Harmony Hills Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wexford, Pennsylvania.
- Location
- 194 Swinderman Road, Wexford, Pennsylvania 15090
- CMS Provider Number
- 395903
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Harmony Hills Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to accurately account for and document controlled substances for multiple residents receiving opioid pain medications. Policy required staff to document each administered dose on the MAR immediately after giving it, but numerous doses of oxycodone, Endocet, Tramadol, and hydrocodone/acetaminophen were signed out on controlled substance records without corresponding MAR entries. These discrepancies occurred across several residents with PRN and scheduled pain medication orders, and facility leadership confirmed that controlled substances were not accurately accounted for.
The facility did not maintain sanitary conditions in the kitchen, including unclean equipment and improper staff hygiene, and failed to consistently monitor refrigerator temperatures on a nursing unit and in several residents' personal refrigerators. Staff interviews confirmed incomplete temperature logs and inconsistent monitoring, in violation of facility policy.
The facility did not conduct care plan conferences or notify three residents with complex medical needs, including depression, paraplegia, high blood pressure, and diabetes, about these meetings. These residents were not given the opportunity to participate in their care planning, and staff confirmed that required notifications and documentation were not provided.
The facility did not provide necessary resident information, such as care plans, to receiving health care providers during hospital transfers for three residents with complex medical conditions, and failed to obtain a physician order for the discharge of another resident sent home. These deficiencies were confirmed through record review and staff interviews.
A resident with dementia, anemia, and depression was started on hospice care, representing a significant change in condition. The facility did not complete the required significant change MDS assessment within the mandated timeframe, as confirmed by the DON during staff interviews.
A resident with multiple medical conditions and limited mobility was found using a personal hot plate warmer at the bedside without assessment, risk identification, or physician's orders. Facility leadership confirmed the presence of the device and acknowledged the lack of safety measures, resulting in an environment not free from potential accident hazards.
A resident with a colostomy did not have the size and type of colostomy appliance specified in physician orders or the care plan, contrary to facility policy and professional standards. The DON confirmed these documentation omissions.
A resident with multiple diagnoses did not have required monthly Medication Regimen Reviews completed for several months. Although the pharmacy sent encrypted recommendations, the facility did not ensure these were reviewed and acted upon by the physician, resulting in missing MRR documentation.
Surveyors found that medications and biologicals were not properly labeled or securely stored in a medication cart, with several insulin pens missing opened dates and not kept in individual bags. In a medication room, two refrigerators lacked temperature monitoring logs, and personal items such as coats and a tote bag were stored alongside medications. An LPN confirmed these deficiencies during interviews.
A resident with dysphagia and an NPO order was found with ice chips at the bedside, despite facility policy and physician directives prohibiting anything by mouth. The DON confirmed that conflicting dietary orders were present and that staff did not adhere to the NPO restriction.
A resident with a vegetarian diet and no milk intake, requiring a high-protein diet due to medical conditions, was served a meal that did not meet her protein needs. Staff confirmed the meal did not align with her documented dietary requirements and preferences.
A resident with dementia, anemia, and depression was documented as receiving hospice care, but the facility failed to coordinate hospice services as required. The hospice binder was missing, and staff confirmed the resident was no longer on hospice without a discharge order or care plan update. The DON and Nursing Home Administrator acknowledged the lack of coordination between hospice and facility services.
The facility did not conduct a required quarterly QAA meeting with all mandated committee members, as attendance records showed the Medical Director was absent for one meeting. This was confirmed by the Nursing Home Administrator, indicating non-compliance with facility policy and regulatory standards.
An LPN failed to perform hand hygiene after removing a soiled dressing and before applying new wound care products for a resident with paraplegia, anxiety, and depression. This action was not in accordance with facility policies on wound care and hand hygiene, resulting in a risk of cross contamination during the dressing change.
The facility failed to maintain sanitary kitchen equipment and did not properly label, date, and store food products, leading to potential unsafe conditions and cross-contamination risks. Observations revealed improperly stored frying pans and hot plates, unlabeled rolls, and inappropriate items in the basement freezer and kitchenette cabinets. These issues were confirmed by the Dietary Manager and the DON.
The facility failed to develop comprehensive care plans for six residents, omitting necessary goals and interventions for the use of bilateral quarter side rails and a Dexacom 6 monitor, despite physician orders. This deficiency was confirmed through staff interviews and record reviews.
