Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 South during CMS and state inspections, most recent first.
Unsafe food storage and kitchen sanitation deficiencies: Surveyors observed multiple unlabeled and undated food and drink items in kitchen refrigerators, a dirty garbage lid, sanitizer stored in an unlabeled cup, a leaking dishwasher booster box, and other sanitation issues in the main kitchen. Surveyors also found a resident's Osmolite tube feeding formula stored in a box directly on the floor in the resident's room.
Housekeeping and maintenance services were inadequate in multiple resident rooms and a common lounge area. Surveyors observed chipped and marred doors, loose dirt, dust, debris in light covers, a stained ceiling tile from a prior roof leak, and a room with an active leak dripping into bins and leaving wet items on the floor. Some room fixtures were also damaged, including loose drawer handles and deteriorating cove base.
A resident with cerebral palsy, epilepsy, an extrapyramidal movement disorder, and severe cognitive impairment was documented as using a trunk restraint daily, but the record lacked a physician order and plan of care for the restraint. Family reported staff used the wheelchair seat belt/harness during feeding, and the NHA and DON confirmed monthly assessments and other required documentation were missing until after surveyor questioning.
The facility failed to provide the highest practicable care for a resident with reddened, flaky facial skin and for another resident whose chart showed a current order for enteral feedings despite a POLST and progress note indicating he did not want artificial nutrition or hydration by tube. The resident stated he did not want his tube feeding, while the record documented preferences for DNR and limited interventions, including no tube feeding.
Failure to complete annual nurse aide performance evaluations. Review of personnel records found no documented evidence that annual EPRs were completed for three nurse aides reviewed. The last evaluations on file for two nurse aides were in December 2024, and the last evaluation on file for one nurse aide was in November 2024. The NHA and DON confirmed the evaluations were not completed annually.
Unsecured and expired medications were found on multiple nursing units. A resident had an expired Normal Saline Solution container on a bedside stand, and an LPN cart contained several loose, unidentified pills and tablets. In addition, a medication cart and a treatment cart were observed unattended and unlocked in hallway areas, and staff confirmed both carts should have been locked when left unattended.
A resident who went out for dialysis three days a week was taking Renvela with her, but the facility had no documented self-administration screen or physician order authorizing self-administration at the time of survey review. The screen and order were completed only after surveyor questioning, and the DON/NHA confirmed the resident had not been assessed before then.
Failure to protect confidential resident information: Survey binders were posted in the main lobby and on North Hall containing full survey letters and deficiency documents with resident identifiers, including names and specific identifiers for two residents. In addition, an LPN was observed discarding an empty medication card with a resident’s name and dosing instructions into a trash receptacle on a med cart instead of securing the identifying information.
The facility failed to notify the Office of the State LTC Ombudsman when three residents were transferred to the hospital. Documentation was absent for multiple hospital transfers involving two residents with repeated transfers and one resident with a single transfer, and the NHA and DON confirmed the missing notifications during interview.
MDS assessments did not accurately reflect the cognitive status of three residents. One resident had Section C coded as not assessed despite a later BIMS of 15 and being alert and oriented, another had multiple Section C items coded not assessed despite a later BIMS of 13 and no noticeable cognitive deficits, and a third resident’s admission MDS also showed Section C not assessed even though the resident was alert and oriented. The NHA confirmed the Section C assessor had gone on leave and the facility did not realize the assessments were incomplete until after the ARD had passed.
Incomplete PTSD Care Plan: A resident with PTSD related to childhood sexual trauma had a care plan with general goals to remain comfortable and safe and avoid crisis episodes, but it lacked individualized interventions for comfort and did not define what a crisis episode looked like or how staff should respond. The plan only listed discussing anger and staying in contact with friends and family, and the issue was reviewed with the NHA and DON.
Failure to provide ADL assistance for a dependent resident by not arranging a requested haircut. The resident was observed with long, disheveled hair and repeatedly stated he wanted his hair cut. The NHA and DON could not explain the delay, and social service documentation showed the resident said yes when asked about a haircut, with no evidence the facility offered it or that he refused.
A resident with a G-tube was observed receiving continuous tube feeding while lying flat in bed on two occasions, despite a physician order to keep the HOB elevated during feeding and for one hour afterward. Facility policy also required HOB elevation during continuous tube feeding and after completion of the feed.
Respiratory care equipment for one resident was observed on a bedside table in an unsanitary condition, with a nebulizer mask showing a white film and dried liquid in the medicine cup, alongside food debris and a used spoon. Another resident with COPD and chronic respiratory failure with hypoxia was ordered continuous O2 at 2 LPM by nasal cannula, but was observed receiving 3 LPM and later 1 LPM instead of the ordered flow rate.
The facility failed to document that an LPN and RN staff had the competencies needed to care for a resident with a wound vac. A resident admitted with a sacral wound had an order for wound vac therapy using black foam at 125 mmhg, but the facility could not provide competency records for four nurses involved in the resident’s care. The NHA and DON confirmed there was no documentation showing these staff had the required wound vac skills.
Failure to Provide Ordered Lorazepam: A resident with bipolar disorder, psychotic disorder with hallucinations, anxiety, and vascular dementia with agitation did not receive ordered Lorazepam gel because the medication was unavailable. The MAR and progress notes showed missed doses while staff documented waiting on pharmacy delivery and contacting the pharmacy, and the pharmacy record showed the refill had only been sent for eight doses and was not reordered again until after multiple missed doses.
Medication administration errors on the North unit resulted in an error rate above 5%. An LPN crushed an ER potassium tablet instead of preparing it as ordered, and the same LPN administered house stock calcium/vitamin D tablets to two residents even though the Vitamin D content did not match the physician orders.
Failure to follow contact precautions for a resident with c-diff. A resident admitted from the hospital with a c-diff diagnosis had an order for contact precautions, but a laundry aide entered the room to put away laundry and an LPN entered to give meds while both wore gloves only and did not don gowns, despite the facility policy requiring gloves and gowns for contact precautions.
Insufficient Annual In-Service Training for Nurse Aide: The facility failed to ensure that one nurse aide received the required 12 hours of annual in-service education. Records showed the aide completed only 3.35 hours in the last year, and the DON and NHA confirmed they could not provide additional documentation showing the required training had been completed.
A facility failed to develop and maintain policy and procedures for monthly medication regimen reviews that included time frames for key steps in the process. The policy required the consultant pharmacist to review each resident’s medication regimen monthly and communicate findings in writing, but it did not specify when the pharmacist must complete the report, notify the DON of urgent irregularities, communicate with the physician, obtain physician response, or when the DON must review the report.
Improper Garbage and Refuse Disposal: The facility failed to properly contain and dispose of garbage and refuse. During an observation with the Dietary Director, a trash dumpster was overflowing with bagged garbage and had a partially open lid, another dumpster lid was open with trash visible, and the recycling dumpster was overflowing with cardboard. Debris, including paper towels, empty boxes, medical gloves, wood shards, an empty beverage can, and paper products, was also observed on the ground near the dumpsters.
A nurse aide, without proper credentials, administered medications and performed medical treatments—including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change—for three residents. These actions were facilitated by an LPN, in violation of professional standards and state regulations requiring specialized training for such tasks.
A resident with schizoaffective disorder did not receive prescribed Ingrezza on multiple occasions because the facility failed to obtain the medication from its pharmacy, instead relying on the resident's family to supply it. Nursing staff documented repeated missed doses and lack of medication availability, with no evidence that the pharmacy was contacted to resolve the issue.
A resident experienced a deficiency in bowel management care due to the facility's failure to adhere to the established protocol. The resident did not have a bowel movement for an extended period, and there was no evidence that prescribed PRN medications were offered. Documentation gaps and a lack of adherence to the protocol led to the resident seeking medical attention independently, resulting in hospital visits for fecal disimpaction and further evaluations.
A resident experienced significant weight loss, but the facility failed to implement necessary interventions or notify the physician. The registered dietitian was aware of the weight loss but did not assess or address the issue, violating the facility's policy on monitoring and intervening in cases of undesirable weight changes.
The facility's main kitchen failed to meet food safety standards, with undated bulk containers, soiled potholders, and dust and debris on equipment and floors. A cooler had rusted shelves, and ceiling vents and tiles were dusty. Food temperatures were not recorded for breakfast meals on two consecutive days. These issues were discussed with the Nursing Home Administrator and DON.
The facility failed to provide consistent ADL care for two residents, one with dementia and another dependent on staff for bathing. Documentation showed infrequent bathing, refusals without re-approach, and lack of hair cleansing. Observations revealed poor grooming, and care plans lacked interventions for refusals. These issues were discussed with the DON.
