Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Greenwood Center For Nursing And Rehab during CMS and state inspections, most recent first.
Unsanitary food storage and handling practices were observed in the dietary dept. A cook was seen in the food prep area with a thick beard and no beard restraint, snow boots were placed on top of an opened box of grease pan liners, rusted shelves were noted in the reach-in refrigerator, and cases of frozen buns were stored on the floor in the walk-in freezer. Several opened thickened juices and thawed Mighty Shakes were also found without required dates, and a dietary aide confirmed the items were not dated.
Failure to Provide Scheduled Showers: Three residents who needed staff assistance for ADLs did not receive showers as scheduled. One resident with dementia received only bed baths despite a twice-weekly shower plan, another cognitively intact resident with venous insufficiency and pulmonary HTN reported no showers or hair washing since admission and was observed with oily, unkempt hair, and a third resident with CHF and ESRD reported repeated delays and had greasy, disheveled hair and beard. Records showed shower schedules were in place, but documentation did not support that the planned showers were provided.
The facility failed to follow a physician order for a resident’s Midodrine by giving it when the SBP was above the hold parameter, failed to keep an ordered blue comfy cushion in place for a resident positioned in a Broda chair, and failed to document or provide ongoing assessment, treatment, or monitoring for a resident’s right foot wound. The issues involved residents with significant medical needs, including orthostatic hypotension, chronic pain syndrome, diabetes, and ESRD, and staff including an LPN, RN, and DON confirmed the missing order compliance and lack of wound documentation.
Infection control practices were not consistently implemented, and a Yankauer suction device used by a resident with a tracheostomy was observed in direct contact with the floor with no designated storage method to keep it clean. The facility also could not show that it evaluated UTI surveillance data for trends or contributing factors, including staff hand hygiene, glove changes, incontinence care, perineal care, or toileting practices, even though about half of the documented UTIs were caused by E. coli or Proteus mirabilis.
Insufficient nursing staffing led to delayed resident care, missed showers, and slow response times for call bells and pain medication. Staffing records showed repeated shortages of NAs, LPNs, and total direct care hours. Several residents reported waiting long periods for PRN pain meds or assistance, one resident remained in bed after breakfast on multiple mornings, another waited 50 minutes for a call bell response and brief change, and others did not receive scheduled showers or had a catheter dressing left unchanged despite a daily order.
Care Plan Did Not Address Ordered Cervical Collar Use: A resident with a left femur fracture, C6 fracture, and dementia had an order to wear a Vista cervical collar at all times except during showering and to use a Sierra collar during bathing. The care plan only addressed altered musculoskeletal status related to fracture and did not include the ordered collar use, the shower collar, or staff responsibilities for monitoring and ensuring consistent use of the prescribed collars.
Failure to consistently implement pressure ulcer prevention measures occurred for a resident with dementia who was severely cognitively impaired, non-ambulatory, and dependent on staff for mobility and transfers. The care plan and MD order required bilateral heel protectors at all times, but surveyors observed the resident seated in a Geri Lounger without the heel protectors in place on multiple occasions, and an aide confirmed they were not being used.
Failure to reassess and modify dressing care after a resident with L hemiplegia and limited ROM developed pain and an acute distal L humerus fracture during routine assistance. Notes showed the resident complained of pain during morning care and dressing, the NP ordered imaging, and later documentation linked the fracture to arm external rotation during upper-body dressing. Staff reported difficulty dressing the resident’s affected side, and there was no evidence of a documented reassessment or changed care approach after the injury.
Inaccurate documentation of resident-to-resident altercation: An RN documented conflicting accounts of an incident between two residents, including one resident with anoxic brain damage and COPD and another with dementia. One record stated the RN saw one resident slap the other, while the other record said the RN only heard a slap. The RN later confirmed she had directly observed the slap, and the DON confirmed she directed the RN to change the note to match the facility's internal investigative process.
Licensed nursing staff administered an antihypertensive medication to a resident on multiple occasions despite physician orders to hold the medication for systolic blood pressure below a specified threshold. The medication was given at least 30 times when the resident's blood pressure was below the ordered parameter, contrary to facility policy and state nursing standards.
A resident with multiple documented medication allergies and intolerances, including to Ondansetron and Gabapentin, was administered these medications on several occasions. Facility staff did not verify or act on the allergy information prior to administration, and there was no evidence of physician justification or pharmacist intervention regarding the use of these contraindicated drugs.
A resident with a history of sexualized behaviors and severe cognitive impairment engaged in repeated sexually inappropriate contact with another severely cognitively impaired resident who could not consent. Despite prior incidents and staff awareness, the facility did not report the initial abuse to authorities and failed to implement adequate safeguards to prevent recurrence, resulting in further sexual harassment.
A resident with severe cognitive impairment was involved in an alleged sexual abuse incident witnessed by an activities aide. The facility's investigation was incomplete, lacking interviews with other staff or alert residents present, and the incident was not reported to the Department of Health. The DON and NHA did not provide evidence of a thorough investigation or compliance with reporting requirements.
A resident with a known history of maladaptive behaviors, including inappropriate sexual conduct, was not adequately monitored or included in ongoing abuse-prevention audits. This led to a repeated incident where the resident sexually abused another resident. The facility's QAPI committee did not address the underlying behavioral risks or monitor the effectiveness of corrective actions, resulting in a recurrence of the deficiency.
Three residents were moved to different rooms within the facility without receiving written notice or an explanation for the change, as required by federal regulations. One cognitively intact resident and another with moderate cognitive impairment were not informed of their right to refuse the move, and interviews confirmed that neither the residents nor their representatives received written notification or reasons for the room changes.
Two residents experienced significant medication errors when an LPN administered the wrong medications to one cognitively intact resident, resulting in hypotension, and another resident with severe cognitive impairment received an excessive dose of Risperidone for nearly two weeks due to a transcription error. Both incidents were attributed to failures in following the Five Rights of Medication Administration and proper order transcription.
The facility did not provide enough nursing staff to meet residents' needs, leading to frequent delays in care such as long wait times for call bell responses, missed showers, and delayed assistance with turning and toileting. Several residents with complex medical conditions reported waiting 30 minutes or more for help, and staff confirmed that low staffing levels made it difficult to provide timely care. Facility records showed that required nurse staffing levels were not met, and the administrator acknowledged these deficiencies.
The facility failed to protect resident privacy by posting a sign outside a resident's room that disclosed a COVID-19 diagnosis and by allowing a staff member to open another resident's personal mail, including social security statements, without authorization. These actions compromised the confidentiality of residents' health and personal information.
The facility did not ensure the accuracy of MDS assessments for two residents. One resident's discharge status was incorrectly recorded as a transfer to a hospital instead of another LTC facility, and another resident was inaccurately documented as receiving dialysis despite no evidence or orders for such treatment. These errors were confirmed through record review and staff interviews.
A resident with venous insufficiency did not receive daily wound care as ordered by the physician, with documentation missing for multiple days and wound dressings not changed as required. Family observations and staff statements confirmed that wound care was not consistently performed or properly documented, and the Nursing Home Administrator acknowledged the failure to follow professional standards of practice.
A resident with chronic kidney disease and acute kidney failure, receiving hemodialysis via a perma-Cath, did not have the required emergency kit with pressure dressing, tape, and clamp at the bedside as directed by the care plan. Observation confirmed the absence of these supplies, and both an LPN and the Nursing Home Administrator acknowledged that facility policy required the kit to be present and accessible for residents on hemodialysis.
A resident with morbid obesity and bradycardia, who was cognitively intact and required bed rails for mobility, was found to have loose and unstable bed rails that were not properly affixed to the bed frame. Observation and interviews confirmed the rails were not installed according to manufacturer specifications, and the facility could not provide documentation of compatibility or proper installation.
A resident with a history of cerebral infarction did not receive a newly prescribed pain medication for several days after returning from a hospital stay. Although the hospital recommended starting gabapentin for pain, the order was not entered or administered until six days later. The facility acknowledged it did not ensure the physician received and acted on the discharge recommendation.
The facility did not consistently honor resident food preferences, as evidenced by two residents repeatedly receiving disliked foods despite their preferences being documented, and no alternative options being offered. A group interview also revealed that only one vegetable option was provided per meal, with no alternatives for those who disliked it. The administrator could not provide documentation of efforts to accommodate these preferences.
