Heritage Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 5701 Phillips Avenue, Pittsburgh, Pennsylvania 15217
- CMS Provider Number
- 395732
- Inspections on file
- 33
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Heritage Care Center during CMS and state inspections, most recent first.
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.
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.
A facility failed to maintain the privacy and confidentiality of a resident's medical information. Signs on a treatment cart and above the resident's bed publicly displayed dietary restrictions, compromising the resident's privacy. The resident had a history of dysphagia, congestive heart failure, Alzheimer's dementia, and hypertension, with a care plan specifying a pureed diet. The RN supervisor confirmed the breach of privacy.
The facility did not conduct a state criminal background check before hiring a registered nurse, as required by its policies. This oversight was confirmed by the DON, highlighting a failure to adhere to procedures designed to prevent abuse, neglect, and misappropriation of resident property.
The facility failed to communicate necessary information to the receiving health care provider for two residents transferred to the hospital. One resident had cancer, diabetes, and depression, while the other had heart failure, high blood pressure, and depression. Essential details like care plan goals and advanced directives were not documented or shared.
A facility failed to provide adequate discharge planning for a resident with necrotizing fasciitis, heart disease, and diabetes mellitus. The resident was discharged with belongings, medication, and instructions but without arranged home health care (HHC) services. The oversight was identified when the resident contacted the social worker, who acknowledged the issue and promised to address it. The Social Service Director confirmed the failure to implement the required discharge plan.
A facility failed to assess and manage a CGM device for a resident with diabetes. The resident's care plan and physician orders did not include the CGM, and the facility lacked a policy for such devices. Interviews confirmed the oversight, despite the resident using a CGM connected to her cell phone.
The facility failed to provide necessary treatment and services for pressure ulcers for two residents. One resident, with Alzheimer's and muscle wasting, was at high risk but lacked a pressure ulcer care plan, and wound care orders were not consistently followed. Another resident, with heart failure and diabetes, had pressure injuries noted without timely documentation or treatment. The DON confirmed these deficiencies, indicating a failure to adhere to professional standards and facility policies.
A resident with an indwelling urinary catheter was observed multiple times with their drainage bag facing the entrance door and not covered with a dignity bag, contrary to the facility's policy and care plan. The Unit Manager RN and DON confirmed the failure to provide appropriate treatment and services.
A facility failed to provide appropriate treatment for a resident with an enteral feeding tube, as observed during a unit tour. The enteral feeding was found hanging with an outdated label, and the syringe and water flush bag were undated, contrary to facility policy. The resident had a history of coronary artery disease, high blood pressure, and cerebral infarction, and was receiving Two-Cal feeding. The oversight was acknowledged by a nurse and confirmed by the DON.
A facility failed to provide trauma-informed care for a resident with PTSD, depression, and diabetes. The care plan did not identify specific PTSD triggers or strategies to avoid them, which is essential to prevent re-traumatization. This deficiency was confirmed by the Social Service Director, highlighting a lapse in adhering to the facility's policy on trauma-informed care.
The facility failed to act on consultant pharmacist recommendations for two months, affecting a resident with heart failure, high blood pressure, and depression. The facility's policy requires monthly drug regimen reviews and action on recommendations, but the Director of Nursing confirmed the lapse for July and September.
The facility's medication error rate was 7.69%, exceeding the acceptable threshold of 5%. An RN failed to administer a Miralax dose and a Lidocaine patch to two residents due to unavailability of the medications. The Nursing Home Administrator confirmed the facility's failure to maintain the required medication error rate.
The facility failed to deliver meals on time for residents on the Third floor. Scheduled delivery times were not met, with the first cart arriving at 12:37 p.m. instead of 12:10 p.m., the second at 12:41 p.m. instead of 12:14 p.m., and the third at 1:09 p.m. instead of 12:17 p.m. The NHA confirmed the delay, violating dietary services and resident rights codes.
A facility failed to maintain complete and accurate medical records for a resident with heart failure, high blood pressure, and depression. The Treatment Administration Record (TAR) lacked signatures for wound care treatments on several dates, despite specific physician orders. This was confirmed by the DON during an interview.
A resident with moderate cognitive impairment and dementia signed a binding arbitration agreement without a representative's involvement. Despite known cognitive issues, the facility allowed the resident to sign based on a BIMS score above ten, leading to a deficiency in ensuring proper authorization.
The facility failed to implement infection prevention and control policies for two residents requiring enhanced barrier precautions (EBP) and proper handwashing. A resident with VRE did not receive insulin with proper hand hygiene, and another resident requiring tracheostomy care did not have EBP followed correctly. These deficiencies were confirmed by staff interviews.
