Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Woodland Park during CMS and state inspections, most recent first.
Two residents who were cognitively intact and incontinent of urine were not provided incontinence briefs that matched their assessed needs and the manufacturer’s sizing chart, compromising their dignity. One bariatric resident weighing 400 pounds was found wearing two size 2 briefs taped together instead of the indicated bariatric size, and only chux pads had been supplied despite her care plan calling for use of a power wheelchair and outdoor activity. Another resident weighing 218 pounds was observed in bed with a modified size 2/L brief that did not fit properly, and only that size was available in the room, even though the sizing chart called for size 3/XL. An LPN confirmed the lack of appropriate sizes, and the NHA and DON acknowledged that residents should receive properly fitting briefs and that bariatric residents should be provided briefs rather than just pads.
Failure to Inform Resident Representatives Before Psychotropic Medication Changes: The facility did not document that resident representatives were informed in advance of the risks, benefits, and treatment alternatives before psychotropic medication starts or dose increases for five residents. The affected residents were cognitively impaired and had diagnoses including dementia, PTSD, anxiety, depression, and Alzheimer's dementia; medications involved included Cymbalta, lorazepam, Zoloft, and Rexulti, and the DON confirmed the missing documentation.
Food storage and dishwashing sanitization were not maintained in accordance with professional standards. In the walk-in cooler, an opened box of eggs and cartons of liquid eggs were stored on a bottom shelf only about 1.0 to 1.5 inches off the floor, with debris on the floor below the shelf, including butter containers and onion skins. The dishwasher had been converted from high temp to low temp chemical sanitization, but repeated sanitizer tests showed no indication of sanitizer, and the DM stated the sanitizer did not work consistently and dishes were being washed by hand using the three-bin sink.
Unclean dining areas and worn resident linens: Surveyors observed dead insects on the windowsills in the 100 hall dining/activity areas while residents were eating, and staff confirmed the insects should have been cleaned up. Surveyors also found two residents with very thin fitted sheets that had holes, and the DON confirmed those sheets should have been thrown out and not used.
A resident with dementia, depression, and anxiety received PRN Xanax for anxiety, but the order did not include a duration and there was no documented prescriber rationale to extend the PRN psychotropic beyond 14 days. The MAR showed multiple administrations of the medication, and the DON confirmed the missing duration and documentation.
The facility failed to provide required written transfer notices, bed-hold notices, and ombudsman notifications when residents were sent to the ER. One resident was cognitively intact with HF and ESRD and had multiple ER transfers for dialysis-related weakness and bleeding; two other residents were cognitively impaired and were transferred for bleeding, abdominal tenderness, and a fall with disorientation. No documentation showed the required notices were given.
The facility failed to complete significant change MDS assessments within the required timeframe for two residents. One resident with Alzheimer's disease who was admitted to hospice had an MDS completed late, and another resident with vascular dementia who was also admitted to hospice had an MDS that was still in progress and not signed as completed. The RNAC confirmed the assessments were not completed as required.
A resident with edema and heart failure had repeated weight gains greater than 3 lbs, but the physician was not notified as ordered. Another resident with HTN received metoprolol even when the pulse was below the ordered hold parameter, and the DON confirmed the medication should not have been given.
Failure to obtain an updated order for the correct Foley catheter size was identified for a resident with cognitive impairment and neurogenic bladder. The resident had an order for an 18 Fr Foley with a 30 cc balloon, but when the catheter could not be flushed, a 16 Fr 30 cc Foley was inserted. An LPN and the DON confirmed the provider should have been notified and a new order obtained when the ordered catheter was not available.
A resident who was cognitively impaired, needed assistance with care, received IV meds, and had osteomyelitis was given IV ceftriaxone, but the MAR had no documented evidence that the IV line was flushed with preservative free 0.9% sodium chloride before and after the doses, despite facility policy requiring it. The DON confirmed the missing documentation.
A resident with depression, anxiety, and PTSD was not assessed for trauma-informed care or for specific PTSD triggers, and the record lacked documentation of measures to prevent or minimize re-traumatization. The resident was cognitively impaired and dependent on staff for daily care needs. The NHA stated she did not believe the resident triggered PTSD, while the MD said the resident was admitted with PTSD and that the family reported the diagnosis had been made years earlier.
The facility's QAPI committee failed to correct recurring deficiencies involving a homelike environment and safe and sanitary food storage. Prior plans of correction for cited deficiencies under F584 and F812 called for audits to be reported to the QAPI committee, but the current survey found those plans were not successfully implemented.
The facility did not serve hot food at the required temperature, as observed when seasoned broccoli was delivered to a resident at 111.0°F, below the policy standard of 120°F. The broccoli was lukewarm and unappetizing, and the Dietary Manager confirmed it should have been hotter.
