Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Medication Administered to Wrong Resident: An RN preparing meds for one resident mistakenly gave them to another resident after briefly assisting him to his wheelchair and then returning to the pills. The cognitively impaired resident, who needed staff help with all daily care and had dementia and HTN, received another resident’s apixaban, atorvastatin, metformin, and metoprolol instead of his own ordered atorvastatin and lisinopril.
The facility failed to provide meals at scheduled times, with lunch and dinner trays arriving 30–100+ minutes late to multiple wings and the main dining room, contrary to its own meal distribution policy and tray delivery logs. Staff reported that meals were routinely late and cited ongoing problems related to new dietary management and staff. A cognitively intact resident who was independent with eating became visibly upset and complained of waiting nearly an hour for lunch, while another cognitively intact resident who required only set-up for eating reported late dinners, including one evening when trays arrived very late. The NHA confirmed that meals were not served at the scheduled mealtimes for residents throughout the facility.
The facility failed to follow its menu and standardized recipes for entrée portion sizes when serving ham at lunch. Two cognitively intact residents, one independent with eating and one requiring set up, were observed receiving only a thin half slice of ham, which they described as too small, cold, or unpalatable, and one refused to eat more after one bite. Observation of the tray line showed staff serving only a small, thin crescent-shaped slice of ham to each resident, and a weighed sample showed the portion was 1 oz instead of the planned 3 oz. The Regional Dining and Nutrition Director confirmed that the recipe required a 3 oz portion and that the prep cook had prepared breakfast-size rather than entrée-size portions, resulting in most residents not receiving the appropriate serving size.
The facility failed to follow its dietary policies requiring hot foods to be held above 135°F and cold foods below 41°F, and to ensure meals were palatable and served at safe, appetizing temperatures. During a lunch test tray, hot items such as chicken, broccoli, and mashed potatoes were found to be lukewarm and below required temperatures, while milk was only slightly above the cold-holding threshold. At a separate dinner meal, a cognitively intact, self-feeding resident received chocolate ice cream that had fully melted to liquid before she began eating and refused it, and additional trays on a unit cart contained single-serve ice creams that were soft, leaking, and not frozen. Staff, including a nurse aide and the NHA, confirmed that the food and ice cream temperatures and consistencies were not appropriate, in violation of facility policy and state dietary regulations.
The facility failed to provide adequate dietary staffing to ensure meals were delivered on time and at proper temperatures and consistencies. On the survey day, lunch and dinner trays to all wings and the main dining room were consistently late, sometimes by more than an hour, with residents waiting in dining areas and a cognitively intact resident expressing hunger and frustration after a prolonged delay. A test tray showed hot foods below required hot-holding temperatures and milk above cold-holding standards, and multiple residents received melted ice cream that had lost its intended consistency, which some refused. Staff interviews indicated that late meals were a common occurrence and that several dietary staff had called off, with the Nursing Home Administrator observed working in the kitchen to cover basic duties.
A facility failed to follow physician orders for Midodrine for three residents by administering the medication when SBP was above the ordered hold parameter of 120 mmHg. The residents had diagnoses including orthostatic hypotension, CAD, HF, and recent falls, and MAR reviews showed repeated doses were given despite elevated BP readings, with the DON and NHA confirming the errors.
Food service safety standards were not followed when a dietary aide prepared lunch trays without a beard or mustache cover, despite facility attire policy requiring facial hair to be restrained. In addition, a solarium refrigerator on C wing contained opened resident food and beverages that were not labeled with resident names or use-by dates, including salad dressing, a partially eaten candy bar, and Gatorade bottles; an LPN and the ADM confirmed the items should have been labeled and dated.
A resident who was cognitively intact and receiving psychotropic meds for depression, anxiety, and bipolar disorder had Prozac and Buspar doses increased after a psych note and MD orders were entered. The record did not show that the resident or representative was informed in advance of the risks, benefits, and treatment alternatives before the dose increases were started.
A cognitively intact resident repeatedly stated she wanted a regular diet and denied swallowing problems, but staff maintained a modified texture diet after speech therapy documented a near choking episode with regular meat and ongoing concerns about rapid intake and large bites. The resident continued to object to ground meats and pureed sides, while the DON and NHA acknowledged she could make her own decisions and that her dietary choice should be honored.
Care plans were not updated to match current resident needs for two residents. One resident's Foley catheter care plan still listed an 18F catheter even though the physician order and observation showed a 16F Foley in place, and another resident's falls care plan still showed a BIMS of 13 and alert/oriented status despite the MDS showing cognitive impairment with a BIMS of 6. The DON confirmed both care plans were inaccurate.
A resident with diabetes and intact cognition had an order for blood sugar checks twice daily, with specific actions required for low or high results. Review of the MAR showed no documented blood sugar results for an extended period, and the DON confirmed the blood sugars were obtained but not recorded in the MAR.