The facility failed to notify the Office of the Long-Term Care Ombudsman Division about the transfer of three residents to the hospital. One resident, with altered mental status, was transferred and returned without notification. Another, with hypertension, was transferred and did not return, and a third, post-joint replacement, was also transferred without returning. The Nursing Home Administrator confirmed the lack of required notifications.
The facility failed to meet the food preferences of six residents, as evidenced by grievances and observations. A resident received pork despite a no-pork preference, and another's meal did not match her ticket, lacking coffee. Observations showed missing items like white toast and condiments, confirmed by staff. The DON and Administrator acknowledged these failures.
A resident with mild to moderate dysphagia was not provided with the appropriate easy to chew diet as prescribed. Instead of white toast, rye toast was served, and cornflakes were included on the tray, which the resident found difficult to eat. An LPN confirmed the facility's failure to adhere to the dietary order.
A resident with specific transfer needs was improperly moved by staff without using the required mechanical lift, resulting in a fall and a dislocated shoulder. The resident had previously fallen out of bed, an incident that was neither documented nor investigated. Staff interviews confirmed that transfer protocols were available but not followed, leading to neglect and harm.
A resident with muscle wasting and atrophy, requiring a mechanical lift for transfers, was improperly assisted by two nurse aides in a shower room, leading to a fall and a dislocated shoulder. The aides did not follow the prescribed transfer method documented in the Kardex. Additionally, a previous undocumented fall from bed contributed to the injury.
A resident with multiple diagnoses experienced a fall in the shower room due to improper transfer methods, resulting in a dislocated shoulder. The facility failed to document and investigate this incident, as well as a previous undocumented fall from bed, indicating a lack of adherence to policies for reporting and investigating potential neglect.
A resident with multiple health issues experienced two falls while receiving care, one of which was not documented or investigated by the facility. The resident reported increased pain, leading to a diagnosis of a dislocated shoulder. The facility's failure to investigate the initial fall prevented ruling out neglect, resulting in a deficiency.
A facility failed to ensure accurate MDS assessments for a resident, indicating she was rarely/never understood, despite evidence of clear communication. Staff interviews confirmed the resident's cognitive abilities, attributing discrepancies to medication effects. The DON and Nursing Home Administrator acknowledged the oversight.
A resident with multiple health issues experienced two falls, one in the shower room and another from the bed, which were not properly documented or addressed by the facility. The second fall resulted in a dislocated shoulder, requiring surgery. The facility failed to use a mechanical lift for transfers, as required, and did not investigate or document the initial fall.
The facility failed to ensure a physician's order included the catheter size for a resident with an indwelling catheter. The order only instructed catheter care and emptying every shift, omitting catheter size and balloon details, contrary to facility policy. This was confirmed by the DON.
The facility did not securely store medications on the second floor, as observed when the medication room door was propped open and a treatment cart was unlocked. This was confirmed by the Assistant DON, violating the policy requiring locked storage for drugs and biologicals.
A resident expressed concerns about delayed meal services, with breakfast and lunch arriving significantly late on the third floor south nursing unit. The facility's meal delivery schedule was not followed, impacting the resident's dining experience. The issue was communicated to the Nursing Home Administrator and DON.
The facility failed to provide a Chef Salad alternative with equal or greater nutrient value. The standardized recipe required specific ingredients and portions, but the observed preparation used a cereal-sized bowl with unportioned turkey, ham, American cheese, and other ingredients, failing to meet the required nutrient value and appeal. The Interim Food Service Director confirmed the deficiency.
The facility failed to provide meals according to resident preferences, with several residents not receiving requested items during breakfast and lunch. Additionally, the facility did not maintain a sufficient supply of alternative menu selections, and the process for selecting alternatives was cumbersome, leading to residents receiving meals they refused to eat.
The facility failed to provide timely meal service on the third floor south nursing unit, with breakfast and lunch meals arriving significantly later than scheduled. Observations revealed delays in tray line operations and meal cart deliveries, contrary to the facility's policy on meal times.
The facility did not resolve five out of twelve grievances within the required timeframe, as per their grievance policy. Grievances logged between April and July 2024 remained unresolved beyond the stipulated five-day period. The Nursing Home Administrator confirmed this failure, which violates PA Code: 201.18(e)(4) Management.
The facility failed to sustain improvements in meal service, as evidenced by continued late meal deliveries and lack of alternate menu selections. The QAPI committee did not assess or analyze the improvements, and the Dietary Department did not provide necessary information. The Nursing Home Administrator confirmed the failure to maintain compliance and resident satisfaction.