A resident with a history of stroke and requiring maximum assistance was found on the floor after a fall, but the emergency contact was not notified until three days later. Documentation and staff interviews confirmed the delay in notification following the incident.
A resident with cognitive impairment and constipation was not administered senna-docusate sodium at the physician-ordered time. Instead, an LPN left the medication at the bedside in the afternoon, and the resident took it unsupervised, contrary to facility policy and the care plan. The DON confirmed that medications should be administered by licensed staff at the prescribed time.
A resident with cognitive impairment and dementia was left with a cup containing three tablets and water at bedside by an LPN, contrary to facility policy requiring staff to observe medication ingestion. The DON confirmed that staff must not leave medications at bedside and must ensure proper administration.
The facility failed to follow its planned menu and recipe instructions, leading to discrepancies in meals served. Residents reported that the kitchen did not always serve the listed menu items. On one occasion, Brussels sprouts were substituted with a vegetable mix without informing residents. Additionally, ground chicken breast was served with poultry gravy instead of the specified citrus glaze, as confirmed by a test tray and the Dietary Director.
The facility did not comply with food storage standards, as observed by surveyors who found coffee boxes on the floor and an unlabeled, undated, and unsealed chocolate cake in the freezer. The Dietary Director confirmed these storage violations.
The facility failed to maintain a clean and homelike environment for two residents. One resident's room had a black and worn carpet that remained dirty despite cleaning attempts. Another resident had a fan blowing on her with visible dirt and debris on the blade cover. Cleaning of resident fans was not part of scheduled duties, but staff would clean them if notified.
The facility failed to verify the nursing licenses of two nurses and the registry status of a nurse aide before their employment, contrary to its abuse prevention policy. The oversight was confirmed by the HR Director, violating state regulations.
A facility failed to develop a care plan for a resident who was cognitively intact and required assistance for daily care needs, including frequent bowel incontinence. Despite the facility's policy requiring a baseline care plan, there was no documented evidence of a care plan addressing the resident's bowel incontinence. The DON confirmed that a care plan should have been developed but was not.
The facility failed to update care plans for two residents, resulting in deficiencies in care management. One resident's care plan did not reflect multiple pain medications prescribed, while another's care plan was outdated, not reflecting a current urinary catheter order. The DON confirmed the need for updates.
A resident, identified as an elopement risk and cognitively intact, repeatedly removed her Wanderguard bracelet and exited the facility without triggering an alarm. Despite being aware of the resident's actions and dissatisfaction, the facility did not implement additional interventions beyond the Wanderguard to prevent her from leaving.
The facility did not verify the registry status of a newly hired nurse aide before she began working. The personnel file lacked evidence of a registry check until several months after her hire date, which was confirmed by the HR Director.
A resident with dementia exhibited behaviors such as hallucinations and anxiety, but the facility failed to document or implement interventions to address these issues. Despite the care plan noting these behaviors, staff did not take further steps to manage the resident's symptoms, and the physician deemed the behaviors as dementia-related without requiring additional psychological services.
A facility failed to document the administration of controlled medications for a resident with a Stage IV pressure ulcer receiving hospice care. Morphine was signed out but not recorded as administered on the MAR, as confirmed by the DON.
A resident's medications were improperly stored at their bedside, and insulin pens on a medication cart were not labeled with opening dates. An LPN left medications on a resident's table, and another confirmed insulin pens should have been dated.
The facility's QAPI committee failed to address recurring deficiencies effectively, leading to repeated citations for issues such as unsafe environments, inadequate abuse and neglect policies, and improper medication management. Despite plans of correction involving audits and committee reviews, the same deficiencies persisted across multiple surveys.
The facility did not provide the required notices to two residents regarding the end of their Medicare coverage. The SNF Beneficiary Protection Notification Review forms were not issued timely, and the Advanced Beneficiary Notices of Non-coverage were not provided. An interview with the Admissions Director revealed a lack of awareness about the requirement to issue these notices.
A resident sustained a head injury due to improper use of a mechanical wheelchair lift. The lift was not in the correct position, and the alarm system failed to alert the staff. The resident, who required assistance for transfers, fell and suffered a subdural hematoma, necessitating hospitalization.
A resident, who required two-person assistance for transfers, sustained a bruise after a nurse aide attempted a solo transfer, contrary to the care plan. The incident involved discrepancies in staff accounts, with the resident becoming weak during the transfer, leading to the use of a hoyer lift. The facility confirmed neglect due to the failure to adhere to the care plan, resulting in disciplinary action against the nurse aide.
A resident, who was care planned for a two-person transfer, was injured when a nurse aide attempted to transfer her alone, resulting in a large bruise. The resident's care plan required extensive assistance from two staff members, but this was not followed, leading to the incident. The nurse aide was terminated for failing to adhere to the care plan.
