Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Saxonburg during CMS and state inspections, most recent first.
Failure to Prevent Retaliation Against Staff: The facility failed to prohibit and prevent retaliation after staff attempted to speak with surveyors and report concerns. Although the handbook and posted notice included anti-retaliation language, five terminated employees had personnel files that did not support the reasons given for termination, and the NHA cited vague reasons such as professionalism, job abandonment, refusal to complete an admission, aggression, and alleged inciting of a verbal riot. Confidential interviews described management questioning staff about speaking with the surveyor, threats of immediate termination for calling the state, and a climate of fear related to complaints about staffing and resident care.
Missed Pressure Ulcer Care for Multiple Residents: The facility failed to complete or document ordered wound care for four residents with pressure ulcers. One resident had paraplegia, MS, and DM with Stage IV and Stage III ulcers; another had COPD, HF, and muscle wasting with facility-acquired Stage III and unstageable ulcers; a third had MS and a Stage IV coccyx ulcer; and a fourth had lymphedema, HTN, and CAD with facility-acquired Stage II thigh ulcers. TARs and progress notes showed multiple missed dressing changes, and the MD said she was not notified that wound treatments were not being completed.
A facility failed to maintain enough nursing staff to meet resident needs, resulting in delayed call light response, missed or late meds, and incomplete hygiene care. Residents reported waiting hours for help, not receiving showers consistently, and being left soiled or unable to get out of bed, while staff described severe shortages, very high resident-to-staff ratios, and admissions continuing despite unsafe staffing. An RN reported working an extended shift because no other RN was available, and leadership confirmed the staffing deficiency.
Late and incomplete medication administration affected 48 of 59 residents. An audit showed numerous scheduled meds, including oral, injectable, and ophthalmic orders, were documented hours after the ordered times, with some residents receiving multiple meds far later than prescribed. The Medical Director stated she was not notified about the missing or late meds, and the NHA confirmed the facility failed to ensure timely and complete administration.
An LPN documented a large number of medications and treatments as given, but later confirmed she did not provide all of them and said another LPN had given some of the care. She stated she was told by the former DON to sign off on items that had been given. The Medical Director was not notified that medications were not received, and facility leadership confirmed the records were not completely and accurately documented.
Failure to Provide Medical Records to Legal Surrogate: The facility did not ensure that a resident’s POA was given access to requested medical records for one resident. The resident had neurogenic bladder, anemia, and a hx of stroke. The request was received, incomplete records were sent, and repeated follow-up attempts by phone, voicemail, and a HIPAA Violation Notice did not result in the records being released; facility leadership confirmed legal approval had been obtained but the records still were not provided.
The facility failed to complete required MDS assessments within the required timeframe for six residents. Review of records showed late admission and annual MDS completions, and the Regional Director of Operations confirmed the deficiency during interview.
Failure to Protect Cognitively Impaired Resident from Sexual Contact: A resident with Alzheimer’s disease and dementia was repeatedly involved in inappropriate interactions with another resident who had a history of sexually inappropriate behavior toward her. Staff documented kissing, repeated room entry, and hands under blankets near the resident’s chest or groin, but redirection was not effective and supervision was not promptly escalated. The situation culminated in the male resident being found with his pants down while the resident touched his penis, and the report also notes an unexplained breast bruise that was not investigated to determine whether it was related to the incident.
Failure to convey resident funds after death. A resident with lung cancer, diabetes, and hyperlipidemia died after staff found her without respirations or pulse, with hospice and the DON notified and family present. Business office records later showed a $650 credit owed to the family, but records did not show the funds were issued, and the BOM confirmed the omission.
The facility failed to report alleged sexual abuse involving two residents after staff observed repeated kissing incidents and documented that one resident attempted to enter the other resident’s room and kissed her on the lips despite being told not to. One resident had dementia and impaired decision-making, and the other had age-related cognitive decline and other chronic conditions. The NHA and DON confirmed the allegations were not reported to the State as required.
Failure to Thoroughly Investigate Alleged Resident Abuse: The facility did not complete a thorough abuse investigation involving two residents after staff observed repeated kissing and one resident later had an unexplained bruise on the underside of her breast. The records showed limited investigation documentation, with no witness statements, resident assessments, other resident interviews, or family notification tied to the incident. The NHA and DON both confirmed the investigation was incomplete.
The NHA and DON failed to effectively manage the facility to ensure residents were free from abuse and to ensure abuse policies were implemented. Their job descriptions required them to direct daily operations in accordance with federal, state, and local standards to assure the highest degree of quality care, but the report states the facility failed to provide fundamental principles of treatment and care and failed to ensure care was delivered in accordance with professional standards and facility policies, resulting in an IJ situation.
Inconsistent Full-Time DON Coverage: The facility failed to ensure the consistent services of a full-time DON. The DON stated she worked multiple roles, including RN supervisor, nurse aide, and sometimes medication cart duties, and typically worked 12 to 16 hours a day, 6 to 7 days a week. She was observed providing direct resident care on the floor while a resident called out for help, and an LPN confirmed the DON was working as a nurse aide and sometimes on the med cart.
Improper Food Storage and Labeling in Kitchen Freezers: The facility failed to properly label, date, and store multiple food items in the kitchen freezers. Surveyors observed opened and unlabeled frozen foods, items without receive dates, and a sealed container that was not properly closed and had an expired use-by date. The Kitchen Manager confirmed the findings and stated that resident food stored in the freezer was not appropriate because chain of custody and food safety were not guaranteed.
Missing Annual Performance Evaluations for Nursing Staff: The facility failed to complete annual performance evaluations for four of five nursing staff records. Facility policy required timely annual evaluations after 90 days, but review of personnel files showed that four NAs did not have evaluations completed based on their hire dates. HR staff confirmed the facility was behind in evaluations and had not completed them for those employees.
A resident representative reported receiving a bill for her mother and said facility calls were not answered, and after speaking in person with a staff member and leaving her contact information, no one returned her call. The NHA stated the former BOM no longer worked there and that she was now handling billing concerns, but she had not been made aware of the issue and had not addressed it.
Failure to document advance directive discussions for two residents. The facility’s records did not show that two residents, both with significant medical diagnoses including HF, HTN, anxiety, COPD, and paraplegia, were given the opportunity to formulate an advance directive or that their resident representatives were provided the required information; a SW confirmed the documentation was not present.
A resident with HTN, DM, and chronic pain developed difficulty breathing and audible wheezing while on O2, and the daughter requested ER transfer. The record showed the daughter was updated, but there was no documentation that the physician was notified of the change in condition or hospital transfer, despite facility policy requiring such notification.
A resident with hyperlipidemia, HTN, dysphagia, and macular degeneration was documented as discharged with her son to an ALF, with scripts and discharge paperwork sent, but the clinical record did not include a physician order for discharge to Assisted Living/Personal care. The care plan called for staff to notify the doctor of discharge plans and help facilitate a safe discharge, and the NHA confirmed the missing discharge documentation.
A resident was transferred to the hospital and later returned, but the facility had no documented evidence that required transfer information was sent to the receiving provider, including care plan goals, advance directive info, resident representative info, and other details needed to meet the resident’s needs. The facility also lacked evidence that the LTC Ombudsman was notified of the transfer, and the DON and NHA confirmed the missing documentation.
Nutrition services failed to meet professional standards for comprehensive care plan development. The facility’s policy called for ongoing monitoring through resident interviews, direct observation, and staff interviews, but the RD stated she had been working remotely, did not come into the building, and did not observe residents or interview staff, residents, or families; she only accessed records remotely and emailed the DON.
A resident with paraplegia, insomnia, and muscle weakness did not receive an ongoing activity program that matched stated preferences for bingo, trivia, and socials. The activity calendar showed limited bingo offerings, the resident reported bingo was missed for a week, documentation reflected only one social activity in 21 days, and the DON confirmed the activity dept had only one staff member who also worked as a nurse aide.
Unsafe bed mobility and wheelchair transport were observed for two residents. A resident with bowel and bladder incontinence and toileting assistance needs reported that an aide moved her roughly during morning care and that she hit her head on a dresser while being rolled in bed. Another resident who used a wheelchair was transported without leg rests, and the EMS transport employee confirmed the leg rests were not applied before pushing the resident down the hallway.
Incorrect Tube Feeding Order and Inadequate Calorie Delivery: A resident with stroke, dysphagia, and HTN was NPO and receiving enteral nutrition via feeding tube, but the order did not specify the Glucerna strength and the resident was actually receiving Glucerna 1.5 at 30 mL/hr. RD notes documented calorie calculations that did not match the formula in use, the DON stated the MD did not want the rate increased due to prior intolerance, and both the RD and community RD confirmed the resident was not receiving the intended formula or documented calorie amount.
Failure to provide appropriate respiratory care for two residents receiving O2 therapy. One resident with HF, respiratory failure, and morbid obesity with alveolar hypoventilation had undated tubing, an empty humidification bottle, and no oxygen care plan despite orders for O2 and BIPAP. Another resident with HF, DM, and COPD had undated O2 equipment, and the care plan was not updated to match the current O2 orders and weekly tubing/humidifier changes.
A resident with low back pain and chronic pain did not receive ordered oxycodone as scheduled and was not assessed for pain each shift as required by the care plan. The MAR showed missed doses, and the resident reported significant pain after admission, stating she did not receive oxycodone until several days later and remained in bed with increased pain; later documentation noted pain rated 8/10 and affecting sleep, therapy, and daily activities.
Failure to identify PTSD triggers in a resident’s care plan. A resident with PTSD, HTN, and insomnia had a care plan that noted a traumatic event but did not identify any PTSD-related triggers, despite the facility policy requiring trigger identification and trigger-specific interventions to reduce retraumatization. The SW confirmed the lapse during interview.
Failure to implement ordered melatonin increase for a resident with insomnia and behavioral health diagnoses. The resident reported nearly constant trouble sleeping, shakiness, and long-standing poor sleep, and was observed with visible tremors and resting in bed with a sheet over his head. Psych ordered melatonin 6 mg nightly, but the order was not reflected in the MAR/orders for nine days, and the NP confirmed the delay.
Pharmacist Medication Review Not Addressed Timely: A resident with HTN, DM, dementia, and depression had a pharmacist medication regimen review that included a pharmacy recommendation requiring a response, but the clinical record did not show a physician response or evidence that the review was acted upon timely. The resident had orders for lorazepam PRN anxiety, a fentanyl patch for pain, and PRN morphine, and the NHA, Interim NHA, and DON confirmed the missing evidence during interview.
