Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eden Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to prevent a new Stage 3 pressure ulcer: A resident with a Braden score of 9, immobility, incontinence, and existing skin injuries developed a facility-acquired sacral Stage 3 PI after the chart failed to show implementation of ordered preventive measures such as side-to-side offloading and barrier cream. Wound service notes repeatedly listed pressure relief, heel offloading, a pressure redistribution surface, and barrier cream, but the record did not document those interventions as carried out, and the resident later required hospitalization for sepsis in the setting of chronic wounds and sacral OM.
Unsanitary kitchen conditions and improper infection control practices were observed in the main kitchen. The ice machine had grime and dark colored debris inside, and a dietary employee was seen wearing a beard guard under the chin. The Dietary Manager confirmed the facility failed to maintain sanitary conditions and proper infection control techniques to prevent cross contamination.
The facility failed to document monthly MRRs reviewed by the attending physician for three residents. Records showed that MRRs for residents with diagnoses including dementia, DM, depression, schizophrenia, COPD, malnutrition, and hyperlipidemia were signed by a CRNP instead of the physician, and the Infection Preventionist confirmed this during interview for two of the residents.
Call bells were not accessible or functional for two residents. One resident with arthritis and muscle weakness had the call bell clipped out of reach on a privacy curtain, and the resident stated it could not be reached. Another resident with muscle weakness and dementia had the call bell cord unplugged from the wall panel, making it inactive until an LPN reconnected it and confirmed it worked. Staff confirmed both call bells were not accessible to the residents.
A resident with depressive disorder, lymphedema, gout, and anxiety disorder had an MDS BIMS score of 11, indicating moderate impairment. The facility opened a resident fund account, but the authorization form lacked a signature date and left blank the section for anyone signing for the resident; although the form was signed by the resident, there was no documentation showing who assisted or that the POA was involved. An LPN/business office staff member stated she was not sure who signed the form.
A resident’s wheelchair was observed with a corroded frame, seat, and wheels covered in grime, debris, and long hairs, and an NA confirmed the condition. Separately, washcloths in the linen supply were found to be very thin and see-through, consistent with resident and council concerns that bath linens were not well kept.
A resident with anemia, hemiplegia/hemiparesis following a CVA, and muscle weakness was observed in bed with a mattress that had bilateral raised edges. The record lacked a physician order, care plan, and assessments or ongoing evaluations for the bolster use, and an IP confirmed the facility did not assess the resident's functional status to determine whether the bolster was a restraint.
The facility failed to provide written transfer notices to the Office of the LTC Ombudsman for two residents who were sent to the hospital. One resident had anemia, hemiplegia/hemiparesis after a CVA, and muscle weakness, while the other had dementia, DM, and major depressive disorder. The NHA confirmed the missing notices during interview.
A facility failed to provide a written summary of the baseline care plan to two residents and/or their representatives within the required timeframe. One resident had diagnoses including a lumbar fracture, morbid obesity, and cirrhosis of the liver, while the other had UTI, DM, and ataxic gait. The NHA confirmed there was no evidence the required baseline care plan summary was provided.
Failure to Apply and Maintain Ordered Hand Splint: A resident with stroke and hemiplegia had orders and a care plan for a left resting hand splint, gentle stretching, and skin checks, but was observed in bed without the splint in place on multiple occasions. When an employee entered the room, the splint was only then applied, and later the splint was observed on the resident covered in dried debris.
A resident with a G tube and orders for continuous enteral nutrition was observed twice with the feeding pump not infusing as ordered. The pump displayed an error message on one occasion and a hold message on another, and LPNs stated they were unaware the pump was not running; one LPN said nurse aides likely placed it on hold for care and did not turn it back on.
Failure to Provide Ordered Respiratory Care: A resident with orders for BiPAP and oxygen was observed without the nasal cannula or BiPAP mask in place and breathing on room air, and the care plan did not include BiPAP care and management. Another resident with an order for PRN nebulizer treatment had nebulizer tubing without a date and a mouthpiece stored on top of the machine instead of in a bag while not in use; an LPN confirmed the observations.
Failure to Provide Trauma-Informed Care and Individualized Care Planning: A resident with depression, anemia, and PTSD symptoms was documented as tearful and endorsing avoidance of trauma reminders, flashbacks, re-experiencing, and dissociation. The resident’s care plan did not include PTSD-related goals or interventions and did not identify triggers or ways to avoid them, and the SW confirmed the facility failed to provide trauma-informed care or an individualized person-centered care plan.
Expired culture swabs and an opened tuberculin vial were found in the 3 South medication room during an observation. An LPN confirmed the items were expired, showing that medications and biologicals were not stored in a safe, secure, and orderly manner.
A facility failed to obtain ordered lab services for a resident with HTN, anxiety, and muscle weakness. The record showed a provider ordered a CBC and BMP for monitoring, but documentation did not show the CBC was completed as ordered, and an IP confirmed the failure.
Surveyors found that the facility discharged two residents without obtaining required physician orders for discharge. One resident with a thoracic vertebra fracture, UTI, and muscle weakness and another resident with atrial fibrillation, diabetes mellitus, and protein-calorie malnutrition both had current diagnoses documented on their MDS assessments, and facility records showed they were discharged. However, review of their most recent physician orders revealed no discharge orders, and the DON confirmed that physician orders for these discharges were not obtained as required.
Surveyors found that the facility did not document or communicate required clinical and administrative information to receiving hospitals for three residents who experienced facility-initiated transfers, including care plan goals, advance directives, specific ongoing care instructions, and representative contact details. For the same three residents, the facility also failed to provide written notice of its bed-hold policy at the time of hospital transfer, despite a policy requiring such information to be given both at admission and at transfer. The DON confirmed these lapses in communication and notification during interview.
Over a three-month period, the facility did not act on or document follow-up to concerns repeatedly raised in Resident Council meetings. Residents reported systemic issues with call bells not being answered timely, agency staff turning off call bells without providing assistance, poor care on weekends, and medications not being delivered on time. Although facility policy requires that all Resident Council feedback be addressed in writing, the follow-up sections of the council minutes for each month were left blank, and the NHA confirmed that residents' views and concerns about care and daily life were not promptly considered or addressed.
Surveyors determined that the facility failed to obtain and document ordered lab results and to notify practitioners and resident representatives for two residents. One resident with a history of stroke, hemiplegia, and UTI had an order for a CMP, and another resident with anemia, heart failure, and hypertension had an order for a one-time BMP; in both cases, there was no documentation that results were obtained or communicated. An LPN reported that lab results were not in the clinical record and that only a supervisor could access the lab computer system, and the DON confirmed these failures, which were inconsistent with facility policies on lab services and change in condition, as well as state nursing services regulations.
The facility did not employ a qualified Food Service Director for several months, assigning the role to an employee who was not a Certified Dietary Manager and for whom no documentation of required qualifications could be produced. During staff interviews, the NHA confirmed the employee had been functioning as the FSD and acknowledged the lack of evidence that she met position requirements, while the FSD reported that an RD typically visited once per week. This resulted in noncompliance with state management requirements for food and nutrition services.
The facility did not provide coffee to about half of its residents due to supply and approval delays, despite residents' preferences and repeated requests. Staff confirmed that running out of coffee was a recurring problem, and the administrator acknowledged the failure to meet resident preferences.
Surveyors observed that food items in the Main Kitchen, including frozen vegetables, chopped onions, and gelatin mix, were not properly labeled or dated according to facility policy. The Dietary Supervisor confirmed the failure to follow required procedures for food storage.
The facility did not individualize care plans for two residents with complex nutritional needs, omitting specific interventions for prescribed diets, supplements, and tube feedings. Additionally, staff were not adequately informed about a resident's physician-ordered fluid restriction, as the order lacked details on fluid distribution between departments. These deficiencies were confirmed by staff interviews and review of clinical records.
The facility did not ensure that monthly medication regimen reviews were completed and documented by a licensed pharmacist for several residents, including those with dementia, chronic pain, and mental health conditions. In some cases, pharmacy-identified irregularities were not addressed by the physician in a timely manner, and for two months, no review was documented for a resident with multiple psychiatric diagnoses. The DON confirmed these lapses in required medication review processes.
