Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Care Center during CMS and state inspections, most recent first.
The facility failed to consider and promptly address repeated Resident Council concerns about resident care and daily life. Residents reported staff using cellphones and earbuds while providing care, trash and dirty linens left in rooms, missed showers, and bed linens not being changed regularly. Meeting minutes showed these issues continued across multiple council meetings, and a resident stated they were supposed to receive showers twice weekly but had received only two showers in three weeks. The Activities Director confirmed the shower audit had still not occurred, and the NHA acknowledged the facility did not act promptly on the concerns.
Surveyors found that the facility did not follow its own transfer and bed-hold policies for a resident who was sent to the hospital. The resident, who had HTN, anxiety, and diabetes, was transferred to an acute-care provider without documented communication of key information such as care plan goals, advance directives, specific care instructions, representative contact information, and other details needed to meet the resident’s needs. The record also lacked written notice to the resident or representative about the facility’s bed-hold policy at the time of transfer. The DON confirmed these failures, which violated resident rights requirements.
A resident with HTN, dementia, and Parkinson’s disease had an MDS indicating a mechanically altered diet and physician orders specifying a pureed texture diet with certain allowed foods. Facility policy required a person-centered care plan with measurable objectives for each resident, but the resident’s care plan only stated to provide diet per order and was not updated to reflect the specific pureed diet and allowances. During an interview, an RNAC confirmed the diet should have been updated in the care plan and acknowledged the failure to maintain an individualized, person-centered care plan consistent with current MD orders.
Surveyors found that multiple resident room sinks had water temperatures too low for comfortable bathing, with readings ranging from the mid-50s°F to high-70s°F. A resident reported that the water had been very cold for months, and another described it as ice-cold and unusable. Observations showed a sink left running without staff present, and NAs reported needing to run water for extended periods or use hallway sinks because those sinks provided warmer water. The Maintenance Director acknowledged that acceptable water temperatures for bathing were not being maintained.
Meal trays repeatedly did not match resident food preferences, with residents and family reporting missing items, incorrect foods, and cold meals. Observations confirmed several errors, including a resident on a puree diet missing yogurt, another resident missing eggs, a resident missing ginger ale, and a resident who could not have tomato sauce receiving beefaroni with tomato sauce despite the tray ticket stating no tomato sauce. Staff, including an RN, CNA, DON, and Regional NHA, confirmed the inaccuracies and that the facility failed to provide food products based on resident preferences.
Improper Food Labeling and Storage in Kitchen Cooler and Freezer: Surveyors observed multiple food items in the main kitchen walk-in cooler and freezer that were not properly labeled or dated, including rolls, bacon, egg patties, and french fries. A crate of iced tea was on the floor, bacon was uncovered, and a bottle of disinfectant was stored with noodles and bread crumbs. The Dietary Manager confirmed the labeling and dating failure.
EBP was not followed for two residents with feeding tubes, as doors lacked required signage and staff were observed entering rooms without gowns. An LPN also failed to use proper hand hygiene and gloves during med pass. The facility further failed to complete infection control surveillance, monitor antibiotic stewardship, and provide or offer flu, pneumonia, and COVID vaccines for the 2025 season, and a resident with COVID did not have the required PPE signage posted.
Failure to implement antibiotic stewardship monitoring was identified when infection control surveillance records did not show antibiotic monitoring for one month. The facility’s policy required usage and outcome data to be collected on a tracking form to support resident antibiotic prescribing practices and facility-wide stewardship, but the Corporate Infection Control Nurse confirmed the monitoring was not completed for that month.
The facility failed to document that 105 of 105 residents were offered influenza and/or pneumococcal vaccines and failed to document that the resident or representative received education on the benefits and potential side effects of the immunizations. Facility policy stated residents are to be offered both vaccines and provided education, but the Corporate Infection Control employee reported the offering and provision had not been completed due to frequent management and ownership changes.
A facility failed to provide residents or their representatives with pertinent COVID-19 vaccine information, including the benefits and potential side effects, for 105 of 105 residents. Review of the 2025 vaccine documentation showed the required education was not documented, and the Corporate Infection Control Employee stated the issue was related to frequent management changes and a change in ownership.
Failure to follow up on resident grievances related to residents’ inability to reach facility departments by land line phone and extensions. Resident council minutes and a resident group interview showed ongoing concerns that residents could not get through, while the DOR and Maintenance Director gave differing explanations about phone access. The DON was informed that the facility had not followed up on these ongoing grievances.
A resident with stroke-related left-sided hemiparesis was given a disposable hot pack without a physician order and without monitoring the time it was applied to her shoulder. In a separate event, a resident with Alzheimer's disease and dementia ingested another resident's meds that were left unattended on the med cart during med pass, and the record lacked timely nurse documentation and witness statements.
The facility failed to maintain consistent and complete dialysis communication for two residents with ESRD and failed to identify the dialysis center location and chair time for another resident. One resident had dialysis orders and a care plan for treatment at one center, another resident had orders and a care plan for a different center, but their dialysis communication forms were often incomplete, missing from the binder, or undated. A third resident with ESRD, COPD, and HF had no dialysis location name or time listed in the physician orders or baseline care plan.
QAPI Program Failed to Correct Repeated Deficiencies The facility's QAPI program failed to correct multiple previously cited deficiencies that were repeated in the current survey. Findings included issues with self-administration of meds, enteral tube feeding labeling, nebulizer and respiratory equipment labeling, dialysis care planning and communication, medication regimen review, med errors, medication and insulin storage, assistance with meals, dietary sanitation, and infection control practices including EBP and handwashing. The DON and NHA were informed that the QAPI program had not corrected the prior deficiencies, with potential impact to all residents.
The facility failed to hold QAA meetings at least quarterly for three quarterly periods in 2025. Review of QAPI sign-in sheets and attendance records showed only one QAPI meeting was held, and the NHA confirmed the missed quarterly QAA meetings during interview.
Dish Machine Not Maintained in Proper Working Order: The facility failed to ensure the dish machine in the Main Kitchen was working properly. During observation, the final rinse temperature was 140 degrees Fahrenheit and the verification strip did not change color to show the required 160 degrees Fahrenheit rinse temperature. The Dietary Manager stated he was unaware the dishwasher was inoperable, directed staff to use Styrofoam containers and cups, and reported maintenance found the machine needed a new motor and would be down.
Failure to Assess Self-Administration of Medications: A resident with anxiety, depression, and PTSD was observed in bed with two unidentified medications left on the bedside table. An RN confirmed there was no documentation showing it had been determined safe for the resident to self-administer medications, and the DON confirmed the medications were stored in the room inappropriately.
Failure to assess and accommodate a resident's request for enabler rails. A resident with a hx of stroke, hemiplegia, and HTN had a BIMS score indicating intact cognition and needed partial/moderate assist to roll left and right. The resident and family said bed rails would help the resident turn side to side and feel safer and more independent, but staff stated the State does not allow side rails. The record had no documentation that enabler rails were ever evaluated, and the DON confirmed the failure.
Incomplete Posting of Required Contact Information The facility failed to post complete and current contact information for Adult Protective Services, the State LTC Ombudsman, and the correct grievance officer information on the Second and Third Floor nursing units. Observations showed missing APS contact details, no name and email for the State LTC Ombudsman, and conflicting grievance postings with multiple grievance officers listed on each unit.
A resident was observed at the nurse's station asking to use the facility phone because there was no phone in the room and no other phone available. The Maintenance Director confirmed that resident telephones for private use were not available on the 2nd and 3rd floor nursing units.
