Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edenbrook North during CMS and state inspections, most recent first.
Unsafe Housekeeping and Maintenance Conditions: Surveyors observed a dirty central supply room, an outdoor storage area behind dumpsters filled with furniture and mattresses, and clutter and damage on a nursing unit including items left on an AC unit, wall damage, stains, cobwebs, dead insects, and broken fixtures. Surveyors also found clothes and hygiene items on the floors of several residents’ closets, and a family member reported one resident’s closet always had clothes on the floor.
Failure to Address Severe Weight Loss and Decreased Intake: The facility did not implement nutritional interventions for three residents with marked weight loss and decreased intake. One resident continued to lose weight after a dietitian note recommending a house shake, while two other residents had severe weight loss documented on weight checks and quarterly reviews, yet no new nutritional interventions were added despite confirmed declines in intake and, for one resident, use of diuretics.
A resident admitted for IV antibiotics after an infected knee replacement had a PICC line ordered for ongoing treatment. MAR/TAR review showed multiple LPNs and an RN documented giving IV ceftriaxone and flushing the PICC with NS, but the facility had no completed licensed staff competencies for PICC line care, and its policies did not include measures to ensure those competencies.
Failure to monitor psychotropic medication use: The facility did not document ongoing monitoring of target behaviors or potential side effects for two residents receiving psychotropic meds. One resident had orders for Lorazepam PRN for agitation and ABH Gel for agitation, and another resident had an order for Aripiprazole at HS for mood regulation. In both cases, the record lacked behavior monitoring, side effect assessment, and related care plan interventions, and the DON confirmed the meds had not been added to the residents’ care plans.
Failure to Provide Transfer and Bed-Hold Notices: A resident requested ER transfer and was sent out for pneumonia and COPD, but the facility did not provide written transfer notice or bed-hold information at the time of transfer. The resident acknowledged the bed hold and transfer notice the next day, and there was no documentation that the resident's responsible party received a copy of the notices. The NHA confirmed the omission.
Inaccurate MDS Coding for Range of Motion Status: The facility failed to ensure MDS assessments accurately reflected the functional status of two residents. One resident’s MDSs inconsistently coded ROM impairment despite deficits present on admission, and another resident with CVA-related left-sided weakness was at times coded as having no ROM impairment. The DON and RN assessment coordinator confirmed the coding errors, and one MDS was later modified after surveyor inquiry.
The facility failed to provide two residents with a summary of their baseline care plan within 48 hours of admission. One resident was admitted after a fall and hip fx and had orders for O2, a Foley, droplet precautions, and apixaban; he said he did not know his d/c goals and denied receiving a care plan copy. Another resident was admitted for IV abx for an infected knee replacement with a PICC line and O2 orders; she also denied receiving her baseline care plan copy.
Failure to provide ADL assistance for dependent residents. Two residents who required staff help with personal hygiene were observed without needed care: one had several days of facial stubble and no documentation of shaving assistance, and another appeared to have oily, unclean hair with no evidence of a scheduled shower being provided over the documented period. MDS assessments and care plans showed both residents needed substantial to maximal staff assistance for hygiene tasks, and facility leadership confirmed the findings.
A resident receiving IV antibiotics through a PICC line had no documented limb restriction signage or other indication to avoid use of the right arm for BP checks or venipuncture. The DON confirmed there were no licensed staff competencies for PICC lines and no policy for documenting all PICC care interventions, and the resident’s care plan initially lacked right arm restrictions despite the PICC in the right upper extremity.
A resident with a smoking assessment allowing continued smoking was found smoking outside the designated area, with cigarettes and a lighter kept in her purse attached to her rolling walker instead of being stored at the nursing station as documented in the smoking agreement and assessment. The facility policy allowed smoking only in posted designated areas, but the resident reported she kept her smoking materials with her and did not return them to the proper location; the NHA and DON confirmed the findings.
A resident receiving supplemental oxygen was observed with the concentrator set below the ordered flow rate on separate occasions. The active physician order required continuous oxygen at 3 L/min, but the concentrator was found set at 2 L/min and later 1.5 L/min, with no order to titrate the flow. An LPN confirmed the ordered rate and stated vital signs, including pulse oximetry, had not been obtained.
The facility failed to offer, educate, or administer COVID-19 vaccines for two residents reviewed for immunizations. One resident had no documented COVID vaccine since a prior dose, and another resident had previously refused the vaccine, but the chart contained no further evidence of later offers or education about the benefits, risks, and side effects. The IP confirmed the findings during interview.
A resident developed significant bruising to the left arm, reported by the responsible party with photos, but staff did not document a detailed assessment of the bruise, did not record it on the weekly skin check, and did not conduct a thorough investigation or report it as an injury of unknown origin per facility policy. Staff accepted the resident’s statement that he had scratched himself without further inquiry. In a separate incident, the same resident’s responsible party filed a grievance alleging that prescription glasses had been stolen, yet the facility did not initiate or document an investigation, obtain witness statements, or notify law enforcement or the Department of Health regarding the potential misappropriation of resident property.
A resident who was assessed as dependent on staff for oral hygiene had a care plan directing that teeth be brushed twice daily, but electronic ADL documentation showed that staff did not document providing this assistance on multiple days within the review period. There was no record that the ordered twice-daily oral hygiene care was consistently provided, leading to a deficiency under ADL care requirements for dependent residents.
A resident who was fully dependent on staff was found with unexplained bruising and swelling on the forehead and hand. The injury was not immediately reported by a nurse aide who first observed it, and the required investigation and reporting to the Department of Health were not completed as per facility policy. The DON confirmed that the incident was not handled according to established procedures.
The facility failed to maintain sanitary conditions in the main kitchen, with debris on a mobile rack, floor drains, and grease trap. A windowsill had dust, a dead bug, and a potato chip. A storage room refrigerator and freezer lacked temperature monitoring records, and tray line food temperatures were undocumented for several dates. The Nursing Home Administrator confirmed these deficiencies.
The facility did not ensure timely return of residents' personal clothing after laundering, affecting multiple residents across all nursing units. A resident reported missing clothing, and observations confirmed that clean laundry was not distributed for at least four days. This issue was acknowledged by the housekeeping supervisor and the Nursing Home Administrator.
The facility failed to assist dependent residents with bathing and personal hygiene, resulting in missed showers and inadequate hair washing for several residents. Observations and records indicated multiple instances of neglect, with some residents receiving minimal assistance despite requiring substantial or complete help. Concerns were raised by family members and documented refusals were not followed by reattempts, highlighting a pattern of neglect in meeting residents' hygiene needs.
A facility failed to document pain levels for a resident receiving Oxycodone for severe pain, as per physician orders. The MAR showed multiple instances where pain levels were not recorded, indicating non-compliance with pain management protocols. This issue was confirmed by the DON and had been previously cited.
The facility failed to implement enhanced barrier precautions for three residents, including one with pressure ulcers, another with ESBL, and a third with a Foley catheter. Observations revealed a lack of signage and PPE, and staff did not use gowns during high-contact activities, contrary to infection control policies.
The facility failed to maintain a clean and safe environment on the 200 Nursing Unit, with issues such as a ripped-off handrail, strong urine odor, stained privacy curtain, damaged drywall, and dusty fan shroud affecting several residents. These deficiencies were confirmed during an interview with the Nursing Home Administrator and DON.
A facility failed to investigate and report an allegation of theft involving a resident's missing $40. Despite the policy requiring immediate notification and investigation, the Nursing Home Administrator only completed a concern form without further action, such as obtaining witness statements or notifying authorities.
A facility failed to implement a comprehensive care plan for a resident with a cardiac pacemaker. Despite a physician's order noting the presence of the pacemaker, no care plan was developed to address the necessary monitoring and assessment. This deficiency was confirmed by the DON during meetings with the Nursing Home Administrator.
