Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harmon House Health & Rehab Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and anxiety had a PRN order for 0.5 mg lorazepam, and the MAR showed repeated administrations over several months. There was no documented evidence that non-pharmacological interventions were attempted before the medication was given, and the DON confirmed this during interview.
A facility failed to follow ordered treatments and medication orders for several residents. One resident’s wound care order for hydrocortisone to the peri-wound area was not documented as completed, a resident with diabetes had missing documentation for A1C-related accu checks, insulin doses were repeatedly held without physician orders or notification, a Zoloft dose increase agreed to by the physician was not transcribed, and Eliquis orders for a resident on dialysis were not entered into the MAR, resulting in the medication not being given as ordered.
Failure to follow medication parameters for three residents. A resident with diabetes had very high blood glucose readings, but the physician was not documented as being notified when the readings were above the ordered threshold. Another resident with cognitive impairment, HF, and HTN received midodrine despite SBP being above the hold parameter on multiple occasions. A third resident with HTN received metoprolol tartrate when SBP was below the ordered hold parameter on multiple occasions, and the DON confirmed the medication was given outside ordered limits.
A facility failed to keep residents’ drug regimens free from unnecessary drugs when antibiotics and a PPI were given outside ordered parameters. One resident received doxycycline for 11 days instead of 10, another continued pantoprazole 40 mg daily after a physician-approved reduction to 20 mg had not been processed, and a third resident received two antibiotic courses for longer than ordered. The DON confirmed the discrepancies.
Accurate MDS assessments were not completed for three residents. One resident with a colostomy was coded as continent of bowel, another resident with a daily wanderguard was not accurately coded for the wander/elopement alarm, and a third resident with hearing aids was coded as having adequate hearing with no hearing aids used despite evidence and resident report to the contrary.
A resident with moderate cognitive impairment and heart failure had a care plan that addressed fall risk and noted hearing aids should be within reach, but it did not include individualized interventions for impaired hearing or hearing aid use. The resident reported difficulty hearing and preferred to wear his hearing aids, yet staff found them stored in a bag or unavailable because they were charging; the DON confirmed no care plan was developed for the resident’s hearing-related needs and audiology later diagnosed mixed hearing loss.
A resident who was cognitively intact, incontinent, and at risk for pressure ulcers developed full-thickness moisture-associated skin damage to the sacrum and had a physician’s order for daily cleansing and Medi-honey application. Although treatment was documented on the TAR prior to discharge, the discharge instructions marked wound care as not applicable, and the drug disposition form did not show that Medi-honey was sent home. The resident was discharged home with home health after staff reviewed medications and instructions with family, but there was no documentation that wound care instructions or Medi-honey were provided, as confirmed by the NHA.
The facility failed to follow CDC-based COVID-19 infection control practices by not promptly testing symptomatic residents who had standing orders allowing COVID-19 testing as needed and by not ensuring proper PPE use in a COVID-19-positive room. One resident experienced fever, respiratory symptoms, and systemic complaints without being tested until later, when a rapid test was finally done and was positive. Another resident had several days of cough, congestion, malaise, and remaining in bed before a rapid COVID-19 test was ordered and found positive, despite active COVID-19 cases in the building. A third resident with cough, body aches, malaise, and wheezing was tested and found positive, and transmission-based precautions were ordered. During the outbreak, a laundry aide entered the shared COVID-19-positive room of two residents wearing only a surgical mask, despite posted droplet precautions and an isolation station with N95s, gowns, gloves, and eye protection, contrary to the facility’s stated requirement that all staff don full PPE when entering COVID-19-positive rooms.
A resident with an indwelling catheter, wound infection, MS, and a Stage 4 pressure ulcer required Enhanced Barrier Precautions per physician's orders. Although appropriate signage was present and the need for infection control was documented, there was no evidence that a comprehensive, individualized care plan addressing these precautions was developed, as confirmed by the DON.
A resident with impaired mobility and pain risk did not receive diclofenac sodium topical gel as ordered, as an LPN failed to use the dosing card to measure the prescribed amount, instead applying unmeasured amounts to the resident's knee. The DON confirmed the medication should have been measured to ensure the correct dose.
Staff failed to follow Enhanced Barrier Precautions and proper hand hygiene while providing high-contact care to a resident with an indwelling catheter, wound infection, and Stage 4 pressure ulcer. Two nurse aides wore only gloves, not gowns, during care activities such as wound dressing changes and incontinent care, and did not perform hand hygiene at appropriate times, contrary to facility policy and infection control guidelines.
