Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Hills Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Unsanitary food storage and service areas: The facility failed to maintain acceptable sanitation practices in the kitchen, dish room, and multiple resident pantry areas. Surveyors observed heavy dirt and debris buildup under kitchen equipment, soiled food delivery cart bumpers, black and bluish residue on ice machine drain hoses, food splatter inside microwaves, debris under light shields, and dirt buildup behind the dishwasher. The FSD and NHA confirmed these areas were to be maintained in a sanitary manner.
A resident with cerebral palsy, intellectual disabilities, and severe cognitive impairment received PRN lorazepam gel for anxiety, agitation, or aggression. The care plan listed behaviors such as grabbing, spitting, screaming, and striking out, but the record did not define those behaviors in measurable terms or show that nonpharmacological interventions were tried and ineffective before 18 administrations. The DON could not provide documentation supporting the use of the psychotropic medication.
Missing Physician Progress Notes for Required Visits: The facility failed to maintain written, signed, and dated physician progress notes for required MD visits for five residents. The records showed only one progress note for each resident, while later faxed notes documented multiple additional visits for residents with conditions including OA, dementia, AD, Parkinsonism, HTN, and anoxic brain damage. The DON confirmed the MD was expected to document each visit, but the notes were not consistently included in the residents’ charts.
A resident with dementia and a history of falls was observed lying on a mattress placed directly on the floor, reducing the sleeping surface to floor level. The care plan did not include this intervention, and the record lacked a physician order, interdisciplinary review, consent, or ongoing monitoring. The DON stated the mattress was placed on the floor to reduce falls and later acknowledged it reduced bed mobility and created a potential restraint.
A resident with dementia, failure to thrive, and finger contractures developed a Stage III pressure ulcer between the right thumb and index finger after palm protectors were used for skin protection. The wound was linked to pressure from the palm protector strap and the resident’s fingernails, yet the DON could not show that skin checks were evaluated as sufficient or that the device-related pressure was analyzed. The resident’s fingernails were later observed to be long and sharp, and they were not trimmed until after surveyor observation.
Failure to provide timely foot care and podiatry services for a resident with DM. The resident’s toenails were thickened, yellowed, and overgrown, with dry, scaling skin on the toes. The resident stated he had not seen the podiatrist recently, was not receiving routine foot care, and that the toenail length caused discomfort. The DON could not provide documentation showing the resident received podiatry care to keep his feet well-kept and address his discomfort.
Failure to provide behavioral health and trauma-informed services: one resident with depression and a reported mugging history had repeated documentation of trauma in psych notes, but the record lacked a trauma assessment, symptom evaluation, or trigger identification; another resident with bipolar disorder, MDD, GAD, and borderline personality disorder received psychotherapy, but the chart did not show the recommended follow-up counseling session. Both residents were cognitively intact, and the DON and NHA could not provide documentation that the services were completed.
Nurse staffing information was not posted in the designated area at the beginning of each shift. Observations in the lobby areas showed the staffing information was missing, and an ADON stated that the information should be posted daily at the start of each shift in a prominent location.
A resident with severe cognitive impairment and behavioral issues was not consistently provided with required one-to-one supervision, allowing another resident to physically strike them during an altercation over music. Staff documentation and direct observation confirmed lapses in supervision, resulting in the resident sustaining a possible nasal fracture.
Failure to Investigate and Report Alleged Staff Abuse: An LPN admitted throwing water in a resident’s face during an argument, and a witness documented a second cup of water being thrown as well. The facility reported the event as a resident-to-resident altercation, but it did not document a complete investigation or report the staff-to-resident abuse allegation to the State Survey Agency, despite the resident’s severe cognitive impairment and the facility’s abuse reporting policy.
A resident with severe cognitive impairment and behavioral disturbances physically abused another cognitively impaired resident during an altercation over the bathroom, resulting in the victim sustaining fractures to the arm and leg that required hospitalization and surgery. Both residents had documented histories of agitation and aggression, and care plans were in place, but the incident still occurred and was classified as physical abuse by the facility.
The facility failed to maintain a sanitary environment in Garage 1, where approximately 50 garbage bags containing various refuse were stored, emitting a foul odor and obstructing egress. The trash compactor had been filled since early January, and excess waste was stored in the garage until an additional pick-up could be scheduled. The Director of Maintenance and the NHA acknowledged the unsanitary conditions and the facility's responsibility to provide a sanitary environment.