Unsecured Medication and Expired Supplies in Storage Areas: A resident’s prescribed Fungicure External Solution was found unsecured on a bedside table, and an LPN confirmed it was not secured. In the main med storage room, multiple expired supplies were observed, including lab tubes, wound dressings, wound vac canisters, and an opened foam kit; an RN confirmed the items were expired and should have been discarded after expiration.
Failure to use EBP during wound care: A resident with an open wound and orders for daily dressing changes did not have EBP signage posted or an EBP order in the chart. During the dressing change, an RN failed to remove gloves and perform hand hygiene after removing the old dressing and before applying the clean dressing, resulting in confirmed cross contamination concerns.
Crash cart checks on the Main Nursing Unit were not consistently documented, with missing RN Supervisor signatures on multiple dates. An observation found an opened, expired Ambu bag and an opened Suction Cath-N-Glove kit on the cart, and an RN confirmed the missing signatures and expired/open supplies.
A cognitively intact resident with bilateral above-knee amputations and opioid dependence, who was particular about receiving ordered oxycodone on time, began yelling when an LPN refused to enter the room and told the resident she did not have to come in while he was screaming. The resident and another cognitively intact resident reported that the NHA then entered, yelled at the resident, called him an addict, stated he sounded like an idiot, and threatened to beat him if he had legs, while the Director of Maintenance repeatedly removed the NHA from the room. Other residents reported hearing prolonged yelling and commotion. The LPN admitted she may have given the resident the middle finger and acknowledged telling him she would not come into the room until he calmed down, while she went outside to smoke. The resident documented these events in a letter to an RN supervisor, reporting feeling unsafe and humiliated, and the DON later confirmed that the facility failed to protect the resident from verbal abuse, resulting in severe psychosocial harm and an Immediate Jeopardy finding.
The facility failed to follow its abuse and neglect policy by allowing a social worker to begin work without a completed criminal background check and by not identifying, reporting, or investigating an allegation of abuse/neglect involving a resident. A cognitively intact resident with bilateral above-knee amputations reported verbal and attempted physical abuse by the NHA and inappropriate behavior by an LPN, documented the concerns in a letter given to an RN supervisor, and stated that nothing was done and the alleged perpetrators continued working. Staff interviews confirmed that the NHA had to be removed from the resident’s room during a verbal altercation, that the NHA continued to work afterward, and that the incident was not entered into the facility’s incident system or reported to required agencies at the time, leading surveyors to cite immediate jeopardy.
The facility failed to provide sufficient nursing staff and used inaccurate staffing assignments, resulting in unmet care needs for multiple residents. Several residents reported not receiving scheduled showers, not being assisted out of bed or back to bed, not having wounds dressed, and waiting extended periods for help such as obtaining portable oxygen. Staff interviews revealed that there were too few aides to turn and reposition residents, that non-nursing personnel such as a cook and a social worker were pulled to provide care without proper NA orientation, and that staffing sheets listed individuals who were not actually delivering resident care. On one shift with over 50 residents, an LPN reported having only one aide per hallway, and the administrator confirmed the facility did not have sufficient nursing staff to meet residents’ physical, mental, and psychosocial needs.
The facility assigned a Nurse Aide to function as the Kitchen Manager and Food Service Director without the required Certified Dietary Manager credentials or other documented qualifications. Over a three‑month period, this individual managed daily dietary operations despite lacking evidence of meeting regulatory requirements for the role. The Interim NHA and DON later confirmed that the facility had no documentation to show that the staff member met Food Service Director qualifications, resulting in noncompliance with state management regulations.
The Nursing Home Administrator failed to effectively manage the facility to ensure residents were free from abuse and to ensure that abuse policies were implemented, creating an immediate jeopardy situation. Review of the NHA’s job description, facility and clinical records, and staff interviews showed that, despite being responsible for directing day-to-day operations in accordance with applicable regulations, the NHA did not ensure that fundamental principles of treatment and care were provided. As a result, residents did not consistently receive treatment and care in accordance with professional standards of practice and facility policies, leading to citations under 28 Pa Code 201.14(a) and 28 Pa Code 201.18(b)(1)(e)(1).
The facility did not maintain an accurate and current facility assessment used to determine needed resources for resident care. The assessment listed former key personnel instead of the current NHA, DON, and ADON, contained census information tied only to a prior year-to-date period, and included resident information that had not been reviewed or updated since a previous assessment date. An interim NHA confirmed that the assessment had not been accurately completed and that resident information reflected data from the last time this employee worked at the facility, rather than current conditions.
Facility failed to meet resident care needs due to short staffing, with missed showers, repositioning, skin protection care, bed assistance, and mechanical lift transfers. Surveyors also found deficiencies in dietary management, including no qualifying coursework or on-site oversight for the Dietary Manager, the HR Director not being trained on Dietary Manager qualifications, an unqualified hire for the vacant DM role, and an outdated Facility Assessment.
The facility failed to follow its own policy requiring that initial comprehensive visits be completed by a physician, not by mid-level practitioners. For three residents—one with anxiety, depression, and lung cancer; one with gastroparesis, anemia, and esophagitis with bleeding; and one with emphysema, O2 dependence, and alcohol dependence with withdrawal—clinical record review showed that a CRNP conducted the initial admission or readmission assessments. Late entry notes documented these initial visits by the CRNP, and during interview the DON and interim administrator acknowledged that physician-completed initial visits did not occur as required.
Surveyors found that the facility did not timely document progress notes for four residents with conditions including anxiety, depression, lung cancer, dementia, tremor, history of falls, gastroparesis, anemia, esophagitis with bleeding, emphysema, O2 dependence, and alcohol dependence with withdrawal. Late entries were made several days after key clinical encounters, including an admission assessment, a right shoulder injection, evaluation of bilateral lower extremity swelling, and assessment for nausea, vomiting, and diarrhea. The DON acknowledged that progress notes were not documented in accordance with required clinical record standards.
Surveyors found that the facility did not provide required education on effective communication to an RN and four NAs hired over a span of several months. Review of staff training records showed no documentation of effective communication training for these direct care staff, despite regulatory requirements for staff development. The interim administrator confirmed during interview that these employees had not received the mandated communication training.
A resident with paraplegia and a Stage III pressure ulcer was care planned and had physician orders for q2h turning/repositioning, heel offloading while in bed, and use of offloading boots in bed. Documentation audits for two consecutive months showed multiple shifts without recorded turning and repositioning. The resident reported needing assistance and stated staff only turned him about twice per shift. During observation, the resident was in bed without the ordered offloading boots, which were found in a chair, and an LPN confirmed they were not applied as ordered. The DON acknowledged that interventions for residents at risk for pressure ulcers are expected to be implemented and documented each shift and confirmed the failure to document application of the offloading boots and to ensure ordered interventions were consistently provided.
The facility failed to maintain required NA staffing ratios per resident per shift, resulting in noncompliance on the majority of shifts reviewed. Despite prior education of the NHA and DON on state CNA ratio requirements, the facility used an outdated staffing hours calculator that did not reflect current regulations and did not maintain or provide the assignment grids that were supposed to guide NA staffing. Review of staffing worksheets and staff interviews showed that required NA coverage was not consistently provided, and surveyors determined the facility did not make a good faith effort to correct and sustain improvement for a previously cited staffing deficiency.
The facility did not maintain sufficient nursing staff to meet residents’ ADL and activity needs, resulting in missed showers, long call light response times, and residents sometimes remaining in bed because there were not enough aides to get them up or return them to bed. Activities such as Bingo and card games were cancelled, and some residents were unable to go to the dining room for meals due to inadequate staff to assist with transport and supervision. Staff reportedly told residents that these cancellations and limitations were due to staffing shortages, and the administrator confirmed that nursing staff levels were insufficient to support residents’ physical, mental, and psychosocial well-being.
A resident with a history of HTN, seizure disorder, and hyponatremia experienced a fall and was found on the floor, laughing, with no apparent injuries and stable VS. Facility policy and the 72-hour neuro assessment protocol required a series of scheduled neuro checks after falls, especially when unwitnessed or involving potential head impact. Although documentation indicated that neuro checks were initiated per protocol, review of the neuro assessment sheet showed that only 8 of 18 required checks were completed. The NHA and DON confirmed that the facility failed to ensure completion of the ordered neurological assessments following the fall.
A resident with dementia and moderate cognitive impairment was confronted in a public hallway by the NHA and a sheriff's deputy about a large unpaid bill, despite having a POA responsible for financial matters. The resident became confused and tearful during the incident, which was witnessed by staff and other residents. Staff expressed concerns about the public nature of the confrontation and the resident's ability to understand, and the NHA later acknowledged the failure to protect the resident from mental/emotional abuse.
A resident with moderate cognitive impairment, diagnosed with Multiple Sclerosis and other conditions, personally signed a Notice of Medicare Non-Coverage form instead of the responsible party. Facility policy requires that information and documentation be provided in a manner appropriate to the resident's cognitive status, but there was no evidence that the responsible party was informed or signed the necessary financial papers.
A resident with moderate cognitive impairment and a documented POA was directly confronted by the NHA and a sheriff's deputy regarding a large unpaid balance, despite the facility's awareness of the POA's authority. The facility failed to involve the resident's legal surrogate in legal actions related to non-payment, resulting in the resident being distressed and confused during the encounter.
A resident with dementia, hypertension, and anxiety was confronted in a hallway by the NHA and a sheriff's deputy regarding an alleged debt, resulting in the resident becoming visibly distressed and tearful. Multiple staff members witnessed the incident, considered it emotional or mental abuse, and submitted written statements. Despite facility policy requiring prompt reporting of abuse allegations, the incident was not reported to the state agency, and staff were discouraged from pursuing the matter.