A resident with quadriplegia and multiple sclerosis was injured during an improper transfer when a nurse aide attempted to use a mechanical lift without the required two-person assistance. The sling pad slipped, causing the resident to fall and sustain a head laceration requiring staples. The nurse aide was aware of the facility's policy but failed to follow it, resulting in the incident.
A resident with quadriplegia and multiple sclerosis was injured during a transfer using a Hoyer lift when only one nurse aide assisted, contrary to the facility's policy requiring a two-person assist. The sling pad slipped, causing the resident to hit his head and sustain a laceration requiring staples.
A facility failed to maintain the confidentiality of residents' medical information, resulting in the unauthorized disclosure of health information for two residents. Resident 6's information was mistakenly given to a family member of another resident, who then shared it with an outside physician. Additionally, Resident 7's information was erroneously provided to the same family member upon their return to the facility.
A resident with multiple sclerosis and quadriplegia required a condom catheter, which was not documented as being changed daily according to facility policy. The issue was identified when the resident's wife requested daily changes, revealing a lack of specific physician's orders and documentation on the MARs.
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization for seven residents. These residents, who had various medical conditions, were transferred to the hospital due to changes in their conditions, but there was no documented evidence of written notices being provided to their responsible parties. This deficiency was confirmed by the Nursing Home Administrator and violated resident rights and discharge policy regulations.
The facility failed to complete comprehensive admission and annual MDS assessments within the required timeframe for five residents. The assessments were completed between 17 to 21 days after admission, exceeding the 14-day requirement. This deficiency was confirmed through clinical records and staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframe for five residents, with each assessment being completed one day late. This non-compliance was confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. A resident did not receive required assessments every shift, another had insulin held incorrectly, a third received an antibiotic for too long, and a fourth was given blood pressure medication when it should have been held. These issues were confirmed by the DON.
The facility failed to document the administration of controlled medications for two residents. One resident, who was cognitively intact and frequently in pain, had oxycodone doses signed out without evidence of administration. Another resident, cognitively impaired and frequently anxious, had diazepam doses signed out with no documentation of administration. These discrepancies were confirmed by the DON.
A resident with decreased mobility was found with the call bell out of reach, contrary to her care plan and facility policy. Interviews with an LPN and the DON confirmed the call bell should have been accessible.
A resident, who was cognitively impaired and dependent on staff, refused their prescribed antidepressant medication on multiple occasions. The facility's policy required notifying the physician of such refusals, but there was no documented evidence that this was done. The DON confirmed the lack of notification.
The facility failed to accurately complete MDS assessments for two residents. One resident was incorrectly coded for PTSD instead of a traumatic brain injury, while another resident's anticoagulant medication was not coded despite being administered. These errors were confirmed by the RNAC and DON.
A facility failed to change a resident's midline catheter dressing when it became loose, as required by policy. The resident, who was receiving IV antibiotics for bacteremia, had a compromised dressing observed on multiple occasions. Staff interviews confirmed the dressing should have been changed but was not.
The facility failed to administer oxygen as prescribed for two residents. One resident with asthma and respiratory failure received oxygen at 4 liters per minute instead of the ordered 2 liters. Another resident on hospice care with pneumonitis received oxygen at 3 liters per minute instead of the prescribed 2 liters. These discrepancies were confirmed by LPNs and the DON, indicating non-compliance with physician orders.
A facility failed to secure a medication cart, leaving it unlocked and unattended while a nurse administered medications. An unmarked medication cup with various tablets and an expired bottle of Rolaids were found in the cart. The LPN and DON confirmed these issues, indicating lapses in medication security and management.
The facility failed to maintain sanitary conditions in food service, as a dietary aide was observed without a beard guard, and the sanitizer level in the sink was consistently above the recommended range. This was confirmed by the Dietary Manager and Nursing Home Administrator.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies in areas such as physician notification, quality of care, intravenous therapy, medication accountability, and infection control. Despite plans of correction involving audits and reviews, the committee was ineffective in addressing these issues.
An LPN failed to perform hand hygiene before administering oral medications and eye drops to a resident, contrary to the facility's infection control policy. The resident had a physician's order for Restasis for dry eyes. Both the LPN and the DON confirmed the lapse in protocol.
