Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greene Health & Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Korsakoff’s dementia repeatedly engaged in close physical and sexualized contact with another resident, including hand-holding, kissing, wandering together, attempts to leave the unit, and being found in the other resident’s bed with his pants unbuttoned and exposed. The resident’s daughter, acting as POA and documented decision maker, had clearly and repeatedly instructed staff that she did not want her father around the other resident and that any contact between them should not be permitted or encouraged. Despite these directives, staff continued to allow the two residents to be together, and the POA found them sitting closely together and holding hands after the bed incident, while leadership acknowledged that the two residents were always together and that the other resident was considered too difficult to redirect.
The facility failed to provide individualized, ongoing activities for residents with dementia in a memory-impaired unit. Facility policy and assessment documents required person-centered dementia care and specialized cognitive activities, but activity staffing was insufficient and no dedicated staff had been available to run activities for an extended period. For multiple cognitively impaired residents, care plans either omitted activity preferences or were not individualized to reflect prior lifestyle or specific interests. Observations showed residents sitting or sleeping in common areas without stimulation, wandering aimlessly, yelling out, and one resident repeatedly exposing her breasts without consistent staff response, while an activity aide only played music or passed donuts and drinks without engaging residents or including all of them. A family member and a RN reported that activities had not been occurring for some time, and leadership acknowledged understaffing in the activity department.
Surveyors found that staff failed to follow multiple physician and practitioner orders, including not administering ordered morning medications to a cognitively impaired resident within the established medication pass time, not obtaining ordered orthostatic BPs for a cognitively impaired resident after a fall, and not ensuring that two cognitively impaired residents involved in a sexual exposure incident were evaluated by psychiatric services as had been communicated to their families.
A resident who was cognitively impaired and dependent on staff for daily care received ordered IV Rocephin via a peripheral IV catheter over several days, but the MAR contained no documentation that the IV line was flushed before and after administration as required by the facility’s IV flushing policy. Review of clinical records and the facility’s policy showed that peripheral IV catheters were to be flushed with normal saline or another recommended solution to maintain patency and prevent mixing of incompatible medications, and the DON confirmed the absence of flushing documentation.
The facility failed to provide individualized dementia-focused treatment, activities, and supervision for several cognitively impaired residents on a memory unit. Care plans did not identify residents’ activity preferences or specify meaningful, personalized activities despite documented dementia, behaviors, and need for assistance. Observations showed residents sitting idle, wandering aimlessly, entering cupboards and rooms, yelling out, and one resident repeatedly exposing herself, while an activity aide only played music or passed donuts and drinks without engaging residents in structured activities. Nursing notes documented frequent falls related to self-transfers, physical altercations, feces smearing, and ongoing intimate contact between two residents despite a family member’s explicit request that they be kept apart. Staff interviews revealed that there had been no consistent activities on the unit, residents were largely unsupervised while staff performed care and med passes, and staffing levels were below required ratios, leaving only two aides for about 30 residents. The deficiency was cited under state regulations for resident care planning and nursing services.
The facility failed to follow its grievance policy when a family member of a resident with moderate cognitive impairment and a UTI voiced concerns about the resident being moved from a private room and staff not being nice. A Case Manager documented receiving a voicemail and stated she would discuss the concerns with management and return the call, but no follow-up call occurred, and no grievance investigation or written grievance decision was documented. The grievance log contained no entry for this complaint, and Social Services confirmed the family's unresolved concerns and lack of contact, reflecting a failure to properly process and document the grievance as required.
A resident with multiple chronic conditions and a complex medication regimen was discharged home without being provided a complete written list of current medications and instructions. Although nursing documentation stated the resident was educated on all discharge orders and medications and that all medications were sent home, the discharge paperwork only listed a limited subset of prescribed drugs, omitting several ongoing medications such as anticoagulants, cardiac medications, anticonvulsants, and supplements. The DON later confirmed there was no documentation that a full and accurate medication list with instructions was given to the resident or family at discharge.
The facility did not develop comprehensive, individualized care plans for three residents with dementia. One resident who was cognitively impaired and needed moderate assistance had no care plan addressing dementia-related care and treatment needs. Another severely confused, independently ambulatory resident with Korsakoff's dementia had repeated documented behaviors involving close physical contact and attempts to leave the unit with another resident, yet no behavior- or dementia-specific care plan was created. A third cognitively impaired resident who required staff assistance had no care plan addressing individual activity preferences, likes, or dislikes. The Activity Director and Social Services Director reported they had not been educated on care planning for dementia needs, which they cited as the reason these dementia and activity care plans were not developed.
A resident with cognitive impairment who required staff assistance for daily care reported peri pain when sitting and was found by an LPN during a shower to have a significantly enlarged prolapse compared to prior observations. The LPN notified a supervisor and documented plans to monitor and await further assessment and possible physician orders, but there was no documentation that an RN performed or recorded an assessment of this change in condition, contrary to state nursing practice standards requiring RNs to collect and analyze ongoing data and provide appropriate nursing care.
A resident who was cognitively intact, required maximum assistance with ADLs, and had diabetes with bilateral cataracts was seen by an optometrist for a diabetic eye exam and cataract evaluation, with a recommendation to return in six months for follow-up. The clinical record contained no documentation that this follow-up appointment was scheduled or completed, and there was no indication that the physician disagreed with the optometrist’s plan of care. The NHA confirmed that no documentation existed to show the recommended follow-up occurred, resulting in a failure to assist the resident in accessing needed vision services.
A resident with severe cognitive impairment and dementia had a care plan requiring use of a chair alarm whenever seated, with staff responsible for ensuring the alarm was always working. On observation, the resident was seated in a Broda chair without a visible chair alarm and later stood up from the chair without any alarm sounding and without staff awareness. An RN and the Nursing Home Administrator both confirmed that the chair alarm should have been in place, demonstrating a failure to follow the facility’s fall-prevention policy and the resident’s care plan.
Two residents with colostomies did not receive care in accordance with facility policy and physician/family directives. For one resident, an LPN failed to date the colostomy bag as ordered to be changed and dated every three days. For another resident, an RN prepared and cut an ostomy wafer at the med cart without measuring the stoma, applied a wafer that was visibly too large, and stated she "just eyeballs" the size instead of using a measuring guide, despite facility policy requiring stoma measurement and cutting the wafer to fit.
Surveyors found that the facility repeatedly failed to meet required NA-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census and staffing schedules showed that the number of NAs scheduled and providing care was consistently below the minimum required based on the number of residents, with shortfalls documented on numerous shifts across several weeks. There were no additional higher-level staff available to offset these NA shortages, and the Administrator confirmed that the required staffing ratios were not met on the identified shifts.
Surveyors found that the facility did not maintain required LPN-to-resident staffing ratios on multiple day, evening, and night shifts. Review of census data and nursing schedules showed that the number of LPNs providing care on several day shifts was slightly below the minimum required based on the census, and at least one evening and one night shift were also understaffed. There were no additional higher-level staff available to offset these LPN shortfalls, and the Administrator confirmed that required LPN staffing ratios were not met on the identified shifts.
Surveyors determined that the facility did not consistently provide the required minimum of 3.2 hours of direct nursing care per resident in multiple 24-hour periods. Review of facility staffing schedules over several weeks showed that, on numerous days, the calculated direct care hours per resident fell below the regulatory threshold. The NHA confirmed during interview that the required daily direct care hours were not met on those days.
Two residents who were cognitively intact and dependent on staff for ADLs, including one with MS and another with post-stroke hemiplegia/hemiparesis and diabetes, experienced excessively long call bell response times that did not align with facility policy or expectations. Call bell logs showed repeated delays ranging from many minutes to about an hour, and one resident reported being placed in bed and not checked on for several hours, with unanswered attempts to reach staff by phone. The ADON acknowledged that these call bell wait times were excessive and inconsistent with the expectation that call bells be answered within five minutes.
A resident with dementia and cognitive impairment, who required staff assistance for ADLs and had a care plan specifying twice-weekly showers on set days with bed baths as an alternative if refused, did not receive showers on numerous scheduled days over a two-month period. Facility policy required honoring bathing preferences and documenting refusals and alternatives, but bathing records showed repeated missed showers with no documentation that showers were offered, refused, or replaced with bed baths. The ADON confirmed the absence of documentation and that the resident should have received showers per her preferences and plan of care.
Staff failed to follow medication storage and supervision requirements when an LPN left a cup containing multiple unlabeled pills on an overbed table for a cognitively intact resident with heart failure, anxiety, and depression, without remaining to observe administration, and when prescription triamcinolone 0.1% cream ordered for dermatitis in another cognitively intact resident with gastroenteritis and colitis was found left unattended on the resident’s bed near the door. The facility’s own policy prohibited leaving medications or chemicals unattended, and leadership confirmed these medications should not have been left unsupervised.
Failure to notify resident representatives and the ombudsman in writing of hospital transfers and bed-hold policy, and failure to complete medication reconciliation for two residents. Residents were transferred for conditions including a fall with fracture, sepsis, UTI, and hypotension, but the facility had no documented written transfer notices or bed-hold notices. Medication reconciliation was also not documented after one resident’s death and another resident’s discharge, and the DON and Interim DON confirmed the omissions.
