Cedar Hill Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Coraopolis, Pennsylvania.
- Location
- 951 Brodhead Road, Coraopolis, Pennsylvania 15108
- CMS Provider Number
- 395620
- Inspections on file
- 40
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Cedar Hill Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who was dependent for lower body dressing arrived at an outside appointment without pants, and the facility failed to report this incident as an allegation of neglect to the State Agency, as required by policy and regulation.
Surveyors found that two residents' MDS assessments did not accurately document the provision of dialysis and oxygen therapy, despite physician orders and care plans confirming these treatments. The discrepancies were confirmed by the RNAC after review of clinical records and staff interviews.
Two residents with diabetes who were prescribed insulin and using continuous glucose monitoring systems (Libre) did not have their care plans updated to include interventions or documentation for the Libre system, despite physician orders and ongoing use. This deficiency was confirmed by both the NHA and DON, who acknowledged the care plans did not reflect the residents' current needs.
A resident with dementia and moderately impaired cognition was not provided with the required assistance to have their food cut into small pieces at mealtime, as specified in their care plan and meal ticket. The resident was observed attempting to tear apart a whole chicken breast with their fingers, and staff confirmed that the necessary assistance was not given.
Two residents did not receive care as ordered by their physicians: one was not consistently provided with a prescribed sling for a fracture, and another used a continuous glucose monitoring device without an active physician order for its use or care, as confirmed by staff interviews and record review.
A resident with an indwelling urinary catheter was found with the drainage bag uncovered and lying on the floor, in violation of facility policy and infection control standards. An LPN confirmed the failure to provide appropriate catheter care and services as required.
A resident with end stage renal disease and a physician-ordered fluid restriction repeatedly received fluids in excess of the prescribed limit, with no evidence of physician review or staff and resident education on the restriction. The facility also lacked orders and documentation for monitoring and dressing changes of the resident's dialysis access site, as confirmed by the DON and Nursing Home Administrator.
A resident with PTSD, dysphagia, and anxiety did not receive trauma-informed care, as there was no completed Trauma Informed Care Evaluation and the care plan addressing PTSD was not completed in a timely manner. This was confirmed by the facility's social worker.
Two residents were served meals that did not match their documented dietary preferences and physician orders, as indicated on their tray assembly tickets. Staff confirmed that the meals provided, including incorrect main dishes and the presence of restricted items like salt packets, did not align with the residents' specified needs.
A resident with multiple diagnoses, including heart failure and cellulitis, was started on a new antibiotic without the required notification to their representative. Facility policy mandates such notifications and documentation, but review of records and staff interviews confirmed this did not occur.
A resident with multiple diagnoses, including heart failure and increased confusion, had a urinalysis with culture and sensitivity (UA/CS) ordered verbally by a Unit Manager to an RN supervisor, rather than by a physician as required by facility policy. The DON confirmed this did not meet professional standards of practice for obtaining physician orders.
The facility did not respond to call bells in a timely manner for several residents with significant medical needs, as shown by repeated complaints, direct observations of long wait times, and resident interviews describing delays in receiving assistance, especially during evening and weekend shifts or when agency staff were present.
The facility failed to use PPE appropriately in two droplet precaution rooms, risking cross-contamination. Observations revealed a housekeeper and a nurse assistant not wearing required PPE, despite signage and availability. Staff interviews confirmed the deficiency, acknowledging the need for full PPE in these rooms.
The facility failed to notify the Department of Health of all positive Covid-19 cases during a current outbreak involving four residents. The Nursing Home Administrator misunderstood the reporting requirements, believing only the initial report was necessary, leading to non-compliance with health department regulations.
The facility failed to maintain the confidentiality of resident health information by placing red signs on the doors of several residents, indicating their COVID-19 infection status. This action violated the residents' privacy rights as confirmed by two RNs, who noted that the facility's previous practice was to use green signs for enhanced droplet precautions.
The facility failed to ensure medications were not left unattended at the bedside for three residents. One resident had a pill left on their bedside table, another had two inhalers without orders for self-administration, and a third had eye drops without physician orders. LPNs confirmed the failure to properly store and secure medications, and the DON acknowledged the issue.