Failure to Prevent Retaliation Against Staff
Penalty
Summary
The facility failed to prohibit and prevent retaliation against employees after staff members made complaints and attempted to speak with the State Survey Agency. Review of the facility handbook showed anti-retaliation language and disciplinary procedures, and a posting in the staff lounge stated that an LTC facility cannot punish or retaliate against an employee for lawfully reporting a crime. Despite those policies, survey interviews and employee file review identified five terminated employees whose terminations were described by the Nursing Home Administrator as being for "professionalism," with additional explanations such as refusal to complete an admission, aggression toward the NHA, alleged inciting of a verbal riot, and job abandonment. The personnel records reviewed for the terminated employees did not contain documentation supporting the reasons given for the terminations. One employee had no disciplinary actions in the prior 12-month rolling calendar and a performance evaluation showing meets or exceeds expectations. Another had one attendance-related disciplinary action and performance evaluations showing meets or exceeds expectations. Two employees had no performance reviews or disciplinary actions documented, and another had no disciplinary actions with performance evaluations showing meets or exceeds expectations. The NHA confirmed that the files did not contain documentation of the behaviors cited as the basis for termination. During confidential staff interviews, multiple employees reported unsafe staffing, residents not receiving timely care, and fear of retaliation for speaking with surveyors or reporting concerns. One staff member stated the Interim DON called to ask why the staff member wanted to speak to the surveyor, and the staff member later reported being terminated by voicemail. Other staff reported being told that if they called the state they would be immediately terminated, that management knew who was calling the state, and that employees were being told to keep their mouths shut. On survey, the facility administration was made aware that the facility failed to prohibit and prevent retaliation for five of fifteen staff members.
Missed Pressure Ulcer Treatments for Four Residents
Penalty
Summary
The facility failed to provide prescribed treatment and services related to pressure ulcer care for four residents. The report states that the facility policy required prevention of avoidable pressure injuries and treatment to heal existing pressure ulcers and prevent infection and additional ulcers. During review of records, observations, and staff interviews, surveyors found repeated missed or undocumented dressing changes and wound treatments for residents with multiple pressure injuries, including Stage IV, Stage III, Stage II, and unstageable wounds. Resident R6 had paraplegia, multiple sclerosis, and diabetes, and was assessed as high risk for pressure ulcer development. The resident had a Stage IV pressure ulcer on the right ischium, a Stage IV pressure ulcer on the coccyx, and a Stage III pressure ulcer on the left ischium. Physician orders directed daily cleansing and dressing changes for the coccyx wound and posterior thigh wounds, but the TAR did not show wound care completed on multiple dates in May and June 2026, with no refusals documented. Resident R16 had COPD, heart failure, and muscle wasting, was at moderate risk for pressure ulcers, and later had facility-acquired Stage III pressure ulcers on both buttocks and an unstageable coccyx wound. Orders required daily then every-other-day dressing changes, but the TAR and progress notes did not show completion on several dates. Resident R26 had multiple sclerosis and neurogenic bladder and had a Stage IV coccyx pressure ulcer. Orders required daily wound care, including a wound vac period, but the TAR failed to show completion on multiple dates, and some entries only referenced progress notes without confirming the dressing change was done. Resident R44 had lymphedema, hypertension, and CAD, and had two facility-acquired Stage II pressure ulcers on the right thigh. Orders required daily then twice-daily dressing changes, but the TAR failed to show completion on multiple dates, with one refusal documented and one progress note that did not confirm treatment. The Medical Director stated she was not notified about wound treatments not being completed, and the Regional Director of Operations and Nursing Home Administrator confirmed the facility failed to provide prescribed treatment and services related to pressure ulcer care for four of five residents.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain the highest practicable physical, mental, and psychosocial well-being for 16 of 20 residents interviewed and/or observed. The deficiency was supported by resident observations showing delayed response to call lights, residents left waiting for assistance, and multiple residents appearing unkempt or soiled. During one observation, a resident’s call light alarmed for about ten minutes before being answered, and a nurse aide walked past the room without checking on the resident. Other observations noted residents with long, unclean fingernails, dirty clothing, greasy or unbrushed hair, facial hair, and malodor. Resident interviews described repeated delays in care and missed or late services. Residents reported call lights taking a long time to be answered, sometimes for hours, and stated that showers were not consistently provided. Several residents said medications were given late or missed entirely, including one resident who reported morning medication was not received until about 1:00 p.m. Another resident stated that when only a few staff were working, showers would not be done at all, and described a colostomy bag that became full and then leaked onto the resident after staff did not return. A resident also reported being left in a wheelchair after therapy and having to cancel a planned family celebration because there were no aides available to get the resident out of bed. Staff interviews confirmed severe staffing shortages and related care failures. Confidential staff reported that staffing was “horrible,” that numbers were being made up, that some shifts had only two CNAs, and that showers, snacks, wound treatments, and resident interaction were not being completed because there was not enough staff. Staff also reported long call light response times, residents waiting to be changed, housekeeping staff helping with meal trays, and admissions continuing despite unsafe staffing. One RN stated she worked from 9:17 a.m. one day until 9:12 a.m. the next day because no other RN was available, and that she received an admission during that period. The Medical Director and the Regional Director of Operations, along with the Nursing Home Administrator, confirmed the facility failed to have sufficient nursing staff to provide nursing and related services for the residents identified.
Late and Incomplete Medication Administration
Penalty
Summary
The facility failed to ensure the complete and timely administration of prescribed medications for 48 of 59 residents. Review of the facility’s Medication Administration policy stated that medications are to be administered by licensed nurses or other legally authorized staff as ordered by the physician and in accordance with professional standards of practice. The deficiency was identified through review of the Medication Admin Audit Report, which showed multiple residents had scheduled medications documented as given hours after the ordered administration times. Examples in the report included residents with morning medications ordered for 7:00 a.m. or 8:00 a.m. that were documented as administered later in the morning, at midday, or in the afternoon. Several residents also had noon or early afternoon medications documented much later than ordered. The report listed numerous instances involving oral, injectable, ophthalmic, and other medications, with delays ranging from minutes to several hours. In some cases, multiple medications for the same resident were documented at the same late time. During interview, the Medical Director confirmed she was not notified by facility staff about missing and/or late medications on the audit date. The Nursing Home Administrator also confirmed that the facility failed to ensure the complete and timely administration of prescribed medications for 48 of 59 residents. The cited regulatory references were 28 Pa. Code 201.14(a), 211.9(a)(1)(d), 211.10(c), and 211.12(d)(1)(3)(5).
Incomplete Medication and Treatment Documentation
Penalty
Summary
The facility failed to ensure that medical records for each resident were completely and accurately documented. A Medication Administration Audit Report for 6/11/26 showed that an LPN documented providing numerous medications and treatments between 2:00 p.m. and 4:00 p.m., including oral, topical, injected, intravenous, inhaled, and ophthalmic medications, blood sugar assessments, nutritional supplements, a tuberculosis test assessment, pain assessments, skilled nursing assessments, whole body skin assessments, vital sign assessments, and a weight assessment. During interview, one LPN confirmed she did not provide all of the medications and treatments, and another LPN stated that some of the medications and treatments had been provided by a different LPN. That LPN also stated she had been told by the former DON to sign off on them since they were given. The Medical Director confirmed she was not notified by facility staff about medications not being received, and the NHA and Regional Director of Operations confirmed the facility failed to make certain that medical records on each resident were completely and accurately documented.
Failure to Provide Medical Records to Resident’s Legal Surrogate
Penalty
Summary
The facility failed to ensure that a resident’s legal surrogate, the power of attorney, was provided access to medical records for one of two residents. Resident R51 was admitted to the facility with diagnoses that included neurogenic bladder, anemia, and a history of stroke. Review of information submitted to the state survey agency showed that a request for patient health information was submitted on 12/19/25, and the custodian was contacted on 12/31/25 after the request was received. The custodian submitted incomplete records on 01/04/26, and from 01/21/26 through 05/26/26, multiple attempts were made to contact the custodian by phone calls, voicemails, and a HIPAA Violation Notice. Despite these efforts, the requested records remained outstanding, and the facility had not released the records without valid justification for the delay. Review of the resident’s electronic medical record did not reveal information related to the request, and facility interviews confirmed that the request had been received by a previous NHA, that legal department approval for release had been obtained, and that the medical records still had not been provided to the requestor.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were completed within the required time frame for six of 24 residents. The RAI User's Manual dated October 2025 stated that an admission MDS assessment must be completed no later than 14 days after admission and that an annual MDS assessment must be completed no later than the ARD. Review of clinical records showed that Resident R3 was admitted on 4/20/26 and had an MDS completion date of 5/15/26; Resident R6 had an annual MDS ARD of 4/22/26 with completion on 5/13/26; Resident R15 had an annual MDS ARD of 4/2/26 with completion on 6/4/26; Resident R17 was admitted on 3/20/26 with MDS completion on 4/3/26; Resident R20 had an annual MDS ARD of 4/22/26 with completion on 5/13/26; and Resident R37 was admitted on 4/6/26 with MDS completion on 4/21/26. During an interview on 6/23/26, the Regional Director of Operations confirmed that the facility failed to make certain that MDS assessments were completed in the required time frame for these residents.
Failure to Protect Cognitively Impaired Resident from Sexual Contact
Penalty
Summary
The facility failed to protect a cognitively impaired resident from non-consensual sexual contact by another resident who had a documented history of sexually inappropriate behavior toward her. Resident R1 had diagnoses of Alzheimer’s disease, dementia, and bipolar disorder, and her MDS indicated moderately impaired cognition with impaired daily decision-making. Resident CR2 was initially documented as cognitively intact, but later records added dementia. The report states that CR2 had repeated sexually inappropriate interactions with R1, including entering her room, kissing her, and being found with his hand under her covers near her chest or groin area. Facility documentation and staff statements show that the behavior escalated over time and that prior boundaries were not effectively enforced. A nurse documented that CR2 attempted to follow R1 into her room and kissed her despite being told not to. Another note stated that constant redirection was not working because he continued to go into R1’s room and became angry when asked to leave. The physician documented that the male resident was wanting to cross personal boundaries and that R1 was not against the relationship, but both residents needed protection. The report also states that the facility did not initiate one-to-one supervision when it was first identified that redirection was ineffective, and that CR2 was not placed on the documented supervision level until later. The deficiency culminated in an incident in which CR2 was found in R1’s room with his pants down and R1 touching his penis, while other documentation described him exposing his genitals to her and her hands being on his genitals. Earlier, staff had also observed CR2 in R1’s room with his hand under her blankets near her groin or breast area. R1 later had a bruise on the underside of her right breast, but the report states the facility did not investigate that bruise to determine whether it was related to the fall or to the sexual incident. The report also states that the facility did not timely obtain psychiatric evaluation for either resident after the incident, and that R1’s family had expressed that they wanted no kissing, touching, or private visiting between the two residents.