Failure to Address Pharmacy Review Findings: The facility did not document timely physician or medical director review of pharmacy medication regimen review recommendations for multiple residents. Issues included delayed lab follow-up for a resident with HTN, CAD, and anemia; failure to address a recommendation to hold simvastatin during daptomycin therapy; missing documentation for pharmacy review findings; and an unaddressed recommendation to monitor LFTs for a resident with elevated ALT while receiving acetaminophen, atorvastatin, and recent Solu-Medrol.
A facility failed to inform two cognitively intact residents or their representatives in advance of the risks and benefits of psychotropic meds and treatment alternatives before starting or increasing antidepressant and antipsychotic therapy. One resident with depression and anxiety was started on Zoloft and increased on Trazodone after reporting anxiety, sadness, anger, and sleep disturbance, while another resident with bipolar disorder and dementia was ordered Olanzapine after being described as irritable, manic, and sleep-deprived. The Social Services Director said she only obtained consent for psych consults, and the DON confirmed there was no documented informed consent for either resident.
Failure to Provide Bariatric Seating: A resident with morbid obesity, non-ambulatory status, and dependence for transfers was not provided a bariatric broda chair despite OT recommending one because her current broda chair was no longer a safe fit. Staff documented that she could not fit safely in the chair, the facility did not have a bariatric broda chair available, and a wider bariatric wheelchair was difficult to use because of doorway limitations. The resident stated she wanted to get out of bed and would sit in a chair outside her room if needed, while the NHA said the facility knew about the recommendation but did not obtain the chair.
Failure to issue required Medicare non-coverage notices for two residents. SNF Beneficiary Protection Notification Review forms showed Medicare Part A coverage ended for two residents while benefit days were not exhausted, but the ABN of Non-coverage was not issued. The BOM stated recent staff changes contributed to the notices not being provided, and the NHA confirmed the residents should have received them when coverage ended.
A facility failed to maintain a clean and homelike environment in the 300/400 hall pantry when surveyors observed a microwave with a moderate to large amount of brownish/black debris inside the cooking cavity and worn paint with exposed metal on the inside frame. The Maintenance Director and ADON said they were not aware of the condition and stated it was unacceptable.
Failure to investigate an unexplained bruise. A resident with decline in status, deconditioning, and weakness was documented by nurse aide notes as having a new bruise of unknown origin on the right wrist and forearm. Although the facility policy required investigation of all suspected abuse, neglect, and injuries of unknown source, there was no documented investigation to rule out abuse or neglect, and the DON confirmed the bruise was not reported to the facility and no investigation was completed.
A facility failed to ensure a possible abuse allegation was reported timely to the NHA for a cognitively impaired resident who was dependent on staff for all daily care needs. Nurse aide documentation noted a bruise of unknown origin on the resident’s right wrist and forearm, but there was no documented evidence the bruise was reported per policy. The DON confirmed the aide should have reported the bruise timely.
Care plans were not revised to match current resident needs for three residents. Two residents’ plans still listed antipsychotic use even though the clinical record showed no evidence they were receiving the medication, and the DON confirmed the plans did not reflect prior GDRs. A third resident’s plan still included ace wraps for skin integrity even though the wraps had been discontinued and there was no documented order for them.
A resident who was cognitively impaired and dependent on staff for transfers and ambulation had MD orders and a restorative care plan for twice-daily walking and stand-and-pivot activities with one assist. The clinical record had no documentation that the resident completed or declined the programs, and the DON confirmed the ambulation and transfer programs were not completed as ordered.
A resident with an indwelling urinary catheter and obstructive uropathy was observed in bed with the catheter drainage bag and tubing lying directly on the floor. The resident’s care plan directed staff not to allow any part of the drainage system to touch the floor, and an LPN and the NHA both confirmed the bag and tubing should not have been in direct contact with the floor.
A resident with PTSD was not assessed for a trauma history or specific triggers to support trauma-informed care. The resident reported a history of domestic violence and identified loud noises, arguing, and some male interactions as triggers, while also stating she sees a female therapist and takes medications that help. The MDS showed the resident was cognitively intact, and the care plan noted antipsychotic meds related to PTSD, but there was no documented trauma assessment, which the DON confirmed.
Failure to Document Controlled Medication Administration: Two residents receiving PRN oxycodone for pain had multiple doses signed out on the controlled drug record without corresponding documentation in the clinical record showing the doses were administered. Both residents were cognitively intact and had pain; the DON confirmed the missing administration documentation.
A resident who was cognitively intact and had bipolar disorder and anxiety received PRN clonazepam multiple times for anxiety. The MAR lacked documentation that non-pharmacological behavioral interventions were attempted before the medication was given, and the DON confirmed those interventions should have been tried first.
An undated, unmarked medication cup containing multiple tablets and capsules was found in the top drawer of the 300 hall med cart. An RN and the DON confirmed the cup should not have been there, and the facility’s med admin policy was intended to support safe, accurate oral med administration.
Incomplete controlled substance documentation was found for two residents. Both residents were cognitively intact and had pain with PRN oxycodone orders, but MAR entries showed doses were administered while the controlled med records did not show the doses being signed out. The DON and Interim DON confirmed the missing documentation.
The facility's QAPI committee failed to correct repeated deficiencies cited in prior and current surveys, including maintaining a homelike environment, transfer notices and bed hold policies, care plan timing and revision, catheter care, and proper storage of drugs and biologicals. Although prior POCs called for audits and QAPI review, the current survey found those plans were not successfully implemented and compliance was not maintained.
Quality Assurance Committee Missing Required Member Attendance. The facility failed to ensure that all required members attended quarterly QAPI meetings. The policy required the NHA, DON, Medical Director, direct care staff, ancillary staff, and a designated Infection Preventionist to participate, but attendance records showed the Infection Preventionist did not attend any meetings in the first and fourth quarters. The DON confirmed the missed attendance during interview.
A resident with an unstageable sacral pressure ulcer did not receive Triad cream every shift as ordered by the physician; instead, the treatment was only applied daily over several days, as confirmed by review of records and staff interview.
A resident with hemiplegia and hemiparesis was not provided with physician-ordered adaptive eating equipment, including a divided plate and specialized utensils, during a meal. Despite clear documentation and communication from therapy and dietary staff, the required devices were not supplied, and the resident and family confirmed their ongoing need.
The facility did not serve food and drink at appropriate temperatures, with hot items found to be lukewarm and cold items not sufficiently chilled during a lunch meal observation. A Dietary Technician confirmed that the foods were not served at the required temperatures, resulting in meals that were not palatable.
The facility did not ensure that refrigerated foods were properly labeled and dated, and failed to maintain cleanliness in key kitchen areas and equipment. Required cleaning tasks were not consistently documented as completed, and significant build-up of food debris and dust was observed on kitchen equipment and surfaces. The Dietary Technician confirmed these deficiencies.
A resident experiencing severe, uncontrolled pain was not assessed by an RN after a significant change in condition, despite facility policy and state regulations requiring such assessment. An LPN documented the pain and communicated with the physician, but there was no evidence of RN involvement or assessment during the episode, as confirmed by the DON.
A resident with cognitive impairment, incontinence, and diabetes did not receive scheduled showers as outlined in her care plan, and there was no documentation of showers given or refusals. Facility policy required at least two weekly showers or documentation of refusals, but records showed missing entries and unexplained 'did not occur' notations, as confirmed by the DON.
A resident with cognitive impairment and a physician's order for routine Naproxen did not receive multiple scheduled doses, as confirmed by MAR review and DON interview, despite the medication being available as a stock OTC item.
A resident with a history of DVT and ongoing pain was not provided adequate pain management when scheduled Tylenol failed to relieve her symptoms. Despite documentation of severe, uncontrolled pain and a request for stronger medication or comfort care, there was no evidence that the physician was promptly contacted for additional interventions. The DON confirmed that the resident's acute pain was not properly managed.
A resident with a history of falls and multiple medical conditions experienced several falls, after which the IDT implemented new interventions such as bed and wheelchair alarms. However, the care plan was not updated to reflect these changes, despite the alarms being in use and staff confirming their application.
A resident with dementia, dependent on staff for transfers, was left without access to her call bell and was not assisted out of bed after staff intentionally moved the call bell out of reach. Multiple staff, including an LPN and RN, were aware of the situation but did not report it promptly, resulting in a failure to protect the resident from abuse and neglect.
A resident with paraplegia and a Stage 4 pressure ulcer did not receive prescribed IV antibiotics as ordered, and there was no documentation that an air mattress recommended by a CRNP and requested by the resident was provided. The DON confirmed these omissions.
The facility did not maintain proper documentation for the administration of controlled medications for three residents with significant pain management needs. Although narcotic pain medications were signed out on controlled drug records, there was no evidence in the clinical records or MAR to confirm that these medications were administered as required by policy.
The facility did not maintain complete and accurate documentation for the administration of controlled substances, as required by policy and regulation. Multiple residents with chronic pain and various diagnoses received opioid medications, but staff failed to record these administrations on the controlled medication records, despite documenting them on the MAR. The DON confirmed the absence of required documentation for these medications.
A resident with severe cognitive impairment exhibited ongoing aggressive and combative behaviors, including refusal of care, verbal aggression, and inappropriate sexual comments. Despite these persistent behaviors and changes to the resident's antipsychotic medication regimen, there was no documented evidence that the physician or CRNP was notified on multiple occasions, resulting in a failure to communicate important changes in the resident's condition.