The facility failed to ensure call bells were within reach for two residents, leading to a deficiency. One resident with hypertension, hyperlipidemia, and depression could not access her call bell, which was confirmed by an LPN. Another resident with hemiplegia, aphasia, and dysphagia also had an inaccessible call bell, confirmed by another LPN. This failure violated resident care policies and nursing services requirements.
A facility failed to ensure that a POLST or physician order for code status was available for a resident with diabetes, hypertension, and hyperlipidemia. A review of the resident's clinical record did not reveal the necessary documents, and an LPN confirmed the absence of a code status, indicating a failure to assure the availability of physician orders for life-sustaining treatment preferences.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the hospital transfers of two residents. One resident with hypertensive heart disease, dementia, and major depressive disorder was not provided with bed hold policy information, and the Ombudsman was not notified. Another resident with anxiety, depression, and high blood pressure was also transferred without Ombudsman notification. The Social Service Director was unaware of the notification requirement.
A facility failed to document a resident's schizoaffective disorder diagnosis according to professional standards. The resident was admitted with major depressive disorder, but the diagnosis of schizoaffective disorder was not recorded until much later, despite symptoms being present. Interviews with staff confirmed the absence of necessary documentation, leading to a deficiency finding.
A resident with chronic kidney disease and other conditions eloped from the facility due to inadequate supervision. The resident was last seen in his room expressing concerns about his son. An LPN assisted him back to his room, but later, the resident was missing, and a car was seen leaving the facility. The resident's son confirmed he was with him but refused to return him or sign an AMA form. Staff interviews revealed the resident had expressed a desire to leave earlier, but no exit-seeking behavior was noted.
A facility failed to specify the size of an indwelling catheter in a physician order for a resident with a foley catheter. The resident, diagnosed with high blood pressure, kidney insufficiency, and depression, had a care plan indicating the catheter's presence, but the order lacked necessary size details, contrary to facility policy.
The facility failed to obtain physician orders and informed consent for the use of enabler/side rail assist bars for two residents. There was no documentation of assessments or evaluations to justify the use of these devices, as confirmed by staff interviews and record reviews.
A facility failed to provide required annual in-service education for an RN, as mandated by their policy. The RN's personnel record lacked documentation for training on essential topics such as resident rights, abuse, infection control, and dementia management. This deficiency was confirmed by the HR Director.
A resident with diabetes did not receive her prescribed Jentadueto medication as ordered, due to a failure in medication administration and documentation. The medication was not administered on a specific day, and although it was reordered, there was no documentation of provider notification. The issue was confirmed by the CRNP and DON.
A facility failed to disinfect a respiratory spacer and prevent cross-contamination during a dressing change. An LPN placed a used spacer in a medication cart without cleaning it, and during a dressing change, did not use a barrier, skipped hand hygiene, and failed to clean the tray table, leading to potential cross-contamination.
The facility failed to notify two residents or their representatives of the bed-hold policy during hospital transfers, as required by their policy. Despite the facility's Transfer Notice of Bed Hold Policy and Readmission policy, which mandates providing written information about the bed-hold policy prior to or at the time of transfer, this was not done for residents with conditions such as hypertensive heart disease, dementia, anxiety, and depression. Staff interviews confirmed the lack of documentation and notification, violating resident rights.
A resident with chronic kidney disease, diabetes, and depression passed away, and the facility failed to convey the resident's funds within the required 30 days. Despite processing a refund request and printing a check, the responsible party had not received the funds eight months later. The Nursing Home Administrator was unaware of the delay, highlighting a lapse in managing resident funds.
The facility failed to address Resident Council concerns for three consecutive months, including issues with call light response times, nurse aides' availability and attitudes, meal setup, and missing clothing items. Despite repeated complaints, there was no evidence of how these concerns were assigned or resolved.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving one resident. According to the facility's Abuse Protection policy, all accidents or incidents, regardless of severity, must be reported to the department supervisor and to State agencies as required. A review of the clinical record showed that a resident, who was dependent for lower body dressing due to multiple diagnoses including high blood pressure, cancer, and a mood disorder, arrived at an outside appointment without any pants on. The outside provider notified the facility of this incident. Despite this notification, the facility did not include the incident in the information submitted to the State Agency. During an interview, the Nursing Home Administrator confirmed that the incident was not identified or reported as an allegation of neglect. This failure to report was found to be in violation of the facility's own policy and state regulations.