The facility failed to provide necessary services to maintain or improve ROM and mobility for three residents. A resident had a therapy referral for daily ROM exercises, but the program was delayed and inconsistently documented. Another resident with impairments had a ROM program established but not initiated until a month later, and a splint brace program was also delayed. A third resident's ROM program was never started, as confirmed by the DON. These issues were previously cited, indicating a recurring problem.
The facility failed to document the competencies of four nursing staff members, including RNs and LPNs, in essential care tasks such as enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified through a review of facility documentation and staff interviews, affecting the care of residents with specific medical needs.
The facility failed to maintain and address pharmacy recommendations for three residents. For one resident, a pharmacist's review note indicated a completed medication review, but there was no evidence of the pharmacist's report or physician's response. Similarly, for another resident, a medication review was completed, but no documentation of recommendations or responses was found. These deficiencies were previously cited earlier in the year.
The facility failed to manage psychotropic medications appropriately for two residents. One resident's Cymbalta dosage was not reduced as recommended by a consultant pharmacist, and another resident received multiple PRN orders for Ativan without proper evaluations or documentation. The facility did not ensure non-medicinal interventions were attempted before administering PRN Ativan, leading to deficiencies in medication management.
The facility failed to follow proper infection control practices during medication administration and a dressing change. An LPN handled medications with bare hands, and a nurse did not use enhanced barrier precautions or maintain a clean field during a dressing change for a resident with a pressure ulcer. These actions were confirmed by staff interviews, indicating a breach in infection prevention protocols.
A resident's dignity was compromised when their catheter bag was observed full, uncovered, and on the floor on two occasions while they were sleeping. This issue was previously cited, indicating a recurring problem with maintaining proper care standards.
The facility failed to maintain a clean and safe environment, with observations of unclean enteral feeding pumps for two residents and persistent strong urine odors in several rooms. Additionally, one resident's room had disorganized items and broken furniture, while another had a damaged wall. These issues were discussed with the Nursing Home Administrator and DON.
A facility failed to thoroughly investigate an injury of unknown origin for a resident with a bruise on the face. The resident was known to be combative during care, but the investigation lacked witness statements and evidence of staff education on managing such behavior. This deficiency was previously cited, indicating a repeated failure to comply with regulations.
A facility failed to ensure accurate assessments for a resident, as a quarterly MDS inaccurately indicated the resident received an anticoagulant medication. Clinical records showed no evidence of such medication being administered during the assessment period. The DON confirmed the MDS was coded in error.
A facility failed to provide the highest practical care for a resident by not implementing a physician's recommendations for hand therapy and warm soaks, despite the resident's complaints of a 'cold hand' and a specialist's advice. The resident had seen a plastic surgeon who noted improvement with exercise and recommended further treatment, which was not documented or implemented until questioned by a surveyor.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy and BiPAP for sleep apnea. The resident's oxygen concentrator was set at 9 LPM without humidification, contrary to the physician's order of 5 LPM. Additionally, the BiPAP mask was improperly stored, increasing infection risk. This deficiency was discussed with the DON.
A facility failed to secure treatments in a resident's room, where open bottles of Dakin's solution and Derma wound cleanser were found on the windowsill. These antiseptics, which should be kept out of reach of children, were improperly stored, as confirmed by the Nursing Home Administrator and DON. This was a repeat deficiency from a previous citation.
The facility failed to follow CDC guidelines for TB screening of newly hired health care personnel. Two newly hired nurse aides did not receive the required pre-employment TB screening, despite providing evidence of prior negative TB tests within 12 months. This deficiency highlights a lapse in the facility's adherence to recommended TB screening procedures.
The facility did not meet the required nurse aide-to-resident ratios during both day and night shifts on multiple occasions. During the day shift, the facility was understaffed on two days, with fewer nurse aides than required for the resident census. Similarly, during the night shift, the facility failed to provide the necessary number of nurse aides on three separate days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day on three occasions. The nursing staff care hours were below the required threshold, with specific deficiencies noted on three days. The Nursing Home Administrator confirmed the shortfall in meeting the regulatory daily hours PPD.
The facility failed to provide adequate assistance with activities of daily living for three residents. A resident requiring supervision for personal hygiene did not receive shaving assistance as scheduled. Another resident with urinary incontinence had lapses in documented oral care and toileting assistance. A third resident, needing help with bathing and oral care, was observed with overgrown fingernails and missed scheduled care. These deficiencies were discussed with the DON and Nursing Home Administrator.
The facility failed to consistently implement restorative programs for two residents with mobility deficits. One resident expressed concerns about walking and was discharged from physical therapy without a restorative program, while another required assistance due to poor balance. Documentation revealed frequent failures to provide and document the required restorative ambulation programs, as confirmed by staff interviews.
A resident reported dissatisfaction with meals, receiving food she is allergic to and dislikes, despite communicating preferences. Staff failed to address meal discrepancies, and the food service director acknowledged mismatched menu tickets, indicating systemic issues in meal planning.
The facility was found to have multiple deficiencies in maintaining a clean and homelike environment across four nursing units. Observations included moisture-related spots on vents, dust accumulation, slimy substances on drip trays, and dead insects in various areas. These issues were noted in dining rooms, nurse stations, hallways, and resident areas, indicating a widespread problem with cleanliness and maintenance.
A resident was prescribed Temozolomide, a cancer medication, without a proper diagnosis or indication for its use. Despite not having a history of cancer or radiation treatments, the medication was ordered and administered for the duration of radiation therapy. The oversight was confirmed by interviews with the facility's administration and medical staff.
The facility failed to investigate and report an allegation of mental abuse involving a resident. Employee 1 was reported to have used her phone inappropriately, potentially taking and sharing photos or videos of residents. Despite a witness statement supporting this claim, the facility did not obtain further statements or notify relevant agencies, violating policy and regulatory requirements.
A facility failed to provide necessary bathing assistance to a dependent resident, as documented in the April 2024 report. The resident, assessed as dependent on staff for bathing, did not receive documented bed baths on three occasions. This deficiency was reviewed with the Nursing Home Administrator.
A resident was administered Temozolomide, a cancer medication, without an appropriate diagnosis. Despite multiple reviews by CRNPs, the medication was not flagged as inappropriate. The facility failed to provide evidence of a medical evaluation before ordering the medication.
Unsafe food storage and kitchen sanitation deficiencies
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the main kitchen. During an initial tour with the Dietary Director, a hand-washing sink was observed starting to detach from the wall, a section of wall behind the dishwasher had flaking paint, and a temperature booster box for the dishwasher was leaking water from underneath the unit. In the kitchen refrigerators, surveyors observed a pitcher of brown liquid and a yellowish liquid that were not labeled, an unreadable facility date on the yellowish liquid, a garbage receptacle lid with extensive dried stains and food debris, an unlabeled plastic cup containing sanitizer for the kitchen thermometer, a small stainless-steel pan with tin foil and no dates or labels, a container identified as diced peppers with no labels or dates, multiple small glasses of liquid drinks that were not labeled or dated, and multiple unlabeled small plastic containers containing cooked eggs. The facility also failed to store a resident's tube feeding formula in a safe and sanitary location on North Hall Nursing Unit. Observation of the resident's room on multiple occasions showed a box stored directly on the floor containing six containers of Osmolite tube feeding formula. The Nursing Home Administrator and DON confirmed that, to prevent potential contamination, the tube feeding formula should not be stored directly on the floor.
Housekeeping and Maintenance Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on three of four nursing units, affecting residents in multiple rooms and common areas. In Resident 2's room, surveyors observed a chipped bathroom door frame, a chipped bathroom door near the bottom corner, a scrape on the inside room door, loose dirt behind the door, and a dirty floor with tracked dirt from the doorway to the bed. In Resident 29's room, loose dirt and pieces of paper were on the floor, and the first and third dresser drawer handles were hanging down on one side, which the resident said had been that way for a while. In Resident 85's room, dust and dirt were noted near the entrance, the cove base was coming off in the corner, and the door had chips of wood near the bottom. Additional observations showed environmental concerns in shared and occupied spaces. In the resident lounge on the East Hall unit, four ceiling lights had a significant accumulation of debris in the protective covers. In Resident 8's room, a large brown stain was observed on a ceiling tile above the recliner, and the resident stated it was from a previous roof leak. In Resident 9's room, the resident reported a roof leak that had started about a week earlier and had slowed from a waterfall to a trickle; surveyors observed a large wheeled garbage bin placed under an exposed pipe dripping into it, with the bin nearly full of clear liquid, two additional trash bins partially filled with clear liquid, and a wet towel on the floor that had dried and yellowed. These conditions were observed repeatedly and discussed with facility leadership.