A resident with Type 2 diabetes and dementia did not receive their Lantus medication on time on multiple occasions, as documented in their MAR for several months. The facility's policy requires medications to be administered within one hour of the prescribed time, but this was not adhered to, as confirmed by the DON.
A pharmacist failed to identify irregularities in a resident's medication regimen, including incorrect dosage and lack of supporting diagnosis for ABH gel, during monthly reviews. The resident, with dementia and under hospice care for Parkinson's, had frequent administration of the medication without proper evaluation. The DON could not provide evidence of reported irregularities.
A facility failed to ensure a physician evaluated the appropriateness of a PRN antipsychotic medication every 14 days for a resident with dementia. The resident was prescribed ABH gel for anxiety or agitation, with orders extending beyond the 14-day requirement without documented clinical necessity. The medication was administered multiple times over several months, and the DON could not provide evidence of evaluation or rationale for extending the order.
The facility failed to maintain accurate clinical records for three residents. Two residents' records lacked documentation of a bed bug incident and related assessments, while another resident's psychiatric evaluation was inaccurately documented, omitting suicidal ideations and incorrectly stating the use of psychotropic medications. The DON confirmed these documentation lapses.
The facility failed to coordinate hospice services for two residents, resulting in a lack of documented communication between hospice and facility staff. Both residents had terminal prognoses and required integrated care, but their hospice communication binders lacked evidence of care provided. The DON could not provide documentation of communication, violating facility policies and state regulations.
A resident with cognitive impairment expressed suicidal ideations, but the facility failed to include these concerns in her care plan. Despite being sent to the emergency department and evaluated by psychiatry, her care plan did not address her safety needs related to her suicidal thoughts, as confirmed by staff interviews.
A resident with a history of morbid obesity, diabetes, and limb amputations engaged in unsafe vaping behaviors, setting off smoke alarms in their room. Despite being cognitively intact and aware of the facility's smoking policy, the resident's care plan was not updated to address these behaviors. Interviews with staff confirmed the lack of care plan revisions, highlighting a deficiency in the facility's response to the resident's non-compliance with the smoking policy.
A resident with COPD and myeloid leukemia received Oxycodone outside the prescribed parameters for pain management. The care plan required medication for pain levels 4-10, but staff administered it for lower pain levels, confirmed by the DON.
A facility failed to create a person-centered care plan for a resident with PTSD, neglecting to identify and mitigate triggers that could cause re-traumatization. Despite the resident's active PTSD diagnosis, the care plan lacked specific interventions, and staff confirmed the absence of a trauma-informed approach tailored to the resident's needs.
The facility failed to ensure residents were fully informed and competent to consent to changes in their Medicare Advantage plans, affecting three residents. Staff discussed insurance changes without residents initiating requests, and there was no documentation of residents' understanding or cognitive assessment prior to disenrollment.
The facility failed to maintain a homelike environment by not ensuring operational heating and adequate hot water temperatures. A wall heating unit in a resident room was non-functional, and the shower room's water temperatures were too low, leading to residents being taken to another shower room for care. Staff confirmed the issue had persisted for weeks.
The facility failed to maintain sanitary practices for managing infectious waste. Infectious waste was found in an open storage shed outside the kitchen, with the shed's doors open and a large accumulation of dried leaves under the waste. The Nursing Home Administrator confirmed the improper storage.
A resident, who was moderately cognitively impaired and required extensive assistance with ADLs, was not provided with the necessary services to maintain adequate personal hygiene. Despite the facility's protocol of showering residents at least once a week, documentation revealed that the resident was only showered once in a month. The DON confirmed the facility's failure to adhere to the planned frequency of showers.
Unsanitary food storage and service areas
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food in the food and nutrition services department and in three of four resident pantry areas, increasing the risk of foodborne illness. During an initial tour with the registered dietitian, the perimeter floor areas of the kitchen, including under the stainless steel counter next to the juice machine, under equipment in the cooks area, and under the ice machine, were visibly soiled with a heavy buildup of dirt and debris. Additional observations showed soiled lower rims and rubber bumpers on food delivery carts in Area Two and Area Three. In Area Three pantry, a thick black substance was hanging from the ice machine condensation drain hose, food splatter was adhered to the interior surface of the microwave, and debris had accumulated under three ceiling light shields. In Area Four pantry, the microwave interior had a worn appearance with food splatter buildup. In Area One pantry, both ice machine condensation hoses were visibly soiled with bluish and black substances, the floor under and around the ice machine was soiled, and debris had accumulated under two ceiling light shields. The dish room also had a two-foot strip of vinyl molding pulled away from the wall behind the dishwasher and dirt buildup on the concrete wall in front of the dishwasher.