The facility failed to properly store medications and supplies in a medication cart, a medication room, and the central supply area. An LPN was observed removing a medication cup from a cart without immediate administration, and various supplies were improperly stored in the medication room. Over-the-counter medications in the central supply area were not secured, accessible to any clinical staff.
The facility failed to ensure that three residents with severe cognitive impairments understood the terms of binding arbitration agreements they signed. Despite having policies to inform residents or their representatives about such agreements, the facility did not adhere to these policies, as evidenced by the residents' low BIMS scores indicating severe impairment. The DON confirmed this oversight.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred to the hospital. Required documentation, including care plan goals and advanced directive information, was not provided, as confirmed by the DON. This is a violation of resident rights under 28 Pa. Code 201.29 (a)(c.3)(2).
A facility failed to ensure accurate MDS assessments for a resident receiving hospice care. Despite a physician's order for hospice admission due to dementia, the MDS assessments incorrectly indicated no hospice care. The RNAC confirmed the inaccuracy, highlighting a lapse in adherence to assessment protocols.
A facility failed to update a resident's care plan to reflect current care needs, including the use of a bunny boot and heel medix boot as per physician orders. The resident, with heart failure, hypertension, and left side hemiplegia, had these orders dated but not included in the care plan, as confirmed by the RNAC.
The facility failed to obtain a physician discharge order for a resident with high blood pressure, depression, and atrial fibrillation, and did not have a physician order for an over the bed trapeze bar for another resident with GERD, depression, and paraplegia. These deficiencies were confirmed by the DON.
The facility did not complete annual performance evaluations for two nurse aides, as required by their policy. The personnel records for these aides lacked performance reviews for their respective evaluation periods. The DON confirmed this failure, which violates staff development regulations.
The facility did not conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of the four quarterly meetings. A review of the facility's QAPI Program policy and attendance records showed no evidence of a March 2024 QAPI meeting. The Nursing Home Administrator confirmed this deficiency during an interview.
A resident with a history of paraplegia and other conditions did not receive their prescribed Tizanidine for spasms due to the facility running out of the medication and delays in reordering. The facility's policy to review medication administration records was not effectively implemented, leading to the resident missing doses for about two weeks.
Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate accounting and documentation of controlled substances for nine of twelve reviewed residents. Facility policy required that the individual administering a medication record the dose on the MAR immediately after administration. For multiple residents receiving PRN and scheduled opioid analgesics, including oxycodone, Endocet (oxycodone/acetaminophen), Tramadol, and hydrocodone/acetaminophen, there were discrepancies between the controlled substance records and the MARs. Specifically, numerous doses were signed out on the controlled substance records on various dates in February 2026 without corresponding documentation of administration on the residents' MARs. For one resident with an order for oxycodone 5 mg every six hours PRN, 15 additional doses were signed out beyond the 10 administrations documented on the MAR. Another resident with Endocet orders for moderate and severe pain had six extra doses signed out without matching MAR entries, while a third resident on Endocet for severe pain had 10 such undocumented doses. Additional residents with PRN oxycodone, Tramadol, and hydrocodone/acetaminophen orders each had multiple doses signed out on the controlled substance records that were not documented as given on the MARs. During an interview, the Nursing Home Administrator and the DON confirmed that controlled substances were not accurately accounted for for these nine residents.
Failure to Maintain Sanitary Food Service and Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to maintain sanitary conditions and proper infection control in food service areas, as evidenced by several observations and staff interviews. In the main kitchen, brown debris was observed on the fan next to the dishwasher, and a dietary aide was seen handling food trays on the lunch tray line without a facial hair covering. The district manager confirmed these lapses, acknowledging that they created the potential for foodborne illness and cross-contamination. Additionally, the facility did not properly monitor refrigerator temperatures on one of two nursing units, with multiple dates missing from the temperature log for the C & D Hall unit. Personal refrigerators in the rooms of three residents were also found without temperature logs, and interviews revealed inconsistent or infrequent monitoring practices. An LPN confirmed that temperature logs for July were not completed and expressed a lack of awareness regarding the monitoring requirement. These failures were in direct violation of the facility's own policies regarding environmental sanitation and infection control.
