East End Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 745 North Highland Avenue, Pittsburgh, Pennsylvania 15206
- CMS Provider Number
- 395773
- Inspections on file
- 24
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at East End Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found unsanitary conditions in the kitchen and dish room, including debris and peeling paint, and the ice machine had not been properly documented for servicing. The Dietary Manager confirmed the failure to maintain sanitary conditions, creating a potential for foodborne illness.
The facility did not implement an antibiotic stewardship program for eleven months, as required by its own policies. Infection control surveillance records lacked documentation of antibiotic monitoring, and both an LPN and the DON confirmed that the program was not in place during this time.
The facility did not ensure that its IPCP was managed by a qualified individual with the necessary knowledge, skills, and time for most of the year. An LPN assigned as infection preventionist was primarily working floor and restorative duties, did not conduct infection mapping, and could not provide information on the antibiotic stewardship program, with the DON confirming the lack of adequate IPCP oversight.
Several residents were left unattended with medications, including pills and topical treatments, without proper assessment, care plans, or physician orders for self-administration. Nursing staff confirmed that required evaluations and documentation for self-administration were not completed, resulting in medications being accessible at bedside without appropriate oversight.
The facility did not consistently complete required dialysis communication forms for two residents and failed to follow a physician-ordered fluid restriction for a resident receiving dialysis. Staff confirmed incomplete documentation and instances where fluid intake exceeded prescribed limits, contrary to facility policy and care plans.
Two residents with severe cognitive impairment, as evidenced by low BIMS scores and documented diagnoses such as dementia and intellectual disabilities, were permitted to sign binding arbitration agreements without verification of their capacity to understand the terms. Facility staff confirmed that proper assessment of the residents' ability to comprehend the agreements was not conducted.
The facility did not maintain infection surveillance for nearly a year and failed to follow COVID-19 testing and isolation protocols for a resident with respiratory symptoms. Additional lapses included improper hand hygiene during wound care and failure to use enhanced barrier precautions during high-contact care activities, as confirmed by staff and direct observation.
A resident with macular degeneration and muscle wasting was assessed in the MDS as having adequate vision, despite reporting significant visual impairment and being unable to identify items on a lunch tray. The RN Assessment Coordinator confirmed the MDS did not accurately reflect the resident's true status.
A resident admitted with a femur fracture, severe malnutrition, neurogenic bladder, a nasogastric tube, and a Foley catheter did not have a baseline care plan developed within 48 hours of admission, and the plan failed to address the resident's catheter and nasogastric tube, as confirmed by the RNAC.
A resident with visual impairment and muscle weakness did not receive timely assistance with toileting and meal setup, despite requiring substantial help per their care plan. The resident's call for toileting help went unanswered for several hours, and staff failed to assist with meal setup, as confirmed by direct observation and staff interviews.
A resident receiving IV antibiotics via a PICC line for an infection did not have their dressing changed according to facility policy, and the IV medication container was not labeled with the required date or time. Staff confirmed these lapses, resulting in a failure to provide care in accordance with professional standards.
Staff failed to properly store and label medications and biologicals in a medication cart and medication room, with multiple medications found unlabeled, not dated, or not stored in bags, and non-medication items present in the medication room. These deficiencies were confirmed by RNs during interviews.
A resident with multiple medical conditions was served a meal containing bread, despite clear documentation and communication of their preference to avoid bread products. Staff and DON confirmed the facility did not follow the resident's dietary preferences.
A facility failed to maintain resident confidentiality when a medication cart was left unattended in a corridor, exposing identifiable and personal information. This breach was confirmed by an RN, highlighting non-compliance with the facility's policy on privacy and medication administration.
The facility failed to notify physicians and document interventions for two residents with diabetes experiencing abnormal blood glucose levels. One resident had high blood glucose levels exceeding the protocol threshold, while another had a hypoglycemic event. Staff interviews revealed inconsistencies in following notification protocols, leading to the deficiency.