A resident with Alzheimer's disease, anxiety, and depression who developed a pressure ulcer on the right heel did not receive care in a manner that maintained dignity when an RN wrote on the dressing after it was applied. The RN acknowledged this action did not uphold the resident's right to dignity, as required by facility policy and state regulations.
Two residents received psychotropic medications without proper clinical justification or required monthly medication regimen reviews. For one resident, an antipsychotic was prescribed without an appropriate diagnosis and the physician did not address the pharmacist's recommendation. For another, multiple psychotropic medications were prescribed, but documentation of required pharmacist reviews was missing.
A resident with a history of cancer, malnutrition, and depression was administered enteral feeding without a physician order following a hospital return. The DON confirmed that enteral feeding was provided for several days without the required order, resulting in a deficiency related to appropriate treatment and services for residents with feeding tubes.
Two residents with physician orders for nebulizer treatments were found to have their nebulizer machines and mouthpieces left on bedside tables, not stored in bags as required by facility policy. An LPN confirmed the equipment was not properly stored when not in use, resulting in a failure to provide appropriate respiratory care.
A resident with end stage renal disease and a history of heart transplant did not have complete dialysis communication forms for multiple dialysis sessions, as required by facility policy. Staff and DON confirmed the failure to consistently provide the necessary communication with the dialysis center.
A resident with a history of sexual abuse did not receive appropriate behavioral health services, as their care plan failed to include specific interventions or considerations related to their trauma history, such as the gender of staff providing care. This was identified through review of clinical records, facility policy, and staff interviews.
Two residents with significant mobility and transfer needs did not have comprehensive care plans specifying required assistance levels. As a result, one resident, dependent on total assist for transfers and bed mobility, was rolled out of bed by a single staff member and sustained bilateral leg fractures. Staff confirmed that care plans lacked critical details for both residents.
A resident with a history of anemia and on anticoagulant therapy experienced a fall, after which staff observed ongoing bruising and pain but did not notify the physician as required. Despite critical INR lab results indicating excessive anticoagulation, there was no timely documentation of physician notification or intervention. The resident later suffered a fractured knee and required a blood transfusion due to a critically low hemoglobin level.
A resident with multiple medical conditions who required total assistance for bed mobility was not provided the necessary support, leading to a fall from bed and subsequent bilateral leg fractures. The care plan lacked clear instructions for bed mobility assistance, and staff did not follow existing orders, resulting in delayed recognition and treatment of injuries.
A resident with anemia, renal failure, and osteoarthritis rolled out of bed onto their knees during care and was assisted back to bed by staff using a Hoyer lift. The incident, documented in the resident's progress notes, was not reported to the state field office as an allegation of neglect within the required 24-hour period, as confirmed by the DON.
A resident with multiple medical conditions experienced a fall during care, resulting in ongoing bruising that was documented over several days. Despite these findings, there was no timely physician assessment of the fall or the bruising, and the resident was later hospitalized with severe anemia and elevated INR, requiring a blood transfusion. Facility leadership confirmed the lack of timely physician involvement following the incident.
A resident with severe cognitive impairment and total dependence on staff was sexually abused by her husband, who was observed by staff inappropriately touching her despite prior warnings. The resident was unable to resist or report the abuse due to her condition, and staff confirmed the incident and the resident's distress. Facility policies prohibiting abuse were not effectively enforced, resulting in actual harm and psychosocial distress for the resident.
Staff failed to timely recognize and report suspicions of sexual abuse involving a resident who was nonverbal and unable to advocate for herself. Multiple nurse aides and LPNs observed ongoing suspicious behaviors by the resident's husband, such as torn briefs and interference with medical devices, and communicated their concerns to nursing leadership. However, these suspicions were not formally reported or acted upon until inappropriate touching was directly witnessed by a staff member.
A resident with severe cognitive impairment and multiple medical conditions did not receive necessary services or adequate protection from inappropriate contact by a frequent visitor. Despite repeated staff concerns and reports of the visitor interfering with medical devices and engaging in inappropriate touching, facility leadership failed to implement effective safety measures or restrictions, resulting in ongoing risk to the resident.
The Nursing Home Administrator and DON failed to manage the facility in a way that ensured necessary care and services were provided to prevent sexual abuse, resulting in actual harm to a resident, including psychosocial and physical harm. The facility did not follow professional standards, policies, or resident rights.
The facility failed to provide timely dental services to three residents, resulting in a deficiency. One resident was not seen by a dentist due to consent and prepayment issues, another was removed from the dental list due to preauthorization problems, and a third was not seen because consent was not obtained. Staff interviews confirmed these failures.
A resident at Platinum Ridge Center for Rehab and Healing experienced a significant change in condition, including blood in their colostomy bag, requiring a medication adjustment. The facility failed to notify the resident's family of this change within the required 24-hour period, delaying communication for 36 days. This breach of protocol was confirmed through staff interviews and a complaint from the resident's representative.
A resident with cerebral infarction, high blood pressure, and aphasia had blood detected in their colostomy bag. Despite a physician's order on December 9 to schedule a colonoscopy, the facility failed to make the appointment by January 13. The resident's representative raised a concern, and the DON confirmed the delay.
The facility did not meet the required nurse aide staffing levels on a specific day, failing to provide adequate coverage during both the day and evening shifts. The day shift had insufficient hours of nurse aide coverage for 88 residents, and the evening shift did not meet the required staffing ratio. These issues were identified through a review of staffing documents and staff interviews.
The facility failed to provide the required number of LPNs during an evening shift, with only 17.26 hours of coverage instead of the required 21.70 hours for 84 residents. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to maintain proper admission documentation for three residents. A resident with moderate cognitive impairment inappropriately signed their own admission packet, while two other residents lacked signed admission packets altogether. This indicates a lapse in the facility's admission procedures and a violation of residents' rights.
The facility failed to label and date food products in the nursing unit pantries, leading to potential cross-contamination. Observations revealed unlabeled and undated items in the 3rd and 2nd floor nursing pantry refrigerators and storage areas. An LPN confirmed this failure, which posed a risk for foodborne illness.
The facility failed to meet the required nurse aide staffing levels over an 18-day period, with shortages during day, evening, and night shifts. The census ranged from 84 to 87 residents, but the number of nurse aides present was consistently below the required ratios. The Nursing Home Administrator confirmed these deficiencies, with no additional higher-level staff available to compensate.
The facility did not meet the required LPN staffing levels during a night shift, with only 3.04 LPNs present for 86 residents, instead of the required 3.44. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide the required 3.2 hours of direct resident care per resident in a 24-hour period on ten out of eighteen days. Nursing schedules and census data revealed that the provided nursing care hours per resident per day (PPD) were below the required threshold, with PPDs ranging from 2.91 to 3.19. The Nursing Home Administrator confirmed this deficiency.
The facility failed to maintain accurate narcotic count sheets and document the disposition of narcotics, leading to discrepancies between MAR and narcotics count sheets for three residents. Documentation showed missing signatures on shift count sheets and inconsistencies in narcotic administration and destruction records. These issues were confirmed by the NHA and DON, indicating a failure to manage controlled substances as per regulations.
Failure to Prevent Facility-Acquired Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer for one resident who was admitted with significant skin breakdown risk factors. The resident had diagnoses including anemia, hemiplegia and hemiparesis following a cerebral infarction, and muscle weakness. On admission, the resident required dependent assistance for rolling, moving from sitting to lying, moving from sitting to standing, and transfers. The admission Braden Scale score was 9, indicating very high risk for pressure ulcer development, and the resident was also incontinent and bedfast. The resident’s admission skin evaluation documented existing unstageable pressure injuries and an unstageable deep tissue injury. A wound service CRNP first evaluated the resident and documented multiple risk factors for skin breakdown, including reduced mobility, generalized weakness, poor nutritional intake, incontinence, and medical conditions affecting healing. The CRNP ordered pressure relief/offloading while in bed, heel offloading, a pressure redistribution mattress, a wheelchair pressure redistribution cushion, incontinence care, nutritional support, and use of house stock barrier cream every shift and as needed as a prophylactic measure. The clinical record, however, failed to include documentation that the ordered preventive measures such as side-to-side offloading while in bed and barrier cream were implemented. Weekly wound notes continued to repeat the same preventive orders, but the record still lacked documentation that the measures were carried out. The resident developed a new Stage 3 sacral pressure injury on 5/6/26, described as facility-acquired and not healed, with measurements and wound characteristics documented over subsequent weeks. The wound notes repeatedly stated that the resident was incontinent and that pressure relief/offloading, barrier cream, and other preventive measures were to continue, yet the chart did not show implementation of those measures as ordered. The record also stated that the care plan did not include the barrier cream every shift and PRN or side-to-side offloading interventions until 7/8/26, and physician orders from 4/21/26 through 7/8/26 did not include orders for those measures. The resident was later hospitalized on 6/22/26 for confusion and suspected sepsis in the setting of chronic wounds, with purulent drainage from a sacral wound and bilateral heel ulcers, and MRI showed osteomyelitis involving the 2nd coccygeal segment. The DON confirmed that the facility failed to develop and implement care and services consistent with professional standards of practice to prevent the new development of a pressure ulcer.