Unnecessary PRN psychotropic medication use without documented nonpharmacological interventions
Penalty
Summary
The facility failed to ensure one resident was free of unnecessary psychotropic medication and failed to demonstrate that individualized, nonpharmacological approaches were used before administering PRN lorazepam gel. Resident 39 was admitted with cerebral palsy and intellectual disabilities and was assessed as severely cognitively impaired with a BIMS score of 03. The care plan identified inappropriate verbal and physical behaviors related to cognitive impairment and intellectual disability, including grabbing female staff, combative behavior during care, spitting, screaming, inappropriate exposure, and striking out at staff and others. The care plan included interventions such as continuous one-to-one supervision, medications as ordered, distraction techniques, soft music, allowing the resident to calm in the room, and visual stimuli such as observing birds. A physician order for lorazepam gel 0.5 mg/ml was entered for application to the posterior neck every eight hours as needed for anxiety, agitation, or aggression related to anxiety disorder. The order was discontinued and reinitiated multiple times, with the same directions, and the record did not define the resident’s behavioral expressions of anxiety, agitation, or aggression in measurable and observable terms to guide when the medication was clinically indicated. The MAR showed 18 administrations of lorazepam gel between January 10, 2026, and February 24, 2026. The record contained no evidence that non-pharmacological interventions were attempted and found ineffective before each of those administrations. During interview, the DON could not provide documented evidence that non-pharmacological interventions were used prior to the 18 doses or that the facility had defined the resident’s behaviors in objective terms to support use of the medication.
Missing Physician Progress Notes for Required Visits
Penalty
Summary
The facility failed to ensure that the attending physician documented required visits by writing, signing, and dating a physician progress note for each visit, as required by facility policy and professional standards of practice. The facility’s Physician Progress Notes Policy stated that physician progress notes must be maintained for each resident and that the attending physician must write, sign, and date the note upon each visit. Clinical record review showed that five sampled residents did not have timely physician progress notes in their records despite multiple physician visits. Resident 8, who had osteoarthritis, had a physician progress note dated June 28, 2025, but no additional notes in the record, although later faxed notes indicated multiple physician visits through March 7, 2026. Resident 161, who had dementia and hypertension, had a physician progress note dated June 28, 2025, with no further notes in the record, although later faxed notes showed physician visits on several dates through January 31, 2026. Resident 68, who had Alzheimer’s disease and Parkinsonism, had a physician progress note dated June 7, 2025, with no additional notes in the record, although later faxed notes showed multiple physician visits through February 14, 2026. Resident 132, who had anoxic brain damage, and Resident 166, who had dementia, each had a physician progress note dated June 14, 2025, with no additional notes in the record, although later faxed notes showed multiple physician visits afterward. The DON confirmed on interview that physicians are expected to write, sign, and date a physician progress note at each visit, and also confirmed that the physician visited Residents 8, 68, 132, 161, and 166 as required, but did not consistently provide written, signed, and dated progress notes for inclusion in the clinical records.
Failure to Recognize Mattress-on-Floor as a Restraint
Penalty
Summary
The facility failed to identify the use of a physical restraint and failed to follow its restraint policy for one resident with dementia and a history of falls. The resident’s quarterly MDS dated January 16, 2026, showed the resident was unable to be interviewed and required partial to moderate assistance with sitting and standing at the side of the bed. The facility policy defined a restraint as a device or equipment that an individual cannot remove and required assessment, physician order, consent, care plan inclusion, and ongoing monitoring before and during restraint use. The resident’s care plan identified fall risk and included interventions such as bed and chair alarms, a low bed, and a floor mat, but it did not include a mattress placed directly on the floor. Surveyors observed the resident lying on a mattress placed directly on the floor on March 10, March 11, and March 12, 2026. The mattress placement reduced the height of the sleeping surface to floor level and may limit the resident’s ability to independently reposition, transfer, or rise from the sleeping surface. The clinical record did not identify the purpose of placing the mattress on the floor, did not include the intervention in the care plan, and did not show evidence of an interdisciplinary team evaluation before it was started. The record also lacked documentation of a physician order, resident or representative notification and consent, assessment of whether it was the least restrictive intervention, attempts at alternatives, or ongoing monitoring while the intervention was in place. The DON stated the mattress was placed on the floor to reduce falls, that the decision was not evaluated by the interdisciplinary team, and later stated the placement reduced the resident’s bed mobility and created a potential restraint.