Failure to Honor POA Decisions Regarding Resident-to-Resident Physical/Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s legal representative was able to exercise decision-making rights regarding the resident’s physical and sexual contact with another resident. Resident 12, who had Korsakoff’s dementia and was assessed as severely confused but independently ambulatory, had a documented power of attorney (POA) held by his daughter, identified as Family Member 1. Clinical records showed repeated instances of close physical contact between Resident 12 and Resident 11, including hand-holding, kissing, walking together, and attempts to leave the unit together. A quarterly MDS dated March 18, 2026, confirmed Resident 12’s severe cognitive impairment. Nursing notes from December 14 and December 29, 2025, documented that Resident 12 was talking with, holding hands with, kissing, and wandering the unit with Resident 11, and that they were trying to leave the unit together. On March 12, 2026, a nurse’s note documented that Resident 12 was found in Resident 11’s bed next to her with his pants unbuttoned and exposed. When the facility notified his daughter/POA, she was angry because she had previously been told that the residents would be separated. In an interview, Family Member 1 stated that in early December, shortly after admission, staff had informed her that Resident 11 had attached herself to Resident 12 like he was her boyfriend, and she clearly communicated that she did not want her father around Resident 11 due to his age and marital status. She reported that during multiple visits, Resident 11 followed them and told Resident 12 they needed to leave together, and that she had explicitly requested that they be separated and that contact between them not be permitted or encouraged. Despite this, when she arrived at the facility after the March 12 incident, she found Resident 12 sitting with Resident 11 at the nurse’s station, holding hands with her head on his shoulder. The Assistant DON confirmed that Resident 11 believed Resident 12 to be her boyfriend, that they were always together, and that although the daughter did not want them together, staff found Resident 11 too difficult to redirect.
Failure to Provide Individualized Activities for Memory-Impaired Residents
Penalty
Summary
The facility failed to provide adequate, ongoing, person-centered activities for all residents in the Memory Impaired Unit (MIU), despite facility policy and assessment requirements. The dementia care policy required staff to be trained in person-centered dementia care and to use individualized, non-pharmacological, meaningful life enrichment activities. The facility assessment stated that the MIU would offer specialized cognitive activities provided by staff trained in dementia care, with life enrichment staffing of one full-time director and three full-time aides. However, the activity department was reported as understaffed, and there had been no dedicated staff available to provide activities in the MIU for at least two months. Review of clinical records for six cognitively impaired residents with dementia showed that their activity needs and preferences were not properly identified or individualized in their care plans. Multiple quarterly MDS assessments documented that these residents were cognitively impaired, dependent on staff for care needs or ambulatory with dementia diagnoses, and in some cases had verbal behaviors. For several residents, the care plans failed entirely to identify activity preferences, and for others, the plans were not individualized to reflect their prior lifestyle or specific activities they enjoyed, despite documentation that activities resembling prior lifestyle were to be provided. Surveyor observations in the MIU showed residents receiving minimal or no meaningful activities or engagement. At one observation, 14 residents sat around tables while an activity aide only played music without engaging them, and one resident repeatedly exposed her breasts by pulling her shirt over her head without consistent staff intervention. On another observation, an activity aide brought a coffee cart with donuts and drinks, but two residents were not offered any, and no group activity or engagement occurred; residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. A family member reported not seeing any activities in the MIU for several months and stated that she tried to interact with residents herself because they otherwise just sat and slept. A RN confirmed that there had not been activities in the MIU for some time and that nursing staff did not have time to provide them, while the Activities Director and Nursing Home Administrator acknowledged that the activity department was understaffed and that there was currently no one available to provide activities in the MIU.
Failure to Follow Physician and Practitioner Orders for Medications, Monitoring, and Psychiatric Evaluation
Penalty
Summary
The deficiency involves multiple failures to follow physician and practitioner orders for several cognitively impaired residents. One resident with cognitive impairment and dependence on staff for daily care had physician orders for multiple morning medications, including Clonidine, Lasix, Memantine, Metoprolol, and Sertraline, to be administered each morning. Interview with an LPN established that morning medications were to be given between 6:15 a.m. and 10:00 a.m., yet as of 12:44 p.m. on the survey date, this resident had not received the ordered morning medications. The Nursing Home Administrator confirmed that the resident did not receive her morning medications as ordered. Another cognitively impaired resident with dementia had a nurse practitioner order for orthostatic blood pressures to be obtained for three days following a fall, but there was no documentation that these orthostatic blood pressures were obtained. Two additional cognitively impaired residents, both ambulatory and diagnosed with dementia, were involved in an incident in which one resident was found in the other's bed with his pants unbuttoned and exposed. Documentation showed that families of both residents were informed and told that each resident would be seen by psychiatric services the following morning. However, there was no documented evidence that either resident was actually seen by psychiatric services after the incident, and facility leadership confirmed that these ordered or communicated psychiatric evaluations did not occur.
Failure to Flush Peripheral IV Catheter During IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure intravenous (IV) catheters were flushed according to its policy for one resident receiving IV medication. The facility’s IV catheter flushing policy, dated April 20, 2026, required that all peripheral IV catheters be flushed between incompatible medications with normal saline or another manufacturer-recommended solution to maintain catheter patency and prevent mixing of incompatible medications/solutions. A comprehensive MDS for Resident 4, dated March 13, 2026, showed the resident was cognitively impaired and dependent on staff for daily care. Physician’s orders dated April 13, 2026, directed staff to insert a peripheral IV catheter and administer 1 g of Rocephin once daily in the evening from April 14 through April 18, 2026. Review of the April 2026 MARs confirmed the resident received the ordered Rocephin doses on those dates, but there was no documented evidence that staff flushed the peripheral IV catheter before and after the medication administration, which was confirmed by the Director of Nursing during interview.
Failure to Provide Individualized Dementia Care, Activities, and Supervision on Memory Unit
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide appropriate treatment and services for multiple residents with dementia residing on the Memory Impaired Unit (MIU). The facility’s own assessment dated April 6, 2026 stated that the MIU offers specialized cognitive activities provided by staff trained in dementia care and that Life Enrichment staffing should include one full-time director and three full-time aides. However, review of care plans and observations showed that residents with dementia did not have individualized activity preferences identified or implemented. For example, quarterly MDS assessments for four cognitively impaired residents with dementia (Residents 9, 10, 11, and 12) showed needs for staff assistance and, in some cases, independent ambulation and behaviors, yet their care plans either failed to identify activity preferences or contained only vague, non-individualized directions such as providing activities resembling a prior lifestyle without specifying what those activities were. Observations on the MIU over two days showed that residents were not being engaged in meaningful or structured activities despite the unit’s stated purpose. On one day, 14 residents were observed sitting around tables in the common room while an activity aide played music but did not engage them in any activity. One resident repeatedly pulled her shirt over her head, exposing her breasts, and staff were not consistently present in the common room to address this behavior. No further activities were observed that day. On the following day, an activity aide brought a coffee cart with donuts and drinks, but service to residents was delayed, two residents were not offered any items, and no group activity or engagement occurred. During these observations, residents were seen wandering aimlessly, getting into cupboards and drawers, yelling out, or sitting and sleeping in the common area without stimulation. Clinical record review and nursing notes documented frequent falls and behavioral incidents among the cognitively impaired residents. One resident (Resident 9) was involved in a physical altercation in which he punched his roommate in the face. Another resident (Resident 10) experienced numerous falls over a span of weeks and months, often while attempting to self-transfer from bed, chairs, or to the bathroom, and was also noted to remove her ostomy bag and smear feces in various places. Residents 11 and 12, both with dementia and independent ambulation, were repeatedly documented as engaging in close physical contact, including holding hands, attempting to leave the unit together, and being found in bed together with exposure noted, despite a family member’s clear request that they be separated and that contact not be permitted or encouraged. Staff interviews revealed that there had not been activities in the MIU for some time, that residents wandered the locked unit without redirection while staff were occupied with care and medication administration, and that staffing levels were below the facility’s own requirements, leaving only two nurse aides for 30 residents at times. The Nursing Home Administrator acknowledged that staffing was out of compliance and that the facility was unable to meet necessary nurse aide ratios or daily PPD, contributing to the failure to provide appropriate dementia-specific treatment and services. The deficiency was cited under 28 Pa. Code 211.11(d) Resident care plan and 28 Pa. Code 211.12(d)(5) Nursing services, based on the lack of individualized activity care planning for residents with dementia, the absence of consistent, specialized cognitive activities and engagement on the MIU, the unmanaged wandering and behavioral issues, and the inadequate staffing that left residents largely unsupervised and without appropriate redirection or structured activities.
Failure to Investigate and Document Family Grievance Regarding Room Change and Staff Behavior
Penalty
Summary
The facility failed to follow its grievance policy by not documenting or investigating a family member's concerns regarding a resident's room change and staff behavior. The written grievance policy, dated April 20, 2026, required the Grievance Official to investigate all oral, written, or anonymous grievances, take immediate action if needed, and complete a written grievance decision that included the date received, a summary of the grievance, steps taken to investigate, pertinent findings or conclusions, whether the grievance was confirmed, and any corrective actions. Resident 6 had an admission MDS indicating moderate cognitive impairment, ability to make needs known, and a urinary tract infection. A nursing note documented that the Case Manager received a voicemail from the resident's family member, who was upset about the resident being moved from a private room and other issues on the 400 wing, and that the Case Manager planned to speak with management and return the call. Despite this, there was no documented evidence that the family member's concerns were followed up on or that any grievance investigation was initiated. The April grievance log contained no entry related to the family member's complaint. The Case Manager later confirmed that she did not make a follow-up call to the family member regarding these concerns. Social Services also confirmed that the family member had concerns about the move from a private room and that staff were not being nice to the resident, and that no call had been made to the family, who were very angry. This lack of investigation and documentation constituted a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by facility policy and 28 Pa. Code 201.29(i) on resident rights.