The facility failed to notify a resident’s responsible party when the resident completed skilled therapy and changed to nursing care without therapy. The resident was admitted for rehab with leukemia and chemotherapy-induced pancytopenia, but the record had no documentation that the responsible party or emergency contacts were informed. The DON confirmed the facility could not provide proof of notification.
Failure to Maintain a Homelike Environment: The facility did not maintain a clean, orderly, and homelike environment for three residents. One resident’s bathroom had linen on the floor, another resident’s bathroom contained trash bags with clothes and multiple packages of wipes on the floor, and a third resident had a soiled diaper left in a trash can that emitted a foul odor. An RN and the DON confirmed the conditions failed to provide a homelike environment.
A facility failed to complete a thorough investigation after a resident with Alzheimer’s disease, failure to thrive, and dementia was reported as possibly ingesting nonprescribed meds. The incident file lacked witness statements and a statement from the assigned nurse, and the Regional Representative confirmed the investigation was incomplete.
Incomplete and Inaccurate MDS Assessments: The facility failed to ensure that MDS assessments were accurate and fully completed for three residents. Records showed each resident was sometimes understood in Section B, yet Section C was coded as rarely/never understood and the BIMS was not completed; Section D was also inconsistently coded, with two residents marked as at least sometimes understood and one as rarely/never understood. The Regional Representative and DON confirmed the assessment errors.
Care plan was not updated for a resident with HTN, COPD, and OCD after Apixaban 5 mg BID was ordered. The care plan did not include a problem, goal, or interventions for blood thinners or bleeding risks, and the DON confirmed the omission.
Unlabeled enteral feeding bags were observed for three residents with G-tubes. The residents had orders for enteral nutrition via pump, but the tube feed bags were hanging without the required label, date, time, or staff initials showing the label was checked against the order. An RN, an LPN, and the DON confirmed the observations.
IV fluids were not administered in accordance with policy for a resident receiving D5 0.45% NS at 50 ml/hr for poor oral intake. During observation, the IV bag lacked the date, time, and initials of the person who hung it, and the IV tubing was not labeled with a date; an LPN confirmed the omissions and the DON later acknowledged the deficiency.
Respiratory care and oxygen equipment were not properly maintained for five residents receiving oxygen therapy. One resident’s nebulizer and tubing were left on a bedside stand without being labeled or stored in a plastic bag, and several residents’ oxygen tubing was observed without required date labels. In addition, one resident’s chart lacked an oxygen order, and two residents’ care plans did not include oxygen management problems, goals, or interventions. RN and LPN staff confirmed the unlabeled equipment, and the DON acknowledged the deficiency.
Medication Error Rate Exceeded Allowed Threshold: The facility had an 8% medication error rate based on 25 medication opportunities and two errors. An LPN preparing a resident’s morning Lispro insulin did not prime the pen before drawing up the 76-unit dose, and the same LPN mixed ordered Miralax into liquid protein and water, discarded the refused mixture, and did not repour the dose as ordered. The DON confirmed the error rate was above the required threshold.
A resident with diabetes and a below-the-knee amputation received an insulin administration error when an LPN did not prime the insulin pen before giving the ordered dose, contrary to manufacturer guidance. In a separate event, another resident with leukemia and pancytopenia had several ordered meds marked as held on the MAR without supporting MD hold orders, and the DON confirmed staff failed to give the meds as ordered before the resident left for an appointment.
Improper Medication and Biological Storage: The facility failed to properly store medications and biologicals in multiple med carts and med rooms. Surveyors found pre-poured meds on a cart, multiple opened inhalers, insulin products, and solutions without open dates, expired butterfly needles in a med room, and a frozen dinner entree stored in a medication refrigerator freezer. RN staff confirmed the unlabeled, expired, and improperly stored items.
Menus posted on the second and third floor nursing units showed three weeks of the current cycle with a print date of 10/25, but they did not include a RD acknowledgement that the menu weeks had been reviewed and approved. During interview, the NHA was informed that the facility had failed to properly approve the current menu cycle with the RD as required.
Failure to provide ordered adaptive eating equipment. A resident who was supposed to use a scoop plate for all meals was observed eating breakfast from a foam container after the dish machine was broken and foam items were being used. The resident stated the scoop plate was needed so she could feed herself, and the Therapy Mgr confirmed the resident was still supposed to be receiving the proper special eating equipment.
Improper Garbage Disposal and Dumpster Containment: During an observation and interview of the outdoor trash compactor and dumpster, trash and debris were seen collecting in the disposal area and the dumpster lid was open. The DM confirmed the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation.
A resident with multiple medical conditions and a goal to return home was discharged without a documented discharge plan, physician's order, or post-discharge plan of care. The facility did not include discharge planning in the care plan or provide required documentation to the resident or caregiver, as confirmed by the DON and review of records.
Surveyors found that food products in the main kitchen were improperly stored, with uncovered containers and a lack of labeling and dating, as well as unsanitary conditions such as food debris on equipment and surfaces. The Dietary Manager confirmed these failures, which created the potential for cross contamination.
Two residents with end stage kidney disease and diabetes mellitus were documented as receiving dialysis in their MDS assessments, but review of their clinical records revealed no active physician orders for dialysis. The DON confirmed the absence of these orders, resulting in a deficiency for not providing safe and appropriate dialysis care.
The facility did not ensure that wound care treatments for two residents, including those with pressure ulcers and surgical wounds, were completed and properly documented as ordered by physicians. Treatment administration records showed multiple missed or undocumented wound care interventions, as confirmed by the DON.
The facility failed to properly store and label food products, maintain cleanliness, and monitor refrigeration temperatures in the Main Kitchen. Chemicals were stored with food items, and several food products were found unlabeled, undated, or with expired dates. The kitchen also had a buildup of grease and debris, and temperature logs were not consistently maintained.
The facility failed to provide a dignified dining experience for four residents during a lunch meal service. Two residents were fed by NAs standing over them, and two others experienced delays in receiving their meal trays compared to their roommates. These actions were confirmed by facility staff, indicating a lack of dignity in the dining experience.
The facility failed to employ a qualified Food Service Director (FSD) for 99 days, as required by their job description and state regulations. The FSD position, essential for managing the Food Service Department, remained vacant, with unqualified staff overseeing operations. This deficiency was confirmed through staff interviews and a kitchen tour.
The facility failed to properly store food and maintain sanitary conditions in the kitchen, leading to potential cross-contamination. Observations revealed ground beef thawing improperly, lack of dishwasher temperature documentation, and unsanitary conditions in the dish room and ice machine. These issues were confirmed by the Dietary Manager.
The facility failed to update care plans for three residents, leading to discrepancies between the care plans and current medical orders. A resident's care plan incorrectly indicated full code status despite a DNR order and hospice consult. Another resident's care plan did not reflect current dietary orders, and a third resident's care plan encouraged fluid intake against a fluid restriction order. These issues were confirmed by facility staff.
The facility failed to provide appropriate respiratory care for three residents. A resident with COPD had a nebulizer mask without a date and not covered as required. Another resident with wheezing had a similar issue with their nebulizer mask. A third resident on oxygen therapy had a nasal cannula without a date indicating when it was last changed. These deficiencies were confirmed by staff and acknowledged by the DON.
The facility failed to maintain consistent communication with the dialysis center for two residents requiring dialysis, resulting in missing or incomplete documentation for 13 visits. Additionally, one resident's care plan lacked management details for an AV shunt, as confirmed by the DON.
The facility did not complete annual performance evaluations for three nurse aides, as required. A review of their personnel files showed no evidence of completed appraisals. The Human Resource Director indicated that a change in facility ownership contributed to this oversight, and the Nursing Home Administrator confirmed the deficiency.
The facility failed to properly store medications on four medication carts and for a resident, with issues such as undated insulin pens and an unlocked medication cart. A resident had an opened bottle of Senna in their nightstand, and staff confirmed these storage failures.