QAPI committee failed to correct repeated deficiencies involving care plan revision, food storage and food handling, and infection control. Prior POCs relied on audits and QAPI review, but the current survey found the facility still had failures under F657, F812, and F880, showing the committee did not successfully implement the planned oversight measures.
An LPN failed to perform hand hygiene before preparing a resident’s meds and again before moving to the next resident during med pass. The resident had orders for multiple meds, including oxycodone, azithromycin, prednisone, Lasix, Sinemet, Trelegy, senna, Pepcid, Vitamin B-12, and Cymbalta. The LPN stated she only performs hand hygiene after three residents, and the DON confirmed hand hygiene should have been done between each resident.
A resident who was cognitively intact and required assistance with daily care had a physician-signed order to discontinue aspirin and famotidine following a pharmacist's recommendation. However, there was no documentation that these medications were discontinued, and the DON confirmed the orders were not followed.
A large, dirty fan with visible debris was observed blowing directly onto a dish dry rack containing clean pots, pans, and dishes. Both the Dietary Manager and the Administrator confirmed the fan's presence and its improper use, which did not comply with the facility's policy for maintaining sanitary dish cleaning areas.
The facility failed to ensure that residents and/or their representatives were given the opportunity to formulate an advance directive or were offered assistance in doing so. This deficiency was identified for six residents, who had varying degrees of cognitive impairment and required different levels of assistance with care needs. Despite these conditions, the facility did not document any efforts to discuss or assist with advance directives, as confirmed by the DON.
The facility did not adhere to its planned menu, resulting in incomplete meal trays for residents. A resident reported missing margarine, sugar packets, condiments, napkins, and flatware on her meal trays. Interviews with other residents confirmed similar issues with missing menu items. The dietary manager acknowledged that while margarine was available, it was not included on the trays as required.
The facility failed to serve food at appropriate temperatures, as per policy. Residents reported receiving cold, overcooked, and unpalatable meals, with missing items like condiments and flatware. Observations confirmed that hot foods were served below the required temperature, and cold foods were above the required temperature. The Dietary Manager acknowledged the issue.
The facility failed to maintain sanitary conditions in food storage and preparation, with unlabeled pizza crusts, ice build-up on the freezer condenser, and a dirty ceiling vent. The ice machine had a pink build-up and was dripping water onto the ice. The sanitizer log lacked documentation of sanitizer strength for meals, as confirmed by the Dietary Manager.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or chronic wounds, leading to infection control deficiencies. Observations revealed lapses in hand hygiene and PPE availability, affecting residents with conditions like MRSA and pressure ulcers. The infection preventionist and DON confirmed these issues, indicating systemic non-compliance with infection control guidelines.
A resident's room in the facility was found to have broken drywall caused by the footrest of the resident's electric wheelchair. The damage was not repaired due to a lack of a work order and the recent resignation of the maintenance director. The resident, who is cognitively intact and dependent on staff for care due to quadriplegia and depression, experienced a non-homelike environment as a result.
A facility failed to complete a quarterly MDS assessment within the required time frame for a resident. The assessment reference date (ARD) was 116 days after the previous annual MDS assessment, exceeding the 92-day requirement. This was confirmed by the DON.
The facility did not update care plans for two residents, failing to reflect changes in anticoagulation therapy and catheter use for one resident, and inaccurately documenting surgical wounds as scars for another. These deficiencies were confirmed by the DON.
A resident, dependent on staff for bathing, did not receive scheduled showers as preferred, receiving bed baths instead. Despite being cognitively intact and having chronic conditions, the resident's preference for showers twice a week was not met due to staff excuses like lack of hot water. The facility lacked documentation of offering or refusal of showers on scheduled days.
A resident with Parkinson's Disease received Midodrine Hydrochloride despite physician's orders to hold the medication if systolic blood pressure (SBP) exceeded 120. The MAR showed multiple instances of administration with SBP readings above the threshold. The DON confirmed the medication was improperly given, violating care standards.
A facility failed to document gastric residual volumes (GRV) for a resident with an enteral feeding tube, as required by its policy. The resident, who was cognitively impaired, had physician's orders to check GRV every shift and take specific actions if GRV exceeded certain levels. However, from January 1 to January 17, 2025, there was no documented evidence of GRV checks, confirmed by the DON.
The facility's QAPI committee failed to correct recurring deficiencies in maintaining a homelike environment, accuracy of assessments, care plan updates, quality of care, and food service standards. Despite developing plans of correction, the committee did not successfully implement these plans, resulting in repeated citations under various F-tags.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in documenting medical conditions. A resident with an ostomy was inaccurately recorded as bowel continent, another resident's Stage 4 pressure ulcer was not reflected in the MDS, a resident receiving Trazadone was not recorded as taking antidepressants, and a resident on Seroquel had an inaccurate GDR documentation.