Failure to Prevent Pressure Ulcer From Palm Protector and Untrimmed Fingernails
Penalty
Summary
The facility failed to timely identify and address risk factors for pressure ulcer development and failed to implement and sustain effective interventions to prevent recurrence for a resident with dementia, failure to thrive, and finger contractures. The resident’s care plan identified risk for skin breakdown to the palms related to contractures and directed use of palm protectors at all times with periodic removal for skin observation and hygiene. Nurse aide documentation indicated palm checks were to be completed once per shift, and on February 12, 2026, a nurse aide removed the palm protectors and found an open area between the right thumb and index finger. The facility’s documentation identified rubbing from the palm protector and the resident’s fingernails as the root cause, and a nurse note later described the wound as related to pressure from the strap of the palm protector. A wound care physician evaluated the injury as a Stage III pressure ulcer with slough, and the wound specialist identified pressure from the resident’s fingernails as the cause. Observations in March showed the right-hand fingernails were long and sharp, and the DON could not provide evidence that the facility evaluated whether once-per-shift skin observation was sufficient for the resident’s contracted fingers or that it analyzed how the palm protector strap contributed to pressure. The resident’s fingernails were not trimmed until after surveyor observation and notification.
Failure to Provide Timely Foot Care and Podiatry Services
Penalty
Summary
The facility failed to consistently provide timely and necessary foot care for one resident with diabetes. The resident’s clinical record showed a physician order for podiatry consultation with follow-up treatment as indicated, and the resident’s last documented podiatry visit was on December 22, 2025. The resident’s admission MDS dated December 14, 2025, indicated the resident was cognitively intact with a BIMS score of 15 and was independently ambulatory. During an observation on March 10, 2026, the resident’s toenails on both feet were thickened, yellowed, extended past the tips of the toes, and rough and uneven. The skin on the toes was thick and scaling across the top and side, and appeared dry, flaky, crusty, and white-gray in appearance. The resident stated he had diabetes, was upset that he had not seen the podiatrist recently, was not receiving routine foot care, and that the length of his toenails caused discomfort. During interview, the DON was unable to provide documented evidence that the resident received podiatry care and services to ensure his feet were well-kept, free of signs of infection, and that his foot discomfort was addressed.
Failure to Provide Behavioral Health and Trauma-Informed Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to residents with mental health needs and a history of trauma, as reflected in the records for two residents. Facility policy stated that residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and that trauma-informed care would address the needs of trauma survivors by minimizing triggers or re-traumatization. Resident 66 was admitted with diabetes and depression and was cognitively intact on admission. Although an admission evaluation form stated he had never experienced a traumatic event and did not have PTSD, psychology progress notes repeatedly documented that he reported a history of trauma, specifically that he had recently been mugged. The clinical record did not contain documented evidence that the facility completed a trauma assessment, evaluated trauma-related symptoms, or identified potential triggers after these repeated reports. During interview, Resident 66 stated he had been assaulted and mugged while living at a homeless shelter before admission and that the experience continued to bother him months later. Resident 22 was admitted with bipolar disorder, major depressive disorder, generalized anxiety disorder, and borderline personality disorder, and was cognitively intact. The care plan identified impaired psychiatric and mood status and included behavioral health consults as needed, and a physician order indicated psychological evaluation and treatment as appropriate. A psychological services note documented supportive psychotherapy, stress management, and solution-focused therapy, and recommended continued treatment for three to six months with follow-up within two to three weeks. The record did not show that the recommended follow-up psychological services appointment or session occurred, and Resident 22 stated he was not currently receiving counseling or therapy and believed he would benefit from additional sessions.
Nurse Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure that current and accurate nurse staffing information was posted in the designated area at the beginning of each shift. Observations in the first floor lobby and second floor lobby on March 11, 2026, at 1:25 PM and March 12, 2026, at 8:10 AM showed that the nurse staffing information was not posted in the facility's designated area. During an interview on March 12, 2026, at 8:20 AM, the Assistant Director of Nursing stated that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location.