Failure to Provide Properly Fitting Incontinence Briefs, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide properly fitting incontinence briefs in accordance with residents’ assessed needs and the manufacturer’s sizing chart, resulting in compromised dignity for two residents. For one resident who was cognitively intact, frequently incontinent of urine, and weighed 400 pounds, surveyors observed that she was wearing two size 2 briefs taped together by staff to fit around her. The facility’s NGB & Bariatric briefs height and weight sizing chart indicated that this resident should have been provided size B/Bariatric briefs for her weight range of 360–440 pounds. Instead of the appropriate bariatric briefs, chux pads were delivered for this resident, despite her care plan indicating that it was very important for her to go outside when the weather was good and that her power wheelchair was to be used when out of bed. During interview, the resident reported embarrassment that her briefs did not fit and expressed concern about potential leakage if she used her new electric wheelchair during an incontinence episode. For a second cognitively intact resident who was always incontinent of urine and weighed 218 pounds, surveyors observed that she was in bed and not wearing a properly fitting brief. Staff had cut the fastening off the side of a size 2/Large brief so it would not scratch her, and only size 2/Large briefs were present in her room. According to the same sizing chart, this resident should have been provided size 3/XL briefs based on her weight. An LPN confirmed that the resident was currently wearing a size 2/Large brief and that no size 3/XL briefs were available at that time. The Nursing Home Administrator and Director of Nursing confirmed that the facility should supply appropriately fitting incontinence briefs for residents who require them and that bariatric residents should be ordered briefs rather than only incontinence pads, demonstrating that the facility did not ensure appropriate incontinence products were available and used for these residents.
Failure to Inform Resident Representatives Before Psychotropic Medication Changes
Penalty
Summary
The facility failed to inform residents and/or their resident representatives in advance of the risks, benefits, and treatment alternatives before starting or increasing psychotropic medications for five of 35 residents reviewed. The report cites the facility policy dated March 13, 2025, which required that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative be informed in advance of the benefits, risks, alternatives, and any black box warnings for antipsychotic medications, with documentation of that discussion in the clinical record. Resident 8 was cognitively impaired, had diagnoses including dementia, PTSD, and anxiety, and received antipsychotic medication. The resident had an order for Cymbalta 25 mg twice daily, which was later increased to 25 mg three times daily, but there was no documented evidence that the resident's representative was informed in advance of the risks, benefits, and treatment alternatives before the dose increase. The DON confirmed this lack of documentation. Resident 10 was cognitively impaired with dementia and received antipsychotic and antianxiety medication. The resident had an order for lorazepam 0.25 mg once daily for generalized anxiety, which was later increased to 0.5 mg twice daily, and there was no documented evidence that the resident's representative was informed in advance before the increase. Resident 11 was cognitively impaired with dementia and had an order for Rexulti 0.5 mg daily for dementia with behavioral disturbance, but there was no documented evidence that the resident's representative was informed in advance before initiation. Resident 19 was cognitively impaired with depression and had a psychiatric recommendation to discontinue Seroquel and increase Zoloft from 50 mg to 75 mg daily; the increased Zoloft order was entered without documented evidence that the resident's representative was informed in advance. Resident 68 was cognitively impaired with Alzheimer's dementia and had a Rexulti titration order from 0.5 mg daily to 1 mg daily and then 2 mg daily, but there was no documented evidence that the resident's representative was informed in advance before initiation. The DON confirmed the lack of documentation for Residents 10, 11, 19, and 68.
Food Storage and Dishwashing Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations of the walk-in cooler on December 1, 2025, and again on December 3, 2025, a shelving unit was seen with an opened box of eggs and a box of liquid egg cartons stored on the bottom shelf approximately 1.0 to 1.5 inches off the ground. Debris was also observed on the floor beneath the shelving unit, including individual butter containers and brown onion skins. The Dietary Director stated that food should be stored at least six inches off the ground and confirmed that the floor under the shelf should be free of debris and food items that had fallen. In addition, observation of the dishwasher on December 3, 2025, showed a high temperature dishwasher that had been converted to a low temp dishwasher with chemical sanitization, but multiple attempts to test the sanitization showed the strips remained white with no indication of sanitizer in the reading. The Dietary Manager confirmed the chemicals had recently been changed, the machine was serviced on December 3, 2025, and that two companies were scheduled to check the machine on December 5, 2025. The manager also stated the sanitizer did not work consistently and that the facility had been washing dishes by hand using the three-bin sink.