Failure to Convey Resident Funds After Death
Penalty
Summary
The facility failed to convey funds credited to a deceased resident’s family after the resident died. Review of the resident trust fund policy dated 1/16/26 indicated the facility was to maintain a system ensuring full, complete, and separate accounting of each resident’s account funds. Closed Resident Record CR3 showed the resident was admitted to the facility and had diagnoses on the MDS assessment dated 9/21/25 that included lung cancer, diabetes, and hyperlipidemia. A clinical nurse note dated 10/30/25 documented that staff were called to the resident’s room by family, assessed her, and found she had no apical pulse, no respirations, and fixed, dilated pupils; she was pronounced dead at 9:28 a.m., with hospice and the DON notified and her daughter and son-in-law present. Review of business office documents dated 5/28/26 showed Closed Resident Record CR3 had a credit of $650 owed to her family. However, review of the resident’s clinical records and business office records did not show that the credit was issued to the family. During an interview on 5/28/26 at 11:56 a.m., the BOM confirmed that the facility failed to convey the funds credited to Closed Resident Record CR3’s family as required.
Failure to Report Alleged Sexual Abuse Between Two Residents
Penalty
Summary
The facility failed to report allegations of sexual abuse for two resident incidents involving Resident R1 and Closed Resident Record CR2. The facility policy titled Abuse, Neglect, and Exploitation required alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, including immediately but no later than 2 hours when abuse is involved. Review of the records showed that Resident R1 had diagnoses including COPD, diabetes, dementia, and impaired cognition for daily decision making, while CR2 had diagnoses including age-related cognitive decline, chronic kidney disease, hypertension, and anxiety disorder. Clinical notes documented repeated kissing between the two residents. On 4/9/26, CR2 was observed attempting to enter R1's room and then kissing R1 on the lips after staff told him he could not do so. On 4/13/26, a nurse aide confronted CR2 after he became angry when told they were not allowed to kiss. On 4/25/26, staff again observed CR2 kissing R1 in front of her room, and the DON also witnessed the kissing. Although the facility documented notifications to families and the physician and noted separation of the residents, the alleged sexual abuse incidents on 4/9/26, 4/13/26, and 4/25/26 were not reported to the State field office as required. The NHA and DON both confirmed the failure to report these allegations.
Failure to Thoroughly Investigate Allegations of Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of allegations involving resident abuse for two residents. The facility policy titled Abuse, Neglect, and Exploitation stated that abuse includes willful infliction of injury, intimidation, punishment, verbal abuse, physical abuse, sexual abuse, and deprivation of goods and services necessary for well-being, and that an immediate investigation is warranted when abuse is suspected or reported. The policy also required identifying staff responsible for the investigation, interviewing all involved persons and witnesses, focusing on whether abuse, neglect, exploitation, or mistreatment occurred, and documenting the investigation completely and thoroughly. One resident had diagnoses including COPD, diabetes, and dementia, with impaired cognition for daily decision making. Staff documented that the two residents were observed kissing, were separated, and both were interviewed by the RN supervisor, with both stating they were friends and had kissed but not touched. Later, the same resident was noted to have a 5 cm reddish bruise on the underside of her right breast, and she stated she had fallen a couple of days earlier after slipping out of her chair and did not recall another incident. Additional notes documented further kissing incidents between the two residents, including one in which a resident attempted to follow the other into her room and kissed her on the lips after being told not to. The facility’s abuse investigation records did not include witness statements, resident assessments, other resident interviews, or family notification related to the 4/25/26 incident. The Nursing Home Administrator confirmed the facility failed to conduct a thorough investigation for the 4/25/26 allegation, and the DON confirmed the facility failed to conduct a thorough investigation for the 4/9/26, 4/10/26, and 4/13/26 allegations involving the same two residents. The cited regulations included 28 Pa. Code: 201.14(a), 201.18(b)(1), 211.10(c)(d), and 211.12(d)(1)(2)(3)(5).
Failure to Manage Abuse Prevention and Policy Implementation
Penalty
Summary
The NHA and DON did not effectively manage the facility to ensure residents were free from abuse and failed to ensure the facility implemented its abuse policies. A review of the NHA and DON job description showed their primary purpose was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations to assure the highest degree of quality care could be provided to residents at all times. Based on the findings in the report, the facility failed to provide the fundamental principles that apply to treatment and care provided to residents and failed to ensure residents received treatment and care in accordance with professional standards of practice and facility policies, resulting in an immediate jeopardy situation.
Inconsistent Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure the consistent services of a full-time Director of Nursing (40 or more hours a week). The DON job description stated the position was responsible for planning, organizing, developing, and directing the overall operation of the Nursing Service Department and included duties such as assisting the Infection Control Coordinator, monitoring in-service training, and ensuring sufficient licensed nurses and nurse aides were scheduled and working during all shifts. Information reported to the State Department of Health indicated the DON started at the facility on 12/22/26. During an interview, the DON stated she completed DON duties Monday through Friday during the daylight shift and could not be on a medication cart, but also said she acted as RN Supervisor and DON two to three times a week and sometimes was assigned a medication cart. She stated it was hard to do all the things and that she typically worked 12 to 16 hours, 6 to 7 days a week. The DON also confirmed she was responsible for nursing education and Infection Preventionist duties. On 4/23/26, the DON was observed working on the floor and stated she was assigned to work as an aide for the daylight shift. She was observed assisting surveyors while a resident called out for help, and she told the resident she would be right there. The DON confirmed she was assigned to the C Wing hallway and was providing direct resident care. An LPN confirmed the DON was working as the nurse aide and that the DON sometimes worked on the medication cart. The Nursing Home Administrator confirmed the facility failed to ensure the consistent services of a full-time DON in the facility.
Improper Food Storage and Labeling in Kitchen Freezers
Penalty
Summary
The facility failed to properly store, label, and date food items in the Main kitchen. Review of the facility policy on dating for food storage indicated that foods removed from original packaging were to be dated, and foods requiring time and temperature control were to be labeled with the common name of the food, the date made, and the use-by date. During observation of the Main Kitchen walk-in freezer, an opened bag of tater tots was found with no label or date, two bags of frozen noodles were not labeled or marked with a received date, three grocery bags of ice cream cups had no label or receive date, and a plastic container of kielbasa and sauerkraut had the lid off-center and was not sealed, with a use-by date of 4/10/26. During observation of the Main Kitchen stand-up freezer, a bag of potatoes was found with no label or receive date. The Kitchen Manager confirmed the findings and stated that the ice cream had been brought in by a resident's family and would not fit into the freezer in the nursing unit provided for resident use. The Kitchen Manager also stated that storing resident food in the freezer was not appropriate because chain of custody of the food and food safety were not guaranteed, and confirmed that the facility failed to properly label, date, and store food items.
Missing Annual Performance Evaluations for Nursing Staff
Penalty
Summary
The facility failed to complete annual performance evaluations for four of five nursing staff personnel records, identified as Nurse Aides E10, E11, E12, and E13. Facility policy titled Employee Performance Evaluations, dated 3/16/26, stated that all employees receive timely, fair, and consistent performance evaluations, with evaluations conducted annually after 90 days. Review of personnel records showed that E10 was hired on 2/7/24 and had a last performance evaluation dated 6/20/24; E11 was hired on 10/30/23 and had a last evaluation dated 11/11/24; E12 was hired on 2/29/24 and had a last evaluation dated 8/7/24; and E13 was hired on 6/22/23 and had a last evaluation dated 6/24/24. The records did not include annual performance evaluations based on each employee’s date of hire. During interview, Human Resource Employee E4 stated the facility was behind in evaluations and trying to get caught up, and confirmed that annual performance evaluations had not been completed for these four nursing staff records.
Failure to Respond to Resident Representative Billing Concerns
Penalty
Summary
The facility failed to ensure that a resident representative had communication and access to persons and services inside the facility for one resident, R64. A resident representative reported receiving a bill on behalf of her mother and stated that when she called the facility, no one answered the phone; she also went in person, spoke with a young staff member, explained the billing concern, and left her name and phone number, but no one returned her call. During interview, the Nursing Home Administrator stated that the Business Office Manager who previously handled billing no longer worked at the facility and that the administrator was now handling these concerns, but she had not been made aware that the resident representative needed to speak with someone about the bill and had not addressed the concern. The administrator acknowledged that failure to return phone calls and answer questions failed to ensure ease of communication with persons inside the facility.
Failure to Document Opportunity to Formulate Advance Directives
Penalty
Summary
The facility failed to provide documentation that residents or resident representatives were given the opportunity to formulate an advance directive for two of three residents reviewed, Resident R4 and Resident R5. The facility policy dated 3/16/26 stated that on admission the facility would determine whether a resident had executed an advance directive and, if not, whether the resident would like to formulate one, and that the facility would provide residents or resident representatives information on formulating advance directives. Resident R4 was admitted to the facility and had an MDS dated 4/7/26 showing diagnoses of heart failure, high blood pressure, and anxiety. Review of the clinical record failed to reveal an advance directive or documentation that Resident R4 was given the opportunity to formulate one. Resident R5 was admitted to the facility and had an MDS dated 2/12/26 showing diagnoses of high blood pressure, COPD, and paraplegia. Review of the clinical record also failed to reveal an advance directive or documentation that Resident R5 was given the opportunity to formulate one. During an interview on 4/22/26 at 12:30 p.m., the Social Worker stated that it was not documented anywhere and confirmed the lack of documentation for both residents.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident R1, who was admitted with diagnoses including high blood pressure, diabetes, and chronic pain. A progress note documented that the resident’s daughter requested transfer to the emergency room because the resident was having difficulty breathing; the resident was found sitting in a wheelchair on oxygen with audible wheezing, and the daughter was updated on the resident’s condition before the resident was sent to the emergency room. Review of the clinical record did not show that the change in condition and hospital transfer were communicated to the physician, despite the facility policy requiring notification of the resident’s physician and family member when there is a significant change in condition or a transfer from the facility.
Missing discharge documentation for a resident transferred to assisted living
Penalty
Summary
The facility failed to ensure that discharge documentation was on record for one closed resident record, Closed Resident Record R64. Facility policy on transfer and discharge required that, for transfer to another provider, the receiving provider be given the contact information of the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, and other necessary information. However, review of R64’s clinical nurse notes, physician orders, and physician assessment documents did not include an order to discharge to Assisted Living/Personal care. Closed Resident Record R64’s admission record showed she was admitted to the facility, and her MDS dated 8/24/25 listed diagnoses of hyperlipidemia, hypertension, dysphagia, and macular degeneration. Her care plan dated 8/20/25 directed staff to notify the doctor of discharge plans and work with the resident to facilitate safe discharge. A clinical nurse note dated 9/12/25 stated that R64 was discharged with her son to an assisted living facility, that scripts were sent, and that discharge paperwork was sent with her son. During interview on 4/23/26, the NHA confirmed the facility failed to ensure discharge documentation was on record for R64, including a physician order to discharge to Assisted Living as required.