Failure to Consistently Implement One-to-One Supervision Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that a resident was protected from physical abuse by another resident due to inconsistent implementation of required one-to-one supervision. According to the facility's abuse prohibition policy and the resident's care plan, one-to-one supervision was mandated for a resident with severe cognitive impairment and behavioral symptoms, including impulsive and combative behaviors. Despite these requirements, documentation and direct observation revealed lapses in supervision, allowing another resident to approach and physically strike the resident under one-to-one supervision. The incident occurred when a cognitively intact resident became agitated by music being played at the nurses' station, removed the speaker, and threw it on the floor. This led to an escalation between the two residents, with spitting and verbal exchanges, followed by the cognitively intact resident striking the other resident in the face multiple times. Witness statements from staff indicated that the assigned nurse aide was present but was unable to prevent the altercation, and the documentation did not consistently demonstrate that one-to-one supervision was effectively maintained at the time of the incident. The resident who was struck sustained a possible nondisplaced nasal fracture and was transported to the hospital for evaluation. Further observation during the survey revealed ongoing noncompliance with the one-to-one supervision policy, as the resident requiring supervision was observed without a staff member in direct line of sight or within reach. Interviews with staff, including the assigned nurse aide and the Director of Nursing, confirmed that one-to-one supervision was required but not consistently implemented. These failures directly contributed to the resident's exposure to physical abuse by another resident.
Failure to Investigate and Report Alleged Staff Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was thoroughly investigated and reported to the State Survey Agency within the required time frame for one resident. The facility’s abuse policy stated that any suspected abuse must be immediately reported and investigated, and that staff must report suspected crimes against residents to the State Survey Agency and local law enforcement within the required time frames. The policy also required documentation of the report and investigation, including interviews and findings. Resident 1 had diagnoses including vascular dementia with psychotic disturbance and primary insomnia, and the resident’s assessment showed severe cognitive impairment with a BIMS score of 0. Resident 2 also had vascular dementia, insomnia, severe cognitive impairment, and used a wheelchair. On January 18, 2026, a written witness statement documented that an LPN engaged in a verbal argument with Resident 1 and threw a cup of water into Resident 1’s face, then threw a second cup of water. The statement further documented that Resident 1 attempted to spit toward the LPN but instead spit on Resident 2, who then struck Resident 1 in the face. The witness removed Resident 1 from the area while the LPN remained to clean the spilled water. During interview, the LPN confirmed she threw water in Resident 1’s face and stated she did so in reaction to Resident 1 yelling profanities at her. The LPN also stated she provided a statement to police. The RN supervisor stated she became aware of the incident that evening and directed the LPN to leave the floor and write a statement; she did not believe the water throw was accidental. The facility reported the event to police and the Area Agency on Aging as a resident-to-resident altercation, but it was unable to provide documentation that it investigated or reported the staff-to-resident allegation involving the LPN throwing water at Resident 1. The risk manager stated the facility did not report or further investigate the staff action because there was no serious bodily injury, sexual abuse, or death, and the facility could not provide documentation showing the allegation was reported to the State Survey Agency or that abuse was ruled out.
Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when a resident sustained serious injuries, including fractures to the humerus and femur, as a result of being physically abused by another resident. The incident took place when one resident, who had a history of dementia with behavioral disturbances and bipolar disorder, entered another resident's room and pushed her after an altercation over the bathroom. Both residents involved were severely cognitively impaired, with documented histories of agitation, aggression, and previous behavioral issues, including verbal and physical outbursts. The facility's records indicated that the resident who perpetrated the abuse had a care plan in place addressing their aggressive behaviors, with interventions such as medication administration, behavioral redirection, and removal from public areas when disruptive. The victim also had a care plan noting risks for psychosocial well-being and a history of agitation and aggression. Despite these care plans, the incident occurred, resulting in the victim being found on the floor in pain, requiring emergency medical attention and subsequent hospitalization for surgical intervention. Documentation showed that staff responded to the incident by separating the residents, initiating neurological checks, and notifying the physician and resident representatives. The event was classified as physical abuse by the facility, and an internal investigation was initiated. The incident was reported to the appropriate protective authorities, and the facility's abuse prohibition policy was reviewed as part of the investigation.
Unsanitary Conditions in Facility Garage
Penalty
Summary
The facility failed to maintain a sanitary environment in one of its buildings, specifically Garage 1, as observed on January 13, 2025. Approximately 50 filled clear plastic garbage bags were stored on the ground, containing various refuse such as blue latex gloves, used resident briefs, bed protective barriers, and human and food waste. Additionally, cardboard boxes and loose latex gloves were scattered on the garage floor. The bags were piled about 4 feet high and extended 20 feet across the garage floor, obstructing the egress to enter the building beyond 8 feet. The building emitted an unpleasant and foul odor, indicating a lack of sanitation. Interviews with staff revealed that the trash compactor had been filled since January 1, 2025, and the excess garbage was stored in the garage until an additional pick-up could be scheduled. The Director of Maintenance acknowledged the situation, explaining that the compactor would fill up again before the next scheduled pickup, necessitating an additional waste removal service. The Nursing Home Administrator confirmed the presence of the garbage bags and acknowledged the facility's responsibility to maintain a sanitary environment for residents, staff, and the public. The deficiency highlights the facility's failure to manage waste effectively, leading to unsanitary conditions in a building used by staff.