Unclean dining areas and worn resident linens
Penalty
Summary
The facility failed to provide a clean and homelike environment in the 100 hall dining and activity areas and in the rooms of two residents whose fitted sheets had holes. In the 100 hall dining room, surveyors observed approximately 30 dead, light brown, dried insects on the windowsill while residents were eating, and dead insects were also observed on the windowsill in the dining/activity room. A nurse aide confirmed the dead insects should have been cleaned up, and the Director of Housekeeping confirmed there should not have been any dead insects in those areas. In addition, Resident 18’s fitted sheet had a hole approximately 5 mm in size near the head of the bed and was very thin and see-through, and Resident 64’s fitted sheet had a hole approximately 3 mm in size and was also very thin and see-through. The Director of Laundry stated sheets with holes could be used if the hole was no bigger than the eraser tip of a pencil, while the DON confirmed the sheets with holes should have been thrown out and not used.
Unnecessary PRN Psychotropic Medication Order Lacked Required Duration
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from unnecessary psychotropic medication. Resident 4 had an admission MDS assessment showing cognitive impairment and use of antidepressant and antianxiety medications, with diagnoses including dementia, depression, and anxiety. Physician orders dated October 2, 2025 included Xanax 0.5 mg every 12 hours as needed for anxiety, and the MAR showed the medication was administered on October 19, October 21, October 23, and October 26, 2025. The facility’s psychotropic medication policy required PRN psychotropic medications to have a documented diagnosis and indication, and PRN orders for psychotropic medications other than antipsychotics were limited to no more than 14 days unless the prescriber documented the rationale for extending the order and specified a duration. The resident’s Xanax order did not include a duration, and there was no documented evidence from a physician or prescriber explaining the rationale for extending the PRN Xanax beyond 14 days. The DON confirmed this during interview on December 4, 2025.
Failure to Notify Residents, Representatives, and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification to residents and their representatives when residents were transferred to the hospital, failed to provide bed-hold notices to responsible parties, and failed to notify the ombudsman of the transfers for three residents. Resident 9 was cognitively intact, required assistance with all daily care needs, and had diagnoses including heart failure and end stage kidney disease. Nursing notes documented multiple transfers to the emergency room for increased weakness and slow response at dialysis, profuse bleeding at the dialysis site, inability to access the fistula site, bleeding from a surgical site, and redness around the port site with the resident not feeling herself. There was no documented evidence that written transfer notification, bed-hold notice, or ombudsman notification was provided for these transfers. Resident 40 was cognitively impaired, required substantial assistance with all daily care needs, and had diagnoses including high blood pressure, high cholesterol, and dementia. A nursing note documented that the resident had a large amount of bleeding from the urinary catheter, abdominal hernias, and tenderness, and was sent to the emergency room. Resident 46 was cognitively impaired and required maximum assistance with daily care needs. A nursing note documented that the resident was found on the floor, was very disoriented, and was sent to the emergency room for evaluation. For both residents, there was no documented evidence that written notification of hospital transfer was provided to the resident's representative, that a bed-hold notice was provided to the responsible party, or that the ombudsman was notified of the transfer as required.
Late and Incomplete Significant Change MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive significant change MDS assessments were completed within the required time frame for two residents. The RAI User's Manual stated that when a significant change in a resident's status is determined, the ARD and the significant change comprehensive MDS assessment must be completed no later than the 14th calendar day after that determination. For Resident 14, the clinical record showed a significant change in condition was identified when the resident was admitted to hospice with a diagnosis of Alzheimer's disease. The significant change MDS was dated October 1, 2025, and section Z0500B documented completion on October 13, 2025, which was five days late. For Resident 102, the clinical record showed a significant change in condition was identified when the resident was admitted to hospice with a diagnosis of vascular dementia. The significant change MDS dated December 1, 2025 was not signed in section Z0500B as completed, and the RNAC confirmed it was still in progress and should have been completed by that date.
Failure to Follow Physician Orders for Weight Monitoring and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with edema and heart failure by not notifying the physician of significant weight gains greater than three pounds. Resident 34 was cognitively impaired, required assistance with care needs, received a diuretic, and had a diagnosis that included heart failure. The physician ordered daily weights for weight gain/increase in edema and notification for weight gain greater than three pounds, but the resident had documented weight increases of 7.9 pounds, 9.5 pounds, and 5.2 pounds on separate occasions in November 2025 with no documented evidence that the physician was notified. The facility also failed to ensure medications were administered as ordered for another resident. Resident 62 was cognitively intact, required assistance with care needs, and had a diagnosis that included high blood pressure. The physician ordered metoprolol 12.5 mg daily and to hold the medication if the pulse was less than 55, but the MAR showed the medication was given when the resident’s pulse was 53 and again when it was 42. The DON confirmed that metoprolol was administered on those dates and should not have been.