A resident expressed concerns about her leg function and had not received therapy for a week. Despite being discontinued from therapy due to limited progress, no restorative ROM program was initiated, contrary to facility policies. The resident's clinical records indicated limited active ROM and slight weakness, but no restorative program was documented.
The facility failed to timely assess and intervene in significant weight loss for two residents. One resident lost 24.5 pounds over several months without proper reweights or interventions, while another experienced a severe weight loss that went unaddressed for four weeks. The facility lacked a system to notify the dietitian of significant weight changes, resulting in inadequate nutritional care.
A facility failed to provide appropriate respiratory care for a resident. Observations showed the resident's oxygen nasal cannula was left unbagged on the bed, and the nebulizer machine and tubing were found on the floor unbagged. Proper cleaning and storage of respiratory equipment are necessary to reduce infection risk, as per the American Association for Respiratory Care.
A facility failed to create an individualized care plan for a resident with dementia. Despite the resident's admission with a dementia diagnosis and a subsequent assessment confirming the condition, the care plan lacked specific interventions to address cognitive loss. This issue was identified during a review with the Nursing Home Administrator.
A facility failed to ensure safe storage of personal food in a resident's refrigerator, which lacked a temperature log. Observations revealed expired and undated food items, and the Nursing Home Administrator confirmed that monitoring should occur to prevent foodborne concerns.
The facility failed to maintain a sanitary environment in an outside employee break area, where various discarded items, including medical gloves and cigarette butts, were observed. An overflowing garbage can and a metal bucket with brown water were also noted. These conditions were reviewed with the Nursing Home Administrator and DON.
The facility failed to meet the required nurse aide-to-resident ratios during day, evening, and overnight shifts over a 21-day period. On several occasions, the number of nurse aides was insufficient, such as on December 25, when only 6 nurse aides were available during the day shift for 118 residents, while 11.80 were required. Similar shortages were noted during evening and overnight shifts, impacting the facility's compliance with state regulations.
The facility did not meet the required 3.2 hours of direct resident care per patient day for 18 out of 21 days reviewed. Nursing staffing hours were insufficient on several days in September, October, and December 2024, with hours ranging from 2.47 to 3.19 PPD. This was confirmed by the Administrator.
The facility failed to assist residents with bathing, grooming, and dressing, despite their dependency on staff. A resident was found with a soiled shirt and unshaven, while others did not receive showers as per their preferences. These issues were discussed with the facility's administration.
The facility failed to adhere to physician orders for several residents, including not documenting weights, blood sugar levels, and vital signs as required. A resident's weight was not monitored or reported as ordered, another resident received insulin despite low blood sugar levels, and a third resident's bowel management protocol was not followed. Additionally, vital signs for a resident with hypotension were not recorded timely.
The facility failed to maintain ROM for two residents. One resident's care plan included a restorative program for immobility, but staff often did not complete or document the tasks. Another resident's care plan involved AROM to reduce fall risk, but documentation showed frequent refusals by a specific employee, despite the resident's usual acceptance of assistance. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide appropriate pain management for four residents due to unclear guidelines for administering pain medications based on severity. Instances were noted where medications like Tramadol and Percocet were given for inappropriate pain levels, indicating systemic issues in pain management practices.
The facility failed to provide trauma-informed and culturally competent care for two residents with PTSD. One resident, admitted in 2022, had a history of premorbid PTSD, but the facility did not identify trauma history or triggers, nor collaborate with family or professionals for care planning. Similarly, another resident admitted in 2023 was diagnosed with chronic PTSD, yet the facility did not address trauma history or collaborate for individualized care. These issues were discussed with the administration.
The facility failed to develop and implement person-centered care plans for two residents diagnosed with dementia, as required. Despite assessments indicating the need for such plans, reviews revealed no evidence of individualized strategies to manage their cognitive loss. This deficiency was discussed with the facility's administration.
A resident's Ativan prescription was not discontinued despite a 14-day non-use period, contrary to physician orders. The medication was administered 17 times without attempting non-pharmacological interventions, highlighting a failure in adhering to medication management protocols.
The facility's main kitchen was found to have unsanitary conditions, including a dirty dry storage room floor, undated and expired food items in refrigerators, and incomplete temperature logs for dishwashers and refrigeration units. Black dirt particles were observed on food storage units, attributed to the air-conditioning unit. These deficiencies were noted during an observation and discussed with a dietary cook and the Nursing Home Administrator.
A resident was unable to exercise their choice to smoke due to a facility policy change that prohibited smoking for new admissions, while grandfathered residents and staff were allowed to smoke in designated areas. The resident, a tobacco user, felt this was unfair and was informed they could only smoke off the property, highlighting a failure to promote resident self-determination.
The facility failed to maintain a clean and safe environment, as two residents reported dirty bathrooms and inadequate room maintenance. Additionally, a resident's bladder scanner was broken, despite a physician's order for its use. The facility was aware of the equipment issue but lacked documentation of repair efforts.
A resident suffered a head injury after falling in her room due to neglect. The fall occurred when the resident attempted to reach a call bell that was not within reach, contrary to her care plan. A physical therapist left the resident in a stationary chair without notifying nursing staff or ensuring the call bell was accessible, leading to the incident.
The facility failed to provide written notice of the bed hold policy to two residents or their representatives at the time of hospital transfer. One resident was transferred due to a change in mental status, and neither received the required notification. The Nursing Home Administrator confirmed these findings.
A resident was not provided with necessary eyeglasses despite an optometry evaluation indicating their need. The resident reported using readers but experiencing blurred vision when watching TV. Documentation showed that bifocal glasses were ordered, but there was no record of their delivery or a follow-up visit. The Nursing Home Administrator stated the glasses were lost, and a new pair was ordered.
A facility failed to timely assess and implement interventions for a resident's pressure ulcer. Despite being identified as at risk, the resident developed a Stage 3 ulcer on the right ankle, with no new treatment orders documented. A care plan was not initiated until seven weeks after the ulcer was identified, and the Director of Nursing confirmed the lack of further documentation of assessment or intervention.
A resident experienced severe weight fluctuations without timely re-weighing or assessment, contrary to the facility's Weight Policy. The resident gained 20 pounds and then lost 14.2 pounds within a short period, but the re-weight was delayed by seven days. The registered dietitian did not provide new recommendations, and there was no notification to the resident's physician or responsible party.
A resident with mild cognitive impairment expressed distress about being held against his will and not being allowed to contact the ombudsman. Despite being oriented and having minimal confusion, the facility did not address his concerns or explore alternative living arrangements. Additionally, there was no evidence of a home assessment to verify claims about the uninhabitability of his home.
The facility failed to properly account for, secure, dispose of, or return medications for two residents. For one resident, there was no documentation of the disposition or security of controlled medications after the resident expired. For another resident, there was no documentation of the disposition of multiple medications upon discharge to the hospital, where the resident later expired.
A facility did not address pharmacy recommendations for a resident's medication diagnosis. The pharmacist requested corrections to the diagnosis for Seroquel on multiple occasions, but the facility failed to update the diagnosis from behaviors to bipolar disorder. The DON confirmed these findings.
The facility's laundry area was found to be unsafe and unclean due to an extensive build-up of wet lint and debris, including medical gloves, a plunger head, and a dirty blanket behind the main washing machines. This was observed during a survey with a laundry aide and the Nursing Home Administrator, highlighting a potential fire hazard.