Plan Of Correction
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. While no resident/residents were directly affected, all garbage cited in the deficiency was removed via a 30-yard dumpster before the surveyor exited the facility. 2. Based on the rationale in number one, no other residents have the potential to be directly affected. 3. Should the need arise, in the future, to temporarily store garbage until a pick-up is possible, it will be stored in appropriate covered containers, in building 1, which is not a part of the licensed facility, to assure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 4. The Maintenance Director/designee will monitor building #1, twice daily x 4 weeks, then 1x daily thereafter. All Dietary, Housekeeping, and Maintenance staff will be inserviced on the process to properly store garbage temporarily in a safe, functional, and sanitary way until a pickup can be arranged. Results of audits will be presented monthly in QAPI.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring timely administration of medications for a resident. Specifically, Resident 129, who was diagnosed with Type 2 diabetes and dementia with agitation, was prescribed Lantus, a medication for diabetes, to be administered daily at 9:30 AM. However, the Medication Administration Record (MAR) for April, May, and June 2024 showed multiple instances where the Lantus injection was administered more than one hour past the scheduled time, contrary to the facility's policy of administering medications within one hour of their prescribed time. The late administration of Lantus was confirmed by the Director of Nursing during an interview, acknowledging that it was inconsistent with professional standards for diabetes management. The Pennsylvania Code and the American Nurses Association Principles for Nursing Documentation emphasize the importance of timely medication administration and accurate documentation to ensure high-quality care. The repeated delays in administering the Lantus injection indicate a deficiency in adhering to these standards, as evidenced by the specific dates and times when the medication was administered late.
Pharmacist Fails to Identify Medication Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review for a resident, leading to the oversight of several irregularities in the resident's medication orders. The resident, who was admitted with dementia and later received hospice care for Parkinson's disease, had a physician order for ABH gel, which included Ativan, Benadryl, and Haldol. The order specified an incorrect dosage of Benadryl and lacked a supporting diagnosis for the use of the medication. Additionally, there was no documented evidence that the physician evaluated the continued need for the prn antipsychotic medication every 14 days. The pharmacist did not identify these irregularities during the monthly medication reviews from August 2023 through June 2024. The resident's MAR indicated frequent administration of the ABH gel, yet the pharmacist failed to report the incorrect dosage, the absence of a supporting diagnosis, and the increased use of the prn medication. During an interview, the DON could not provide evidence that the pharmacist had reported or identified any irregularities in the resident's medication regimen reviews.
Failure to Evaluate PRN Antipsychotic Medication Appropriateness
Penalty
Summary
The facility failed to ensure that a physician evaluated the appropriateness of an as-needed anti-psychotic medication every 14 days for a resident diagnosed with dementia. The resident was prescribed ABH gel, a combination of Ativan, Benadryl, and Haldol, to be applied topically every 6 hours as needed for anxiety or agitation. The physician's orders for this medication were issued for 30-day durations on two occasions, without documentation of the clinical necessity for extending the PRN order beyond the 14-day requirement. Additionally, there was no evidence in the resident's clinical record that the use and need for the PRN antipsychotic had been evaluated for continued appropriateness. The medication administration record revealed that the ABH gel was administered 25 times in May, 15 times in June, and 6 times in July. During an interview, the Director of Nursing was unable to provide documented evidence that the physician had evaluated the resident's use of the PRN antipsychotic for continued appropriateness or documented the clinical rationale for extending the order. This lack of documentation and evaluation led to the deficiency cited under F756, as well as violations of specific Pennsylvania Code regulations related to medical director and pharmacy services.