Failure to Attempt Non-Pharmacological Interventions Before PRN Lorazepam
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering a psychotropic medication for one resident with cognitive impairment and a diagnosis of anxiety. The resident had a physician order for 0.5 mg lorazepam as needed for anxiety, and the MAR showed multiple administrations of lorazepam across March, April, and May 2026. Review of the clinical record found no documented evidence that non-pharmacological interventions were tried before these doses were given, and the DON confirmed during interview that no such interventions had been attempted for the listed administrations and that they should have been.
Failure to follow ordered treatments and medication orders
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for five residents. For one resident with a left lateral foot wound, the wound care consultant documented orders for hydrocortisone cream to be applied daily to the peri-wound area with dressing changes, but the Treatment Administration Record did not show that the cream was applied. The DON stated the wound care consultant’s notes were not reviewed to identify the change in orders and that the ordered treatment was not completed because the provider did not give verbal orders to the wound care nurse. For another resident with diabetes who received Lantus, insulin lispro, and metformin, a pharmacy medication regimen review noted that an A1C was not available in the record and fingerstick monitoring could not be found. After the physician reviewed the A1C results, the physician noted that accu checks were to be done with meals for five days, but there was no documented evidence that this order was transcribed into the clinical record or completed. The DON confirmed that the accu check order was not transcribed and was not carried out as it should have been. Additional record review showed that insulin orders for one resident were repeatedly held without physician orders or notification, including both insulin aspart before meals and Lantus twice daily. Another resident’s psychiatric recommendation to increase Zoloft from 75 mg daily to 100 mg daily was agreed to by the physician, but there was no documented evidence that the increase was transcribed or implemented. For a resident with end stage renal disease on dialysis, Eliquis orders from hospital discharge paperwork were signed by an RN but were not entered into the medication orders, and the resident did not receive Eliquis as ordered; the DON stated the orders should have been clarified with the physician.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to follow physician orders for medication administration for three residents. One resident with diabetes was cognitively intact, required staff assistance with daily care, and had an order for Novolin R insulin by sliding scale before meals and at bedtime, including instructions to call the physician if blood glucose was greater than 400 mg/dL. Review of the MAR showed blood glucose readings of 414 mg/dL and 448 mg/dL, and there was no documented evidence that the physician was notified on either occasion. A second resident with cognitive impairment, heart failure, and high blood pressure had an order for midodrine 2.5 mg twice daily with instructions to hold the medication if systolic blood pressure was greater than 130 mm Hg. Review of the MAR showed midodrine was administered on multiple occasions when the resident’s systolic blood pressure was above the ordered hold parameter, including readings of 132, 145, 142, 140, 136, 159, 132, 138, 146, 131, 144, 133, 137, and 138 mm Hg. A third resident with hypertension was ordered metoprolol tartrate 100 mg daily with instructions to hold the medication if systolic blood pressure was less than 120 mm Hg or heart rate was less than 65 beats per minute. Review of the MAR showed the medication was administered on multiple occasions when systolic blood pressure was below the ordered parameter, including readings of 110, 112, 118, 106/72, and 115 mm Hg. The DON confirmed that the medication was given outside the ordered parameters for this resident.
Unnecessary Drug Regimen Due to Medication Administration Beyond Ordered Duration and Unprocessed Dose Reduction
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs for three residents. Resident 1 was cognitively intact, needed staff assistance with daily care, and had diagnoses including a foot infection and diabetic ulcer. A physician order was written for doxycycline 100 mg twice daily for 10 days after a wound culture was obtained, but the MAR showed the antibiotic was administered from the evening of April 25 through the morning of May 6, totaling 11 days. The DON confirmed that the resident received antibiotics for 11 days instead of the ordered 10 days. Resident 2 was cognitively impaired, needed staff assistance with daily care, and had osteoporosis with pathological fracture. A pharmacy medication regimen review noted the resident had been receiving pantoprazole 40 mg daily and recommended reducing the dose to 20 mg daily after the prescriber accepted the recommendation, but the order had not yet been processed. The MAR showed the resident continued to receive 40 mg daily from December 9, 2025, through January 12, 2026, and the DON confirmed the dose reduction should have been processed when it was approved. Resident 50 was cognitively impaired, needed staff assistance with daily care, and had heart failure. For a UTI, the resident was ordered amoxicillin-clavulanate 875-125 mg twice daily for 7 days, but the MAR showed 8 days were administered. Later, cefuroxime axetil 500 mg twice daily was ordered for 5 days for another UTI, but the MAR showed 6 days were administered. The DON confirmed both antibiotic courses were given longer than ordered.