Inaccurate MDS Documentation for Dialysis and Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the care and treatments provided to two residents. For one resident with end stage renal disease, high blood pressure, and diabetes, the MDS did not indicate that dialysis was performed, despite physician orders and the care plan confirming regularly scheduled dialysis sessions. This omission was confirmed by the Registered Nurse Assessment Coordinator (RNAC) during an interview. For another resident with diabetes, high blood pressure, and dependence on supplemental oxygen, the MDS did not indicate that oxygen therapy was being provided, even though physician orders and the care plan documented continuous oxygen use via nasal cannula. The RNAC also confirmed this discrepancy during an interview. These findings were based on a review of facility policy, the RAI User's Manual, clinical records, and staff interviews.
Failure to Update Care Plans for Residents Using Continuous Glucose Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current status and needs of two residents. For one resident with diagnoses including hypertension, depression, and diabetes, physician orders indicated the use of both fast-acting and long-acting insulin, as well as a continuous glucose monitoring system (Libre). However, the resident's care plan did not include interventions or documentation related to the use of the Libre system, despite its active use as ordered by the physician. Similarly, another resident with atrial fibrillation, hypertension, and type 2 diabetes mellitus was prescribed insulin and also utilized a Libre continuous glucose monitoring system with self-checks. The care plan for this resident also failed to address the use of the Libre system. These omissions were confirmed by both the Nursing Home Administrator and the Director of Nursing during interviews, who acknowledged that the care plans were not updated to reflect the residents' current needs as required by facility policy and regulatory standards.
Failure to Provide Required Mealtime Assistance
Penalty
Summary
A deficiency was identified when staff failed to provide appropriate assistance with meals for a resident diagnosed with heart failure, atrial fibrillation, and dementia, who had moderately impaired cognition as indicated by a BIMS score of 12. The resident's care plan and meal ticket both specified that staff were to cut food into small pieces at mealtimes. However, during an observation, the resident was seen sitting in a wheelchair at bedside, attempting to tear apart a whole chicken breast with their fingers, indicating that staff had not followed the care plan instructions. A nurse aide confirmed that the resident was not provided the required assistance, and the DON also acknowledged the failure to comply with the care plan. The facility's policy on the flow of care, which requires continuous implementation to promote quality of life and mandates that the charge nurse evaluate compliance, was not followed in this instance. This resulted in the resident not receiving the necessary support to maintain their ability to perform activities of daily living, specifically during mealtime.
Failure to Follow Physician Orders for Treatment and Device Management
Penalty
Summary
The facility failed to provide care and treatment as ordered by the physician for two residents. For one resident with diagnoses including high blood pressure, cancer, and a fracture, the physician ordered the resident to wear a sling at all times except for hygiene. However, observations on two separate occasions found the resident without the sling, and staff interviews confirmed that the sling was not in place as ordered. For another resident with diagnoses of atrial fibrillation, hypertension, and type 2 diabetes mellitus, the clinical record showed an order for insulin administration and noted the use of a continuous glucose monitoring device (libre). However, there was no active physician order for the use, care, or changing of the glucose monitoring device. The DON confirmed that no such order was present in the resident's record.
Failure to Provide Proper Catheter Care and Maintain Infection Control Standards
Penalty
Summary
A deficiency was identified when a resident with a history of high blood pressure, obstructive and reflux uropathy, and urinary tract infection was observed with an indwelling urinary catheter. The resident's catheter drainage bag was found lying uncovered on the floor, contrary to facility policy and standard infection control practices. This observation was confirmed by an LPN, who acknowledged that the drainage bag was not covered as required. The facility failed to ensure that appropriate treatments and services were provided for the use of an indwelling urinary catheter for this resident, as documented in the clinical record and confirmed through staff interview.