Deficiencies in Clinical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as required by professional standards of practice. For two residents, the facility did not document the presence of bed bugs in their room, nor did it record any physical assessments for potential effects such as bites or skin irritation. Additionally, there was no documentation indicating that the residents' representatives were informed of the room changes due to the bed bug issue. The Director of Nursing confirmed that these assessments were performed but not documented in the clinical records. For another resident, the facility failed to accurately document the resident's psychiatric evaluation. The resident had expressed suicidal ideations, but the psychiatry note did not reference this critical information. Furthermore, the note inaccurately stated that the resident was receiving psychotropic medications, although the medication administration record showed no such prescriptions or administration at that time. The Director of Nursing confirmed the inaccuracies in the psychiatric documentation. These deficiencies highlight a failure in maintaining accurate and complete medical records, which is essential for ensuring informed decision-making and high-quality care. The lack of documentation regarding the bed bug incident and the resident's psychiatric evaluation indicates a significant oversight in the facility's record-keeping practices.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to ensure the coordination of hospice services with facility services to meet the needs of two residents, identified as Resident 98 and Resident 101. Resident 101 was admitted with diagnoses including dementia and atherosclerotic heart disease, and had a terminal prognosis with hospice care related to cerebral atherosclerosis. The care plan required collaboration between nursing staff and the hospice team to meet the resident's needs, with scheduled visits from hospice nurse aides and a registered nurse. Similarly, Resident 98, diagnosed with Parkinson's disease and quadriplegia, was under hospice care with a care plan that also required integrated care from facility and hospice staff. However, there was no documented evidence of communication between hospice staff and facility nursing staff in the residents' clinical records or hospice communication binders. An observation revealed that the hospice communication binder for both residents contained no documentation of care provided by hospice staff. During an interview, the Director of Nursing was unable to provide evidence of communication between hospice staff and facility staff regarding the care and services provided to Residents 98 and 101. The lack of documentation and communication was a violation of the facility's policies and state regulations, which require proper coordination and documentation of care to ensure residents' physical and psychosocial needs are met.
Failure to Develop Comprehensive Care Plan for Suicidal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who expressed suicidal ideations and distress. The resident, who was admitted with diagnoses including anoxic brain damage and disorientation, was noted to have stated intentions to harm herself. Despite these statements, the resident's care plan did not address her expressed suicidal thoughts or wishes to die. The facility's staff, including the Director of Nursing and Social Services, confirmed that the care plan lacked specific measures to address the resident's safety needs related to her suicidal ideations. The resident was moderately cognitively impaired and had no functional limitations in her range of motion. After expressing suicidal thoughts, she was sent to the emergency department for evaluation and later returned to the facility. A psychiatric evaluation noted her anxiety and depression but did not reference her previous suicidal statements. The lack of a person-centered care plan that included these critical safety concerns was confirmed by staff interviews, highlighting a deficiency in addressing the resident's individualized needs.
Failure to Update Care Plan for Resident's Unsafe Smoking Behaviors
Penalty
Summary
The facility failed to review and revise a resident's care plan concerning unsafe smoking behaviors and non-compliance with the facility's smoking policy. The resident, who was cognitively intact with a BIMS score of 15, had a history of morbid obesity, diabetes, pressure ulcers, opioid abuse, and limb amputations. Despite being aware of the facility's smoking policy, the resident engaged in vaping in his room on multiple occasions, setting off smoke alarms and prompting intervention from staff and the fire department. The resident's care plan, which addressed various behavioral issues, did not include updates related to his vaping activities or non-compliance with the smoking policy. Interviews with facility staff, including a social worker and the Director of Nursing, confirmed that the resident's care plan had not been updated to reflect the resident's smoking contract or his non-compliance with the facility's smoking policy. Despite meetings with the resident to discuss the smoking contract and the resident's acknowledgment of the policy, there was no documented evidence of care plan revisions to address these issues. This oversight was identified during a survey conducted in July 2024.
Improper Administration of Pain Medication
Penalty
Summary
The facility failed to administer pain medication in accordance with physician orders for a resident diagnosed with chronic obstructive pulmonary disease and myeloid leukemia. The resident's care plan indicated a potential for pain related to cancer, rib fracture, and pneumonia, with interventions to administer medications as per physician orders. A physician's order dated June 3, 2024, specified that Oxycodone HCL Oral Tablet 5 mg should be administered every six hours as needed for moderate to severe pain, rated from 4 to 10 on a pain scale. However, the medication administration record revealed that the facility staff administered the opioid medication outside the prescribed parameters. The resident received Oxycodone on several occasions for pain levels of 0 and 3, which were below the prescribed threshold. The Director of Nursing confirmed that the facility staff administered the medication outside the parameters of the physician's orders, acknowledging the facility's responsibility to ensure compliance with the prescribed pain management plan.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including PTSD, major depression, intellectual disability, and dementia, had an annual Minimum Data Set assessment indicating an active diagnosis of PTSD. Despite this, the care plan did not include specific interventions to identify and mitigate triggers that could re-traumatize the resident. The care plan, initially dated January 8, 2024, lacked documented evidence of attempts to identify the resident's triggers or to develop strategies to decrease exposure to these triggers. Interviews with facility staff, including a social worker and the Director of Nursing, confirmed the absence of a trauma-informed care approach tailored to the resident's needs. The social worker acknowledged that the facility had not identified the resident's specific past experiences or attempted to gather information from the resident's family or past social and medical history to develop appropriate interventions. The Director of Nursing confirmed that the facility did not provide trauma-informed care in accordance with professional standards, failing to account for the resident's specific experiences to prevent re-traumatization.