Missing restraint documentation for a resident using a wheelchair harness and seatbelt
Penalty
Summary
The facility failed to obtain appropriate documentation for a device used as a physical restraint for one resident with cerebral palsy. The facility policy stated that physical restraints are only to be used appropriately to treat a resident’s medical symptoms, that an adaptive equipment assessment should be completed if a device may limit freedom of movement, and that if the device is found to be limiting movement, a restraint assessment, physician order, informed consent/education, care plan update, and restraint review are required. For the resident reviewed, the clinical record showed use of a trunk restraint daily on multiple MDS assessments, and the record also included a restraint use assessment for a harness and seatbelt in the wheelchair. The assessment noted the resident was at significant risk of serious or fatal injury if a fall occurred out of the chair due to cerebral palsy, epilepsy, an extrapyramidal movement disorder, and severe cognitive impairment. Interview with the resident’s family revealed staff used the seat belt/harness restraint when feeding the resident, with the wheelchair upright during feeding and tilted/reclined when the resident was seated in the hallway. Review of the clinical record showed there was no physician order or plan of care addressing the restraint, and the facility had no documentation of monthly assessments until after surveyor questioning. The Nursing Home Administrator and DON confirmed there was no documentation of monthly assessments, a physician order, or a plan of care addressing the restraint until after surveyor questioning.
Failure to Follow Resident Preferences for Skin Care and Tube Feeding
Penalty
Summary
The facility failed to provide the highest practicable care for Resident 3 related to skin condition. On observation, the resident’s cheeks and forehead were reddened, and white flaking skin was noted on the forehead, cheeks, and eyebrows, with many white flakes also seen around the collar of the resident’s shirt. A clinical record review identified a medical progress note stating the resident had some dried skin on the face, but no further documentation could be identified regarding the dry skin. The facility also failed to provide the highest practicable care for Resident 11 related to advance care planning. The resident was observed in bed sleeping with a tube feeding hung at the bedside, and the resident later stated that he did not want his tube feeding. The clinical record showed a current physician order for enteral feedings, while the resident’s POLST indicated he did not want artificial hydration or nutrition, including artificial nutrition by tube. The POLST was updated to continue reflecting no hydration and artificial nutrition by tube, and a physician assistant progress note documented that the resident requested DNR status with limited additional interventions, including no antibiotics, hydration, or artificial nutrition by tube.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed. Employee 1 had a hire date of September 21, 2022, Employee 2 had a hire date of May 1, 2019, and Employee 3 had a hire date of September 29, 2021. Review of the employee personnel records found no documented evidence that annual performance evaluations were completed for Employees 1, 2, and 3. The last performance evaluations on file for Employees 1 and 3 were December 5, 2024, and the last performance evaluation on file for Employee 2 was November 20, 2024. During an interview on February 10, 2026, at 2:23 PM, the NHA and DON confirmed that performance evaluations were not completed annually for the three nurse aides reviewed.
Unsecured and Unlabeled Medications Found on Nursing Units
Penalty
Summary
Drugs and biologicals were not secured and stored in accordance with accepted professional principles on multiple nursing units. On the North nursing unit, Resident 11 had a container of Normal Saline Solution on the bedside stand with an expiration date of February 19, 2022, observed in the resident’s room on February 8, February 9, and February 10, 2026. The finding was reviewed with the Nursing Home Administrator and DON on February 10, 2026. Additional observations showed unsecured medications and treatment supplies in facility carts. On February 11, 2026, the North nursing unit medication cart contained several unsecured and unidentified medications in the bottom of two drawers, including multiple loose pills and tablets of different colors and shapes. On February 8, 2026, the [NAME] nursing unit medication cart was observed parked in the hallway near the nursing station, unattended and unlocked, and the surveyor was able to open it and access resident medications while residents were ambulating nearby. On February 9, 2026, the North nursing unit treatment cart was also observed parked in the hallway, unattended and unlocked, and the surveyor was able to access resident medicated treatments and medical supplies. Staff interviews confirmed both carts should have been locked before being left unattended.
Failure to Assess Self-Administration of Dialysis Medication
Penalty
Summary
The facility failed to determine whether Resident 22 was capable of self-administering medication before allowing the resident to take Renvela with her when she left the facility for dialysis. The resident was admitted on January 5, 2026, and had physician orders for dialysis Monday, Wednesday, and Friday with a chair time of 11:00 AM, transportation by step van, and lunch provided by dietary. She also had an order for Renvela 800 mg, three tablets by mouth three times a day, initiated on January 8, 2026. During interview, Resident 22 stated that she went out of the facility to dialysis three days a week and took her lunch and a large white pill with her to dialysis. Review of the clinical record showed no evidence of a Self-Administration Screen or physician order authorizing Resident 22 to self-administer Renvela at the time of surveyor review. The facility did not complete the Self-Administration Screen until after surveyor questioning, and the order for Resident 22 to self-administer Renvela on dialysis days was also obtained only after surveyor questioning. The Nursing Home Administrator confirmed that Resident 22 was not assessed to self-administer her medication until after surveyor questioning.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to ensure residents’ rights to secure confidential personal and medical information in the main lobby, on the North Hall Nursing Unit, and for three residents reviewed. In the main lobby and in the hallway in front of Nurse Station 1 on North Hall, a facility binder titled Pennsylvania Department of Health Survey Book was observed containing recent survey results and plans of correction. Review of the binder contents showed full health survey letters and complaint deficiency letters, including a deficiency letter and Statement of Deficiencies from a February 16, 2024 survey that listed the full names and specific resident identifiers for Residents 11 and 60. The issue also involved medication disposal on North Hall. During a medication pass, a medication cart had a trash receptacle attached to the side containing an empty medication card with a prescription label for Resident 53. The label included the resident’s name and dosing instructions for mycophenolate mofetil oral capsules. An LPN stated that the resident identifiers should not have been thrown into regular trash and that they should be torn off and placed in the shredder bin near the nurse station. The facility was cited for failing to protect the privacy of personal and medical information for Residents 11, 53, and 60.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when three residents were transferred to the hospital. Resident 3 was sent to the hospital on November 5, 2025, December 13, 2025, and January 30, 2026, but there was no documented evidence that the Ombudsman was notified for any of those transfers. Resident 6 was transferred to the hospital from December 23, 2025 to December 26, 2025, and there was no documented evidence of Ombudsman notification for that transfer. Resident 36 was transferred to the hospital on November 6, 2025, and November 22, 2025, and there was no documented evidence that the Ombudsman was notified for either transfer. The Nursing Home Administrator and DON confirmed these findings during interview on February 11, 2026.
MDS Cognitive Assessments Were Not Completed Accurately
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ cognitive status for 3 of 19 residents reviewed. For Resident 29, a quarterly MDS dated January 9, 2026 documented Section C cognitive patterns with dashes, indicating the resident was not assessed for cognition, even though another quarterly MDS showed no cognitive impairment with a BIMS score of 15. The resident was interviewed on February 9, 2026 and was observed to be alert and oriented with no noticeable cognitive deficits. The NHA confirmed the resident was cognitively intact and stated the social service director responsible for Section C had gone on leave, and the facility did not realize the assessment was incomplete until after the assessment reference date had passed, so the resident was coded as not assessed. For Resident 70, a quarterly MDS and a Discharge Return Anticipated MDS documented multiple Section C items as not assessed, while a later quarterly MDS showed a BIMS score of 13. The resident was interviewed and found to be alert, with no noticeable cognitive deficits and appropriate responses. For Resident 22, an admission MDS documented Section C cognitive patterns with dashes, indicating the resident was not assessed for cognitive status, although the resident was interviewed and found to be alert and oriented with no noticeable cognitive deficits. The NHA and DON reviewed these findings and confirmed the assessments were not completed as required because the staff member responsible for Section C had gone on leave and the facility did not realize the assessments were incomplete until after the assessment reference dates had passed.
Incomplete PTSD Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for Resident 9 related to a diagnosis of PTSD. Resident 9 told the surveyor that he had been diagnosed with PTSD related to childhood sexual trauma, and the clinical record showed the PTSD diagnosis dated March 8, 2025. Review of the current comprehensive plan of care showed only two goals, that the resident would remain comfortable and safe in his environment and would not have episodes of crisis, with two interventions listed: discussing feelings of anger with the resident and maintaining contact with friends and family. The care plan did not describe individualized interventions to help the resident remain comfortable in his environment, and it did not define what an episode of crisis would look like for the resident or how staff should address such episodes to achieve the stated goals. This information was reviewed with the Nursing Home Administrator and DON.
Failure to Provide Requested Hair Care Assistance
Penalty
Summary
The facility failed to provide ADL assistance for a dependent resident by not ensuring he received a haircut despite repeated indications that he wanted one. During observation, the resident was found sleeping in bed with hair that appeared long, shoulder length, and disheveled. In separate interviews, the resident stated that he wished to have his hair cut and later repeated that desire, saying he was not sure why it was taking so long. The Nursing Home Administrator and DON were informed of the findings and were unable to explain why the resident had not received a haircut for an extended period. Social service documentation later recorded that the social worker asked the resident if he would like a haircut and he said yes, and there was no evidence that the facility offered the haircut or that the resident refused it.