Failure to Maintain Dialysis Fluid Restrictions and Access Site Monitoring
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who required hemodialysis and a strict fluid restriction. Despite physician orders specifying a daily fluid restriction of 1200cc, with detailed breakdowns for dietary and nursing staff, the resident repeatedly received fluids in excess of the prescribed limit on multiple days. Documentation showed that the resident's fluid intake exceeded the ordered amount on at least ten occasions, and there was no evidence that the physician reviewed these overages or that the resident or staff were educated on the importance of adhering to the fluid restriction as outlined in the care plan. Additionally, the facility did not ensure that orders were in place to monitor the resident's dialysis access site for bleeding, infection, or erosion, nor were there orders to change the dressing as required. The Medication Administration Record lacked documentation of the total fluid intake for certain days, and interviews with staff confirmed gaps in monitoring and documentation. The Director of Nursing and Nursing Home Administrator acknowledged these failures, confirming that the facility did not maintain the resident's fluid restriction as ordered and did not have appropriate orders or monitoring in place for the dialysis access site.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), dysphagia, and anxiety. The resident's record showed that, despite having physician orders for anxiety medications, there was no Trauma Informed Care Evaluation completed to identify and address the resident's trauma-related needs. Additionally, the care plan for PTSD was not completed in a timely manner. This was confirmed during an interview with the facility's social worker, who acknowledged the absence of the required evaluation and the delay in care plan completion. These findings demonstrate that the facility did not take necessary steps to eliminate or mitigate triggers that could cause re-traumatization for the resident, as required by regulatory standards.
Failure to Follow Resident Dietary Preferences and Tray Assembly Tickets
Penalty
Summary
The facility failed to follow tray assembly tickets reflecting resident dietary preferences and physician orders for two residents. For one resident with diagnoses including anemia, hypertension, and diabetes, the tray assembly ticket specified a hamburger on a bun with ketchup, but the resident was served Salisbury steak with gravy instead. The nurse aide confirmed the discrepancy, stating the tray was given without checking the ticket, and acknowledged that the meal did not match the resident's listed preferences. Another resident with heart failure, hypertension, and depression had a physician order for a regular diet with no mayonnaise and no salt packet. Despite the tray assembly ticket specifying cornflake chicken breast and other items, the resident was served Salisbury steak with gravy and noodles. Additionally, the resident's tray included two salt packets, contrary to the dietary restriction. Both the nurse aide and the Dietary Director confirmed that the meals served did not align with the tray assembly tickets or the residents' dietary preferences and restrictions.
Failure to Notify Resident Representative of New Antibiotic Initiation
Penalty
Summary
The facility failed to notify the resident representative of the initiation of a new antibiotic for one of three residents reviewed. According to the facility's policy, the responsible party or guardian must be informed of changes in the resident's condition or occurrences, and the nurse is required to document the name of the person notified, along with the date and time, in the nurse's notes. For the resident in question, who had diagnoses including high blood pressure, depression, and heart failure, a new order for Keflex was started to treat cellulitis of the right hip. The physician's progress notes confirmed the clinical assessment and the start of the antibiotic treatment. However, a review of the resident's progress notes did not show any documentation that the resident's representative was notified about the new antibiotic. This was further confirmed during an interview with the Nursing Home Administrator, who acknowledged that the notification did not occur. The deficiency was cited under multiple Pennsylvania Codes related to the responsibility of the licensee, management, resident care policies, and nursing services.
Failure to Follow Professional Standards for Physician Orders
Penalty
Summary
The facility failed to follow professional standards of practice in obtaining physician orders for one resident. Specifically, a Unit Manager provided a verbal order for a urinalysis with culture and sensitivity (UA/CS) to a Registered Nurse supervisor, despite not being a physician. The facility's policy requires that telephone or verbal orders must be recorded in the clinical record by the nurse receiving the order and must be provided by a physician. The resident involved had diagnoses of high blood pressure, depression, and heart failure, and was experiencing increased confusion, prompting the order for the UA/CS. The Director of Nursing confirmed that the Unit Manager was not authorized to give such orders, resulting in a failure to adhere to professional standards of practice.