Unsanitary Kitchen Conditions and Improper Infection Control
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, creating the potential for cross contamination. During an observation with the Food Service Director in the main kitchen on 7/20/26 at 9:15 a.m., the ice machine was observed to have a buildup of grime and dark colored debris inside. During a separate observation on 7/20/26 at 10:00 a.m., a dietary employee was observed wearing a beard guard under the chin. In an interview on 7/20/26 at 10:15 a.m., the Dietary Manager confirmed that the facility failed to maintain sanitary conditions and practice proper infection control techniques to prevent cross contamination in the main kitchen.
MRRs Signed by CRNP Instead of Physician
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician monthly for three residents. Review of the facility policy indicated a licensed pharmacist reviews each resident's medication regimen at least monthly. However, the cited MRRs for Resident R4, Resident R11, and Resident R26 were signed by a Certified Registered Nurse Practitioner (CRNP) rather than by the physician as required. Resident R4 was admitted on 10/8/25 and had diagnoses including dementia, diabetes mellitus, and major depressive disorder; the 3/6/26 MRR was signed by a CRNP. Resident R11 was admitted on 8/28/25 and had diagnoses including depression, schizophrenia, and COPD; the 2/25/26 MRR was signed by a CRNP, which was confirmed by the Infection Preventionist during interview on 7/24/26. Resident R26 was admitted on 12/17/25 and had diagnoses including dementia, protein-calorie malnutrition, and hyperlipidemia; the 5/5/26 MRR was signed by a CRNP, and the Infection Preventionist also confirmed this during interview on 7/24/26.
Call bells were not accessible or functional for two residents
Penalty
Summary
The facility failed to accommodate the call bell needs for two residents. Facility policy stated that each resident is to have a means to call staff directly for assistance from the bed, toileting/bathing areas, and from the floor, and that the resident call system must remain functional at all times. Resident R67, who had diagnoses of high blood pressure, arthritis, and muscle weakness, was observed lying in bed with the call bell clipped to the privacy curtain to the right of the resident and out of reach. During the observation, R67 stated, "How the hell am I supposed to reach that?" A nurse aide later confirmed that the call bell was not accessible and unavailable for the resident's use. Resident R85, who had diagnoses of high blood pressure, muscle weakness, and dementia, was observed lying in bed with the call bell wrapped around the left side rail, but the cord was unplugged from the wall panel and could not be activated. An LPN confirmed the cord was unplugged, then plugged it back in and verified that the call bell worked, with the light outside the room on and audible dinging heard at the nurse's station. The LPN also confirmed that the call bell was not accessible and that the facility failed to accommodate the resident's call bell needs.
Resident Fund Account Authorization Not Properly Documented
Penalty
Summary
The facility failed to ensure that a resident’s right to manage financial affairs was upheld by obtaining a signed authorization for the resident fund account. Resident R37 was admitted to the facility with diagnoses including depressive disorder, lymphedema, gout, and anxiety disorder. The resident’s MDS assessment dated 3/30/26 showed a BIMS score of 11, indicating moderate impairment. The care plan directed staff to actively involve the resident and the resident’s family in the plan of care. Review of the resident fund authorization form showed the account was opened with a fax date of 4/16/26, but the form had no signature date and the section for anyone signing for the resident was left blank. Although the form was signed by Resident R37, there was no additional information showing who assisted or authorized the account, and further review did not show that the resident’s POA was involved in opening the fund account. The facility’s trial balance dated 7/20/26 showed the resident’s account remained active. During interview, the LPN/business office staff member stated she was not sure who signed the form and confirmed the account start date as 4/16/26.
Unsafe Wheelchair Condition and Poor-Quality Bath Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident’s wheelchair and failed to have bath linens in good condition for one of three bath linen items. Facility policy on Homelike Environment stated that staff and management are to maximize characteristics of the facility that reflect a personalized, homelike setting, including clean, sanitary, and orderly surroundings and clean bed and bath linens that are in good condition. On observation, the resident was sitting in a wheelchair socializing with others, and the chair’s frame, seat, and wheels were noted to be corroded with grime, debris, and long hairs. A nurse aide confirmed the condition of the wheelchair. In addition, an anonymous complaint stated residents did not have access to linens, and during a Resident Council meeting, two of six residents said washcloths were not well kept and could be seen through. When the linen storage area was observed, washcloths were available, but a brand-new package was opened and the washcloths were found to be very thin and see-through; the Nursing Home Administrator confirmed this observation.
Failure to Assess Mattress Bolster as a Possible Restraint
Penalty
Summary
The facility failed to assess the functional status of Resident R1 to determine whether the use of a bolster on the mattress was a restraint. Resident R1 was admitted with diagnoses including anemia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and muscle weakness. The facility policy defined physical restraints as any manual method or mechanical device, material, or equipment attached to or adjacent to the resident's body that the resident cannot remove easily and that restricts freedom of movement or normal access to the body. During observation, Resident R1 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. The clinical record did not include a physician order for bolsters, a plan of care related to bolster use, or any assessments or ongoing evaluations for the use of bolsters on the resident's mattress. An Infection Preventionist confirmed in interview that the facility failed to assess the resident's functional status to determine whether the bolster was a restraint.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide a written transfer notification to a representative of the Office of the Long-Term Care Ombudsman Division for two residents who were transferred to the hospital. Resident R1 was admitted to the facility with diagnoses including anemia, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and muscle weakness. R1 was transferred to the hospital and later returned to the facility, but the clinical record did not include documented evidence that a written transfer notice was provided to the Ombudsman for that hospitalization. Resident R4 was admitted to the facility with diagnoses including dementia, diabetes mellitus, and major depressive disorder. R4 was transferred to the hospital and later returned to the facility, but the clinical record also lacked documented evidence that the facility provided a written notification to the Office of the Long-Term Care Ombudsman for that hospitalization. During interviews, the Nursing Home Administrator confirmed that the facility failed to provide the required transfer notices for these residents.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to the resident and/or representative for two residents reviewed. Facility policy stated that a baseline plan of care to meet a resident’s immediate health and safety needs is to be developed within 48 hours of admission and include the minimum healthcare information needed to properly care for the resident, including initial goals, physician orders, dietary orders, therapy services, and social service information. Resident R94 was admitted with diagnoses of fracture of the first lumbar vertebra, morbid obesity, and cirrhosis of the liver. The clinical record lacked evidence that a written summary of the baseline care plan was reviewed 14 days after admission. Resident R78 was admitted with diagnoses of urinary tract infection, diabetes mellitus, and ataxic gait. The clinical record lacked evidence that a written summary of the baseline care plan was provided to the resident and/or representative. During interview, the NHA confirmed there was no evidence that the written summary of the baseline care plan was provided to either resident within the required timeframe.
Failure to Apply and Maintain Ordered Hand Splint
Penalty
Summary
The facility failed to ensure a resident with limited mobility received the ordered services, equipment, and assistance to maintain or improve mobility. Resident R64 was admitted with diagnoses including stroke, hemiplegia, and high blood pressure. The resident’s physician orders and care plan directed staff to apply a left resting hand splint with morning care, remove it with evening care, provide gentle stretching to the left hand, fingers, and wrist before applying the splint, and check the skin before and after application, with therapy to be alerted to any skin issues or changes. On 7/20/26, the resident was observed in bed at 9:00 a.m. and again at 12:00 p.m. without the left hand splint in place as ordered. During the 12:03 p.m. observation, Therapy Employee E12 entered the room and stated the splint was not on, but she was putting it on the resident at that time. On 7/21/26 at 11:00 a.m., the resident was again observed in bed with the splint on the left hand, and the splint was covered in a light tan dried debris on the fabric.