A resident with a history of heart failure, high blood pressure, leukemia, and dementia left the facility with his son and did not return, leading to an elopement classification. The facility declined the resident's readmission after hospitalization, citing an AMA discharge without proper documentation or education. The DON confirmed the resident should have been allowed to return.
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.
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.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical information, specifically for a resident identified as R77. The facility's policy on resident rights, dated 9/25/24, guarantees privacy and confidentiality as per federal and state law. However, during observations on the third-floor nursing unit, signs were found on the treatment cart and above the resident's bed, indicating that Resident R77 should not be given candy due to being on a pureed diet. These signs publicly displayed the resident's dietary restrictions, thereby compromising her privacy. Resident R77's medical history includes diagnoses of dysphagia, congestive heart failure, Alzheimer's dementia, and hypertension, which were current at the time of the review. The resident's care plan and physician orders specified a regular diet with pureed texture. The Registered Nurse supervisor confirmed during an interview that the facility did not uphold the privacy and dignity of Resident R77's information as required by the facility's policies and relevant state codes.
Failure to Conduct Pre-Employment Background Check
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the prevention of abuse, neglect, and misappropriation of resident property by not conducting a state criminal background check prior to hiring a registered nurse, identified as Employee E2. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention policy, as well as its Background Screening Investigations policy, both dated 9/25/24, require that background checks be completed before employment to ensure that no individuals with a history of abuse or neglect are hired. However, a review of Employee E2's personnel record revealed that she was hired on 11/15/24 without a completed state criminal background check. This oversight was confirmed during an interview with the Director of Nursing on 12/6/24.
Failure to Communicate Resident Information During Transfers
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 to the hospital and expected to return. For Resident R48, who had diagnoses of cancer, diabetes, and depression, 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 specific needs at the receiving facility. This lack of communication occurred when Resident R48 was transferred to the hospital and subsequently returned to the facility. Similarly, for Resident R53, who had diagnoses of heart failure, high blood pressure, and depression, the facility did not document the communication of essential information to the receiving health care provider. This included 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 specific needs. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to communicate the necessary resident information for these two residents.
Inadequate Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a resident, identified as CR1, which did not align with the resident's discharge goals and needs. CR1 was admitted with diagnoses including necrotizing fasciitis, heart disease, and diabetes mellitus. Upon discharge, CR1 left the facility with their brother, along with belongings, medication, a medication list, and discharge instructions. The nurse educated CR1 on wound care and follow-up appointments. However, the facility did not ensure that home health care (HHC) services were arranged for CR1 at the time of discharge. This oversight was confirmed when the social worker received voicemails from CR1 stating the absence of HHC services, prompting the social worker to apologize and promise to rectify the situation. The Social Service Director confirmed the facility's failure to implement the required discharge plan for CR1.
Failure to Assess and Manage CGM Device
Penalty
Summary
The facility failed to properly assess and manage a continuous glucose monitoring device (CGM) for one of its residents, identified as Resident R309. The resident, who was admitted to the facility with diagnoses including knee replacement, high blood pressure, and diabetes, had a CGM connected to her personal cell phone. However, the facility did not have a policy in place for CGM devices, and the resident's current physician orders and care plan did not include the CGM for care and management. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the lack of assessment, physician orders, and a care plan for the CGM device, despite the resident's use of it.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, as determined by a review of facility policy, clinical records, observations, and staff interviews. Resident R35, who was admitted with Alzheimer's disease, dementia, and muscle wasting, was identified as being at very high risk for pressure ulcers with a Braden Scale score of 9. Despite this, the resident's care plan did not include a pressure ulcer care plan. A stage 3 coccyx wound was identified on 11/18/24, but there was no documentation of wound measurements until later, and the wound care orders were not consistently followed, as evidenced by the lack of a dressing during an observation on 12/3/24. Resident R4, admitted with congestive heart failure, muscle wasting, and diabetes mellitus, also experienced deficiencies in pressure ulcer care. The resident's admission assessment noted pressure injuries on the left buttock and coccyx, but no measurements were documented until 10/14/24, despite physician orders for wound care being in place from 10/1/24. This delay in documentation and treatment indicates a failure to adhere to professional standards of practice for pressure ulcer management. The Director of Nursing confirmed the facility's failure to provide necessary treatment and services for pressure ulcers for these two residents. The report highlights deficiencies in the facility's adherence to its own policies and professional standards, as well as a lack of timely and appropriate documentation and care planning for residents at risk of or experiencing pressure ulcers.