Improper positioning during tube feeding
Penalty
Summary
Appropriate treatment and services were not provided for a resident who was receiving nutrition through a G-tube. Facility policy for continuous tube feeding stated that the head of the bed should be elevated at least 30 degrees during feeding and for 30 to 60 minutes after feeding unless contraindicated. However, observation of the resident showed the feeding pump actively administering feed while the resident was in bed with the bed in a flat position. A second observation the following day again showed the feeding pump actively administering feed through the resident’s feeding tube while the resident was in bed with the bed in a flat position. The resident had a physician’s order dated March 3, 2024, directing that the head of bed be elevated while the tube feed was running and for one hour after the feed was completed every shift for prevention of aspiration. The findings were reviewed with the Nursing Home Administrator and the DON.
Respiratory Care Equipment Not Kept Sanitary and Oxygen Not Given as Ordered
Penalty
Summary
Respiratory care equipment was not stored in a sanitary manner for one resident. Observation of the resident’s bedside table on February 8, 2026, showed a nebulizer machine with attached tubing and a nebulizer mask with a medicine cup on the table. The mask appeared to be coated in a slightly opaque white film, and dried droplets of liquid were noted inside the medicine cup. A repeat observation on February 9, 2026, again showed the nebulizer machine with tubing and mask on the bedside table, with the mask still appearing coated in a slightly opaque white film and droplets of liquid inside the medicine cup. The same bedside table also had food debris/crumbs, a dried drop of red liquid, and a spoon that appeared to have been previously used. For another resident, the facility did not provide respiratory care consistent with the physician’s order. The resident was admitted with COPD, and chronic respiratory failure with hypoxia was added to the clinical record on April 25, 2025. A physician’s order initiated on July 1, 2024 directed staff to administer continuous oxygen at 2 LPM by nasal cannula. However, observations on February 8, 2026 showed the resident receiving oxygen at 3 LPM, and an observation on February 10, 2026 showed the resident receiving oxygen at 1 LPM.
Inadequate Nursing Competency for Wound Vac Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to care for a resident with a wound vac. Resident 3 was admitted on November 20, 2025, and later had a physician order dated January 13, 2026, directing nursing staff to apply a wound vac to the sacral wound using black foam and a setting of 125 mmhg. When surveyors requested nursing competencies related to the resident’s wound vac care, the facility was unable to provide any competency documentation for Employees 4 and 5, who were LPNs, or Employees 6 and 7, who were RNs. The Nursing Home Administrator and DON reviewed the findings on February 11, 2026, and confirmed there was no documentation showing that these four employees had specific competencies and skill sets to care for the resident’s wound vac needs.
Failure to Provide Ordered Lorazepam
Penalty
Summary
The facility failed to obtain and provide physician-ordered medication for one resident with bipolar disorder, psychotic disorder with hallucinations, restlessness and agitation, generalized anxiety disorder, and vascular dementia with agitation. The resident was admitted on June 16, 2017, and her December 2025 MAR showed an order for Lorazepam 0.5 mg/ml gel, 1 ml topically twice daily. The MAR documented missed doses on December 25 and 26 at 8:00 AM and 8:00 PM, and on December 27 at 8:00 AM because the medication was not available. Progress notes documented that the Lorazepam gel was unavailable and that staff were awaiting pharmacy delivery, with repeated notes indicating the medication had not arrived and pharmacy would be contacted. A pharmacy order status report showed the medication was reordered on December 15, 2025, but only enough for eight doses was sent, and it was not reordered again until December 27 after the resident missed five doses. Pharmacy communication confirmed the refill request was received after hours on December 27 and that the medication was then filled and shipped. The DON and NHA confirmed the information during interview.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate below five percent on the North Nursing Unit, with a reported error rate of 11.54 percent based on 26 medication opportunities and three medication errors. During observation of Resident 75’s medication administration, an LPN crushed an ordered Potassium Chloride ER 20 mEq tablet and placed it in pudding with other crushed medications, even though the physician order directed that the tablet be dissolved in a small amount of fluid for slurry. The medication was not prepared as ordered. Resident 75 also had an order for Calcium 600 plus D plus Minerals chewable tablets, but an LPN prepared and administered a house stock Calcium 600 plus Vit D3 medication that contained Calcium 600 mg and Vitamin D 5 mcg, which did not match the ordered concentration. The same LPN later prepared and administered the same house stock Calcium 600 plus Vit D3 medication to Resident 94, whose order specified Calcium 600 plus D plus minerals 600-400 mg-unit twice daily; the house stock medication contained 200 units of Vitamin D rather than the ordered 400 units. The LPN confirmed that the Vitamin D dose in the house stock medication did not match the physician order for Resident 94.
Failure to Follow Contact Precautions
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection for one resident who was on contact precautions for Clostridioides difficile (c-diff). The facility policy for Isolation Precautions stated that residents suspected or confirmed to have a communicable disease transmitted by direct or indirect contact should be placed on contact precautions, with gloves and gown worn prior to entering the room and during direct care. Resident 22 was admitted on January 5, 2026, and had a physician order for contact precautions for c-diff initiated the same day. The resident reported that she came to the facility from the hospital due to c-diff. Observation of Resident 22 showed Employee 11, a laundry aide, entering the room to put away the resident’s laundry while wearing gloves but not a gown. A later observation showed Employee 10, an LPN, entering the room to administer medications while also wearing gloves but not a gown. The findings were reviewed with the NHA and DON, who confirmed that staff are to wear gloves and gowns when entering a resident’s room on contact precautions.
Insufficient Annual In-Service Training for Nurse Aide
Penalty
Summary
The facility failed to ensure that each nurse aide received 12 hours of in-service training annually for one of three nurse aides reviewed, Employee 1. Employee 1 was hired on September 21, 2022, and a review of her personnel and education records showed that she completed only 3.35 hours of in-service education in the last year. During an interview on February 9, 2026, the surveyor requested Employee 1's training records from the Nursing Home Administrator and the Director of Nursing, and the facility later provided records on February 10, 2026 confirming the limited training hours. On February 11, 2026, the Director of Nursing and the Nursing Home Administrator confirmed the findings and were unable to provide any additional documentation showing that Employee 1 had received the required 12 hours of annual in-service training.
Medication Regimen Review Policy Lacked Required Time Frames
Penalty
Summary
The facility failed to develop and maintain policies and procedures for monthly medication regimen reviews that included specific time frames for the different steps in the process. A review of the facility policy titled, Medication Regimen Review, showed that the consultant pharmacist was to review each resident’s medication regimen at least monthly and communicate findings and recommendations in writing on a medication regimen review report, but the policy did not specify when those written findings were to be completed. The policy also did not include time frames for the pharmacist to contact the DON or designee when irregularities required immediate action, for the pharmacist to communicate irregularities to the physician, for physician response, or for the DON or designee to review the medication regimen report. The deficiency was reviewed with the NHA on February 10, 2026, at 10:05 AM.
Improper Garbage and Refuse Disposal
Penalty
Summary
The facility failed to properly contain and dispose of garbage and refuse. During observation of the main dumpsters outside near the rear of the building with the Dietary Director, a trash dumpster was found with bagged garbage overflowing and a lid partially ajar because of the excess trash, and another dumpster lid was open with bagged trash visible. Debris was observed on the ground, including multiple paper towels, three empty oatmeal creme pie boxes, at least two medical gloves, wood shards, an empty beverage can, and paper products adjacent to the dumpsters. A recycling dumpster was also overflowing with cardboard, and a large construction dumpster had paper trash visible near its perimeter. The deficiency was reviewed with the NHA and DON.
Unlicensed Staff Administered Medications and Treatments
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three residents. On a specific date, a nurse aide (NA) administered prescribed medications and performed medical treatments, including oral, PEG tube, and subcutaneous medication administration, as well as a dressing change, for three residents. These actions were performed on behalf of a licensed practical nurse (LPN), who was aware of and facilitated the NA's involvement in medication administration and treatment procedures. The NA's actions included administering oral medications and subcutaneous insulin to one resident, administering medications via PEG tube and subcutaneous insulin to another, and completing a dressing change on a surgical site for a third resident. Pennsylvania regulations require specialized training and credentialing for medication administration, which the NA did not possess. Resident interviews and facility documentation confirmed that the NA performed these tasks, and the LPN acknowledged facilitating the NA's actions. The incident was discovered and reported to the Director of Nursing (DON) several days later. The facility's failure to ensure that only appropriately licensed and credentialed staff administered medications and performed medical treatments resulted in a breach of professional standards of quality for the affected residents.