Incomplete Medication Information Provided at Discharge
Penalty
Summary
The facility failed to provide a complete and accurate list of medications and instructions to a resident and her responsible party at the time of discharge to home. The resident’s admission MDS from November 2025 showed she was cognitively intact, incontinent of bowel and bladder, and at risk for pressure ulcers without any current ulcers. A subsequent MDS from March 2026 documented that she was moderately cognitively impaired but able to make her needs known and had a urinary tract infection. Physician orders dated in March and April 2026 included multiple medications: acetaminophen, allopurinol, Eliquis, famotidine, folic acid, Lantus, levetiracetam, levothyroxine, a multivitamin, nadolol, Novolog on a sliding scale, pregabalin, polyethylene glycol, thiamine, tramadol, and Xifaxan. On the day of discharge, a nursing note documented that a family member came to take the resident home and that the resident was educated on all discharge orders and medications, with all belongings and medications, including narcotics, sent home. However, the written discharge instructions provided to the resident only listed Novolog, Lantus, acetaminophen, and polyethylene glycol as current medications with instructions. There was no documented evidence that the resident or her family received a complete list of all current medications and instructions corresponding to the full set of physician orders. In an interview, the Director of Nursing confirmed the absence of documentation showing that a complete medication list and instructions were provided, constituting a failure to meet the requirements of 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.
Failure to Develop Comprehensive Dementia and Activity Care Plans
Penalty
Summary
The facility failed to develop comprehensive, individualized care plans addressing dementia-related care needs for multiple residents. For one resident with dementia who was cognitively impaired and required moderate assistance with daily care needs, a quarterly MDS assessment documented these conditions, but there was no corresponding care plan to address her individual care and treatment needs related to dementia. Another resident, assessed as severely confused, independently ambulatory, and diagnosed with Korsakoff's dementia, also had no documented care plan addressing his dementia or behaviors despite multiple nursing notes describing ongoing behavioral issues. For this severely confused resident, clinical documentation showed repeated episodes of close physical contact and boundary issues with another resident, including holding hands, kissing, walking together while attempting to leave the unit, and being found in the other resident's bed with his pants unbuttoned and exposed. Despite these documented behaviors and the family’s prior concern about separation, no individualized behavioral or dementia-specific care plan was developed. Additionally, a third resident with dementia, who was cognitively impaired and required staff assistance for daily care needs, had no documented care plan addressing individual activity preferences, likes, or dislikes. The Activity Director and Social Services Director stated they had not been educated regarding care planning for residents’ dementia needs, which they identified as the reason dementia-specific and activity care plans were not in place for these residents.
Failure to Obtain RN Assessment After Resident’s Change in Condition
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not obtaining a timely assessment by a registered nurse (RN) when a resident experienced a change in condition. According to the Pennsylvania Nursing Practice Act, an RN is required to collect complete and ongoing data, analyze health status, compare data with norms, and carry out nursing actions to promote, maintain, and restore well-being. Resident 8 had a quarterly MDS assessment indicating cognitive impairment and a need for staff assistance with daily care. On the evening of March 29, 2026, the resident reported pain in the peri area when sitting in a chair in the dining area, though she denied pain when lying in bed or walking. During a shower, an LPN was called to observe the resident’s peri area, where a previously observed prolapse was now noted to be very enlarged, more than three times its prior size. The LPN reported the prolapse and the resident’s pain with sitting to a supervisor and documented that they would monitor and await the supervisor’s assessment and any changes made by the physician. However, there was no documented evidence that an RN assessed the resident’s change in condition or that such an assessment was recorded in the medical record. In an interview, the Clinical Consultant confirmed that the resident should have been assessed by an RN and that this assessment should have been documented.
Failure to Arrange Recommended Optometry Follow-Up for a Resident
Penalty
Summary
The facility failed to follow an optometrist’s recommendation for a follow-up eye examination for one of 14 residents reviewed. A quarterly MDS assessment dated December 31, 2025, documented that Resident 5 was cognitively intact and required maximum assistance for daily care needs. An optometry consult dated March 21, 2025, showed that the resident, who had diabetes and bilateral cataracts, was seen for a diabetic eye exam and cataract evaluation, and the optometrist recommended a return visit in six months for a follow-up examination. There was no documented evidence in the clinical record that this six-month follow-up appointment was scheduled or completed, nor was there documentation that the resident’s physician disagreed with or altered the optometrist’s plan of care. In an interview on April 22, 2026, at 3:10 p.m., the Nursing Home Administrator confirmed that there was no documentation that the recommended follow-up appointment had been completed, constituting a failure to assist the resident in gaining access to necessary vision services, in violation of 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Implement Care-Planned Chair Alarm for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a fall-prevention device was in place as care planned for one resident. Facility policy on fall prevention and management, dated April 20, 2026, stated that when risks are identified, preventive measures are to be implemented as care planned. A comprehensive MDS assessment for Resident 10, dated January 29, 2026, documented severe cognitive impairment, limited ability to be understood, and diagnoses including dementia. The resident’s care plan, dated March 5, 2026, specified that she was to utilize a chair alarm while in her chair and that staff were to ensure the alarm was always working. On April 21, 2026, at 11:56 a.m., Resident 10 was observed sitting in a Broda chair with no chair alarm visible. A subsequent observation at 12:27 p.m. showed the resident standing up from the chair without any alarm sounding and without staff awareness of her standing. In an interview at 12:34 p.m., RN 2 confirmed that the resident’s chair alarm was not in place and that it should have been. In a later interview at 3:50 p.m., the Nursing Home Administrator also confirmed that the chair alarm should have been in place, indicating noncompliance with the resident’s care plan and the facility’s fall-prevention policy.
Failure to Follow Colostomy Care Policy for Two Residents
Penalty
Summary
The facility failed to provide proper colostomy care for two residents who were cognitively impaired and dependent on staff for daily care. For one resident, a quarterly MDS assessment documented the presence of an ostomy and a physician’s order directed that the colostomy bag and setup be changed every three days and that the bag be dated when changed per family request. During an observation with an LPN, the resident’s colostomy bag was found with no date marked anywhere on it. The LPN confirmed during interview that the colostomy bag was not dated and acknowledged that it should have been. For the second resident, a quarterly MDS assessment also documented cognitive impairment, dependence on staff for all daily care needs, and the presence of a colostomy. During an observation, an RN was seen preparing and changing the resident’s colostomy appliance. The RN cut the ostomy wafer at the medication cart without measuring the stoma, then cleaned the skin, applied skin prep, and placed the wafer and bag. The wafer was visibly large compared to the stoma, and the RN did not measure the stoma or apply the wafer close to it, instead stating she “just eyeballs it.” Review of the facility’s colostomy care policy showed that staff were required to measure the stoma using a measuring guide and trace and cut the wafer opening to the correct size, and the DON confirmed that staff should measure the stoma to cut the wafer to size.