Failure to Provide Appropriate Catheter Care and Privacy
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The resident, who had a history of stroke, non-Alzheimer's dementia, and obstructive uropathy, was observed on multiple occasions with their Foley catheter drainage bag positioned facing the entrance door on the bed frame, contrary to the care plan instructions. The drainage bag was not covered with a dignity bag for privacy, which was a requirement according to the facility's catheter care policy. The observations were confirmed by the Unit Manager RN during each instance, and the Director of Nursing acknowledged the facility's failure to provide the necessary treatment and services. The facility's policy indicated that catheter tubing and drainage bags should be kept off the floor and privacy should be maintained, which was not adhered to in this case. This deficiency was noted for one of the four residents reviewed with an indwelling urinary catheter.
Failure to Ensure Proper Enteral Feeding Tube Management
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. The facility's policy on enteral tube feeding via continuous pump required that formulas be discarded within four hours if kept at room temperature. However, during a tour of the unit, it was observed that the enteral feeding for a resident was hanging at the bedside with a date of several days prior, indicating non-compliance with the policy. Additionally, the syringe and water flush bag were undated, further suggesting a lack of adherence to proper procedures. The resident involved had a history of coronary artery disease, high blood pressure, and cerebral infarction, and was receiving Two-Cal feeding as per the physician's order. The registered nurse acknowledged the oversight and removed the outdated materials upon noticing the discrepancy. The Director of Nursing confirmed the facility's failure to provide the necessary treatment and services for the resident with an enteral feeding tube, as required by the regulations.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident identified as R89, who is a trauma survivor with a diagnosis of Post Traumatic Stress Disorder (PTSD), depression, and diabetes. The facility's policy on Trauma Informed Care and Culturally Competent Care emphasizes the importance of recognizing and responding to the effects of trauma to avoid re-traumatization. However, the care plan for Resident R89 did not identify specific PTSD triggers or strategies to avoid them, which is a critical component of trauma-informed care. This deficiency was confirmed during an interview with the Social Service Director, who acknowledged the facility's failure to identify and mitigate potential triggers for Resident R89, potentially leading to re-traumatization.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRR) were completed by the facility after the consultant pharmacist made recommendations for two out of six months, specifically in July 2024 and September 2024. According to the facility's policy, a licensed pharmacist is required to review each resident's drug regimen at least once a month, including a review of the resident's medical chart. The policy also mandates that written communication of the pharmacist's recommendations be sent to the attending physician and Director of Nursing, and that facility staff act upon these recommendations. However, during a clinical record review and staff interviews, it was found that the facility did not act upon the recommendations made by the consultant pharmacist in the specified months. Resident R53, who was admitted to the facility with diagnoses of heart failure, high blood pressure, and depression, was one of the residents affected by this deficiency. The clinical pharmacy review notes indicated that recommendations were made in July 2024 and September 2024, but the Director of Nursing was unable to produce the pharmacy recommendations for these months during an interview. This failure to act upon the pharmacist's recommendations was confirmed by the Director of Nursing, highlighting a lapse in the facility's adherence to its own policies and procedures regarding medication regimen reviews.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69% based on 26 medication opportunities with two errors. During a medication administration pass, a Registered Nurse (RN), identified as Employee 1, did not administer a 17 gram dose of Miralax to a resident in the morning as ordered because the medication was unavailable in the medication cart. The resident's clinical record later confirmed that the Miralax was not administered due to being out of stock. In another instance, the same RN failed to administer a 4% topical Lidocaine patch to another resident as ordered, again due to the medication being unavailable. The resident's clinical record confirmed the Lidocaine patch was not administered. An interview with the Nursing Home Administrator confirmed the facility's failure to ensure a medication error rate below five percent.
Delayed Meal Delivery on Third Floor
Penalty
Summary
The facility failed to deliver meals in a timely manner for residents on the Third floor during a meal observation. The facility's cart delivery document indicated specific meal delivery times for different hallways on the Third floor, with the first cart scheduled to arrive at 12:10 p.m., the second at 12:14 p.m., and the third at 12:17 p.m. However, during the observation, the first lunch cart did not arrive until 12:37 p.m. for the 328 hallway/3-South, the second cart arrived at 12:41 p.m. for the 301 hallway/3-East, and the third cart arrived at 1:09 p.m. for the 316 hallway/3-West and main dining/common area. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required meal delivery times for the Third floor residents. This deficiency is in violation of 28 Pa. Code: 211.6(a) Dietary services and 28 Pa Code: 201.29 (d) Resident rights.