Enteral Feeding Pump Left in Error or Hold Status
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. Resident R64 was admitted with diagnoses including stroke, hemiplegia, and high blood pressure, and had physician orders for Glucerna 1.5 to be administered via G tube at 87 ml/hr from 9:00 a.m. to 9:00 p.m. for a total of 1,044 ml over 12 hours. The resident’s care plan directed staff to administer enteral nutrition per physician orders. During observation on 7/20/26 at 10:48 a.m., Resident R64 was in bed connected to the enteral feeding pump, but the pump screen displayed an error message and the feeding was not infusing as ordered; the feeding bag was labeled as hung at 9:00 a.m. An LPN confirmed the pump was not running and was unaware of the issue. During a later observation on 7/21/26 at 1:29 p.m., the resident was again observed connected to the pump, which displayed a hold error message. Another LPN stated she was not aware the pump was on hold and did not turn it to hold, and indicated that nurse aides must have placed it on hold for care and did not turn it back on.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
Appropriate respiratory care was not provided for a resident who had physician orders for BiPAP at bedtime and as needed, with settings of inspiratory pressure 15, expiratory pressure 6, and oxygen at 5 liters by nasal cannula at bedtime, as well as oxygen at 5 lpm by nasal cannula every shift for respiratory failure. The resident’s care plan did not include care and management of the BiPAP machine. During observation, the resident was resting in bed without a nasal cannula in place and without a BiPAP mask on, and was breathing on room air only. When asked why the oxygen was not on, the resident stated staff had taken it off and did not put it back on. An LPN confirmed the oxygen was not in place as ordered, and the Infection Preventionist confirmed the care plan failed to include BiPAP care and management. Appropriate respiratory care was also not provided for another resident with a physician order for Ipratropium-Albuterol nebulizer solution every 6 hours as needed for shortness of breath or wheezing. During observation, the resident’s nebulizer machine was on the bedside table, the tubing had no date observed, and the mouthpiece was stored on top of the machine rather than in a bag while not in use. An LPN confirmed these observations and confirmed the facility failed to provide appropriate respiratory care for the resident.
Failure to Provide Trauma-Informed Care and Individualized Care Planning
Penalty
Summary
The facility failed to provide trauma-informed care and failed to develop and implement an individualized person-centered care plan for Resident R30, who was identified as being at risk for re-traumatization. Facility policy stated that trauma-informed care involves understanding and responding to the effects of trauma, incorporating knowledge about trauma into care plans and practices to avoid re-traumatization, and developing individualized care plans that address past trauma while identifying and decreasing exposure to triggers. The resident’s clinical record showed admission to the facility, an MDS dated 4/17/26 listing diagnoses of high blood pressure, depression, and anemia, and a psychiatry progress note dated 5/13/26 documenting that the resident became tearful while describing depression and PTSD symptoms. The psychiatry note stated the resident endorsed avoidance of trauma reminders, flashbacks, re-experiencing, and dissociation. Review of the comprehensive care plan showed it did not include goals or interventions related to PTSD and did not identify any triggers or how to avoid them. During an interview on 7/23/26 at 1:59 p.m., Social Worker Employee E8 confirmed that the facility failed to provide trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization and failed to develop and implement an individualized person-centered care plan for Resident R30.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to store medications and biologicals in a safe, secure, and orderly manner in one of three medication rooms, the 3 South Medication Room. During an observation, surveyors found eight culture swabs expired on one date, nine culture swabs expired on another date, ten culture swabs expired on a third date, and a tuberculin vial labeled as opened on a specific date. An LPN confirmed during interview that the items observed were expired as noted.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered for one of five residents reviewed, Closed Resident Record CR99. The clinical record showed CR99 was admitted to the facility and had diagnoses of high blood pressure, anxiety, and muscle weakness. A physician order dated 6/17/26 directed the facility to obtain a CBC and BMP one time only for monitoring on 6/22/26. Review of the record did not reveal documentation that the CBC was obtained and completed as ordered on 6/22/26. During an interview on 7/23/26 at 1:11 p.m., Infection Preventionist Employee E7 confirmed that the facility failed to obtain laboratory services as ordered for CR99.
Failure to Obtain Physician Orders for Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to obtain required physician discharge orders for two residents prior to their discharge. For one resident admitted with a thoracic vertebra fracture, urinary tract infection, and muscle weakness, review of the admission MDS dated 12/11/25 showed these diagnoses remained current, and facility documents showed the resident was discharged on a later date; however, the most recent physician orders contained no order authorizing discharge. For a second resident admitted with atrial fibrillation, diabetes mellitus, and protein-calorie malnutrition, review of the 5-day MDS dated 3/2/26 indicated the diagnoses remained current, and facility documents showed this resident was also discharged on a later date, again without any corresponding physician discharge order in the clinical record. During an interview on 3/18/26 at 1:45 p.m., the Director of Nursing confirmed that there were no physician orders for these discharges as required under 28 Pa. Code 211.12(d)(1)(5) for nursing services. These findings were based on review of clinical records, MDS assessments, facility-provided discharge documentation, and staff interview, which together demonstrated that the facility discharged two of three reviewed residents without documented physician authorization for discharge.
Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers during facility-initiated transfers for three of four sampled residents and failed to provide required written bed-hold policy notifications at the time of hospital transfer. Facility policies dated 5/19/25 required that, upon transfer or discharge, details be documented in the medical record and appropriate information be communicated to the receiving provider, and that residents or their representatives receive written information about bed-hold policies both in advance (at admission) and at the time of transfer. For each of the three residents, clinical record review showed no documented evidence that specific information such as care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs was communicated to the hospital. Resident 1, with diagnoses including atherosclerotic heart disease, COPD, and dysphagia, was transferred to the hospital and remained there, but the record lacked documentation of the required transfer information and written bed-hold policy notice at the time of transfer. Resident 2, with high blood pressure, depression, and muscle weakness, was transferred to and returned from the hospital the same day, yet the record similarly lacked documentation of communicated care plan goals, advance directives, ongoing care instructions, representative information, and written bed-hold policy notice. Resident 3, with atrial fibrillation, high blood pressure, and cerebral infarction, was transferred to the hospital and returned the following day, and the record again showed no documented evidence of the required transfer communication or written bed-hold policy notice at the time of transfer. In an interview, the Director of Nursing confirmed these failures for the three residents, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) regarding resident rights.
Failure to Address Resident Council Concerns on Call Bells and Medication Timeliness
Penalty
Summary
The facility failed to honor residents' rights to have their views considered and to receive prompt action on concerns raised through the Resident Council over a three-month period. The facility’s Resident Council policy dated 5/19/25 states that the council is intended to provide a forum for discussion of concerns and suggestions for improvement, and that all feedback and requests from the council are to be addressed in writing to the council. However, review of Resident Council meeting minutes for December 2025, January 2026, and February 2026 showed that residents repeatedly raised systemic concerns about care and services, but the “follow up” sections of the forms were left blank, with no documented response or action by the facility. In December 2025, the Resident Council minutes documented ongoing concerns about call bells not being answered timely, with residents reporting that call bell wait times were too long, agency staff were turning off call bells without entering rooms to provide assistance, and agency staff were providing poor care on weekends, including not answering call bells and using their phones instead of giving care. In January 2026, the minutes again documented old/unfinished business regarding call bells not being answered timely, with no further information or follow-up recorded. In February 2026, residents reported systemic concerns about medications not being delivered timely, and again the follow-up section was blank. During an interview on 2/23/26, the Nursing Home Administrator confirmed that the facility failed to consider the views of residents and act promptly on concerns and recommendations regarding resident care and life in the facility for all three months reviewed.