Failure to Timely Respond to Resident Call Bells
Penalty
Summary
The facility failed to accommodate the call bell needs of four out of nine residents, as evidenced by multiple sources including policy review, resident council meeting minutes, grievance logs, direct observations, and interviews with staff and residents. Facility policies require that call lights be answered as soon as possible and that care be provided continuously to promote quality of life, with call lights kept within reach and answered in a timely manner. Despite these policies, repeated concerns about delayed call bell responses were documented in resident council meeting minutes over several months, and a grievance was filed by a family member regarding call bell response times. Specific residents affected included individuals with significant medical needs such as deep vein thrombosis, multiple sclerosis, anemia, heart failure, cancer, diabetes, and reduced mobility. Interviews revealed that residents experienced prolonged wait times for assistance, with reports of waiting over an hour for help, particularly during evening and weekend shifts or when agency staff were present. One resident described having to use a cup to urinate due to lack of timely assistance, while another reported an incontinence episode and waiting over an hour for help, resulting in the need for a complete bed bath. Observations confirmed that call lights were not answered promptly, with one instance showing a 17-minute wait time. Staff interviews, including with the Director of Nursing and the Nursing Home Administrator, confirmed awareness of complaints regarding call bell response times, especially on weekends. The facility's failure to respond to call bells in a timely manner for these residents was acknowledged, constituting a deficiency in meeting the residents' needs and preferences as required by facility policy and state regulations.
Inappropriate Use of PPE in Droplet Precaution Rooms
Penalty
Summary
The facility failed to appropriately use Personal Protective Equipment (PPE) in two out of 18 droplet precaution rooms, which are designated for infection control measures to prevent the spread of diseases transmitted through respiratory droplets. During a tour of the COVID and exposed unit, it was observed that although droplet isolation signage and PPE were available at each room, staff members did not adhere to the required PPE protocols. Specifically, a housekeeper and a nurse assistant were observed not wearing the appropriate PPE, such as gowns, gloves, masks, and eyewear, while performing their duties in these rooms. Interviews with staff confirmed the deficiency, as both the nurse assistant and a registered nurse acknowledged the requirement to wear full PPE, including an N-95 mask, gown, gloves, and face covering, when entering droplet isolation rooms. The Director of Nursing also confirmed the facility's failure to use PPE appropriately, which posed a potential risk for cross-contamination and the spread of infections. The clinical records of residents in the affected rooms indicated current physician orders for droplet isolation and COVID testing, with care plans updated to reflect these isolation needs.
Plan Of Correction
1. All residents in rooms 227-236 have been assessed by the DON to ensure that no harm has occurred by not wearing appropriate PPE in their rooms. No findings noted. 2. All Covid isolation rooms have been assessed to ensure that they have the appropriate signage outside of their rooms and orders. 3. IP or Designee will educate Employees on the appropriate PPE to wear in isolation rooms. 4. DON or designee will audit 5 covid isolation rooms for 4 weeks to ensure that staff are wearing appropriate PPE. All findings will be reported to QAPI.
Failure to Report All Positive Covid-19 Cases
Penalty
Summary
The facility failed to notify the Department of Health of all health department reportable diseases, specifically during a current outbreak of Covid-19. Documentation reviewed on January 30, 2025, revealed that the facility did not report all positive Covid-19 cases, which included four residents. This oversight was identified during a review of the facility's documentation and confirmed through staff interviews. During an interview, the Nursing Home Administrator (NHA) admitted to not reporting all positive Covid-19 cases, believing that only the initial report was necessary. This misunderstanding led to the facility's failure to comply with the notification requirements for reportable diseases, as outlined in the regulations. The deficiency was confirmed by the NHA during the interview process, highlighting a gap in the facility's adherence to mandatory reporting protocols.