Failure to Provide Prescribed Medication Due to Pharmacy Service Lapse
Penalty
Summary
The facility failed to obtain and provide a prescribed medication, Ingrezza, for a resident with a history of schizoaffective disorder. Upon admission, the resident's hospital discharge records indicated the need to continue Ingrezza 40 mg nightly. However, nursing documentation showed that the pharmacy did not supply the medication, and instead, the resident's sister was expected to bring it in. There was no documentation explaining why the pharmacy was not contacted or able to provide the medication, and the Ingrezza was the only medication not obtained through the facility's pharmacy. Review of the Medication Administration Record (MAR) revealed that nursing staff did not administer the resident's nightly Ingrezza on multiple occasions, documenting that the medication was not available from the pharmacy or not found in the medication cart. Further nursing notes indicated ongoing communication with the resident's sister regarding the medication, but no evidence was found that the pharmacy was contacted to resolve the issue. These findings were confirmed by a registered nurse during an interview.
Failure in Bowel Management Protocol
Penalty
Summary
The facility failed to provide the highest practical care related to bowel management for a resident, as evidenced by the lack of adherence to the established bowel management protocol. The protocol required the administration of Milk of Magnesia, Dulcolax suppository, and Fleet's enema in a sequential manner if the resident did not have a bowel movement over several days. However, documentation revealed that the resident did not have a bowel movement for an extended period, and there was no evidence that the prescribed PRN medications were offered or refused by the resident. Additionally, there was a gap in documentation from February 1 to 5, 2025, due to a transition in facility ownership, which contributed to the oversight in the resident's care. The resident experienced significant discomfort and sought medical attention independently, resulting in a hospital visit where fecal disimpaction was performed. The resident's condition was further complicated by rectal bleeding and abdominal pain, leading to additional hospital evaluations. The facility's failure to follow the bowel management protocol and adequately document the resident's bowel movements resulted in a deficiency in providing the highest practical care, as confirmed by interviews with facility staff and a review of the resident's clinical records.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to implement necessary interventions to maintain acceptable nutritional parameters for a resident, identified as Resident 1, who experienced significant weight loss. According to the facility's policy, a significant weight change is defined as a 5 percent change over 30 days, 7.5 percent over 90 days, or 10 percent over 180 days. Resident 1 was admitted on June 21, 2024, and experienced a severe weight loss of 8.04 percent in 30 days and 12.71 percent in less than 90 days. Despite these significant changes, there was no evidence that the staff obtained a re-weight or notified the resident's physician, nor were there any assessments or interventions documented to address the severe weight loss. The registered dietitian, identified as Employee 1, confirmed awareness of the resident's weight loss but admitted to waiting for weight verifications and did not assess or implement interventions to address the issue. The facility's policy requires cooperation between nursing staff and the dietitian to monitor and intervene in cases of undesirable weight variances, but this protocol was not followed. The lack of action and communication regarding the resident's significant weight loss constitutes a deficiency in the facility's care practices.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, as observed during a survey. Two large bulk containers labeled as 'flour' and 'sugar' lacked dates indicating when the products were placed or needed to be used by. Additionally, several white potholders were found on top of the convection oven, soiled with dried foods and significantly stained. The bottom shelf of the steamer and prep table, as well as the lower shelf of the production table, contained dust and dried food debris. The flooring under and behind the steamer and the table beside it had dried food and debris buildup, with a pipe area caked with dried food and debris. Further observations revealed that a two-door cooler had multiple shelves with exposed rust-colored metal due to worn-off protective coating. Ceiling vents and tiles over the coolers and serving line were covered in dust, with one tile significantly stained and drooping. The plate warming unit had dried food splatter and debris. The food serving temperature log for January 21 and 20, 2025, showed no recorded temperatures for breakfast meals, indicating a failure to check food temperatures. A follow-up observation on January 23, 2025, found potholders on the convection oven blackened and covered in dried food. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Bulk containers and soiled potholders were removed from service, with the contents of the containers discarded. Shelves in the steamer and prep areas were immediately cleaned, along with the floor and pipes in the steamer area. Cooler shelves were replaced, ceiling tiles were changed, and vents were thoroughly cleaned. Additionally, the plate warmer underwent a deep cleaning. Although the temperature logs for the food on the trayline for the cited dates could not be completed, the cook received proper education, and logs for future meals were successfully recorded. Like: Potholders and cooler shelves will be inspected to ensure they remain in good condition. Items that are worn or soiled will be replaced proactively. The structured cleaning schedule was revised for the steamer area, prep areas, floors (including pipe), vents, and plate warmer. Staff will be assigned specific cleaning tasks with checklists. The food service director/designee will review the checklists to verify compliance. Cooks and staff will receive ongoing training on the importance of maintaining accurate temperature logs. The food service director/designee will review logs daily to ensure they are completed correctly. Educations: Food Safety and Sanitation training will be completed with all kitchen staff including the importance of maintaining cleanliness in food preparation areas with focus on proper cleaning and sanitizing procedures for kitchen equipment, shelves, and floors. Additionally, staff will be educated on the importance of maintaining accurate temperature logs for food safety compliance, proper techniques for measuring and recording food temperatures, and how to troubleshoot and respond to temperature irregularities. Audits: Food Service Director/designee will complete a daily audit to ensure temperatures, bulk container labeling and dating, and cleaning tasks for floors (including pipe area) and shelves are completed. The daily audit will also include visual inspection for the cleanliness of potholders, ceiling tiles, and vents. Daily audits will be completed x 21 days, and will then be completed weekly.
Failure to Provide Consistent ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for two residents, as evidenced by clinical record reviews and staff interviews. Resident 65, who was dependent on staff for bathing, had a significant change MDS assessment indicating the importance of choosing between different types of baths. However, task documentation showed inconsistent bathing schedules and instances where the resident refused or was not documented as having received a bath. There was no evidence that staff re-approached or offered bathing opportunities on subsequent shifts or days. Additionally, there were multiple instances where hair cleansing was either not documented or refused, with no follow-up actions taken by the staff. Observations of Resident 65 revealed disheveled hair, indicating a lack of proper grooming. Resident 89, admitted with dementia and adult failure to thrive, required assistance with bathing and personal hygiene. Task documentation indicated that showers were scheduled twice a week, but records showed infrequent bathing and numerous refusals without documentation of re-approach or alternative bathing opportunities. The care plan for Resident 89 lacked interventions for addressing bathing refusals. These deficiencies were discussed with the Director of Nursing during the survey, highlighting the facility's failure to ensure consistent and adequate ADL care for dependent residents.
Plan Of Correction
Cited: Resident 65 and resident 89 bathing preferences were collected and honored. • Like: Facility wide sweep will be completed to ensure residents bathing preferences are honored. • Education: NHA/designee will educate staff on resident bathing preferences. • Audits: NHA/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure resident bathing preferences are being honored. Results will be taken through QAPI.
Failure to Implement ROM Programs for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) and mobility for three residents. Resident 65 had a therapy restorative referral indicating the need for active and active assisted range of motion exercises to be performed one to two times daily. However, the nursing staff did not implement the restorative nursing program until several days after the referral, and there were multiple dates where the program was not documented as completed. Resident 42 had impairments in her upper and lower extremities, and although a restorative ROM program was established, it was not initiated until nearly a month later, after the surveyor's intervention. Additionally, Resident 42 was supposed to have a splint brace program, which was also not implemented in a timely manner. Resident 70 had a limited ROM on one side of his body, and a ROM program was established for him as well. However, there was no evidence that the program was ever initiated. The Director of Nursing confirmed that the ROM program for Resident 70 was never started. These deficiencies were previously cited in earlier surveys, indicating a recurring issue with the facility's ability to provide adequate nursing services to maintain or improve residents' ROM and mobility.
Plan Of Correction
Cited: Residents 42, 65, and 70 range of motion programs were reviewed with IDT team and were reevaluated by therapy. - Like: The facility will complete a two-week look back on residents who were discharged from therapy to review if resident is appropriate for ROM program and ensure it is initiated. - Educations: DON/designee will educate nursing staff and ensuring ROM program recommendations from therapy are followed appropriately. - Audits: DON/designee will audit 5 residents weekly x 4 weeks then monthly x 2 months to ensure residents who are discharged from therapy have appropriate ROM programs initiated if appropriate. Results will be taken through QAPI.
Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for specific care tasks, including enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. This deficiency was identified during a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses (RNs) and two licensed practical nurses (LPNs). These employees were responsible for the care of residents with various medical needs, such as enteral tube feedings, tracheostomies, indwelling catheters, and pressure ulcers. The facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters, five residents with pressure ulcers, five residents with enteral tube feedings, and one resident with a tracheostomy. Despite these care requirements, the facility was unable to provide documentation confirming that Employees 4, 5, 6, and 7 had the specific competencies and skill sets necessary to meet these residents' needs. This lack of documentation was confirmed during an interview with the Director of Nursing, indicating a failure to ensure that nursing staff were adequately prepared to provide the required care.