Failure to Obtain and Communicate Ordered Laboratory Results
Penalty
Summary
Surveyors found that the facility failed to obtain and document laboratory results as ordered by physicians and failed to document notification of those results to the ordering practitioners and resident representatives for two of three residents reviewed. For one resident with diagnoses including stroke, hemiplegia, and urinary tract infection, a physician order dated 2/18/26 directed staff to obtain a CMP in the morning for monitoring. The clinical record contained no documentation that the CMP results were obtained, and there was no evidence that the physician or the resident representative were notified of any results. An LPN stated that the lab results were not in the clinical record and that she did not have access to the computer system where lab results are stored, indicating only the supervisor had such access. For another resident with diagnoses including anemia, heart failure, and hypertension, a physician order dated 2/11/26 directed staff to obtain a one-time BMP on 2/12/26. The clinical record contained no documentation that the BMP results were obtained, and there was no evidence that the physician or the resident representative were notified of the results. The resident’s representative reported that blood work had been done a few weeks prior and that, despite multiple inquiries, no one could provide the lab results. The same LPN again indicated that lab results were not in the clinical record and that she lacked access to the lab computer system. The DON confirmed that the facility failed to obtain laboratory results as ordered and failed to provide evidence of notification to the physician or resident representative for these two residents, in violation of facility policies on laboratory services/reporting and change in condition/status, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Failure to Employ a Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) with appropriate competencies and credentials to manage the daily operations of the Dietary Department for four of twelve months, from October 20, 2025, through January 8, 2026. During an interview on January 8, 2026, at 11:00 a.m., the Nursing Home Administrator stated that Employee E1 had been employed as the FSD since October 20, 2025, and acknowledged that she was not a Certified Dietary Manager. In a separate interview at 11:10 a.m., FSD Employee E1 reported that the Registered Dietitian typically comes to the facility once per week. At 11:30 a.m. the same day, the Nursing Home Administrator confirmed that the facility could not provide documented evidence that FSD Employee E1 met the qualifications required for the Food Service Director position, resulting in noncompliance with Pa Code: 201.18(e)(6) regarding management requirements. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency in the report.
Failure to Provide Food Products Based on Resident Preferences
Penalty
Summary
The facility failed to provide food products based on resident preferences, specifically by not supplying coffee to approximately 38 out of 76 residents. Multiple residents reported not receiving coffee with their breakfast, and staff interviews confirmed that coffee was unavailable due to supply issues. The Certified Dietary Manager stated that coffee orders required third-party approval, which delayed delivery, and that there was no coffee in the building on the day in question. Staff also indicated that running out of coffee was a recurring issue, and purchasing coffee from a store depended on the availability of petty cash. Observations during meal service revealed residents requesting coffee and being informed by staff that none was available. The Nursing Home Administrator confirmed the failure to provide coffee as a food product based on resident preferences. The deficiency was documented under Pa Code: 201.14(a) Responsibility of licensee.
Failure to Label and Date Food Products in Main Kitchen
Penalty
Summary
The facility failed to comply with its policy regarding the labeling and dating of food products stored in the Main Kitchen. During an observation, surveyors found a bag of frozen vegetables in the walk-in freezer without a receive date, an opened bag of chopped onions in the reach-in refrigerator with no label or date, and four bags of gelatin mix in the dry storage room with no receive date. The Dietary Supervisor confirmed that these food items were not properly labeled or dated as required by facility policy.
Failure to Individualize Nutritional Care Plans and Communicate Fluid Restrictions
Penalty
Summary
The facility failed to individualize care plans to address specific nutritional concerns for two residents and did not ensure staff awareness of fluid restriction orders for another resident. For one resident with Alzheimer's disease, osteoporosis, and swallowing difficulties, the care plan did not include resident-specific interventions for the prescribed pureed diet, thickened liquids, and nutritional supplements, despite physician orders for these items. The care plan only listed general interventions such as providing the ordered diet and supplements, without detailing how these should be implemented for the resident's unique needs. Another resident with cancer, malnutrition, and depression experienced significant weight loss and received more than half of their calories through tube feeding. The care plan for this resident failed to document the ongoing weight loss, the resident's tendency to pull out or refuse the feeding tube, or specific interventions related to the prescribed tube feeding formula. Staff interviews confirmed that these individualized concerns and interventions were not reflected in the care plan. Additionally, a resident with high blood pressure, end stage renal disease, and a history of heart transplant had a physician order for a fluid restriction of 1800 mL per 24 hours. However, the order did not specify how the fluid allowance should be divided between nursing and dietary departments, and direct care staff were not made aware of the fluid restriction details. Facility staff acknowledged that the lack of clear breakdown and communication failed to ensure that acceptable nutritional parameters were maintained for this resident.
Failure to Complete and Act on Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRR) for several residents, as required by facility policy. For one resident with Alzheimer’s disease, hypertension, and diabetes, the MRR for one month only listed current medications without any recommendations or evidence that the medications were reviewed. The Director of Nursing (DON) confirmed that monthly medication reviews were not completed as required. Another resident with high blood pressure, dementia, and chronic pain had an MRR that identified an antipsychotic medication order without an appropriate diagnosis, but there was no documentation that the physician addressed or signed off on the pharmacist’s recommendation. The DON confirmed that irregularities reported by pharmacy were not acted upon in a timely manner for this resident. Additionally, for a resident with anxiety, depression, and bipolar disorder, there was no documentation that MRRs were completed by the consultant pharmacist for two consecutive months. The DON confirmed the absence of these reviews. These findings indicate that the facility did not consistently provide documentation of completed MRRs or ensure timely follow-up on pharmacy-identified irregularities for multiple residents.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) provided wound care to a resident diagnosed with Alzheimer's disease, anxiety, and depression, who had developed a pressure ulcer on the right heel. During the wound care observation, the RN wrote on the dressing after it had already been placed on the resident's heel. The RN later confirmed that this action failed to maintain the resident's dignity, as required by facility policy and resident rights outlined in the admission agreement. The incident was documented as a failure to provide care in a manner that maintains resident dignity, in violation of state regulations.
Failure to Ensure Medication Regimens Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary psychotropic medications for two residents. For one resident with diagnoses including high blood pressure, dementia, and chronic pain, the consultant pharmacist identified that an order for Seroquel, an antipsychotic medication, lacked an appropriate diagnosis and requested physician review. However, there was no documentation that the physician addressed or signed off on this recommendation, as required by facility policy. For another resident with anxiety, depression, and Bipolar Disorder, the clinical record showed multiple psychotropic medications prescribed, including Diazepam, Lorazepam, Sertraline, and Trazodone. The facility was unable to provide documentation that the required monthly medication regimen reviews (MRRs) were completed by the consultant pharmacist for two specific months. The DON confirmed the absence of this documentation and acknowledged the failure to ensure the medication regimens were free from potentially unnecessary psychotropic medications.
Failure to Obtain Physician Order for Enteral Feeding After Hospital Return
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services, as required. Clinical record review showed that the resident, who had diagnoses of cancer, malnutrition, and depression, was admitted with a physician's order for enteral feeding, which was discontinued prior to a hospital transfer. Upon the resident's return from the hospital, there was no physician order for enteral feeding from the date of return through several days, despite documentation that the feeding was being administered. This lapse was confirmed by the Director of Nursing, who acknowledged the absence of a physician's order for the enteral feeding during this period.
Failure to Properly Store Nebulizer Equipment for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required nebulizer treatments. According to facility policy, nebulizer equipment must be completely dry and stored in a plastic bag when not in use. However, during observations, both residents' nebulizer machines and mouthpieces were found on their bedside tables, not stored in bags as required. This was confirmed by a Licensed Practical Nurse, who acknowledged that the equipment was not properly stored when not in use. Resident R30 had diagnoses including high blood pressure, atrial fibrillation, and asthma, and had a physician's order for albuterol sulfate nebulization as needed for shortness of breath. Resident R38 had diagnoses of high blood pressure, anxiety, and hypothyroidism, with a physician's order for ipratropium-albuterol inhalation solution as needed for wheezing. Despite these orders and the residents' medical needs, the facility did not adhere to its own policy for safe and appropriate respiratory care, as evidenced by the improper storage of nebulizer equipment.
