Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eldercrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Kitchen staff failed to wear proper hair and beard restraints in the Main Kitchen. An NA, a Dietary Aide, and another employee were observed without hair nets or a beard guard, and the Dietary Mgr was later observed with a hair net that did not fully cover her hair. The Dietary Mgr and NHA confirmed staff should wear hair nets and beard restraints while in the kitchen.
The facility failed to document, investigate, resolve, and protect residents from reprisal when grievances and concerns were raised. Review of grievance records found unresolved complaints, and residents reported that staff involved in the concerns confronted them during the investigative process, causing fear of reprisal. The DON confirmed the failures affected multiple residents.
Failure to Protect Residents From Potential Abuse and Neglect: The facility did not identify several resident grievances and staff interactions as potential abuse or neglect. A nurse aide argued with a resident’s granddaughter in the resident’s room and continued caring for the resident afterward, two residents reported that nurse aides did not answer call bells and used a loud voice, and another resident said she felt fearful after reporting an aide who later confronted her in her room. The DON stated the incidents were not investigated as abuse or neglect.
Failure to Investigate and Report Allegations of Abuse/Neglect: The DON did not identify multiple grievances as potential abuse or neglect, did not investigate the allegations, and did not report them as required. Events included a nurse aide arguing with a resident’s granddaughter in the resident’s room, reports that nurse aides did not answer call bells and used a loud voice, and a resident reporting fear of retaliation after complaining about an aide’s behavior.
Failure to assess and treat a pressure ulcer was identified for a resident with COVID, DM, kidney disease, and AFib who required max assist to roll in bed and had bilateral LE impairment. After readmission from the hospital, the skin assessment did not include a skin exam, and a later nurse assessment of the coccyx found a 5 cm x 1 cm open area, with treatment ordered at that time; the DON confirmed the deficiency.
Inaccurate assessments and care plans for bedrail use: The facility failed to maintain accurate care plans and ongoing assessments for three residents with two top enabler bars on their beds. Records for residents with MS, dysphagia, malnutrition, anxiety, CVA, and DM did not include assessments for enabler bar use or related goals and interventions, and the DON confirmed the deficiency.
Insufficient nursing staffing and delayed response to call bells were identified for multiple residents. Two residents reported that Nurse Aides on afternoon shifts did not answer call bells and used a loud voice, and another resident stated staff did not answer call bells timely and that she waited at least an hour for assistance. The DON stated she did not investigate the grievance and confirmed the facility failed to provide sufficient staffing to meet residents' highest practicable well-being.
Cross-contamination occurred during glucometer use and medication preparation when an RN did not clean the glucometer between resident blood sugar checks and handled oral medications with bare hands while preparing them for a resident. The RN stated he had not been told what to clean the glucometer with and did not know he was not to touch resident medications with his bare hands; the DON confirmed the failures.
The facility failed to post the resident complaint statement and had incomplete APS and Medicaid Fraud Unit information on the required posting board. Surveyors observed the board between nursing unit hall 1 and hall 2, but access was blocked by two carts. The NHA confirmed the blocked board and the missing/incomplete required postings.
The facility failed to display required written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits. Surveyors found the posting board between hall 1 and hall 2 lacked the required information and was blocked by two cart stations, and the NHA confirmed the obstruction and missing posting.
Two residents with diabetes experienced significant medication errors due to delayed administration of both scheduled and sliding scale insulin doses, contrary to prescriber orders and facility policy. These delays were confirmed through record review and staff interviews, and one resident suffered a hypoglycemic event requiring emergency intervention.
The facility failed to meet required staffing levels for NAs on several shifts between January 2 and January 7, 2025. The daylight shift was notably understaffed, with fewer hours provided than required based on the resident census. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels over a six-day period, failing to provide the mandated minimum of one LPN per 25 residents during the day shift on five days, one LPN per 30 residents during the evening shift on all six days, and one LPN per 40 residents during the night shift on all six days. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
Two residents, both cognitively intact, were neglected during a specific shift, with no documented care provided. A nurse reported that one resident was not attended to due to instructions from the DON and NHA. The DON confirmed the lack of investigation into these incidents.
The facility failed to investigate and report potential neglect for two residents, who were not provided care during a specific shift. Both residents, who were cognitively intact, lacked documented care, and the DON admitted to not investigating the allegations. This inaction violated the facility's policy and several Pennsylvania Code regulations.
