Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Of Greenwood Hill during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of dementia-related behaviors, including verbal aggression and unsafe wandering, did not have an individualized care plan that addressed her specific needs. Despite ongoing documentation of escalating behaviors and safety risks, the facility relied on generic interventions such as room changes and redirection, without revising the care plan to include dementia-specific strategies or environmental modifications. The facility also lacked a documented Dementia Care Program or policy, and staff education on dementia care was not translated into individualized care planning or consistent implementation.
The facility failed to protect a resident from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
Surveyors found that multi-dose vials of Tuberculin in two medication rooms were either not dated upon opening or not discarded within the required 30-day period, contrary to facility policy and manufacturer guidelines. Staff interviews confirmed that these procedures were not followed, resulting in improper medication storage and labeling.
A resident with major depressive disorder was not referred for a required PASRR Level II evaluation after a suicide attempt, psychiatric hospitalization, and readmission, despite a significant change in condition and newly evident serious mental health issues. Staff and record reviews confirmed the facility did not initiate the necessary referral process.
A resident with diabetes and severe cognitive impairment experienced a low blood glucose event, but did not receive prompt carbohydrate treatment as required by protocol. Documentation also showed that the RN supervisor and physician were not notified of the hypoglycemic episode until after the resident had a fall and was found lethargic.
Two residents did not have fully developed or implemented care plans to address their individualized needs. One resident with severe cognitive impairment and language barriers lacked communication interventions and updated fall and elopement prevention strategies in the care plan. Another resident with significant mobility deficits had care plan interventions for bed mobility that were not reflected in the Kardex or communicated to direct care staff, resulting in a lack of implementation.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors. These lapses resulted in a deficiency related to environmental safety and resident supervision.
The facility did not provide required written notifications, including the specific reason for transfer, to several residents and their representatives when initiating transfers to a hospital. Documentation was lacking, and notifications were not given in a manner understandable to the residents or their representatives.
Multiple residents with various medical conditions experienced significant delays in staff response to call lights, often waiting from 20 minutes to several hours for assistance with needs such as toileting, pain medication, and incontinence care. These delays occurred across all shifts and led to discomfort, distress, and residents sometimes attempting unsafe self-care. The facility's policy requires prompt responses, but this standard was not met, as confirmed by resident interviews and grievance reviews.
A resident at Edenbrook of Greenwood Hill was sexually abused by a nurse aide, which was witnessed by another staff member. The resident, who was cognitively intact, confirmed the abuse had been ongoing for a month. The facility failed to prevent and detect the abuse, leading to Immediate Jeopardy.
The facility's administration failed to prevent the sexual abuse of a resident due to inadequate use of resources and non-fulfillment of essential job duties by the NHA and DON. The facility did not implement effective policies to prevent abuse and failed to investigate and report alleged violations properly.
The facility's abuse prohibition policy lacks specific procedures for identifying and investigating abuse, including guidance on recognizing different types of abuse and handling evidence in sexual abuse cases. The policy does not provide staff with clear instructions, increasing the risk of incomplete investigations and failure to protect residents.
A facility failed to conduct a thorough investigation into an alleged sexual abuse incident involving a resident and a nurse aide. The resident, who was cognitively intact, confirmed the incident and previous similar interactions. The investigation was incomplete as it did not include interviews with all potential witnesses or involved staff members present during the incident.
The facility failed to provide adequate activities for residents, with complaints about limited evening options and lack of variety. Two residents did not have personalized activity plans or documented participation, despite their specific needs and preferences. The NHA confirmed the deficiency.
The facility failed to provide necessary dental services for two residents. One resident, with multiple sclerosis, did not receive assistance in obtaining recommended dentures until a survey inquiry. Another resident, with paraplegia, reported a missing lower denture, but the facility did not investigate or document the issue. These actions resulted in deficiencies under federal dental service guidelines.
The facility failed to provide consistent evening snacks to residents, despite a policy requiring snacks if the time between dinner and breakfast exceeds 14 hours. Eight cognitively intact residents reported not receiving snacks, citing shortages and staff not distributing them. The NHA could not explain the discrepancy, confirming the policy to offer snacks.
The facility failed to maintain sanitary food storage and service practices, increasing the risk of food-borne illness. Observations revealed thawed nutritional shakes without thaw or discard dates, uncovered and undated canned fruit cocktail, and food products stored directly on the floor. Additionally, a buildup of pink-colored slime was found on the ice machine's condensation hose. These unsanitary conditions were confirmed by the facility's registered dietitian and nursing home administrator.