The facility failed to provide adaptive feeding devices for three residents, as required by their care plans. A resident with heart conditions was served a meal without the ordered divided plate and incorrect drink consistency. Another resident with seizure disorder and hypothyroidism, and a third resident with Alzheimer's and dementia, were both served meals on regular plates instead of divided plates. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to provide beds, mattresses, and functional furniture in 13 rooms on the first floor. The NHA stated that beds from other floors were returned to the rental company and new beds for the first floor had not yet arrived, leaving no available beds in the building. This deficiency was confirmed by the DON during a tour.
The facility failed to ensure safe self-administration of medications for two residents. One resident with mental health and cognitive disorders was observed self-administering a nebulizer solution without proper documentation or assessment. Another resident with fractures and muscle weakness was seen taking pills unsupervised, with no orders for self-administration. The Nursing Home Administrator confirmed the lack of safety determination for these residents.
Resident Council Concerns Not Addressed Promptly
Penalty
Summary
The facility failed to consider resident views and act promptly on concerns and recommendations raised through the Resident Council regarding resident care and daily life in the facility. Facility policy stated the Resident Council was intended to provide a forum for residents, families, and resident representatives to discuss concerns and suggestions for improvement, with a Resident Council Response Form used to track issues and their resolution. Meeting minutes showed repeated resident concerns about staff using earbuds and cellphones while working with residents, garbage and dirty linens not being removed from rooms for long periods of time, beds not being made, sheets not being changed when needed, and showers not occurring consistently on shower days. Resident Council minutes from February, March, and April 2026 documented that these same issues remained unresolved across multiple meetings. The minutes reflected repeated discussion of staff use of earbuds and cellphones during resident care, as well as ongoing complaints that trash and dirty linens were not being removed promptly. Nursing-related concerns also continued, including reports that showers were missed and bed linens were not changed regularly. The minutes show that the facility repeatedly discussed clarifying responsibilities and auditing shower schedules, but the concerns continued to be listed as ongoing issues month after month. A resident submitted a concern stating they were supposed to receive showers twice weekly but had received only two showers in three weeks, and that aides were constantly on their cellphones while providing care. During interviews on 5/5/26, residents reported seeing staff on cellphones and earbuds while providing care, stated that showers were not being given consistently, and reported not knowing their shower schedule. The Activities Director confirmed the shower audit had still not occurred, and the Nursing Home Administrator confirmed the facility failed to consider resident views and act promptly on concerns and recommendations for three consecutive months.
Failure to Communicate Transfer Information and Provide Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when a resident was transferred to the hospital, and failed to provide required written notice of the bed-hold policy. Facility policy on Transfer or Discharge Documentation dated 10/10/25 required that details of a transfer or discharge be documented in the medical record and that appropriate information be communicated to the receiving health care facility or provider. Facility policy on Bed-Holds and Returns dated 10/10/25 required that all residents or their representatives be provided written information regarding the facility bed-hold policy at the time of transfer. The clinical record for one resident, admitted on an unspecified date and assessed on 2/23/26 with diagnoses including hypertension, anxiety, and diabetes, showed that the resident was transferred to the hospital on 2/22/26 and did not return. Review of this resident’s clinical record revealed no documented evidence that the facility communicated specific information to the receiving health care provider for a transfer where the resident was expected to return. Missing information included the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs at the receiving facility. The record also lacked documented evidence that the resident or the resident’s representative was provided written information about the facility’s bed-hold policy at the time of the hospital transfer on 2/22/26. During an interview on 4/14/26, the Director of Nursing confirmed that the facility failed to ensure necessary resident information was communicated to the receiving provider and failed to notify the resident or representative of the bed-hold policy for this transfer, in violation of 28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.
Failure to Update Resident’s Person-Centered Diet Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to maintain an updated, person-centered care plan individualized to a resident’s specific needs. Facility policy dated 10/10/25 required that a person-centered care plan with measurable objectives and timetables be developed and implemented for each resident to address physical, psychosocial, and functional needs. For one resident, identified as R6, the care plan dated 12/30/25 only indicated to provide diet per order and did not reflect the resident’s current, specific dietary requirements. Review of R6’s clinical record showed admission on an unspecified date and an MDS dated 3/30/26 documenting diagnoses of hypertension, dementia, and Parkinson’s disease, with MDS Section K indicating a mechanically altered diet. Physician orders dated 4/10/26 specified a pureed texture diet with allowance for bananas, cakes, and soft cookies. However, these detailed diet orders were not incorporated into the resident’s care plan. During an interview on 4/14/26, the RN Assessment Coordinator confirmed that the diet should have been updated in the care plan to reflect the current physician orders and acknowledged that the facility failed to ensure an updated, individualized, person-centered care plan for this resident, in violation of 28 Pa. Code 201.24(e)(1)(5) and 211.12(d)(1)(3)(5).
Failure to Maintain Acceptable Hot Water Temperatures for Resident Bathing
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not maintaining acceptable hot water temperatures for bathing in multiple resident rooms. Review of the facility’s "Homelike Environment" policy dated 10/7/25 showed the facility’s obligation to provide such an environment. During a tour with the Maintenance Director, surveyors measured water temperatures at resident room sinks and found them to be significantly below acceptable levels for bathing: 60°F for Resident R1, 59°F for Resident R2, 77°F for Resident R3, 55°F for Resident R4, 73°F for Resident R5, and 79°F for Resident R6. Resident interviews confirmed ongoing issues with water temperature. One resident stated the water was very cold and reported it had been that way for six months, while another described the water as ice-cold and not suitable even for washing a dog. During observation, a resident’s sink was seen running with no staff present, and a nurse aide reported that staff sometimes had to let the water run for up to 30 minutes to get it warm enough for bathing. Another nurse aide stated that staff sometimes used hallway sinks instead of resident room sinks because the hallway sinks, being used more often, tended to have warmer water. The Maintenance Director confirmed that the facility failed to maintain acceptable water temperatures for bathing for six of seven sampled residents.
Meal trays did not match resident food preferences
Penalty
Summary
The facility failed to provide residents with food products based on their preferences for 18 of 27 residents. The report states that the facility policy required resident food preferences to be obtained within 72 hours of admission and entered into the electronic meal tracking system, but multiple residents and staff reported repeated meal inaccuracies and missing items on trays. During interviews, residents stated that meals were often not what they selected, items were missing, and the problem happened across breakfast, lunch, and dinner. Observed meal trays confirmed several inaccuracies. Resident R10, who was on a nectar thick puree diet and had diagnoses including parkinsonism, cerebrovascular accident, and takotsubo syndrome, was supposed to receive two yogurts, nectar thick orange juice, nectar thick milk, puree hot cereal, and puree French toast, but no yogurt was on the tray. Resident R43, who had diagnoses including cerebral ischemia, high blood pressure, and cerebrovascular accident, stated he did not eat breakfast because he did not want French toast and the eggs were not sent; the tray ticket listed scrambled eggs, but none were provided. Resident R70 reported missing ginger ale on lunch trays, and observation confirmed the tray ticket included ginger ale but none was present. Resident R108 stated they could not have tomato sauce, yet the lunch tray contained beefaroni with tomato sauce even though the tray ticket clearly indicated pasta with no tomato sauce. Other residents and family members reported ongoing concerns that food was cold, items were missing, and requested foods such as yogurt or kosher foods were not consistently provided. During interviews, staff members confirmed the trays were incorrect and that the facility failed to provide residents with food products based on their preferences. The DON and Regional Nursing Home Administrator also confirmed the facility failed to provide residents with food products based on their preferences for 18 of 27 residents.