Unsafe Housekeeping and Maintenance Conditions
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to maintain a clean, comfortable, orderly, and homelike environment in the central supply room, an outdoor storage area behind the dumpsters, one nursing unit, and several resident closets. On April 21, 2026, surveyors observed the central supply room with a blackened floor around the refrigerator and freezer, dust, debris, leaves, a wooden pallet, and rolled-up blue disposable gloves under the pallet. In the outdoor area behind the dumpsters, surveyors observed a large pile of furniture items, including two wooden bed frames, a metal bed frame, multiple mattresses, two wooden chairs with cushions, and bedside tables. The Maintenance Director stated that the area behind the dumpsters was an additional storage area and that the items were to be brought back in and used for residents if needed. On the third floor nursing unit, surveyors observed sneakers, balled-up gloves, and a blanket sitting on an air-conditioning unit behind chairs, and later observed the same items still there. In the dining room/sunroom area, surveyors observed a hole in the wall with a phone jack wire extending from it, multiple splash and drip stains on the lower wall, a balled-up paper towel on top of the soda machine, four empty wheelchairs with a deflated air mattress on top of them, a purse and sweater on one wheelchair, an empty sealed plastic lunch container with ketchup packets and a plastic spoon on a table, cobwebs with dead insects around the windows and windowsill, dark-colored objects inside both ceiling light fixtures, and broken drywall and peeling paint around the air-conditioning unit. Surveyors also observed clothes and hygiene items on the floors of the closets in the rooms of four residents, and a family member stated that one resident's closet always had clothes on the floor.
Failure to Address Severe Weight Loss and Decreased Intake
Penalty
Summary
The facility failed to implement interventions to promote acceptable nutritional status for three residents who experienced significant weight loss. Resident 82 was admitted weighing 110.0 pounds and then lost weight to 101.0 pounds by March 11, 2026, a 9-pound, 8% severe loss in less than 30 days, with continued decline to 100.6 pounds and then 98.0 pounds. A dietitian note on March 12, 2026 recommended adding a house shake, but no further nutritional review could be identified in the chart after the continued weight loss was documented. During interview, the dietitian stated the resident had not been reviewed because the name was closer to the end of the alphabet. Resident 84 was admitted weighing 170.4 pounds and later had weights of 160.3 pounds, 143.0 pounds, and 140.6 pounds, including a 19.7-pound, 12.28% severe loss in one month. A quarterly assessment noted decreased food and fluid intake and that the resident met criteria for being at risk of malnutrition, but no nutritional interventions were added, and a weight change note confirmed the severe loss without new interventions. Resident 7 had a weight of 178.8 pounds and then dropped to 153.8 pounds, a 25-pound, 13.98% severe loss in one month, with a reweight of 154.4 pounds. A quarterly assessment documented decreased intake, and a weight change note confirmed the 24.4-pound, 13.6% loss in one month, but no nutritional interventions were added; the dietitian confirmed this and stated the resident was on two diuretic medications with no changes to those medications.
Lack of Staff Competency for PICC Line Care
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the specific competencies needed to care for a resident receiving intravenous therapy through a PICC line. Resident 119 was admitted on April 18, 2026 for ongoing antibiotic therapy related to an infected right knee replacement, and physician orders included a PICC line in the right upper extremity and intravenous ceftriaxone sodium 2 grams in the afternoon for the knee infection. Review of the resident’s MAR and TAR for April 2026 showed that an LPN, another LPN, a third LPN, and an RN documented administering the IV ceftriaxone, and two LPNs documented flushing the resident’s PICC line with normal saline. The facility’s policies on PICC line care, dressing changes for vascular access devices, and maintaining patency of peripheral and central vascular access devices did not include measures to ensure staff competencies for PICC line care and use, and the DON confirmed on April 24, 2026 that the facility had no licensed staff competencies completed related to PICC lines.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor target behaviors and potential side effects for psychotropic medication use for two residents reviewed for medication regimen concerns. Facility policy required assessment of specific behaviors or symptoms, identification of potential causative factors, documentation of the resident’s response to non-pharmacological interventions, and ongoing monitoring and documentation of behavior symptoms and medication side effects after psychotropic medication was started. Resident 6 had active orders for Lorazepam 0.5 mg every 12 hours as needed for agitation and ABH Gel applied topically in the morning for agitation. The clinical record did not contain evidence of ongoing monitoring of target behavior symptoms, ongoing assessment for potential side effects, or care plan interventions related to the antianxiety or antipsychotic medications. The DON confirmed that Resident 6’s antipsychotic and antianxiety medications had not been added to the care plan. Resident 3 had an active order for Aripiprazole 2 mg at bedtime for mood regulation, but the record likewise lacked evidence of ongoing monitoring of target behavior symptoms, ongoing assessment for potential side effects, or care plan interventions related to the antipsychotic medication. The DON confirmed that Resident 3’s antipsychotic medication had not been added to the care plan.
Failure to Provide Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that the resident's representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for one resident reviewed for hospitalization. Clinical record review showed that the resident requested transfer to the ER at 3:54 AM on January 11, 2026, and was transferred to the ER at 4:02 AM, where the resident was admitted for pneumonia and COPD. The record contained no evidence that the resident was provided written transfer notice or bed-hold information at the time of transfer. Further review showed that the resident acknowledged a bed hold and transfer notice on January 12, 2026, the day after the hospital transfer, and there was no documented evidence that the facility provided a copy of the bed hold and transfer notice to the resident's responsible party. The Nursing Home Administrator confirmed in interview on April 24, 2026, that the facility did not provide the written transfer and bed-hold notices at the time of transfer or provide the responsible party with a copy of those notices.
Inaccurate MDS Coding for Range of Motion Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected the residents’ functional status for two residents. For Resident 6, the admission MDS dated September 4, 2025, and a significant change MDS both indicated range of motion impairment only to one upper extremity, while later quarterly MDS assessments documented range of motion impairments to an upper extremity and lower extremity on one side. During interview, the DON and the RN assessment coordinator stated the September 4, 2025, and November 21, 2025, MDS assessments were incorrect and that Resident 6 should have been coded with lower extremity range of motion impairment on all assessments because the deficits were present on admission and did not represent a decline. For Resident 9, nursing documentation showed she returned from the hospital with left lower extremity and left upper extremity weakness and was diagnosed with an acute ischemic right MCA CVA, with left-sided weakness, confusion, and hallucinations. Despite this, quarterly and significant change MDS assessments at different points coded her as having no range of motion impairments, while other quarterly assessments coded upper and lower extremity range of motion impairments on one side. When the surveyor asked for documentation of the facility’s response to the decline reflected in the MDS assessments, nursing documentation entered after the surveyor’s questioning showed the facility submitted a modification to the February 16, 2026 MDS because it had been incorrectly coded with no range of motion impairments. The DON later confirmed that staff had incorrectly coded that assessment.
Failure to Provide Baseline Care Plan Summary Within 48 Hours
Penalty
Summary
The facility failed to provide two residents and their representatives with a summary of the baseline care plan within 48 hours of admission. Resident 120 was admitted on April 7, 2026, after a fall and hip fracture at home with hospitalization and surgery. Admission orders included supplemental oxygen at 3 liters per minute continuously, a Foley catheter for failed voiding trials, droplet precautions for human metapneumovirus, and apixaban. During interview, Resident 120 stated he did not know his discharge goals, did not know whether he would use home health after discharge, and denied receiving a copy of his care plan since admission. Review of his care plan did not show entries related to supplemental oxygen until April 21, 2026, and staff later documented meeting with him to deliver, review, and have him sign the baseline care plan after the surveyor questioned the issue. Staff also confirmed that the baseline care plan did not include supplemental oxygen despite the physician order and use since admission. Resident 119 was admitted on April 18, 2026, for ongoing IV antibiotic therapy related to an infected right knee replacement. Admission documentation noted supplemental oxygen use, and physician orders included a PICC line to the right upper extremity, ceftriaxone sodium 2 grams IV in the afternoon for knee infection, and supplemental oxygen at 4 liters per minute at rest and 8 liters per minute during activity. During interview, Resident 119 denied receiving a copy of her care plan since admission and showed the surveyor a folder she had kept to verify that she had not received the baseline care plan. Social services later documented meeting with her and providing the baseline care plan after the surveyor raised the concern.