Failure to Obtain Updated Foley Catheter Order
Penalty
Summary
The facility failed to obtain an updated order for the correct Foley catheter size when the ordered catheter was not available for Resident 40, who was cognitively impaired, required assistance with care needs, and had a diagnosis of neurogenic bladder. The resident’s physician order specified an 18 French Foley catheter with a 30 cc balloon, with permission to use a 5-10 cc balloon if a 30 cc balloon was not available. A nursing note documented that the resident’s catheter could not be flushed and that a 16 French 30 cc Foley catheter was inserted. During interview, an LPN stated that if the facility ran out of the Foley catheter, the provider was to be notified and a new order obtained, and the DON confirmed that the provider should have been notified that the ordered catheter was not available and a new order should have been obtained.
Failure to Flush IV Line Before and After Antibiotic Administration
Penalty
Summary
The facility failed to flush an intravenous catheter per its policy for one resident who was cognitively impaired, required assistance with care needs, received IV medications, and had a diagnosis of osteomyelitis. The facility policy dated March 13, 2025, required IV catheters to be flushed at regular intervals to maintain patency and before and after medication administration, using only preservative free 0.9% sodium chloride for saline flushes. The resident had physician orders for 2 grams of ceftriaxone IV daily for five days, and the MAR showed the antibiotic was administered on November 4 and 5, 2025. However, there was no documented evidence that the resident's IV line was flushed with saline before and after the ceftriaxone administrations, and the DON confirmed this lack of documentation during interview.
Failure to Assess PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including depression, anxiety, and PTSD was assessed for trauma-informed care and that specific triggers were identified or addressed to help prevent or minimize re-traumatization. A Quarterly MDS assessment for the resident indicated cognitive impairment and dependence on staff for daily care needs. The clinical record contained no documented evidence that the facility identified the resident’s specific PTSD triggers or implemented measures for staff to prevent or minimize those triggers. During interview, the NHA stated she believed the resident did not trigger PTSD and that if the doctor thought it was a real diagnosis the resident would have been reassessed quarterly. The MD stated the resident was admitted with PTSD and that the family reported the diagnosis had been made years earlier, adding that she believed the daughter would know the resident better than anyone.
QAPI Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility's QAPI committee failed to correct recurring quality deficiencies identified in prior and current surveys. Based on review of the facility's plans of correction for the annual survey ending October 3, 2024, and the results of the current survey ending December 4, 2025, repeated deficiencies were found related to a homelike environment and safe and sanitary food storage. For the homelike environment deficiency cited under F584, the prior plan of correction stated the facility would complete audits and report the results to the QAPI committee for review, but the current survey found the QAPI committee failed to successfully implement that plan. For the safe and sanitary food storage deficiency cited under F812, the prior plan of correction also stated the facility would complete audits and report the results to the QAPI committee for review, but the current survey found the QAPI committee failed to successfully implement that plan.
Failure to Serve Hot Food at Required Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures as required by its policy, which states that hot food should be served at a temperature of at least 120 degrees Fahrenheit at the point of service. On August 19, 2025, during lunch service, the food cart left the main kitchen and arrived at the 100 unit within one minute, but the last resident was not served until 13 minutes later. At that time, the temperature of the seasoned broccoli was measured at 111.0 degrees Fahrenheit, which was below the required standard. The broccoli was observed to be lukewarm and unappetizing. The Dietary Manager confirmed during an interview that the broccoli should have been hotter. This deficiency was cited under 28 Pa. Code 211.6(b) Dietary Services.
Failure to Timely Notify Resident Representative After Fall
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition following a fall. A cognitively intact resident with a history of stroke, who required maximum assistance for daily care, was found on the floor in front of her wheelchair while attempting to get up. Although this incident was documented in the nursing notes, there was no evidence in the clinical record that the resident's emergency contact was informed of the fall until three days later. Staff interviews confirmed that the notification was delayed, despite the requirement for immediate notification of such events.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to ensure that care and treatment were provided in accordance with physician's orders and professional standards of practice for one resident. According to the facility's medication administration policy, licensed nurses are required to administer medications as ordered, verify medication details with the Medication Administration Record, and observe the resident consuming the medication. For a resident with cognitive impairment, constipation, and dementia, the care plan specified administration of medications as ordered to address constipation. Physician's orders directed that the resident receive three tablets of senna-docusate sodium by mouth once daily at 8:00 p.m. However, on the day of observation, a medication cup containing three red pills and a cup of water was left at the resident's bedside in the afternoon, and the resident took the pills at that time. An LPN confirmed leaving the medication at the bedside and identified it as senna-docusate, acknowledging it was to be administered in the evening. The DON confirmed that licensed staff are responsible for administering medications at the physician-ordered time.