Failure to Notify and Involve Residents in Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and did not ensure that residents or their representatives were notified in advance of care conference meetings for three of five residents reviewed. According to the facility's policy, residents and their families or responsible parties have the right to participate in planning care and treatment, and should be notified of care plan meetings and offered the opportunity to attend. However, review of clinical records and staff interviews revealed that residents with diagnoses including depression, migraines, paraplegia, high blood pressure, cerebral infarction, diabetes, and heart failure were not invited to or made aware of care plan meetings. These residents reported never having attended such meetings and expressed a desire to participate if they had been informed. Staff interviews confirmed that care conferences were due for these residents at specific intervals, but the facility could not provide documentation of meetings or evidence that invitations were sent. The Nursing Home Administrator acknowledged awareness of the lapse, confirming that care plan conferences had not been conducted and residents or their representatives were not notified as required. This failure was identified for three residents with significant medical conditions, in violation of resident rights as outlined in facility policy and state regulations.
Failure to Communicate Resident Information During Transfers and Obtain Physician Discharge Order
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during hospital transfers for three residents. Specifically, for these residents, the clinical records did not contain documented evidence that their care plans or care plan goals were provided to the hospital at the time of transfer. This lack of communication included residents with significant medical histories such as acute pancreatitis, diabetes mellitus, hypertension, dysphagia, cancer, and heart failure. The absence of this documentation was confirmed through review of facility policy, clinical records, and staff interviews. Additionally, the facility failed to obtain a written physician order for the discharge of one resident who was sent home. The clinical record for this resident, who had diagnoses including high blood pressure, diabetes, and depression, did not include the required physician order for discharge. The Nursing Home Administrator confirmed both the lack of communication of resident information during hospital transfers and the missing physician order for discharge.
Failure to Complete Significant Change Assessment After Hospice Initiation
Penalty
Summary
The facility failed to conduct a significant change assessment for one resident following a major change in condition. According to the RAI User's Manual, a comprehensive assessment must be completed within fourteen days when a resident experiences a significant change in physical or mental status. In this case, a resident with diagnoses of dementia, anemia, and depression was placed on hospice care, which constitutes a significant change in condition requiring such an assessment. Review of the resident's records showed that hospice care was initiated, but the required significant change MDS assessment was not completed within the mandated timeframe. This omission was confirmed by the Director of Nursing during an interview. The deficiency was identified through review of clinical records and staff interviews, and it was determined that the facility did not meet regulatory requirements for timely assessment following a significant change in the resident's status.
Failure to Prevent Accident Hazards Related to Personal Hot Plate Use
Penalty
Summary
The facility failed to ensure a resident environment free from potential accident hazards for one of three residents reviewed. Facility policy required that every effort be made to keep the resident's environment as free of accidental hazards as possible. A review of the clinical record for a resident with diagnoses including diabetes, renal insufficiency, and high blood pressure revealed no assessment, risk identification, ongoing evaluation, or physician's orders regarding the use of a personal hot plate warmer for coffee cups at the bedside. The resident's care plan indicated a need for 24-hour care and supervision due to limited mobility and self-care deficits. During observation, the resident was found sitting on the bed with a small hot plate device on the bedside stand, actively in use to keep coffee warm. Interviews with the resident confirmed the use of the device, and facility leadership acknowledged the presence of the hot plate and the lack of appropriate safety measures. The facility confirmed that the environment was not free of potential accidental hazards for this resident.
Failure to Document and Specify Colostomy Appliance Details
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for one resident. Facility policy required the use of an appropriate pouching system based on stoma type, output, and skin sensitivity, with documentation of stoma type, pouching, and wafer system size in the medical record. Review of the resident's clinical record showed a diagnosis of colostomy, with physician orders to change the colostomy skin barrier appliance every three days and as needed, but the order did not specify the size and type of appliance to be used. Additionally, the resident's care plan did not include the size and type of colostomy appliance. The Director of Nursing confirmed these omissions during an interview.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly Medication Regimen Reviews (MRR) for a resident with diagnoses including depression, migraines, and paraplegia. According to facility policy, a pharmacist is required to review each resident's drug regimen at least once a month and report any irregularities to the attending physician and the Director of Nursing. However, clinical record review revealed that the facility was unable to provide completed MRRs for this resident for several months, specifically December 2024, April 2025, May 2025, and June 2025. Interviews with the Director of Nursing confirmed that although the facility received encrypted emails from the pharmacy containing recommendations, the process of having these recommendations reviewed and completed by the physician was not followed. This lapse resulted in the failure to complete the required MRRs for the resident, as documented in the clinical records and confirmed by staff interviews.