A resident with multiple sclerosis and dysphagia, who had a care plan and physician's order for staff-assisted feeding with a maroon dysphagia spoon, was observed being fed with a standard teaspoon instead. The required adaptive utensil was not provided or used during the meal, and this was confirmed by the nurse aide and acknowledged by the administrator.
Surveyors found that food items, including nectar-thick juices and milk, were stored in the refrigerator without required date markings, and clean dishes were left uncovered in the tray line area. The dietary manager confirmed these practices did not meet sanitary standards, resulting in a deficiency related to food storage and service.
The facility did not meet the required nurse aide to resident ratios on 12 out of 21 shifts reviewed, as per the 28 PA Code regulations effective July 1, 2023. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the shortfall in staffing levels, with no additional higher-level staff available to compensate.
The facility did not meet the required nurse aide to resident ratios for 17 out of 21 shifts reviewed, as per Pennsylvania regulations effective July 1, 2024. Staffing records from February 4 to February 10, 2025, show consistent understaffing, with the number of nurse aides falling short of the required numbers based on the facility's census. The Nursing Home Administrator confirmed the deficiency, and no additional higher-level staff were available to compensate.
The facility did not meet the required LPN to resident ratios on three occasions during the night shift. On specific days, the number of LPNs was below the required level for the resident census, and no additional higher-level staff were available to compensate. The Nursing Home Administrator confirmed the staffing shortfall.
The facility did not meet the required minimum of 2.87 hours of direct resident care per resident in a 24-hour period. On two occasions, the facility provided less than the mandated hours, with 2.74 and 2.68 hours of care per resident. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident per day on several dates in February 2025. Staffing levels were insufficient, with the lowest being 2.68 hours. The Nursing Home Administrator confirmed the failure to consistently provide the required care hours.
A facility failed to involve a resident and their representative in the care planning process, as required by policy. The resident, who was severely cognitively impaired and had diagnoses including pneumonia and COPD, had a family member designated as their representative. However, there was no documented evidence of their participation or invitation to the care plan meeting, which was confirmed by the DON.
The facility failed to meet the required nurse aide to resident ratios on multiple occasions, with staffing records showing insufficient nurse aides during day, evening, and night shifts. The Director of Nursing confirmed the shortfalls, and no additional higher-level staff were available to compensate for the deficiencies.
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, with staffing levels consistently below the mandated numbers for day, evening, and night shifts. The Director of Nursing confirmed the deficiencies, and no higher-level staff were available to compensate for the shortfall.
The facility failed to meet the required LPN to resident ratios across multiple shifts, with insufficient staffing levels on 14 out of 21 shifts reviewed. The day, evening, and night shifts all fell short of the required LPN staffing levels, as confirmed by the Director of Nursing.
The facility did not meet the required 2.87 hours of direct nursing care per resident per day on three occasions, providing only 2.56 and 2.55 hours instead. This was confirmed by the DON during an interview.
The facility did not meet the required 3.2 hours of direct resident care per day on six out of seven days reviewed. Staffing levels were below the minimum, with hours ranging from 2.55 to 3.01 per resident. The DON confirmed the inconsistency in providing the required care hours.
A resident with COVID-19 and other health issues experienced a deterioration in condition, including difficulty breathing and unobtainable oxygen saturation levels. Despite new orders for oxygen and respiratory treatment, there was no timely assessment or follow-up documentation by medical staff. The resident's condition worsened, leading to a fatal outcome after delayed medical intervention. Interviews revealed that payment restrictions contributed to the delay in treatment.
A resident sustained a fracture during a linen change, and the facility failed to conduct a thorough investigation. Despite the resident being cognitively intact, the facility did not obtain her account of the incident, relying only on staff statements. This lack of comprehensive investigation and documentation hindered the facility's ability to demonstrate an effective QAPI program.
The facility failed to respond promptly to residents' call bells, with reports of delays up to several hours, particularly during night shifts and weekends. Residents were left in soiled conditions due to these delays. Additionally, there was no functioning call bell in the activity room, leaving residents without a means to request assistance. The Nursing Home Administrator confirmed these issues but could not explain the untimely responses.
The facility failed to maintain a clean and orderly environment in both the West and East Nursing Units. Observations revealed gouges and holes in walls, bubbling paint, chipped surfaces, and cleanliness issues such as leftover food trays, dirty gloves, and stains. The East Unit had missing paint and exposed cork on furniture. The Nursing Home Administrator confirmed the facility's obligation to maintain a clean environment.
A resident with chronic respiratory failure did not receive supplemental oxygen as ordered, with observations showing incorrect oxygen levels and inadequate equipment maintenance. LPNs confirmed the discrepancies, and the facility acknowledged the failure to adhere to professional standards.
The facility failed to follow physician orders for pain management, leading to inappropriate administration of pain medications for several residents. A resident with chronic pain received Tramadol for pain levels below the prescribed range, while another with chronic kidney disease was given Oxycodone similarly. A third resident with a fracture had unclear orders for Acetaminophen and Hydrocodone-Acetaminophen, resulting in inconsistent administration. Additionally, a resident with a cholecystectomy tube lacked an individualized pain management plan despite severe pain.
The facility failed to accurately account for controlled medications for three residents. Doses of Oxycodone for two residents were signed out but not recorded on the MAR. Additionally, for a resident with PTSD and anxiety, both standing and as-needed orders for Lorazepam were recorded on the same controlled substance record, leading to inaccuracies. These issues were confirmed by the NHA and an LPN.
The facility failed to serve meals that are palatable, attractive, and at a safe and appetizing temperature. Several residents reported dissatisfaction with the temperature and taste of the food, with one resident relying on sandwiches due to the low quality of meals. A test tray revealed that hot meal items were served below the recommended safe temperature range, and the food was described as lukewarm and not palatable. The registered dietitian confirmed the expectation for food to be served at safe and appetizing temperatures, which was not met.
The facility failed to provide meals that met residents' dietary preferences and restrictions, leading to dissatisfaction. A resident requiring a low-sodium diet received high-sodium meals, while another often received meals that did not match her selections. The facility also lacked a system to manage menu substitutions, resulting in unavailable planned alternates.
A facility failed to ensure accurate MDS Assessments for a resident, incorrectly documenting that the resident did not receive pain medication, despite records showing Acetaminophen was administered 5 times in 5 days. Additionally, the MDS inaccurately reflected the resident's orthopedic surgery history, omitting a left ankle fracture and subsequent ORIF surgery. An administrator confirmed these inaccuracies.
The facility failed to update the care plans for two residents after significant changes in their medical conditions. One resident had a suprapubic catheter placed, and the other experienced a fall resulting in an ankle fracture. The care plans were not revised to reflect these changes and necessary interventions, as confirmed by the Nursing Home Administrator.
A facility failed to accurately assess and manage a resident's bowel and bladder function. Despite a diary indicating frequent urinary incontinence, the admission assessment incorrectly noted the resident as continent. The MDS assessment later confirmed frequent incontinence. Interviews with the DON and Administrator acknowledged the error and the need for a management program.
A facility failed to provide person-centered care for a resident requiring hemodialysis. The resident's clinical records lacked documented physician's orders for dialysis treatment, and the care plan did not specify dialysis days, emergency care procedures, necessary supplies, or transportation plans. This deficiency was confirmed by the Nursing Home Administrator.