A resident was observed smoking on facility grounds despite the facility's Non-Smoking Policy. The resident's care plan acknowledged their smoking habit but lacked specific details for safe smoking. The resident signed out for a leave of absence, retrieved smoking materials from the nurse's station, and smoked across the street without staff presence. Facility management was aware but failed to enforce the policy.
A resident with newly diagnosed schizophrenia and narcissistic personality disorder was not referred for a PASRR Level II evaluation. Despite the need for one-to-one supervision due to uncontrolled psychosis, the facility failed to report the resident's mental health conditions to the state's mental health authority.
A resident with dysphagia and a gastrostomy tube had a PEG-Tube dislodged due to the facility's failure to ensure the use of an abdominal binder as per the care plan. The binder was found on the bedside table, and the resident required hospital transfer for tube reinsertion. The DON confirmed the incident but lacked documentation of effective binder implementation.
A resident with a history of dysphagia, hypertension, and dementia received unnecessary antibiotics after a fall. The emergency room suspected a UTI and prescribed antibiotics, but the urine culture to confirm the infection was not completed. Despite no symptoms or lab confirmation, the resident received 14 doses of Bactrim DS. The DON confirmed the administration was unjustified.
The facility failed to notify the State Long-Term Care Ombudsman of resident transfers to hospitals, as required by regulations. Despite providing written notices to residents and their representatives, there was no evidence of notification to the Ombudsman for five residents transferred between March and September 2024. The Nursing Home Administrator confirmed this lapse, which had been ongoing since October 2020.
The facility did not ensure the Department of Health's survey results were accessible to residents and visitors in two nursing units. Residents were unaware of the survey results' location, and observations showed the results were either blocked or not posted. The NHA acknowledged the facility's responsibility to provide access.
Failure to Individualize and Revise Dementia Care Plan for Resident with Escalating Behaviors
Penalty
Summary
The facility failed to develop, revise, and consistently implement an individualized, person-centered care plan to address dementia-related behaviors for a resident with a history of cerebral infarct and alcohol-induced persisting dementia. The resident was moderately cognitively impaired and exhibited a sustained pattern of escalating behaviors, including verbal aggression, resistance to care, unsafe wandering, and entering other residents' rooms. The care plan included only broad and generic interventions, lacking specific, actionable strategies tailored to the resident's repeated aggressive behaviors and safety risks. Despite documentation over several months showing the resident ambulating independently during episodes of agitation, being verbally abusive, and having conflicts with roommates and visitors, the care plan was not revised to address these ongoing issues. Interventions primarily consisted of room changes, redirection, and brief calming measures, without evidence of meaningful updates to include dementia-specific strategies, environmental modifications, or structured interventions. Nursing documentation repeatedly noted the resident's inability to be redirected and disruptive behaviors affecting other residents and staff. The facility was unable to provide a Dementia Care Program or policy during the survey, and although staff education materials on dementia care were available, there was no evidence that this education was translated into individualized care planning or consistent implementation for the resident. Interviews with facility leadership confirmed the failure to revise and implement an effective care plan to address the resident's documented dementia-related behaviors.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Properly Label and Discard Multi-Dose Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of multi-dose medications in accordance with its own policy and manufacturer guidelines. During an observation of the second-floor medication room, a multi-dose vial of Tuberculin was found in the medication refrigerator that had been opened and dated July 2, 2025, but had not been discarded within the required 30 days, remaining available for use 36 days past the recommended discard date. The manufacturer’s instructions specify that vials in use for more than 30 days should be discarded, and this was confirmed by a Registered Nurse Unit Manager at the time of observation. Additionally, in the third-floor medication room, another multi-dose vial of Tuberculin was found opened and available for use, but it was not dated when opened, making it impossible to determine if it was within the safe usage period. An LPN confirmed the vial was opened and not dated. Interviews with the Nursing Home Administrator and DON confirmed that facility policy requires medications to be dated upon opening and removed upon expiration, but these procedures were not followed in these instances.