Plan Of Correction
1. All Covid-19 positives have been reported to the DOH through the ERS system. 2. The NHA or designee will complete a look back to ensure that all Covid-19 positives within the last 30 days have been reported. 3. The Regional NHA will educate the NHA and DON on reporting all cases of Covid-19. 4. The NHA or designee will audit that all new Covid-19 cases are reported to the DOH for the next month. All findings will be reported to QAPI.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident healthcare information for twelve residents. This deficiency was identified through a review of facility policies, observations, and staff interviews. The facility's policy on the Health Insurance Portability and Accountability Act (HIPAA) and resident rights, both dated 4/17/24, emphasized the importance of keeping resident health information private and confidential. However, during observations on 09/17/24, it was noted that signs printed in red ink were placed on the outside of several residents' doors, indicating their infection with COVID-19. This action directly disclosed the residents' health status to anyone passing by, thereby violating their privacy rights. Interviews with Registered Nurses (RN) Employee E14 and Employee E3 confirmed the breach of confidentiality. RN Employee E14 acknowledged that the facility should not disclose specific health conditions, while RN Employee E3 noted that the signs were new and questioned their appropriateness, as the facility previously used green signs for enhanced droplet precautions. Both RNs confirmed that the facility failed to adhere to the required standards for maintaining the confidentiality of residents' health information, as stipulated by 28 Pa. Code 201.29(j) and 28 Pa. Code 211.5(b).
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside for three residents. During an observation, a round white pill was found unattended on a resident's bedside table, and the resident indicated that the nurse left before they finished taking their medication. An LPN confirmed the failure to properly store and secure medications. Another resident had two inhalers on their overbed table without physician orders for self-administration or instructions to leave them at the bedside. An LPN stated the resident was alert and could keep them at the bedside, but later removed the medications and confirmed the failure to secure them. A third resident had a bottle of eye drops on their bedside table without physician orders for self-administration. An LPN assumed the resident's son brought them and removed the eye drops, confirming the failure to properly store and secure medications. The Director of Nursing confirmed the facility's failure to store drugs and biologicals in a safe, secure, and orderly manner for these residents.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident R30, who was diagnosed with hypertension, hyperlipidemia, and depression, was observed sitting in her wheelchair with her call light button wrapped on the enabler/side rail assist bar on the opposite side of the bed, making it inaccessible. When asked what she would do if she needed help, Resident R30 expressed uncertainty as she could not reach her call bell. This was confirmed by an LPN who acknowledged that the call bell was out of reach. Similarly, Resident R108, who had diagnoses of hemiplegia of the right dominant side, aphasia following cerebral infarction, and dysphagia, was observed with his call bell hanging off the right-side bed rail, also out of reach. Resident R108 confirmed his inability to reach the call light, and this was corroborated by another LPN. The facility's failure to ensure that call bells were accessible to these residents was a violation of their resident care policies and nursing services requirements, as well as resident rights.
Failure to Ensure POLST Availability for a Resident
Penalty
Summary
The facility failed to ensure that a Physician Orders for Life Sustaining Treatment (POLST) or a physician order for code status was available for a resident, identified as Resident R336. This deficiency was identified during a review of the facility's policy on Advanced Directives and the clinical records of Resident R336, who was admitted with diagnoses including diabetes, hypertension, and hyperlipidemia. On a specific date, a review of the resident's clinical record did not reveal a POLST or a physician order for code status. During an interview, an LPN confirmed the absence of a code status for the resident, indicating a failure to assure the availability of the necessary physician orders and POLST for the resident's life-sustaining treatment preferences.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of two residents to the hospital. Resident R41, who had a history of hypertensive heart disease, dementia, and major depressive disorder, was transferred to the hospital on July 17, 2024, but there was no documented evidence that the resident or their representative received written information about the facility's bed hold policy at the time of transfer. Additionally, the facility did not provide written notification to the Ombudsman for this hospitalization. Similarly, Resident R107, who was diagnosed with anxiety, depression, and high blood pressure, was transferred to the hospital on October 21, 2023, and returned to the facility later. The facility also failed to document evidence of notifying the Ombudsman about this hospitalization. During interviews, the Social Service Director admitted to not notifying the Ombudsman of hospital transfers, indicating a lack of awareness of this requirement. This oversight was confirmed during a subsequent interview with the Nursing Home Administrator.