Unsanitary food storage and handling practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food in the food and nutrition services department, increasing the risk of food-borne illness. During the initial kitchen tour with a cook, the surveyor observed the cook in the food preparation area with a thick beard and no beard restraint. The surveyor also observed a pair of snow boots placed directly on top of an opened box of grease pan liners on a bottom shelf in the food preparation area, three shelves in the reach-in refrigerator next to the tray line that were heavily rusted, and six cases of frozen buns placed directly on the floor in the walk-in freezer. In the walk-in refrigerator, the surveyor found one container of honey thickened cranberry juice, one container of nectar thickened cranberry juice, and one container of nectar thickened orange juice that were not dated when opened, despite manufacturer directions to use within 10 days after opening. The surveyor also observed nine thawed 4-ounce containers of Mighty Shakes that did not have a thaw date, despite manufacturer directions to use within 14 days after thawing. A dietary aide confirmed the items were not dated, and the consultant dietitian confirmed the dietary department was to be maintained in a sanitary manner and that foods should be dated and stored to prevent potential contamination of food and food-borne illness.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for assistance with activities of daily living received showers as planned to maintain acceptable standards of personal hygiene. Based on clinical record review, observations, and resident and staff interviews, three of 26 sampled residents were affected: Residents 5, 119, and 11. Their task reports showed showers were scheduled twice weekly, but documentation did not show that the planned showers were provided. Resident 5 was admitted with diagnoses including a left femur fracture, a cervical vertebra fracture, and dementia, and an admission MDS indicated substantial/maximal assistance was needed for showering/bathing with severe cognitive impairment. The resident’s task report scheduled showers twice weekly, but the Documentation Survey Report showed no showers after admission and only bed baths. There was no documented evidence of shower refusal, preference for bed baths, or that the planned showers were provided. Resident 119 was admitted with venous insufficiency and pulmonary hypertension, and the admission MDS indicated moderate assistance was needed for showering/bathing. The resident was cognitively intact and told the surveyor that staff had not provided or offered a shower since admission, that he preferred showers over bed baths, and that his hair had not been washed since admission; observation showed oily, unkempt hair. Resident 11 was admitted with congestive heart failure and end stage renal disease, and the admission MDS indicated moderate assistance was needed for showering/bathing. The resident stated he had only received one shower since admission and described repeated delays when asking for a shower; observation showed greasy, disheveled hair and beard. His records showed showers were scheduled twice weekly, but he received no showers in December 2025 and none in January 2026, with only two sink baths documented in December and one shower refusal noted on one date. The NHA acknowledged residents should have been provided showers as scheduled but could not explain why showers were not consistently provided.
Medication, positioning, and wound care failures
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for Resident 5 by administering Midodrine hydrochloride outside of the physician-ordered hold parameters. The resident had diagnoses including orthostatic hypotension, atrial fibrillation, and supraventricular tachycardia. A physician ordered Midodrine 10 mg by mouth three times daily for 14 days, with instructions to hold the medication for systolic blood pressure greater than 120 mmHg. Review of the MAR showed the medication was given six times when the documented systolic blood pressure was above the ordered limit, including readings of 136/74, 125/64, 127/70, 130/74, and 124/56 on two administrations. The facility also failed to ensure consistent implementation of a physician-ordered therapeutic positioning device for Resident 106. The resident had diagnoses including chronic pain syndrome, lumbar intervertebral disc degeneration, and muscle weakness. A physician ordered the resident to be positioned out of bed in a Broda chair with a blue comfy cushion and an additional gel cushion for pressure reduction. During observation, the resident was seated in the Broda chair without the ordered blue comfy cushion in place, and a family member stated the cushion had not been present for at least one week. An LPN confirmed the order existed and acknowledged the cushion was not present at the time of observation. The facility further failed to provide appropriate wound care, treatment, and monitoring for Resident 9. The resident had diagnoses including diabetes and end-stage renal disease and was cognitively intact with a BIMS score of 14. A progress note documented a small wound on the right lateral foot and noted nursing staff were notified, but the record contained no additional documentation of assessment, treatment, or monitoring. The resident reported the wound had been bothering her and stated no one had looked at it since the initial bandage was applied. An RN observed the wound on the right foot and described it as oval, with a reddish-pink center and dry, flaky surrounding skin, and both the RN and DON were unable to provide documented evidence of care or treatment for the wound.
Infection Control and Surveillance Deficiencies
Penalty
Summary
The facility failed to consistently implement infection prevention and control practices and failed to ensure that reusable medical equipment intended for oral use was stored in a manner that prevented contamination for one resident. Resident 16 was admitted with cancer of the throat and a tracheostomy and was cognitively intact. During observations, a Yankauer suction device used by the resident for oral suctioning was seen in direct contact with the floor in the resident's room on two occasions, and no storage method was observed that would prevent the device from contacting the floor. The resident stated there was no designated place to store the device when finished and that it sometimes fell to the floor, yet he continued to use it even after it had contacted the floor. The facility also failed to evaluate infection surveillance data to determine potential contributing factors and identify the need for corrective actions. Review of infection control logs for October, November, and December 2025 showed documented urinary tract infections, and about 50 percent were caused by E. coli or Proteus mirabilis. The Assistant DON/Infection Control Preventionist stated the facility could not provide evidence that it evaluated or analyzed the infection data for trends or contributing factors, including staff hand hygiene, glove use between residents, timely incontinence care, perineal care, or toileting practices for independent residents. The facility also could not provide evidence that it evaluated possible causes specific to the E. coli and Proteus mirabilis infections.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and staffing records showed repeated shortages during the review period. From January 7, 2026, through January 13, 2026, the facility did not meet the state minimum requirement for nurse aides on 14 of 21 shifts reviewed, did not meet the minimum requirement for LPNs on 2 of 21 shifts, and did not meet the state minimum requirement for total direct care nursing hours on 2 of 7 days reviewed. Resident 104, who had diagnoses including heart failure and was cognitively intact with a BIMS score of 15, had an order for tramadol 50 mg every 12 hours as needed for severe pain with instructions to try non-pharmacological interventions first. During interview, the resident reported waiting one to two hours for PRN pain medication after notifying staff, and said this had happened repeatedly over the prior month. Resident 76, who had chronic heart failure and was cognitively intact with a BIMS score of 14, had an order for tramadol 50 mg every six hours as needed for severe pain with non-pharmacological interventions required first. The resident reported waiting between ten minutes and three hours for PRN pain medication and stated she had waited over one hour on four occasions in the prior 30 days. Resident 53, who had chronic respiratory failure and bilateral above-knee amputations and was cognitively intact with a BIMS score of 15, had care planned dependence on staff for toileting and two-person transfers. The resident reported multiple episodes of waiting over one hour for pain interventions and frequent delays in being assisted out of bed in the morning. Observations on two mornings showed the resident still in bed after breakfast, and staff confirmed the resident had not yet been assisted out of bed and that preferred timing had not been discussed. Staff also stated they prioritized residents with appointments because of assignment size. Resident 87, who had congestive heart failure and diabetes and was cognitively intact with a BIMS score of 15, was incontinent of bladder and bowel and dependent on staff for toileting and hygiene. The resident reported that call bell responses often took longer than 15 minutes, and during observation the call bell had been activated since 1:20 PM for a brief change. Staff did not respond until 2:10 PM, a wait of 50 minutes. Resident 5, with fractures of the left femur and sixth cervical vertebra and severe cognitive impairment, was scheduled for showers twice weekly but received no showers after admission and only bed baths. Resident 119, who had venous insufficiency and pulmonary hypertension and was cognitively intact with a BIMS score of 14, also had scheduled showers twice weekly but reported none had been provided since admission; observation noted oily, unkempt hair. Resident 11, with neuromuscular dysfunction of the bladder and end stage renal disease, was moderately cognitively impaired with a BIMS score of 10 and reported only one shower since admission, greasy hair and beard, delayed call bell responses of 45 minutes to 1.5 hours, and a suprapubic catheter dressing that had not been changed for three days despite a daily dressing order. Resident 103, with a left tibia fracture and hypertension and a BIMS score of 9, reported frequent waits of over 30 minutes for call bell response, and a family member stated the facility was understaffed, especially on weekends and holidays, and described a recent episode where the resident was left on a bed pan for over thirty minutes.
Care Plan Did Not Address Ordered Cervical Collar Use
Penalty
Summary
Resident 5 was admitted with diagnoses including a left femur fracture, a fracture of the sixth cervical vertebrae, and dementia. A physician's order dated December 18, 2025, directed the resident to wear a Vista cervical collar at all times except during showering and to use a Sierra (peach) cervical collar during bathing. On January 11, 2026, the resident was observed wearing a Vista cervical collar. Review of the comprehensive care plan in effect at the time of survey identified an intervention for altered musculoskeletal status related to fracture, but it did not identify the ordered use of the Vista cervical collar, the alternate collar for showering, or staff responsibilities for monitoring, applying, or ensuring consistent use of the prescribed collars. The Nursing Home Administrator confirmed on January 13, 2026, that the facility failed to ensure Resident 5's comprehensive care plan was developed and implemented to fully address the resident's medical and treatment needs related to cervical spine stabilization. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing services.