Failure to Communicate Transfer Information and Notify Ombudsman
Penalty
Summary
The facility failed to ensure that required resident information was communicated to the receiving health care provider when Resident R1 was transferred to the hospital and later returned to the facility. The clinical record showed that Resident R1 was admitted to the facility, had an MDS dated 3/31/26 listing diagnoses of high blood pressure, diabetes, and chronic pain, and was transferred to the hospital on 3/19/26 before returning on 3/23/26. Review of the record found no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or other information needed to meet the resident’s needs at the receiving facility. The facility also failed to provide documented evidence that a written transfer notification was sent to the Office of the Long-Term Care Ombudsman for Resident R1’s hospitalization. Facility policy stated that transfer information must include practitioner contact information, resident representative contact information, advance directive information, and other information necessary to meet the resident’s needs. During interviews, the DON confirmed there was no evidence that the necessary information was communicated to the receiving health care institution or provider, and the NHA confirmed there was no documented evidence that the Ombudsman was notified of the transfer.
Nutrition Services Did Not Meet Professional Standards for Care Plan Development
Penalty
Summary
The facility failed to ensure that nutrition services met professional standards of quality for comprehensive care plan development for two months, March and April 2026. Review of the facility’s Nutritional Management policy dated 3/1/26 and previously dated 1/21/26 stated that monitoring of the resident’s condition and care plan interventions would occur on an ongoing basis, including interviewing the resident or resident representative, directly observing the resident, and interviewing direct care staff about the resident’s interventions and reporting responsibilities. During a telephonic interview on 4/22/26 at 12:46 p.m., the RD confirmed that she had worked from home for the past two months, now worked in Ohio, and did not come into the building. She stated that she accessed records remotely and communicated needs to the DON by email, but did not observe residents or conduct interviews with staff, residents, or families, and confirmed that current practices failed to meet professional standards of quality for comprehensive care plan development.
Insufficient Activity Program and Staffing
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of Resident R15. The facility policy stated that residents would be provided an ongoing program of activities based on their comprehensive assessment, care plan, and preferences, with facility-sponsored group, individual, and independent activities designed to meet each resident’s interests. Review of the April 2026 activity calendar showed bingo scheduled only twice that month during the reviewed period, and Resident R15’s care plan and quarterly activity participation review identified bingo, trivia, and socials as preferred activities. Resident R15 was admitted and readmitted with diagnoses including paraplegia, insomnia, and muscle weakness. During interview, the resident stated the facility usually had bingo three times a week, but bingo was only offered once the prior week. Documentation showed the resident participated in a social activity for only one of 21 days, and the facility failed to document activities provided for the resident. The Director of Activities confirmed bingo was cancelled on one scheduled day, stated bingo was scheduled every Monday and Wednesday with residents calling bingo on Saturdays, and stated it was difficult to document activities. The Director of Activities also stated she was the only employee in the activity department and helped on the floor as a nurse aide. During resident council interview, two of seven residents voiced concerns about insufficient activity staff and missing bingo activities for a week.
Unsafe Bed Mobility and Wheelchair Transport
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards and provide safe bed mobility for one resident. Resident R32 had diagnoses including anxiety disorder, hyperlipidemia, and diabetes, and her care plan indicated she was occasionally incontinent of bowel and bladder and required assistance with toileting needs. During the incident, she reported that a nurse aide moved her roughly while providing care, told her to roll to the left, and that she hit her head on the dresser. The resident’s dresser was observed near her window, and no bruising or pain was noted on observation. The resident stated that she rang the bell twice and that the aide was “like a gazelle” and “like a wild woman.” She said the aide was hysterical with her, changed her instead of taking her to the bathroom, and was pretty rough during the process. The nurse aide stated she checked residents who stayed in bed, asked Resident R32 if she needed the bedpan, rolled her over, placed her on the bedpan, washed her up, and gave morning care. The aide stated the resident did not say she was hurt and did not show signs of pain, but acknowledged that the resident was rolled twice during care and that she may have been moved toward the dresser. The facility also failed to ensure leg rests were applied to another resident’s wheelchair before transport. Resident R53 had diagnoses including adult failure to thrive, unsteadiness on feet, and muscle wasting and atrophy, and used a wheelchair. During observation, the resident was sitting in the wheelchair without leg rests, and EMS transport began pushing the resident down the hallway without them. The EMS transport employee confirmed he failed to apply the leg rests and failed to ensure the resident’s environment remained free of accident hazards.
Incorrect Tube Feeding Order and Inadequate Calorie Delivery
Penalty
Summary
The facility failed to ensure that Resident R10, who had diagnoses of stroke, difficulty swallowing, and high blood pressure and was receiving nutrition through an enteral feeding tube, received appropriate treatment and services related to the tube feeding. The resident’s MDS indicated tube feeding use, and the clinical record showed a Medical Nutrition and Hydration Evaluation on 3/26/26 stating the resident was NPO and receiving Jevity 1.2 at 30 mL per hour continuously, with a recommendation to increase the rate to 65 mL per hour for 20 hours per day to meet estimated calorie needs. A physician order dated 4/1/26 directed Glucerna at 30 mL continuously, but the order did not specify the type or strength of Glucerna to be provided. A later RD evaluation on 4/9/26 documented the resident was receiving Glucerna at 30 mL per hour continuously and stated the current tube feed provided 720 calories, with a recommendation to continue the tube feeding as ordered, even though the report states the resident was receiving 830 to 1,140 calories less than estimated needs. During observation on 4/22/26, the resident was receiving Glucerna 1.5 at 30 mL per hour. The DON stated the physician did not want the rate increased because the resident had trouble tolerating the feeding in the hospital, but there was no documentation of that decision in the clinical record. The RD later confirmed the resident was not receiving the required calories, that this was based on advice from a community RD, and that the facility failed to document this. The community RD also confirmed she intended Glucerna 1.2, not 1.5, and acknowledged the facility failed to provide the correct formula because the order was not written correctly.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving oxygen therapy. Resident R14 had diagnoses of heart failure, respiratory failure, and morbid obesity with alveolar hypoventilation, and had physician orders for one liter of oxygen every shift and BIPAP at bedtime and naps. During an observation, R14 was found lying in bed with oxygen on, with undated nasal cannula tubing and an empty humidification bottle dated 4/13/26. The resident’s care plan did not include a care plan for oxygenation use, and the RN Supervisor confirmed the facility failed to implement a care plan for R14’s oxygen use. Resident R44 had diagnoses of heart failure, diabetes, and COPD, and had physician orders for oxygen at two liters per minute via nasal cannula every shift and to change the humidifier and tubing weekly on Sundays. During an observation, R44 was lying in bed with oxygen on, and the oxygen nasal cannula and humidification bottle were not dated. The resident’s care plan intervention still reflected oxygen as needed for shortness of breath rather than the current plan of care, and staff confirmed the tubing and humidification bottle were missing dates and should be changed weekly. The RN also confirmed that R44’s oxygen care plan was not updated to reflect the current plan of care.
Failure to Assess and Administer Ordered Pain Medication
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with low back pain, anxiety, and chronic pain. The resident’s care plan identified pain or risk for pain and discomfort and included interventions to administer pain medications as ordered, observe for side effects and effectiveness, complete pain assessments, and observe for pain each shift. Physician orders included Tylenol as needed and oxycodone for low back pain, with the oxycodone order later changed to scheduled dosing every 6 hours for pain. The clinical record did not include evidence that the resident’s pain was monitored and assessed each shift from 3/21/26 to 3/23/26, and the MAR showed the facility did not administer the ordered 5 mg oxycodone every 6 hours during that period. The resident later reported that after arriving at the facility she was in pain, did not receive any oxycodone until Tuesday after arriving on Friday evening, and spent the weekend in bed with increased pain. A progress note documented the resident lying in bed and stating she had a lot of pain in her hips, and the MDS indicated pain was present almost constantly, affected sleep and therapy participation, limited day-to-day activities, and was rated 8/10.
Failure to Identify PTSD Triggers in Care Plan
Penalty
Summary
The facility failed to provide trauma informed care for Resident R43, who had a diagnosis of PTSD, high blood pressure, and insomnia. Review of the facility’s Trauma Informed Care policy showed that the facility was to identify triggers that may retraumatize residents with a history of trauma and add trigger-specific interventions to the care plan to decrease exposure to those triggers or mitigate their effects. However, review of Resident R43’s care plan for PTSD showed that it identified a traumatic event but did not identify any triggers related to PTSD. During an interview, the Social Worker confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization for Resident R43.
Failure to Implement Ordered Melatonin Increase for Resident With Insomnia
Penalty
Summary
The facility failed to ensure Resident R50 received appropriate behavioral health management to maintain the highest practicable well-being. The facility policy stated residents should receive necessary behavioral health services to support their highest level of mental and psychosocial functioning. Resident R50’s record showed diagnoses of unspecified dementia with other behavioral disturbances, depression, and schizoaffective disorder, and the care plan directed staff to monitor, document, and report adverse reactions related to antidepressant therapy, including changes in behavior or mood such as insomnia. The MDS indicated the resident reported trouble falling asleep or staying asleep 12-14 days in the last two weeks, and a psych re-evaluation documented ongoing insomnia with no relief in four years and a request to increase melatonin. The psych note ordered melatonin to be discontinued and replaced with 6 mg nightly for sleep disorder, and the plan and education were reviewed with the resident and nursing staff. During interview and observation, Resident R50 stated he was shaky all the time, was not getting much sleep at night, and had not slept well for five years; the resident was also observed with visible tremors and later resting in bed with a sheet over his head. Review of physician orders failed to show the melatonin increase had been entered, and the Nurse Practitioner confirmed the facility had not increased the melatonin to 6 mg as ordered for nine days. The Regional Director of Clinical Operations confirmed the facility failed to ensure the resident received appropriate behavioral health management.