The facility failed to maintain documentation for the emergency generator's annual maintenance and testing for 2024, affecting the entire facility. An interview with the Facilities Administrator and Assistant Maintenance Director confirmed the absence of required documentation, indicating non-compliance with NFPA standards for emergency power systems.
The facility failed to maintain proper hazardous area enclosures, as the door to a storage closet in the Rehabilitation Room did not latch due to tape on the striker plate. This affected one of eight smoke compartments, confirmed by the Facility Administrator and Assistant Maintenance Director.
The facility failed to maintain cooking facilities according to NFPA 101 standards, affecting one smoke compartment. Documentation for semiannual kitchen fire suppression testing and hood/duct cleanings for the latter half of 2024 was missing. The Facility Administrator and Assistant Maintenance Director confirmed these deficiencies.
The facility failed to document the administration of controlled medications for two residents who were cognitively impaired and receiving opioids for pain. Doses of oxycodone were signed out for administration, but there was no evidence in the MAR or clinical records to confirm administration or proper disposal of unused medication. The Director of Nursing confirmed the lack of documentation.
The facility failed to complete accurate MDS assessments for a resident. The quarterly MDS assessment incorrectly indicated that the resident did not use a wander/elopement alarm, despite having a physician's order and care plan for the use of a Wanderguard. This discrepancy was confirmed by the DON.
A resident, who was cognitively intact, managed to leave the building without staff knowledge and was found outside. The incident was not documented in the resident's clinical record, nor was there any evidence of an assessment upon her return. Interviews with staff confirmed the incident and the lack of documentation.
Medication Administered to Wrong Resident
Penalty
Summary
The facility failed to ensure medications were administered to the correct resident for one resident reviewed. The resident had cognitive impairment, required staff assistance for all daily care needs, and had diagnoses including dementia and high blood pressure. Current physician orders included atorvastatin 10 mg at bedtime and lisinopril 5 mg once daily for this resident. A nursing note documented that a staff member reported the resident inadvertently received medications ordered for another resident. The medications administered in error were apixaban 5 mg, atorvastatin 40 mg, metformin 500 mg, and metoprolol 25 mg. A witness statement indicated that an RN was preparing medications for one resident when the other resident came to the bedroom door, the RN assisted him to his wheelchair, then returned to the pills, believed they were for the resident who approached, crushed them, and administered them. The RN later realized the resident did not have diabetes and reported the error to the RN supervisor. The NHA confirmed that the resident mistakenly received another resident's medications.
Failure to Provide Timely Meal Service According to Scheduled Mealtimes
Penalty
Summary
The deficiency involves the facility’s failure to serve meals at the scheduled times established in its own meal distribution policy and tray delivery logs. The policy dated June 26, 2025, required timely delivery of meals to dining locations, but observations and records on March 18, 2026, showed significant delays for both lunch and dinner across all wings (A, B, C, D) and the main dining room. Lunch trays scheduled for delivery between 11:55 a.m. and 12:40 p.m. arrived between 12:45 p.m. and 2:22 p.m., with delays ranging from 50 minutes to 1 hour and 42 minutes. Dinner trays scheduled between 5:30 p.m. and 6:10 p.m. arrived between 6:04 p.m. and 7:17 p.m., with delays of 34 minutes to 1 hour and 7 minutes. Staff interviews indicated that meals were routinely late by 10–20 minutes and that breakfast and supper on the same day and the previous evening had also been significantly delayed. Residents were directly affected by these delays. A quarterly MDS for one cognitively intact resident who was independent with eating showed that this resident became visibly upset in the dining room, stating it had almost been an hour and expressing hunger while slapping the table. An admission MDS for another cognitively intact resident who required only set-up for eating showed that this resident reported dinner trays being late on the survey day and recalled a recent Sunday when dinner did not arrive until 8:45 p.m. Activity and nursing staff attributed the ongoing delays to new dietary management and staff. The Nursing Home Administrator confirmed that lunch and dinner meals were served late and not at the scheduled mealtimes for all residents in the affected wings and the main dining room, in violation of 28 Pa. Code 201.14(a) regarding the responsibility of the licensee.