Failure to Refer Resident for PASRR Level II Evaluation After Psychiatric Hospitalization
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental health issues for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. The resident, who had a diagnosis of major depressive disorder, was admitted to the facility and subsequently experienced a suicide attempt, leading to transfer to a community emergency department and involuntary commitment to a psychiatric hospital for evaluation and stabilization. Upon readmission to the facility, there was no documented evidence that the facility initiated a PASRR Level II referral through the state mental health authority, despite the resident's significant change in condition and emergence of serious maladaptive behaviors. Staff interviews and clinical record reviews confirmed that the facility did not communicate the need for a PASRR Level II evaluation following the resident's psychiatric hospitalization and readmission. This omission was acknowledged by the Nursing Home Administrator, who confirmed that the required referral was not made after the resident's suicide attempt and subsequent return to the facility.
Failure to Provide Timely Hypoglycemia Management and Notification
Penalty
Summary
The facility failed to provide person-centered care and adhere to professional standards of practice for diabetes management for one resident with severe cognitive impairment and a diagnosis of diabetes. The resident had physician orders for insulin administration based on blood glucose levels, with specific instructions to notify the physician and RN supervisor if blood glucose was less than 70 mg/dL, and to treat hypoglycemia promptly with 15 to 20 grams of fast-acting carbohydrates. On the date in question, the resident's blood glucose was recorded at 54 mg/dL, and the scheduled insulin dose was held as per orders. Despite the low blood glucose reading, there was no documented evidence that the resident received orange juice or any other carbohydrate in a timely manner as required by the hypoglycemic protocol. Additionally, there was no documentation that the RN supervisor or physician were notified of the hypoglycemic event until after the resident experienced a fall from their wheelchair and was found to be lethargic but responsive. The lack of timely intervention and notification was confirmed by the Nursing Home Administrator, and the documentation did not reflect adherence to the facility's policy or physician orders regarding hypoglycemia management.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to fully develop, revise, and implement person-centered comprehensive care plans for two residents. For one resident with dementia and diabetes, who was severely cognitively impaired and primarily Spanish-speaking, the care plan did not include interventions for effective communication, despite staff acknowledging the need for Spanish-speaking support or an interpreter. Additionally, after the resident experienced a fall and was identified as high risk for both falls and elopement, the care plan was not updated to reflect new treatment goals or interventions for fall prevention or wandering risk. For another resident with cerebral palsy, quadriplegia, and significant mobility deficits, the care plan specified the need for two staff members to assist with repositioning and turning in bed. However, this intervention was not reflected in the Kardex system used by nurse aides, and there was no documentation that direct care staff were informed of the requirement for two caregivers for safe bed mobility. The Nursing Home Administrator was unable to provide evidence that these care plan interventions were communicated to staff, resulting in a lack of implementation of the resident's individualized care needs.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Written Transfer Notifications to Residents and Representatives
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding facility-initiated transfers to a community hospital. Specifically, for five residents, the facility did not document or deliver written notices that included the specific reason for each transfer. The notifications were either missing the required information or were not provided in a language and manner understandable to the resident or their representative. This was identified through a review of clinical records, transfer notification forms, and staff interviews. For each of the five residents reviewed, the transfer notification forms did not specify the reason for the transfer in writing, nor was there evidence that the notifications were communicated in an understandable way. During an interview, the nursing home administrator was unable to provide documentation that these notifications had been given as required. The deficiency was cited under 28 Pa. Code 201.14(a) for failure to meet the responsibility of the licensee regarding required notifications.
Failure to Respond Timely to Resident Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes each resident's quality of life by not responding promptly to residents' requests for assistance, as required by facility policy. Multiple residents reported significant delays in staff response after activating their call lights, with wait times frequently ranging from 20 minutes to over an hour, and in some cases, up to four hours. These delays were corroborated by resident interviews and a review of grievances filed with the facility. The facility's policy mandates prompt and courteous responses to call lights, but this standard was not met according to the residents' accounts. Several residents with varying medical conditions, including heart failure, major depressive disorder, agoraphobia, diabetes, morbid obesity, COPD, acute respiratory failure, and peripheral vascular disease, described repeated experiences of waiting extended periods for assistance. For example, one resident reported waiting over four hours for help, often when requesting pain medication, while another resident described being left on the toilet for over an hour, resulting in discomfort and pain. Another resident stated that she frequently soiled herself due to long waits for bathroom assistance, and a grievance documented a two-hour wait for toileting help. Delays were reported across all shifts, with particular issues noted during the night shift. Residents also expressed frustration and distress due to these delays, with some resorting to self-transfer to avoid soiling themselves, despite recognizing the safety risks. The Nursing Home Administrator confirmed that all residents should be treated with dignity and respect and receive timely care but was unable to explain the cause of the untimely staff responses. The findings were based on clinical record reviews, facility policy, grievances, and resident and staff interviews.