A resident with multiple health conditions, including chronic kidney disease and diabetes, did not receive proper weekly assessments and updates for a pressure ulcer on the right heel. The facility failed to document wound assessments and maintain continuous treatment orders, as confirmed by staff interviews.
A facility failed to provide timely podiatry care for a resident with a history of onychomycosis and dry, cracked feet. Despite the facility's policy to provide nail hygiene services, the resident did not receive podiatry services from April to September. Observations confirmed the resident's feet were in poor condition, and an LPN acknowledged the lack of treatment.
A facility failed to provide appropriate urinary catheter care for a resident with a suprapubic catheter. The resident was observed without a privacy-dignity cover on the catheter drainage bag, contrary to facility policy. This deficiency was confirmed by staff interviews, highlighting a lapse in adhering to established care procedures.
The facility failed to provide appropriate respiratory care for two residents. One resident, with hypertension, depression, and diabetes, was observed receiving oxygen without a date on the tubing, and their nebulizer and CPAP equipment were improperly stored. Another resident, with shortness of breath, COPD, and respiratory failure, also received oxygen without a dated nasal cannula. These deficiencies were confirmed by an RN and acknowledged by the DON, indicating non-compliance with facility policies on respiratory care.
The facility failed to label and store medications properly on the 3 South medication cart, with an undated vial of Lispro insulin and food stored alongside medications. Additionally, the third-floor treatment cart was found unlocked and unattended, violating security protocols. These issues were confirmed by an RN and an LPN, indicating non-compliance with facility policies.
The facility failed to maintain infection control standards in the laundry room, did not provide necessary PPE signage for a resident under Enhanced Barrier Precautions, and did not adhere to proper protocols during a medication pass and dressing change, leading to potential cross-contamination.
Failure to Maintain Sanitary Conditions in Kitchen and Dish Room
Penalty
Summary
Surveyors observed unsanitary conditions in the facility's main kitchen and dish room, including brown debris and peeling paint on the dish room walls, as well as brown debris in the ice machine. During staff interviews, the Dietary Manager was unable to provide documentation of the last service date for the ice machine. The Dietary Manager confirmed that the facility failed to maintain sanitary conditions in these areas, which created the potential for foodborne illness. No information about specific residents or their medical conditions was provided in the report.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for eleven consecutive months, from September 2024 through August 2025. Review of the facility's infection control policies indicated that the antibiotic stewardship program was intended to improve antibiotic use and was to be managed by the Infection Preventionist in collaboration with the medical director, pharmacist, nursing, and administrative leadership. However, infection control surveillance records for the specified period lacked documentation of any antibiotic monitoring. During interviews, the Infection Preventionist LPN confirmed that antibiotic monitoring was not completed for the majority of the year and was unable to provide further information about the stewardship program, deferring to the Director of Nursing. The Director of Nursing also confirmed the failure to implement the program during this period.
Failure to Designate Qualified Infection Preventionist for IPCP Oversight
Penalty
Summary
The facility failed to ensure that its Infection Prevention and Control Program (IPCP) was overseen by a qualified individual with the necessary knowledge, skills, and dedicated time to perform the required duties for eleven out of twelve months. According to facility policy, the infection preventionist is responsible for conducting surveillance of infections, providing education based on findings, and overseeing the antibiotic stewardship program. However, interviews revealed that the designated infection preventionist, an LPN, was primarily assigned to floor duties and the restorative program during this period, leaving insufficient time to fulfill IPCP responsibilities. The infection preventionist admitted to not mapping infections and being unable to track the spread of infections within the building. Additionally, the infection preventionist was unable to answer questions regarding the antibiotic stewardship program, deferring to the Director of Nursing for information. The Director of Nursing confirmed that the facility did not have an individual adequately assessing, developing, implementing, monitoring, and managing the IPCP for the majority of the year. The lack of infection mapping and oversight of the antibiotic stewardship program were specifically noted as deficiencies. The findings were based on a review of facility policies and staff interviews, and the cited regulations included requirements for management, personnel records, and nursing services.
Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine the ability of four residents to self-administer medications, as required by facility policy. Observations revealed that residents were left unattended with medications at their bedside, including pill cups and topical medications, without documented care plans or physician orders authorizing self-administration. For example, one resident with diagnoses of high blood pressure, diabetes, and constipation was found with a pill cup containing medication, and staff confirmed there was no care plan for self-administration. Another resident with dementia and dependence on renal dialysis was also left with a pill cup containing multiple pills, again without a care plan in place. Additional findings included topical medications such as Voltaren gel and Aspercream found in a resident's room without corresponding physician orders or assessments for self-administration. In another instance, a bottle of Flonase nasal spray was left on a resident's bedside stand after being given by a nurse, with the intention for the resident to use it later, but without proper assessment or documentation. Interviews with nursing staff and the Director of Nursing confirmed that the required assessments and care plans for self-administration of medications were not completed for these residents.
Failure to Maintain Dialysis Communication and Adhere to Fluid Restrictions
Penalty
Summary
The facility failed to maintain consistent communication regarding dialysis care for two residents who required such services and did not ensure that care and treatment orders, including fluid restrictions, were followed for one resident. For one resident with diagnoses including heart failure, renal insufficiency, and hypertension, dialysis communication forms were found to be incomplete on multiple occasions, as confirmed by an LPN. For another resident with dementia, dependence on renal dialysis, and hypertension, the facility did not adhere to a physician-ordered daily fluid restriction on several days, with documented fluid intake exceeding the prescribed limit. Additionally, required dialysis communication sheets were missing for several treatment dates. Interviews with staff, including LPNs and the Director of Nursing, confirmed these deficiencies, specifically the lack of completed communication forms and failure to maintain fluid restrictions as ordered. Facility policies required tracking of intake/output per provider order and consistent communication with the dialysis provider before and after each treatment, but these procedures were not consistently followed for the residents in question.
Failure to Ensure Resident Capacity for Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement prior to signing. Specifically, two residents with severe cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores of four and zero, respectively, were allowed to sign binding arbitration agreements. Both residents had significant medical histories, including intellectual disabilities, diabetes mellitus, chronic kidney disease, dementia, and major depressive disorder, and their Minimum Data Set (MDS) assessments confirmed severe cognitive impairment at the time the agreements were signed. Review of facility documents, resident clinical records, and staff interviews confirmed that the facility did not verify the residents' capacity to comprehend the agreements. The Admission Director acknowledged that the facility failed to ensure the residents understood the terms of the binding arbitration agreements, resulting in the deficiency for two of the three residents reviewed.
Failure to Implement Infection Control Program and Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program as required by state and federal guidelines. For a period of eleven out of twelve months, there was no documented surveillance of infections, and the infection preventionist was unable to provide evidence of infection mapping or tracking. During interviews, the infection preventionist confirmed that no surveillance activities had been conducted for nearly a year, despite facility policies requiring systematic prevention, identification, and control of infections among staff and residents. One resident with a history of dementia, COPD, and hypertension exhibited symptoms consistent with COVID-19, including shortness of breath, wheezing, and low oxygen saturation. Despite these symptoms, there was no evidence that the resident was tested for COVID-19 or placed under droplet precautions as required. The resident continued to move throughout the unit without a mask, and staff interviews confirmed that isolation and testing protocols were not followed according to facility policy and regulatory guidance. Additional deficiencies were observed in infection control practices during resident care. An LPN failed to remove gloves and perform hand hygiene before handling wound care supplies and solutions after a dressing change for a resident with a sacral wound. In another instance, a resident with an order for enhanced barrier precautions did not have these precautions implemented during a high-contact activity, as the LPN did not wear a gown while flushing a nasogastric tube. These lapses were confirmed by staff interviews and direct observation.