Failure to Document Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not properly identifying a resident's diagnosis of schizoaffective disorder. The resident, identified as R45, was admitted with a history of major depressive disorder and other medical conditions but did not have a documented diagnosis of schizoaffective disorder until March 10, 2021. Prior to this date, the resident's clinical records, including the History and Physical assessment and PASRR screening, did not reflect this diagnosis, despite psychiatric progress notes indicating symptoms consistent with schizoaffective disorder. Interviews with facility staff, including social services and the nursing home administrator, revealed that there was no additional documentation to support the diagnosis of schizoaffective disorder before March 10, 2021. A new PASRR screening provided by the administrator also failed to acknowledge the diagnosis of a serious mental illness. This lack of documentation and failure to diagnose according to professional standards resulted in a deficiency finding by the surveyors.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision, resulting in the elopement of a resident identified as Closed Resident Record CR132. The resident, who had been admitted with chronic kidney disease, hyperlipidemia, and generalized muscle weakness, was last seen in the facility at approximately 5:30 p.m. on 6/22/24. Despite expressing concerns about his son earlier in the day, there was no indication of elopement risk during a conversation with a staff member. However, later that evening, the resident was found to be missing from his room, and a search was initiated by the staff, including the Nursing Home Administrator and Director of Nursing, with the assistance of local police. The investigation revealed that an Agency LPN had seen the resident attempting to transfer from a travel wheelchair to his wheelchair and assisted him back to his room. The resident mentioned waiting for his son, and the LPN informed the nurse of this interaction. However, the resident was not located in his room later, and a car was seen leaving the facility around the time of his disappearance. The resident's son was later contacted and confirmed that the resident was with him, but he refused to return the resident or sign an AMA discharge form. Interviews with staff indicated that the resident had expressed a desire to leave the facility earlier in the day, but no exit-seeking behavior was observed. The facility's elopement policy was not effectively implemented, as the resident was able to leave the premises without proper authorization or supervision. The incident highlighted a lapse in the facility's supervision and monitoring processes, as the resident was able to leave the facility without staff knowledge, resulting in an elopement.
Lack of Catheter Size Specification in Physician Order
Penalty
Summary
The facility failed to include physician order specifications for the size of an indwelling catheter for a resident with a foley catheter. The resident, who was admitted with diagnoses of high blood pressure, kidney insufficiency, and depression, had a care plan indicating the presence of a foley catheter. However, the physician order dated 9/12/24 did not specify the size of the catheter and balloon, which is a requirement according to the facility's policy on medication and treatment orders. This omission was identified during a review of the resident's clinical records and was communicated to the Director of Nursing.
Failure to Obtain Orders and Consent for Bed Rails
Penalty
Summary
The facility failed to adhere to its policy regarding the use of enabler/side rail assist bars, resulting in deficiencies for two residents. For Resident R30, the facility did not have a current physician order for the use of enabler/side rail assist bars, as confirmed by a Licensed Practical Nurse. Additionally, there was no evidence of an assessment to determine the resident's symptoms or reasons for using the side rails, nor was there informed consent obtained from the resident or their legal representative. Similarly, for Resident R75, the facility did not have physician orders for the use of enabler/side rail assist bars, and there was no documentation of a Side Rail Assist Bar Evaluation or consent. The Director of Nursing confirmed that the facility did not conduct ongoing accurate assessments to ensure the enabler/side rail assist bars were used appropriately to meet the residents' needs and address the associated risks. These actions and inactions led to the facility's failure to comply with the regulations outlined in 28 Pa. Code 201.14(a), 211.10(c)(d), and 211.12(d)(1)(5).
Failure to Provide Annual In-Service Education for RN
Penalty
Summary
The facility failed to ensure that nursing staff received the required annual in-service education for one out of six nursing personnel, specifically Registered Nurse Employee E5. The facility's in-service training policy mandates that all personnel complete annual training on various topics, including resident rights, abuse, neglect, behavioral health, infection control, and dementia management, as a condition of continued employment. However, a review of RN Employee E5's personnel record revealed the absence of documentation for these mandatory in-services. This deficiency was confirmed during an interview with the Director of Human Resources, who acknowledged the lapse in ensuring that RN Employee E5 received the necessary annual training.