Medication Administration Policy Not Followed for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a licensed nurse failed to properly administer medication to a resident with cognitive impairment, dementia, and constipation. According to the facility's policy, medications are to be administered by licensed nurses who must verify the medication against the Medication Administration Record (MAR) and observe the resident consuming the medication. However, during an observation, the nurse left a medication cup containing three red, round tablets and a cup of water at the bedside of the resident, who was lying in bed on the locked memory unit. The resident later sat up and took the pills without the nurse present. Interviews with both the LPN involved and the Director of Nursing confirmed that the nurse should not have left the medication at the bedside and was required to remain with the resident to observe ingestion. The failure to follow the facility's medication administration policy and professional standards resulted in the medication not being stored or administered appropriately for the resident.
Menu and Recipe Discrepancies in Dietary Services
Penalty
Summary
The facility failed to adhere to its planned menu, as evidenced by several discrepancies between the written menu and the meals served. According to the facility's policy, menus should be prepared in advance and followed, with any substitutions recorded only in emergency situations. However, an interview with residents revealed that the kitchen did not always serve the items listed on the menu. On September 30, 2024, the kitchen staff prepared and served a vegetable mix of green beans, wax beans, and carrots instead of the Brussels sprouts listed on the menu. The Dietary Manager admitted to forgetting to order Brussels sprouts and substituted them without informing the residents or the resident council president. Further discrepancies were observed on October 1, 2024, when the facility served ground chicken breast with poultry gravy instead of the citrus glaze specified in the recipe. A test tray confirmed that the ground chicken did not have the citrus glaze and tasted different from the regular texture chicken breast. The Dietary Director acknowledged that the ground chicken should have had the citrus glaze, indicating a failure to follow the planned menu and recipe instructions.
Non-compliance with Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper food storage practices. During an initial tour of the main kitchen, surveyors observed two cardboard boxes of coffee stored directly on the floor, which is against the facility's policy requiring dry storage items to be at least six inches off the floor. Additionally, in the three-door freezer, a box containing approximately two-thirds of a chocolate cake was found without a date, label, or seal, contrary to the facility's policy that mandates all freezer items be labeled, dated, and sealed according to Hazardous Analysis Critical Control Point (HACCP) guidelines. The Dietary Director confirmed these observations, acknowledging the non-compliance with the established food storage protocols.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents. For one resident, who was cognitively intact and used a wheelchair due to cerebral palsy, the carpet in his room was observed to be black and worn. Despite attempts to clean it, the condition of the carpet did not improve. The Director of Maintenance acknowledged the carpet's poor condition and mentioned plans to replace it with vinyl flooring, but no timeline or work schedule was established. Another resident, who was also cognitively intact and had diagnoses including COPD and a history of congestive heart failure, was observed with a fan blowing directly on her. The fan had a moderate amount of visible dirt and debris on the blade cover. The Director of Maintenance and the Director of Housekeeping both stated that cleaning resident fans was not part of their scheduled duties, but they would clean them if notified. The Director of Nursing confirmed that the fan cover should have been clean, but it was not.
Failure to Verify Nursing Licenses and Registry Status
Penalty
Summary
The facility failed to ensure that the status of nursing licenses was checked with the State Board of Nursing for two nurses and did not complete a Nurse Aide Registry verification for one nurse aide. The facility's policy on abuse prevention, dated March 15, 2024, mandates conducting background checks and not employing individuals with disciplinary actions against their professional licenses. However, the personnel files for a registered nurse and a licensed practical nurse showed no documented evidence of license verification with the State Board until October 2, 2024, despite their start dates being in April and July 2024, respectively. Additionally, the personnel file for a nurse aide revealed no documented evidence of registry verification until October 2, 2024, although the aide started working in July 2024. An interview with the Human Resources Director confirmed these findings, acknowledging the lack of timely verification of licenses and registry status for the involved staff members. This oversight is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(e)(1).
Failure to Develop Care Plan for Bowel Incontinence
Penalty
Summary
The facility failed to develop a care plan for a resident, identified as Resident 61, who was reviewed during a survey. According to the facility's policy dated March 15, 2024, a baseline care plan should be developed for each resident to provide effective person-centered care and meet professional standards. A significant change Minimum Data Set (MDS) assessment for Resident 61, dated September 6, 2024, indicated that the resident was cognitively intact, required assistance for daily care needs, and experienced frequent bowel incontinence. Task records for September 2024 confirmed that the resident had two or more episodes of bowel incontinence weekly. However, there was no documented evidence of a care plan addressing the resident's bowel incontinence needs. The Director of Nursing confirmed on October 3, 2024, that a care plan should have been developed for this issue but was not.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for two residents, leading to deficiencies in their care management. For one resident, the care plan was not revised to include multiple pain medications prescribed over several months, despite significant changes in the resident's medication regimen. This resident, who was cognitively intact and required assistance for daily care needs, had been prescribed morphine sulfate and a fentanyl transdermal patch for chronic pain. However, there was no documented evidence that the care plan was updated to reflect these changes in pain management. Another resident, also cognitively intact and requiring assistance for daily care needs, had a care plan that was outdated and did not reflect current medical orders. The resident had a physician's order for a urinary catheter due to urinary retention, but the care plan still included interventions for bladder incontinence and the use of pantiliners, which were no longer applicable. The Director of Nursing confirmed that the care plans for both residents should have been updated to reflect their current medical needs and interventions.