Inaccurate MDS Coding for Ostomy, Wander Alarm, and Hearing Aid Use
Penalty
Summary
Accurate MDS assessments were not completed for three residents. For one resident with a colostomy, physician orders showed the colostomy skin barrier appliance was to be changed every seven days, and the bowel record showed the resident was using a colostomy for bowel movements. However, the quarterly MDS coded the resident as having an ostomy but also coded bowel continence as always continent, rather than coding bowel continence as not rated for a resident with a colostomy during the look-back period. For another resident, physician orders included a wanderguard electronic bracelet for daily safety checks, and the medication administration record showed the wanderguard was in place daily during the seven-day look-back period. The quarterly MDS did not accurately code the wander/elopement alarm. For a third resident, the inventory checklist showed hearing aids were present, and the resident stated he had difficulty hearing, did not have his hearing aids in, and preferred to have them in; staff then located and assisted with placing the hearing aids. Despite this, the quarterly MDS coded hearing as adequate and indicated no hearing aids were used.
Incomplete Care Plan for Hearing Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan with specific, individualized interventions for Resident 50’s hearing-related care needs. The facility policy for Comprehensive Care Planning required a person-centered care plan with measurable goals and timetables to address residents’ medical, nursing, mental, and psychosocial needs, but the care plan for Resident 50 only addressed fall risk and noted that hearing aids were to be within reach at the bedside. The quarterly MDS for Resident 50 indicated moderate cognitive impairment, need for staff assistance with daily care needs, and a diagnosis that included heart failure. Resident 50’s inventory checklist showed one hearing aid and batteries present on admission and a second hearing aid present after admission. During interview, the resident stated he had difficulty hearing and preferred to have his hearing aids in, but staff found the hearing aids in a bag on top of the dresser and assisted him with placing them correctly. On another interview, the resident again reported difficulty hearing and said he did not have his hearing aids because they were charging. The DON confirmed there was no care plan developed to address the resident’s impaired hearing and use of hearing aids, and later reported the resident was seen by audiology and diagnosed with mixed hearing loss.
Failure to Provide Wound Care Instructions and Supplies at Discharge
Penalty
Summary
The deficiency involved the facility’s failure to provide complete discharge information and necessary wound care supplies to a resident being discharged home. The facility’s discharge planning policy required development and implementation of a discharge plan that focused on the resident’s discharge goals, preparation for transition to post-discharge care, and reduction of preventable readmissions. The resident’s admission MDS showed the resident was cognitively intact, incontinent of bowel and bladder, and at risk for developing pressure ulcers, with no existing pressure ulcers at that time. On a later date, the resident developed full-thickness moisture-associated skin damage on the sacrum measuring 6.2 x 3.6 x 0.2 cm, and a physician’s order was initiated for daily cleansing of the sacrum with soap and water, patting dry, and application of Medi-honey once a day. The TAR documented that Medi-honey was applied on two consecutive days prior to discharge. On the day of discharge, nursing documentation indicated the resident was discharged home, medications were reviewed with a family member, and discharge instructions were provided. However, the written discharge instructions, which indicated the resident was being discharged home with home health, did not reflect that the resident was receiving wound care, as the wound care section was marked “N/A.” The drug disposition form showed that medications were sent home with the resident, but there was no documentation that Medi-honey was provided. In an interview, the Nursing Home Administrator confirmed there was no documented evidence that the resident or family received Medi-honey or wound care instructions upon discharge, despite the active physician’s order for daily wound treatment to the sacrum.