Sexual Abuse by Staff Member at LTC Facility
Penalty
Summary
Edenbrook of Greenwood Hill was found to be non-compliant with federal and state regulations following an incident involving sexual abuse of a resident by a facility staff member. The deficiency was identified during an abbreviated complaint survey, which revealed that a nurse aide, Employee 3, engaged in sexual acts with a resident, Resident 1, who was cognitively intact. The incident was witnessed by another staff member, Employee 1, who reported seeing Employee 3 receiving oral sex from Resident 1. This incident was not isolated, as further investigation revealed that Employee 3 had engaged in similar inappropriate conduct with Resident 1 over the course of a month. The facility's failure to prevent, identify, and respond appropriately to the sexual abuse placed Resident 1 and all other residents at risk for further harm. Despite having an abuse prevention policy in place, the facility did not detect the ongoing abuse, which was only brought to light when Employee 1 witnessed the act and reported it. Interviews with staff and the resident confirmed the occurrence of prior sexual encounters initiated by Employee 3, which went unnoticed by the facility's management. The deficiency was classified as Immediate Jeopardy due to the facility's inability to protect residents from abuse by staff members. The report highlights the facility's lack of effective monitoring and intervention, which allowed the abuse to continue undetected. The Immediate Jeopardy was identified on February 13, 2025, following the incident on February 9, 2025, when the sexual act was observed.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator, if possible safely, until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education will include that while alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. Directed in-servicing will be completed for licensed nurses to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. A random sampling of residents (BIMS 12 and above) interviews to determine if any abuse occurred and if appropriate steps were followed. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.
Removal Plan
- An internal investigation was immediately initiated.
- The employee who left the resident with the perpetrator was suspended.
- The accused perpetrator was removed from the facility.
- The nursing agency was notified of the alleged accusation towards their employee.
- The abuse policy will be reviewed and revised.
- The facility staff will be educated on the abuse policy and procedure, protecting resident safety which includes remaining with the resident, and guidelines on preserving an investigative scene. Further no staff will be permitted to work until this education has been completed.
- The facility immediately completed resident interviews with those residents with BIMS of 12 and above to determine if any other residents were affected.
- The facility assessed residents with BIMS under 12 for signs of abuse.
- The QAPI Committee will reconvene to review the root cause of the noncompliance.
- The NHA or designee will take a random sampling of residents and interview them to determine if any abuse has occurred and if appropriate steps were followed. Further, a random sampling of employee interviews will be completed to ensure they know how to identify and respond to abuse. These audits will occur daily until further direction.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility's administration failed to effectively utilize its resources to ensure the safety and well-being of its residents, resulting in the sexual abuse of one resident. The investigation revealed that the nursing home administrator (NHA) and the director of nursing (DON) did not fulfill their essential job duties, which include ensuring resident safety and adherence to regulatory guidelines. The job descriptions for both the NHA and DON emphasize the importance of managing safety, responding to resident concerns, and preventing abuse, neglect, and exploitation. However, these responsibilities were not adequately executed, leading to the cited deficiencies. The deficiencies were identified under the Code of Federal Regulatory Groups for Long Term Care, specifically related to the Freedom from Abuse, Neglect, and Exploitation. The facility failed to develop and implement effective policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Additionally, there was a lack of evidence that alleged violations were thoroughly investigated, and measures were not taken to prevent further potential abuse while investigations were in progress. The failure to report the results of investigations to the appropriate authorities within the required timeframe further highlights the administration's shortcomings in maintaining resident safety.
Plan Of Correction
1. Accused perpetrator suspended. Employee who left resident to obtain assistance suspended. Investigation completed. Nursing agency was notified. Abuse policy reviewed and revised. The facility staff educated on the Abuse Policy protecting the resident's safety which includes remaining with the resident, guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The NHA and DON will be educated by the Regional Director of Operations or designee on their job descriptions. The NHA and DON will participate in the directed education to include a review of the federal regulation citation F600 and the accompanying guidelines for these regulatory requirements. 4. The Regional Director of Operations or designee will review facility incidents weekly for 12 weeks to ensure compliance and report findings to the facility QAPI Committee.