Failure to Provide ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide activities of daily living assistance for dependent residents, including shaving and bathing care. Resident 30 was observed on April 21, 2026, with several days of stubble on his face, and the stubble was still present the next day when he said he would like to be shaved. His quarterly MDS dated February 27, 2026, showed that nursing staff assessed him as requiring substantial to maximum assistance with personal hygiene, including shaving, but there was no documentation that staff were providing shaving assistance. The Nursing Home Administrator and DON confirmed that Resident 30 was unable to shave himself and wanted to be shaved. Resident 9 was observed on April 21, 2026, with long straight hair that appeared oily and not clean. Her quarterly MDS and significant change MDS assessed her as dependent on substantial to maximal staff assistance for showering/bathing, and her care plan stated that she required staff assistance for bathing/showering. Her bathing task history showed an established shower schedule, but review of April 2026 documentation showed no evidence that she received a shower from April 1 through first shift on April 21, 2026, with entries reflecting bed baths, no data, or bathing marked not applicable. The care plan did not indicate that she refused bathing assistance, and the Nursing Home Administrator and DON reviewed these concerns during interview.
PICC Line Care and Limb Restriction Not Implemented
Penalty
Summary
The facility failed to implement the highest practicable care related to a central venous catheter for one resident who was admitted for ongoing IV antibiotic therapy after an infected right knee replacement. The resident had a PICC line in the right upper extremity for ceftriaxone sodium 2 grams IV daily. Facility policies for PICC care, dressing changes, and maintaining patency of vascular access devices did not include measures the facility would implement in the resident’s plan of care to ensure highest practicable care, such as emergency kit/procedures, staff competencies, or limb restrictions. The Director of Nursing confirmed that no licensed staff competencies had been completed related to PICC lines and that there was no policy for implementing and documenting all care interventions necessary for PICC line use. The resident stated that staff used the IV access site in her right bicep area to administer antibiotics and that she reminded staff not to use her right arm for blood pressure checks as needed. Observation confirmed IV tubing in the right bicep area, but there was no signage or other indication in the room or on the resident to restrict use of the right arm. A unit manager/infection preventionist confirmed there was no indication of limb restriction in the room or on the resident, then obtained a laminated sign to post above the bed. The resident’s record showed a physician order for right arm limb restrictions entered after surveyor questioning, and the care plan initially developed for IV medication and PICC line use did not include right arm restriction until after that point.
Smoking Materials Not Secured and Resident Smoked Outside Designated Area
Penalty
Summary
The facility failed to ensure an environment free from potential accident hazards for one resident regarding smoking. The facility policy stated smoking was only permitted in posted designated areas and prohibited elsewhere, but it did not specify where smoking materials were to be stored when not in use. The resident’s smoking agreement stated that smoking and lighting materials would be kept in a designated area and not in the resident’s possession, labeled and identified by resident, and collected and returned to the appropriate location at the end of the smoking period. The resident’s clinical record showed a smoking assessment indicating nursing staff determined the resident could continue smoking without incident and that the facility would store her lighter and cigarettes. During interview, the resident stated she knew she was to smoke in the designated outdoor smoking area. However, she also reported she always had her cigarettes and lighter with her and did not return them to the appropriate location. Observation showed the resident smoking on the concrete next to a red brick pillar rather than in the designated smoking area. Later interview confirmed her cigarettes and lighter were in her purse attached to her rolling walker and not at the nursing station. The NHA and DON confirmed these findings.
Failure to Follow Ordered Supplemental Oxygen Flow
Penalty
Summary
The facility failed to implement supplemental oxygen administration according to the physician’s order for one resident reviewed for oxygen concerns. Resident 120 was observed in his room with oxygen via a concentrator set at 2 liters per minute on April 21, 2026, and later observed with the concentrator set at 1.5 liters per minute on April 23, 2026. The active physician’s order dated April 7, 2026, directed staff to administer supplemental oxygen continuously at 3 liters per minute every shift, and there were no orders allowing staff to titrate the flow lower. Review of the resident’s care plan showed no entries related to supplemental oxygen use until April 21, 2026. An LPN confirmed the order required 3 liters per minute and stated she had not obtained the resident’s vital signs, including oxygen saturation, as of the interview. The DON was informed of these concerns during the survey.
Failure to Offer and Document COVID-19 Immunizations
Penalty
Summary
The facility failed to offer, provide education regarding the benefits, risks, and potential side effects of, or administer a COVID-19 immunization for two of five residents reviewed for immunizations. The deficiency was identified during review of select facility policies and procedures, clinical records, and staff interview, and involved Residents 30 and 36. Resident 30 was admitted on May 19, 2022, and his immunization history showed he had not received a COVID vaccine since July 23, 2024. His clinical record contained no additional information showing that the facility offered or administered a COVID immunization after that date. Resident 36 was admitted on July 9, 2021, and her immunization history showed she refused a COVID vaccine on June 30, 2022. Her clinical record contained no additional information showing that the facility offered her a COVID vaccine or provided education regarding the benefits, risks, and potential side effects after that refusal. The infection preventionist confirmed these findings during interview.
Failure to Investigate Injury of Unknown Origin and Alleged Misappropriation of Property
Penalty
Summary
The facility failed to follow its abuse, neglect, and injury-of-unknown-origin policies when a resident developed significant bruising to the left arm and when an allegation of stolen prescription glasses was made. The facility’s policies required immediate notification of the Nursing Home Administrator and DON, coordination of a thorough investigation with witness statements, interviews of all potentially involved or observing parties, assessment and documentation of injuries, and timely reporting to the state agency and law enforcement when indicated. The resident’s responsible party emailed the social worker with photos of serious bruising on the resident’s left arm and questioned its cause. Although an RN assessed the arm and noted a large bruise to the upper forearm, there was no clinical record documentation of the bruise, including size or color, and the weekly skin check for that date recorded no skin issues. Staff statements indicated the resident reported he had scratched himself and denied anyone grabbing him, and the Administrator and DON acknowledged that no thorough investigation was completed due to accepting this explanation. The facility also failed to investigate and report an allegation of potential misappropriation of the same resident’s prescription glasses. The resident’s responsible party filed a grievance stating that the resident’s prescription glasses had been stolen previously and that another pair left at the bedside was now missing, using the word “stolen,” and noting that the eyeglass case remained in the room but not the glasses. The social worker documented the grievance and the use of the term “stolen,” but there was no investigation documented in the clinical record into the potential misappropriation of property. The Administrator and DON confirmed that the facility did not complete an investigation, obtain witness statements, or notify law enforcement or the Department of Health regarding this allegation. These failures occurred despite facility policies requiring timely and thorough investigations and reporting of alleged neglect, injuries of unknown origin, and misappropriation of resident property.
