Friendship Village Of South Hi
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 1290 Boyce Road, Pittsburgh, Pennsylvania 15241
- CMS Provider Number
- 395688
- Inspections on file
- 25
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Friendship Village Of South Hi during CMS and state inspections, most recent first.
A resident with a traumatic brain injury, subdural hematoma, and cervical fracture reported to an RN that during care he was boosted in bed, his head struck the headboard, and he experienced increased numbness and tingling in his left forearm and fingers, with pins and needles in his upper extremities and feet. The RN documented the complaint and noted no obvious head injury, no increased pain, and an intact CTO brace with a missing foam piece, and the resident’s care plan called for caution during transfers and bed mobility. However, nursing staff did not enter an incident report or initiate an investigation of this allegation of potential rough handling/abuse as required by facility policy and state law, and the event was not reported to administration until the family later raised concerns, at which point leadership confirmed the failure to immediately report and investigate.
Grievance boxes on three nursing units were mounted at heights between 55 and 61 inches, making them inaccessible to residents in wheelchairs. On one unit, an armchair further blocked access to the box. The Nursing Home Administrator confirmed the lack of accessibility, which did not comply with facility policy or federal accessibility requirements.
Thirteen residents with significant medical needs did not receive timely assistance with ADLs, as evidenced by prolonged call light response times ranging from 20 minutes to over an hour. Multiple residents and families reported repeated delays, and facility records confirmed these extended wait times, despite residents' dependence on staff for essential care.
Surveyors found that two medication rooms contained multiple expired medical supplies and medications, including dressings, ointments, and syringes, as well as personal belongings of former residents. The DON confirmed that the facility failed to ensure proper storage and disposal of these items, contrary to facility policy.
A resident who required a two-person assist for transfers was moved by a single CNA, resulting in a deep skin tear on the right shin that required 17 sutures. The resident, with multiple medical conditions and non-weight bearing status, was injured when their leg struck the wheelchair leg rest holder during the transfer. The CNA did not check the resident's transfer status as documented in the Kardex, leading to neglect and actual harm.
A resident with severe cognitive impairment and multiple diagnoses was found to have their bed placed against the wall without a physician's order or documented medical reason. Facility policy and state regulations require written authorization for physical restraints, but no such documentation was present in the clinical record or care plan, and staff confirmed the lack of compliance.
A resident with Alzheimer's and other medical conditions was administered Seroquel, a psychotropic medication, both as a scheduled and PRN order for agitation and depression. The PRN order exceeded the facility's 14-day policy limit, and there was no documented clinical rationale or evidence of behaviors to justify continued use. Staff confirmed the failure to ensure the medication regimen was free from unnecessary psychotropic medication.
A resident who required a two-person assist for transfers due to multiple medical conditions was transferred by a single CNA, contrary to the care plan and Kardex instructions. During the transfer, the resident's leg struck the wheelchair leg rest holder, causing a deep skin tear that required 17 sutures. The CNA did not verify the resident's transfer status before performing the transfer alone, resulting in actual harm.
The facility did not post the required contact information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups, making this information inaccessible to residents and their representatives. This was confirmed during observations and an interview with the NHA.
The facility did not display required written information about how to apply for and use Medicare and Medicaid benefits, or how to receive refunds for previous payments covered by these benefits. This was confirmed during observations and an interview with the NHA.
The facility did not revise or update care plans for two residents to reflect their current care needs. One resident's care plan lacked interventions for a bed placed against the wall, which acted as a physical restraint, while another resident's care plan did not accurately reflect their level of independence with oral care and lacked documentation of personal hygiene services. Facility leadership confirmed these deficiencies.
The facility did not provide or document required training on the Quality Assurance and Performance Improvement (QAPI) Program for staff. Review of records and staff interviews confirmed the absence of QAPI-related education, and the administrator acknowledged the deficiency.
The facility failed to provide four residents the opportunity to formulate an advance directive, as required by policy. Despite being admitted with various health conditions, their clinical records lacked documentation of being offered this right. The DON and NHA confirmed this deficiency during an interview.
The facility did not notify the State Ombudsman Office of resident transfers and discharges for over four years, from 2019 to 2024. This was confirmed through document reviews and interviews, with the Nursing Home Administrator acknowledging the lapse. The State Ombudsman Office had not received notifications since 2019, violating resident rights as per PA Code: 201.29(f)(g).