Failure to Follow COVID-19 Symptom Testing Protocols and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow CDC-based infection prevention and control guidelines for early detection, testing, and appropriate PPE use during a COVID-19 outbreak. CDC guidance cited in the report emphasizes routine assessment of all residents for COVID-19 symptoms, prompt testing of anyone with even mild symptoms regardless of vaccination status, and use of N95 respirators, gowns, gloves, and eye protection for all HCP entering rooms of residents with suspected or confirmed COVID-19. The facility had 18 residents develop COVID-19 between late December and early January and 11 active cases at the time of the on-site visit, yet staff practices and testing decisions did not consistently align with these guidelines. For Resident 4, who had a standing physician order allowing COVID-19 testing as needed per protocol, nursing documentation on one date showed a low-grade fever, body aches, chills, shortness of breath, and a dry cough. Despite these symptoms and the standing order, no COVID-19 test was performed at that time. Later in the month, the resident again exhibited symptoms including headache, fatigue, malaise, cough, and a temperature of 100.4°F, at which point a rapid COVID-19 test was performed and was positive, and isolation/combined droplet/contact precautions were ordered. During interview, the IP and DON stated that symptomatic residents would typically be tested, but that this depended on the practitioner, and the DON confirmed that Resident 4 had standing orders for testing that were not used on the earlier symptomatic date. For Resident 10, who also had a standing order permitting COVID-19 testing as needed, multiple nursing notes over several days documented cough, congestion, malaise, pale skin, and remaining in bed due to not feeling well, while the facility already had active COVID-19 cases. COVID-19 testing was not obtained until several days after the onset of these symptoms, when the CRNP was notified and ordered a rapid COVID-19 swab that resulted positive, and isolation/combined droplet/contact precautions were then ordered. For Resident 11, a nursing note documented that the resident did not feel well, had a moist productive cough, body aches, malaise, and expiratory wheezing; a rapid COVID-19 swab was ordered and was positive, and transmission-based precautions were ordered. Additionally, an observation showed a laundry aide entering the shared COVID-19-positive room of Residents 10 and 11 wearing only a surgical mask, despite droplet precaution signage and an isolation station with N95 masks, gowns, gloves, and eye protection at the door. The laundry aide acknowledged he should have gowned and possibly worn an N95 and confirmed he did not initially realize the PPE was available, while the IP confirmed that all staff entering COVID-19-positive rooms were required to don gloves, an N95, eye protection, and a gown.
Failure to Develop Comprehensive Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with specific and individualized interventions for a resident who required Enhanced Barrier Precautions. The facility's policy required that each resident have a care plan with measurable goals and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. For the resident in question, the quarterly MDS assessment documented significant care needs, including an indwelling catheter, a wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer in the sacral region. Physician's orders specified the use of Enhanced Barrier Precautions, and signage was observed outside the resident's room indicating the required infection control measures for high-contact care activities. Despite these documented needs and orders, there was no evidence in the clinical record that a comprehensive care plan addressing the resident's Enhanced Barrier Precautions had been developed. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of such documentation. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Measure and Administer Topical Medication per Physician Order
Penalty
Summary
A deficiency was identified when staff failed to follow physician's orders and manufacturer’s directions for administering diclofenac sodium topical gel 1 percent to a resident. The physician's order specified that four grams of the gel should be applied to the resident's right knee four times daily, and the manufacturer's instructions required the use of a dosing card to measure the correct amount. During a medication administration observation, an LPN applied the gel to the resident's knee without using the dosing card, instead squeezing unmeasured amounts onto her gloved finger and applying it to the resident’s knee. The resident involved had impaired mobility and was at risk for pain, as documented in the care plan and Minimum Data Set assessment. The LPN confirmed in an interview that she did not use the dosing card, believing it was only provided with prescription strength gel, not the over-the-counter version supplied by the facility’s pharmacy. The DON also confirmed that the gel should have been measured to ensure the correct dose was administered as ordered.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC, as well as its own policy, during the care of a resident with an indwelling catheter, wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer. The resident had physician's orders for Enhanced Barrier Precautions (EBPs), which require staff to wear gloves and gowns during high-contact care activities. Despite clear signage and policy, two nurse aides entered the resident's room wearing only gloves and proceeded to provide high-contact care, including rolling the resident, removing soiled dressings, providing incontinent care, and handling a mechanical lift sling, without donning gowns as required. Additionally, one of the nurse aides failed to remove gloves and perform hand hygiene after removing wound dressings and providing incontinent care, before continuing with other care tasks. Both aides only removed their gloves and used hand gel after several care activities had already been performed. These actions were confirmed by the Director of Nursing to be inconsistent with facility policy and infection control guidelines, specifically regarding the use of gowns and proper hand hygiene during care for residents on EBPs.