Failure to Provide Ordered Oral Hygiene Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide required activities of daily living (ADL) assistance with oral hygiene to a dependent resident. Clinical record review showed that the facility admitted Resident CR2 on October 8, 2025, and the most recent MDS dated January 14, 2026, assessed the resident as dependent on staff for oral hygiene. The resident’s Kardex directed that his teeth were to be brushed twice daily. However, review of the Documentation Survey Report for January 1 through February 11, 2026, showed no documentation that staff assisted the resident with oral hygiene twice daily on 18 of 41 days reviewed, and there was no documentation indicating that staff were providing the ordered twice-daily oral hygiene assistance. These findings were discussed with the Nursing Home Administrator and DON on March 9, 2026. This deficiency was cited under 42 CFR 483.24(a)(2) for failure to provide ADL care for dependent residents and referenced a previously cited deficiency from April 4, 2025, as well as 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an injury of unknown origin for a resident who was dependent on staff for all activities of daily living. The resident was found with a discolored and swollen forehead, and later developed bruising under her left eye and on her right hand. Documentation showed that the resident stated she had fallen and was picked up off the floor, but could not recall who assisted her. A nurse aide observed bruising during a shower but did not report it immediately, only notifying the LPN after the bruising worsened the next morning. The facility's policy required immediate assessment, notification, and investigation of such injuries, including prompt reporting to the Department of Health if abuse or neglect was suspected. Despite these requirements, the facility did not ensure timely reporting or a thorough investigation to rule out neglect or prevent further injuries. The DON confirmed that staff are expected to report all injuries of unknown origin at the time of identification, but this did not occur in this case. The failure to follow policy resulted in a lack of appropriate investigation and reporting to the necessary authorities regarding the resident's injuries.
Deficiency in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and maintain the environment in a safe and sanitary condition in the main kitchen. During an observation with the dietitian, it was noted that a mobile rack holding bowls had debris and felt greasy, two floor drains contained extensive debris, and the perimeter of the grease trap in the dishwasher area had a significant build-up of food debris. Additionally, a windowsill was found with dust, a dead bug, and a discarded potato chip. In a storage room adjacent to the main kitchen, a refrigerator and freezer holding resident food items lacked documented temperature monitoring. Furthermore, there were missing documented tray line food temperatures for several dates in March 2025. The Nursing Home Administrator confirmed the absence of temperature monitoring records for the refrigerator and freezer units.
Failure to Timely Return Residents' Personal Clothing
Penalty
Summary
The facility failed to assist residents in retaining and using their personal possessions, specifically their clothing, across all three nursing units. An interview with Resident 22 revealed that she was unable to locate several pairs of pants and shirts. Observations in the facility's laundry area showed a large bin overflowing with bagged dirty personal laundry and nine large bins of clean laundry that had not been distributed to residents for at least four days. This clean laundry belonged to multiple residents, including Residents 2, 19, 22, 64, 88, 92, 106, and 121, indicating a systemic issue in the timely return of laundered clothing to residents. The observations were confirmed by Employee 3, the housekeeping supervisor, and the Nursing Home Administrator.
Failure to Assist Dependent Residents with Bathing
Penalty
Summary
The facility failed to assist dependent residents with bathing and personal hygiene, as evidenced by multiple instances of missed showers and inadequate hair washing for several residents. Resident 2 reported missing scheduled showers multiple times across January, February, and March 2025, despite requiring substantial assistance with bathing. Resident 21 was observed with disheveled and greasy hair, and records indicated he only had his hair washed a few times in February and March 2025, despite scheduled shower days. Resident 96 was also observed with unkempt hair and had several missed bath days documented, although she was dependent on staff for bathing. Resident 121's family expressed concerns about the resident's hygiene, and records showed only one bed bath was completed in March 2025, with several days marked as non-applicable without documented reasons. Resident 121 required substantial assistance for bathing, and there was no evidence of staff reapproaching after a refusal. Resident 88, who required substantial assistance, only received seven showers in three months, with several days marked as not applicable. Resident 92, dependent on staff for bathing, received only four showers in three months, with no evidence of reattempts after refusals. Resident 117, requiring partial to moderate assistance, also received only four showers since admission, with refusals documented but no reapproaches. The facility's failure to provide adequate bathing assistance for these residents was discussed with the Nursing Home Administrator and Director of Nursing, highlighting a pattern of neglect in meeting the personal hygiene needs of dependent residents.
Failure to Document Pain Levels for Pain Medication Administration
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for a resident, identified as Resident 108. The clinical record review revealed that the resident had physician orders for Oxycodone 5 mg, 2 tablets by mouth every 4 hours as needed for severe pain rated between 7 to 10. However, the medication administration record (MAR) for February and March 2025 showed that staff did not document the resident's pain level on multiple occasions when the medication was administered. This lack of documentation occurred on several dates and times, indicating a failure to adhere to the physician's orders regarding pain management. The deficiency was identified during a review of the resident's clinical records and was confirmed in an interview with the Director of Nursing. The report highlights that the staff did not administer the pain medications according to the physician-ordered pain scale levels, which is a requirement under the facility's pain management protocols. This oversight was previously cited in a survey conducted on May 23, 2024, indicating a recurring issue with the facility's compliance with pain management standards.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents, leading to deficiencies in infection prevention and control. Resident 106, who had bilateral heel pressure ulcers and was receiving wound care and antibiotic treatment, was not placed on enhanced barrier precautions. Observations revealed that there was no signage or personal protective equipment (PPE) available in the resident's room, and staff did not wear gowns during wound care activities, despite the presence of wound drainage. Resident 2, who had a urinalysis indicating ESBL in her urine and was hospitalized, did not have enhanced barrier precautions initiated upon her return to the facility. Similarly, Resident 67, who had a Foley catheter for bilateral obstructive uropathy, did not have appropriate signage or PPE available outside their room. These observations were confirmed during meetings with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to infection control policies.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and orderly environment on the 200 Nursing Unit, affecting several residents. Observations revealed multiple deficiencies: a handrail in Resident 67's bathroom was ripped off the wall, leaving six open holes in the drywall; a strong urine odor was present in the 2 East hallway; Resident 108's privacy curtain had a large yellow dried stain; the drywall near Residents 97 and 84's areas was marred and gouged; and Resident 19's fan shroud was covered in dust and debris. These issues were confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Investigate and Report Alleged Theft
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of misappropriation of resident property, specifically involving Resident 38. The policy titled 'Vulnerable Adult Abuse and Neglect Prevention' mandates that upon receiving a complaint of alleged maltreatment, the Nursing Home Administrator must be notified immediately, and an investigation coordinated by the Director of Nursing or their designee. This investigation should include obtaining witness statements and interviewing all parties involved. Additionally, the facility is required to report to the State agency within specified timeframes depending on the severity of the incident and notify law enforcement if the concern is criminal in nature. In this case, Resident 38 reported to a licensed practical nurse that $40 was missing, indicating potential theft. However, the Nursing Home Administrator, upon being informed, only completed a resident concern form and did not proceed with a full investigation, nor did they obtain witness statements, notify law enforcement, or report the incident to the Department of Health. This inaction was confirmed during an interview with the Nursing Home Administrator, highlighting a failure to adhere to the facility's established policies and procedures for handling such allegations.
Failure to Implement Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with a cardiac pacemaker. The clinical record review revealed that the resident had a medical history that included a surgically implanted cardiac pacemaker, as noted in a physician's order dated July 2, 2021. However, upon review of the resident's clinical record on April 1, 2025, it was found that no care plan had been developed to address the pacemaker or the necessary monitoring and assessment associated with it. This deficiency was confirmed by the Director of Nursing during a meeting with the Nursing Home Administrator and Director of Nursing on April 2, 2025, and again on April 3, 2025.