Failure to Administer Diabetic Medication as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for a resident, identified as R385. The resident, who was admitted with diagnoses including diabetes, chronic kidney disease, and morbid obesity, had a physician's order for Jentadueto, a diabetes medication, to be administered twice daily. However, a review of the Medication Administration Record for September 2024 revealed that the medication was not administered on September 10, 2024. Although the medication was reordered by an LPN, there was no documented evidence that the provider was notified of the missed dose. During a Resident Council Meeting, a resident expressed concern about the unavailability of diabetic medication. In a subsequent interview, the resident confirmed that the facility did not have her diabetic medication available and was informed it was being reordered. Interviews with the CRNP and the Director of Nursing confirmed the missed dose and the lack of documentation regarding the notification of the provider. The Director of Nursing acknowledged the failure to provide the medication as per the physician's order.
Infection Control Deficiencies in Respiratory Equipment and Dressing Change
Penalty
Summary
The facility failed to properly disinfect a respiratory equipment spacer for one resident and prevent cross-contamination during a dressing change for another. In the first instance, a Licensed Practical Nurse (LPN) administered medication using an albuterol inhaler with a spacer to a resident. After the administration, the LPN placed the spacer into a plastic bag and stored it in the medication cart without cleaning it according to the manufacturer's instructions. The LPN admitted to not knowing the proper procedure and confirmed that the facility did not properly disinfect the respiratory equipment. In the second instance, during a dressing change for a resident with a left foot amputation, the LPN did not place a barrier under the wound before cleansing, failed to perform hand hygiene after cleansing the wound, and did not clean the tray table after removing supplies. The LPN also took a bottle of Vashe wound cleanser into the resident's room and returned it to the treatment cart without proper precautions. The LPN confirmed these actions, indicating a failure to prevent cross-contamination during the dressing change.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's Transfer Notice of Bed Hold Policy and Readmission policy mandates that written information about the bed-hold policy be provided to residents or their legally responsible parties prior to or at the time of transfer to a hospital or other temporary leave. However, this procedure was not followed for two residents who were transferred to the hospital. Resident R41, who had diagnoses including hypertensive heart disease, dementia, and major depressive disorder, was transferred to the hospital and later returned to the facility. The clinical record for Resident R41 lacked documented evidence that the resident or their representative received written information about the bed-hold policy at the time of transfer. Similarly, Resident R107, with diagnoses of anxiety, depression, and high blood pressure, was also transferred to the hospital and returned without documented evidence of notification about the bed-hold policy. Interviews with facility staff confirmed these omissions, indicating a failure to comply with the facility's policy and resident rights as outlined in 28 Pa. Code: 201.29(b)(d)(j).
Delayed Conveyance of Resident Funds After Death
Penalty
Summary
The facility failed to convey resident funds and close the account upon discharge or death in a timely manner for one of the five resident records reviewed. Resident R1, who had chronic kidney disease, diabetes, and depression, was pronounced dead at the facility. Despite the requirement under the Code of Federal Regulations to convey the resident's funds within 30 days of death, the responsible party for Resident R1 had not received any refund checks from the facility eight months after the resident's death. The facility's business office had processed a refund request, and a check was printed on the same day the refund was approved. However, the check had not been cleared as of the date of the report. The Nursing Home Administrator was unaware of the delay in sending the refund, indicating a lapse in the facility's management of resident funds. This deficiency was identified during a review of facility policy, clinical records, resident fund account statements, and staff interviews.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to provide evidence that Resident Council concerns were assigned to the appropriate department, facility responses to Resident Council concerns, and how the facility resolved the repetitive Resident Council concerns for three consecutive months (January, February, and March 2024). The Resident Council meeting minutes indicated ongoing issues such as call lights not being answered, nurse aides being unavailable or on their phones, attitudes of nurse aides, meal trays not being set up, and missing clothing items. These concerns were consistently reported but not addressed adequately by the facility. The Grievance and Complaint Log for February and March 2024 also reflected similar issues, including unacceptable call light response times, attitudes from nurse aides, cold meals, and lack of assistance with meals. Despite these repeated complaints, the facility did not have a Resident Council policy and failed to document how these concerns were being resolved. The Nursing Home Administrator confirmed the lack of evidence regarding the assignment and resolution of these concerns during an interview on March 15, 2024.
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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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