Incomplete Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as evidenced by the case of one resident. The review of the facility's policy on Medication and Treatment Orders indicated that orders for treatments should be consistent with safe and effective order writing, requiring a signature. However, the Treatment Administration Record (TAR) for a resident, who was admitted with diagnoses of heart failure, high blood pressure, and depression, showed missing documentation. Specifically, the TAR lacked signatures confirming the completion of prescribed treatments on several dates in November and December. The resident's physician orders included specific wound care instructions for the right posterior thigh, which changed from using Medihoney to Hibiclens and triad over the course of the treatment period. Despite these orders, the TAR did not reflect completed treatments on multiple occasions, as confirmed by the Director of Nursing during an interview. This lack of documentation indicates a failure to maintain complete and accurate medical records for the resident, which is a requirement under the relevant clinical records regulation.
Failure to Ensure Representative Signed Arbitration Agreement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a representative signed a binding arbitration agreement on behalf of a resident who lacked the capacity to understand the agreement terms. The resident, identified as R96, had a documented history of cognitive impairment, including unspecified dementia, and a BIMS score of 11, indicating moderate cognitive impairment. Despite this, the arbitration agreement was electronically signed by the resident on 8/2/24, without the involvement of an authorized representative. Interviews with facility staff, including the Director of Nursing and the Admissions Coordinator, revealed that the resident's cognitive impairment was known at the time of admission. The Admissions Coordinator believed that a BIMS score above ten allowed the resident to sign the agreement, despite the resident's documented dementia and suspected worsening neurocognitive impairment. The Nursing Home Administrator confirmed the facility's failure to ensure a representative signed the agreement, acknowledging the oversight in the process.
Failure to Implement Infection Control Policies
Penalty
Summary
The facility failed to implement infection prevention and control monitoring policies for enhanced barrier precautions (EBP) and proper handwashing procedures. Specifically, for Resident R16, who had a physician order for EBP due to Vancomycin-resistant Enterococci (VRE) and a Foley catheter, the Registered Nurse (RN) Employee E1 did not wash hands prior to administering insulin. Additionally, the Occupational Therapist, Employee E9, provided direct care without wearing a gown, which is required under EBP. These actions were confirmed by the RN and the Nursing Home Administrator during interviews. For Resident R48, who required EBP for tracheostomy care, the RN Employee E24 failed to wear a gown while providing tracheostomy care, despite washing hands and wearing gloves. This was confirmed during an interview with the RN and the Director of Nursing (DON). The facility's failure to adhere to these infection prevention and control policies was noted for two of the three residents reviewed, highlighting lapses in the implementation of EBP and hand hygiene protocols.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for three residents. Resident R1, who was admitted with diagnoses including altered mental status and cognitive communication deficit, was transferred to the hospital and returned to the facility without documented evidence of a written notification to the Ombudsman. Similarly, Resident R3, admitted with hypertension and morbid obesity, was transferred to the hospital and did not return, yet there was no documented notification to the Ombudsman. Resident R2, admitted for aftercare following joint replacement surgery, was also transferred to the hospital without returning, and the facility again failed to document a notification to the Ombudsman. The Nursing Home Administrator confirmed during an interview that the facility did not provide the required transfer notices for these residents. This deficiency was identified during a review of clinical records and staff interviews, indicating a failure to comply with the regulation requiring timely notification to the Ombudsman for resident transfers or discharges. The report cites 28 Pa. Code 201.29(a)(c.3)(2) regarding resident rights, underscoring the facility's obligation to ensure proper communication and documentation in such instances.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy of accommodating resident food preferences, as evidenced by multiple grievances and observations. The policy, last reviewed on 9/25/24, mandates that individual food preferences be assessed upon admission and communicated to the interdisciplinary team. However, the facility did not follow these guidelines for six out of twelve residents. For instance, Resident R4 submitted a grievance on 8/12/24, indicating that pork items were repeatedly included in his meals despite a clear indication on his meal ticket to exclude pork. Similarly, Resident R5's grievance highlighted discrepancies between her meal ticket and the food she received, including the absence of coffee with her meal. Observations conducted on 8/16/24 further revealed the facility's failure to provide residents with their specified food preferences. During breakfast, Resident R1 did not receive the requested white toast, a fact confirmed by LPN Employee E1. At lunch, Residents R10 and R11 did not receive lettuce, tomato, or pickle, and Resident R12 did not receive two coffees, as confirmed by Nurse Aide Employee E2. The Director of Nursing and the Nursing Home Administrator acknowledged these failures during an interview on 10/17/24, confirming the facility's inability to meet the food preferences of six residents.