Failure to Ensure Consistent Communication with Dialysis Center
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for a resident who required hemodialysis services. According to facility policy, ongoing communication and collaboration with the dialysis facility is required, including the use of a dialysis communication form to be sent with the resident and reviewed upon return for each dialysis session. Review of the clinical record for a resident with diagnoses of high blood pressure, end stage renal disease, and heart transplant status revealed that the required communication forms were incomplete for eight separate dialysis dates within a specified period. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the communication forms were not consistently completed as required by policy. This deficiency was identified through review of clinical records, facility policy, and staff interviews, and was cited under relevant state codes for responsibility of licensee, resident care policies, and nursing services.
Failure to Provide Behavioral Health Services for Resident with Trauma History
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with a documented history of sexual abuse. Review of the resident's care plan showed that, although it acknowledged the history of sexual abuse and aimed to minimize traumatic symptoms, it did not include specific behavioral health interventions or considerations, such as the gender of staff providing care, that would address the resident's trauma history. The trauma assessment for the resident indicated no identified triggers or severity, despite the hospital record noting an assessment for possible sexual assault. Facility policy on trauma-informed and culturally competent care requires individualized care plans that incorporate trauma history and preferences, including those related to personal care and staff assignments. However, the resident's care plan lacked these individualized behavioral health supports. This deficiency was confirmed through review of clinical records, facility policy, and staff interviews, demonstrating a failure to ensure the resident received appropriate behavioral health services to maintain their highest practicable well-being.
Failure to Develop Comprehensive Care Plans Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the specific care needs of two residents, resulting in harm to one resident. For one resident with diagnoses including anemia, renal failure, and osteoarthritis, physician orders and MDS assessments indicated a need for total assist of two persons via Hoyer lift for transfers and dependence on staff for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers. During care, the resident rolled out of bed while only one staff member was present, resulting in bilateral leg fractures and subsequent hospitalization. Staff interviews confirmed that the care plan lacked necessary details regarding bed mobility assistance at the time of the incident. Another resident with muscle weakness, ataxic gait, and obesity also had physician orders requiring total assist of two via Hoyer lift for transfers, but the clinical record did not include a care plan for transfer status or bed mobility. Staff interviews confirmed the absence of a care plan addressing these needs. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the failure to develop comprehensive care plans for both residents.
Failure to Provide Timely Care and Physician Notification After Fall and Critical Lab Results
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a history of anemia, renal failure, and osteoarthritis, who was also at risk for bleeding due to anticoagulant (Warfarin) use. After the resident experienced a fall, staff observed bruising and pain, but there was no evidence that the physician was notified of these symptoms as required by the care plan and facility policy. The resident continued to exhibit bruising and pain over several days, and documentation failed to show timely physician notification or intervention regarding these ongoing symptoms of bleeding. Laboratory monitoring of the resident's INR, which is critical for patients on Warfarin, revealed dangerously high values on multiple occasions. Despite these critical lab results, the clinical record did not include evidence of timely notification to the physician or documentation of interventions in response to the abnormal findings. The resident's Warfarin was not discontinued until after a critical INR was reported, and there was a lack of documentation regarding the physician's response to the critical lab values and the resident's ongoing symptoms. Ultimately, the resident developed a significant bruise and pain in the left knee, which was later found to be fractured. The resident was transferred to the hospital, where laboratory results showed a critically low hemoglobin level and a supratherapeutic INR, necessitating a blood transfusion. The facility's failure to follow its own policies for monitoring, notification, and intervention after a fall and in response to abnormal lab results led to harm for the resident.
Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that appropriate assistance for bed mobility was provided to a resident, resulting in the resident rolling out of bed and sustaining bilateral leg fractures. The resident had significant medical conditions, including anemia, renal failure, osteoarthritis, and was non-ambulatory and bed-bound at baseline. Physician orders and the Minimum Data Set indicated the resident required total assistance of two persons for transfers via Hoyer lift and was dependent for bed mobility. However, the resident's care plan did not specify the required level of assistance for bed mobility or transfers, and staff did not consistently follow the documented requirements. On the day of the incident, a nurse aide was providing care to the resident alone and attempted to reposition the resident without the required second staff member. During this process, the resident rolled out of bed onto their knees while holding onto the bed rail. The resident was subsequently assisted back to bed by three staff members using a Hoyer lift. Following the fall, the resident developed extensive bruising and later complained of pain, which was initially managed with Tylenol. Despite ongoing documentation of bruising and pain, there was a lack of timely physician notification and assessment regarding the resident's injuries. Over the following weeks, the resident continued to exhibit bruising and pain, and eventually was found to have sustained bilateral leg fractures, requiring hospitalization and a blood transfusion due to a critically low hemoglobin level. Interviews with staff revealed confusion and inconsistency regarding the documentation and implementation of bed mobility and transfer assistance requirements. The facility's investigation confirmed that the appropriate assistance was not provided, and the care plan did not adequately address the resident's needs for bed mobility, directly contributing to the resident's injuries.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within 24 hours to the local state field office for one resident. The resident, who had a history of anemia, renal failure, and osteoarthritis, was involved in an incident where they rolled out of bed onto their knees while being assisted by staff. The event was documented in the resident's progress notes, and the resident was assisted back to bed by three staff members using a Hoyer lift, with no redness observed on the knees at the time. However, a review of documentation submitted to the state field office showed that this incident was not reported as required. The Director of Nursing confirmed during an interview that the facility did not report the allegation of neglect within the mandated timeframe.
Failure to Ensure Timely Physician Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to ensure a timely physician assessment was completed after a resident experienced a fall. The resident, who had a history of anemia, renal failure, and osteoarthritis, was admitted and later readmitted to the facility. On the evening of the fall, an LPN was called to the resident's room after the resident rolled out of bed during care. Subsequent clinical records documented ongoing bruising to the resident's right shin over several days following the incident. Despite these findings, there was no evidence in the clinical record that a physician assessed the resident's fall or the resulting bruising in a timely manner. The resident was later admitted to the hospital with significant medical concerns, including a critically low hemoglobin level and supratherapeutic INR, requiring a blood transfusion. A late entry progress note by the Medical Director, entered more than a month after the fall, did not address the fall or the bruising. Facility leadership confirmed that a timely physician assessment was not completed after the fall.
Failure to Protect Resident from Sexual Abuse by Family Member
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and multiple medical conditions, including dementia, multiple sclerosis, anxiety disorder, and neurogenic bladder, from sexual abuse by her husband. The resident was completely dependent on staff for all activities of daily living and was unable to provide a description of the incident due to her cognitive status. Staff observed the resident's husband inappropriately touching her genital area, specifically with his gloved fingers inside her vagina, while the resident appeared teary-eyed and unable to resist or stop the abuse. Prior to the incident, staff had frequently heard the husband being told by nursing staff not to touch his wife inappropriately, to which he responded that he could touch her if he wanted because she was his wife. On the day of the incident, a staff member witnessed the abuse and immediately reported it to nursing staff, who then found the husband at the bedside with a glove on and the resident's brief ripped, containing an unusual amount of pubic hair. The resident confirmed through nodding and verbal responses that her husband had touched her inappropriately and that she did not want him to continue visiting. The facility's policies clearly defined abuse, including sexual abuse, and emphasized the right of residents to be free from such mistreatment. Despite these policies, the facility did not prevent the abuse or ensure the resident's safety, resulting in actual harm, psychosocial distress, and physical discomfort for the resident. The deficiency was confirmed by both the Nursing Home Administrator and the Director of Nursing.
Failure to Timely Recognize and Report Suspected Sexual Abuse
Penalty
Summary
The facility failed to recognize and report timely suspicions of sexual abuse for a resident, despite multiple staff members having ongoing concerns about inappropriate behavior by the resident's husband. Staff interviews revealed that nurse aides and LPNs had observed suspicious behaviors over an extended period, such as the resident's briefs being repeatedly torn, the husband wearing a glove on one hand, and the resident's catheter and G-tube being disturbed after his visits. Staff frequently had to instruct the husband to stop touching the resident and to seek assistance from staff if the resident needed care. Despite these repeated observations and suspicions, no formal report was made until a staff member directly witnessed inappropriate touching. The resident in question was nonverbal and unable to advocate for herself, making her particularly vulnerable. Staff described feeling uncomfortable with the husband's actions, noting that he often asked to see the resident's rectum and was observed lingering near her genital area. Staff communicated their concerns to nursing leadership, including the DON and administrators, but the behavior was dismissed as normal or attributed to the husband's affection. The lack of direct evidence led to inaction, and the suspicions were not escalated or formally reported as potential abuse until the incident was witnessed firsthand. Facility policy and federal regulations require the identification, assessment, and timely reporting of all possible incidents of abuse, including sexual abuse. In this case, the facility's failure to act on staff suspicions and observations resulted in a delay in recognizing and reporting the abuse. The deficiency was confirmed by the facility's own leadership, who acknowledged that suspicions were not reported until the abuse was directly observed.