Failure to Immediately Report and Investigate Resident Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to immediately report and investigate a resident’s allegation of potential abuse/neglect as required by policy and state law. Facility policy (RISKWATCH Incident/Accident Occurrence Reporting System) required that incidents such as alleged abuse, rough handling, equipment-related incidents involving a resident, and injuries of unknown origin be entered completely and accurately by the licensed nurse or first responder prior to the end of the shift and as close to the time of the incident as possible, with documentation on the 24-hour report and alert monitoring per change of condition standards. A resident with diagnoses including traumatic subdural hematoma, displaced fracture of the seventh cervical vertebra, and traumatic brain injury reported to an RN that during care the previous night, when he was being boosted in bed, his head hit the headboard and he was experiencing increased numbness and tingling in his left forearm and first and second fingers, with pins and needles in the left upper extremity, right hand, and both feet. The RN documented that there was no obvious head injury or increased pain and that the cervical-thoracic orthosis brace was intact, though missing a foam piece underneath the bottom portion. Despite this report from the resident, and the resident’s plan of care indicating he had potential/actual impairment related to a cervical collar and impaired mobility requiring use of caution during transfers and bed mobility to prevent striking extremities against hard or sharp surfaces, the nursing staff did not make an incident report or initiate an investigation at that time. The Nursing Home Administrator confirmed that the resident and family reported the event to nursing staff on the date of the RN’s note without staff making a report in accordance with facility policy and state requirements. An investigation was not initiated until later, after the family emailed facility administration with concerns related to the event. The Nursing Home Administrator and Director of Nursing acknowledged that the facility failed to immediately report and investigate the resident’s allegation in response to allegations of abuse, neglect, exploitation, or mistreatment.
Grievance Boxes Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents on three nursing units: Dogwood, Pinewood, and Specialty Care. Observations revealed that the grievance boxes were mounted at heights of approximately 55 inches, 61 inches, and 60 inches above the floor, respectively, which placed them out of reach for residents using wheelchairs. Additionally, on the Specialty Care unit, an armchair was found blocking access to the grievance box, further limiting accessibility. Interviews with the Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents in these locations. The facility's policy supports residents' and family members' rights to voice grievances without discrimination or reprisal, and federal regulations require that grievance procedures be accessible to all residents, including those with disabilities. However, the facility did not comply with these requirements, as evidenced by the placement and obstruction of the grievance boxes.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary care and services to thirteen out of twenty-four residents who required assistance with activities of daily living (ADLs). Facility policy states that residents unable to perform ADLs independently must receive appropriate care to maintain nutrition, grooming, and hygiene. However, multiple residents and their families reported excessive wait times for staff assistance after activating call lights, with documented delays ranging from 20 minutes to over an hour. These concerns were corroborated by group interviews, resident council minutes, and grievance records, all indicating ongoing dissatisfaction with response times. Clinical record reviews revealed that affected residents had significant medical conditions such as malignant neoplasm of the colon, diabetes mellitus, dementia, hip fractures, Parkinson's disease, and other chronic illnesses. Many required substantial or maximal assistance with personal hygiene, mobility, and toileting, as indicated by their Minimum Data Set (MDS) assessments. Despite these needs, call light audits consistently showed prolonged response times, with several instances exceeding 30 minutes and some over an hour, directly impacting residents who were dependent on staff for essential care. Interviews with residents, family members, and facility leadership confirmed the pattern of delayed responses. Residents expressed frustration and described frequent experiences of waiting extended periods for help, particularly with ADLs. The facility's own documentation, including call light logs and grievance records, substantiated these reports. The deficiency was acknowledged by both the Nursing Home Administrator and the Director of Nursing, who confirmed that necessary care and services were not consistently provided to the identified residents.
Improper Storage and Disposal of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and disposed of in two out of three medication rooms, as required by facility policy and regulatory standards. During observations, multiple expired medical supplies and medications were found in both the Secure Care Unit and Dogwood Unit medication rooms. Items identified included expired calcium alginate dressings, gelling fiber dressings, a latex Foley catheter, Bacitracin zinc ointment, and various other medical supplies and medications with expiration dates ranging from 2021 to 2025. Additionally, the facility policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued, outdated, or deteriorated medications or biologicals, but this was not followed as evidenced by the presence of these expired items. Further, in the Dogwood medication room, personal belongings of former residents, such as hearing aids, eyeglasses, a cell phone, and other miscellaneous articles, were found stored under the sink. These items belonged to residents who had been discharged from the facility as far back as 2020. The Director of Nursing confirmed during an interview that the facility did not ensure proper storage or disposal of medical supplies, medications, and personal items in the medication rooms.
Failure to Follow Transfer Protocols Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, and diabetes, and was non-weight bearing on the left lower extremity. The resident's care plan and Kardex clearly indicated the need for a two-person assist for all transfers, and the facility's policies required staff to follow these directives to prevent harm. During the transfer from wheelchair to bed, the CNA performed the transfer alone, contrary to the resident's documented needs. As a result, the resident sustained a deep skin tear on the right shin, which was discovered after the transfer when the resident's pants were removed. The wound was significant, measuring 4.5 cm by 5 cm by 1 cm, with exposure of adipose tissue, and required 17 sutures at the hospital. The incident was attributed to the resident's leg striking the wheelchair leg rest holder during the improper transfer. Staff interviews confirmed that other nurse aides were able to describe how to access and follow a resident's required transfer status. The Nursing Home Administrator acknowledged that the facility failed to protect the resident from neglect, as the CNA did not check the transfer status on the Kardex and did not provide the required level of assistance, resulting in actual harm to the resident.