Failure to Consistently Use Ordered Heel Protectors
Penalty
Summary
Failure to consistently implement planned measures to prevent the development or worsening of pressure ulcers was identified for one resident. The resident was admitted with dementia and, on the quarterly MDS dated October 7, 2025, was documented as severely cognitively impaired, dependent on staff for mobility and transfers, non-ambulatory, and at risk for pressure ulcers. The resident’s care plan, initially dated January 23, 2025, identified potential for pressure ulcer development related to immobility and included use of a pressure-reduction mattress, transfer out of bed to a Geri Lounger chair as tolerated, and bilateral heel protectors at all times. A physician order dated September 17, 2025, also directed that bilateral heel protectors be applied at all times. During observations on January 11, 2026, at 12:30 PM and 1:15 PM, the resident was seated in a Geri Lounger chair without the bilateral heel protectors in place. During another observation on January 12, 2026, at 2:00 PM, the resident was again seated in the Geri Lounger chair without the heel protectors in place. At that time, a nurse aide confirmed the heel protectors were not in place. The Nursing Home Administrator later confirmed that the facility did not consistently implement the planned intervention for heel protectors for this resident.
Failure to Reassess Dressing Care After Injury
Penalty
Summary
The facility did not demonstrate consistent reassessment and modification of care interventions for a resident with left hemiplegia and atrophy of the left limb after an injury risk was identified during routine care. The resident’s quarterly MDS showed dependence on staff for bed mobility and dressing, and the resident was not interviewable, with a BIMS score of 10 indicating moderate cognitive impairment. Clinical notes documented that the resident complained of left shoulder pain during morning care and while receiving assistance with dressing, and a nurse practitioner evaluated the resident and ordered diagnostic imaging. Facility investigative documentation later identified an acute fracture of the distal left humerus. A physician note stated the fracture was consistent with stress occurring during external rotation of the arm, a motion that can occur during upper-body dressing, especially in individuals with limited range of motion. During interview, a nurse aide described difficulty dressing the resident’s left side because of reduced range of motion and stiffness related to the resident’s medical conditions, and stated they were not aware of any changes to the dressing approach or specific safety guidance after the event. The nursing home administrator did not provide evidence that the facility completed a documented reassessment of the resident’s dressing needs or implemented modified interventions tailored to the resident’s limited mobility and vulnerability to injury after the fracture was identified.
Inaccurate Documentation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that resident medical records were accurate and complete for two residents involved in a resident-to-resident altercation. Resident 90 was admitted with diagnoses including anoxic brain damage and COPD, and Resident 102 was admitted with dementia. A nursing progress note for Resident 102 documented that while the resident was in the lounge and yelled for help, Resident 90 wheeled over and slapped Resident 102 in the face. The note also documented that the RN separated the residents, completed a nursing assessment, initiated neurological checks, provided emotional support, and notified the physician and the resident's emergency contact. A separate nursing progress note for Resident 90, completed by the same RN, documented that the RN observed the two residents in the lounge and then heard a slap, but did not document directly seeing Resident 90 strike Resident 102. During interview, the RN confirmed that this documentation in Resident 90's record was not accurate and stated that she had directly observed Resident 90 slap Resident 102. The RN further stated she was directed by the DON to change her documentation from seeing the slap to hearing a slap so the note would align with the facility's internal investigative process. The DON confirmed directing the RN to document that she heard a slap rather than saw Resident 90 slap Resident 102, and acknowledged that the description of the incident differed between the two residents' medical records.
Failure to Follow Physician Orders for Antihypertensive Medication Administration
Penalty
Summary
Nursing staff failed to administer a prescribed antihypertensive medication, Norvasc (Amlodipine Besylate), in accordance with physician orders and facility policy for a resident with multiple cardiac and respiratory diagnoses, including congestive heart failure, respiratory failure with hypoxia, atherosclerotic heart disease, and hypertension. The physician's order specified that the medication should be held if the resident's systolic blood pressure was less than 120 mm/Hg. Despite this, clinical record review showed that the medication was administered on at least 30 occasions when the resident's systolic blood pressure was below the ordered threshold. Facility policy required staff to verify medication allergies and obtain vital signs prior to medication administration, and state nursing standards mandate that licensed nurses provide care in accordance with professional standards and maintain accurate records. Documentation revealed that the medication was repeatedly given outside the prescribed parameters, and this was confirmed by the Nursing Home Administrator during an interview. The failure to follow physician orders and professional standards resulted in multiple medication administration errors for the resident.
Administration of Contraindicated Medications Despite Documented Allergies
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from significant medication errors. A review of clinical records, facility policy, pharmacy records, and interviews revealed that a resident with documented allergies and intolerances to several medications, including Ondansetron and Gabapentin, was administered these medications despite their allergy status. The resident's medical history included Type 2 Diabetes, congestive heart failure, and nausea and vomiting. The facility's policy required staff to verify medication allergies and obtain vital signs as applicable before administering medications. However, the resident received Ondansetron on ten occasions and Gabapentin daily for over two weeks, even though both were listed as allergies or intolerances in the resident's records. The resident reported being aware of her allergy to Ondansetron and stated that it caused her to vomit, which she had previously communicated to her physician. There was no documentation provided by the facility to show that the physician justified the use of these medications despite the allergy listings. Additionally, the consultant pharmacist's monthly reviews did not identify or recommend discontinuation of the contraindicated medications. The Nursing Home Administrator acknowledged that the medications were administered despite the documented allergies and that no physician justification could be provided.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse and harassment by another resident, despite documented evidence of prior sexually inappropriate behaviors. One resident, who was severely cognitively impaired and had a history of sexualized behaviors, including making sexual comments and gestures toward staff, was known to require two-person assistance for care and had been referred to psychiatric services. Despite these interventions, the resident continued to display inappropriate behaviors, including an incident where he attempted to inappropriately grab staff. Another resident, also severely cognitively impaired and lacking the capacity to consent to sexual contact, became the victim of sexual abuse during a scheduled activity, where the first resident was observed touching her breast and genital area. Staff intervened immediately, but the incident was not reported to the Department of Health, as facility leadership did not perceive intent on the part of the perpetrator and only increased supervision as a response. A subsequent incident occurred in the dining room, where the same resident touched the victim's buttocks, which was witnessed and documented by staff. Only after this second incident did the facility report the matter to the appropriate authorities and implement more stringent supervision and separation measures. The facility's documentation and interviews with leadership revealed a lack of sufficient safeguards to prevent recurring sexual harassment or abuse, and there was no evidence that the facility ensured the victim was free from such abuse, as required by policy and regulation.
Failure to Conduct Complete Investigation and Reporting of Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure a complete and accurate investigation into an alleged incident of sexual abuse involving a resident with severe cognitive impairment. According to the facility's abuse policy, all reports of abuse must be promptly reported to appropriate agencies and thoroughly investigated. However, after an activities aide reported witnessing one resident grab another resident's breast and genital area during an activity, the only written statement obtained was from the reporting staff member. No additional written statements or interviews from other staff or alert and oriented residents present at the time were included in the investigation file. The Director of Nursing (DON) concluded that the incident was not reportable due to both residents being incapable and the absence of injury, despite an eyewitness account describing inappropriate touching. The facility did not document any efforts to interview other potential witnesses or follow up on the eyewitness account, nor did it report the incident to the Department of Health as required by policy and federal regulations. Interviews with the DON and Nursing Home Administrator confirmed that they did not believe the incident was reportable and were unable to provide evidence that the investigation was complete or compliant with facility policy and regulatory requirements. The resident involved had a diagnosis of dementia and was assessed as severely cognitively impaired at the time of the incident.
Failure to Prevent Recurrence of Resident-to-Resident Sexual Abuse Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to maintain compliance with regulations requiring the protection of residents from sexual abuse. Despite a known history of maladaptive behaviors, including inappropriate sexual comments, touching staff inappropriately, wandering into female residents' rooms, and grabbing residents' wheelchairs, one resident was not adequately monitored or included in ongoing audits intended to prevent abuse. On August 27, 2025, this resident was witnessed by staff sexually abusing another resident by touching her genital area over her clothing without consent. Clinical record reviews confirmed the perpetrator's behavioral history, but there was no evidence that this risk was addressed in the facility's quality assurance or performance improvement activities. The Quality Assurance and Performance Improvement (QAPI) committee did not identify or address the underlying causes of the original deficiency, as their plan focused only on the previously identified incident and did not evaluate or implement targeted prevention strategies for residents with known behavioral risks. Internal audits conducted after the initial survey did not include the resident with a history of maladaptive behaviors, nor did they monitor the effectiveness of corrective actions beyond the initial audits. As a result, the facility's failure to identify and address these risk factors contributed to the recurrence of resident-to-resident sexual abuse.