Improper Food Labeling and Storage in Kitchen Cooler and Freezer
Penalty
Summary
The facility failed to properly label and date food products in the walk-in cooler and freezer in the designated main kitchen. A review of the facility Food Storage policy dated 10/7/25 indicated that food storage areas shall be maintained in a clean, safe, and sanitary manner. During an observation of the main designated kitchen on 11/18/25 at 10:30 a.m., surveyors observed a crate of iced tea on the floor of the walk-in cooler, two bags of rolls out of the original package with no label or date, bacon not covered with no label or date, one bag of egg patties with no label or date, two bags of french fries with no label or date, and a bottle of disinfectant stored on the shelf with noodles and an open container of bread crumbs. During an interview on 11/18/25 at 11:15 a.m., the Dietary Manager confirmed that the facility failed to properly label and date food products.
Infection Control and EBP Failures
Penalty
Summary
Enhanced barrier precautions were not followed for two residents with enteral feeding tubes. Resident R60 was admitted with malnutrition, schizophrenia, and anemia, and had a physician order for EBP for a G-tube. On observation, the resident’s door had no signage for EBP or PPE outside the room, and staff were seen entering and exiting without gowns. RN E4 later confirmed the missing signage and PPE requirement was not in place as required. Resident R99 was admitted with respiratory failure, larynx cancer, and a tracheostomy. Her physician order indicated EBP for wounds and a feeding tube, but it did not include the tracheostomy status requiring EBP. On observation, her door also had no signage for EBP or PPE outside the room, and staff were seen going in and out without donning gowns. The resident indicated staff did not wear gowns while providing care, and RN E4 confirmed the missing signage. During a medication pass observation, LPN E6 failed to use proper handwashing and gloving technique by popping several medications into a bare hand and then placing them into a medication cup. In addition, the facility did not complete infection control surveillance from November 2024 through November 2025, did not monitor antibiotic stewardship for May 2025, and did not provide or offer flu, pneumonia, or COVID-19 vaccines for the 2025 season to 105 of 105 residents. Resident R116 was admitted with a fracture of the right lower leg and COVID, but no signage was noted to identify required PPE, the door was open, and the PPE on the door did not include all required items. The DON and corporate infection control staff confirmed the failures in infection control practices, surveillance, antibiotic monitoring, and vaccine documentation.
Failure to Implement Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for one of 11 months, May 2025. Review of the facility’s infection control policies and procedures showed that the Antibiotic Stewardship Program required usage and outcome data to be collected and documented on a facility tracking form to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. However, review of the facility’s infection control surveillance records for December 2024 through November 2025 did not include documentation showing that antibiotic monitoring was completed for May 2025. During interview on 11/19/25 at 1:30 p.m., the Corporate Infection Control Nurse confirmed that the facility failed to implement an antibiotic stewardship program for May 2025.
Failure to Document Influenza and Pneumococcal Vaccine Offers and Education
Penalty
Summary
The facility failed to document that each resident was offered influenza and/or pneumococcal immunization and failed to document that the resident or the resident's representative received education about the benefits and potential side effects of the vaccines for 105 of 105 residents reviewed. A review of the facility's Pneumococcal Vaccine and Influenza Vaccine policies, dated 10/17/25 with a previous review date of 9/25/24, stated that vaccines are administered according to CDC recommendations, that all residents are offered pneumococcal and influenza vaccines, and that the resident or legal representative will be provided information and education regarding benefits and potential side effects, with documentation in the medical record. During interview, the Corporate Infection Control employee stated that due to frequent changes in facility management and ownership, the offering and provision of the flu and pneumonia vaccines had not been completed.
Failure to Provide COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that pertinent information regarding COVID-19 immunizations was provided to residents or their representatives, including the benefits and potential side effects of the COVID-19 vaccine, for 105 of 105 residents. Review of the Infection Control Practices for the 2025 vaccine documentation showed that this information was not included in the records. During interview, the Corporate Infection Control Employee stated that frequent changes in the facility management team and change in ownership contributed to the facility's failure to provide the required immunization information to residents or their representatives.
Failure to Follow Up on Resident Grievances
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal and did not establish prompt follow-up on grievances for eleven residents. The facility policy dated 2/1/25 stated that residents, resident representatives, and responsible parties have the right to voice concerns and file grievances, with the grievance official to acknowledge receipt within 3 business days and issue a written decision within one week unless extenuating circumstances existed. Review of resident council minutes from July 2025 through October 2025 showed ongoing resident concerns about using land line telephones in resident rooms and department phone extensions, with residents reporting they were unable to get through. During a resident group interview on 11/17/25, residents stated they could not get in touch with facility departments and were given a list of extensions that they were unable to use with the current phone system. During interviews on 11/18/25 and 11/19/25, the Director of Activities and Maintenance Director gave differing explanations about whether residents with land lines could use the extensions or had to call the facility number and be connected. On 11/21/25, the DON was informed that the facility failed to follow up on resident grievances for ongoing resident concerns.
Unsafe Hot Pack Use and Inadequate Supervision During Medication Pass
Penalty
Summary
The facility failed to protect Resident R111 from a potential burn accident when a disposable hot pack was provided without a physician order and without monitoring the time it was placed on the resident's left shoulder. During observation, the resident asked a staff aide to get the hot pack from the bedside stand drawer and place it on her left shoulder, and the aide saw the disposable hot pack and said the nurse would be told. The resident stated that the nurses always give her hot packs. Review of the clinical record showed the resident was admitted with diagnoses including stroke causing left-sided hemiparesis, and the current physician's orders did not include use of a hot pack. An LPN confirmed the resident did not have an order for a hot pack, and a PT stated that therapy does not keep hot packs because nursing keeps disposable hot packs on the unit. The facility also failed to provide adequate supervision for Resident R20 during med pass. Resident R20 was admitted with diagnoses including Alzheimer's disease, adult failure to thrive, and dementia. Review of progress notes and the incident summary showed that on 10/31/25 the resident ingested another resident's medications that had been left unattended on the med cart, with documentation indicating the resident may have taken a sip of medication mixed with water on top of the medication cart. The record also showed no nurse progress note until 11/1/25, and the facility provided no statement from the nurse on R20's assignment or any witness statements. The regional representative confirmed the facility failed to provide adequate supervision for Resident R20 as required.
Incomplete Dialysis Communication and Missing Dialysis Location Information
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required dialysis services. Resident R6 had diagnoses of ESRD, hypertension, and anxiety disorder, with physician orders and a care plan directing dialysis at Fresenius Kidney Care on Tuesday, Thursday, and Saturday with an 11:45 a.m. chair time. Review of the dialysis communication forms from 10/1/25 through 11/18/25 showed multiple forms with incomplete clinical documentation, several forms not found in the nursing unit dialysis binder, and three undated forms with incomplete clinical data. Resident R24 had diagnoses of ESRD, hypertension, and atrial fibrillation, with physician orders and a care plan directing dialysis at Davita Northside on Monday, Wednesday, and Friday with a 6:00 a.m. chair time. Review of the dialysis communication forms from 10/1/25 through 11/18/25 showed multiple forms with incomplete clinical documentation and several forms not found in the nursing unit dialysis binder. In addition, Resident R120, who had diagnoses including COPD, heart failure, and ESRD, did not have the location name and time of the dialysis center identified in the current physician orders or baseline care plan. Staff interviews confirmed the facility failed to provide consistent and complete communication with the dialysis center for Residents R6 and R24 and failed to identify the dialysis center location and time for Resident R120.