Failure to Provide Appropriate Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident received food prepared in a form designed to meet their individual dietary needs. Specifically, Resident R7, who was on an easy to chew diet due to mild to moderate dysphagia, was not provided with the appropriate meal. During an observation, it was noted that the resident's breakfast meal ticket indicated an easy to chew diet order, which included white toast. However, the resident was served rye toast instead, and an unopened bowl of cornflakes was also present on the tray. The resident expressed difficulty in eating the provided food. A Licensed Practical Nurse confirmed that the facility did not adhere to the prescribed easy to chew diet for the resident.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to prevent neglect, resulting in harm to a resident identified as Resident R1. The resident, who had diagnoses including vitamin C deficiency, generalized edema, muscle wasting, and atrophy, required maximum assistance with a mechanical lift for transfers. Despite this requirement being documented in the resident's Kardex and communicated by the physical therapist, two nurse aides attempted to transfer the resident without the mechanical lift, leading to a fall in the shower room. This incident resulted in a dislocated shoulder for the resident. Further investigation revealed that the resident had previously fallen out of bed when an aide rolled her too forcefully, causing her to brace herself with her arm and sustain an injury. This earlier fall was not documented in the resident's medical record, nor was it investigated by the facility. The lack of documentation and investigation of the initial fall, combined with the improper transfer in the shower room, highlights a pattern of neglect in providing necessary care and services to prevent harm to the resident. Interviews with staff confirmed that the transfer requirements were clearly documented and accessible in the Kardex, yet the staff involved did not adhere to these instructions. The facility's failure to ensure that staff followed the prescribed transfer protocols directly contributed to the resident's injury, demonstrating a significant lapse in the standard of care expected in such settings.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to provide appropriate assistance with an appropriate device to prevent falls for a resident, resulting in actual harm. The resident, who had diagnoses including muscle wasting and atrophy, required maximum assistance of two people with a mechanical lift for transfers, as indicated in their physical therapy evaluation. However, during a transfer in the shower room, two nurse aides attempted to stand the resident up at a grab bar, contrary to the prescribed use of a mechanical lift, leading to the resident's legs giving out and a subsequent fall. The incident occurred when the resident was being transferred from a shower chair, which was not suitable for someone requiring a mechanical lift. The nurse aides involved were not familiar with the resident's transfer requirements, which were documented in the Kardex. Despite the availability of this information, the aides proceeded with an improper transfer method, resulting in the resident being lowered to the floor and later diagnosed with a dislocated shoulder. Additionally, the resident reported a previous fall from bed, which was not documented or investigated by the facility. This earlier incident, where the resident was rolled out of bed by an aide, contributed to the resident's shoulder injury. The lack of documentation and investigation of the initial fall highlights a failure in the facility's processes to ensure resident safety and proper care documentation.
Failure to Investigate Resident Falls and Potential Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to conduct a thorough investigation of an incident involving a fall sustained by a resident while receiving care. The resident, who had diagnoses including Vitamin C deficiency, generalized edema, muscle wasting, and atrophy, experienced a fall in the shower room when two nurse aides attempted to dress her by standing her up at a grab bar. Her legs gave out, resulting in a fall. Although the resident was immediately assessed and sent to the ER for possible trauma, it was later discovered that her left shoulder was dislocated, requiring surgery. The investigation revealed that the resident should have been lifted by a mechanical lift for transfers, which was not done. Additionally, the resident reported a previous fall that occurred when an aide rolled her out of bed, which was not documented or investigated by the facility. The Nursing Home Administrator confirmed that this fall was not recorded in the resident's medical record, and no investigation was conducted. This lack of documentation and investigation indicates a failure to adhere to the facility's policies and procedures for reporting and investigating incidents of potential neglect, as required by local, state, and federal regulations.
Failure to Investigate Resident Falls
Penalty
Summary
The facility failed to conduct a thorough investigation of an incident involving a fall sustained by a resident while receiving care, which led to a deficiency. The resident, who had diagnoses including Vitamin C deficiency, generalized edema, muscle wasting, and atrophy, was involved in two separate incidents. The first incident occurred when the resident was being dressed in the shower room by two nurse aides, resulting in a fall when her legs gave out. The second incident, which was not documented or investigated, involved the resident falling out of bed when an aide rolled her too hard during a diaper change. The resident reported increased pain in her left arm following these incidents, which led to a diagnosis of a dislocated shoulder. The facility's failure to document and investigate the initial fall out of bed on 7/22/24, as confirmed by the Nursing Home Administrator, contributed to the deficiency. The lack of documentation and investigation prevented the facility from ruling out neglect, as required by their policies and state regulations.