Improper Storage and Documentation of Medications and Biologicals
Penalty
Summary
The facility failed to store medications and biologicals properly and securely in one of three medication carts and failed to maintain safe, secure, and orderly storage in one of two medication rooms. Specifically, during an observation, several insulin pens belonging to different residents were found in the C and D Hall medication cart without being labeled with the date opened and not stored in individual bags as required. Additionally, an inhaler spacer was also not stored in a bag. These findings were confirmed by an LPN during an interview. Further observations in the C and D Hall medication storage room revealed that two refrigerators used for medication storage did not have temperature monitoring logs as required by facility policy. The same storage room also contained personal items, including two winter coats belonging to a discharged resident and a tote bag belonging to staff, stored on a shelf. These issues were acknowledged by the LPN during the interview, confirming the failure to maintain proper storage and documentation practices for medications and biologicals.
Failure to Enforce NPO Orders for Resident with Dysphagia
Penalty
Summary
The facility failed to adhere to physician orders and its own policy regarding the provision of food in a form appropriate to individual resident needs. Specifically, a resident with diagnoses including high blood pressure, dysphagia, and cancer was admitted with an order for an NPO (nothing by mouth) diet and was receiving nutrition via a feeding tube. Despite this, the resident was observed with a large Styrofoam cup of ice chips and a spoon at her bedside, which was confirmed by a registered nurse to be inconsistent with the NPO order. Further review revealed that the resident's clinical record included an order for a 'holiday free diet,' which conflicted with the NPO status. The Director of Nursing confirmed that the resident should not have had an order for a holiday free diet while under NPO restrictions. The facility's policy clearly states that no food, liquid, or medication should be administered by mouth to residents with an active NPO order unless specifically directed by a physician or speech-language pathologist, and all staff are required to strictly adhere to these orders. The failure to follow these protocols resulted in the deficiency.
Failure to Meet Vegetarian Resident's Dietary Protein Needs
Penalty
Summary
A deficiency occurred when a resident who is a vegetarian and does not consume milk reported that her dietary needs were not being met. The resident, who has a history of right femur fracture, falls, neuropathy, and a surgical incision requiring 64 grams of protein daily, was observed receiving a lunch tray that did not meet her protein requirements. The tray included buttered noodles, green beans, and pears, which did not provide adequate protein for her condition. Staff confirmed that the meal provided did not align with the resident's documented dietary needs and preferences.
Failure to Coordinate Hospice Services for Resident Receiving End-of-Life Care
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for a resident requiring end-of-life care. According to the facility's policy, hospice care should be coordinated and delivered in partnership with contracted hospice providers, in accordance with regulations and the resident's care plan. The resident in question had diagnoses of dementia, anemia, and depression, and was documented as receiving hospice care per the Minimum Data Set and physician orders. The care plan also indicated the resident had chosen hospice services and had an advanced directive in place. During an observation, the hospice binder for the resident could not be located at the nurse's station, and an LPN confirmed that the resident did not have a hospice binder. The DON later stated that the resident was no longer on hospice services, but there was no discharge order to stop hospice, nor was the care plan updated to reflect this change. The Nursing Home Administrator confirmed the facility's failure to coordinate hospice services with facility services to meet the resident's end-of-life care needs.
Failure to Hold QAA Meeting with All Required Members
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members for one of three quarterly meetings in Quarter One of 2025. According to the facility's QAPI Committee Charter policy, QAPI is intended to be a systematic and comprehensive process for monitoring performance and identifying improvement opportunities. However, a review of QAPI sign-in sheets and attendance records for the specified quarter showed that the Medical Director was not present at the meeting. This was confirmed by the Nursing Home Administrator during an interview, who acknowledged that the required QAA meeting did not include all mandated committee members as stipulated by facility policy and regulatory requirements.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to perform proper hand hygiene during a dressing change for a resident diagnosed with paraplegia, anxiety, and depression. According to the facility's wound care and hand hygiene policies, staff are required to wash and dry hands thoroughly after removing soiled dressings and before proceeding with further wound care. During an observed dressing change, the LPN removed a soiled dressing and cleansed the wound but did not complete hand hygiene before applying Medi-honey and covering the wound with border gauze. This lapse was confirmed during a staff interview, where the LPN acknowledged not performing hand hygiene after removing the soiled dressing. The failure to adhere to established infection prevention and control protocols resulted in a risk of cross contamination during the wound care procedure for the resident.