QAPI Program Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility's QAPI program failed to correct previously cited deficiencies identified in the prior State Survey and Certification survey ending 12/6/24. Review of the facility documentation showed that the QAPI policy described a process for measuring indicators, implementing performance improvement projects, and monitoring corrective actions, but the current survey found repeated deficiencies across multiple areas that had already been cited and addressed in prior plans of correction. Repeated deficiencies were identified related to self-administration of medications for one resident, enteral tube feeding via continuous pump labeling for three residents, nebulizer and respiratory equipment labeling for five residents, dialysis care physician orders and care planning for three residents, medication regimen review for one resident, medication error rate greater than 5% for one resident with an 8% error rate, medication storage and insulin storage in three medication carts and two medication rooms, assistance with meals and special equipment for one resident, dietary sanitation and food storage including refrigerator temperature logs, and enhanced barrier precautions and handwashing for two residents with enteral feeding tubes and one resident observed during medication administration. During interview on 11/21/25 at 12:00 p.m., the DON and NHA were informed that the facility's QAPI program failed to correct the previously cited deficiencies. The report states this had the potential to affect 105 of 105 residents.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly for three of three quarterly meetings in 2025, covering quarters one, two, and three. Review of Quality Assurance and Performance Improvement (QAPI) sign-in sheets and attendance records showed only one QAPI meeting was held in 2025, on October 16, 2025. During an interview on 11/20/25 at 8:35 a.m., the Nursing Home Administrator confirmed the facility failed to conduct QAA meetings at least quarterly as required.
Dish Machine Not Maintained in Proper Working Order
Penalty
Summary
The facility failed to ensure the dish machine was in proper working order in the Main Kitchen. During observation of the dish room, the final rinse temperature was 140 degrees Fahrenheit, and the dishwasher temperature verification strip did not change color, indicating it did not meet the proper rinse temperature of 160 degrees Fahrenheit. During interview, the Dietary Manager confirmed he was not aware the dishwasher was inoperable and had directed staff to use Styrofoam containers and cups. He also stated maintenance staff had looked at the dish machine and determined it needed a new motor and would be down. On a later interview, the Dietary Manager again confirmed the facility failed to ensure the dish machine was in proper working order in the Main Kitchen.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for Resident R42 to self-administer medications. The facility policy on Resident Self-Administration of Medications, dated 10/7/25, stated that residents may self-administer medications only if the interdisciplinary team determines the practice is clinically appropriate and documents assessment items including medication storage, responsible party for storage, documentation of administration, and the location where drugs will be administered. Resident R42 was admitted to the facility and had an MDS dated 10/13/25 that listed anxiety, depression, and PTSD. On 11/17/25 at 9:45 a.m., the resident was observed in bed with two unidentified medications on the bedside table. At 10:00 a.m., an RN confirmed the medications were left at bedside and that there was no documentation showing it had been determined safe for the resident to self-administer medications. At 2:30 p.m., the DON confirmed the medications were stored in the resident room inappropriately and that the facility had failed to determine whether it was safe for Resident R42 to self-administer medications.
Failure to Assess and Accommodate Request for Enabler Rails
Penalty
Summary
The facility failed to assess and accommodate a resident's request for enabler rails. The facility policy on Accommodation of Needs stated that the environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Review of the clinical record for Resident R13 showed admission to the facility, a MDS dated 11/15/25 with diagnoses of stroke, hemiplegia, and high blood pressure, a BIMS score of 14 indicating the resident was cognitively intact, and a GG0170 score of 3 for rolling left and right, meaning the resident required partial/moderate assistance. During an interview on 11/17/25, the resident and a family member stated the resident would feel a lot safer and more independent if the bed had rails to help with turning side to side. When asked why the resident did not have rails, the response was that the State does not allow side rails. Review of the clinical record did not show documentation that enabler rails were ever evaluated for the resident, and the DON confirmed the facility failed to assess and accommodate the resident's request for enabler rails.
Incomplete Posting of Required State Agency and Grievance Contact Information
Penalty
Summary
The facility failed to post complete and current contact information for Adult Protective Services, the State Long Term Care Ombudsman, and correct grievance officer information on two nursing units, the Second Floor and Third Floor. During observations on 11/17/25 and 11/19/25, the postings on these units did not reveal the contact information for Adult Protective Services, the name and email of the State Long Term Care Ombudsman, and contained conflicting grievance information, with three grievance processes posted on the second floor and four posted on the third floor, along with multiple grievance officers listed on each posting. During an interview on 11/19/25 at 3:16 p.m., the Nursing Home Administrator was informed of these findings.
Lack of Resident-Only Telephones on Nursing Units
Penalty
Summary
The facility failed to ensure that all residents had access to a resident-only telephone on the second and third floor nursing units. During an observation on 11/18/25 at 12:20 p.m., Resident R100 was at the nurse's station on the third floor and asked to use the facility phone, stating that they do not have a phone in their room and that this is always the phone they use to call their loved one. Resident R100 also stated that there is no other phone to use. During an interview on 11/19/25 at 12:43 p.m., the Maintenance Director, Employee E11, confirmed that the facility does not have resident telephones for private use on the second and third floor nursing units.
Failure to Notify Responsible Party of Therapy Discharge
Penalty
Summary
The facility failed to notify the resident’s responsible party of a change in nursing care status when Resident R119 completed skilled nursing care with therapy and transitioned to nursing care without therapy. The clinical record showed the resident was admitted with leukemia, unspecified not having reached remission, and antineoplastic chemotherapy induced pancytopenia, and was admitted for therapy and rehabilitation. The record indicated therapy was completed on 10/7/2025, but there was no documentation that the resident’s responsible party or emergency contacts were informed of the discharge from therapy. Interviews on 11/20/25 and 11/21/25 indicated that neither of the responsible parties listed on the admission sheet and involved in the resident’s care were notified of the change in condition, and the DON confirmed on 11/21/25 that the facility could not provide documentation showing the responsible party/emergency contact was informed of completion of therapy and the change in nursing care status.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents. A review of the facility’s Homelike Environment policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment and that staff and management are to maximize characteristics of a personalized, homelike setting, including a clean, sanitary, and orderly environment. The cited regulation also required housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. During observations, Resident R7’s bathroom had linen on the floor, and the resident stated she did not know the linen was there. Resident R24’s bathroom had two trash bags with clothes on the floor and approximately 18 packages of wipes. Resident R24 was not in the room at the time. RN E9 later confirmed the conditions of the bathrooms for Residents R7 and R24 and stated the facility failed to provide a homelike environment. In a separate observation, Resident R46 had a soiled diaper lying in his trash can that emitted a foul odor, and his wife stated she thought he was soiled but that it was from the diaper left in the can. LPN E6 removed the diaper and apologized to the resident’s wife, and the DON confirmed the facility failed to maintain a homelike environment for these three residents.
Incomplete Investigation of Possible Medication Ingestion
Penalty
Summary
The facility failed to initiate a thorough investigation for an incident involving Resident R20, who was admitted with diagnoses including Alzheimer's disease, adult failure to thrive, and dementia. The resident's MDS dated 11/9/25 showed the diagnoses remained current. Nursing progress notes dated 11/1/25 at 5:52 a.m. documented that the MD on rounds had been informed earlier that the resident may have ingested nonprescribed medications. Review of the incident investigation showed there were no witness statements and no statement from the nurse assigned to R20. During an interview on 11/20/25 at 2:30 p.m., the Regional Representative confirmed the facility did not conduct a complete investigation of the incident as required.