Failure to Provide Written Notice Prior to Facility-Initiated Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, to residents and/or their representatives prior to facility-initiated room changes for three of eight residents reviewed. Clinical record reviews showed that residents were moved from their original rooms to different wings within the facility without any documented evidence that written notification or explanation was given in advance. This included one resident who was cognitively intact and another who was moderately cognitively impaired, as indicated by a BIMS score of 12. Both residents and their representatives were not informed in writing about the reason for the move, nor were they given the opportunity to refuse the room change or to be involved in the process as required by federal regulations. Interviews with the affected residents revealed that they were not told why their rooms were being changed and were not made aware of their right to refuse the move. One resident expressed frustration at being moved after over a year in the same room and stated that she would have refused the change if she had been informed of her rights. The Nursing Home Administrator was unable to provide any documentation showing that written explanations were given to the residents or their representatives prior to the room changes.
Significant Medication Errors Due to Administration and Transcription Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first case, a resident with a history of Type 2 diabetes and a recent upper arm fracture, who was cognitively intact, was mistakenly given Hydralazine 75 mg and Clonidine 0.2 mg, both antihypertensive medications, instead of her prescribed pain medication. This error occurred when the resident approached the nurse during medication preparation for another resident, leading the nurse to inadvertently place the wrong medications in the resident's cup. The resident subsequently experienced hypotension, with a blood pressure reading of 80/52, but did not report symptoms such as dizziness or chest pain at the time of assessment. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, depression, and a history of upper arm fracture was affected by a medication transcription error. Following a provider's recommendation for a gradual dose reduction of Risperidone from 1 mg to 0.75 mg at bedtime, the nurse entered the new order for 0.75 mg but failed to discontinue the existing 1 mg order in the electronic system. As a result, the resident received a combined nightly dose of 1.75 mg of Risperidone for nearly two weeks before the error was discovered. No adverse effects were documented during this period. Both incidents were confirmed by the Nursing Home Administrator and were determined to be the result of failures to follow professional standards of practice, including the Five Rights of Medication Administration and proper transcription of physician orders. These deficiencies were identified through clinical record review, medication error reports, and staff interviews.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed care and unmet resident needs. Multiple residents reported waiting 30 minutes or longer for assistance, with some instances of waiting up to two hours, particularly during weekend shifts. Residents with significant medical needs, such as those with multiple sclerosis, dysphagia, cancer with a laryngectomy stoma, PEG tube, cerebral infarction, peripheral vascular disease, depression, and Parkinson's disease, experienced delays in care, including assistance with turning, repositioning, and toileting. One resident reported having to attempt unsafe self-transfers due to long wait times, and another reported holding her bowels as long as possible because of the delays. Observations and interviews confirmed that call bells were not answered in a timely manner, and staff acknowledged being unable to respond promptly due to insufficient staffing. One nurse aide stated that only two staff were assigned to a hallway where many residents required two-person assistance, making it difficult to meet residents' needs. Documentation showed that a resident received fewer showers than desired, with staff citing lack of staffing as the reason for substituting bed baths for showers. Group interviews with residents further corroborated the ongoing issues with delayed responses and inadequate care provision. A review of nurse staffing data revealed that the facility did not meet state minimum requirements for nurse aide and nurse staff direct care hours on at least one shift. The Nursing Home Administrator confirmed the failure to meet these requirements and acknowledged the facility's responsibility to provide sufficient nursing staff. The administrator was unable to explain the ongoing reports of untimely staff responses or the specific observed delay in responding to a resident's call bell.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain residents' rights to privacy and confidentiality in two separate instances. For one resident with acute respiratory failure and a recent COVID-19 diagnosis, a sign was posted outside the resident's room that specifically identified the resident as having SARS-CoV-2 (COVID-19) or symptoms with positive testing. This sign was visible to anyone passing by, thereby compromising the resident's right to privacy regarding their health status. The Nursing Home Administrator later confirmed that the sign had been redacted to remove identifying information, but at the time of observation, the resident's confidential health information was exposed. In a separate incident, another resident with morbid obesity and major depressive disorder reported not receiving her incoming mail, specifically her monthly social security statements, unopened. The resident stated she had repeatedly asked the business office manager about this issue and only received a copy, not the original statement. The business office manager admitted to opening the resident's social security statements to assist with account balancing and tax purposes, despite the facility not being the resident's representative payee. The Nursing Home Administrator confirmed that residents have the right to receive their mail unopened and was unable to provide documentation that this right was upheld for the resident.
Inaccurate MDS Assessments for Discharge Status and Dialysis
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. For one resident, the discharge return-not-anticipated MDS assessment inaccurately indicated that the resident was discharged to a short-term general hospital, when clinical documentation and staff interview confirmed the resident was actually discharged to another long-term care facility. This discrepancy was verified through a review of the progress note and confirmed by the Nursing Home Administrator. For another resident with a diagnosis of stage 4 chronic kidney disease, the admission MDS assessment incorrectly documented that the resident was receiving dialysis both prior to and during their stay at the facility. A review of the clinical record found no evidence of dialysis orders or treatments, and the DON confirmed that the resident had not received dialysis at the hospital prior to admission or while at the facility. These inaccuracies in the MDS assessments were identified through clinical record review and staff interviews.
Failure to Follow Physician Orders for Wound Care and Incomplete Documentation
Penalty
Summary
The facility failed to provide wound care services in accordance with physician orders and professional standards of practice for one resident. The resident, who was admitted with diagnoses including pneumonia and venous insufficiency, had a physician's order for daily wound care to the left calf, specifying the use of oil emulsion dressing, ABD, and Kling, with the dressing to be checked each shift and replaced if missing. Documentation in the Treatment Administration Record showed that wound care was only recorded as completed on select days, with no documentation for at least two days when care was required. Facility policy required that all dressing changes be marked with the date, time, and staff initials, and that wound care be documented at the time of completion. A family member reported concerns after observing that the resident's wound dressing was not changed as ordered, with the dressing dated several days prior to their visit. Staff witness statements confirmed that wound care was not consistently performed as documented, with one LPN acknowledging uncertainty about whether the treatment was completed and another confirming that documentation was signed off without the care being provided. The Nursing Home Administrator confirmed that staff failed to consistently perform and document wound care in accordance with physician orders and facility policy.
Failure to Maintain Emergency Dialysis Supplies at Bedside
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency dialysis supplies for a resident receiving hemodialysis. According to the care plan for the resident, who had chronic kidney disease and acute kidney failure and received hemodialysis via a right chest perma-Cath, an emergency kit containing pressure dressing, tape, and a clamp was required to be at the bedside on the wall. This intervention was intended to provide immediate access to supplies in the event of complications such as hemorrhage or catheter dislodgement. However, during an observation, surveyors found that the emergency kit was not present or accessible in the resident's room, and there were no visible emergency clamps or pressure dressings as directed by the care plan. Staff interviews confirmed that the emergency kit should have been present and accessible, in accordance with both the resident's care plan and facility policy. The Nursing Home Administrator also verified that facility policy required emergency kits to be maintained in the rooms of residents receiving hemodialysis. The absence of these critical emergency supplies constituted a failure to follow the individualized care plan and facility policy for a resident with significant renal conditions requiring hemodialysis.
Failure to Ensure Proper Installation of Bed Rails
Penalty
Summary
The facility failed to ensure the correct installation of bed rails for one resident. The resident, who had diagnoses including morbid obesity and bradycardia, was assessed as cognitively intact and had a care plan that included the use of a bariatric bed with bilateral bed rails to assist with mobility. The interdisciplinary care team recommended the use of bed rails, and informed consent was obtained from the resident. However, during an interview and observation, the resident reported that the bed rails were loose and shifted when used for support. Direct observation confirmed that the bed rails were visibly unstable and not properly affixed to the bed frame. Further investigation revealed that the bed rails were not secured to the bed frame and moved when the resident attempted to use them. The facility was unable to provide documentation that the bed rails were compatible with the bariatric bed frame or that they had been installed according to the manufacturer's specifications. The facility's policy required adherence to manufacturer instructions for bed rail installation, but this was not followed in this instance.