The facility did not employ a qualified Director of Dining Services to oversee the Dietary Department. The Dietitian visits weekly, and the Head of Dietary, who is still in training, was absent. The Head of Dietary's personnel file lacked evidence of meeting the required qualifications for the position, as confirmed by the NHA.
A facility failed to follow infection control protocols during a dressing change for a resident with a leaking colostomy bag. The ADON did not perform proper handwashing, failed to don appropriate PPE, and did not maintain the resident's privacy. Contaminated items were improperly handled, violating several Pennsylvania Code regulations.
A resident's privacy was compromised during a dressing change conducted at the entrance of their room with the door open, allowing passersby to see. The Assistant Director of Nursing confirmed the breach of privacy, violating resident rights.
A facility failed to administer a scheduled medication for a resident with prostate cancer, as documented in the MAR. The resident did not receive the drug Erleada for eight days due to its unavailability, and the facility did not contact the provider for an alternative or order change. The DON confirmed the failure to provide the medication.
A resident with prostate cancer did not receive the prescribed cancer treatment drug Erleada for eight days due to unavailability, as documented in the MAR. The facility's policy requires medications to be administered as ordered, but this was not followed, which was confirmed by the DON.
An LPN in a facility misappropriated narcotic medication by documenting administrations to residents without their consent or knowledge. A cognitively intact resident reported not receiving the medication, while another resident, with a history of addiction, denied receiving narcotics despite documentation. The facility's policies prohibit such actions, yet the LPN's behavior suggests a pattern of drug diversion, highlighting a failure to protect residents' rights.
The facility failed to investigate the misappropriation of resident property for eight residents, involving suspicious medication administrations by an LPN. Despite policies defining misappropriation, the facility did not confirm with residents whether they received medications as documented, nor did they investigate additional doses signed out on paper but not in the electronic medical record. This oversight involved multiple residents and medications, indicating a systemic issue in managing potential misappropriation.
The facility failed to provide adequate nursing staff, resulting in residents experiencing long wait times for assistance and being left in soiled briefs. Multiple residents reported waiting hours for care, with one resident left soiled overnight. The Director of Nursing confirmed the staffing inadequacies, affecting the well-being of several residents.
A facility failed to report the misappropriation of resident property involving two residents. An LPN documented administering oxycodone to these residents, which they later denied receiving. The DON was informed of suspicious medication administration, and further investigation revealed patterns of drug diversion by the LPN. Despite these findings, the facility only reported the suspected drug diversion for one resident, failing to include the misappropriation involving the second resident.
The facility failed to maintain an infection prevention and control program, leading to a significant outbreak of GI illness among residents and staff. The facility did not document surveillance, allowed ill staff to work, and failed to educate staff on precautions, resulting in 26 residents contracting the illness and two being hospitalized.
A facility failed to notify a physician about a resident's low blood glucose levels, despite multiple readings below 70 mg/dL. The resident, with a history of diabetes, hypertension, and atrial fibrillation, had several low readings recorded, but there was no documentation of physician notification as required by facility policy. The DON confirmed these findings.
The facility failed to provide medically related social services and complete psycho-social based assessments upon admission for four residents. Despite being oriented and having no noted behaviors, the necessary psycho-social assessments were missing from their records. This deficiency was confirmed by the Director of Social Services and the Nursing Home Administrator.
The facility failed to involve two residents in the development of their discharge plans and did not document their approval, despite having policies that require such involvement. Both the Director of Social Services and the Nursing Home Administrator confirmed this deficiency.
Kitchen Staff Failed to Wear Proper Hair and Beard Restraints
Penalty
Summary
The facility failed to properly restrain hair in the Main Kitchen to prevent potential cross contamination. The facility policy on Code of Dress and Personal Appearance, reviewed 7/31/25, stated employees are to use effective hair restraints such as hair nets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces. During an observation on 11/12/25 at 9:55 a.m., Nurse Aide Employee E3 and Dietary Aide Employee E4 were in the kitchen without hair nets, and Employee E5 was observed without a beard guard. The Dietary Manager later confirmed staff should be wearing hair nets and beard guards while in the kitchen. During a second observation on 11/14/25 at 10:45 a.m., Employee E5 was again in the kitchen without a beard guard, and the Dietary Manager was observed with a hair net covering only the hair in a bun at the crown of her head, leaving the forehead to crown exposed and uncovered. The Dietary Manager stated the hair net must have slipped up, and the Nursing Home Administrator confirmed kitchen staff should wear hair nets to cover all hair and beard restraints if facial hair is present.