Incomplete and Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for three residents. The Long-Term Care Facility Resident Assessment Instrument User's Manual dated October 2024 stated that Section C, Question C0100 should be coded as 0 if a resident is rarely or never understood, or coded as 1 and the BIMS completed if the resident is at least sometimes understood. It also stated that Section D, Question D0100 should be coded as 0 if a resident is rarely or never understood, or coded as 1 and the mood interview completed if the resident is at least sometimes understood. Review of the records for three residents showed that each was coded in Section B as sometimes understood, yet Section C was coded as rarely/never understood and the BIMS was not completed. For two residents, Section D was coded as 1, indicating they were at least sometimes understood, while for the third resident Section D was coded as 0, indicating rarely/never understood. During interviews, the Regional Representative and the DON confirmed that the facility failed to make certain the MDS assessments were accurate and fully completed for these three of twelve residents.
Care Plan Missing Blood Thinner Information
Penalty
Summary
The facility failed to update the care plan for one resident to accurately reflect the resident's current status. Review of the facility's Comprehensive Person-Centered Care Plans policy dated 10/7/254 indicated that the care plan should describe services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including services for each element of care. Review of the resident's admission record showed she was admitted on [DATE], and the MDS dated 9/5/25 listed diagnoses of hypertension, COPD, and OCD. Current physician orders included Apixaban 5 mg twice daily, but review of the care plan on 11/20/25 at 12:00 p.m. showed it did not include a problem, goal, or interventions for blood thinners or the risks involved for bleeding. During interview on 11/20/25 at 12:05 p.m., the DON confirmed the facility failed to update the care plan for this resident to accurately reflect the current status.
Unlabeled enteral feeding bags observed for three residents
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications for three residents with G-tubes. Facility policy for enteral feedings required staff to verify the enteral nutrition label against the order before administration and to document the resident name, identification, room number, formula type, preparation date and time, route, access site, method, rate, and initials showing the label was checked against the order. Resident R60 had diagnoses including malnutrition, schizophrenia, and anemia, and had an order for Osmolite 1.5 via cyclic feeds through a G-tube at 110 ml/hr by pump from 6:00 p.m. to 6:00 a.m. During observation, the tube feed bag was hanging on the pole without a label, date, time, or the name of the person who hung it. Resident R99, with diagnoses including respiratory failure, larynx cancer, and tracheostomy, had an order for Jevity 1.5 via continuous feeding through a G-tube at 55 ml/hr by pump to a total volume of 1100 ml, and the tube feed bag was also observed hanging without a label, date, time, or the name of the person who hung it. Resident R117, with diagnoses including bipolar disease, adult failure to thrive, and muscle weakness, had an order for Nutren 2.0 via cyclic feeds through a G-tube at 50 ml/hr by pump for 20 hours, and the tube feed bag was likewise observed hanging without a label, date, time, or the name of the person who hung it. Nursing staff confirmed these observations, and the DON confirmed the facility failed to ensure appropriate treatment and services for these residents.
IV Fluids Not Properly Labeled
Penalty
Summary
The facility failed to provide prescribed parenteral fluids consistent with professional standards of practice for one resident, R93. The resident was admitted to the facility and had diagnoses including anemia, high blood pressure, and peripheral vascular disease. A physician order dated 11/17/25 directed Dextrose-Sodium Chloride IV solution 5-0.45 percent at 50 ml/hr intravenously every shift for poor oral intake. During an observation on 11/17/25 at 11:20 a.m., R93 was seen in bed receiving IV fluids through a peripheral catheter in the left wrist at 50 ml/hr. The IV fluid bag did not indicate the date, time, or who hung the bag, and the IV administration set tubing was not labeled with a date as required by facility policy. An LPN confirmed these labeling omissions during interview, and the DON later confirmed that the facility failed to provide the prescribed parenteral fluids consistent with professional standards of practice for R93.
Respiratory Care and Oxygen Equipment Not Properly Maintained
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for five sampled residents who were receiving oxygen therapy. Facility policy required oxygen cannulas and tubing to be changed every seven days or as needed, with oxygen tubing kept in a plastic bag when not in use, and nebulizer circuits stored in a plastic bag marked with the resident’s name and date between uses. The report identified deficiencies involving Residents R35, R74, R99, R105, and R120, all of whom had physician orders or care plan references related to oxygen use. Resident R35 had diagnoses including hypertension, COPD, and heart failure, and her physician orders directed weekly oxygen tubing changes with labeling and placement of clean tubing in a plastic bag. Her care plan did not include a problem, goal, or interventions for oxygen management. During observation, she was in bed using oxygen, but the tubing was not labeled with a date and the nebulizer and tubing were left on the bedside stand without being labeled or stored in a plastic bag. RN E1 confirmed these conditions. Resident R74 was observed in bed using oxygen, but her tubing was not labeled with a date, and her current physician orders did not include an order for oxygen administration even though her care plan referenced oxygen settings per orders. Resident R99, who had respiratory failure, larynx cancer, and a tracheostomy, was observed using oxygen through an aerosol trach mask, and the tubing was not labeled with a date. Resident R105, with diagnoses including hypertension, COPD, and OCD, had a care plan that did not include a problem, goal, or interventions for oxygen management, and her oxygen tubing was also not labeled with a date. Resident R120, with COPD, heart failure, and end stage renal disease, was observed using oxygen and her tubing was not labeled with a date. LPN E3 confirmed the unlabeled equipment for Residents R99, R105, and R120, and the DON confirmed the facility failed to provide appropriate respiratory care and maintain oxygen equipment for the five residents.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent for Resident R19, with a documented error rate of 8% based on 25 medication opportunities and two medication errors. During a medication observation on 11/18/25 at 8:11 a.m., an LPN prepared to administer R19’s morning Lispro insulin dose and verified the correct insulin and dose, but was not aware that the pen needed to be primed before drawing up the 76-unit dose. During the same observation, the LPN also failed to properly administer 17 grams of Miralax ordered for R19; the nurse mixed the Miralax into liquid protein and water, the resident refused the mixture, the nurse discarded it, and did not repour the Miralax as ordered. The DON later confirmed that the facility failed to ensure a medication error rate below five percent.
Significant medication errors involving insulin administration and missed ordered medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors. For Resident R19, who had diagnoses including Charcot joint, diabetes, and a right below-the-knee amputation, the physician ordered Insulin Lispro 100 units/mL, 76 units subcutaneously each morning for breakfast, with the meal sitting in front of the resident. During medication observation, an LPN prepared to administer the insulin but did not prime the insulin pen before drawing up the 76-unit dose. The LPN stated she was not aware of the manufacturer’s guideline requiring the pen to be primed before each injection, and the DON later confirmed the facility failed to administer the correct dose by not priming the insulin pen needle as required. For Resident R119, who had leukemia and antineoplastic chemotherapy-induced pancytopenia, physician orders included multiple medications such as isavuconazonium sulfate, letermovir, levofloxacin via PEG tube, magnesium oxide, and olanzapine. The MAR showed code 16 for these medications, indicating they were outside parameters for administration or held per MD orders, but the clinical record did not include physician orders authorizing holds. The DON confirmed the medications were not given as ordered because staff failed to realize the resident was out to an appointment and the medications needed to be given before leaving the facility.
Improper Medication and Biological Storage
Penalty
Summary
The facility failed to store medications and biologicals properly in three medication carts and two medication rooms. During observation of the Second Floor East medication cart, pre-poured morning medications were found for residents R25, R42, R32, and R108, and several opened medications were not labeled with a date, including ipratropium solution, albuterol nebulizer solution, budesonide solution, and a Lantus insulin pen. RN E5 confirmed that the medications had been pre-poured and not administered at the time of dispensing as required, and that the identified medications were not labeled with a date when opened. Additional observations found opened medications without dates on the Second Floor South medication cart, including a Trelegy inhaler and ipratropium solution, and on the Third Floor South medication cart, including liraglutide, Lantus insulin pens and vials, Novolog insulin pen, Humalog insulin pens and vials, Breolipta inhaler, fluticasone inhaler, and albuterol inhalers and vials. In the Third Floor medication room, a package of butterfly needles had expired, and RN E9 confirmed they should have been disposed of. In the Second Floor medication room, a frozen dinner entree was stored in the medication refrigerator freezer, and RN E9 confirmed it was not permitted there. The DON confirmed the facility failed to store medications and biologicals properly for the identified carts and medication rooms.