Inaccurate MDS Assessment of Resident's Cognitive Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status for one of two residents. Specifically, the MDS assessment for a resident with diagnoses of Vitamin C deficiency, generalized edema, muscle wasting, and atrophy inaccurately indicated that the resident was rarely/never understood, and the Brief Interview for Mental Status (BIMS) assessment was not completed. This discrepancy was identified during a State Agency interview where the resident was able to clearly articulate details about a recent fall and subsequent surgery, contradicting the MDS assessment. Interviews with facility staff, including the Director of Nursing (DON), Registered Nurse Assessment Coordinator (RNAC), and Physical Therapy (PT) staff, confirmed the resident's cognitive abilities and communication skills. The RNAC, who completed the MDS assessment, attributed the discrepancy to the resident's medication affecting her mental status. However, both the DON and Nursing Home Administrator acknowledged that the resident was cognitively intact and should have had a BIMS assessment completed, highlighting a failure in the facility's assessment process.
Failure to Document and Address Resident Falls
Penalty
Summary
The facility failed to document and implement interventions for a fall involving a resident, identified as Resident R1. The resident was admitted with diagnoses including Vitamin C deficiency, generalized edema, muscle wasting, and atrophy. On one occasion, while being assisted by two nurse aides in the shower room, the resident's legs gave out, resulting in a fall. Although the resident was assessed immediately after the incident, it was later discovered that the resident should have been transferred using a mechanical lift, which was not done. This oversight led to a dislocated shoulder, requiring medical intervention and surgery. Additionally, the resident reported a previous fall that occurred when an aide rolled her out of bed, which was not documented or investigated by the facility. The Nursing Home Administrator confirmed that this earlier fall was not recorded in the resident's medical record, nor were any interventions put in place following the incident. This lack of documentation and failure to investigate the initial fall contributed to the deficiency identified by the surveyors.
Failure to Specify Catheter Size in Physician's Order
Penalty
Summary
The facility failed to ensure that a physician's order included the catheter size for a urinary catheter for one of two residents. The facility's policy on Indwelling Catheter Insertion requires a physician's order to specify the catheter size and the amount of sterile water used to inflate the balloon. However, for Resident R2, who was admitted with diagnoses including obstructive uropathy, difficulty swallowing, and pain, the physician's order dated 6/27/24 only instructed to perform catheter care and empty the catheter every shift, without specifying the catheter size or balloon details. This deficiency was confirmed during an interview with the Director of Nursing on 9/15/24.
Medication Storage Deficiency on Second Floor
Penalty
Summary
The facility failed to store all drugs and biologicals in a safe, secure, and orderly manner on the second floor nursing unit. During an observation and interview, it was noted that the door to the second floor medication room was propped open, and a treatment cart containing medications was unlocked. This was confirmed by the Assistant Director of Nursing, indicating a breach in the facility's policy that requires all compartments containing drugs and biologicals to be locked when not in use and that unlocked medication carts should not be left unattended.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to provide residents with a dignified dining experience during breakfast and lunch meals on 7/26/24. The facility's policy on the frequency of meals indicates that meals should be served at times comparable to community meal times or according to residents' needs, preferences, and requests. However, the meal delivery schedule was not adhered to, as observed during the breakfast and lunch services on the third floor south nursing unit. The breakfast meal cart, scheduled to arrive at 7:42 am, was delivered at 8:35 am, 53 minutes late. Similarly, the lunch meal cart, scheduled for 12:10 pm, arrived at 1:28 pm, one hour and 18 minutes late. Resident R1 expressed concerns about the timeliness of meal services, stating that breakfast was over 50 minutes late and lunch was over an hour late. The resident highlighted the uncertainty of meal arrival times and hoped for corrective measures. This concern was communicated to the Nursing Home Administrator and Director of Nursing during an interview on the same day. The report indicates that a reasonable person would expect timely meal service and desire to know when meals will be served.