Inadequate Abuse Policy and Investigation Procedures
Penalty
Summary
The facility failed to fully develop and implement an abuse prohibition policy that includes specific procedures for identifying and investigating abuse. The existing policy, titled "Abuse and Neglect Prevention," outlines the facility's commitment to providing care in an environment free from abuse, neglect, mistreatment, or exploitation. However, the policy lacks detailed guidance on recognizing different types of abuse, such as mental/verbal, sexual, physical abuse, and deprivation of goods and services. This omission leaves staff without clear procedures to identify abuse, neglect, and exploitation of residents, and misappropriation of resident property. Additionally, the facility's policy on investigating allegations of abuse is incomplete. While it requires immediate notification of the administrator and removal of implicated staff from resident care areas, it does not include procedures for handling evidence in cases of sexual abuse. The policy fails to instruct staff on preserving evidence, such as avoiding washing linens or clothing, destroying documentation, or bathing the resident before a forensic examination. This lack of guidance could interfere with thorough investigations by the facility and external authorities. An interview with the Nursing Home Administrator confirmed these deficiencies, highlighting the risk of incomplete investigations and failure to protect residents from further harm.
Plan Of Correction
1. The Abuse Policy was reviewed and updated, including guidelines on preserving an investigation scene. 2. The facility immediately completed interviews with those residents BIMS 12 and over to determine if any other residents were affected by this deficient practice. The facility assessed residents with BIMS under 12 for signs of abuse. 3. The facility staff will be educated on the appropriate abuse procedure including remaining with the resident involved in a potential abuse investigation, secluding/observing the alleged perpetrator if possible safely until police arrive, and preserving an investigation scene including materials and victim for potential testing. Education includes that while the alleged perpetrator is onsite, escort the alleged perpetrator to the nursing supervisor office or lobby area to wait and be available to be interviewed when the police arrive. 4. A random sampling of staff will be interviewed to validate knowledge of Abuse Policy and preserving an investigation scene. Audits will occur daily for 7 days, weekly x 12 weeks with results reported to QAPI for further review.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough and complete investigation into an alleged incident of sexual abuse involving a resident and a nurse aide. The incident was reported by another nurse aide who witnessed inappropriate sexual conduct between the resident and the implicated staff member. The resident, who was cognitively intact, later confirmed the occurrence of the incident and previous similar interactions with the staff member. Despite these serious allegations, the facility's investigation was incomplete as it did not include interviews or statements from all staff members present during the incident. The resident involved in the incident was admitted to the facility with chronic obstructive pulmonary disease, type 2 diabetes, and muscle wasting. A recent assessment indicated that the resident was cognitively intact, with a BIMs score of 15. The incident was reported when a nurse aide observed the staff member engaging in inappropriate conduct with the resident. The resident later confirmed the incident and previous similar interactions with the staff member, indicating a pattern of inappropriate behavior. The facility's investigation was found lacking as it did not include interviews with all potential witnesses or involved staff members, such as the LPN and RN Supervisor who were present on the unit during the incident. This omission left gaps in the investigation, failing to provide a complete account of the events and staff awareness of the interactions between the resident and the implicated staff member. The facility's failure to conduct a thorough investigation was confirmed by the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Investigation completed. 2. The NHA or designee will review abuse investigations within the last 30 days to validate abuse investigations are completed timely. 3. The Regional Director of Operations will educate the NHA on timely completion of investigations, investigation process, preservation of evidence. The NHA will educate the IDT on the timely and accurate completion of abuse investigations. 4. The NHA or designee will audit abuse investigations weekly for 12 weeks to ensure investigations are completed timely and report findings to the QAPI committee.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide adequate and ongoing activities tailored to meet the needs, interests, preferences, and functional and cognitive abilities of its residents. During a group interview, several alert and oriented residents expressed dissatisfaction with the limited variety and availability of evening activities. Specific complaints included the lack of engaging options beyond Bible study, a desire for more frequent bingo sessions, and a broader variety of activities, including arts and crafts and outdoor options. A review of the activity calendar confirmed that evening activities were limited, with a reduction planned for the following month. Additionally, the facility did not adequately address the activity needs of two specific residents. Resident 31, who is cognitively intact and has a preference for independent activities, reported not having a current activity calendar and no recent visits from the activities department. His care plan indicated a preference for activities such as watching the news, being outdoors, and playing cards, but there was no documented evidence of his participation in activities or room visits. Similarly, Resident 95, who is severely cognitively impaired, had no documented activity assessment or care plan to meet her needs, nor evidence of participation in activities. The Nursing Home Administrator confirmed the lack of an ongoing program of activities for these residents.