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by an incident involving a resident who was transferred incorrectly, resulting in a fall and a head laceration requiring staples. The facility's policy on mechanical lifts required a two-person assist for all mechanical lifts, including Hoyer lifts. However, during the transfer of a resident with quadriplegia and multiple sclerosis, Nurse Aide 1 attempted to transfer the resident alone using a mechanical lift. This resulted in the sling pad slipping from under the resident, causing him to hit his head on the headboard and sustain a laceration. The resident, who was cognitively intact and dependent on staff for daily care needs, was transferred to the emergency room where he received three staples to the back of his head. The incident report confirmed that Nurse Aide 1 was aware of the facility's policy requiring two-person assistance for transfers but failed to adhere to it. The Director of Nursing confirmed that Nurse Aide 1 should have had a second person assist with the transfer, as per the facility's policy.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident who was dependent on staff for care, including transfers and bed mobility, due to quadriplegia and multiple sclerosis. The facility's policy required a two-person assist for all mechanical lifts, including Hoyer lifts. However, an incident occurred where the resident was transferred using a Hoyer lift by only one nurse aide. During the transfer, the sling pad slipped from under the resident, causing him to hit his head on the headboard and sustain a laceration that required staples. The resident was cognitively intact and understood by others, as indicated in a recent Minimum Data Set assessment. The incident report confirmed that the transfer was conducted by a single staff member, contrary to the facility's policy. The Director of Nursing confirmed that two people should have been involved in the transfer, highlighting the failure to adhere to established safety protocols for resident transfers using mechanical lifts.
Confidentiality Breach of Residents' Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information, affecting two of the seven residents reviewed. The incident involved the unauthorized disclosure of health information for two residents. Specifically, Resident 6's health information was mistakenly provided to a family member of another resident, Resident 1, who then shared it with an outside physician. Additionally, when the family member returned to the facility, they requested Resident 1's health information but were erroneously given Resident 7's health information instead. The facility's policy on privacy, dated January 22, 2024, stipulates that protected health information should only be used and disclosed as permitted under HIPAA rules. However, the investigation dated September 15, 2024, revealed that these policies were not adhered to, resulting in the breach of confidentiality for Residents 6 and 7. The Nursing Home Administrator confirmed the breach during an interview, acknowledging that the health information of Residents 6 and 7 was improperly disclosed to Resident 1's family member.
Incomplete Documentation of Condom Catheter Care
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident who required the use of a condom catheter. The facility's policy stated that condom catheters should be changed daily and as needed. However, a review of the resident's Medication Administration Records (MARs) for several months revealed no documented evidence that the catheter was being changed daily as per the policy. This discrepancy was identified when the resident's wife requested daily changes, leading to the realization that there was no specific physician's order for this practice. The resident, who had multiple sclerosis and quadriplegia, was understood to require an external catheter due to neuromuscular dysfunction of the bladder. Despite the care plan and physician's orders indicating the need for catheter care every shift, the lack of documentation on the MARs until a specific order was obtained highlighted a gap in adherence to the facility's policy. Interviews with staff confirmed that the catheter was being changed during routine catheter care, but this was not properly documented until the issue was addressed following the family's request.
Failure to Notify Residents and Guardians of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their legal guardians regarding the reasons for hospitalization, as required by regulations. This deficiency was identified for seven residents during a review of clinical records and staff interviews. The residents involved were cognitively intact and required assistance with daily care needs, with various medical conditions such as diabetes, myocardial infarction, pressure sores, dementia, chronic obstructive pulmonary disease, and infections. For each of the seven residents, nursing notes documented instances where they were transferred to the hospital due to changes in their medical conditions, such as shortness of breath, increased confusion, unresponsiveness, and infections. Despite these transfers, there was no documented evidence that written notices were provided to the residents' responsible parties, explaining the reasons for the transfers. This lack of documentation was confirmed during an interview with the Nursing Home Administrator. The specific cases included residents being sent to the hospital for issues like a large area under a cast needing debridement, an unstageable diabetic pressure ulcer, and abnormal lab results indicating renal failure. The facility's failure to provide the required written notifications violated resident rights and discharge policy regulations, as outlined in 28 Pa. Code 201.25 and 28 Pa. Code 201.29(f)(g).
Late Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive admission and annual Minimum Data Set (MDS) assessments were completed within the required time frame for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 12, 53, 65, 69, and 77 were completed beyond this timeframe, with delays ranging from 17 to 21 days after admission. The deficiency was confirmed through a review of clinical records and staff interviews, which revealed that the comprehensive MDS assessments for these residents were completed late. The Nursing Home Administrator acknowledged the late completion of these assessments during an interview. This failure to adhere to the mandated assessment schedule was identified as past non-compliance.
