in a deficiency. The clinical records and staff interviews revealed that the facility did not follow its protocol for weight monitoring and nutritional assessment, leading to the resident's unaddressed weight loss and potential complications related to malnutrition.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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