Inaccurate MDS Assessment of Resident's Vision
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with diagnoses including depression, macular degeneration, and muscle wasting. The MDS indicated that the resident's vision was adequate, despite the resident stating he was visually impaired and unable to see much. During observation, the resident was unable to identify the food on his lunch tray and reported that no one had informed him about it. The Registered Nurse Assessment Coordinator confirmed that the MDS did not accurately represent the resident's actual visual status. This deficiency was identified through review of clinical records, resident interviews, and staff interviews.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by its own policy. The resident was admitted with multiple complex medical conditions, including a left femur fracture, severe protein-calorie malnutrition, and a flaccid neuropathic bladder, and had a new nasogastric tube and a Foley catheter in place. Review of the clinical record showed that while assessments were completed for the Foley catheter, the baseline care plan did not include the resident's catheter or nasogastric tube. This omission was confirmed by the Registered Nurse Assessment Coordinator during an interview.
Failure to Provide Timely ADL Assistance and Meal Setup
Penalty
Summary
A deficiency occurred when a resident with diagnoses of depression, macular degeneration, and muscle wasting, who required substantial to maximal assistance with toileting and personal hygiene, did not receive timely Activity of Daily Living (ADL) assistance. The resident, who is legally blind and has limited ability to dress or undress due to weakness, reported that after activating the call light at 11 a.m. for toileting assistance, a nurse aide responded at 11:20 a.m. and stated they would return, but did not come back until approximately four hours later. During this period, the resident remained without the needed assistance, and the nurse aide admitted to being aware of the request but was delayed due to being on break. The interaction between the resident and the nurse aide was described as argumentative, and the resident expressed concerns about staff professionalism and facility understaffing. Additionally, the resident was observed sitting in front of a lunch tray without knowledge of its contents and confirmed that no one had assisted with meal setup, as required by their care plan. A registered nurse acknowledged the failure to provide necessary meal setup assistance. These findings were corroborated by clinical record reviews, staff and resident interviews, and direct observations, demonstrating a failure to provide required ADL support as outlined in the resident's care plan and facility policy.
Failure to Follow PICC Line and IV Medication Labeling Protocols
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a peripherally inserted central catheter (PICC) in accordance with professional standards of practice. Facility policy required that intermittent infusion medication containers and administration sets be labeled with the date, time, and nurse's initials, and that PICC dressings be changed weekly or as needed. During an observation, the resident's PICC site dressing was found to be dated from admission, with only a piece of tape added later to reinforce it, rather than a full dressing change as required. Additionally, the IV medication solution container hanging at the resident's bedside was not labeled with a date or time. The resident involved had a history of infection and inflammatory reaction due to an internal right knee prosthesis, atrial fibrillation, and high blood pressure, and was receiving IV antibiotics for an infection. Staff interviews confirmed that the dressing had not been changed according to policy and that the IV medication container was not properly labeled. These actions and inactions resulted in the facility not meeting professional standards for the safe and appropriate administration of IV fluids and care of the PICC line.
Improper Storage and Labeling of Medications and Biologicals
Penalty
Summary
Facility staff failed to properly store and label medications and biologicals in both the fourth-floor medication cart and the fourth-floor medication room. During an observation, the medication cart was found to contain a Lovenox syringe not labeled with a name and not stored in a bag, a Lispro insulin pen not labeled with the date opened and not stored in a bag, a Lantus insulin pen not stored in a bag, and a bottle of Timolol eye drops that was opened but not labeled with a date. These findings were confirmed by a registered nurse during an interview. In the fourth-floor medication room, a grey tote was observed on the countertop containing multiple medication card packs with various quantities of tablets, as well as a bottle of muscle and joint support. Additionally, a clear plastic bag contained more medication card packs, and an oxygen tank holder was found to contain two umbrellas and a sweater. A registered nurse confirmed that medications to be returned to the pharmacy were not securely stored and that non-medication items were present in the medication room, which is contrary to facility policy.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide food in accordance with a resident's documented preferences. Resident R19, who has diagnoses including depression, macular degeneration, and muscle wasting, was observed during lunch with a biscuit on their plate, despite their meal ticket specifying 'NO BREAD/NO PASTA.' The resident expressed frustration that their preference to avoid bread products was not being honored. Staff interviews, including with a registered nurse and the Director of Nursing, confirmed that the facility served food products containing bread to the resident, contrary to their stated preferences.