Failure to Prevent Elopement Risk for a Resident
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for Resident 55, who was identified as an elopement risk. The resident, who was cognitively intact, had a history of verbalizing a desire to leave the facility and had previously removed her Wanderguard bracelet, an electronic device intended to alert staff when she approached an exit. Despite this knowledge, the facility did not implement additional interventions beyond the Wanderguard to prevent her from leaving. On two occasions, the resident was able to exit the building without triggering an alarm, as she had removed the Wanderguard. The Director of Nursing confirmed awareness of the resident's actions and dissatisfaction with residing at the facility, yet no further measures were taken to address the risk of elopement.
Failure to Verify Nurse Aide Registry Status
Penalty
Summary
The facility failed to verify the registry status of a newly hired nurse aide before allowing her to work. Specifically, the personnel file for Nurse Aide 3 showed that she was hired on July 10, 2024, but there was no documented evidence of a registry check until October 2, 2024. This oversight was confirmed during an interview with the Human Resources Director on October 2, 2024, who acknowledged that the registry check should have been completed prior to the nurse aide's start date.
Failure to Address Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia. The resident, who had a history of cerebrovascular accident/stroke and anxiety, exhibited behaviors such as screaming, yelling, refusal of care, and hallucinations, including seeing snakes and dinosaurs. Despite these behaviors being documented in the care plan, there was no evidence of interventions being implemented to address the resident's delusions or hallucinations. Observations revealed that the resident frequently called out, cried, and looked for her family, indicating a need for additional support and intervention. Staff interviews and record reviews indicated that the facility did not document any new interventions to manage the resident's anxiety, confusion, and hallucinations. The Nursing Home Administrator confirmed that the staff were following the existing care plan, but acknowledged the lack of documented interventions to assist the resident. The physician consulted believed the behaviors were related to dementia and did not require outside psychological services, yet the facility did not take further steps to address the resident's ongoing symptoms.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 12. According to the facility's policy, when administering a controlled medication, both the controlled drug record form and the Medication Administration Record (MAR) must be signed. However, for Resident 12, there were instances where morphine was signed out on the controlled drug record but not signed as administered on the MAR. This discrepancy was noted on specific dates in September 2024. Resident 12 was moderately cognitively impaired, had a Stage IV pressure ulcer, and was receiving hospice care, including opioid medication for pain management. The resident's spouse confirmed that the resident received pain medication prior to dressing changes due to significant pain. Despite this, the Director of Nursing confirmed that there was no documented evidence in the clinical records to indicate that the signed-out doses of morphine were administered to the resident, highlighting a failure in the facility's medication administration process.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications for a resident and did not label multi-dose insulin pens with the date they were opened. During an observation, a resident was found sleeping with a medicine cup full of pills on his bedside table. The medications included various tablets and capsules, and the resident's clinical record did not indicate that he was cleared to self-administer his medications. An LPN admitted to pouring the medications earlier in the shift and leaving them on the table because the resident preferred to take them with lunch, acknowledging that this was not appropriate. Additionally, an inspection of a medication cart revealed that several insulin pens, including glargine, Basaglar, and Toujeo SoloStar, were opened but not dated. These insulin pens have specific discard timelines after being opened, which were not adhered to. An LPN confirmed that the insulin pens should have been dated, and the Nursing Home Administrator acknowledged both the improper storage of the resident's medications and the failure to date the insulin pens.