Failure to Ensure Safety and Provide Necessary Services for Resident with Dementia
Penalty
Summary
The facility failed to provide necessary services and appropriate treatment for a resident diagnosed with dementia, resulting in a lack of safety measures and inadequate protection of the resident's rights. The resident, who had severe cognitive impairment as indicated by a low BIMS score and diagnoses including dementia, multiple sclerosis, anxiety disorder, and neurogenic bladder, was admitted to the facility and had a care plan that included monitoring cognitive function and providing psychosocial support. Despite these documented needs, the facility did not ensure the resident's safety or address ongoing concerns related to the resident's husband’s behavior during visits. Multiple progress notes and staff interviews revealed that the resident's husband frequently visited, interfered with medical devices such as the G-tube and Foley catheter, and repeatedly engaged in inappropriate touching of the resident's genital area. Staff members reported longstanding suspicions and discomfort regarding the husband's actions, including torn briefs, requests to see the resident's rectum, and the use of gloves during visits. These concerns were communicated to nursing leadership and administration over an extended period, but no effective interventions were implemented to prevent or address the inappropriate behavior until a direct incident was witnessed by an employee. The facility's failure to document and act upon these repeated concerns, as well as to implement safety restrictions or protections as outlined in their own policies, resulted in the resident being subjected to ongoing inappropriate contact and a lack of necessary services to ensure her safety. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not provide the required services or protections for the resident with dementia.
Failure to Prevent Sexual Abuse Due to Ineffective Facility Management
Penalty
Summary
The facility's Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to prevent sexual abuse. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to protect Resident R1 from sexual abuse, resulting in actual harm, including psychosocial and/or physical harm and physical discomfort. The facility did not provide care and treatment in accordance with professional standards of practice, facility policies, and resident rights, as required by federal and state regulations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to meet the needs of three residents, resulting in a deficiency. Resident CR1 was admitted with a physician's order for dental evaluation and treatment, but despite being placed on a dental list after a missing tooth was reported, there was no evidence of a dental visit from August 2024 to January 2025. The facility's documents indicated a lack of consent and prepayment issues as reasons for the delay. Resident R2, admitted with a history of stroke and muscle weakness, had a dental evaluation and a denture impression taken in September 2024. However, due to preauthorization issues, the resident was removed from the dental list, and there was no evidence of a follow-up dental visit in January 2025. The resident expressed frustration over the delay in receiving dentures. Resident R3, with a history of high blood pressure and cancer, was also not seen by a dentist due to the facility's failure to obtain consent for treatment. Despite being scheduled for a dental visit, the resident was removed from the list. Interviews with staff confirmed the facility's failure to provide timely dental services to these residents, as required by regulations.
Plan Of Correction
There were no ill effects noted to patients CR1, R2 and R3. CR1 has discharged out of facility, and therefore was unable to rectify. All consents were obtained for R2 and R3 and called in to Facility Dental Services. R2, R3, and family was notified of consents and dental status. Dentist has verified consent and list for upcoming appointments with resident R2 and R3. Nursing notes for the last week have been reviewed for any indications that any dental services are necessary. Dental lists continue to be checked daily for any new dental issues. If urgent situation arises, facility will send to outside dentist. Nursing home administrator (NHA) educated Medical Records clerk and Appointment Scheduler on facility protocol of Dental Services. NHA will educate all nursing Staff on documentation of needs of dental services and dental lists that are to be utilized at each nursing station in a timely manner. Audits to be completed by Director of Nursing or Designee for 3 times a week times 2 weeks, 2 times a week times 2 weeks, and 1 time a week times 2 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
Platinum Ridge Center for Rehab and Healing was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. The facility failed to promptly inform the family of a significant change in the medical condition of a resident, identified as Resident CR1. The resident, who had a history of cerebral infarction, ileostomy, and aphasia, experienced a change in condition when blood was noted in their colostomy bag. This incident required a change in medication, specifically a reduction in the dosage of Eliquis, a blood thinner. The facility's policy mandates that the physician and resident representative be notified within 24 hours of any significant change in a resident's condition. However, in this case, the resident's responsible party was not informed of the change in condition or the medication adjustment until 36 days after the event. This delay in communication was confirmed through a review of clinical records and staff interviews, including an admission by the Director of Nursing that the notification was not timely. The deficiency was further highlighted by a concern raised by the resident's representative, who reported not receiving updates about the resident's condition or medication changes. Interviews with staff, including an LPN and the Director of Nursing, corroborated the failure to adhere to the notification policy. This lapse in communication violated the resident's rights and the facility's responsibility to keep family members informed of significant changes in the resident's health status.
Plan Of Correction
There were no adverse effects or harm to resident CR1. CR1 has been discharged from the facility. The Director of Nursing (DON) / Designee will educate the nursing staff on notifying the resident, resident's physician, and resident representative when there is an injury, decline, transfer, discharge, room change, or medication change. DON / designee will perform audits daily x2 weeks, 3x a week for 1 week, and then 2x a week for one week. To ensure that notification of injury, decline, transfer, discharge, room change, and medication changes are being completed. This plan of correction will be monitored in daily clinical meetings and monthly Quality Assurance Meetings until facility compliance is met.
Failure to Timely Schedule Colonoscopy for Resident
Penalty
Summary
The facility failed to schedule an appointment for outside services in a timely manner for a resident, identified as CR1, who was admitted with diagnoses including cerebral infarction, high blood pressure, and aphasia. On December 9, 2024, a nurse aide reported blood in the resident's colostomy bag to an LPN, who confirmed the presence of blood and notified the RN supervisor. The RN tested the stool, which was positive for blood, and the physician was informed, resulting in a new order to schedule a colonoscopy. However, a review of the resident's clinical record from December 10, 2024, through January 13, 2025, showed no attempt was made to schedule the colonoscopy. A concern was raised by the resident's representative on January 16, 2025, about the failure to schedule the procedure. The Director of Nursing confirmed during an interview on January 30, 2025, that the facility did not schedule the appointment in a timely manner.
Plan Of Correction
Appointment was not able to be rectified with patient CR1 as resident was discharged from the facility. Order was placed for colonoscopy for facility to facility transfer that was sent with patient. All orders for the previous week have been addressed for any appointments that need to be made and done so in a timely manner. Nursing home administrator to educates Medical Records Clerk and Appointment Scheduler on appointment orders and having appointments made within a timely manner. After appointments are made, the resident and responsible party will be notified of the appointments. Audits will be performed on appointment orders by Director of Nursing or Designee 3 times a week x3 weeks, 2 times a week x2 weeks, and 1 time a week x2 weeks. This plan of correction will be monitored at the Monthly Quality Assurance meeting until substantial compliance has been met.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the day and evening shifts on January 20, 2025. Specifically, during the day shift, the facility had a census of 88 residents but provided only 64.06 hours of nurse aide coverage instead of the required 66.00 hours. Similarly, on the evening shift, the facility did not meet the required staffing ratio of one nurse aide per 11 residents. These deficiencies were identified through a review of staffing documents and staff interviews conducted by the surveyors.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide ratio on 1/20/25. The Director of Nursing, Human Resources, and the Schedule will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator or designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. Facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Staffing Deficiency in LPN Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nursing assistants and licensed practical nurses (LPNs) on specific shifts. On 1/17/25, during the evening shift, the facility did not provide the minimum required number of LPNs, with only 17.26 actual hours of LPN coverage against the required 21.70 hours for a census of 84 residents. This deficiency was confirmed by the Nursing Home Administrator during an interview on 1/24/25. Additionally, the facility did not provide the necessary nursing assistants on certain shifts, as confirmed by the Nursing Home Administrator, although specific details of these shifts were not provided in the report.