Plan Of Correction
Cited: Employees 4, 5, 6, and 7 completed the following competencies: enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes. • Like: HR/designee will complete audit of current employees to ensure appropriate competencies are completed. • Education: NHA/designee will educate the staff educator to ensure plan of current staff to obtain appropriate competencies. • Audits: Staff educator/designee will audit 5 employees including new hires weekly x 4 weeks then monthly x 2 months to ensure staff have appropriate competencies completed. Results will be taken through QAPI.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain and address pharmacy recommendations for three residents, as required by §483.45(c) Drug Regimen Review. For Resident 23, a pharmacist's monthly medication review note dated June 10, 2024, indicated that a medication review was completed, but there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations. The Nursing Home Administrator and Director of Nursing confirmed that the pharmacy recommendation for this date could not be located. Similarly, for Resident 49, a medication review was completed by the consultant pharmacist on November 10, 2024, but there was no documentation of the pharmacist's recommendations or any response from the physician or facility. For Resident 42, a pharmacist's review note also dated June 10, 2024, indicated a completed medication review with a directive to "see report for recommendation," yet no evidence of the pharmacist's report or physician's response was found. The Nursing Home Administrator and Director of Nursing confirmed the absence of the pharmacy recommendation for this date. These deficiencies were previously cited on February 16, 2024, and May 22, 2024.
Plan Of Correction
Cited: Residents 23, 42, and 49 pharmacy recommendations were reviewed by the physician with a response. • Like: The facility will complete a two-week look back to review pharmacy recommendations to ensure there is a physician response. • Education: DON/designee will educate the licensed staff to ensure responses are provided to pharmacy recommendations. • Audits: DON/designee will audit 5 resident pharmacy recommendations weekly x 4 weeks then monthly x 2 months to ensure physician response is provided. Results will be taken through QAPI.
Failure to Manage Psychotropic Medications Appropriately
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medications for two residents. Resident 9 was admitted on January 16, 2023, and was receiving Buspar and Cymbalta. A consultant pharmacist recommended a dose reduction of Cymbalta from 90 mg to 60 mg on July 13, 2024, which the physician agreed to on July 24, 2024. However, the facility did not implement this change until January 17, 2025, as confirmed by the Nursing Home Administrator and Director of Nursing. Resident 65 had multiple PRN orders for Ativan, a psychotropic medication, without appropriate stop dates or evaluations by a physician to justify the extensions beyond 14 days. The facility's documentation lacked evidence of non-medicinal interventions before administering the PRN Ativan. The consultant pharmacist recommended evaluating the necessity of the PRN Ativan, but the facility's physician and contracted physician's assistant opted to continue the medication with a 90-day stop date due to ongoing anxiety, without proper documentation of behaviors or provider evaluations to justify this decision. The facility's failure to adhere to regulatory requirements for psychotropic medications resulted in deficiencies related to unnecessary drug use. The surveyor confirmed these findings with the Nursing Home Administrator and Director of Nursing, highlighting the lack of compliance with medication management protocols and the absence of necessary documentation to support the continued use of psychotropic medications for Resident 65.
Plan Of Correction
• Cited: Resident 9 and resident 65 medication regime was reviewed and properly addressed by the physician. • Like: The facility will complete a medication regime review for current residents to ensure they are free for unnecessary medications directly related to physician recommendation to decrease Cymbalta and review of PRN antianxiety medication without supporting documentation. • Education: DON/designee will educate nursing staff to ensure the pharmacist and resident 39's recommendations are followed to avoid unnecessary medications as well as recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. • Audits: DON/designee will audit 5 random residents weekly x 4 weeks then monthly x 2 months to ensure the pharmacist resident 39's recommendations are followed to avoid unnecessary medications. Audit will also include recommendation to decrease Cymbalta and review of PRN anti-anxiety medications without supporting documentation. Results will be taken through QAPI.
Infection Control Deficiencies During Medication Administration and Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration for two residents. An LPN was observed preparing medications for two residents using her bare hands, which is against standard infection control procedures. She handled various medications, including Famotidine, Mucinex, and Clopidogrel, without wearing gloves, and placed them into medication cups. This practice was confirmed during an interview with the LPN, indicating a breach in infection prevention protocols. Additionally, during a dressing change for a resident with a left lateral heel pressure ulcer, the facility's infection preventionist and wound nurse did not follow proper infection control measures. The nurse failed to clean the overbed table before placing supplies on it, did not change gloves after removing the old dressing, and did not use enhanced barrier precautions, such as wearing a gown. The absence of a sign indicating the need for enhanced barrier precautions on the resident's door further highlighted the lapse in infection control practices. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies, which included improper medication handling and inadequate infection control during a dressing change. These observations demonstrate a failure to maintain a safe and sanitary environment, as required by the facility's infection prevention and control program.
Plan Of Correction
Cited: Employee's #8 was required to complete a medication administration pass competency with the DON. Employee #9 was required to complete a treatment completion competency and was provided education relating to adherence to Enhanced Barrier Precautions. Like: Licensed staff will complete a medication administrator competency directly related to infection prevention with medication preparation as well as following enhanced barrier precautions, and general infection control practices with dressing changes. Education: DON/designee will educate nursing staff to ensure medication administration follows infection control procedures as well as following enhanced barrier precautions, and general infection prevention practices with dressing changes. Audits: Infection Preventionist/designee will audit 4 residents weekly then monthly x2 months to ensure medication administration follows infection control guidelines. Results will be taken through QAPI.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of the residents sampled. Specifically, Resident 61 was observed on two separate occasions with their catheter bag full of urine, uncovered, and laying on the floor. These observations were made from the hallway while the resident was sleeping in bed, indicating a lack of privacy and dignity in the care provided. The observations were made on January 21 and January 22, 2025, and were discussed with the Director of Nursing on January 24, 2025. This deficiency was previously cited on February 16, 2024, indicating a recurring issue with maintaining resident dignity and proper care standards. The facility's failure to address this issue demonstrates a lack of adherence to the resident's rights to a dignified existence and quality care.
Plan Of Correction
Cited: Resident 61's Catheter bag was placed in a cover and moved to the non-hallway side of the bed. • Like: Residents requiring the use of a urinary catheter were audited to ensure the catheter bags were covered and placed on the non-hallway side of the bed. • Education: DON/designee will educate nursing staff catheter bags being in covers and on non-hallway side of the beds. • Audits: DON/designee will audit residents with catheter bags to ensure they are in covers and placed on non-hallway sides of the bed. Audits will be completed weekly x4 weeks then monthly x 2 months. Results will be taken through QAPI.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across all four nursing units, as evidenced by multiple observations of unclean conditions and strong odors. Resident 85 was observed with an enteral feeding pump that had dried brown liquid splatters on its exterior, indicating a lack of proper cleaning. Similarly, Resident 56's feeding pump, pole, and bagged supplies were also found with dried brown liquid splatters. These observations were reviewed with the Director of Nursing and the Nursing Home Administrator. Additionally, the West Nursing Unit was noted to have a persistent strong odor of urine in the rooms and bathrooms of Residents 68 and 14 over several days. Resident 39's room was found to have a strong urine smell, a dirty floor, and disorganized items on nightstands with broken handles. The walls were marred and peeling. Resident 50's room had a cove base coming off the wall with crumbled pieces on the floor. These issues were brought to the attention of the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
Cited: Resident 85 and resident 56 feeding pump pole was cleaned. Resident 68 and resident 14's rooms and bathroom were cleaned to ensure free of urine odor. Resident 39's night stand handles were repaired by maintenance director. Items in resident 39's room were organized. Resident 50's cove base was repaired in his room behind the head of the bed. • Like: Feeding pumps and poles facility wide were cleaned. Resident rooms and bathrooms facility wide were cleaned to ensure free of urine odor. Resident room floors were cleaned and resident room cove basing and walls were cleaned and repaired as needed. • Education: NHA/designee will educate the environmental staff on ensuring feeding poles and pumps and resident rooms and bathrooms are properly cleaned. NHA/designee will educate maintenance department on ensuring handles of night stands and wall and cove basing are repaired appropriately. • Audits: Environmental Director/designee will audit 5 random resident rooms and bathrooms to ensure cleanliness as well as odor weekly x 4 weeks and monthly x 2 months. Maintenance director/designee will audit 5 night stands and 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure night stands are appropriate as well as cove basing and walls. Results will be taken through QAPI.