Failure to Investigate Grievances and Protect Residents from Reprisal
Penalty
Summary
The facility failed to document, investigate, resolve, and protect residents from reprisal during the investigative process when residents filed or identified concerns and grievances. Review of the facility grievance procedure showed that resident concerns were to go through the Grievance Officer, identified as the Nursing Home Administrator, and that the facility was responsible for reviewing, investigating, and resolving each grievance while protecting the resident from reprisal. However, review of grievances from June 2025 through November 2025 identified two filed grievances that had not been investigated, and three residents were not protected from reprisal as documented within the grievances. During the Resident Council Meeting, the council consensus stated that the facility had not protected residents during investigations related to grievances. In an individual interview, Resident R6 stated that after a concern was given to the ADON, the NA involved came back and asked why the resident had turned her in, which caused fear of reprisal. The DON confirmed that the facility failed to document, investigate, resolve, and protect residents from reprisal during the investigative process for 11 of 18 residents identified in the report.
Failure to Protect Residents From Potential Abuse and Neglect
Penalty
Summary
The facility failed to ensure residents were free from potential abuse and neglect for five of six residents reviewed, including R31, R50, R41, and R29. Review of the facility’s Identifying Neglect policy dated 7/31/25 stated that all staff, volunteers, and contractors are trained to identify abuse and neglect as it may occur against residents. However, a grievance dated 8/28/25 indicated that R31’s granddaughter was visiting when Nurse Aide Employee E3 argued with her in the resident’s room and then continued arguing with her outside. The DON’s information and interview on 11/12/25 at 12:10 p.m. did not show that the facility identified the event as potential abuse or neglect, and the nurse aide continued to care for the resident after the altercation. A grievance dated 9/10/25 stated that R41 and R50 reported nurse aides on the afternoon shifts did not answer call bells and used a loud voice. During the 11/12/25 interview, the DON stated she did not identify the grievance as potential abuse or neglect and did not investigate the incident or protect the residents from continued abuse or neglect because staff were not all identified. On 11/13/25 at 8:40 a.m., R29 stated she had reported Nurse Aide Employee E2 to the ADON for speaking about another resident in front of her in a concerning manner, and R29 said she was fearful and concerned about retaliation after E2 came into her room and asked why she reported her. The DON later confirmed that the facility failed to protect residents from potential abuse and neglect.
Failure to Investigate and Report Allegations of Abuse/Neglect
Penalty
Summary
The facility failed to initiate a thorough investigation for allegations of abuse and neglect involving multiple residents, and failed to report the allegations as required. A facility policy titled Abuse Investigating and Reporting stated that reports of abuse, neglect, exploitation, misappropriation of property, mistreatment, and injuries of unknown source are to be promptly reported to the Administrator, investigated, and reported to the appropriate agencies. However, a grievance dated 8/28/25 described a situation in which a nurse aide argued with Resident R31’s granddaughter in the resident’s room and then continued arguing outside; the DON later stated the facility did not identify this as potential abuse or neglect, did not investigate, and did not report it. Resident R31 had diagnoses including Alzheimer’s dementia and heart failure, and an MDS dated 10/11/25 showed a BIM score of 15/15. A grievance dated 9/10/25 stated that Residents R41 and R50 reported nurse aides on the afternoon shifts did not answer call bells and used a loud voice. Resident R41 had diagnoses including diabetes, asthma, and lymphoma, and Resident R50 had diagnoses including a stroke and lung disease; both had BIM scores of 15/15. During interview, the DON stated the grievance was not identified as potential abuse or neglect, was not investigated, and was not reported. Resident R29 stated she reported a nurse aide for speaking about another resident in front of her in a concerning manner and later feared retaliation when the nurse aide asked why she reported her. The DON confirmed the facility failed to identify concerns of alleged abuse or neglect, failed to investigate potential abuse or neglect, and failed to report allegations for five of six residents named in the report.