Improper Food Storage and Sanitation in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and did not properly label, date, and store food products, leading to potential unsafe conditions and cross-contamination risks. During an observation of the main kitchen, it was noted that frying pans and hot plates were stored without being inverted, which was confirmed by the Dietary District Manager. Additionally, a bag of rolls in the kitchen refrigerator was found without labels or dates, which was acknowledged by the Dietary Manager. Further observations in the basement freezer revealed non-food items such as a water bottle, Gatorade, and a coffee can, which were confirmed by the Dietary Manager as belonging to housekeeping. In the kitchenette on the C and D level hallway, inappropriate items like a lunch bag, a bottle of diet Pepsi, and a tube of adhesive were found in the cabinets. The Director of Nursing confirmed these items should not be in the kitchen pantry area, indicating a failure to properly label, date, and store food products, thus creating potential unsafe conditions and cross-contamination risks.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for six out of ten residents, as required by their policies and regulations. The care plans did not include necessary goals and interventions for the use of bilateral quarter side rails for positioning, despite physician orders indicating their use. This deficiency was observed in residents with various medical conditions, including atrial fibrillation, hypertension, coronary artery disease, heart failure, hyperlipidemia, anemia, diabetes, depression, and paraplegia. The absence of these interventions in the care plans was confirmed through staff interviews and review of clinical records. Additionally, the facility did not include interventions for the use of a Dexacom 6 monitor for blood glucose monitoring in one resident's care plan. This oversight was acknowledged by the Registered Nurse Assessment Coordinator. The Director of Nursing confirmed the facility's failure to develop comprehensive care plans to meet the residents' needs, as required by the applicable state codes and facility policies.
Improper Storage of Medications and Supplies
Penalty
Summary
The facility failed to properly store medical supplies and biologicals in several areas, including a medication cart, a medication room, and the central supply area. During an observation, an LPN was seen removing a medication cup containing pills from the top drawer of a medication cart, which was not administered immediately as required by the facility's policy. The LPN confirmed that the medications were prepared but not administered, indicating a failure to properly store medical supplies in the medication cart. Additionally, in the first-floor medication room, various medical supplies were improperly stored, including blood draw tubes and needle hubs under the sink, and a bottle of medication labeled Abilify belonging to a resident was found in an unlocked cupboard. The LPN confirmed these observations and acknowledged the failure to properly store medical supplies and biologicals. Furthermore, the central supply area contained over-the-counter medications that were not properly secured, as confirmed by the Director of Nursing, who stated that the area could be accessed by any clinical staff.
Failure to Ensure Resident Capacity for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that three residents had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified through a review of facility documents, resident clinical records, and staff interviews. The facility's policy requires that residents or their representatives be informed of the nature and implications of binding arbitration agreements to make informed decisions. However, the facility did not adhere to this policy for three residents, as evidenced by their severe cognitive impairments. Resident R17, diagnosed with high blood pressure, dementia, and heart failure, had a BIMS score of six, indicating severe cognitive impairment, yet signed the arbitration agreement. Similarly, Resident R25, with high blood pressure, depression, and cerebral infarction, had a BIMS score of seven, also indicating severe impairment, and signed the agreement. Resident R29, diagnosed with high blood pressure, coronary artery disease, and diabetes, had a BIMS score of seven, indicating severe impairment, and signed the agreement. The Director of Nursing confirmed the facility's failure to ensure these residents understood the arbitration terms.
Failure to Communicate Resident Information Upon Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for two residents who were transferred from the facility. According to the facility's policy on Documentation of Resident Discharge and Deaths, specific documentation such as the resident transfer form, face sheet, advance directive, medication administration record, current history and physical, physician and verbal orders, and pertinent diagnostic testing should be provided to the receiving facility. However, for Resident R21, who was transferred to the hospital, there was no documented evidence that the facility communicated the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all necessary information to meet the resident's needs at the receiving facility. Similarly, Resident R28 was transferred to the hospital without documented evidence of communication of the required information to the receiving health care provider. The Director of Nursing confirmed during an interview that there was no evidence of the necessary information being communicated for these two residents. This failure to communicate essential information upon transfer is a violation of the residents' rights as outlined in 28 Pa. Code 201.29 (a)(c.3)(2).