Failure to Ensure Informed Consent for Medicare Plan Changes
Penalty
Summary
The facility failed to develop and implement policies and procedures in accordance with CMS guidance to protect residents from being disenrolled from Medicare Health Plans without their informed consent. The deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and interviews with staff and residents. The facility did not ensure that residents were fully informed of the risks associated with disenrolling from Medicare Advantage plans, nor did they assess the residents' cognitive competence to make such decisions. Three residents were affected by this deficiency. Resident 3, who was cognitively intact with a BIMS score of 13, was disenrolled from her Medicare Advantage plan without documented evidence of her initiating the request or understanding the implications. Similarly, Resident 4, also cognitively intact, was disenrolled from his plan without proper documentation of his or his representative's understanding of the change. Resident 5, who was not available for interview, was also disenrolled without evidence of initiating the request or understanding the change. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, confirmed that the facility lacked operational policies and procedures for assisting residents with changes to their Medicare health care coverage. The staff admitted to discussing insurance changes with residents during open enrollment without the residents initiating these requests, which contributed to the deficiency.
Inadequate Maintenance of Heating and Water Temperatures
Penalty
Summary
The facility failed to provide maintenance services necessary to maintain a comfortable and homelike environment for residents. Specifically, one of the two wall heating units in a resident room was not operational, and the hot water temperatures in the area 4 shower room were inadequate, with the shower water at 88 degrees Fahrenheit and the sink water at 80 degrees Fahrenheit. During observations, two nurse aides confirmed that the water temperatures had been cold for weeks, preventing resident showers and personal care in that shower room. As a result, residents from this side of the unit had to be taken to the shower room on the opposite side for care. The facility administrator acknowledged that maintenance services were expected to ensure comfortable water and room temperatures.
Improper Storage of Infectious Waste
Penalty
Summary
The facility failed to maintain sanitary practices for managing infectious and hazardous waste storage on its grounds. During an observation on April 1, 2024, at 11 AM, multiple red plastic bags and closed cardboard boxes containing infectious waste were found in an open storage shed located in a parking area outside the facility's kitchen. The shed's doors were open, exposing the waste. Additionally, there was a large accumulation of dried leaves under the bags and boxes of infectious waste. The Nursing Home Administrator confirmed during an interview at approximately 1 PM on the same day that the infectious waste was not stored properly in the storage shed.
Failure to Maintain Adequate Personal Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary services to maintain adequate personal hygiene and grooming for a resident who was dependent on staff for assistance with bathing and showering. Resident 2, who was moderately cognitively impaired and required extensive assistance with activities of daily living, including bathing, reported to the surveyor that she had only been showered once recently, despite the facility's protocol of showering residents at least once a week. The Director of Nursing confirmed that the nurse aide is responsible for documenting when a resident is showered in the electronic clinical record. A review of Resident 2's clinical records revealed that she was admitted with diagnoses including hemiplegia and communication deficit, necessitating assistance with personal care. The quarterly MDS Assessment indicated her need for extensive assistance with ADLs. However, documentation from March 6, 2024, to March 29, 2024, showed that Resident 2 was only showered once during this period, with no evidence of being offered or receiving a shower or tub bath weekly as required. The Director of Nursing acknowledged the facility's inability to demonstrate compliance with the planned frequency of showers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 370 citations issued within 25 miles in the last 12 months — including the 5 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Weatherly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion At St Luke Village, The | 7.1 mi | ★★★★★ | 8 | 0 |
| Manor At St Luke Village,the | 7.2 mi | ★★★★★ | 16 | 0 |
| Mahoning Operating Llc | 8.2 mi | ★★★★★ | 12 | 0 |
| Mountain City Nursing & Rehabilitation Center | 8.5 mi | ★★★★★ | 1 | 0 |
| Summit At Blue Mountain Nursing & Rehab Ctr, The | 8.6 mi | — | 0 | 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.