Failure to Assess and Treat Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for Resident R35. The resident was admitted with diagnoses including COVID, diabetes, kidney disease, and heart fibrillation, and the MDS dated 11/7/25 indicated those diagnoses remained current. The MDS also identified bilateral lower extremity impairment and that the resident required maximum assistance to roll left to right in bed. Facility policy stated residents are to be assessed on admission within eight hours for existing pressure ulcer/injury and risk factors, with reassessment weekly and with any change in condition. After the resident was sent to the hospital for altered mental status and low blood pressure and then readmitted, the readmission skin assessment did not include an examination of the skin. A progress note dated 11/13/25 stated that a Nurse Aide had the nurse assess the resident’s coccyx area, which revealed a 5 cm x 1 cm open area, and a treatment was ordered at that time. During interview, the DON confirmed the facility failed to make certain the resident was provided necessary treatment and services, consistent with professional standards of practice, for a pressure ulcer.
Inaccurate assessments and care plans for bedrail use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails/enabler bars were used to meet residents’ needs and that the risks associated with bedrail usage were addressed for three residents. Facility policy on Proper Use of Bed Rails stated that the resident’s diagnosis, size and weight, sleep habits, medications, acute medical interventions, underlying medical conditions, delirium, ability to toilet self, cognition, communication, mobility, and risk of falling are to be considered as part of the comprehensive assessment when determining whether bed rails meet the resident’s needs. Resident R4 had diagnoses of multiple sclerosis, anxiety disorder, and depression, and two top enabler bars were observed on the bed during the survey. The clinical record did not include an assessment for enabler bar use and did not include goals or interventions related to enabler bar use in the care plan. Resident R32 had diagnoses of dysphagia, malnutrition, and anxiety disorder, and two top enabler bars were observed on the bed; the record likewise lacked an assessment for enabler bar use and lacked related care plan goals and interventions. Resident R42 had diagnoses of CVA, diabetes mellitus, and malnutrition, and two top enabler bars were observed on the bed; the record also lacked an assessment for enabler bar use and lacked related care plan goals and interventions. The DON confirmed the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for these three of six residents.
Insufficient Nursing Staffing and Delayed Response to Call Bells
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of 11 of 18 residents, including Residents R700, R701, R702, R703, R704, R705, 706, 707, R41, R50, and R29, and failed to have a licensed nurse in charge on each shift. A grievance dated 9/10/25 stated that Residents R41 and R50 reported Nurse Aides on the afternoon shifts on the prior Sunday and Monday did not answer call bells and used a loud voice. During an interview on 11/12/25, the DON stated she did not investigate the grievance and acknowledged the facility failed to provide sufficient staffing to provide services to attain or maintain the residents' highest practicable well-being. During an interview on 11/13/25, Resident R29 stated staff did not answer call bells in a timely manner and that she had waited at least an hour for assistance. Later that morning, the DON confirmed the facility failed to provide sufficient staffing to provide services to attain or maintain the resident's highest practical well-being.
Cross-Contamination During Glucometer Use and Medication Administration
Penalty
Summary
The facility failed to prevent the potential for cross-contamination during glucometer use for three residents. During observations, RN E7 did not clean the glucometer before or after checking the blood sugar of Resident R42, did not clean the glucometer before or after checking Resident R14, and did not clean the glucometer before using it for Resident R46. After using the glucometer for Resident R46, RN E7 applied alcohol-based hand sanitizer to his hands, rubbed his hands together, and then picked up the glucometer and rubbed it with his hands and the sanitizer. During interview, RN E7 stated he was never told what to clean the glucometer with. The facility also failed to prevent the potential for cross-contamination during medication administration for Resident R5. While preparing oral medications at the medication cart, RN E7 touched an allergy relief tablet with his bare hands while dispensing from a multi-use over-the-counter medication, and later touched two beet root gummies with his bare hands while placing them into the medication cup for Resident R5. RN E7 stated he did not know that he was not to touch resident medications with his bare hands. The DON confirmed the facility failed to prevent the potential for cross-contamination during glucometer use and medication administration.
Incomplete Required State Agency and Complaint Postings
Penalty
Summary
The facility failed to post a statement that residents may file a complaint with the State Survey Agency and had incomplete information for Adult Protective Services (APS) and the Medicaid Fraud Unit on the required posting board. During observations on 11/13/25 at approximately 2:00 p.m., surveyors found a posting board containing only a portion of the required facility postings between nursing unit hall 1 and hall 2, and access to the board was blocked by two carts placed in front of it. During rounds and an interview on 11/13/25 at approximately 2:30 p.m., the Nursing Home Administrator confirmed that the posting board was blocked by the two carts and that the facility had failed to post the required complaint statement and had incomplete APS and Medicaid Fraud Unit information.