Deficiency in Nutrient Value of Chef Salad Alternative
Penalty
Summary
The facility failed to provide alternate menu selections of equal or greater nutrient value for the Chef Salad alternative selection. A review of the facility's standardized recipe for Chef Salad revealed that it should consist of one cup of salad greens, including lettuce, salad greens, red cabbage, shredded carrots, and radishes, topped with two slices of cucumbers, a green pepper ring, two ounces of turkey, one ounce of ham, one ounce of Swiss cheese, and two hard-cooked egg wedges, served with a salad dressing of choice. However, during an observation of the preparation of the alternative meal selection, it was found that the salad was prepared by placing a handful of tossed salad mix into a cereal-sized bowl, with turkey, ham, American cheese that was not portioned correctly, two hard-cooked egg wedges, diced tomatoes, and diced cucumbers. The Interim Food Service Director confirmed that the Chef Salad prepared as an alternative menu selection failed to meet the criteria of equal or greater nutrient value and appeal.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to its policy of accommodating resident food preferences, as evidenced by the events on 7/26/24. During breakfast and lunch meals, several residents did not receive their requested food items. For instance, one resident requested pancakes but received a waffle, and multiple residents did not receive the Fruit Berry Mix they preferred. Another resident did not receive diced carrots and coffee for lunch, while another was not provided with mandarin oranges. Additionally, a resident who dislikes chocolate was served Boston Cream Pie and refused to eat the meal provided, declining to request an alternative. The facility also failed to maintain a sufficient supply of alternative menu selections as promised on the Always Available Menu. Items such as egg salad, tuna salad, chicken noodle soup, and tomato soup were not available, and the facility did not offer a Chef salad of equal or greater nutrient value and appeal. The process for selecting alternative menu items was cumbersome, requiring residents or their representatives to complete a form or call the kitchen by specific times, which was not always feasible. This led to situations where residents received meals they refused to eat, as noted by a resident's representative who expressed concerns about the new process.
Delayed Meal Service on Third Floor South Nursing Unit
Penalty
Summary
The facility failed to provide timely meal service for breakfast and lunch on 7/26/24, as observed on the third floor south nursing unit. The breakfast meal delivery cart arrived at 8:35 am, which was 53 minutes later than the scheduled delivery time of 7:42 am. Additionally, during the lunch meal service, the meal delivery cart arrived at 1:28 pm, which was one hour and 18 minutes late compared to the scheduled delivery time of 12:10 pm. Observations during the tray line operations revealed that at 11:50 am, there were no food products in the hot steam wells, delaying the start of tray line operations to 12:35 pm, approximately 47 minutes late. The facility's policy on the frequency of meals indicates that meals should be served at times comparable to community meal times or according to residents' needs, preferences, and requests. However, the facility did not adhere to this policy, resulting in delayed meal services for the residents.
Failure to Resolve Grievances Promptly
Penalty
Summary
The facility failed to resolve five out of twelve grievances within the required timeframe, as per their grievance policy. The grievances in question were logged on specific dates between April and July 2024, namely 4/1/24, 4/28/24, 5/19/24, 6/12/24, and 7/1/24. According to the facility's WeCare Heritage Care Center Grievance Policy and Procedure, all grievances should be investigated and resolved within a five-day period. However, a review of the facility's grievance log indicated that these grievances remained unresolved beyond the stipulated timeframe. During an interview conducted on 7/26/24, the Nursing Home Administrator confirmed the facility's failure to resolve the grievances as required by their policy. This deficiency is in violation of PA Code: 201.18(e)(4) Management, which mandates the prompt resolution of grievances to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Sustain Meal Service Improvements
Penalty
Summary
The facility failed to assess, analyze, and sustain improvements in deficient practices identified during abbreviated surveys. Specifically, the facility was cited for failing to provide meals in a timely manner and for not offering alternate meal selections of equal or greater nutritional value and appeal. The Quality Assurance Process Improvement (QAPI) committee meeting minutes for May, June, and July did not show evidence of assessment and analysis of these improvements. The Dietary Department did not submit information regarding the improvement process for these citations, and it was unclear whether the improvements corrected the deficient practices and sustained them. Observations on July 26 revealed that the facility continued to deliver meal carts late for breakfast and lunch, indicating a failure to sustain the improvements outlined in their Plan of Correction (POC). Additionally, the facility did not display alternate menu selections for lunch and dinner meals and failed to include a dessert selection on the menu, resulting in residents not receiving proper food preferences. During an interview on August 2, the Nursing Home Administrator confirmed the facility's failure to properly assess, analyze, and sustain improvements due to the Dietary Department's inability to maintain compliance and resident satisfaction.
Facility Failed to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to permit Resident R9 to return after hospitalization, as required by regulations. Resident R9, who had a history of heart failure, high blood pressure, leukemia, and dementia, was admitted to the facility and later left the premises with his son under the pretense of getting fresh air. The resident did not return, and the facility classified this as an elopement. The facility notified Adult Protective Services (APS) and was unable to locate the resident until APS found him at home and sent him to the ER for evaluation. The hospital determined that Resident R9 required 24/7 care, and his family requested his return to the facility. However, the facility declined readmission, citing that the resident had discharged against medical advice (AMA). The facility's records did not show that the resident was educated about the consequences of an AMA discharge, nor was there evidence of a physician's order for discharge. The Director of Nursing confirmed that the resident did not express a desire to discharge AMA and should have been allowed to return to the facility.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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