Pharmacist Medication Review Not Addressed Timely
Penalty
Summary
The facility failed to provide evidence that the licensed pharmacist’s monthly medication regimen review was reviewed and acted upon timely for one sampled resident, Resident R8. The facility’s Medication reconciliation policy stated that monthly reconciliation included pharmacy consultation access to all medication areas and records and required responses to medication irregularities reported by the pharmacy consultant. Resident R8 was admitted on [DATE] and, on the 4/8/26 MDS, was documented with hypertension, diabetes, dementia, and depression. His care plan dated 4/20/26 included depression, administering medications as ordered, and monitoring for side effects. Resident R8’s physician orders included lorazepam concentrate 0.5 ml sublingually every 4 hours as needed for anxiety, fentanyl patch 25 mcg transdermally every 72 hours for pain, and morphine 10 mg sublingually every 2 hours as needed for pain. The pharmacist medication review dated 2/9/26 showed a medication regimen review with a pharmacy recommendation requiring a response, but the medication and recommendation details were not documented. The clinical record did not include a physician response to the pharmacy recommendation. During interview, the NHA, Interim NHA, and Mobile DON confirmed the facility failed to provide evidence that the pharmacist’s medication regimen review was reviewed and acted upon timely for Resident R8 as required.
Unsecured Medication and Expired Supplies in Storage Areas
Penalty
Summary
Drugs and biologicals were not stored securely in the facility’s Main Storage Room, and one resident’s medication was left unsecured. Resident R45, who was admitted with diagnoses including adult failure to thrive, urinary tract infection, and anxiety, had a physician order for 1% Fungicure External Solution to be applied to the fingernails topically twice a day for fungal treatment for four weeks. During observation, the resident’s bottle of Fungicure External Solution was found unsecured on the bedside table, and an LPN confirmed that the medication was not secured. In the Main Storage Room, multiple medical supplies were observed expired during a medication storage room review. The expired items included lavender, mint, and pink lab tubes, black foam wound dressing supplies, a black foam kit that was opened, [NAME] Foam Dressing, Drape File Dressing, wound vac canisters, and a large foam kit. An RN confirmed the expired supplies and stated they should have been disposed of after the expiration date.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to prevent cross contamination and failed to implement appropriate transmission-based precautions for one resident with an open wound. Facility policy for Enhanced Barrier Precautions indicated that gown and glove use should be employed during high-contact resident care activities for residents with wounds, and the clean dressing change policy required gloves to be removed after the old dressing was taken off, followed by hand hygiene and clean gloves before continuing wound care. Resident R3 had diagnoses including high blood pressure, diabetes, and anxiety, and had a physician order for daily wound care to the area above the left knee using wound cleanser, xeroform, calcium alginate, and a super absorbent dressing. During observation of the resident’s room, there was no signage posted at the door indicating the resident was ordered Enhanced Barrier Precautions, and the resident’s physician orders did not include an order for EBP. During the dressing change, the RN failed to remove gloves and wash hands after removing the old dressing and before applying the clean dressing. The RN confirmed the failure to implement Enhanced Barrier Precautions and to prevent cross contamination during the dressing change, and the Nursing Home Administrator confirmed the resident should have been in Enhanced Barrier Precautions.
Crash Cart Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep the Main Nursing Unit crash cart in safe operating condition. Facility documentation stated the emergency cart was to be checked daily by the night shift RN Supervisor for expiration dates and missing items, but the records reviewed showed missing signatures on multiple dates in January and February 2026. During an observation of the crash cart at the Main Nurses Station, the surveyor found an opened Ambu bag that had expired and an opened Suction Cath-N-Glove kit. During an interview, RN Employee E3 confirmed the missing signatures and the expired/open supplies on the crash cart.
Verbal Abuse and Threats by Administrator and LPN Toward Resident Requesting Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and mental abuse by facility leadership and nursing staff, resulting in severe psychosocial harm in the form of embarrassment and humiliation. The facility’s own abuse policy, reviewed with a date of 1/21/26, states that the facility will not tolerate abuse, neglect, or exploitation and defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal and mental abuse. Despite this policy, a cognitively intact resident with bilateral above-knee amputations and opioid dependence, who had a physician’s order for oxycodone 10 mg every four hours, reported that when he requested his pain medication, an LPN refused to assist and told him she would not come into his room while he was screaming. The resident stated that this led him to yell and scream for help. The resident reported that the Nursing Home Administrator (NHA) then came to his room and verbally abused and threatened him. According to the resident, the NHA told him he sounded like an idiot and stated that if the resident had legs, he would beat his “a**,” and also yelled out the resident’s medical history, including calling him an addict, in a manner that could be heard by others. The resident stated that the Director of Maintenance had to pull the NHA out of his room twice. Another cognitively intact resident confirmed witnessing the altercation, stating that the NHA physically threatened the resident, referenced his medical information, and called him an addict, and that the Director of Maintenance had to carry the NHA away twice. Two additional residents reported hearing yelling and commotion lasting approximately 20 minutes, describing it as sounding like people fighting and exchanging words. The LPN involved acknowledged that the resident was screaming for his medications and that she told him his pain medication was scheduled every four hours and that she did not have to come into the room if he continued screaming, stating she would not enter until he calmed down. She reported going outside to cool down and smoke a cigarette while the resident continued to scream, and she admitted that she may have given the resident the middle finger. The resident reported that the LPN gave him the middle finger behind the curtain and then directly to his face when confronted, and he documented these events in a written letter given to an RN supervisor, stating he felt verbally and physically threatened by the NHA, unsafe with the NHA around, and that his personal information was being yelled in the hall. The RN supervisor confirmed receiving the written concern and hearing from several employees that the incident was “pretty bad.” The DON acknowledged that the NHA was asked to see the resident and confirmed that the facility failed to protect the resident from verbal abuse, which caused severe psychosocial harm. Surveyors determined that this failure created an Immediate Jeopardy situation for one of six residents reviewed.
Removal Plan
- Identify root cause of the Immediate Jeopardy as staff failure to follow the facility abuse policy.
- Assess Resident R1 for adverse outcomes related to the abuse/neglect allegation.
- Offer Resident R1 coping and trauma support by RN Supervisor or designee.
- Ensure appropriate services are provided to Resident R1 if adverse outcomes occurred from abuse/neglect by Mobile DON or designee.
- Assess/interview all residents for abuse/neglect by Mobile DON or designee for indications of fear, trauma, or abuse/neglect.
- Notify physician/POA (if applicable) of any adverse findings and update the medical record.
- Review and update care plans as appropriate by Mobile DON or designee.
- Ensure appropriate services are provided to residents if adverse outcomes occurred from abuse/neglect.
- Report to appropriate agencies by Mobile DON or designee.
- Complete head-to-toe skin assessments for all residents, document findings in the medical record, notify attending physicians of any negative results, and ensure appropriate services are provided if adverse outcomes occurred.
- Interview staff by Regional Director of Operations or designee for allegations of abuse/neglect that have not been reported.
- Review incidents by Mobile DON or designee to ensure no incidents occurred that went unreported and immediately report any identified incidents that meet criteria.
- Review the Abuse/Neglect Policy for appropriateness and what to do if the alleged perpetrator is the DON or NHA and update if needed, including adding the corporate compliance number for staff to use if DON/NHA is involved or staff feel uncomfortable reporting to facility leadership.
- Re-educate all house staff by Regional Director of Operations or designee on the abuse/neglect policy, including the corporate compliance number for staff to use if DON/NHA is involved or staff feel uncomfortable reporting to facility leadership.
- Conduct audits to ensure no abuse or neglect is identified by reviewing residents.
- Review nursing documentation by Mobile DON or designee to ensure no incidents occurred that were unreported to administration.
- Review all audits and policy changes related to the Immediate Jeopardy at an Ad Hoc QA meeting.
- Have the QAPI committee review all findings upon completion of audits.
Failure to Follow Abuse Policy, Conduct Timely Background Checks, and Protect Resident from Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its own abuse, neglect, and exploitation policy, including required criminal background checks and mandated reporting and investigation of abuse/neglect allegations. The facility’s written policy stated that all employees must have criminal background checks completed prior to hire and that records of such checks must be retained in employee files. Review of the social worker’s (Employee E1) personnel file showed a hire date of 1/27/26, but the criminal background check for this employee was not completed until 3/12/26. During an interview, the DON and NHA confirmed that this staff member began working without a completed background check, contrary to facility policy. The deficiency also includes the facility’s failure to identify, report, and investigate an allegation of abuse/neglect involving one resident, and failure to protect that resident from the alleged perpetrators. Resident R1, who had bilateral above-knee amputations and opioid dependence and was documented as cognitively intact with a BIMS score of 15, reported that on 3/11/26 he experienced verbal and attempted physical abuse from the NHA and felt unsafe when the NHA was in the facility. The resident stated he wrote a letter detailing the events and gave it the same day to an RN supervisor (Employee E3), whom he described as the only person he trusted. The resident reported that the facility did nothing, did not investigate, and allowed the alleged perpetrators to continue working. Multiple staff interviews corroborated that an incident occurred and that the NHA continued to work afterward. A COTA (Employee E5) stated he arrived about five minutes after the incident, described the NHA as intimidating with a short fuse, and confirmed the NHA worked the remainder of that day. The Director of Maintenance (Employee E4) confirmed he had to remove the NHA from the resident’s room to deescalate the situation and that the NHA continued to work that day. The resident’s written letter described verbal and attempted physical abuse by the NHA, a HIPAA violation involving personal information being yelled in the hall, and an LPN (Employee E2) making an obscene gesture behind a curtain and then directly to the resident when confronted. The RN supervisor (Employee E3) confirmed receiving the written concern on 3/11/26 and stated she was unsure to whom to give it because the allegation involved the NHA. The facility failed to document or process this allegation as an incident and did not report it to the State Agency or other required entities at the time it occurred. Review of facility incident logs and information submitted to the State Agency on 3/11/26 and 3/12/26 showed no inclusion of Resident R1’s abuse/neglect allegation. The DON acknowledged being aware of a verbal altercation on 3/11/26 and stated that the NHA was asked to see the resident and that corporate instructed them not to call the police. The DON confirmed that the NHA and LPN E2 were not suspended and continued to work in the facility, and that the facility failed to timely report, investigate, notify appropriate agencies, and protect residents from further abuse/neglect related to this event. The NHA was only suspended two days after the alleged abuse/neglect occurred. These failures, combined with the lack of a timely background check for Employee E1, resulted in an immediate jeopardy situation as cited by surveyors.
Removal Plan
- Identify root cause of the Immediate Jeopardy as staff failure to follow the facility abuse policy.
- Assess Resident R1 for adverse outcomes related to the abuse/neglect allegation.
- Offer Resident R1 coping and trauma support by RN Supervisor or designee.
- Ensure appropriate services are provided to Resident R1 if adverse outcomes occurred from abuse/neglect by Mobile DON or designee.