Failure to Investigate Resident Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident 42, who was reviewed for abuse. A clinical record review revealed that on December 30, 2024, a nurse noted a bruise on the right side of Resident 42's face, measuring 3 cm x 2 cm, with a dark bluish and purplish color. The bruise was located outside the right eye. The resident was known to be combative during care, and staff were instructed to walk away if the resident became combative to prevent self-inflicted injuries. However, there were no follow-up progress notes related to the event until January 22, 2025, after a surveyor inquired about the incident. The facility's investigation into the event was inadequate, as it did not include witness statements from staff regarding how the injury may have occurred, nor was there evidence of staff education on interventions for managing the resident's combative behavior. An interview with the Director of Nursing confirmed the lack of witness statements and staff education documentation. This deficiency was previously cited on May 22, 2024, indicating a repeated failure to comply with regulations prohibiting and preventing abuse, neglect, and exploitation of residents.
Plan Of Correction
Cited: Per follow up investigation, abuse and neglect was ruled out for resident 42. Like: Facility will do a two week look back of injuries of unknown origin to ensure a full investigation was completed. Education: DON/designee will educate nursing staff on the facility Abuse Policy and Procedure, Incident and Accident Investigations to ensure residents with injuries of unknown origins are fully investigated to rule out potential abuse/neglect. Audits: Residents with injuries of unknown origins will be audited weekly x4 then monthly x2 to ensure injuries are fully investigated. Results will be taken through QAPI.
Inaccurate MDS Assessment for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident. A clinical record review for this resident revealed a discrepancy in the quarterly Minimum Data Set (MDS) dated November 6, 2024. The facility staff had assessed the resident as receiving an anticoagulant medication during the last seven days of the assessment period. However, further review of the clinical records showed no evidence that the resident had received such medication during that time. An interview with the Director of Nursing confirmed that the MDS was coded in error regarding the administration of the anticoagulant medication.
Plan Of Correction
Step 1: Re-education on coding accuracy. Please obtain signatures of all applicable MDS coordinators from the facility (See attached Section N of the RAI Manual): Immediate Remedy and Re-education/MDS modification submitted by Regional. Step 2: Audit most recently completed OBRA MDS Assessment 100% of current residents, any coding errors identified to be fixed. **See Audit tool. **Tip** You can pull an MDS item response specific for MDSs and how this question N0415E was coded- then review the MAR for that time frame. To be completed by Facility MDS. Completed Audit to be reviewed by Regional MDS. Step 3: Continued Audit needs: 10 completed MDSs to be reviewed by 2nd MDS coordinator and/or regional. To be completed weekly x 4 weeks:
Failure to Implement Consultant Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure the highest practical care for a resident, identified as Resident 93, by not implementing consultant recommendations. Resident 93, who had a history of pain and stiffness in his right hand, was observed on January 21, 2025, complaining of a 'cold hand' with no grasp and partially contracted fingers. He mentioned that he sits on his hand to warm it and straighten his fingers. A review of his clinical record showed that he had seen a plastic surgeon on January 13, 2025, who noted improvement in his range of motion with some exercise. The physician recommended warm soaks twice a day and resuming hand therapy. However, there was no documentation that the facility implemented these recommendations. The Director of Nursing confirmed these findings during an interview on January 24, 2025, acknowledging that the recommendations were only implemented after the surveyor's inquiry.
Plan Of Correction
Cited: Resident 93 has orders regarding soaking hands and orders reflecting therapy to assist with hand therapy. • Like: The facility will do a two-week look back to ensure residents who attend appointments and return with follow up recommendations, that recommendations are timely addressed. • Education: DON/designee will educate nursing staff on ensuring appointment follow up recommendations are addressed timely. • Audits: DON/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure recommendations from resident appointments are followed up timely. Results will be taken through QAPI.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident who required oxygen therapy and BiPAP for sleep apnea. The clinical record for the resident indicated a physician's order for oxygen to be administered at 5 liters per minute (LPM) via nasal cannula continuously during the day and evening, and 6 to 7 LPM at bedtime with BiPAP. However, observations revealed that the resident's oxygen concentrator was set at 9 LPM without humidification, which deviated from the prescribed order. Additionally, the resident's BiPAP mask was found unbagged and improperly stored, lying on the floor behind the oxygen concentrator and on the bedside stand during different observations. This improper handling and storage of respiratory equipment could increase the risk of infection, as noted by the American Association for Respiratory Care, which emphasizes the importance of proper cleaning and storage of nebulizer equipment to reduce infection risk. The deficiency was discussed with the Director of Nursing during the survey.
Plan Of Correction
Cited: Resident 43's oxygen order was clarified. Resident 43's Bipap mask was placed in an appropriate bag. • Like: Facility-wide sweep was completed to ensure residents who have active oxygen orders are correctly being followed. Facility-wide sweep also completed to ensure appropriate respiratory supplies are stored in bags appropriately. • Education: DON/designee will educate nursing staff on ensuring oxygen orders are followed and respiratory equipment is stored appropriately. • Audits: DON/designee will audit 5 residents per week x 4 weeks then monthly x 2 months to ensure oxygen orders are appropriately followed and that respiratory equipment is stored appropriately. Results will be taken through QAPI.
Failure to Secure Treatments in Resident's Room
Penalty
Summary
The facility failed to secure treatments on one of its nursing hallways, specifically the North Hall, involving a resident identified as Resident 56. During observations conducted on three separate occasions, open bottles of Dakin's solution and a bottle of Derma wound cleanser were found on the windowsill in Resident 56's room. These items are antiseptics used for treating and preventing infections in wounds, and their labels indicated that they should be kept out of reach of children and that medical help should be sought if swallowed. The deficiency was confirmed during a meeting with the Nursing Home Administrator and the Director of Nursing, who acknowledged that the items should not have been stored on the windowsill. This incident was a repeat deficiency, as a similar issue had been cited previously on February 16, 2024. The facility's failure to properly store these drugs and biologicals violated both federal regulations and state codes related to pharmacy and nursing services.
Plan Of Correction
Cited: All solutions and cleansers were removed from the window sill of resident 56. • Like: Facility-wide sweep will be completed to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Educations: DON/designee will educate staff to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. • Audits: DON/designee will audit 5 resident rooms weekly x 4 weeks then monthly x 2 months to ensure treatment supplies/biologicals are not stored on the window sill in residents' rooms. Results will be taken through QAPI.
Failure to Implement TB Screening for New Hires
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) recommendations for tuberculosis (TB) screening and testing for newly hired health care personnel. Specifically, the facility did not implement the required pre-employment TB screening procedures for two of the five newly hired employees reviewed. According to the CDC guidelines, all U.S. health care personnel should be screened for TB upon hire using either a TB blood test or a two-step TB skin test. Additionally, if a previous documented negative TB result is provided within 12 months before new employment, only a single test is required. However, the facility did not follow these guidelines for Employees 2 and 3. Employee 2, a nurse aide, was hired on November 14, 2024, and provided evidence of a negative TB skin test dated March 4, 2024, which was within 12 months of being hired. Despite this, there was no evidence of any further testing, such as a one-step, blood test, or chest x-ray, upon their employment at the facility. Similarly, Employee 3, also a nurse aide, was hired on December 10, 2024, and provided evidence of a prior negative TB blood test dated August 5, 2024, within 12 months of hire. Again, there was no evidence that Employee 3 received any further testing prior to employment with the facility. This lack of adherence to the CDC's TB screening guidelines constitutes a deficiency in the facility's pre-employment screening procedures.
Plan Of Correction
Cited: Employees 2 and 3 will have a full TB screen completed. • Like: HRD/designee will complete a sweep of current staff members to ensure all staff have completed a TB screen. • Educations: NHA/designee will educate the HRD to ensure all staff have completed a TB screen upon hire. • Audits: HRD/designee will audit 5 staff members' files weekly x4 weeks and monthly x 2 months to ensure all staff have completed a TB screen upon hire. Results will be taken through QAPI.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by the regulation effective July 1, 2024. Specifically, during the day shift, the facility did not provide the minimum of one nurse aide per 10 residents on two occasions. On December 29, 2024, with a census of 97 residents, only 9.55 nurse aides were available, falling short of the required 9.70. Similarly, on January 18, 2025, with a census of 101 residents, only 8.50 nurse aides were present, whereas 10.10 were needed. Additionally, during the night shift, the facility failed to maintain the required one nurse aide per 15 residents on three occasions. On January 1, 2025, with a census of 96 residents, only 4.85 nurse aides were available, while 6.10 were required. On January 19, 2025, with a census of 103 residents, 6.10 nurse aides were present, but 6.87 were needed. Lastly, on January 21, 2025, with a census of 102 residents, only 4.47 nurse aides were available, whereas 6.80 were required. These deficiencies were confirmed through an interview with the Nursing Home Administrator on January 23, 2025.