Failure to Timely Complete MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframe for five residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 calendar days after the ARD. However, the assessments for Residents 2, 17, 47, 59, and 72 were completed 15 days after their respective ARDs, exceeding the allowed timeframe. The specific instances of non-compliance included Resident 2's assessment, which was completed one day late, and similar delays for Residents 17, 47, 59, and 72. These delays were confirmed during an interview with the Nursing Home Administrator. The deficiency was identified as past non-compliance, indicating that the facility had previously failed to adhere to the required timelines for completing MDS assessments.
Failure to Follow Physician's Orders for Medication and Assessments
Penalty
Summary
The facility failed to adhere to physician's orders for four residents, leading to deficiencies in care. For Resident 17, the facility did not consistently perform the required full head-to-toe assessments with vital signs every shift, as ordered by the physician. Documentation showed that the assessment was only completed once, despite the order for it to be done per shift. Resident 37, who was moderately cognitively impaired and had diabetes, had their insulin held on multiple occasions when their blood sugar levels were above the threshold that required holding the medication, contrary to the physician's orders. Resident 40, who was cognitively intact and receiving antibiotics, was administered Cipro for 11 days instead of the prescribed 10 days, resulting in two additional doses. Resident 46, who was cognitively impaired and had hypertension, received metoprolol tartrate on several occasions when their systolic blood pressure was below the threshold that required holding the medication, as per the physician's orders. These actions were confirmed through interviews with the Director of Nursing, who acknowledged the discrepancies between the physician's orders and the care provided.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, as revealed through a review of policies, clinical records, and staff interviews. For one resident, who was cognitively intact and frequently experienced pain, there were physician's orders for oxycodone to be administered as needed. However, the controlled drug record indicated that doses were signed out on several occasions, but there was no documented evidence in the clinical record that these doses were actually administered. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, another resident, who was cognitively impaired and frequently experienced anxiety, had physician's orders for diazepam to be applied as needed. The controlled drug record showed that doses were signed out on specific dates, but again, there was no documented evidence in the clinical record that these doses were administered. This lack of documentation was also confirmed by the Director of Nursing. These findings indicate a failure to adhere to the facility's policy and applicable laws regarding the documentation and administration of controlled substances.
Failure to Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring that the call bell was within reach. Resident 8, who required maximum assistance for transfers and toileting due to decreased mobility, was observed on June 24, 2024, with the call bell hanging off the back of the bed onto the floor, out of her reach. The resident's care plan specified that the call bell should be within reach, and the facility's policy, dated August 14, 2023, also required that the call light be within easy reach. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the call bell should have been accessible to the resident.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner about a change in the resident's condition, specifically the refusal of medication. According to the facility's policy dated August 14, 2023, the physician should be notified if a resident refuses medication for more than 24 hours. Resident 52, who was cognitively impaired and dependent on staff assistance, was receiving an antidepressant, Lexapro, as per physician's orders dated June 23, 2023. The resident refused the medication on multiple occasions in June 2024, specifically on the 1st, 2nd, 3rd, 4th, 17th, and 18th. However, there was no documented evidence that the physician was informed of these refusals. This was confirmed during an interview with the Director of Nursing on June 26, 2024.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete accurate comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD) in Section I16100, despite a social service note stating that the resident had not experienced or witnessed a life-threatening or traumatic event. The Registered Nurse Assessment Coordinator confirmed that the section should have been coded for a traumatic brain injury instead. For another resident, the MDS assessment failed to code for anticoagulant medication in Section N0415E1, even though the resident had been receiving Warfarin, an anticoagulant, as per physician's orders during the seven-day look-back period. The Director of Nursing confirmed that the resident had received the medication and should have been coded accordingly.