- Assess/interview all residents for abuse/neglect for indications of fear, trauma, or abuse/neglect by Mobile DON or designee.
- Notify physician/POA (if applicable) of any adverse findings and update the medical record.
- Review and update care plans as appropriate by Mobile DON or designee.
- Complete head-to-toe skin assessments for all residents and document findings in the medical record.
- Notify attending physicians of any negative results from resident assessments.
- Report any adverse outcomes/findings to appropriate agencies.
- Interview staff for allegations of abuse/neglect that have not been reported in the last 30 days by Regional Director of Operations or designee.
- Review incidents to ensure no incidents occurred that went unreported and immediately report any that meet criteria by Mobile DON or designee.
- Review the Abuse/Neglect Policy for appropriateness, including what to do if the alleged perpetrator is the DON or NHA, and update if needed.
- Add the corporate compliance hotline number to the abuse/neglect policy for staff to use if DON/NHA are involved or staff are uncomfortable reporting to facility leadership.
- Re-educate all house staff on the abuse/neglect policy, including use of the corporate compliance hotline when leadership is involved, by Regional Director of Operations or designee.
- Educate HR (or designee) that criminal background checks must be completed prior to hire.
- Audit all staff HR files to ensure all background checks are present and do not allow any employee to return to work until a missing criminal background check is completed.
- Conduct audits to ensure all existing employee files contain criminal background checks and all new hires have checks completed prior to start date.
- Conduct audits of resident care needs to ensure no abuse/neglect is identified.
- Review nursing documentation to ensure no incidents occurred that were unreported to administration by Mobile DON or designee.
- Review all audits and policy changes related to the Immediate Jeopardy at an ad hoc QA meeting.
- Have the QAPI committee review all findings.
Insufficient Nursing Staff and Inaccurate Staffing Assignments
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure accurate staffing practices. The facility’s own policy dated 1/15/26 states it will maintain staffing practices consistent with federal regulations, state law, and professional standards while supporting safe and effective care. However, multiple residents reported that the facility was understaffed, resulting in missed showers, inadequate hygiene, and insufficient assistance with mobility and positioning. One resident stated they were not showered before a doctor’s appointment, did not have a buttocks wound dressed, and were left sitting on their buttocks all day. Another resident reported not getting out of bed for months due to lack of staff and not receiving regularly scheduled showers on Tuesdays and Fridays. Additional residents described similar issues related to inadequate staffing. One resident reported that when they get up during the day, there often are not enough staff to put them back to bed. Another resident stated that staff are “plugged into” nurse aide positions but do not provide care or remain on the floors. A resident with Lyme disease, whose skin becomes very itchy, reported receiving only five showers in six weeks despite being scheduled for two per week and stated there were days they were not cleaned up at all. Another resident reported waiting over an hour for staff to obtain a portable oxygen tank so they could leave their room. Staff interviews and staffing records further demonstrated insufficient and inaccurately represented staffing. A nurse aide reported there were not enough staff to turn and reposition residents and that it was hard to find help when two-person assistance was needed. Multiple staff members stated the facility “lies” on the staffing sheet by listing employees who are not actually providing resident care, including a cook and a social worker who were pulled to the floor without nurse aide job descriptions or orientation in their files, and a nurse aide who was scheduled but found folding linens in the laundry instead of providing care. On a shift with a census of 52 residents, an LPN reported having only two, possibly three aides, effectively leaving one aide per hallway. The interim administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the identified residents.
Unqualified Staff Assigned to Food Service Director Role
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for a three‑month period from January 2026 through March 2026. Staff interviews and review of employee files showed that the individual functioning as the Kitchen Manager, Employee E21, had been hired on 1/21/26 and had worked as Kitchen Manager since 1/28/26, but was a Nurse Aide and not a Certified Dietary Manager. During an interview on 3/12/26, at 9:57 a.m., Employee E21 confirmed she was not a Certified Dietary Manager. In a subsequent interview on 7/21/24 at 1:40 p.m., the Interim NHA (Employee E12) and the DON confirmed that the facility could not provide documented evidence that Employee E21 met the qualifications required for the Food Service Director position, resulting in noncompliance with PA Code 201.18(e)(6) regarding management. No specific residents, medical histories, or clinical conditions were mentioned in relation to this deficiency in the report.
Failure of Facility Administration to Implement Abuse Policies and Professional Care Standards
Penalty
Summary
The deficiency involves the Nursing Home Administrator (NHA) failing to effectively manage the facility to ensure residents were free from abuse and to ensure the facility implemented its abuse policies, resulting in an immediate jeopardy situation. A review of the NHA’s job description showed that the primary purpose of the position was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations governing LTC facilities so that the highest degree of quality care could be provided to residents at all times. However, based on review of the job description, facility and clinical records, and staff interviews, surveyors determined that the NHA did not fulfill these responsibilities, as the facility failed to provide fundamental principles that apply to treatment and care, and failed to ensure that residents received treatment and care in accordance with professional standards of practice and facility policies. These failures were cited under 28 Pa Code 201.14(a) Responsibility of licensee and 28 Pa Code 201.18(b)(1)(e)(1) Management. The report does not provide specific resident identifiers, clinical histories, or detailed descriptions of individual abuse incidents, but it establishes that the facility’s administration and management, under the NHA’s direction, did not ensure implementation of abuse policies or adherence to professional standards and facility policies in the treatment and care of residents.
Failure to Maintain Accurate and Current Facility Assessment
Penalty
Summary
The facility failed to accurately complete and update its facility-wide assessment used to determine necessary resources for competent resident care during routine operations and emergencies. Review of the Facility Assessment dated 3/26/25 showed that the section listing key personnel still identified the previous Nursing Home Administrator, previous Director of Nursing, and previous Assistant Director of Nursing rather than current leadership. The census section referenced a time period of the 2025 year to date without current information, and the section titled “Information about our residents” had not been reviewed or updated since 3/26/25. During an interview on 3/14/26, the Interim Nursing Home Administrator (Employee E12) confirmed that the facility failed to accurately complete the Facility Assessment and that all information about the residents reflected the last time this employee had worked at the facility, rather than current resident data. These findings were cited under 28 Pa. Code 201.18(b)(3)(e)(2) related to management requirements.
Failure to Meet Resident Care, Dietary, Staffing, and Assessment Requirements
Penalty
Summary
The facility failed to put forth a good faith effort to correct deficient practices cited during the prior survey, including staffing, dietary management, employment process, and the Facility Assessment. Survey findings showed the facility did not provide adequate staffing to meet resident needs, did not provide qualifying coursework for the Dietary Manager, did not provide on-site oversight of daily dietary operations, did not train the Human Resources Director who was responsible for hiring qualified staff for the Dietary Manager position, hired an unqualified applicant to fill the vacant Dietary Manager role, and did not keep the Facility Assessment current and accurate as required. During interview, the DON confirmed the facility had failed to meet resident needs by not providing showers to residents. Review of April 2026 ETARs showed the facility also failed to provide showers, repositioning, skin protection care, assistance out of bed, and assistance with mechanical lift transfers. Staff interviews confirmed the facility was short staffed, resulting in staff failing to meet resident needs. The facility also failed to provide coursework for the current Dietary Manager to obtain the required qualifications and failed to provide on-site oversight of dietary operations, while the HR Director responsible for hiring was not included in the in-service training on Dietary Manager qualifications. The Facility Assessment was also not updated with current leadership information.
Failure to Ensure Physician-Completed Initial Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician completed required initial comprehensive visits, as mandated by facility policy and state regulations. The facility’s “Physician Visits and Physician Delegation” policy, dated 6/1/24 and last reviewed 1/21/26, specifies that a PA, NP, or CNS may not perform initial comprehensive visits. Despite this, review of clinical records showed that initial visits for three residents were conducted by a Certified Registered Nurse Practitioner (CRNP), identified as Employee E20, rather than by a physician. For one resident admitted with anxiety, depression, and lung cancer, a late entry note dated 3/1/26 (effective 2/25/26) documented that the CRNP completed the initial admission visit. For another resident with gastroparesis, anemia, and esophagitis with bleeding, who had been discharged home and then readmitted, a late entry note entered on 2/25/26 (effective 2/23/26) showed that the CRNP assessed the resident following readmission, constituting the initial visit. For a third resident admitted with emphysema, oxygen dependence, and alcohol dependence with withdrawal, a late entry note entered on 6/26/26 (effective 6/25/26) documented that the CRNP performed the initial visit. During an interview, the DON and Interim Nursing Home Administrator acknowledged that the facility failed to ensure a physician completed the initial visits for these three residents.
Untimely Documentation of Resident Progress Notes
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to appropriately and timely document progress notes in the clinical records for four residents. For one resident with anxiety, depression, and lung cancer, the initial admission visit was documented as a late entry on 3/1/26 for an encounter that occurred on 2/25/26, resulting in a four-day delay in documentation. Another resident with dementia, tremor, and a history of falling received a right shoulder injection on 3/5/26, but the corresponding progress note was not entered until 3/13/26, eight days later. A third resident with gastroparesis, anemia, and esophagitis with bleeding was seen for increased swelling in both lower extremities on 1/19/26, but the progress note was entered as a late entry on 1/23/26, four days later. A fourth resident with emphysema, oxygen dependence, and alcohol dependence with withdrawal was evaluated for nausea, vomiting, and diarrhea on 2/23/26, yet the related progress note was not entered until 2/25/26, two days later. During an interview, the Director of Nursing acknowledged that the facility failed to appropriately and timely document progress notes in the clinical records for all four residents, in violation of 28 Pa. Code 211.5(f)(g)(h) regarding clinical records.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
Surveyors determined that the facility failed to provide required training on effective communication for five of five sampled direct care staff members. Review of the facility’s employee listing showed that one RN and four NAs were hired on various dates between 10/30/23 and 12/4/24. Examination of facility-provided education documents and individual training records for these staff members revealed no evidence that they had received education on effective communication as required by facility policy and state regulations. During an interview on 3/14/26 at 1:00 p.m., the Interim Nursing Home Administrator confirmed that the facility had not provided effective communication training to these identified staff members. The deficiency was cited under 28 Pa Code: 201.14(a) Responsibility of licensee, 28 Pa Code: 201.18(b)(1) Management, and 28 Pa Code: 201.20(a)(6)(d) Staff development, based on the lack of documented training and the administrator’s acknowledgment of this omission.