Breach of Resident Confidentiality on Medication Cart
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of its medication carts. During an observation, a medication cart located in the corridor outside a resident's room was left unattended, displaying a resident listing with identifiable and personal information visible to passersby. This incident was confirmed by a Registered Nurse (RN) during an interview, acknowledging the breach of confidentiality. The facility's policy on General Dose Preparation and Medication Administration emphasizes the importance of observing each resident's privacy and rights, including blocking unnecessary access to the Medication Administration Record (MAR). However, this policy was not adhered to, resulting in the exposure of sensitive resident information.
Failure to Notify Physicians and Document Interventions for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal blood glucose levels and document appropriate interventions for two residents with diabetes. Resident R30 had a history of hypoglycemia and was on a specific insulin protocol that required physician notification for blood glucose levels above 400 mg/dL. However, on two occasions, the resident's blood glucose levels exceeded this threshold, reaching 468 mg/dL and 443 mg/dL, without any documented notification to the physician as required by the protocol. Similarly, Resident R63, who had impaired glucose tolerance related to diabetes, experienced a hypoglycemic event with a blood glucose reading of 63 mg/dL. Despite the facility's policy to notify physicians for blood glucose levels below 70 mg/dL, there was no documentation of physician notification or clinical interventions for this resident's low blood sugar level. Interviews with facility staff revealed a lack of clarity and consistency in following the protocol for notifying physicians about hypoglycemic events. The Assistant Director of Nursing and other nursing staff acknowledged the failure to notify physicians and document interventions for these residents. The facility's policies indicated that hypoglycemia should be treated as a nursing measure, but there was a lack of documentation and adherence to the protocol, leading to the deficiency. The report highlights the need for consistent communication and documentation practices to ensure resident safety and compliance with physician orders.
Failure to Assess and Update Wound Treatments
Penalty
Summary
The facility failed to properly assess and update wound treatments for a resident, identified as R30, who had a history of skin impairment. The facility's policy required routine skin care and weekly assessments of pressure ulcers, including measurements and evaluations of the wound's condition. However, the facility did not adhere to these protocols. Specifically, there was a lack of documented wound assessments for the resident's right heel during the week of June 12, 2024, and a gap in physician orders for continued wound treatment from June 5 to June 19, 2024. Resident R30 had multiple diagnoses, including chronic kidney disease, diabetes, hypertension, and hyperlipidemia, which could contribute to skin integrity issues. Despite these conditions, the facility did not conduct a weekly assessment of the resident's unstageable deep tissue injury on the right heel, as required by their care plan. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the oversight in wound assessment and treatment updates, leading to the deficiency noted in the report.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide adequate and timely podiatry care for Resident R85, as determined by a review of facility policy, resident clinical records, and interviews with residents and staff. The facility's policy, dated April 1, 2024, indicated that it would provide basic services, including nail hygiene services. However, Resident R85, who was admitted with diagnoses including sarcoidosis, COPD, chronic pain syndrome, and a history of urinary tract infections, did not receive podiatry services from April 2024 to September 2024. The resident's care plan dated August 29, 2024, indicated a risk of skin breakdown, yet there were no physician orders or treatments for the resident's feet. Observations and interviews revealed that Resident R85 had a history of onychomycosis and dry, scaly skin on his feet. On September 30, 2024, the resident's left foot was observed to be dry, cracked, and in need of nail trimming. By October 3, 2024, the resident stated he had not seen a podiatrist in three months and had refused antifungal pills due to already taking too many medications. An LPN confirmed that there were no treatments for the resident's feet, acknowledging the facility's failure to provide adequate and timely podiatry care.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of a urinary catheter for a resident, identified as Resident R84. The facility's policy on Indwelling Urinary Catheter Care Procedure, dated 6/1/24, requires that clinical staff with demonstrated competence provide urinary catheter care, including ensuring that the drainage bag is covered with a privacy-dignity cover. However, during an observation on 9/30/24, Resident R84 was seen sitting in a wheelchair with the urinary catheter bag connected to the chair without a privacy-dignity bag. Resident R84's clinical record indicated that the resident was admitted with diagnoses of diabetes, heart failure, and peripheral vascular disease, and had a physician's order for a suprapubic catheter due to neurogenic bladder. The deficiency was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged that the facility did not ensure the appropriate use of a urinary catheter for Resident R84, as required by the facility's policies.