Menu Cycle Not Approved by Registered Dietician
Penalty
Summary
The facility failed to properly approve the current menu cycle with the registered dietician for two of two nursing units, the second and third floor nursing units. During observation on 11/17/25 and 11/18/25, menus were posted on both units showing three different weeks with a print date of 10/25, but the menus did not include a registered dietician acknowledgement that the weeks of the diet menu had been reviewed and approved. During interview on 11/18/25, the NHA was informed that the facility had failed to properly approve the current menu cycle with the registered dietician as required.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who needed them and failed to ensure appropriate assistance with meal consumption. During observation on 11/18/25, Resident R111 was attempting to eat breakfast from a foam container and stated that she was supposed to have a scoop plate so she could feed herself, but the dish machine had been broken and the facility had been using foam. Review of the resident’s current care plan showed that a scoop dish was to be used for all meals. During interview on 11/21/25, the Therapy Manager stated she could not provide documentation for the assessment for need of a scoop plate because it was before WE Care took over, but confirmed the resident was still supposed to be receiving it and that the facility failed to provide proper special eating equipment for Resident R111.
Improper Garbage Disposal and Dumpster Containment
Penalty
Summary
The facility failed to properly contain and dispose of garbage in the outside dumpster area. During an observation and interview of the outdoor trash compactor and dumpster, trash and debris were seen collecting in the disposal area, and the dumpster lid was open. The Dietary Manager confirmed these conditions and acknowledged that the facility failed to properly contain and dispose of garbage in the outside dumpster area to prevent potential rodent and insect infestation.
Failure to Develop and Implement Resident-Centered Discharge Planning
Penalty
Summary
The facility failed to develop and implement discharge planning processes that focused on a resident's discharge goals, as required by facility policy and regulatory standards. Specifically, for one resident with diagnoses including cerebral infarction, Moyamoya disease, and diabetes mellitus, who was assessed as cognitively intact and expressed a goal to return to the community, the facility did not document a comprehensive discharge plan or goals of care related to returning home. Although the resident and physician discussed plans for discharge to home with a paid caregiver, these plans were not reflected in the resident's care plan or supported by appropriate documentation in the clinical record. The facility's policies require that a post-discharge plan be developed and reviewed with the resident or their representative at least 24 hours before discharge, and that nursing services obtain discharge orders, prepare summaries, and provide necessary documentation to the resident or caregiver. However, the clinical record for the resident did not contain evidence of a physician's order for discharge, a documented discharge summary, or a post-discharge plan of care. Additionally, there was no documentation that the required information was communicated to the receiving provider or that the resident or caregiver received the necessary discharge documents. During an interview, the DON confirmed that the facility did not develop or implement discharge planning processes that addressed the resident's discharge goals. The lack of documentation and planning was identified through a review of facility policy, clinical records, and staff interviews, and was found to be out of compliance with several state regulatory requirements regarding resident care policies, management, and resident rights.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors observed multiple deficiencies in the main kitchen, including a container of mashed potatoes and a container of food thickener that were both left uncovered, with the thickener also lacking a label and date. Additional findings included dried food and brown debris on a food slicer, dried food and debris on a roucoup, food debris in a steamer, food debris on the bottom storage shelving of the steam table, and brown debris on the wall and ceiling beside the clean side of the dishwasher. During an interview, the Dietary Manager confirmed that these conditions represented failures in proper food storage and maintaining sanitary conditions, creating the potential for cross contamination. No information about specific residents or their medical conditions was provided in the report.
Failure to Maintain Active Physician Orders for Dialysis
Penalty
Summary
The facility failed to maintain active physician orders for dialysis for two residents diagnosed with end stage kidney disease and other significant health conditions. Review of the clinical records showed that both residents were admitted with diagnoses including end stage kidney disease and diabetes mellitus, and their Minimum Data Set (MDS) assessments indicated they were receiving dialysis while residing in the facility. However, upon review of their physician orders, it was found that neither resident had an active order for dialysis at the time of the survey. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the physician orders for both residents did not include dialysis, despite documentation in the MDS that dialysis was being provided. The lack of active physician orders for dialysis was cited as a failure to provide safe and appropriate dialysis care and services, as required by state regulations.
Failure to Document and Complete Pressure Ulcer and Wound Care Treatments
Penalty
Summary
The facility failed to accurately assess and document pressure ulcer care for two residents. One resident, with a history of chronic obstructive pulmonary disease, hypertension, and anxiety, was admitted with an unstageable pressure ulcer. Physician orders directed specific wound care, including cleansing, application of betadine, and leaving the wound open to air with changes every shift. However, treatment administration records showed multiple dates where the prescribed wound care was not documented as completed over two consecutive months. Another resident, with diagnoses including chronic obstructive postlaminectomy syndrome, diabetes mellitus, and morbid obesity, had a lumbar spine surgical wound. Physician orders required daily wound cleansing and dressing changes. Treatment administration records for this resident also revealed several dates where the required wound care was not documented as completed. The Director of Nursing confirmed that the facility failed to complete treatments as ordered for both residents.
Deficiencies in Food Storage and Sanitation in Main Kitchen
Penalty
Summary
The facility failed to adhere to its own policies regarding food storage and sanitation in the Main Kitchen. Observations revealed that dish machine chemicals were improperly stored on the same rack as food items, and food products in the storeroom were not dated with receiving dates. Additionally, several coolers contained unlabeled and undated food items, including pre-portioned containers of pineapple chunks, diced peaches, chef salads, fruit cocktail, applesauce, mayonnaise, and slaw dressing. Some sandwiches were found with expired dates, and cases of juice and milk were stored directly on the floor of the walk-in refrigerator. Furthermore, food products were found out of their original cases without proper labeling and dating. The facility also failed to maintain cleanliness and sanitation standards in the Main Kitchen. The exhaust hood, air vents, bulkhead over food preparation tables, stove top, and grill were observed to have a buildup of grease, dust, debris, food particles, and spillage. Additionally, the facility did not consistently monitor and record refrigeration/freezer temperatures twice daily as required. These deficiencies were confirmed by the Nursing Home Administrator and Registered Dietitian, indicating a failure to maintain a clean, safe, and sanitary environment, which could potentially lead to foodborne illness.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for four residents during a lunch meal service. Observations revealed that two residents, who required assistance with feeding, were fed by nursing assistants standing over them while they lay in bed. This practice was confirmed by a Registered Dietitian and a Registered Nurse Manager, who acknowledged that standing over residents while feeding them did not provide a dignified dining experience. Additionally, there were issues with the timely delivery of meal trays. Two residents did not receive their meal trays at the same time as their roommates, leading to delays. One resident was observed standing at the door of his room, inquiring about his meal tray, while his roommate had already received theirs. The Registered Dietitian confirmed that the facility failed to properly organize the meal tray delivery, resulting in a delay and a lack of dignity in the dining experience for these residents.