Repeated Deficiencies in Facility's Quality Assurance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. The deficiencies identified include the failure to provide a safe, clean, and homelike environment, develop and implement abuse and neglect policies, and create comprehensive care plans. Additionally, the facility was cited for not being free from accident hazards, failing to maintain accurate accounts of controlled medications, and improper labeling and storage of drugs and biologicals. Further deficiencies were noted in the facility's failure to prepare and follow menus that meet residents' needs and to store, prepare, and serve food in a sanitary manner. These issues were consistently identified in surveys conducted over several months, indicating a pattern of non-compliance with nursing home regulations. The QAPI committee's role in reviewing audit results and ensuring compliance was ineffective, as the same issues persisted across multiple survey periods. The repeated citations suggest that the facility's plans of correction, which included conducting audits and reporting findings to the QAPI committee, were not successful in achieving compliance. The ongoing deficiencies highlight the committee's inability to implement effective quality assurance systems to maintain regulatory standards and improve the delivery of care and services.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required notice to residents or their representatives regarding the end of Medicare coverage for two residents who remained in the facility for long-term care. For Resident 62, Medicare coverage began on July 11, 2024, and ended on July 30, 2024. The facility did not issue the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form at least 48 hours in advance, and the Advanced Beneficiary Notice of Non-coverage (ABN) was not issued. Similarly, for Resident 95, Medicare coverage started on June 19, 2024, and ended on July 10, 2024, but the ABN was not issued. An interview with the Admissions Director revealed a lack of awareness regarding the requirement to issue the ABN when residents remain in the facility.
Failure to Ensure Safe Transfer on Wheelchair Lift
Penalty
Summary
The facility failed to ensure safe techniques were used during a transfer onto a mechanical wheelchair lift, resulting in a head injury for a resident. The manufacturer's directions for the lift indicated that the platform must be at floor level when loading and unloading. However, Nurse Aide/Transporter 1 did not verify that the lift was in the correct position before attempting to transfer the resident. The aide unhooked the safety mechanisms and attempted to maneuver the resident onto the lift, but due to the lift not being in the proper position, both the aide and the resident fell, causing the resident to sustain a head injury. The resident, who was cognitively intact and required extensive assistance for transfers, suffered a subdural hematoma and other injuries as a result of the fall. The incident report and interviews revealed that the alarm system on the lift did not activate to warn the aide that the lift was not in the correct position. The resident was subsequently hospitalized for evaluation and treatment of the head injury, which included reversing her blood thinner medication and starting antiseizure medication. The Director of Nursing confirmed that the failure to ensure the lift was in the correct position led to the fall and injury.
Neglect Due to Failure to Follow Transfer Care Plan
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by an incident involving Resident 4, who was care planned to require extensive assistance from two staff members for transfers. On April 7, 2024, Resident 4, who was cognitively intact and required assistance with care needs, was involved in an incident where she sustained a large bruise on her lower back and buttocks. The bruise was discovered after therapy noted it, and upon assessment, it was found to be firm upon palpation, although the resident denied pain or discomfort. The resident reported that she may have bumped off the arm of her wheelchair when she became weak during a transfer from her wheelchair to her bed. The investigation revealed discrepancies in staff accounts regarding the transfer. Nurse Aide 1 was identified as attempting to transfer Resident 4 alone, despite the care plan requiring two-person assistance. Nurse Aide 1 claimed that she and Nurse Aide 2 attempted the transfer, but Resident 4 became weak, leading to the use of a hoyer lift. However, Nurse Aide 2's statement indicated that she was not present initially and only arrived after being called for help. Nurse Aide 3 corroborated that Nurse Aide 1 sought her assistance after the initial attempt failed, and they used the hoyer lift to complete the transfer. The facility's investigation confirmed that Nurse Aide 1 did not adhere to the care plan, resulting in the neglect of Resident 4. The Director of Nursing and the Nursing Home Administrator verified that the resident was indeed care planned for a two-person transfer at the time of the incident. The failure to follow the care plan led to the resident's injury, and the facility took disciplinary action against Nurse Aide 1, who was suspended and later terminated for her inability to follow the care plan despite previous education on the matter.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff implemented care-planned interventions for a resident, resulting in injury. The comprehensive care plan policy required a person-centered care plan with measurable objectives and timeframes to meet the resident's needs. A quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact, required assistance with care needs, and had no fall history. The care plan specified that the resident required extensive assistance from two staff members for transfers. However, an incident occurred where the resident was transferred by one nurse aide, contrary to the care plan, resulting in a large bruise on the resident's back. The resident reported that the nurse aide attempted to transfer her alone, despite the care plan requiring two-person assistance. The resident recalled the incident and stated that her leg gave out during the transfer, causing her to fall onto the wheelchair armrest. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the resident was care planned for a two-person transfer at the time of the incident. The nurse aide involved was terminated for not following the care plan, despite previous education on the matter.
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 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orbisonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Huntingdon Park | 18.8 mi | ★★★★★ | 23 | 0 |
| Westminster Woods At Huntingdo | 20.2 mi | ★★★★★ | 7 | 0 |
| Fulton County Medical Center | 21.7 mi | ★★★★★ | 0 | 0 |
| Brookview Health Care Center | 23.4 mi | ★★★★★ | 1 | 0 |
| Chambers Pointe Health Care Center | 23.6 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.