Failure to Timely Administer Prescribed Medication After Hospital Discharge
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed medication for a resident following discharge from a hospital. The resident, who had a diagnosis including cerebral infarction, was recommended by the hospital to begin gabapentin 100 mg three times daily for pain and discomfort. Despite this recommendation being included in the hospital discharge summary, the medication was not entered into the resident's clinical record or administered until six days after the resident's return to the facility. During this period, the resident's medication administration record showed no doses of gabapentin were given, and the physician's order for the medication was not entered until several days after the discharge. The resident's representative expressed concern about the lack of pain management, recalling the hospital's prescription for gabapentin. The Nursing Home Administrator acknowledged that the facility did not ensure the attending physician received and acted upon the hospital's discharge recommendation, resulting in a delay in the resident receiving the prescribed medication.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate individual food preferences for residents, as evidenced by multiple observations and interviews. One resident consistently received meals containing eggs and Brussels sprouts, despite documented dislikes for these items on his meal ticket, and was not offered alternative options. During a meal observation, this resident was served Brussels sprouts, and he expressed ongoing dissatisfaction with the lack of alternatives. Another resident reported repeatedly receiving broccoli on his meal tray, even though his meal ticket indicated a dislike for broccoli, and the dietary manager confirmed that no alternate vegetable was provided when broccoli was on the menu. Additionally, during a group interview, a resident stated that only one vegetable option was available per meal, and no alternatives were offered if a resident disliked the provided vegetable. The nursing home administrator was unable to provide documentation showing efforts to accommodate these food preferences. These findings demonstrate that the facility did not make sufficient efforts to honor resident food preferences, as required, to enhance meal satisfaction.
Failure to Provide Prescribed Adaptive Dining Equipment for Resident with Dysphagia
Penalty
Summary
A resident with multiple sclerosis and dysphagia was admitted to the facility and had a care plan that included aspiration precautions. Following a documented choking episode, the care plan was revised to require staff-assisted feeding using a small maroon dysphagia spoon at all meals, as recommended by the speech-language pathologist. A physician's order also specified that the resident was to receive meals with the maroon spoon due to dysphagia and aspiration risk, along with a prescribed puree diet and honey-thick liquids. During a breakfast observation, the resident was served and fed with a standard silver teaspoon instead of the prescribed maroon spoon. The nurse aide feeding the resident confirmed that the maroon spoon was not present or used. The Nursing Home Administrator acknowledged that the facility failed to provide and use the prescribed adaptive equipment in accordance with the physician's orders.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
During an initial kitchen tour with the dietary manager, surveyors observed several unsanitary food storage and service practices. Specifically, two opened bottles of nectar-thick juice were found in the walk-in refrigerator without any date of opening, despite manufacturer instructions to use the product within 10 days after opening. Additionally, a container of nectar-thick orange juice covered with plastic wrap and a pitcher of nectar-thick milk were also present in the refrigerator without any date markings. These items were not stored in accordance with professional standards for food safety and handling. Further observation revealed that the dish dispenser in the tray line area lacked a cover, leaving clean dishes exposed to potential contaminants. The dietary manager confirmed during the tour that the department was expected to maintain sanitary conditions and that all foods should be properly dated and stored to prevent contamination and foodborne illness. These findings indicate a failure to follow established food safety protocols in the dietary services department.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. Specifically, the regulation requires a minimum of 1 nurse aide per 12 residents during the day and evening shifts, and 1 nurse aide per 20 residents overnight. A review of the facility's staffing records revealed that on 12 out of 21 shifts reviewed, the facility did not provide the minimum required number of nurse aides. For instance, on February 4, 2025, the day shift had 6.75 nurse aides instead of the required 8.25 for a census of 99 residents, and the evening shift had 7.53 nurse aides instead of the required 8.42 for a census of 101 residents. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no excess higher-level staff available to compensate for the staffing shortfall. This failure to comply with staffing regulations was documented across multiple shifts, indicating a pattern of non-compliance with the mandated staffing levels.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum number of nurse aides per residents on 17 out of 21 shifts reviewed. The required ratios are 1 nurse aide per 10 residents during the day, 1 per 11 residents in the evening, and 1 per 15 residents overnight. The staffing records from February 4 to February 10, 2025, show consistent understaffing across various shifts, with the number of nurse aides falling short of the required numbers based on the facility's census. The deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged the failure to meet the staffing requirements on the specified dates. The report does not mention any additional higher-level staff being available to compensate for the deficiency, indicating a lack of adequate staffing to meet regulatory requirements. No specific residents or their conditions are mentioned in the report, and the focus remains on the facility's inability to provide the mandated nurse aide coverage.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on three occasions during the night shift. Specifically, on February 6, 2025, the facility had 3.09 LPNs on the day shift instead of the required 4.08 for a census of 102 residents. On February 8 and 9, 2025, the facility had 4.13 LPNs on the day shift, falling short of the required 4.16 for a census of 104 residents. No additional higher-level staff were available to compensate for this deficiency. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
1. Facility cannot retroactively correct past LPN ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 2.87 hours of direct resident care per resident in a 24-hour period, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2023. On February 5, 2025, the facility provided only 2.74 hours of direct care nursing per resident, and on February 9, 2025, it provided 2.68 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 12, 2025, who acknowledged the facility's failure to consistently provide the minimum required nursing care hours to each resident daily.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA nursing hours are met. 5. Audits will be submitted to QAPI for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct resident care per resident per day, as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. A review of the facility's staffing levels revealed that on several dates in February 2025, the facility provided less than the required nursing care hours. Specifically, on February 4, 5, 6, 7, 8, 9, and 10, the facility's direct care nursing hours per resident were below the mandated 3.2 hours, with the lowest being 2.68 hours on February 9, 2025. An interview with the Nursing Home Administrator on February 12, 2025, confirmed the facility's failure to consistently provide the minimum required general nursing care hours to each resident daily. This deficiency was identified through a review of nurse staffing records and resident census data, which highlighted the facility's inability to meet the regulatory requirements for nursing care hours on the specified dates.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their designated representative were involved in the development and implementation of the resident's person-centered plan of care. According to the facility's policy, residents and their representatives should be encouraged to participate in care planning by being given sufficient notice of care plan meetings. However, for one resident, identified as Resident 3, there was no documented evidence that either the resident or their representative were invited to or participated in the November 2024 quarterly interdisciplinary care plan meeting. Resident 3, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, was noted to be severely cognitively impaired with a BIMS score of 06. Despite the resident's cognitive impairment and the involvement of a family member as the resident's representative, the facility did not document any invitation or participation of the resident or their representative in the care planning process. This was confirmed by the Director of Nursing during an interview, acknowledging the facility's responsibility to involve residents and their representatives in care plan development.
Plan Of Correction
1. Care conference for R3 was scheduled for 1/7/25 and RR is attending with resident. 2. Facility completed 30 day lookback to ensure each applicable MDS has a care conference scheduled with RR or resident invite. 3. Facility implemented new process which includes tracking form to ensure each applicable scheduled MDS has a care plan scheduled with RR and/or resident invite and completion of care plan. NHA educated RNAC and LNAC on this new process. 4. NHA/designee will audit scheduled MDS' weekly for 4 weeks and then monthly for 2 months to ensure the applicable MDS' have a care plan scheduled with RR and resident invite sent and care plan completed. 5. Audits will be submitted to QAPI for review.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on several occasions, as evidenced by a review of staffing records and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides required during the day shift on December 21, 24, 25, and 26, 2024, with the number of nurse aides falling short of the required 8.5 for a census of 102 residents. Additionally, on December 24, 2024, the evening shift was understaffed with only 5.09 nurse aides instead of the required 8.42 for a census of 101 residents. Furthermore, the night shift on December 24 and 25, 2024, also failed to meet the minimum staffing requirements, with fewer nurse aides than the required 5.1 and 5.0 for the respective census counts. The Director of Nursing confirmed during an interview that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report indicates that no additional higher-level staff were available to compensate for the staffing deficiencies on these occasions. This lack of adequate staffing could potentially impact the quality of care provided to the residents, although the report does not specify any direct consequences or risks that occurred as a result of the staffing shortfalls.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.