Failure to Maintain Required NA-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to meet state-mandated NA-to-resident staffing ratios on multiple dates across day, evening, and night shifts. Review of census and staffing data for March 8–14, March 22–28, and April 5–11, 2026, showed that the number of NA hours actually worked fell below the minimum required based on the resident census. For example, on March 8, 2026, with a census of 105 residents requiring 10.50 NAs on the day shift, only 8.10 NAs were scheduled and provided care. On March 9, 2026, the same census of 105 residents required 10.30 NAs on the day shift, but only 6.88 NAs were provided. Similar shortfalls occurred on numerous other day shifts. On March 12, 2026, a census of 105 residents required 10.50 NAs, but 7.03 NAs were provided; on March 13, 2026, 10.50 NAs were required and 6.89 were provided; on March 14, 2026, 10.50 NAs were required and 8.16 were provided. On March 22, 2026, a census of 101 residents required 10.10 NAs, but 8.15 were provided; on March 24, 2026, a census of 102 residents required 10.20 NAs, but 9.07 were provided; on March 25, 2026, a census of 103 residents required 10.30 NAs, but 8.60 were provided; on March 27, 2026, a census of 106 residents required 10.60 NAs, but 8.65 were provided. In April, on April 5, 2026, a census of 108 residents required 10.80 NAs, but 9.81 were provided; on April 6, 2026, the same census required 10.80 NAs, but 7.04 were provided; on April 7, 2026, 10.80 NAs were required and 9.05 were provided; and on April 9, 2026, a census of 109 residents required 10.90 NAs, but 8.70 were provided. The facility also failed to meet required NA staffing ratios on several evening and night shifts. On the evening shift, with a census of 105 residents on March 8, 13, and 14, 2026, 9.55 NAs were required each evening, but only 8.81, 8.21, and 8.62 NAs, respectively, were provided. On March 28, 2026, with a census of 107 residents requiring 9.73 NAs on the evening shift, only 9.31 NAs were provided. On the night shift, on March 11, 2026, a census of 104 residents required 6.93 NAs, but 6.13 were provided; on March 14, 2026, a census of 105 residents required 7.00 NAs, but 6.09 were provided; on March 22, 2026, a census of 101 residents required 6.73 NAs, but 6.68 were provided; and on March 27, 2026, a census of 106 residents required 7.07 NAs, but 6.42 were provided. The surveyors also determined there were no additional excess higher-level staff available to compensate for these NA staffing deficiencies, and the Administrator confirmed on interview that the required NA-to-resident ratios were not met on the identified dates.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held two times daily to review the scheduled staffing hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Maintain Required LPN-to-Resident Staffing Ratios Across Multiple Shifts
Penalty
Summary
The facility failed to meet state-required LPN-to-resident staffing ratios on multiple shifts over specified dates. Review of census data and nursing time schedules showed that on several day shifts, the number of LPNs scheduled and providing care was below the minimum requirement based on the facility’s census. On March 8, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, only 1.80 LPNs provided care. On March 9 and March 12, 2026, with a census of 103 residents requiring 4.12 LPNs on each day shift, only 4.00 LPNs provided care on each of those days. On March 14, 2026, with a census of 105 residents requiring 4.20 LPNs on the day shift, 4.03 LPNs provided care. On April 6, 2026, with a census of 108 residents requiring 4.32 LPNs on the day shift, 4.00 LPNs provided care, and on April 9, 2026, with a census of 108 residents requiring 4.36 LPNs on the day shift, 4.06 LPNs provided care. The facility also failed to meet minimum LPN staffing ratios on at least one evening and one night shift. On an evening shift on March 8, 2026, with a census of 105 residents requiring 3.50 LPNs, only 3.44 LPNs provided care. On a night shift on March 13, 2026, with a census of 105 residents requiring 2.63 LPNs, only 2.06 LPNs provided care. The review further determined that there were no additional excess higher-level staff available to compensate for these LPN staffing shortfalls. In an interview on April 20, 2026, the Administrator confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the identified days and shifts.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing staff ratios to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the scheduled hours per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff ratios to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. Ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 5/11/2026
Failure to Meet Minimum Daily Direct Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.2 hours of direct nursing care per resident per 24-hour period on 12 of 21 reviewed days. Review of nursing time schedules for March 8 through 14, March 22 through 28, and April 5 through 11, 2026, showed that on multiple specific dates the total direct care hours per resident fell below 3.2, with documented levels of 2.58, 3.00, 2.98, 2.80, 2.74, 3.01, 2.91, 3.15, 3.08, 2.89, 3.15, and 3.02 hours depending on the day. These figures were derived from staffing information furnished by the facility and reflected the total general nursing care hours provided across the entire facility for each 24-hour period reviewed. In an interview on April 20, 2026, at 8:52 a.m., the Nursing Home Administrator confirmed that the facility did not meet the required daily direct resident care hours on the identified days.
Plan Of Correction
1. Actions taken for the situation identified: The facility cannot retroactively address the incidents. No residents were adversely affected. 2. How the facility will act to protect residents in similar situations: The facility will schedule, monitor and manage the nursing direct care hours to meet the requirements 3. System changes and measures to be taken: The Nursing Home Administrator has reviewed the required hours per patient day requirements with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings are being held to review the staffing hour per patient day and ratios for the current and upcoming day(s) to ensure that the facility meets the requirements. 4. Monitoring mechanisms to assure compliance: The Nursing Home Administrator/designee will conduct audits of the nursing staff direct care hours to determine compliance weekly for four (4) weeks then monthly for two (2) months. Noted areas of non-compliance will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings, and further action plans and audits will continue until substantial compliance is achieved. From that point forward, ongoing self-monitoring will help to ensure facility continues to meet quality standards. 5. Date Corrective Action will be completed: Substantial compliance is expected by 05/11/2026
Failure to Maintain Resident Dignity Through Timely Call Bell Response
Penalty
Summary
The facility failed to maintain resident dignity by not responding promptly to call bells for two residents who were cognitively intact and dependent on staff for assistance with toileting, hygiene, and transfers. For one resident with multiple sclerosis, a quarterly MDS dated January 9, 2025, showed he was alert, oriented, and able to make his needs known, but required staff assistance for daily care. Interview with this resident on February 28, 2023, revealed he had to wait an extended period for staff to respond to his call bell. Review of his call bell logs for January and February 2026 showed multiple instances of prolonged response times, including waits of 19, 21, 27, 19, 60, 41, and 18 minutes on various January dates, and 16 and 46 minutes on February 1, 2026. These delays occurred despite a facility policy dated October 28, 2025, stating that staff alerted to an activated call light are responsible for responding promptly to promote a secure atmosphere for residents. Another resident, with an annual MDS dated January 6, 2026, was cognitively intact and required staff assistance for daily care needs due to hemiplegia and hemiparesis following a stroke, as well as diabetes. A grievance form dated December 15, 2025, documented that this resident reported being put to bed around 10:00 p.m. and not being checked on until about 4:00 a.m., during which time he attempted to call the nurses’ station with his cellphone but received no answer until staff eventually came and told him they were short staffed. Review of his call bell log from December 14–16, 2025, showed that his call bell was activated on December 14, 2025, at 9:19:49 p.m. and the response time was one hour and 47 seconds. In a February 3, 2026, interview, the resident stated that it took staff a long time to get him into bed after his request and that he sometimes called the front desk to get a faster response, but that night no one answered the phone. The Assistant DON acknowledged in a February 3, 2026, interview that the documented call bell wait times were excessive and not acceptable, and stated that she expects call bells to be answered within five minutes, noting that anyone can answer a call bell.
Failure to Provide Showers per Resident Preference and Care Plan
Penalty
Summary
Surveyors identified a failure to provide bathing care according to a resident’s preferences and care plan. Facility policy dated October 28, 2025, required that residents be bathed or showered according to their preferences to maintain hygiene and skin condition, and that the charge nurse speak with any resident who refused, attempt alternative arrangements, and document refusals in the medical record. Resident 5 had a quarterly MDS dated December 4, 2025, showing cognitive impairment, dementia, and a need for staff assistance with daily care needs including bathing. The resident’s care plan dated July 29, 2024, specified a preference for showers twice weekly on Wednesdays and Saturdays, with the option to refuse and receive a bed bath instead. Review of the bathing detail report for Resident 5 from December 1, 2025, through January 31, 2026, showed multiple missed showers on scheduled Wednesdays and Saturdays, including but not limited to December 6, 10, 13, 17, 20, 24, 27, 29, 2025, and January 3, 7, 10, 17, 21, 24, and 31, 2026. There was no documentation that showers were offered on these dates, that the resident refused, or that alternative bathing such as a bed bath was provided. In an interview on February 3, 2026, at 1:06 a.m., the Assistant DON confirmed there was no documented evidence that staff offered showers and that the resident should have received showers per her stated preferences and plan of care, resulting in noncompliance with 28 Pa. Code 211.12(d)(5) Nursing services.
Unsupervised and Unsecured Medications Left at Bedside
Penalty
Summary
Facility staff failed to ensure medications were properly stored and labeled, resulting in drugs being left unattended at the bedside for two residents. For one resident who was cognitively intact, required assistance with daily care, and had diagnoses including heart failure, anxiety, and depression, surveyors observed an unsupervised medicine cup containing twelve unlabeled pills on the overbed table while the resident was lying in bed. The resident reported that she was aware the pills were there and that nurses frequently left her pills sitting on the table. The LPN responsible acknowledged that he had left the medications in the room because he believed the resident would take them after eating breakfast and confirmed he did not remain in the room to observe medication administration, contrary to the facility’s medication administration policy that staff should not leave medications or chemicals unattended. For another cognitively intact resident who required assistance with daily care and had diagnoses including noninfective gastroenteritis and colitis, physician orders directed the use of triamcinolone 0.1% cream to the back and hips twice daily for dermatitis. During observation, surveyors found a box of triamcinolone 0.1% cream left on the bottom left side of the resident’s bed near the door, unsupervised by staff. The Assistant DON confirmed in both cases that medications and topical prescription products should not have been left unsupervised in the residents’ rooms, indicating noncompliance with the facility’s policy and state requirements for pharmacy and nursing services regarding proper labeling and secure storage of drugs and biologicals.
Failure to Notify Representatives of Hospital Transfers and Complete Medication Reconciliation
Penalty
Summary
The facility failed to provide written notification to the resident representative and the ombudsman regarding the reason for hospitalization and failed to notify the resident about the facility’s bed-hold policy at the time of transfer for Residents 2, 29, and 105. Resident 2 was transferred to the hospital after a fall with a radius fracture, Resident 29 was admitted to the hospital with sepsis and a urinary tract infection, and Resident 105 was admitted to the hospital with sepsis and hypotension. For each of these residents, there was no documented evidence that the emergency contact or responsible party and the ombudsman received written notice of the transfer or bed-hold information. The facility also failed to complete medication reconciliation for Residents 103 and 105. Resident 103’s record showed that the resident ceased to breathe and the body was being released to the funeral home, but there was no documented medication reconciliation after death. Resident 105’s record showed that the resident’s son picked up her personal effects and that she would not be returning to the facility, but there was no documented medication reconciliation after discharge. The DON and Interim DON confirmed that the required notices and medication reconciliations were not completed.