Failure to Implement Restorative ROM Program for a Resident
Penalty
Summary
The facility failed to provide appropriate restorative range of motion (ROM) programs for a resident, identified as Resident 64, to maintain her range of motion. Resident 64 expressed a desire to return home but was concerned about her legs not functioning properly. Despite her ability to use her arms, she had not received any therapy for about a week. Clinical records indicated that she was discontinued from occupational and physical therapy on March 8, 2025, due to limited progress and non-compliance. The occupational therapy discharge summary noted limited active ROM due to general weakness, while the physical therapy discharge summary indicated slight weakness in her bilateral extremities. Both therapy summaries concluded that no restorative program was indicated, and her prognosis to maintain her current level of functioning was excellent with consistent staff support. However, there was no documentation in Resident 64's clinical record that any restorative programs were initiated. An interview with the Nursing Home Administrator confirmed these findings, indicating a failure to implement a range of motion program for Resident 64, as required by the facility's resident care policies and nursing services regulations.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to provide timely assessments and implement interventions to maintain acceptable nutritional parameters for two residents. Resident 112 experienced a significant weight loss of 24.5 pounds over a period from November 2024 to January 2025, with no weight obtained in December 2024 and no reweight conducted after the significant weight loss was noted in January 2025. Despite the resident's diet being upgraded, there was no further monitoring or intervention for her weight loss until February 2025, when a dietitian noted the resident's significant weight loss and risk for malnutrition, yet no new interventions were initiated. The resident's weight continued to fluctuate without appropriate reweights or interventions. Resident 88 also experienced a severe weight loss of 14 pounds in March 2025, which was not assessed in a timely manner. The facility lacked a system to notify the dietitian of significant weight changes, resulting in a delay in addressing the resident's nutritional needs. The dietitian only completed a weight change note four weeks after the severe weight loss was identified. These deficiencies highlight the facility's failure to adhere to its policy for monitoring and addressing significant weight changes, leading to inadequate nutritional care for the residents.
Inadequate Respiratory Care for a Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, identified as Resident 19. Observations on multiple occasions revealed that Resident 19's oxygen nasal cannula was left lying on their bed unbagged while the oxygen concentrator was running. Additionally, the resident's nebulizer machine was found sitting on the floor in front of the oxygen concentrator, with the nebulizer tubing also lying on the floor unbagged. These observations were made on April 1, 2, and 3, 2025, and were discussed with the Director of Nursing on April 3, 2025. According to the American Association for Respiratory Care, proper cleaning of nebulizer equipment is essential to reduce infection risk, and the equipment should be rinsed, washed with soap and hot water, and stored properly after each use.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The resident was admitted on April 1, 2024, with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. A significant change Minimum Data Set Assessment conducted on December 18, 2024, confirmed the diagnosis of dementia, and the facility determined that a care plan should be developed. However, the care plan initiated on April 5, 2024, did not include individualized interventions to address the resident's dementia and cognitive loss. This deficiency was identified during a review with the Nursing Home Administrator on April 3, 2025.
Failure to Monitor Resident Refrigerator for Food Safety
Penalty
Summary
The facility failed to ensure the safe and sanitary storage and handling of personal food products brought in from outside sources for a resident on the 200 Nursing Unit. During an observation of a resident's room, it was noted that the resident had a personal refrigerator without a temperature monitoring log. Inside the refrigerator, there were several items, including a container of cottage cheese with a best by date of January 13, 2025, a gallon of sweet tea with a sell by date of January 24, 2025, and two undated Styrofoam containers. A subsequent observation revealed additional items, including an undated Styrofoam container and two applesauce containers with a use by date of March 14, 2025. The Nursing Home Administrator acknowledged that resident refrigerators should be monitored for foodborne concerns.
Unsanitary Conditions in Employee Break Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in an outside designated employee break area located on the facility grounds. During an observation on April 1, 2025, various plastic and paper products, a hairnet, wet pieces of cardboard, and several balled-up medical gloves were found discarded on the ground. Additionally, multiple cigarette butts were scattered around the perimeter, and there was a significant build-up of dead leaves. An overflowing garbage can containing a brief and a metal bucket with brown-colored water and discarded cigarette butts were also observed. These findings were reviewed with the Nursing Home Administrator and Director of Nursing on April 2, 2025.
Staffing Deficiencies in Nursing Services
Penalty
Summary
The facility failed to comply with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services staffing levels. Specifically, the facility did not maintain the required minimum number of nurse aides per resident during various shifts over a 21-day review period. During the day shift, the facility was understaffed on eight days, with the number of nurse aides falling short of the required ratio of one nurse aide per 10 residents. For example, on December 25, 2024, with a census of 118 residents, only 6 nurse aides were available, whereas 11.80 were required. The evening and overnight shifts also experienced staffing shortages. The evening shift was understaffed on 15 days, with the number of nurse aides not meeting the required ratio of one nurse aide per 11 residents. On December 25, 2024, with a census of 118 residents, only 7.20 nurse aides were available, while 10.73 were required. Similarly, the overnight shift was understaffed on 12 days, failing to meet the required ratio of one nurse aide per 15 residents. On December 25, 2024, with a census of 118 residents, only 6.40 nurse aides were available, whereas 7.87 were required. These findings were confirmed by the facility's administrator during an interview.
Plan Of Correction
Unable to retroactively correct. The facility will provide staffing to meet the ratio based on July 1, 2024 regulation change of 1 nurse aide per 10 residents on day shift, 1 nurse aide per 11 residents on evening shift, and 1 nurse aide per 15 residents on night shift. DON and RN Supervisors will be re-educated on staffing ratio minimums and the appropriate response to unplanned variations in ratio. NHA/designee during weekday daily review of nursing schedules will be discussed at the monthly QAI meeting for further review and recommendation.
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 patient day (PPD) for 18 out of the 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Administrator. Specific dates where the facility did not meet the required hours include several days in September, October, and December 2024, with PPD ranging from 2.47 to 3.19 hours, all below the mandated 3.2 hours. The deficiency was confirmed by the Administrator on December 30, 2024.
Plan Of Correction
Unable to retroactively correct. The facility will provide staffing to meet the ratio based on July 1, 2024 regulation change of 3.2 hours PPD. DON and RN Supervisors will be re-educated on staffing ratio minimums and the appropriate response to unplanned variations in ratio. NHA/designee during weekday daily review of nursing schedules will review PPD to ensure that 3.2 is met. These audits will be discussed at the monthly QAPI meeting for further review and recommendation.
Failure to Assist Residents with Daily Living Activities
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, grooming, and dressing, for residents who were dependent on staff support. Resident 1 was observed with a soiled shirt and unshaven face, despite being assessed as requiring substantial assistance for personal hygiene. The resident expressed that staff only changed his shirt on shower days and refused to assist with shaving, which he could not perform himself due to his condition. His clinical records confirmed his dependency on staff for these tasks. Similarly, other residents were not provided with their preferred bathing schedules. Resident 3, who required maximum assistance for bathing, only received two showers in the past month, with minimal documentation of refusals. Resident 5, also needing substantial assistance, received only two showers in the same period, with some days marked as not applicable without explanation. Resident 7, who preferred showers twice a week, received only one shower in the last 30 days. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to meet the residents' care needs as per their preferences and assessments.