Plan Of Correction
Cited: Unable to correct staffing ratios for CNA's on the five days selected during the review. • Like: Staffing coordinator/designee will review the last two weeks to ensure staffing ratios are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. • Educations: NHA/designee will educate the staffing coordinator to ensure staffing ratios are met. • Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing ratios are met.
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 three specific days. This deficiency was identified during a review of nursing staff care hours for the periods of November 23, 2024, through November 29, 2024, December 26, 2024, through January 1, 2025, and January 17, 2025, through January 23, 2025. On January 1, 2025, the facility provided 3.05 hours PPD, on January 18, 2025, 3.07 hours PPD, and on January 19, 2025, 3.14 hours PPD. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required daily hours PPD on these dates.
Plan Of Correction
Cited: Unable to correct the staffing PPD for the three days reviewed. Like: Staffing coordinator/designee will review the last two weeks to ensure staffing PPD are met. The facility is rolling out a new recruitment and retention plan under new ownership. This includes recruiting for regional recruiter, facility wage analysis, mentor program and employee retention initiatives. Educations: NHA/designee will educate the staffing coordinator to ensure staffing PPD are met. Audits: Staffing coordinator/designee will audit five random days weekly x 4 weeks then monthly x 2 months to ensure staffing PPD is met.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for three residents, as observed and documented by surveyors. Resident 2, who requires supervision and cueing for personal hygiene, was observed with several days of beard growth and reported not receiving shaving assistance during his shower, which was provided on an unscheduled day. Resident 3, with a history of urinary incontinence and recurrent urinary tract infections, did not receive documented oral care on multiple occasions across three months, and there were significant lapses in documented toileting assistance, particularly during the night shift. Resident 4, who requires assistance with bathing and oral care, was observed with overgrown fingernails and reported that staff should trim them. Documentation revealed missed shower and oral care assistance on several occasions over three months. The surveyor discussed these deficiencies with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to adhere to the care plans developed for these residents. The facility had previously been cited for similar deficiencies, indicating ongoing issues with providing necessary nursing services as required by regulations. The lack of documentation and observed lapses in care suggest a systemic issue in ensuring that residents receive the assistance they need for daily living activities.
Inconsistent Implementation of Restorative Programs for Mobility Deficits
Penalty
Summary
The facility failed to provide adequate services for mobility deficits for two residents. Resident 2 expressed concerns about walking and requested an evaluation, which led to physical therapy services being initiated. However, after being discharged from skilled physical therapy, there was no restorative program implemented. The plan of care for Resident 2 included encouraging participation in restorative programs, but documentation revealed inconsistent assistance with the restorative ambulation program. Interviews confirmed that the program was not consistently completed as required. Similarly, Resident 4 required restorative programs due to poor balance and an unsteady gait. The plan of care included instructions for staff to encourage participation in restorative programs. However, task list documentation showed that staff frequently failed to document assistance with the restorative ambulation program. The surveyor's review highlighted these deficiencies in the care provided to both residents, indicating a lack of consistent implementation of restorative programs as outlined in their care plans.
Failure to Accommodate Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to provide food that accommodated the preferences and allergies of a resident, identified as Resident 5. During an interview, Resident 5 expressed dissatisfaction with the meals, rating them a seven out of ten, and reported receiving food she is allergic to, such as strawberries, and food she dislikes, such as rice. Despite having communicated her preferences during care conferences, these were not reflected in her meal tray tickets. On one occasion, her meal included peaches, which were listed as a disliked food, and rice, which was not listed as disliked, while the tray ticket indicated she should receive noodles and green beans, which were not provided. The issue was further compounded by the inaction of staff members. Employee 2, an activities staff member, confirmed the meal provided did not match the tray ticket but did not know how to address the concern and failed to report it. Employee 1, the food service director, acknowledged that the menu tickets did not match the planned meal items, indicating a systemic issue in meal planning and delivery. The concerns were reviewed with the Nursing Home Administrator and the Director of Nursing, highlighting a failure in dietary services as per 28 Pa. Code 211.6 (a).
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across four nursing units, as observed on August 6, 2024. In the main dining room of the [NAME] Nursing Unit, there were three ceiling vents with dark moisture-related spots and a smaller vent with a significant dust-like substance. A nourishment ice cart at the South/West nurse station had a drip tray with a slimy, black substance. Additionally, a brown moisture stain was noted on a ceiling tile near an exit sign, and a vent in the hallway had significant moisture accumulation. The nourishment room behind the South/West nurse's station also had a vent with a dust-like substance. Further observations on the South Nursing Unit revealed wall heating/air conditioning units with black substance accumulation and dead insects. Ceiling lights in the lounge and resident hallway contained debris and dead insects. The North Nursing Unit had a large water-stained ceiling tile and a refrigerator with dust, debris, and an unsmoked cigarette on top. Resident 1's bathroom vent had a significant dust accumulation, and the physical therapy area had dusty vents and ceiling tiles. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Unnecessary Medication Prescribed Without Proper Indication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications. A closed clinical record review and staff interviews revealed that a resident, who did not have a history of cancer or radiation treatments, was prescribed Temozolomide, a medication used to treat certain types of brain cancer. The initial verbal physician order for Temozolomide was dated April 10, 2024, and was signed electronically by a certified registered nurse practitioner on April 15, 2024. The order instructed staff to administer the medication daily for the duration of radiation therapy, despite the resident not being prescribed radiation therapy. The nursing staff discontinued the initial order on April 22, 2024, but a new verbal order with the same administration parameters was entered on the same day and electronically signed by a doctor on April 24, 2024. The practitioner did not identify that Temozolomide was included in the resident's medication profile without an appropriate diagnosis or indication for its use. Interviews with the Nursing Home Administrator, the Director of Nursing, and a medical records employee confirmed these findings. The facility implemented Temozolomide in the resident's medication regimen without adequate indications for its use, violating several Pennsylvania Code regulations related to pharmacy, medical director, and nursing services.
Failure to Investigate and Report Alleged Mental Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of mental abuse involving a resident. The CMS State Operations Manual defines mental abuse as conduct causing humiliation, intimidation, fear, shame, agitation, or degradation, including abuse facilitated by technology. The facility's policy, however, did not include the inappropriate use of technology, such as taking resident pictures or videos, as examples of mental abuse. This oversight contributed to the facility's failure to address the situation appropriately. The incident involved Employee 1, a nurse aide, who was reported to have used her electronic device inappropriately. An Employee Education/Counseling Form noted that Employee 1 was educated on the facility's policy prohibiting the use of recording devices. However, there was no detailed information on how Employee 1 used her phone, and her statement denied taking any photos or videos of residents. Despite this, a witness statement from another employee indicated that Employee 1 was allegedly taking pictures and videos of residents and sending them to others, including her boyfriend. The Nursing Home Administrator confirmed that the facility did not attempt to obtain statements from Employee 1's boyfriend or other involved staff members. Additionally, the facility failed to notify the Department or other agencies about the allegation of inappropriate photo or video taking. This lack of thorough investigation and reporting violated the facility's policy and regulatory requirements, leading to the deficiency.
Failure to Provide Bathing Assistance to Dependent Resident
Penalty
Summary
The facility failed to provide necessary bathing assistance to a dependent resident, identified as Resident CR1, during her stay from an unspecified date to May 10, 2024. According to the admission MDS dated April 3, 2024, Resident CR1 was assessed as being dependent on staff for bathing. The Documentation Survey Report for April 2024 indicated that nurse aides were responsible for providing a bed bath to Resident CR1 on Tuesdays and Saturdays. However, the report showed that staff did not document the completion of a bed bath on three specific dates: April 13, April 16, and April 27, 2024. This deficiency was discussed with the Nursing Home Administrator on May 23, 2024.
Medication Administered Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a physician supervised the care of a resident, identified as Resident CR1, who was administered a medication without an appropriate diagnosis. Resident CR1 was given Temozolomide, a medication used to treat certain types of brain cancer, despite not having a history of cancer or undergoing radiation treatments. A verbal physician order for Temozolomide was issued on April 10, 2024, and signed by a certified registered nurse practitioner (CRNP) on April 15, 2024, without identifying the lack of an appropriate diagnosis. Throughout multiple visits, another CRNP reviewed Resident CR1's medication list but failed to identify the inappropriate inclusion of Temozolomide. Although the initial order was discontinued on April 22, 2024, a new verbal order with the same parameters was entered and signed by a doctor on April 24, 2024, again without recognizing the absence of a valid diagnosis. Interviews with the Nursing Home Administrator, Director of Nursing, and medical records staff confirmed these findings, and the facility could not provide evidence of a medical evaluation conducted before ordering the medication.
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What surveyors actually found near you
We read the 182 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
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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 North | 0 mi | ★★★★★ | 21 | 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 |
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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.