Staffing Deficiencies in Nurse Aide Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum number of nurse aides required for the day, evening, and night shifts on several dates in December 2024. For the day shift, the facility was consistently short of the required 10.20 nurse aides for a census of 102 residents, with staffing levels ranging from 7.28 to 9.66 nurse aides. Similarly, the evening shift was understaffed on several occasions, with the number of nurse aides falling short of the required 9.27 to 9.36 for a census of 102 to 103 residents. The night shift also experienced deficiencies, with staffing levels below the required 6.67 to 6.87 nurse aides for a census of 100 to 103 residents. The Director of Nursing confirmed that the facility did not meet the required nurse aide to resident ratios on the specified dates. Additionally, there were no higher-level staff available to compensate for the staffing deficiencies. This lack of adequate staffing was identified during a review of the facility's weekly staffing records and was corroborated by staff interviews, highlighting a systemic issue in maintaining the mandated staffing levels necessary for resident care.
Plan Of Correction
1. Facility cannot retroactively correct past nursing ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit ratios weekly for 4 weeks and then monthly for 2 months to ensure CNA ratios are met. 5. Audits will be submitted to QAPI for review.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios across multiple shifts, as evidenced by a review of staffing records. Specifically, the facility did not provide the minimum LPN staffing levels on 14 out of 21 shifts reviewed. On the day shift, the facility consistently fell short of the required 1 LPN per 25 residents, with staffing levels ranging from 2.91 to 4.06 LPNs for a census of 102 residents, where 4.08 LPNs were required. Similarly, the evening shift did not meet the required 1 LPN per 30 residents, with staffing levels between 2.06 and 3.22 LPNs for a census of 101 to 102 residents, where 3.37 to 3.40 LPNs were needed. The night shift also failed to meet the required 1 LPN per 40 residents, with staffing levels ranging from 1.38 to 2.19 LPNs for a census of 100 to 103 residents, where 2.50 to 2.58 LPNs were necessary. The Director of Nursing confirmed that no additional higher-level staff were available to compensate for these deficiencies. This lack of adequate staffing was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to meet the required LPN to resident ratios on the specified dates.
Plan Of Correction
1. Facility cannot retroactively correct past LPN ratios. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilize agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary ratios. Nursing scheduler was educated on this new process. 4. NHA will audit LPN ratios weekly for 4 weeks and then monthly for 2 months to ensure LPN ratios are met. 5. Audits will be submitted to QAPI for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 2.87 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's staffing levels, which revealed that on three specific dates, the facility provided only 2.56 and 2.55 hours of direct care nursing per resident. These dates were December 21, 24, and 25, 2024. An interview with the Director of Nursing confirmed the facility's failure to consistently meet the required nursing care hours on these days.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident per day. This deficiency was identified through a review of the facility's staffing levels and confirmed by an interview with the Director of Nursing. On six out of the seven days reviewed, the facility's staffing levels were below the required minimum, with direct care nursing hours per resident ranging from 2.55 to 3.01 hours. Specific dates where the facility fell short include December 20, 21, 23, 24, 25, and 26, 2024. The Director of Nursing confirmed the inconsistency in meeting the required nursing care hours during an interview conducted on January 2, 2025.
Plan Of Correction
1. Facility cannot retroactively correct past nursing hours. 2. Facility continues to recruit for open nursing positions through online systems and fliers and utilizing agency staff. 3. Facility implemented a system of daily staffing meetings to ensure efforts were met to meet the necessary nursing hours. Nursing scheduler was educated on this new process. 4. NHA will audit nursing hours weekly for 4 weeks and then monthly for 2 months to ensure CNA Nursing hours are met. 5. Audits will be submitted to QAPI for review.
Failure to Timely Assess and Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality for Resident CR1, who was admitted with diagnoses including COVID-19, cognitive communication deficit, and acute kidney failure. Upon admission, the resident was placed in the facility's designated COVID-19 isolation hallway. Initial assessments noted stable vital signs and diminished lung sounds without complaints of shortness of breath. However, the resident's condition deteriorated, and the facility staff were unable to obtain an oxygen saturation level despite multiple attempts. The resident exhibited difficulty breathing and was using accessory muscles to assist with breathing. The facility's certified registered nurse practitioner (CRNP) was contacted, and new orders for oxygen and respiratory treatment were given. However, there was no documented evidence that the CRNP or any other medical professional examined or evaluated the resident after the change in condition. The resident's symptoms of shortness of breath began hours before the nebulizer treatment was administered, and there was no follow-up assessment or documentation of the resident's condition after the treatment. This lack of timely assessment and documentation failed to ensure the resident's immediate medical needs were met. The situation escalated when the resident's daughter reported that the resident had stopped breathing. Despite immediate CPR efforts by the facility staff and the arrival of EMS, the resident expired. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the resident was not timely assessed after the change in condition. It was also noted that the CRNP and the Physician could not see the resident in the same 24-hour period due to payment restrictions, which contributed to the delay in treatment.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to demonstrate the implementation of an ongoing Quality Assurance and Performance Improvement (QAPI) program, specifically in investigating and analyzing the root cause of adverse events. This deficiency was identified through the case of a resident who sustained a significant injury. The resident, who was cognitively intact, experienced a fracture during a linen change after wound care treatment. Despite the resident's ability to provide a coherent account of the incident, the facility did not obtain a witness statement from her, relying solely on the statements of the staff involved. The incident involved a nurse and a wound care nurse aide who were changing the resident's bed linens. During the process, the resident's knee was reportedly pulled, resulting in a pop sound and subsequent pain. The facility's documentation indicated that proper technique was used, but the resident's account contradicted this, stating that the nurse pulled her knee without supporting her shoulder or hip. The facility did not thoroughly investigate the incident, as evidenced by the lack of a resident statement and the inconsistency between the staff's and the resident's accounts. The facility's failure to conduct a comprehensive investigation and obtain all relevant witness statements hindered their ability to accurately identify the root cause of the incident. This lack of thorough investigation and documentation meant that the facility could not demonstrate an effective QAPI program. Consequently, there was no evidence of corrective actions or performance improvement activities being developed or implemented to prevent similar incidents in the future.
Untimely Response to Call Bells and Lack of Assistance in Activity Room
Penalty
Summary
The facility failed to provide timely responses to residents' requests for assistance, negatively impacting their quality of life. Resident 40, who is cognitively intact, reported that staff do not answer call bells promptly, especially during the night shift, with wait times often exceeding 45 minutes. Despite reporting this issue to the facility, no action was taken. Resident 26, also cognitively intact, experienced delays of several hours for call bell responses, resulting in sitting in their own feces for extended periods. This resident expressed feelings of neglect and concern about making staff upset by using the call bell. Resident 79, with moderate cognitive impairment, had a family member lodge a complaint about staff ignoring the call bell, leading to waits of up to two hours. This resident requires assistance to the bathroom and is left in urine and feces when staff do not respond. Resident 3, who is cognitively intact, reported waiting a couple of hours on weekends and 30 minutes to an hour during weekdays for assistance. Additionally, the survey team found that there was no functioning call bell in the activity room, leaving residents without a means to request help. The Nursing Home Administrator confirmed the lack of a call bell in the activity room and was unable to explain the untimely staff responses.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in resident areas on both the West and East Nursing Units. Observations on the West Nursing Unit revealed multiple deficiencies, including gouges and holes in the walls of resident rooms, bubbling paint, and chipped surfaces. Additionally, there were issues with cleanliness, such as a dinner tray from the previous evening left on a nightstand, dirty used gloves, food particles, and wrappers on the floor. Stains were observed on a resident's pillowcase, and urinals half-filled with urine were found on the floor. The bathroom door lock was broken, and there were spots on the privacy curtains. Other rooms had dirty urinals, dirt and debris on the floor, and chipped wood on doors. On the East Nursing Unit, a missing section of paint was observed beneath a wall-mounted hand sanitizer dispenser, and the protective edge of an over-the-bed table was removed, exposing the cork underneath. These observations were confirmed by the Nursing Home Administrator, who acknowledged that the facility is expected to be maintained daily to ensure a clean and sanitary environment for residents. The report highlights the facility's failure to uphold the residents' right to a safe, clean, comfortable, and homelike environment as required by regulations.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide supplemental oxygen administration as ordered for a resident diagnosed with shortness of breath and chronic respiratory failure with hypoxia. The resident was admitted with physician's orders for oxygen at 2 liters per minute per nasal cannula, with specific instructions for maintaining the oxygen equipment. However, observations revealed that the resident's oxygen was consistently set at incorrect levels, either at 5 liters per minute or 3 liters per minute, contrary to the physician's orders. Additionally, the humidification water canister was not replaced as needed, remaining empty and dated from May 4, 2024, despite the requirement for regular maintenance. Further observations indicated that the resident's oxygen tank was empty on multiple occasions, and the oxygen tubing was not dated, suggesting a lack of proper equipment management. Interviews with LPNs confirmed these discrepancies, acknowledging the failure to adhere to the physician's orders and maintain the oxygen equipment as required. The Nursing Home Administrator and Director of Nursing also confirmed the facility's failure to provide oxygen administration and care consistent with professional standards of practice.