Missing Medicare and Medicaid Benefit Information Posting
Penalty
Summary
The facility failed to display written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits. During observations on 11/13/25 at approximately 2:00 p.m., surveyors found the posting board between nursing unit hall 1 and hall 2 did not have information about the application process for Medicare and Medicaid benefits or refunds for previous payments covered by Medicare and Medicaid. The posting board was also blocked by two cart stations placed in front of it. During rounds and an interview on 11/13/25 at approximately 2:30 p.m., the NHA confirmed the posting board was blocked by the two carts and that the facility failed to display the required written information in the building.
Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin for two residents with diabetes. Facility policy required medications to be administered according to prescriber orders and within specified timeframes, but multiple instances were documented where insulin Lantus and Lispro were administered significantly later than ordered. For one resident, Lantus insulin scheduled for 9:00 a.m. was repeatedly given after noon, and Lispro insulin, which should be administered before meals based on blood glucose readings, was often delayed by several hours. Similar delays were observed for another resident, with both scheduled and sliding scale insulin doses administered well past the prescribed times. These delays in insulin administration were confirmed through review of medication administration records and staff interviews. One resident experienced a hypoglycemic event, with a blood glucose reading of 36, after delayed insulin administration, requiring intervention per hypoglycemic protocol and subsequent transfer to the hospital. Facility leadership acknowledged that insulin administration did not adhere to the facility's medication administration policy, resulting in significant medication errors for both residents.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between January 2, 2025, and January 7, 2025. Specifically, the facility did not provide the mandated number of NAs per resident on the daylight shift for four out of six days, on the evening shift for two out of six days, and on the night shift for one out of six days. The daylight shift was particularly understaffed, with the facility providing significantly fewer hours than required based on the resident census. This deficiency was confirmed by the Nursing Home Administrator during an interview on January 8, 2025.
Plan Of Correction
Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on CNA staffing ratios regulation effective July 1, 2024. Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify CNA ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/Designee will monitor staffing sheets. Nursing Home Administrator/designee is reviewing all current staffing contracts to ensure most up to date rates are in place and has posted open positions on employment platform. Findings will be reported to QAPI.
LPN Staffing Deficiency Over Six-Day Period
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on multiple shifts over a six-day period. Specifically, the facility did not provide the mandated minimum of one LPN per 25 residents during the day shift on five out of six days, one LPN per 30 residents during the evening shift on all six days, and one LPN per 40 residents during the night shift on all six days. This deficiency was confirmed through a review of the facility's staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to provide the required LPN coverage on the specified shifts.
Plan Of Correction
Nursing Home Administrator will re-educate the Director of Nursing and Scheduler on LPN staffing ratios regulation effective July 1, 2024. Nursing Home Administrator/Designee will audit staffing sheets weekly for four weeks to identify LPN ratio is met during staffing meeting. Moving forward, the Nursing Home Administrator/designee will monitor staffing sheets. Nursing Home Administrator/Designee is reviewing all current staffing contracts to ensure the most up to date rates are in place and has posted open positions on the employment platform. Findings will be reported to QAPI.
Neglect of Two Cognitively Intact Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as R21 and R300, were free from neglect. Resident R21, who was admitted with a stroke resulting in left-sided paralysis and glaucoma, was reported by a Registered Nurse to have not received care from 7:30 p.m. to 11:00 p.m. on a specific date. The Nurse Aide on duty claimed she was not allowed in the resident's room per instructions from the DON and NHA. The Documentation Survey Report for Resident R21 did not show any documented care during the 3-11 shift on that date. Similarly, Resident R300, who had stage IV kidney disease and Guillain-Barre Syndrome, also did not have documented care for the same shift on the same date. The DON confirmed the lack of investigation into these incidents and identified the Nurse Aide involved. Both residents were cognitively intact, as indicated by their BIMS scores of 14, suggesting they were aware of their surroundings and capable of reporting neglect.
Failure to Investigate and Report Alleged Neglect
Penalty
Summary
The facility failed to investigate and report potential neglect for two residents, R21 and R300, as required by their Abuse Prevention Program policy. Resident R21, who was admitted with a stroke and left-sided paralysis, was allegedly not provided care during a specific shift, as reported by a registered nurse. The documentation for that shift did not include any recorded care for R21. Similarly, Resident R300, who had stage IV kidney disease and Guillain-Barre Syndrome, also lacked documented care during the same shift. Both residents were cognitively intact, as indicated by their Minimum Data Set assessments. The Director of Nursing (DON) admitted to not investigating the allegations of neglect for these residents. During interviews, the DON could not recall why the nurse aide claimed they were not allowed to care for the residents, nor could they remember the name of the nurse aide involved. The facility's policy mandates that all reports of neglect be promptly reported and thoroughly investigated, which was not adhered to in this case. This failure to act is a violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, resident care policies, and nursing services.