Plan Of Correction
There were no effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 1/17/25. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on the New July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit nursing staff through all platforms as well as utilize bonus structures and outside agencies. Audits of licensed nursing staff will be completed weekly x4 by the NHA/Designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Failure to Maintain Proper Admission Documentation
Penalty
Summary
The facility failed to maintain proper admission documentation for three out of seven residents reviewed. Resident R1, who was admitted with a BIMS score indicating moderate cognitive impairment, was found to have signed their own admission packet, which is inappropriate given their cognitive status. This indicates a lapse in ensuring that residents with cognitive impairments are provided with the necessary support during the admission process. Additionally, the facility did not have signed admission packets for Residents R2 and R3. Resident R2 was admitted with diagnoses including encephalopathy, chronic kidney disease, and anemia, while Resident R3 was admitted with multiple rib fractures, a urinary tract infection, and lack of coordination. The absence of signed admission documentation for these residents suggests a failure in the facility's admission procedures, which is a violation of the residents' rights and the facility's admission policy.
Plan Of Correction
Residents R1, R2, R3 admission paperwork has been corrected. A whole house audit of correct admission paperwork will be completed for all residents to ensure that patients with a BIMS of 13 or higher or family have reviewed and signed all proper paperwork. Education with the Admission Director and Concierge on facility and state regulation of admission paperwork will be performed to ensure all paperwork is done upon admission. BIMS will be checked prior to the patient signing. Admissions paperwork will be signed by residents with a BIMS of 13-15, which indicates the patient is cognitively intact. Audits will be completed by Admissions or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 2 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Failure to Label and Date Food Products in Nursing Pantries
Penalty
Summary
The facility failed to properly label and date food products in the nursing unit pantries, which created the potential for cross-contamination. During an observation of the 3rd floor nursing pantry refrigerator, several items were found without labels or dates, including a milkshake, cottage cheese with fruit, a Celsius drink, an acai bowl in the freezer, a frozen sandwich, and pumpkin cheesecake ice cream. Additionally, the 3rd floor nursing pantry storage contained two bowls of raisin bran and a box of donuts without labels or dates. On the 2nd floor, a container of ramen and a square package of ramen were also found without labels or dates. During an interview, an LPN confirmed that the facility's failure to properly label and date food products created the potential for foodborne illness. This deficiency was noted under the regulations 28 Pa. Code: 201.18(b)(1) Management, 28 Pa. Code: 211.6(c) Dietary services, and 28 Pa. Code: 201.14(a) Responsibility of license.
Plan Of Correction
1st, 2nd, and 3rd floor nursing kitchen pantries were cleaned and all food items without dates have been removed. All new food items and resident snacks will have proper date and will be discarded after 3 days per protocol. Education to Dietary Director and dietary employees on labeling and dating all food/drink items that are distributed from kitchen. Education also provided to nursing staff that all non-patient related items are not permitted in patient pantries. Audits to be performed by Director of Nursing or Designee 3 times a week x2 weeks, 2 times a week x2 weeks, 1 time a week x2 weeks to ensure all pantries are clean, organized, and proper dates are used. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide staffing levels as per the regulation effective July 1, 2024. Specifically, the facility did not provide the minimum required number of nurse aides per resident during various shifts over an 18-day period. During the day shift, the facility was short of the required nurse aide staffing on eleven days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was consistently below the required ratio of one nurse aide per 10 residents. Similarly, during the evening shift, the facility failed to meet the required staffing levels on eleven days, with the census ranging from 84 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 11 residents. Additionally, the facility did not meet the required staffing levels during the night shift on three days, with the census ranging from 85 to 87 residents, but the number of nurse aides present was below the required ratio of one nurse aide per 15 residents. The Nursing Home Administrator confirmed these deficiencies during an interview, acknowledging the failure to provide the minimum required nurse aide staffing levels across the different shifts. There was no indication of additional higher-level staff being available to compensate for these deficiencies.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of the decreased nurse aide to resident ratios on 12/1/24 through 12/18/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 nurse aide to resident ratios by the Nursing Home Administrator or Designee. To ensure sufficient nursing aide staffing ratios to comply with state laws, staffing meetings will be held 3 days a week to review staffing and the projected nursing assistant staff ratios for the current day, as well as the upcoming week. If projected staffing levels are below the required minimum staffing ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum staffing and ratio requirement. The facility will continue to recruit CNAs through all platforms and utilize bonuses and outside staffing agencies. Audits of nurse aide ratios will be completed weekly x4 by the NHA/designee to ensure nurse aide ratios are met. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
LPN Staffing Shortage on Night Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the night shift on December 14, 2024. According to the nursing time schedules reviewed for the period from December 1, 2024, to December 18, 2024, the facility did not provide the minimum of one LPN per 40 residents, as mandated by the regulation effective July 1, 2023. On the night of December 14, 2024, the facility had a census of 86 residents, requiring 3.44 LPNs, but only 3.04 LPNs were present. This staffing shortage was confirmed by the Nursing Home Administrator during an interview on December 19, 2024, at 2:00 p.m., who acknowledged the failure to meet the staffing requirement without any additional higher-level staff to compensate for the deficiency.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased licensed nurse staffing ratios on 12/14/24. The Director of Nursing, Human Resources, and the Scheduler will be re-educated on new July 1 licensed nurse to resident ratios by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review the licensed nursing staff ratios for the previous and current day, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the state mandated ratios, then the facility will reach out to current staff and to the staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit nursing staff through all platforms as well as utilize bonus structures and outside agencies. Audits of licensed nursing staff ratios will be completed weekly x4 by the NHA/designee to ensure licensed staff ratios meet the state minimums. Results of the audits will be reported to our QAPI committee monthly for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on ten out of eighteen days. This deficiency was identified through a review of nursing schedules and census information from December 1, 2024, to December 18, 2024. On specific dates, the facility's provided nursing care hours per resident per day (PPD) fell below the required threshold, with PPDs ranging from 2.91 to 3.19. The Nursing Home Administrator confirmed the failure to meet the required nursing hours during an interview conducted on December 19, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased HPPD on 12/1/24 through 12/17/24. The Director of Nursing, HR and Scheduler will be re-educated on the state requirement for HPPD by the Nursing Home Administrator or Designee. Staffing meetings will be held 3 days a week to review HPPD from the previous day and the projected HPPD, as well as the upcoming week to ensure appropriate staffing levels. If projected staffing levels are below the minimum of 3.2 HPPD, then the facility will reach out to current staff and staffing agencies to enlist staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Audits of HPPD will be completed 5 days a week x4 by the NHA/designee to ensure HPPD meets the state minimums. Results of the audits will be submitted to the QAPI committee monthly for review and recommendations.
Inaccurate Narcotic Documentation and Discrepancies in LTC Facility
Penalty
Summary
The facility failed to maintain accurate narcotic count sheets and document the disposition of narcotics accurately, leading to discrepancies between Medication Administration Records (MAR) and narcotics count sheets for three of five closed record residents. The facility's policy on the management of controlled drugs requires that Schedule II to V controlled drugs be disposed of in accordance with federal and state regulations. However, the review of facility documentation revealed several instances where the shift count sheets were incomplete, with missing signatures from nurses coming on or going off duty on multiple dates. This lack of documentation accuracy was confirmed during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON). For the residents involved, the facility's documentation showed inconsistencies in the administration and destruction of narcotics. One resident, admitted with acute kidney failure and diabetes mellitus, had a fentanyl patch and hydrocodone marked as destroyed, but the quantity destroyed was not documented. Another resident, with thrombocytopenia and unspecified cirrhosis of the liver, had discrepancies in the recorded administration of morphine between the MAR and the narcotic count sheet. A third resident, with acute kidney failure and hypertension, had tramadol marked as destroyed without indicating the amount. These documentation failures were acknowledged by the NHA and DON, highlighting the facility's inability to accurately track and manage controlled substances as required by regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brackenridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Rehabilitation & Healthcare Center | 2.1 mi | ★★★★★ | 27 | 0 |
| Harmar Village Health & Rehab Center | 6.4 mi | ★★★★★ | 33 | 1 |
| Kadima Rehabilitation & Nursing At Cheswick | 7 mi | ★★★★★ | 20 | 1 |
| Willows Of Presbyterian Senior | 7.7 mi | ★★★★★ | 25 | 0 |
| Concordia At Rebecca Residence | 8.3 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.