Failure to Implement and Document Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility failed to provide necessary treatment and services, consistent with professional standards of practice, for a resident with a pressure ulcer. Facility policy on Pressure Injury Prevention and Management required that treatment and services be provided to heal pressure injuries, that preventive interventions be implemented for all residents with pressure injuries, and that these interventions be documented in the care plan and communicated to staff. The resident, admitted with abnormal posture, paraplegia, and a right ankle pressure ulcer, had an MDS indicating a current Stage III pressure ulcer. The care plan and physician orders directed staff to encourage turning and repositioning every two hours and as needed, float heels while in bed, and apply offloading boots when in bed. However, review of the resident’s Documentation V2 Reports for February and March showed missing evidence of turning and repositioning each shift, with a total of 39 undocumented instances in February and 17 in March. During interview, the resident reported getting out of bed only once a day, needing assistance with turning and repositioning, and stated that staff turned and repositioned him maybe twice a shift. Observation found the resident lying in bed without the ordered offloading boots in place; the boots were seen in a chair, and the resident stated staff had not offered to put them on that day. An LPN confirmed the offloading boots were not on as ordered. The DON stated that for residents at risk for pressure ulcers or with wounds upon admission, interventions such as turning and repositioning, air mattress, wedges, or bunny boots are entered upon admission and are expected to be documented at least each shift, and confirmed the facility failed to document that the offloading boots were applied while the resident was in bed each shift. The Nursing Home Administrator and DON confirmed the facility failed to ensure necessary treatment and services were provided for the resident’s pressure ulcer, in violation of 28 Pa. Code 211.12(d)(5) Nursing services.
Failure to Maintain Required Nurse Aide Staffing Ratios
Penalty
Summary
The deficiency involves the facility’s failure to provide the required number of Nurse Aides (NAs) per resident per shift as required by state regulations. Surveyors determined that, for the period from 1/25/26 through 2/13/26, the facility did not meet required NA staffing ratios for 40 of 63 shifts. A review of the facility’s staffing worksheet showed that the facility was using an outdated staffing hours calculator that did not reflect current NA ratio regulations, and the Nursing Home Administrator (NHA) confirmed that the incorrect calculator was being used. The documentation provided by the facility also lacked the assignment grids that were supposed to designate required NA ratios and be reviewed during labor meetings. Based on review of documents and staff interviews, surveyors concluded that the facility failed to make a good faith effort to correct and sustain improvement for a previously cited deficiency related to NA staffing ratios (Citation P5520). Despite prior education provided to the NHA and Director of Nursing (DON) on the required state Certified Nurse Aide ratios, the facility’s practices did not result in compliance with current staffing requirements. The failure to maintain required NA staffing levels and to use accurate tools to calculate staffing was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 28 Pa. Code: 201.18(b)(1) Management, and 28 Pa. Code: 211.12(d)(1)(2)(3)(4)(f.1)(i)(2) Nursing services.
Insufficient Nursing Staff Leading to Missed ADLs and Cancelled Activities
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs for activities of daily living (ADLs) and activities participation, resulting in unmet care needs for five of six interviewed residents. Facility policies dated 1/15/26 required staff to provide necessary services for bathing, dressing, grooming, oral care, transfers, ambulation, toileting, eating, and communication, and to assist residents to and from activities with accommodations in schedules and timing. Multiple residents reported that there were not enough aides, especially on the 2 p.m. to 10 p.m. shift, leading to missed showers on scheduled shower days, prolonged call light response times of up to an hour, and residents sometimes not being gotten out of bed at all because there was not enough staff to return them to bed. Residents also reported that activities, including Bingo and card games, were repeatedly cancelled or not attended because of insufficient staff to assist with transport and supervision. Several residents stated that Bingo, normally held three times a week, had not occurred for about a week, and that they were sometimes unable to go to the dining room to eat because there were not enough staff to supervise and help those who needed assistance. Staff reportedly informed residents that activities and dining room attendance were being limited or cancelled due to staffing shortages, particularly on specific shifts. The Nursing Home Administrator confirmed that the facility did not have sufficient nursing staff to provide nursing and related services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the affected residents.
Failure to Complete Required Neurological Checks After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to complete required neurological assessments following a resident fall. Facility policy on Fall Prevention and Management dated 1/15/26 states that in the event of a fall, a licensed nurse will assess the resident, the physician/NP and responsible party will be notified, and appropriate documentation and interventions will be completed. The 72-Hour Neurological Assessment Sheet further specifies that for all falls, neurological checks are to be completed at defined intervals (initial assessment, then every 15 minutes x4, every 30 minutes x4, every hour x2, and once per shift for 72 hours), and that unwitnessed falls or falls in which the head is struck require neuro checks and physician notification for any change in condition. The resident involved, identified as R1, had diagnoses including hypertension, seizure disorder, and hyponatremia, and experienced a fall on 1/18/26. A nursing progress note documented that at 4:15 p.m. the resident was found on the floor in his room, sitting on his buttocks, laughing, with the wheelchair at bedside and the bed on its side. The resident denied pain or discomfort, range of motion was within normal limits, no apparent injuries were noted, and vital signs were stable. The note stated that neuro checks were initiated per facility protocol. However, review of the 72-Hour Neurological Assessment Sheet dated 1/18/26 showed that only 8 neurological checks were completed out of 18 required opportunities. In an interview, the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure the resident received the neurological assessments after the fall, resulting in the cited deficiency under 28 Pa. Code 201.14(a), 211.10(d), and 211.12(d)(1)(5).
Failure to Protect Resident from Mental Abuse and Intimidation During Public Debt Collection
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a diagnosis of dementia and anxiety was subjected to mental abuse and intimidation by facility staff in a public hallway. The resident, who had a Power of Attorney (POA) assigned to handle financial matters, was confronted by the Nursing Home Administrator (NHA) and a sheriff's deputy regarding an outstanding facility bill of $26,827. The confrontation took place in a public area, with other residents and staff present, and involved repeated verbal statements about the resident owing money and threats of issuing 30-day notices. The resident became visibly distraught, tearful, and expressed confusion about the situation, stating they did not understand why they were being held or what the debt referred to. Multiple staff members witnessed the incident and expressed concern about the appropriateness of discussing private financial matters in a public space, especially given the resident's cognitive status. Written statements from staff described the resident as confused and tearful during and after the incident. Some staff members reported feeling pressured not to report the event as abuse, and there was a lack of a formal investigation into the incident. The facility's own policies required that such matters be handled privately and with the appropriate responsible party, in this case, the POA, rather than the resident. Interviews with staff and a representative from the sheriff's office confirmed that the resident's POA should have been the party served with legal or financial documents, not the resident with dementia. The NHA acknowledged that the situation was not handled appropriately and that the resident was not protected from mental/emotional abuse. The incident resulted in psychosocial harm and mental anguish to the resident, as evidenced by the resident's emotional response and the application of the reasonable person concept.
Failure to Obtain Responsible Party Signature for Financial Documentation
Penalty
Summary
The facility failed to ensure that the responsible party signed financial papers for a resident with moderate cognitive impairment. According to facility policy, residents must be informed of their rights both orally and in writing, and information should be provided in a manner the resident can understand, taking into account any health or mental status limitations. The clinical record review showed that a resident with a BIMS score of 11, indicating moderate impairment, was admitted with diagnoses including Multiple Sclerosis, muscle wasting and atrophy, and hyperlipidemia. Despite this cognitive status, the resident personally signed a Notice of Medicare Non-Coverage (NOMNC) form. There was no documentation that the responsible party was informed or that they signed the necessary financial papers related to the ending of Medicare coverage. During staff interview, the Nursing Home Administrator confirmed that residents with moderate impairment should not sign NOMNC forms and acknowledged the failure to have the responsible party complete the required documentation. This deficiency was cited under 28 Pa. Code 201.18(b)(2) Management and 28 Pa. Code 201.29(a) Resident rights.
Failure to Utilize Resident's Power of Attorney in Legal Action for Non-Payment
Penalty
Summary
The facility failed to ensure that a resident's legal surrogate, specifically the designated Power of Attorney (POA), was utilized for legal actions regarding non-payment of bills. The resident in question had a documented diagnosis of dementia with moderate cognitive impairment, as indicated by a BIMS score of 10, and her son was identified as her POA in the clinical record. Despite this, the facility sent invoices for a significant outstanding balance to both the resident and her POA, but when legal action was initiated for non-payment, the facility did not engage the POA and instead involved the resident directly. On one occasion, the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about the unpaid balance, repeatedly informing her of the debt and the facility's practice of issuing 30-day notices. The resident, who was visibly distressed and expressed confusion about the situation, was not given the benefit of her POA's representation during this process. The NHA later confirmed that the facility failed to utilize the resident's POA for the legal action, despite being aware of the POA's authority and the resident's cognitive impairment.
Failure to Report Alleged Abuse Involving Resident with Dementia
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with dementia, high blood pressure, and anxiety. According to the facility's policy, all allegations of abuse, neglect, or exploitation must be reported to the Administrator and the Department of Health within 24 hours. On the date in question, the Nursing Home Administrator (NHA), accompanied by a sheriff's deputy, confronted the resident in a public hallway about an alleged debt, repeatedly stating the amount owed and referencing issuing 30-day notices. The resident became visibly distraught, crying and expressing confusion about the situation. Multiple staff members, including the Former Director of Nursing (FDON), Former Activities Director (FAD), and Former Social Worker (FSW), witnessed the incident and described it as emotional or mental abuse. Written statements were submitted by at least two staff members, detailing the resident's distress and the intimidating nature of the encounter. Despite these reports and the facility's policy, the incident was not reported to the state agency as required. The FDON acknowledged awareness of the situation but claimed not to have received any written statements, while other staff confirmed they submitted statements and were discouraged from pursuing the matter further. The NHA later confirmed that the facility failed to report the abuse allegation. A review of incidents submitted to the state agency showed no record of the staff-to-resident abuse allegation for the incident in question.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,051 citations issued within 25 miles in the last 12 months — including the 18 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saxonburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia Lutheran Health And Human Care | 2.4 mi | ★★★★★ | 0 | 0 |
| Quality Life Services - Sarver | 6.3 mi | ★★★★★ | 16 | 0 |
| Sunnyview Nursing And Rehabilitation Center | 7.9 mi | ★★★★★ | 8 | 0 |
| Eden Nursing & Rehabilitation Center | 9.9 mi | ★★★★★ | 6 | 0 |
| St Barnabas Nursing Home | 10 mi | ★★★★★ | 15 | 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 August 2026) and official state health department websites.