Failure to Employ Qualified Director of Dining Services
Penalty
Summary
The facility failed to employ a qualified Director of Dining Services (DDS) to manage the daily operations of the Dietary Department. During an interview, it was revealed that the Dietitian visits the facility weekly, and the Head of Dietary, who is currently enrolled in classes to become a Dietary Manager, was not present. A review of the personnel file for the Head of Dietary showed that they did not meet the educational, experiential, and certification requirements for the DDS position. The Nursing Home Administrator confirmed the lack of documented evidence that the Head of Dietary met the necessary qualifications for the role.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to adhere to proper infection control techniques during a dressing change for a resident identified as R143. The Assistant Director of Nursing (ADON) did not perform thorough handwashing before beginning the procedure. Additionally, the ADON and a Licensed Practical Nurse (LPN) did not wear gowns despite the potential for contamination from blood and body fluids. The overbed table was not adequately cleared of personal items, risking contamination. The resident had a leaking colostomy bag, and the wound was adjacent to the leak, which contained stool. The ADON removed the ostomy bag and cleansed both the stoma and the wound without changing gloves or washing hands between procedures. Further, the ADON placed a box of gloves, Dakin's solution, and hand sanitizer on the overbed table, which was not properly sanitized. The resident's door was left open during the procedure, compromising privacy. The ADON acknowledged that the resident was under enhanced precautions, yet there was no sign or PPE available in the room. After the procedure, contaminated items were not disposed of properly, as the ADON returned them to the treatment cart. These actions violated several Pennsylvania Code regulations related to infection control, staff development, and resident care policies.
Resident Privacy Breach During Dressing Change
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during a medical procedure. On November 26, 2024, from 11:15 a.m. to 11:44 a.m., a resident had a dressing change to the abdomen at the entrance of their room with the door open. This allowed any passerby to see the procedure, compromising the resident's privacy. The Assistant Director of Nursing confirmed during an interview that the resident's personal privacy was not maintained, which is a violation of resident rights as per 28 Pa. Code: 201.29(j).
Failure to Administer Scheduled Medication
Penalty
Summary
The facility failed to provide a scheduled medication for Resident R147, who was admitted with diagnoses including prostate cancer, a pacemaker/defibrillator, and a left femur fracture. The resident's clinical record indicated the use of the drug Erleada for prostate cancer treatment. However, the Medication Administration Record (MAR) showed that from November 18, 2024, through November 25, 2024, the medication was documented as unavailable and not administered. During an interview, the Director of Nursing confirmed that the facility did not provide the medication and failed to contact the provider for an alternative drug or order change. As a result, Resident R147 did not receive the prescribed cancer treatment drug for eight days.
Failure to Administer Cancer Medication as Ordered
Penalty
Summary
The facility failed to ensure that significant medications were administered as ordered by the physician for a resident. The facility's policy on Medication Administration, dated 2024, requires that all medications be administered in accordance with prescriber orders and within the required time frame. However, a review of the clinical record for a resident admitted with diagnoses including prostate cancer, a pacemaker/defibrillator, and a left femur fracture, revealed that the cancer treatment drug Erleada was not administered for eight consecutive days due to unavailability. This lapse was confirmed during an interview with the Director of Nursing, who acknowledged the failure to administer the medication as ordered. The resident's Medication Administration Record (MAR) indicated that from November 18 to November 25, the drug was documented as unavailable and not given. This oversight was identified as a deficiency under the regulations governing the responsibility of the licensee, pharmacy services, and resident care policies.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property, specifically involving the wrongful administration of narcotic pain medication. The investigation revealed that an LPN, identified as Employee E1, documented the administration of oxycodone to several residents without their consent or knowledge. Resident R1, who was cognitively intact with a BIMS score of 15, reported not receiving the medication at the times documented by the LPN. Similarly, Resident R2, who also had a BIMS score of 15, denied receiving narcotics, preferring Tylenol due to a history of addiction. Despite this, the LPN recorded multiple administrations of oxycodone to Resident R2. Further investigation into Resident R3, who was also cognitively intact, showed a single administration of oxycodone by the same LPN, which was inconsistent with the resident's reported pain levels. Resident R4, who had a BIMS score of 4 due to dementia, was documented to have received oxycodone by the LPN, despite not exhibiting behaviors typically associated with severe pain. The facility's Director of Nursing confirmed the discrepancies in medication administration and the failure to protect these residents from misappropriation. The facility's policies on abuse, neglect, and misappropriation clearly prohibit such actions, yet the LPN's documentation and actions suggest a pattern of drug diversion. The investigation highlighted the facility's inability to ensure the safety and rights of its residents, as outlined in the Pennsylvania Code regarding nursing services and resident rights. The report underscores the need for stringent monitoring and adherence to policies to prevent such occurrences.