Failure to Address Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to respond to pharmacy medication regimen review recommendations for five residents, and the clinical record did not show that the pharmacist’s findings were reviewed by the medical director or practitioner as required. The cited issue involved monthly drug regimen review and irregularity reporting under the facility’s medication regimen review policy, which stated that time-sensitive concerns identified by the pharmacist were to be escalated for immediate action and addressed in a timely manner. For Resident 11, the quarterly MDS showed cognitive impairment, partial assistance needs, and diagnoses of hypertension, coronary heart disease, and anemia. A pharmacy consultant recommended a CMP, fasting lipids, CBC, magnesium, iron, and vitamin D levels on the next lab day, but the physician order was not written until later and the blood work was completed on a different date. The Interim DON confirmed the recommendation should have been addressed sooner because it was time sensitive. For Resident 29, the quarterly MDS showed the resident was cognitively intact, dependent on staff for daily care, and receiving an antibiotic. The pharmacist recommended temporarily discontinuing simvastatin during daptomycin therapy, but there was no documented evidence that the medical director reviewed the recommendation. For Resident 37 and Resident 57, pharmacy medication regimen review notes indicated irregularities and recommendations to be reviewed, but there was no documented evidence of the pharmacy review findings or that they were reviewed by the medical director or practitioner. For Resident 71, the quarterly MDS showed cognitive intactness, assistance needs, oxygen and IV medication use, and diagnoses including hypertension, hyperlipidemia, CHF, and respiratory failure; the pharmacist noted an elevated ALT and recommended considering an LFT panel, but there was no documented evidence that the physician addressed the recommendation.
Failure to Inform Residents of Psychotropic Medication Risks, Benefits, and Alternatives
Penalty
Summary
The facility failed to inform two residents or their resident representatives in advance of the risks and benefits of psychotropic medications and the available treatment alternatives before starting the medications. Resident 37 was cognitively intact, understood information, and had diagnoses of depression and anxiety. After reporting anxiety, sadness, anger, and increased sleep disturbances, the resident was evaluated by psychology and described as having gone three days without sleeping, feeling upset and depressed, feeling jumpy, and wanting to cry a lot. The psychology consult recommended starting Zoloft and increasing Trazodone at bedtime, and physician orders were written for Trazodone 100 mg at bedtime and Zoloft 100 mg daily for depression. Resident 57 was cognitively intact, required assistance, was understood, and had diagnoses including bipolar disorder and dementia. A psychology consult noted that the resident appeared not to have slept, was irritable, and reported still being manic, with a recommendation to increase Olanzapine by adding a morning dose. Physician orders then included Olanzapine 10 mg daily in the morning. The clinical record for both residents contained no documented evidence that the facility informed the resident or resident representative in advance of the risks and benefits of the psychotropic medication or alternative treatment options. The Social Services Director stated she obtained signed consents for psychiatry consult services but did not obtain consents for psychotropic medications, and the Interim DON confirmed there was no documented evidence of informed consent for either resident.
Failure to Provide Bariatric Seating
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident 96 by not providing a bariatric broda chair. The resident’s quarterly MDS dated September 17, 2025, showed she was cognitively intact, non-ambulatory, dependent for wheelchair mobility and transfers, and had morbid obesity. An OT evaluation dated September 12, 2025, documented that her current seating was a broda chair with a huntingtons package, that she weighed 340 pounds, and that the chair’s maximum weight was 350 pounds. The OT recommended a bariatric broda chair with a huntingtons package because of the resident’s increased risk for pressure injury with the current seating system, and noted the facility did not have a bariatric broda chair available. On November 3, 2025, the resident was observed lying in a bariatric bed and stated she wanted to get out of bed, but said they did not have a chair big enough and that she had previously gotten up before but no longer did because staff said she was not safe in her chair. A dietary note stated that nursing and therapy reported she was unable to fit safely in her broda chair due to weight gain. A physician note indicated she had a bariatric wheelchair to promote out-of-bed activity, but that a wider wheelchair was difficult to accommodate because of facility door frames. The OT stated a bariatric broda chair was being looked at for trial because the resident did not fit well in her current chair and there was concern for skin impairment, but the facility did not have one. The resident said she would be agreeable to sit in a chair outside her room if it meant she could get out of bed, and the NHA stated the facility was aware of the recommendation and could have gotten her one but did not because of the possibility she might be placed elsewhere to a facility that could better meet her needs.
Failure to Issue Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required notice to the resident or the resident's representative after Medicare coverage ended for two residents reviewed. For Resident 40, a Skilled Nursing Facility Beneficiary Protection Notification Review form dated October 15, 2025 showed Medicare coverage began on September 27, 2025, with the last covered day on October 10, 2025; the form also indicated the facility initiated discontinuation from Medicare Part A coverage and that benefit days were not exhausted, but an Advanced Beneficiary Notice of Non-coverage was not issued. For Resident 106, a similar form dated June 6, 2025 showed Medicare coverage began on June 2, 2025, with the last covered day on June 6, 2025; the facility initiated discontinuation from Medicare Part A coverage and benefit days were not exhausted, but the Advanced Beneficiary Notice of Non-coverage was not issued. The Business Office Manager stated there had been recent staff changes and the notices were not provided as required, and the Nursing Home Administrator confirmed that both residents should have received the notices when Medicare coverage ended.
Unclean Microwave in Pantry
Penalty
Summary
The facility failed to provide a clean and homelike environment in the 300/400 hall pantry. During observation of the pantry, the inside ceiling of the microwave cooking cavity had a moderate to large amount of brownish/black removable substance, and three areas on the inside frame of the microwave had worn paint with exposed metal ranging from one half inch to six inches in length. The facility policy on homelike environment stated that staff and management were to maintain, to the extent possible, a clean and sanitary environment. The microwave owner's manual for the model in use stated that the appliance should not be operated if damaged in any way. The Maintenance Director and ADON stated they were not aware of the debris or the worn paint and exposed metal, and both said the condition was unacceptable.
Failure to Investigate Unexplained Bruise
Penalty
Summary
The facility failed to ensure that a resident was free from abuse or neglect when Resident 7 was documented by nurse aide documentation on October 11, 2025, as having a new bruise of unknown origin on the right wrist and forearm. The facility's abuse policy stated that all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation, misappropriation of resident property, and injuries of unknown source must be investigated, but there was no documented evidence that the facility investigated the bruise to rule out abuse or neglect as the cause. Resident 7's care plan noted an overall decline in status with activities of daily living related to deconditioning and weakness and that the resident would be monitored for signs and symptoms of skin and/or wound infections. The Interim DON confirmed on November 4, 2025, that the facility was not made aware of the new bruise of unknown origin and did not complete an investigation to rule out abuse.
Failure to Timely Report Possible Abuse Injury
Penalty
Summary
The facility failed to ensure that allegations of possible abuse were reported timely to the Nursing Home Administrator for one resident. The facility’s abuse policy stated that all allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to direct supervision, and that the resident’s responsible party and attending physician, if appropriate, would be notified. A quarterly MDS assessment for the resident showed the resident was cognitively impaired and dependent on staff for all daily care needs. Nurse aide documentation noted that the resident had a bruise of unknown origin on the right wrist and forearm, but there was no documented evidence that the nurse aide reported the bruise per facility policy. The DON confirmed in interview that the nurse aide should have reported the bruise timely.
Care Plans Not Updated to Match Current Resident Needs
Penalty
Summary
The facility failed to ensure that resident care plans were updated and revised to reflect current care needs for three residents. A quarterly MDS for one resident showed cognitive impairment and dependence on staff for care needs, but the care plan dated earlier still indicated the resident was receiving an antipsychotic medication even though the clinical record showed no documented evidence of antipsychotic use as of November 4, 2025. A second resident’s care plan also continued to list antipsychotic medication use despite the clinical record showing no documented evidence of such medication as of November 4, 2025. The DON confirmed that the care plans for both residents did not reflect gradual dose reductions completed in January 2025 and should have been updated to show they were no longer on the antipsychotic. For a third resident, an annual MDS showed cognitive impairment and need for assistance with care needs, and the care plan identified potential altered skin integrity related to limited mobility, altered cardiovascular status, and edema, with an intervention for ace wraps on in the morning and off in the evening. However, there was no documented evidence in the clinical record that the resident was ordered ace wraps. The DON confirmed that the ace wraps had been discontinued on July 29, 2025, and that the care plan should have been revised to reflect that they were discontinued.
Failure to Complete Ordered Ambulation and Transfer Programs
Penalty
Summary
Resident 10 was assessed as cognitively impaired and dependent on staff for transfers and ambulation on the quarterly MDS. Physician orders directed the resident to walk in the corridor 50 feet with a rollator and one assist twice daily, and to stand and pivot from bed to wheelchair with one assist twice daily for up to 15 minutes. A restorative care plan repeated these requirements, stating the resident was to stand and pivot twice a day for 15 minutes each time and walk in the corridor 50 feet with a rollator and gait belt twice a day for 15 minutes. The clinical record contained no documented evidence that the resident was offered and declined, or completed, the standing/pivoting and ambulation program twice per day as ordered. The DON confirmed that the stand and pivot program and the ambulation program were not completed twice per day per the physician's orders or the care plan.