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for two residents, leading to deficiencies in their care. Resident 92, who has multiple sclerosis and is cognitively intact, had a dental consultation in June 2024 recommending full upper dentures. Despite this recommendation, the facility did not assist the resident in obtaining the dentures until inquiries were made during the survey. The resident expressed frustration over the lack of assistance, and the facility's Nursing Home Administrator confirmed the responsibility to ensure residents receive dental care but could not provide evidence of follow-up actions until the survey. Resident 31, who has paraplegia and is also cognitively intact, reported a missing lower denture, which staff were aware of. The resident had received a full lower denture in April 2024, but there was no documentation indicating the facility identified or investigated the missing denture. The resident's care plan noted non-compliance with proper denture care, but the facility did not follow its policy to determine responsibility for the replacement of the denture. The facility's failure to assist Resident 92 with obtaining dentures and to investigate the missing denture for Resident 31 resulted in deficiencies under federal guidelines for dental services. The facility did not provide necessary follow-up or documentation to support their actions, leading to a lack of appropriate dental care for these residents.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, as evidenced by a review of scheduled facility mealtimes, facility policy, and resident and staff interviews. The facility's policy, last reviewed on September 26, 2024, mandates that all residents, unless NPO, should be offered a bedtime snack if the time between the evening meal and breakfast exceeds 14 hours. This snack should include items from at least two food groups, one of which provides protein. However, the scheduled mealtimes revealed that the time between dinner and breakfast does exceed 14 hours, yet residents reported not consistently receiving the required snacks. During a group interview, eight cognitively intact residents expressed that they were not consistently offered a nourishing evening snack, citing that the facility often runs out of snacks and staff do not always distribute them. The Nursing Home Administrator was unable to explain why the facility was not offering the snacks as per policy, despite confirming that it is the facility's policy to do so. This deficiency was noted under 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain acceptable food storage and service practices, which increased the risk of food-borne illness in three of four resident pantries. During an initial tour of the kitchen, it was observed that 40 four-ounce thawed nutritional shakes were stored in the refrigerator without a thaw or discard date, contrary to manufacturer instructions that required consumption within 14 days of thawing. Additionally, five sheet trays containing servings of canned fruit cocktail were found uncovered and undated in the refrigerator. Furthermore, six cases of assorted food products were improperly stored directly on the floor in the dry storage room. These practices were confirmed as unsanitary by the facility's registered dietitian. Further observations in the resident pantries revealed additional deficiencies. In the Third-Floor resident pantry refrigerator, two four-ounce thawed nutritional shakes were found without a thaw or discard date. Similarly, the Second-Floor resident pantry refrigerator contained one four-ounce thawed nutritional shake without a thaw or discard date. On the First-Floor, the end of the condensation hose from the ice machine had a heavy buildup of pink-colored slime, indicating unsanitary conditions. The nursing home administrator confirmed that sanitary practices for food and ice storage should be maintained in the resident pantries.
Failure to Enforce Non-Smoking Policy
Penalty
Summary
The facility failed to implement its established Non-Smoking Facility Policy, which mandates a smoke-free environment for residents, staff, and visitors. Despite the policy, a resident, identified as Resident 100, was observed smoking on facility grounds. The resident's care plan acknowledged their smoking habit but lacked details on the location of smoking materials, specific times for smoking, or any necessary equipment for safe smoking. Additionally, the resident was noncompliant with the facility's smoking policy, and the last smoking assessment was outdated, having been completed in February 2024. During the survey, it was observed that Resident 100 signed out for a leave of absence without staff presence, retrieved a crossbody bag containing cigarettes and a lighter from the nurse's station, and proceeded to smoke across the street from the facility. The facility's management, including the Nursing Home Administrator and the Director of Nursing, were aware of the resident's actions but failed to provide documented evidence that the Non-Smoking Facility Policy was enforced. This oversight was confirmed during interviews with the facility's management.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental disorders for a Preadmission Screening and Resident Review (PASRR) Level II evaluation. Resident 114, who was initially screened negative for serious mental illness, was later diagnosed with schizophrenia and narcissistic personality disorder. Despite these diagnoses, there was no documented evidence of the facility reporting these conditions to the state's mental health authority for a PASRR Level II evaluation. The deficiency was identified through a review of clinical records and staff interviews. A psychiatric consultation note revealed that Resident 114's psychosis was not under control, requiring one-to-one supervision. The Director of Social Services admitted to not reporting the resident's mental health diagnoses, and the Nursing Home Administrator confirmed the facility's responsibility to ensure referrals for PASRR Level II evaluations for residents with newly evident serious mental disorders.