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement policies and procedures to investigate the misappropriation of resident property for eight out of nine residents. The facility's policy on abuse, neglect, and misappropriation defines misappropriation as the wrongful use of a resident's belongings or money without consent. Despite this, the facility did not adequately investigate suspicious medication administrations documented by an LPN, which were not received by the residents as claimed. This issue was identified through a review of clinical records, facility policies, and staff interviews. Several residents, including those with cognitive impairments and those who were alert and oriented, were involved in the incidents. For instance, one resident with a BIMS score indicating cognitive intactness reported not receiving pain medication that was documented as administered by an LPN. Another resident, who had a history of addiction, stated she did not receive narcotics despite documentation indicating otherwise. The facility's investigation documents failed to show any attempt to confirm with the residents whether they received the medications, nor did they investigate additional doses signed out on paper but not documented in the electronic medical record. The facility's failure to investigate these discrepancies in medication administration records and controlled drug records indicates a lack of adherence to their own policies. The Director of Nursing confirmed that the facility did not implement the necessary procedures to investigate these incidents, which involved multiple residents and medications such as oxycodone and tramadol. This oversight suggests a systemic issue in managing and investigating potential misappropriation of resident property, particularly concerning controlled substances.
Insufficient Nursing Staff Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and observations. Residents reported extended wait times for assistance, with some waiting up to 2.5 hours for care. Several residents were left in soiled briefs and clothing, indicating a lack of timely incontinence care. One resident reported being left soiled overnight and not receiving care until the following afternoon, despite having diarrhea for several days. The facility's records corroborated the lack of incontinence care provided during this period. The Director of Nursing confirmed the facility's failure to maintain adequate staffing levels to ensure the highest practicable physical, mental, and psychosocial well-being of the residents. The deficiency was identified in five out of eight residents reviewed, highlighting a systemic issue with staffing levels and the ability to provide necessary care. The facility's policy on Activities of Daily Living, which mandates services to maintain good nutrition, grooming, and hygiene, was not adhered to, resulting in compromised resident care.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report a misappropriation of resident property involving two residents, identified as Resident R1 and Resident R2. The issue arose when a Licensed Practical Nurse (LPN), identified as Employee E1, documented the administration of narcotic pain medication, oxycodone, to these residents, which they later denied receiving. The Director of Nursing (DON) was informed of a suspicious medication administration involving Resident R1, who was alert and oriented, and denied receiving the medication at the reported time. Further investigation revealed that Resident R2, who also had a history of avoiding narcotics due to past addiction, similarly denied receiving the medication that was documented as administered by the same LPN. The clinical records and Medication Administration Records (MAR) for both residents showed multiple instances where oxycodone was documented as administered by LPN Employee E1. Resident R1's MAR indicated several administrations of oxycodone, particularly between the evening and early morning hours, which the resident denied receiving. Similarly, Resident R2's MAR showed documented administrations of oxycodone by the same LPN, despite the resident's preference for Tylenol and denial of receiving narcotics. The Controlled Drug Record further indicated discrepancies, as no further medication was available for Resident R2 until a new order was received, contradicting the documented administrations. The facility's investigation revealed patterns of drug diversion by LPN Employee E1, affecting both residents. Despite these findings, the facility only reported the suspected drug diversion for Resident R1 to the State Survey Agency, failing to include the misappropriation involving Resident R2. This oversight in reporting the full extent of the drug diversion constitutes a deficiency in the facility's responsibility to report suspected abuse, neglect, or theft, as required by their policy and state regulations.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program, resulting in a significant outbreak of gastrointestinal (GI) illness among residents and staff. The facility did not document surveillance of residents and staff with GI illness, failed to preclude ill staff from working, and did not provide adequate education to staff on appropriate precautions related to GI illness. This led to 26 out of 43 residents contracting GI illness, with two residents requiring hospitalization due to severe symptoms and complications such as dehydration and pneumonia. The report details multiple instances where staff members continued to work despite showing symptoms of GI illness, violating the recommended 48-hour symptom-free period before returning to work. For example, Employee E1 worked during their illness and returned to work without completing the required symptom-free period, subsequently falling ill again. Similar patterns were observed with other employees, contributing to the spread of the illness among residents. The facility's failure to enforce these guidelines directly impacted the health and safety of the residents. Additionally, the facility did not provide formal education to staff on GI illness precautions and hand hygiene audits, as confirmed by multiple staff interviews. This lack of education and adherence to infection control protocols further exacerbated the outbreak. Residents reported that staff did not consistently wear personal protective equipment (PPE) such as gowns when caring for those with GI illness, increasing the risk of transmission. The facility's inadequate response and lack of proper infection control measures led to widespread illness and hospitalizations among residents.