Failure to Adhere to Physician Orders and Monitor Residents
Penalty
Summary
The facility failed to provide the highest practicable care for several residents by not adhering to physician orders regarding weights, medications, and vital signs. For Resident 3, the facility did not document daily weights as ordered and failed to notify the physician when the resident's weight fell below 320 pounds or changed significantly over short periods. This lack of documentation and communication occurred on multiple occasions, indicating a pattern of non-compliance with the physician's orders. Resident 41's care was compromised by the facility's failure to monitor and document blood sugar levels consistently. There were instances where blood sugar levels were not recorded, and when they were, the facility did not notify the physician when levels were outside the prescribed parameters. Additionally, the facility administered Lantus insulin despite orders to hold it if blood sugar levels were below 120 mg/dL, which happened on several occasions. For Resident 88, the facility did not follow the bowel management protocol, failing to offer or document the administration of PRN medications for constipation over several days. Resident 67's vital signs were not monitored as ordered after a diagnosis of hypotension, with a significant delay in taking and recording vital signs. These deficiencies were identified during a survey and discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Maintain Range of Motion for Two Residents
Penalty
Summary
The facility failed to provide services to maintain the range of motion (ROM) for two residents, identified as Residents 28 and 56. For Resident 28, the clinical record review revealed a care plan that included a restorative program to address immobility, involving ROM exercises for the bilateral lower and upper extremities, and a program to ensure the resident was out of bed for at least one hour each day. However, documentation showed that staff frequently did not complete or document these restorative tasks on multiple occasions across March, April, and May 2024. Additionally, there were frequent refusals by Resident 28 to get out of bed, but there was no documentation indicating a change in the current level of function or notification to therapy. For Resident 56, the care plan included restorative nursing for active range of motion (AROM) to maintain bilateral lower extremity strength and reduce fall risk. However, task documentation indicated that a specific employee frequently documented resident refusals of services, despite the resident's usual acceptance of staff assistance. An interview with Resident 56 revealed that she was independent with her care and did not indicate refusals of her restorative program services. The surveyor discussed these findings with the Nursing Home Administrator and Director of Nursing.
Inadequate Pain Management Practices
Penalty
Summary
The facility failed to provide appropriate pain management for four residents, as evidenced by the lack of clear guidelines for administering physician-ordered pain medications based on pain severity. For Resident 3, there were orders for both Acetaminophen and Oxycodone, but no documentation indicated which medication should be used for mild, moderate, or severe pain. Similarly, Resident 96 had orders for Acetaminophen and Morphine Sulfate, but the facility did not specify which medication to administer for different pain levels, leading to potential confusion in pain management. Resident 56's medication administration records showed instances where pain medications were given for inappropriate pain levels, such as administering Tramadol for a pain level of 0. Resident 123 also received Percocet for pain levels that did not align with the prescribed parameters. These findings indicate a systemic issue in the facility's pain management practices, where staff administered medications without adhering to the prescribed pain level guidelines, potentially compromising the residents' care.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident 93 was admitted on May 19, 2022, and later diagnosed with chronic PTSD on October 9, 2022. Despite a psychiatry note from August 23, 2022, indicating a history of premorbid PTSD, the facility did not identify the resident's history of trauma or any triggers in the care plan. There was no evidence of collaboration with the resident, their family, or healthcare professionals to develop individualized interventions. Similarly, Resident 112 was admitted on October 27, 2023, and diagnosed with PTSD on February 11, 2024. A psychiatry note from February 5, 2024, confirmed the diagnosis of chronic PTSD, yet the facility again failed to identify the resident's trauma history or triggers. The clinical record showed no collaboration with the resident, family, or mental health professionals to create personalized care strategies. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing on May 22, 2024.
Failure to Implement Person-Centered Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for two residents diagnosed with dementia, leading to a deficiency in providing appropriate treatment and services. Resident 34 was admitted with a diagnosis of dementia with agitation, and her admission Minimum Data Set Assessment indicated the need for a care plan addressing her cognitive loss. However, a review of her care plan revealed no evidence of a person-centered approach to manage her dementia, which should have included direct care and activities focused on understanding, preventing, relieving, and accommodating her distress or loss of abilities. Similarly, Resident 87, diagnosed with dementia, also lacked a person-centered care plan despite the facility's assessment indicating the necessity for one. His significant change Minimum Data Set Assessment confirmed the diagnosis, yet the care plan review showed no implementation of strategies to address his cognitive loss. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide tailored care for residents with dementia.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications, specifically concerning the administration of Ativan for anxiety. Resident 41 had a physician's order for Ativan 0.5 mg to be taken as needed every 8 hours for increased anxiety, with a stipulation to discontinue after 14 days of non-use. Despite a pharmacy recommendation on February 8, 2024, to evaluate the necessity of the medication or to implement a 14-day stop date, the PRN Ativan order continued through March, April, and May 2024. During this period, staff administered the medication 17 times without attempting non-pharmacological interventions 19 times prior to administration. The clinical record review revealed that there were two separate 14-day periods of non-use, from March 14 to April 3, 2024, and from April 13 to April 27, 2024, which should have triggered the discontinuation of the medication as per the order dated February 11, 2024. However, the medication was not discontinued, indicating a failure to adhere to the physician's order and the pharmacy's recommendation. This oversight was identified during a surveyor's review with the Nursing Home Administrator on May 22, 2024.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the main kitchen, as observed on May 20, 2024. The dry storage room floor was dirty with black marks and sticky substances, and debris such as cardboard, plastic utensils, and a coffee mate packet were found on the floor. Black dirt particles were noted on the top shelves of two food storage units, which Employee 4, a dietary cook, attributed to the air-conditioning unit, although it was not operational at the time. Additionally, the refrigerator contained undated food items, including a bag of lettuce, waffles, and sausage patties, while another refrigerator had expired cabbage and undated sandwiches and salads. Spillage and stuck cardboard were observed on the bottom shelf of a freezer. Temperature logs for the dishwasher were inaccurately recorded for lunchtime, despite the observation occurring at 8:15 AM. Furthermore, temperature logs for the refrigerators and freezers were incomplete, with no entries for the evening shift from May 14-17, 2024. These issues were discussed with Employee 4 during the observation, and the Nursing Home Administrator was informed of the concerns on May 21, 2024. The facility was previously cited for similar deficiencies on July 25, 2023, under 42 CFR 483.60(i)(2) and 28 Pa. Code 201.14 (a).
Violation of Resident's Right to Self-Determination Regarding Smoking
Penalty
Summary
The facility failed to ensure that residents could make choices about significant aspects of their lives, such as smoking, for one of the residents reviewed. The Nursing Home Administrator (NHA) stated that the facility became non-smoking for new admissions starting in April 2023, although three grandfathered residents were still allowed to smoke in a designated area. Staff were also permitted to smoke in a separate designated area on the facility property. Resident 1, who was admitted after the policy change, expressed dissatisfaction with the inability to smoke on the premises, noting that it was unfair that others, including staff and grandfathered residents, were allowed to smoke. The NHA confirmed that Resident 1 was informed of the non-smoking policy upon admission and had signed a non-smoking agreement. Despite this, Resident 1, a tobacco user, felt that the policy was inequitable. Social Services documentation indicated that the policy and the grandfathering of certain residents were explained to Resident 1, and it was noted that the resident could smoke off the facility property. The facility's actions were found to be in violation of the resident's right to self-determination and choice, as outlined in 28 Pa. Code 201.29(a) Resident rights.
Deficiencies in Cleanliness and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by observations and interviews conducted by surveyors. On two of the three nursing units, residents expressed concerns about the cleanliness of their bathrooms. Resident 56 reported a dirty toilet and a blackened floor, which was confirmed by a surveyor's observation. Similarly, Resident 60 noted that the condition of her bathroom led to her clothing becoming soiled. The surveyor observed that the room had unpainted patches and holes in the walls, indicating inadequate maintenance. Additionally, the facility did not ensure the proper functioning of medical equipment, specifically the bladder scanner, for one resident. Resident 1 had a physician's order for bladder scanning five times a day, but the equipment was found to be broken. The bladder scanner had a cracked probe and was covered in a sticky substance, rendering it non-functional. Despite repeated documentation by staff about the malfunctioning equipment, there was no evidence that the physician was informed, nor was there documentation of efforts to repair or replace the device. Interviews with the Nursing Home Administrator and Director of Nursing revealed that they were aware of the broken bladder scanner but could not provide details on when repairs were requested or any interim solutions. The facility's failure to maintain a clean environment and ensure the availability of functional medical equipment resulted in deficiencies that compromised the residents' right to a safe and comfortable living space.