Inadequate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, R16 and R46, as identified through a review of facility policy, observations, staff interviews, and clinical record review. Resident R16, who has diagnoses of hypertension, depression, and diabetes, was observed receiving oxygen via nasal cannula without a date on the tubing, and the nebulizer equipment and CPAP mask were not stored in a bag when not in use. This was confirmed by RN Employee E1. Resident R16 had active physician orders for continuous oxygen therapy, nebulizer treatment, and CPAP use, with specific instructions for equipment maintenance and storage that were not followed. Similarly, Resident R46, diagnosed with shortness of breath, COPD, and respiratory failure, was observed receiving oxygen via nasal cannula without a date on the tubing. This was also confirmed by RN Employee E1. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for both residents. The facility's policies on oxygen administration and non-invasive positive pressure ventilation were not adhered to, as evidenced by the lack of proper equipment maintenance and documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding the labeling and storage of medications and biologicals. During an observation, it was found that the 3 South medication cart contained a vial of Lispro insulin that was not labeled with the date it was opened, and a medicine cup with a pill labeled 'PEN' was improperly stored. Additionally, the bottom drawer of the same medication cart contained five half peanut butter and jelly sandwiches, which is against the facility's policy of not storing food with medications and biologicals. A Registered Nurse (RN) confirmed these findings, indicating a lapse in following the facility's medication labeling and storage protocols. Furthermore, the facility failed to secure treatment medications and supplies on the third-floor treatment cart. During an observation, the treatment cart was found unlocked and unattended in front of the nursing station and elevator, with no staff nearby. A Licensed Practical Nurse (LPN) confirmed that the cart was indeed unlocked, highlighting a failure to secure treatment medications and supplies as required by the facility's policies. These deficiencies were noted under the relevant Pennsylvania Code sections for nursing and pharmacy services, as well as resident care policies.
Infection Control Deficiencies in Laundry, PPE Signage, and Resident Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry room, as observed during two separate inspections. Protective gowns were not available for laundry personnel while sorting and washing dirty laundry, and clean linen carts were left uncovered, exposing them to potential contaminants. Additionally, a used isolation gown was found on a clean linen cart, and dirty clothes were stored under a table used for folding clean linen. These practices increased the risk of cross-contamination. The facility also failed to provide appropriate PPE signage for a resident under Enhanced Barrier Precautions (EBP), which is necessary to ensure that employees, visitors, and family members use PPE when required. The absence of signage was confirmed by the Infection Preventionist and the Director of Nursing, indicating a lapse in the implementation of infection control measures. Furthermore, during a medication pass and a dressing change, staff did not adhere to proper infection control protocols. A registered nurse did not perform hand hygiene or change gloves before handling medications, leading to potential cross-contamination. Similarly, an LPN did not establish a clean barrier field during a dressing change, allowed a resident's wound to touch a brief, and handled wound cleanser without maintaining sterility, further compromising infection control efforts.
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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