Failure to Change Compromised IV Dressing
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing of IV dressings for a resident, leading to a deficiency. The policy required that midline catheter dressings be changed weekly and whenever the dressing's integrity was compromised, such as when it became wet, loose, or soiled. Additionally, staff were expected to assess the midline insertion site with each medication administration. However, observations on multiple occasions revealed that the midline dressing on a resident's right arm was loose and had lost its integrity, indicating that the dressing was not changed as required by the facility's policy. The resident involved was moderately cognitively impaired and had medical conditions including bilateral stasis leg ulcers and bacteremia, for which they were receiving intravenous antibiotics. Despite the physician's orders for the administration of Zosyn three times a day, the compromised dressing was not addressed promptly. Interviews with a Licensed Practical Nurse and the Director of Nursing confirmed that the dressing was visibly loose and should have been changed when its integrity was compromised, but it was not, leading to the deficiency finding.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that residents received oxygen as ordered by the physician for two residents. Resident 8, who was cognitively intact and had diagnoses including asthma and respiratory failure, was observed receiving oxygen at a flow rate of 4 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by both a Licensed Practical Nurse and the Director of Nursing, indicating a failure to adhere to the physician's orders. Similarly, Resident 70, who was severely cognitively impaired and on hospice care with diagnoses including pneumonitis and anxiety, was observed receiving oxygen at a flow rate of 3 liters per minute instead of the ordered 2 liters per minute. This was also confirmed by a Licensed Practical Nurse and the Director of Nursing. These findings demonstrate a failure to provide respiratory care in accordance with physician orders, as required by the facility's policy and state regulations.
Medication Security and Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications in one of the four medication carts reviewed. During an observation, it was noted that the lower level medication cart was left unlocked and unattended while a nurse was administering medications to residents in a room with the door shut, blocking the nurse's view of the cart. This lack of supervision could potentially lead to unauthorized access to medications. Additionally, an undated and unmarked medication cup containing various tablets was found in the top drawer of the cart, indicating a lapse in proper medication labeling and handling procedures. Further inspection of the stock drawer in the same medication cart revealed an opened bottle of Rolaids with an expiration date that had already passed. Interviews with the LPN and the Director of Nursing confirmed these findings, acknowledging that the medication cart should have been kept in full view while in use, and that expired medications and unmarked medication cups should not have been present in the cart. These observations highlight deficiencies in the facility's adherence to pharmacy and nursing service regulations.
Sanitation Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served under sanitary conditions, as required by professional standards for food service safety. Observations in the main kitchen revealed that a dietary aide did not have a beard guard covering his beard, which was confirmed by the Dietary Manager. Additionally, the sanitizer level in the three-compartment sink was consistently recorded at 500 parts per million (ppm) on multiple dates, exceeding the manufacturer's recommended level of 200-400 ppm. This was confirmed by the Nursing Home Administrator, who acknowledged that the sanitizer level was not within the recommended range on the specified dates.
Repeated Deficiencies in Quality Assurance Processes
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included issues with notifying the physician or responsible party about changes in a resident's condition, quality of care, intravenous therapy, accountability of controlled medications, proper storage and labeling of medications, food preparation and storage under sanitary conditions, and infection control practices. Despite developing plans of correction that included audits and reporting results to the QAPI committee, the facility was unable to effectively address these recurring issues. The deficiencies were identified in surveys conducted on various dates, including July 20, September 18, and October 25, 2023, as well as the current survey ending June 27, 2024. The facility's plans of correction consistently involved completing audits and reviewing the results as part of quality assurance, but the QAPI committee was ineffective in implementing these plans to ensure ongoing compliance with the regulations. The repeated nature of these deficiencies indicates a systemic issue within the facility's quality assurance processes.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during medication administration, as observed during a survey. The facility's policy, dated August 14, 2024, required staff to perform hand hygiene before administering medications, including eye drops. However, on June 26, 2024, an LPN was observed administering oral medications and eye drops to Resident 15 without performing hand hygiene. Resident 15 had a physician's order for Restasis, an eye medication for dry eyes, to be administered twice daily. The LPN confirmed during an interview that she did not perform hand hygiene as required. The Director of Nursing also confirmed the lapse in protocol during a subsequent interview.
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 462 citations issued within 25 miles in the last 12 months — including the 6 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 Mount Pleasant
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Scottdale Healthcare & Rehabilitation Center | 2.4 mi | ★★★★★ | 14 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 10 mi | ★★★★★ | 11 | 0 |
| Hempfield Manor | 10.1 mi | ★★★★★ | 20 | 0 |
| Westmoreland Manor | 10.7 mi | ★★★★★ | 9 | 0 |
| Twin Lakes Rehabilitation And Healthcare Center | 10.8 mi | ★★★★★ | 29 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.