Failure to Implement Abdominal Binder Leads to PEG-Tube Dislodgement
Penalty
Summary
The facility failed to provide necessary care to prevent complications with a gastric feeding tube for a resident diagnosed with dysphagia and a gastrostomy tube. The resident had a physician's order for Jevity 1.5 Enteral Liquid to be administered via PEG-Tube at a rate of 68 ml/hr, with a water flush of 50 ml every hour during the pump infusion. The resident's care plan included the use of an abdominal binder to prevent the tube from being dislodged, along with frequent skin checks due to the resident's tactile response to the PEG placement. An investigation report revealed that nurse aides found the resident's g-tube dislodged, with the balloon intact, and the abdominal binder was found on the bedside table instead of being worn by the resident. The resident was sent to the hospital for reinsertion of the PEG tube. The director of nursing confirmed the incident but failed to provide documented evidence that the facility effectively implemented the use of the abdominal binder to prevent the dislodgement of the PEG-tube.
Unnecessary Antibiotic Administration Due to Lack of Confirmation
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotic medication. Resident 88, who had a history of dysphagia, hypertension, and dementia, was admitted to the facility after a fall. During an emergency room visit, a slight urinary tract infection was suspected, and antibiotics were prescribed. However, the urine culture results, which were supposed to confirm the infection, were not available in the resident's clinical record. The facility's Infection Preventionist confirmed that the urine culture and sensitivity report was not completed as indicated in the emergency room record. Despite the lack of evidence confirming a urinary tract infection, Resident 88 received 14 doses of Bactrim DS, an antibiotic, over a period of seven days. The Director of Nursing later confirmed that the administration of the antibiotic was not clinically justified due to the absence of symptoms or laboratory confirmation of a urinary tract infection. This oversight led to the unnecessary administration of antibiotics, violating the regulations that require a resident's drug regimen to be free from unnecessary medications.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to comply with regulatory requirements regarding the notification of facility-initiated transfers. Specifically, the facility did not provide copies of written notices of transfers to a representative of the Office of the State Long-Term Care Ombudsman for five residents who were transferred to hospitals. These residents were transferred on various dates between March and September 2024, and although they received written notices, there was no documented evidence that the Ombudsman was notified as required. An interview with the Nursing Home Administrator confirmed that there was no evidence of such notifications being sent to the Ombudsman since October 1, 2020. This oversight was identified during a review of clinical records, facility-initiated transfer notices, and staff interviews, highlighting a systemic failure to adhere to the notification requirements set forth by the regulations.
Inaccessible Survey Results
Penalty
Summary
The facility failed to ensure that the Department of Health's most recent survey results were readily accessible to residents and visitors in two out of three nursing units. During a resident council interview, alert and oriented residents indicated they were unaware of where the survey results were posted. An observation in Unit 2 revealed that the survey results binder was blocked by a medication cart, and the binder did not contain the most recent survey from August 2024. In Unit 3, the survey results were not posted or accessible without staff assistance. The Nursing Home Administrator confirmed the facility's responsibility to make these results accessible.
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 223 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pottsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schuylkill Center | 0.8 mi | ★★★★★ | 16 | 0 |
| Gardens At York Terrace, The | 2.2 mi | ★★★★★ | 0 | 0 |
| Green Valley Skilled Nursing And Rehabilitation Ce | 2.3 mi | ★★★★★ | 11 | 0 |
| Rosewood Rehabilitation And Nursing Center | 3.2 mi | ★★★★★ | 1 | 0 |
| Seton Manor Nursing And Rehabilitation Center | 4.3 mi | ★★★★★ | 6 | 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.