Neglect Resulting in Resident Injury Due to Inaccessible Call Bell
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in injury. Resident 60 experienced a fall in her room, which led to a head laceration requiring emergency medical attention and sutures. The incident occurred after a physical therapy session conducted by Employee 2, who left the resident in a stationary chair without ensuring the call bell was within reach. This was contrary to the resident's care plan, which required staff to ensure the call light was accessible to encourage the resident to use it for assistance as needed. The resident attempted to reach the call bell, which was placed across the bed, leading to her losing balance and falling. The facility's failure to ensure the call bell was within reach and to alert nursing staff about the resident's situation contributed to the neglect. The facility's management acknowledged that only a limited number of therapy department staff were re-educated on the importance of call bell accessibility, indicating a lack of comprehensive staff education on fall prevention and adherence to care plans.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives received written notice of the facility's bed hold policy at the time of transfer to a hospital. This deficiency was identified for two residents during a clinical record review. Resident 19 was transferred to the hospital from May 13-17, 2024, without evidence of written notification of the bed hold policy being provided to him or his responsible party. Similarly, Resident 126 was transferred to the hospital on March 3, 2024, due to a change in mental status, and there was no evidence that she or her responsible party received written notification of the bed hold policy. The Nursing Home Administrator confirmed these findings during a meeting on May 23, 2024.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain vision for a resident. The resident reported that she was informed by an eye doctor last year that she needed eyeglasses, but she has not received them. She currently uses readers for close-up vision but experiences blurred vision when watching television. An optometry evaluation from June 1, 2023, indicated that bifocal glasses were ordered for the resident, with a follow-up visit recommended in six months. However, there is no documentation of the eyeglasses being delivered, a follow-up visit occurring, or the resident refusing these services. A Care Plan Note from August 28, 2023, shows the resident inquired about her glasses, and a voicemail was left to check on their status. The Nursing Home Administrator later revealed that the glasses were supposedly sent to the facility but could not be located, prompting a new order for the glasses.
Failure to Timely Address Pressure Ulcer
Penalty
Summary
The facility failed to adequately assess and implement timely interventions for a pressure ulcer on a resident's right ankle. The resident was admitted on July 9, 2021, and a skin check on January 9, 2024, revealed a red and painful ankle, but no new treatment orders were documented in the Treatment Administration Record for January 2024. The resident's pressure ulcer was assessed as a Stage 3 ulcer by wound care, measuring 0.5 cm by 0.5 cm by 0.1 cm. Despite the resident being identified as at risk for pressure ulcers in a Braden assessment on August 16, 2023, a subsequent assessment started on January 4, 2024, was not completed until January 11, 2024, after the ulcer was identified. The facility did not initiate a care plan to address the pressure ulcer until February 26, 2024, which was seven weeks after the ulcer was identified. The Director of Nursing confirmed that there was no further documentation of assessment or intervention for the pressure ulcer since January 15, 2024. The facility's policy required timely assessment and intervention for skin integrity issues, which was not adhered to in this case, leading to a deficiency in the care provided to the resident.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for a resident, identified as Resident 64. According to the facility's Weight Policy, any resident experiencing a weight change of five or more pounds should be re-weighed within 24 hours, and significant weight changes should be reviewed by a dietitian with potential interventions recommended. However, Resident 64 experienced a severe weight gain of 20 pounds (23.26 percent) between December 6, 2023, and January 3, 2024, followed by a severe weight loss of 14.2 pounds (13.25 percent) by January 16, 2024. Despite these significant fluctuations, the re-weight was not conducted until seven days after the initial severe weight gain, and there was no evidence of assessment or notification to the resident's physician or responsible party. The clinical record review revealed that Resident 64's medications did not include diuretics or appetite-enhancing medications, and the registered dietitian, identified as Employee 3, had no new recommendations at the time of the weight change note dated January 16, 2024. An interview with Employee 3 confirmed the delay in re-weighing and the lack of assessment or communication regarding the severe weight changes. This deficiency indicates a failure to adhere to the facility's policies and procedures concerning weight management and resident care, as outlined in the 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to Resident 6, who was admitted on April 1, 2024. Observations and interviews revealed that Resident 6 was visibly upset, expressing concerns about being held against his will and not being allowed to contact the local ombudsman. Despite having a BIMS score indicating only mild cognitive impairment, the resident felt imprisoned and was not informed about his rights or given the opportunity to discuss his situation with the Nursing Home Administrator, whom he had requested to see for over a month. Clinical records and staff interviews confirmed that Resident 6 was oriented and had minimal confusion, yet he was preoccupied with leaving the facility. Nursing documentation noted his repeated requests to speak with the facility's management and his threats to involve legal action or the police. Despite these concerns, there was no evidence that the facility addressed his desire to leave or explored alternative living arrangements, such as an assisted living facility. The facility also failed to verify claims made by the resident's emergency contact regarding the uninhabitability of his home. There was no documentation to suggest that a home assessment was conducted to confirm these allegations. Furthermore, the facility did not provide evidence that Resident 6 was deemed incapable of making his own decisions by a medical professional, highlighting a lack of appropriate social services to ensure his well-being.
Failure to Account for and Dispose of Medications
Penalty
Summary
The facility failed to properly account for, secure, dispose of, or return physician-ordered medications for two residents. For Resident 125, who had physician orders for Lorazepam, Morphine Sulfate, and Hyoscyamine Sulfate, there was documentation of counting the Lorazepam and Morphine medications after the resident expired. However, there was no documentation regarding the disposition or security of these controlled medications, nor was there any documentation accounting for the Hyoscyamine after the resident's death. This issue was discussed with the Director of Nursing during an interview. For Resident 126, who was admitted to the hospital and expired there, the facility failed to document the disposition of multiple medications upon her discharge from the facility. These medications included Dexamethasone, Furosemide, Gabapentin, Novolog, Cyclobenzaprine HCl, Dicyclomine HCl, Linzess, Methocarbamol, Apixaban, Breo Ellipta Inhaler, Cyanocobalamin, Empagliflozin oral, Ergocalciferol, Fluoxetine HCI, Insulin glargine, Levothyroxine, Ropinirole HCl, and Seroquel. The lack of documentation regarding the disposition of these medications was also reviewed with the Director of Nursing.
Failure to Address Pharmacy Recommendations for Medication Diagnosis
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed for a resident. The clinical record review and staff interview revealed that the pharmacist conducted monthly medication reviews for the resident and made recommendations on several occasions, specifically on October 10, 2023, November 13, 2023, January 9, 2024, and February 8, 2024. The pharmacist requested that the nursing staff correct the diagnosis for Seroquel on the medication administration record to reflect bipolar disorder, as the current diagnosis was listed as behaviors. Despite these recommendations, there was no evidence in the resident's clinical record that the facility addressed the medication regimen reviews related to the diagnosis for Seroquel. The Director of Nursing confirmed these findings during an interview on May 23, 2024.
Unsafe and Unclean Laundry Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the laundry area, as observed during a survey. During an inspection of the main laundry area, an extensive build-up of wet lint and debris was found behind the main washing machines. The debris included three discarded medical gloves, a plunger head, and a dirty blanket. This accumulation of lint and debris not only affects the performance of the dryers but also poses a potential fire hazard. The observation was made in the presence of a laundry aide and the Nursing Home Administrator.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 189 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Williamsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook South | 0 mi | ★★★★★ | 28 | 0 |
| Wecare At Sycamore Rehabilitation And Nursing Cent | 1.6 mi | ★★★★★ | 41 | 0 |
| Williamsport Home, The | 2.4 mi | ★★★★★ | 19 | 0 |
| Valley View Rehab And Nursing Center | 2.6 mi | ★★★★★ | 16 | 0 |
| Rose View Rehab And Care Center | 2.9 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.