Failure to Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of changes in a resident's blood glucose levels, which is a deficiency in their care protocol. The clinical records and staff interviews revealed that the facility did not inform the physician about a resident's low blood glucose levels, which were recorded multiple times during the night. The resident, who was admitted with diagnoses including diabetes, hypertension, and atrial fibrillation, had blood glucose readings of 52, 59, 60, 56, and 61 mg/dL at various times. Despite the facility's policy requiring immediate notification of the physician for blood glucose levels below 70 mg/dL, there was no documentation of such notification. The Director of Nursing confirmed these findings during an interview.
Failure to Provide Medically Related Social Services and Psycho-Social Assessments
Penalty
Summary
The facility failed to provide medically related social services and complete psycho-social based assessments upon admission for four out of five closed resident records. The Social Services Coordinator's job description requires the assessment of each resident within seven days of admission. However, the clinical records for residents CR1, CR2, CR3, and CR4 did not include the required psycho-social assessments upon their respective admissions. These residents had various diagnoses, including diabetes, gastrointestinal hemorrhage, hypertension, hypothyroidism, pelvis fracture, anxiety disorder, chronic obstructive pulmonary disease, vascular dementia, hyperlipidemia, and chronic kidney disease. Despite being oriented and having no noted behaviors, the necessary psycho-social assessments were missing from their records. During interviews, the Director of Social Services and the Nursing Home Administrator confirmed the facility's failure to provide the required medically related social services and complete the psycho-social assessments for the mentioned residents. This deficiency was identified through a review of clinical records and staff interviews, highlighting a significant lapse in the facility's adherence to its own policies and regulatory requirements. The deficiency was cited under 28 Pa. Code 211.16 (a) Social Services and 28 Pa. Code 211.5 (h) Clinical records.
Failure to Involve Residents in Discharge Planning
Penalty
Summary
The facility failed to involve two residents in the development of their discharge plans, as required by their policies. For Closed Resident Record CR1, the clinical record indicated that the resident was discharged to personal care with his belongings, but there was no documentation showing that the discharge plan was reviewed with him or that he had provided input or approval. CR1 had diagnoses including diabetes, gastrointestinal hemorrhage, hypertension, and hypothyroidism. Despite the care plan and physician orders indicating the discharge plan, the necessary review and approval by the resident were not documented prior to discharge. Similarly, for Closed Resident Record CR4, the clinical record showed that the resident was discharged home with occupational therapy, physical therapy, and nursing services, but again, there was no documentation indicating that the discharge plan was reviewed with her or that she had provided input or approval. CR4 had diagnoses including hyperlipidemia, diabetes, and chronic kidney disease. Both the Director of Social Services and the Nursing Home Administrator confirmed that the facility failed to involve the residents in the development of their discharge plans and did not document their approval as required by the facility's policies.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,313 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Munhall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| John J Kane Regional Center-gl | 1.7 mi | ★★★★★ | 5 | 0 |
| Heritage Care Center | 3 mi | ★★★★★ | 43 | 0 |
| Squirrel Hill Wellness And Rehabilitation Center | 3.3 mi | ★★★★★ | 15 | 0 |
| Rose Meadows Health & Rehab Center | 3.5 mi | ★★★★★ | 11 | 0 |
| Riverside Health & Rehab Center | 3.5 mi | ★★★★★ | 31 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.