Improper Indwelling Catheter Drainage Bag Placement
Penalty
Summary
The facility failed to ensure proper care for an indwelling urinary catheter for one resident reviewed who had a catheter. The facility policy stated that the urinary drainage bag must be placed below bladder level but not on the floor, and the resident’s care plan also directed staff not to allow the tubing or any part of the drainage system to touch the floor. The resident was cognitively intact and had an indwelling urinary catheter and a diagnosis of obstructive uropathy. During observation, the resident was lying in bed with the indwelling urinary catheter drainage bag and tubing lying directly on the floor on the left side of the bed. An LPN confirmed that the catheter bag and tubing should not have been on the floor and should have been hanging on the bed or in a basin, and stated that therapy had just brought the resident back and put him in bed. The NHA also confirmed that the catheter bag and tubing should not have been in direct contact with the floor.
Failure to Assess Trauma History and PTSD Triggers
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder received an assessment for a history of trauma and trauma-informed care to identify and reduce triggers that could re-traumatize the resident. The facility policy dated July 22, 2025 stated that Social Services was responsible for assisting with individualized care plans and for assessing residents who are trauma survivors to provide culturally competent, trauma-informed care, including identifying triggers and interventions to reduce the risk of re-traumatization. Resident 81’s admission MDS dated October 21, 2025 showed the resident was cognitively intact and had a diagnosis of PTSD. The care plan revised October 29, 2025 noted the resident was receiving antipsychotic medications related to PTSD. During interview, the resident stated she had been in a domestic violence situation for 10 years with her first husband and identified loud noises, arguing, and some male interactions as triggers; she also reported following with a female therapist and taking medications that help. There was no documented evidence that the facility completed an assessment of the resident’s trauma history to identify specific triggers, and the DON confirmed this during interview on November 6, 2025.
Failure to Document Administration of Controlled Pain Medication
Penalty
Summary
Controlled medication accountability was not maintained for two residents receiving oxycodone. Facility policy required documentation of medication administration, including controlled substances, in accordance with applicable law, but review of the controlled drug records and clinical records showed that signed-out doses were not documented as administered. For Resident 37, a quarterly MDS dated August 14, 2025, showed the resident was cognitively intact, had pain, took opioid medications, and had diagnoses including heart failure. Physician orders dated June 3, 2025, included oxycodone 5 mg every four hours as needed for pain. The controlled drug record for August 2025 showed oxycodone 5 mg was signed out on August 10 at 11:30 p.m. and August 20 at 10:30 a.m., but there was no documented evidence in the clinical record that these doses were administered. For Resident 73, a quarterly MDS dated September 29, 2025, showed the resident was cognitively intact, required assistance with care needs, had pain, and was taking an opioid medication. Physician orders dated August 7, 2025, included oxycodone 5 mg every four hours as needed for moderate to severe pain. Review of the controlled drug record from August through October 2025 showed multiple oxycodone doses signed out, including one entry with no documented time on September 12, but there was no documented evidence in the clinical record that the signed-out doses were administered on the listed dates and times. The DON confirmed there was no documented evidence that the doses were administered.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary psychotropic medications by not documenting attempts at non-pharmacological behavioral interventions before giving as-needed clonazepam for anxiety. The facility policy on psychotropic gradual dose reduction stated that psychotropic medications would be used only when necessary and beneficial and that a plan of care would include specific non-pharmacological interventions, which would also be placed on the Resident Care Card. Resident 81 had an admission MDS assessment showing the resident was cognitively intact and had diagnoses including bipolar disorder and anxiety. The care plan noted the resident was receiving psychotropic medications related to depression and anxiety. Physician orders included clonazepam 1 mg once daily as needed for anxiety, and the MAR showed the medication was administered multiple times for anxiety. For each of those administrations, there was no documented evidence that non-pharmacological behavioral interventions were attempted first. The DON confirmed that such interventions should have been attempted before giving the as-needed clonazepam.
Unsecured Medications Found in Medication Cart
Penalty
Summary
Medications were found unsecured in the top drawer of the 300 hall medication cart during observation, when an undated and unmarked medication cup containing multiple tablets and capsules was discovered in the drawer. The facility’s medication administration policy, dated March 26, 2025, stated that it was intended to provide a method for the safe, accurate administration of oral medications to residents. Registered Nurse 4 confirmed at the time of the observation that the undated and unmarked medication cup containing medications should not have been in the top drawer of the medication cart, and the Interim Director of Nursing also confirmed that the cup should not have been there.
Incomplete Controlled Substance Documentation
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurately documented for two residents. The facility policy on medication administration, dated July 22, 2025, required staff to document medication administration and treatment information, including when medications were given and PRN medications, on the appropriate forms. A review of records and staff interviews showed that controlled substance documentation was missing for administered doses of oxycodone for two residents. Resident 37 had a quarterly MDS assessment dated August 14, 2025, showing the resident was cognitively intact, required assistance, was understood, had pain, took opioid medications, and had diagnoses including heart failure. The resident had an order for oxycodone 5 mg every eight hours as needed for pain. The MAR showed oxycodone was administered on August 11 at 1:54 a.m. and August 18 at 11:31 a.m., but the controlled medication record had no documented evidence that those doses were signed out. Resident 73 had a quarterly MDS assessment dated September 29, 2025, showing the resident was cognitively intact, required assistance with care needs, had pain, and was taking an opioid medication. The resident had an order for oxycodone 5 mg every four hours as needed for moderate to severe pain. The MAR showed oxycodone was administered on August 9 at 5:30 a.m., September 15 at 5:27 a.m., and October 14 at 9:18 p.m., but the controlled medication record had no documented evidence that those doses were signed out.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility's QAPI committee failed to correct repeated quality deficiencies identified in prior and current surveys. The report states that the facility had previously developed plans of correction after the survey ending October 31, 2024, which included quality assurance systems intended to maintain compliance with cited nursing home regulations, but the current survey ending November 6, 2025, again identified deficiencies involving maintaining a homelike environment, transfer notices and bed hold policies, care plan timing and revision, catheter care, and the proper storage of drugs and biologicals. For each of these repeated deficiencies, the facility's prior plans of correction called for audits and review of results by the QAPI committee, yet the current survey found that the committee failed to successfully implement those plans. The report specifically states that the QAPI committee was ineffective in maintaining compliance with the regulations related to a homelike environment, transfer notices and bed hold policies, care plan timing and revision, catheter care, and storage of drugs and biologicals.
Quality Assurance Committee Missing Required Member Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance Committee attended quarterly meetings. The facility’s Quality Assurance and Performance Improvement policy, dated March 12, 2025, stated that meetings would be held at least quarterly and would include the Nursing Home Administrator, DON, Medical Director, direct care staff, staff from ancillary departments, and a designated Infection Preventionist. Review of the committee attendance records showed that the Infection Preventionist did not attend any meetings held during the first and fourth quarters of 2024-2025. The DON confirmed in an interview on November 5, 2025, at 11:30 a.m. that the Infection Preventionist did not attend those Quality Assurance Committee meetings.
Failure to Follow Wound Care Orders for Pressure Ulcer
Penalty
Summary
The facility failed to follow wound care recommendations for a resident with an unstageable pressure ulcer to the sacral area. The resident, who was cognitively intact and required assistance with daily care, was identified as being at risk for pressure ulcers. A wound consultation and physician's orders specified that Triad cream should be applied to the sacral wound every shift. However, review of the Treatment Administration Record showed that the cream was only applied daily over a four-day period, rather than every shift as ordered. This was confirmed by the Assistant Director of Nursing, who acknowledged that the treatment was not administered according to the physician's instructions.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
A deficiency occurred when staff failed to provide a resident with the assistive eating devices as ordered by the physician. The resident, who was cognitively intact and had a history of hemiplegia and hemiparesis following a cerebral infarction, required set-up assistance with eating and was specifically ordered to use a divided plate with dycem underneath and left angled black ridged non-weighted utensils for all meals. Occupational therapy and physician documentation confirmed the ongoing need for these adaptive devices, and a dietary slip was completed to communicate these requirements. During a lunch meal observation, the resident was found without the required divided plate and utensils. Both the resident and his sister confirmed that these items were necessary for him to eat independently, as he used the edge of the divided plate to assist with getting food onto his utensils. The Dietary Manager initially indicated that the adaptive equipment had been discontinued and the resident was not listed as needing them, but later confirmed that current dietary communication sheets still indicated the need for these devices. The resident did not receive the ordered adaptive equipment during the observed meal.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food and drink at palatable and safe temperatures, as required by its own policy. According to the policy, hot foods should be plated at 135°F and cold foods at 41°F or below. During a lunch meal observation, a test tray revealed that hot items such as potato encrusted fish and sliced carrots were served at 121.1°F and 120.4°F, respectively, while cold items like creamy coleslaw, fruit cup, and milk were served at 67.7°F, 62.0°F, and 59.8°F, respectively. These temperatures were confirmed by tasting to be neither hot nor cold enough to be palatable. The Dietary Technician acknowledged that the foods were not served at the proper temperatures.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions as required by policy and professional standards. Review of the facility's policy indicated that refrigerated foods should be marked with the date for consumption or disposal, but observations in the main kitchen revealed multiple cartons and containers of prepared salads in the walk-in refrigerator that were not labeled or dated. Additionally, the deep cleaning calendar showed that required cleaning tasks, such as cleaning the outside of the dish machine and wiping walls, were not consistently documented as completed, with only two days signed off for the entire month. Further inspection found significant build-up of food debris and dust on kitchen equipment, including the convection oven, grease trap, ceiling vent, and ice machine filter, as well as dirty flooring around the stove and ice machine. The Dietary Technician confirmed that the food should have been labeled and that the areas identified were dirty and needed cleaning.