Lack of Qualified Food Service Director for 99 Days
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) to manage the daily operations of the Food Service Department for a period of 99 days. The job description for the FSD, dated September 25, 2024, outlined the responsibilities of planning, organizing, developing, and directing the overall operation of the Food Services department in accordance with established standards and regulations. The position required the individual to be a graduate of an accredited dietetic training course approved by the American Dietetic Association or to be registered as a Food Service Director in Pennsylvania. During a tour of the Main Kitchen on February 19, 2025, a Registered Dietitian confirmed that the facility did not employ a Food Service Director at that time. Further interviews with the Nursing Home Administrator on February 19 and 20, 2025, confirmed that the facility had not provided a full-time FSD since November 24, 2024. The individuals who were sharing the responsibility of overseeing the daily operations of the main kitchen did not meet the educational and qualification requirements for the FSD position, resulting in the facility's failure to provide a qualified director for the food services department.
Improper Food Storage and Sanitation Issues in Kitchen
Penalty
Summary
The facility failed to properly store food products and maintain sanitary conditions in the main kitchen, which created the potential for cross-contamination. During an observation, two packages of ground beef were found thawing on the third shelf of the walk-in cooler, and there was no documentation available to verify the dishwasher's temperature. Additionally, the dish room contained a floor fan with brown debris, walls with food debris, and an ice machine with a brown, slimy substance. These conditions were confirmed by the Dietary Manager, Employee E11, during an interview.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update care plans for three residents, which did not accurately reflect their current medical status and needs. Resident R33's care plan incorrectly indicated the resident as a full code, despite having a POLST indicating Do Not Attempt Resuscitation and a hospice consult order. Additionally, the care plan did not include a plan for hospice care, which was confirmed by the Director of Nursing. Resident R60's care plan was not updated to reflect the current dietary orders, as it still indicated a different texture and consistency than what was prescribed by the physician. Similarly, Resident R4's care plan encouraged fluid intake, contrary to the physician's order for a fluid restriction. These discrepancies were confirmed by the Registered Dietitian and the Director of Nursing, highlighting the facility's failure to revise care plans as required by their policy and state regulations.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by observations and staff interviews. Resident R19, diagnosed with schizoaffective disorder, bipolar disorder, and dementia, had a physician's order for Ipratropium-Albuterol Solution via nebulizer for COPD. However, the nebulizer mask was found on the bedside stand without a date and not covered with a bag, contrary to facility policy. Similarly, Resident R42, with a history of stroke, hemiplegia, and Alzheimer's disease, had orders for albuterol sulfate via nebulizer for wheezing. The nebulizer mask for this resident was also observed on the bedside stand without a date and not covered with a bag. Resident R53, diagnosed with heart failure, high blood pressure, and depression, required oxygen via nasal cannula. During an observation, the nasal cannula was found without a date indicating when it was last changed, which is a deviation from the facility's policy on respiratory therapy infection prevention. Interviews with the Unit Manager RN and another RN confirmed these deficiencies, and the Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for these residents.
Inadequate Dialysis Communication and Care Planning
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents, both of whom required dialysis services. Resident R63, diagnosed with high blood pressure, end-stage renal disease (ESRD), and heart failure, had physician orders for dialysis three times weekly. However, the dialysis communication sheets for Resident R63 were missing or incomplete for the past 13 dialysis visits. This was confirmed by the Unit Manager RN, indicating a lack of proper documentation and communication with the dialysis center. Similarly, Resident R86, also diagnosed with heart failure, high blood pressure, and ESRD, had physician orders for dialysis three times weekly and required monitoring of an AV shunt. The care plan for Resident R86 failed to include care and management of the AV shunt, and the dialysis communication sheets were also missing or incomplete for the past 13 visits. The Director of Nursing confirmed the facility's failure to provide consistent communication with the dialysis center and the lack of a care plan for monitoring the access site for Resident R86.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for three nurse aides, identified as Employees E14, E15, and E16. A review of their personnel files showed no documented evidence of completed annual appraisals as required. Employee E14 was hired in 1988, Employee E15 in 2019, and Employee E16 in 2022. An interview with the Human Resource Director revealed that the facility changed ownership in May 2024, which contributed to the inability to produce the required evaluations. The Nursing Home Administrator confirmed the failure to complete these evaluations, which is a requirement under the specified Pennsylvania Code regulations.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to properly store medications on four medication carts and for one resident, as observed during a survey. Medications on the Second Floor [NAME] Hall Medication Cart were not stored properly, with Resident R2's Novolog pen being undated. The Two East Medication cart was found unlocked near the nurses' station. Additionally, Resident R87 had an opened bottle of Senna in their nightstand drawer, which was confirmed by the resident and a Registered Nurse Supervisor as a failure to secure medications. Further observations revealed that the Third Floor East Hall Medication Cart contained undated medications for Residents R25 and R21, including Humalog and Insulin Lispro pens. The 3rd Floor South Hall Medication Cart also had undated and unlabeled insulin pens. A sign in the Third floor medication room indicated that all insulins should be dated when opened and labeled for single resident use. These findings were confirmed by various nursing staff, indicating a failure to adhere to the facility's medication storage policy.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices for three residents, as required by their care plans and physician orders. Resident R6, who has high blood pressure, heart failure, and coronary artery disease, was observed with a lunch tray that did not include the ordered divided plate and had a drink of regular consistency instead of the prescribed nectar thick consistency. Similarly, Resident R33, with high blood pressure, seizure disorder, and hypothyroidism, was served breakfast on a regular plate instead of the required divided plate. Resident R35, diagnosed with Alzheimer's disease, dementia, muscle wasting, and atrophy, was also served lunch on a regular plate instead of a divided plate, as confirmed by the nurse aide feeding the resident. The facility's policy on assisting residents with in-room meals requires staff to ensure that the correct diet and necessary non-food items, such as special devices, are provided. However, observations and staff interviews revealed that these requirements were not met for the three residents. The Nursing Home Administrator confirmed the facility's failure to provide the necessary adaptive feeding devices, which is a violation of the residents' rights and dietary services regulations.
Deficiency in Providing Beds and Furniture on First Floor
Penalty
Summary
The facility failed to provide essential furniture, including beds and mattresses, in resident rooms on the first floor. During a tour, it was observed that 13 out of 13 rooms on the first floor were missing beds and mattresses, with some rooms also lacking chairs. This deficiency was confirmed by both the Nursing Home Administrator (NHA) and the Director of Nursing during interviews and tours of the unit. The NHA explained that the beds from the second and third floors had been sent back to the rental company and replaced with those intended for the first floor. However, since the first floor was closed, the facility decided to purchase new beds for that floor, which had not yet arrived. As a result, there were no available beds in the building to use on the first floor if needed, leading to the deficiency in providing a homelike environment as per the facility's policy.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for two residents, R19 and R24. Resident R19, who has diagnoses including schizoaffective disorder, bipolar disorder, and dementia, was observed self-administering a nebulizer solution without a care plan, order, or interdisciplinary assessment to confirm it was safe for her to do so. A Licensed Practical Nurse handed her the nebulizer solution and left the room, assuming she would take it when ready. However, there was no documentation or assessment in her clinical record to support this practice. Similarly, Resident R24, who was admitted with a fracture of the neck, muscle weakness, and a fracture of the pelvis, was observed taking pills from a cup on her bedside table without supervision. A Registered Nurse confirmed that there were no orders for self-administration of medication for this resident. The Nursing Home Administrator acknowledged the facility's failure to determine the safety of self-administration for these residents, which is a violation of the facility's policy and state regulations.
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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.
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Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Squirrel Hill Wellness And Rehabilitation Center | 0.3 mi | ★★★★★ | 15 | 0 |
| Ivy Park Post Acute | 1.3 mi | ★★★★★ | 10 | 1 |
| John J Kane Regional Center-gl | 1.7 mi | ★★★★★ | 5 | 0 |
| Upmc Magee-womens Hospital Tcu | 1.9 mi | ★★★★★ | 5 | 0 |
| Burgh Care Center | 2 mi | ★★★★★ | 47 | 0 |
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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.