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of a resident, identified as Resident R31. According to the facility's policy, the Registered Nurse Assessment Coordinator (RNAC) is responsible for establishing an assessment date and ensuring that the assessment reference date accurately reflects the resident's care needs. However, a review of Resident R31's clinical records and MDS assessments revealed discrepancies. Specifically, the MDS assessments for Resident R31, dated 6/9/24 and subsequent assessments, incorrectly indicated that the resident was not receiving hospice care, despite a physician's order dated 2/25/24 admitting the resident to hospice care for dementia. During an interview, RNAC Employee E1 confirmed the inaccuracy in the resident's assessments. The deficiency was identified as a failure to accurately code Section O0110K1 (Hospice care) in the MDS, which should have reflected the resident's hospice care status. This oversight was noted for one of three residents reviewed, highlighting a lapse in the facility's adherence to the Resident Assessment Instrument (RAI) User's Manual and the facility's own policy regarding accurate resident assessments.
Care Plan Update Failure for Resident
Penalty
Summary
The facility failed to update the care plan for Resident R23 to accurately reflect the current status and care needs. The facility's policy requires a comprehensive care plan to be completed and reviewed within seven days of the Minimum Data Set (MDS) completion. Resident R23, who was admitted with diagnoses of heart failure, hypertension, and left side hemiplegia, had physician orders dated 9/18/24 for a bunny boot on the right foot and a heel medix boot on the left foot while in bed. However, a review of the care plan on 10/17/24 revealed that it did not include these orders. This deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC) Employee E1.
Lack of Physician Orders for Discharge and Equipment
Penalty
Summary
The facility failed to ensure that a resident had a physician discharge order to return home, as required by their policy. This deficiency was identified for one of three residents reviewed, specifically for a resident with a history of high blood pressure, depression, and atrial fibrillation. The resident was discharged home without a documented physician discharge order, which was confirmed by the Director of Nursing during an interview. Additionally, the facility did not have a physician order for the care and management of an over the bed trapeze bar for another resident. This resident, who was admitted with diagnoses including GERD, depression, and paraplegia, was observed with a trapeze bar over their bed. However, a review of the resident's physician orders revealed no documentation for the trapeze bar, a fact also confirmed by the Director of Nursing.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two nurse aides, Employee E6 and Employee E7, as required by their Performance Evaluations policy. The policy, reviewed on June 17, 2024, mandates that each employee's job performance be reviewed and evaluated at least annually. However, upon reviewing the personnel records, it was found that NA Employee E6 did not have a performance review completed for the evaluation period from March 18, 2023, to March 18, 2024. Similarly, NA Employee E7's personnel record lacked a performance review for the period from August 1, 2023, to August 1, 2024. During an interview on October 16, 2024, the Director of Nursing confirmed the facility's failure to conduct these required evaluations. This deficiency is in violation of 28 Pa Code: 201.20 (a)(b)(c)(d) concerning staff development.
Failure to Conduct Required Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for one of the four quarterly meetings, specifically the period from December 2023 through February 2024. This deficiency was identified through a review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, dated June 17, 2024, which mandates an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and quality of life for residents. The review of the Quality Assurance and Performance Improvement sign-in sheets and attendance records revealed that the facility did not provide evidence of conducting a QAPI meeting in March 2024. During an interview on October 18, 2024, the Nursing Home Administrator confirmed the failure to conduct the required quarterly QAA meetings with all necessary committee members for the specified period.
Failure to Ensure Medication Availability for Resident
Penalty
Summary
The facility failed to implement pharmaceutical services to ensure the availability and administration of prescribed medications for a resident. The resident, who had a medical history including paraplegia, anxiety disorder, and diabetes, was prescribed Tizanidine (Zanaflex) 2 mg to be taken three times a day for spasms. However, the medication was not available on July 8th and 9th, as noted in the medication administration record (MAR). The resident reported missing the medication for about two weeks, starting from the Fourth of July weekend, due to the facility running out of the medication and delays in reordering it from the pharmacy. The facility's medication packaging policy suggests that nurses review the MAR prior to passing medications to prevent errors, but this was not effectively implemented in this case. The resident's care plan indicated that medications should be provided as ordered and their effectiveness documented, which was not adhered to. The Director of Nursing confirmed the failure to ensure the availability and administration of the prescribed medication, acknowledging the deficiency in pharmaceutical services for the resident.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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