Failure to Ensure RN Assessment After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a registered nurse (RN) assessed a resident following a significant change in condition. According to the Pennsylvania Nursing Practice Act and the facility's own policies, an RN is required to assess residents after a change in condition, particularly when there is new or worsening pain. In this case, a resident who was cognitively intact and required assistance with daily care experienced severe, uncontrolled pain that was not relieved by scheduled Tylenol. The resident cried out in pain when moved, expressed distress, and verbalized a desire to die due to the pain. Documentation showed that an LPN noted the resident's pain and communicated with the physician regarding comfort care, stronger pain medication, or hospice, but there was no evidence that an RN assessed the resident during this episode. The Director of Nursing confirmed that there was no documented RN assessment at the time of the resident's pain episode, despite facility policy and state regulations requiring such an assessment. The lack of RN assessment and documentation following the resident's significant change in condition constituted a failure to meet professional standards of quality and the facility's own protocols for pain management and change in condition.
Failure to Provide Scheduled Showers and Document Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled according to her care plan and preferences. Facility policy required that residents be bathed or showered at least twice weekly, or as per their preference, and that refusals be reported to the charge nurse, who would then document the refusal and attempt to make alternative arrangements. For the resident in question, the care plan specified a preference for showers twice weekly on the day shift, with a prompt bed bath and skin checks if a shower was refused. A review of the resident's records, including the bathing detail report and weekly skin sheets over a six-week period, showed no documented evidence that the resident received showers as scheduled or that she refused them, which would have triggered a bed bath. The DON confirmed the lack of documentation and was unable to explain why some days were marked as 'did not occur.' The resident was cognitively impaired, required moderate assistance with bathing, was occasionally incontinent, and had diabetes, all of which were relevant to her care needs at the time of the deficiency.
Failure to Administer Ordered Pain Medication
Penalty
Summary
A cognitively impaired resident who required partial to moderate assistance and received routine pain medication was admitted with a physician's order for 500 mg of Naproxen to be administered twice daily with meals. Review of the resident's Medication Administration Record (MAR) for August 2025 showed that the Naproxen was not documented as given on several specified dates and times. The Director of Nursing confirmed that the resident did not receive the ordered Naproxen doses on those occasions, despite the medication being available as a stock item in the emergency box and as an over-the-counter medication.
Failure to Provide Timely Pain Management for Resident with Acute Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was experiencing acute pain. According to the facility's pain management policy, a pain evaluation should occur with any new onset of pain, and the physician should be notified of new or significantly increased pain. The resident, who was cognitively intact and required assistance with daily care, had a physician order for scheduled Tylenol. On one occasion, the resident was found to have a deep vein thrombosis (DVT) in the left lower extremity and was started on anticoagulant therapy. Despite this, nursing documentation indicated that the resident continued to experience significant pain that was not relieved by the scheduled Tylenol, including crying out in pain during care and expressing distress about her pain. A note was placed in the physician's communication book requesting comfort care, stronger pain medication, or hospice, but there was no documented evidence that the physician was contacted at that time for additional interventions or treatment to relieve the resident's pain. The Director of Nursing confirmed that the resident's acute pain was not controlled as it should have been. This lack of timely physician notification and intervention for uncontrolled pain constituted a failure to follow the facility's pain management policy and provide adequate nursing services.
Failure to Update Care Plan After Falls and New Interventions
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated to reflect changes in care needs following multiple falls and the implementation of new safety interventions. The resident, who had a history of falls, left shoulder injury, left hip fracture, and conditions such as deconditioning, limited mobility, vertigo, orthostatic hypotension, and weakness, experienced several falls over a period of time. After each fall, the interdisciplinary team met and decided on new interventions, including the addition of bed and wheelchair alarms to help prevent further incidents. Despite these interventions being implemented, there was no documented evidence that the resident's care plan was revised to include the use of bed and wheelchair alarms. Observations confirmed the presence of these alarms in use, and staff interviews verified their application, but the care plan did not reflect these updates. This failure to update the care plan was confirmed by the Director of Nursing and was not in accordance with the facility's policy or regulatory requirements.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
Facility staff failed to protect a resident with dementia, who was dependent on staff for transfers and had no behavioral issues, from abuse and neglect. The incident involved a nurse aide removing the resident's call bell, making it inaccessible, and refusing to assist the resident out of bed over a weekend. Documentation and witness statements confirmed that the resident repeatedly requested to get out of bed and that her call bell was intentionally moved out of reach. The resident verbally reported not having access to her call bell, and staff observed the call bell draped over the nightstand. Multiple staff members, including two nurse aides and an RN, were aware of the situation. One nurse aide admitted to removing the call bell, while another was aware of the action and did not intervene. The RN was informed by the aides that the call bell was moved to prevent the resident from bothering them due to their workload. The incident was not reported in a timely manner as required by the facility's abuse policy, and the investigation determined that the resident was not allowed out of bed and was left without access to her call bell.
Failure to Follow Physician Orders for Medication and Pressure Ulcer Equipment
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician's orders for one resident. The resident, who was cognitively intact and required staff assistance for daily care, had diagnoses including paraplegia, wound infection, and a Stage 4 pressure ulcer. Physician's orders specified that the resident was to receive 4.5 grams of Piperacillin-tazobactam intravenously every eight hours. However, the Medication Administration Record showed no documented evidence that the resident received the antibiotic as ordered on three occasions within a specified day. Additionally, the resident requested bed rails and an air mattress for repositioning and pressure ulcer management. A wound consult by a CRNP recommended an air mattress for the resident's pressure ulcers. Despite these recommendations and requests, there was no documented evidence in the clinical record that the resident received an air mattress. The Director of Nursing confirmed that the resident did not receive the IV antibiotic as ordered and that there was no documentation of the air mattress being provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for three out of five residents reviewed. Facility policy required documentation of controlled substance administration in accordance with applicable law, including recording when medications are given on appropriate forms. For three residents, controlled drug records showed that doses of narcotic pain medications were signed out on specific dates and times. However, there was no corresponding documentation in the residents' clinical records or Medication Administration Records (MAR) to confirm that these medications were actually administered at those times. The residents involved were cognitively intact and had significant pain management needs, with diagnoses such as fractures, osteoarthritis, chronic pain syndrome, fibromyalgia, and polyneuropathy. Each had physician orders for opioid or narcotic pain medications, either scheduled or as needed. Despite these orders and the signing out of medications on controlled drug records, the lack of documentation in the MAR or clinical records was confirmed by the Director of Nursing, indicating a failure to ensure proper tracking and accountability for controlled substances as required by facility policy and state regulations.
Failure to Document Controlled Substance Administration in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents, specifically regarding the documentation of controlled substance administration. According to the facility's medication administration policy, staff are required to document the administration of controlled substances in accordance with applicable law, including recording each dose on the appropriate controlled medication record. However, for all five residents reviewed, there were multiple instances where narcotic pain medications such as Tramadol, oxycodone-acetaminophen, oxycodone, and hydrocodone-acetaminophen were administered as documented on the Medication Administration Record (MAR), but there was no corresponding documentation on the controlled medication record for those administrations. The residents involved were all cognitively intact and required assistance with care needs. Each had significant pain management needs and diagnoses such as multiple sclerosis, chronic pain, polyneuropathy, spinal stenosis, osteoarthritis, fibromyalgia, and fractures. Physician orders for these residents included scheduled and as-needed administration of opioid medications for pain control. Despite these orders and the administration of the medications as recorded on the MAR, the required documentation on the controlled medication record was missing for several dates and times for each resident. The Director of Nursing confirmed during an interview that there was no documented evidence on the controlled medication sheets for the administration of the specified medications to the five residents on the identified dates and times. This lack of documentation was found to be inconsistent with both facility policy and regulatory requirements for clinical records and nursing services.
Failure to Notify Provider of Ongoing Resident Behaviors During Medication Changes
Penalty
Summary
The facility failed to notify the physician or provider regarding ongoing behavioral issues for one resident who was severely cognitively impaired and required staff assistance for daily care. The resident exhibited repeated episodes of combative and aggressive behavior, including refusing care and medications, verbal aggression, yelling, wandering into other residents' rooms, making inappropriate sexual comments, and being physically combative with staff. Despite these ongoing behaviors, there was no documented evidence that the physician or Certified Registered Nurse Practitioner (CRNP) was notified on multiple occasions when these incidents occurred. The resident's care plan included a Gradual Dose Reduction (GDR) of antipsychotic medication unless clinically contraindicated. However, nursing notes indicated that the resident's behaviors persisted or increased during the period when the GDR was implemented and after the antipsychotic medication was discontinued. The lack of communication with the physician or CRNP regarding these ongoing and escalating behaviors meant that the provider was not informed in a timely manner to potentially prevent the GDR or address the resident's needs. The Director of Nursing confirmed that the provider was not notified about the ongoing behaviors or the inappropriateness of the GDR for this resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 681 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hill Rehabilitation & Healthcare Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Saint Anne Home | 2 mi | ★★★★★ | 2 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 2.7 mi | ★★★★★ | 11 | 0 |
| Twin Lakes Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 29 | 1 |
| Redstone Highlands Health Care | 3.1 mi | ★★★★★ | 15 | 1 |
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.