Inadequate Adherence to Pain Management Protocols
Penalty
Summary
The facility failed to adhere to physician orders for pain management regimens for several residents, leading to inappropriate administration of pain medications. Resident 54, diagnosed with chronic pain disorder, rheumatoid arthritis, and progressive neuropathy, received Tramadol for pain levels lower than the prescribed range of 8-10 on multiple occasions in April and May 2024. Similarly, Resident 86, with chronic kidney disease and muscle weakness, was administered Oxycodone for pain levels below the prescribed range of 8-10 during the same period. Resident 17, who had a left ankle fracture and underwent surgery, had conflicting physician orders for pain management. The orders did not specify when to administer Acetaminophen versus Hydrocodone-Acetaminophen, leading to the administration of Hydrocodone-Acetaminophen for varying pain levels from 2 to 9. This lack of clarity in the physician orders was confirmed by the facility's administration. Additionally, Resident 190, who had a cholecystectomy tube, did not have an individualized pain management plan despite experiencing severe pain. The resident consistently reported pain levels of 8 or higher, yet the care plan did not address her pain management needs. This oversight was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Inaccurate Accounting of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications for three residents. For Resident 64, there were discrepancies in the administration of Oxycodone, a narcotic opioid pain medication, as doses were signed out but not recorded on the Medication Administration Record (MAR) on specific dates. Similarly, for Resident 52, doses of Oxycodone were signed out on multiple occasions, but the administration was not documented on the MAR. These inconsistencies were confirmed by the Nursing Home Administrator. For Resident 54, who had diagnoses including PTSD and anxiety, there was a failure to maintain separate controlled substance records for standing and as-needed orders of Lorazepam (Ativan). Both orders were recorded on the same controlled substance record, and the same blister pack was used, leading to an inaccurate record of medication administration. This issue was also confirmed by the Nursing Home Administrator and an LPN.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to serve meals that are palatable, attractive, and at a safe and appetizing temperature, as determined by observations, resident and staff interviews, and test tray results. Several residents expressed dissatisfaction with the temperature and taste of the food. Resident 40 mentioned that the food is often not hot enough, while Resident 45 and Resident 79 stated that the food could taste better and is never hot when served. Resident 3 reported that the food is not served hot and does not taste good, leading them to rely on sandwiches due to the low quality of the meals. An observation of Resident 40's lunch revealed that the cream of vegetable soup appeared unappetizing, with a white semi-translucent color and lumpy consistency. A test tray conducted on the B Hall Nursing Unit showed that the hot meal items were served at temperatures below the recommended safe range, with chicken noodle soup at 125 degrees Fahrenheit, chicken parmesan at 116 degrees Fahrenheit, penne pasta at 112 degrees Fahrenheit, and Italian vegetables at 115 degrees Fahrenheit. The food was described as lukewarm and not palatable, with the Italian vegetables being soggy and soft. An interview with the registered dietitian confirmed that the food was expected to be palatable, attractive, and served at safe and appetizing temperatures, which was not achieved in this instance.
Failure to Accommodate Dietary Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals that accommodated residents' dietary preferences and restrictions, leading to dissatisfaction among several residents. Specifically, the facility did not consistently provide food items as selected by residents, nor did it adequately accommodate low-sodium dietary needs. For instance, Resident 3, who required a low-sodium diet, repeatedly received high-sodium meals and was not informed when her selected meal options were unavailable. This resident also reported significant weight gain since admission due to the lack of healthier food options. Additionally, Resident 40 frequently received meals that did not match her selections, such as receiving a ham steak instead of a meatball sandwich. The facility's dietary services were further compromised by a lack of available menu items and substitutions. During a group meeting, several residents expressed that their food preferences were not honored, citing instances where planned alternates like cheesesteak and meatball sandwiches were unavailable due to missing ingredients. The dietary manager confirmed that substitutions were often necessary due to incomplete food orders and acknowledged the absence of a substitution list to track and ensure appropriate replacements. This lack of organization and communication contributed to the residents' dissatisfaction with their meals.
Inaccurate MDS Assessment for Pain Management and Orthopedic Surgery
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the quarterly MDS Assessment for a resident dated March 12, 2024, inaccurately indicated that the resident did not receive scheduled or as-needed pain medication in the last 5 days. However, a review of the resident's March 2024 Medication Administration Record showed that the resident received physician-prescribed Acetaminophen as needed for pain 5 times in the last 5 days. Additionally, the MDS Assessment inaccurately documented the resident's orthopedic surgery history. It indicated no repair fractures of the pelvis, hip, leg, knee, or ankle, despite a nurse's note from February 14, 2024, stating that the resident had a left ankle fracture following a fall. Another note from March 5, 2024, confirmed the resident was readmitted to the facility after undergoing open reduction and internal fixation (ORIF) surgery for a fracture dislocation of the left ankle on March 1, 2024. An interview with the administrator confirmed the inaccuracies in the MDS Assessment regarding pain medication and orthopedic surgery.
Failure to Update Care Plans Following Changes in Condition
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for two residents following significant changes in their medical conditions. Resident 77, who was admitted with diagnoses including malignant neoplasm of the prostate and obstructive and reflex uropathy, had an indwelling catheter care plan last revised on March 19, 2024. However, after a suprapubic catheter was placed on April 5, 2024, the facility did not update the care plan to reflect this change and the new interventions required for the suprapubic catheter. Similarly, Resident 17, admitted with COPD and diabetes mellitus, experienced a fall resulting in a left ankle fracture. After undergoing surgery for the fracture and being readmitted to the facility, the care plan, last revised on February 23, 2024, was not updated to address the potential for pain and new interventions related to the ankle fracture. Interviews with the Nursing Home Administrator confirmed the facility's failure to revise and update the care plans for both residents.
Failure to Accurately Assess and Address Incontinence
Penalty
Summary
The facility failed to accurately assess and address the bowel and bladder function of Resident 86, who was admitted with diagnoses including chronic kidney disease, unsteadiness on feet, and muscle weakness. A three-day bowel and bladder diary indicated frequent urinary incontinence, contradicting the admission assessment that noted the resident as continent. The Admission Minimum Data Set assessment later confirmed frequent incontinence of both bowel and bladder. Interviews with the Director of Nursing and the Nursing Home Administrator revealed that the initial assessment was incorrect, and a program to manage the resident's mixed incontinence should have been initiated.
Failure to Provide Person-Centered Dialysis Care
Penalty
Summary
The facility failed to provide person-centered care for a resident receiving hemodialysis services. The resident, who was admitted with stage 4 chronic kidney disease and dependence on renal dialysis, had no documented physician's orders for dialysis treatment. The clinical records lacked information on the schedule or frequency of the dialysis treatments, which is crucial for managing the resident's condition. Additionally, the resident's care plan did not include essential details such as the dialysis days, emergency care procedures, necessary supplies for the dialysis access site, and the transportation plan to and from dialysis treatments. This oversight was confirmed during an interview with the Nursing Home Administrator, highlighting a significant gap in the care planning process for the resident's dialysis needs.
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 197 citations issued within 25 miles in the last 12 months — including the 4 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 Tamaqua
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Luke's Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 7 | 0 |
| Manor At St Luke Village,the | 8.2 mi | ★★★★★ | 16 | 0 |
| Pavilion At St Luke Village, The | 8.4 mi | ★★★★★ | 8 | 0 |
| Mountain City Nursing & Rehabilitation Center | 9.5 mi | ★★★★★ | 1 | 0 |
| Mahoning Operating Llc | 10.5 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Greenwood Center For Nursing And Rehab.
100% money-back within 48 hours.
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.