Failure to Ensure Resident Free from Physical Restraint Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, high blood pressure, and lumbar radiculopathy was found to have their bed placed against the wall without a physician's order or documented medical justification. The facility's policy requires that residents be free from physical restraints unless authorized in writing by a physician for a specific and limited period or in emergencies. In this case, there was no documentation in the resident's clinical record, plan of care, or progress notes to support the use of the bed against the wall as a restraint or to indicate a medical reason for this intervention. The resident in question had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, there was no evidence of a physician's order or care plan goal related to the bed placement. During staff interviews, it was confirmed that the facility failed to ensure the resident was free from the use of a physical restraint without proper authorization, as required by both facility policy and state regulations.
Failure to Prevent Unnecessary Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication. According to the facility's policy, psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and must be supported by documented clinical rationale. For one resident with diagnoses including Alzheimer's disease, high blood pressure, and lumbar radiculopathy, the clinical record showed ongoing orders for Seroquel (Quetiapine) both as a scheduled and PRN medication for agitation and depression. The PRN order for Seroquel exceeded the 14-day limit set by policy, and there was no documentation of behaviors or clinical justification for continued use during the specified period. Additionally, a new PRN order for Seroquel was written at the request of the resident's family, again without documented evidence of behaviors or clinical rationale in the progress notes. Staff interviews confirmed that the facility did not ensure the resident's medication regimen was free from unnecessary psychotropic medication, as required by both facility policy and regulatory standards.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required a two-person assist as documented in the care plan and Kardex, was transferred by a single CNA. The resident had significant medical conditions, including COPD, heart failure, diabetes, and was non-weight bearing on the left lower extremity. The care plan specifically indicated the need for caution during transfers to prevent skin injuries, and the Kardex clearly stated the requirement for a two-person assist for transfers. During the transfer from wheelchair to bed, the CNA performed the task alone, contrary to the documented requirements. The resident's right shin struck the wheelchair leg rest holder during the transfer, resulting in a deep skin tear. The injury was discovered after the transfer when the resident's pants were removed, revealing a large, deep skin tear with exposure of adipose tissue. The wound measured 4.5 cm by 5 cm, was 1 cm wide and deep, and required immediate medical attention. The incident was reported by the CNA and assessed by nursing staff, who confirmed the extent of the injury. The resident was sent to the hospital, where the wound required 17 sutures. Documentation and staff interviews confirmed that the CNA did not check the resident's transfer status prior to the transfer and did not follow the required two-person assist protocol, directly leading to the resident's injury.
Failure to Post Required State Agency and APS Contact Information
Penalty
Summary
The facility failed to post required information for Adult Protective Services (APS) and other pertinent State agencies and advocacy groups in a manner accessible and understandable to residents and their representatives. During observations conducted in the building, it was found that there was no posted list containing the names, addresses (mailing and email), and telephone numbers of State agencies such as the State Survey Agency, State licensure office, APS, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the required postings.
Failure to Display Medicare and Medicaid Benefit Information
Penalty
Summary
The facility failed to display written information for residents and their responsible persons regarding how to apply for and use Medicare and Medicaid benefits, as well as how to receive refunds for previous payments covered by these benefits. During observations conducted in the building, it was noted that this required information was not posted. Additionally, during an interview, the Nursing Home Administrator confirmed that the facility did not have the necessary written information displayed as required by regulations. No information was provided to residents or applicants for admission about these benefits or the refund process.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update care plans for two of eighteen residents to accurately reflect their current status, as required by facility policy and state regulations. For one resident with Alzheimer's, high blood pressure, and lumbar radiculopathy, the care plan did not include goals or interventions related to the resident's bed being placed against the wall, which created a physical restraint on one side. There was also no physician order for this intervention, and the care plan did not address this aspect of the resident's care. For another resident with non-Alzheimer's dementia, high blood pressure, and depression, the care plan indicated total dependence on staff for oral care. However, nursing progress notes documented that the resident was independent in oral care, and there was a lack of documentation regarding the provision and assistance level of personal hygiene services on multiple dates. Interviews with the resident and family confirmed that oral care was not provided daily or routinely. The DON and Nursing Home Administrator acknowledged the failure to update care plans for these residents.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to provide documented training on its Quality Assurance and Performance Improvement (QAPI) Program for staff, as required by its own Facility Assessment and state regulations. Review of facility documents and education records did not show evidence of QAPI-related training for staff. During interviews, the Nursing Home Administrator was unable to provide documentation or confirm that any staff education included QAPI content, and ultimately acknowledged that the required training had not been conducted or documented. This deficiency was identified through review of records and staff interviews, with no additional information or documentation available to demonstrate compliance.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for four residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, dated 10/1/24 and 1/4/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of four residents, who were admitted with various diagnoses including diabetes, anxiety, high blood pressure, dementia, muscle weakness, and a history of falls, did not contain an advance directive or documentation that they were given the opportunity to formulate one. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the absence of such documentation in the clinical records of these residents, indicating a failure to uphold the residents' rights as per 28 Pa. Code: 201.29(b)(d)(j) regarding resident rights.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period exceeding four years, from September 2019 through September 2024. This deficiency was identified through a review of facility documents, information from the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. The State Ombudsman Office confirmed that they had not received the required notifications since August 2019. The Nursing Home Administrator acknowledged the failure to report these transfers and discharges as required by the Pennsylvania Code: 201.29(f)(g) concerning resident rights.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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