Failure to Provide Planned Entrée Portion Sizes at Lunch
Penalty
Summary
The facility failed to ensure that dietary staff served the appropriate planned portion sizes as required by facility policy and posted menus. The facility’s policy on food quality and palatability stated that menu items are to be prepared according to the menu, production guidelines, and standardized recipes. The posted lunch menu indicated residents had a choice of ham or chicken, and the dietary guide sheet specified that the honey glazed ham portion was to be 3 ounces. During the lunch meal, observations showed that residents were being served only one small, thin crescent-shaped slice of ham. When weighed on a food scale at the surveyor’s request, the ham portion was found to weigh only 1 ounce instead of the required 3 ounces. A quarterly MDS for one resident showed that she was cognitively intact, able to understand and be understood, and independent with eating. Observation of this resident during lunch revealed she had only one half slice of thinly sliced ham and she complained that the portion was small and cold. An admission MDS for another resident showed that she was cognitively intact, able to understand and be understood, and required set up for eating. Observation of this resident at lunch revealed she also had one half slice of thin, curled ham, which she described as very thin and tasting like leather; she took one bite and refused to eat more. The Regional Dining and Nutrition Director confirmed that the ham slice should have weighed 3 ounces per the recipe and later stated that the prep cook had prepared breakfast-size portions instead of entrée-size portions, resulting in most residents not receiving the planned 3-ounce serving of ham.
Failure to Serve Palatable Food at Safe Temperatures and Consistencies
Penalty
Summary
The facility failed to ensure that food and beverages were served at palatable and appropriate temperatures and consistencies, as required by its own policies and the FDA Food Code. The facility’s food preparation and food quality policies required hot foods to be held above 135°F, cold foods below 41°F, and all foods to be palatable, attractive, and served at safe and appetizing temperatures. During a test tray observation on the D nursing unit lunch meal, the meal cart left the kitchen at 2:01 p.m., arrived on the unit at 2:02 p.m., and the last resident was served at 2:15 p.m. When the test tray was checked at 2:17 p.m., the chicken breast with gravy measured 118°F, broccoli 116°F, mashed potatoes with gravy 125°F, and milk 45°F. The chicken and broccoli were described as lukewarm and not palatable at those temperatures. The Dining and Nutrition Director confirmed that the food should have been served at a higher temperature. The facility also failed to maintain appropriate temperature and consistency for frozen dessert items. A quarterly MDS for one cognitively intact resident showed that she was independent with eating. During a dinner meal observation in the main dining room, this resident received a serving of chocolate ice cream that, by the time she began eating, had completely melted to a liquid consistency; she refused it, stating she did not want it because it was no longer ice cream. Further observation of the B wing dinner cart revealed single-serving chocolate ice cream containers that were very soft, with lids popping off and liquid ice cream leaking out. A nurse aide confirmed that the ice creams on the B wing dinner trays were melted, and the Nursing Home Administrator agreed that the ice cream on another resident’s tray was not frozen or firm as it should have been. These findings occurred under the regulatory requirements of 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.6(f) Dietary Services.
Insufficient Dietary Staffing Causing Late Meals and Improper Food Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient dietary staff to ensure meals were prepared, transported, and served at scheduled times and at appropriate temperatures and consistencies. Facility policies required timely meal distribution and proper temperature maintenance for hot and cold foods. Tray delivery logs showed scheduled lunch and dinner delivery times for each wing and the main dining room. On the identified survey date, lunch and dinner trays were repeatedly delivered significantly later than the scheduled times to all wings (A, B, C, D) and the main dining room. Staff interviews, including with an activity aide and nurse aides, indicated that late meals were a routine occurrence and that breakfast had also been delayed that morning. Multiple specific observations documented substantial delays in meal service. Lunch trays for B wing, C wing, the main dining room, D wing, and A wing were between 50 minutes and 1 hour and 42 minutes late. Dinner trays for the main dining room and all wings were between 34 minutes and 1 hour and 7 minutes late. Residents were observed waiting in the dining room for meals, with one cognitively intact resident, independent with eating, verbally expressing frustration and hunger after waiting nearly an hour for lunch and striking the table. Another cognitively intact resident, requiring only set-up for eating, reported that dinner trays were late that evening and recalled a recent Sunday when dinner did not arrive until 8:45 p.m. The facility also failed to maintain food at palatable and safe temperatures and appropriate consistencies, as required by its policies. A test tray on D wing showed hot foods (chicken breast with gravy, broccoli, mashed potatoes with gravy) below the required hot-holding temperature, and the chicken and broccoli were described as lukewarm and not palatable; the milk was above the cold-holding standard. During dinner service, a cognitively intact resident in the main dining room received chocolate ice cream that had completely melted to a liquid consistency and refused it. Additional observations of the B wing dinner cart showed single-serving ice cream containers so soft that lids popped off and liquid ice cream leaked out. Staff, including a nurse aide and the Nursing Home Administrator, confirmed that the ice cream was melted and not frozen or firm. The Dietary Director reported that three dietary staff members had called off that day, and the Nursing Home Administrator was observed working in the kitchen as a dishwasher.
Failure to Hold Midodrine When SBP Exceeded Ordered Parameters
Penalty
Summary
The facility failed to administer Midodrine as ordered for three residents whose physician orders required the medication to be held when systolic blood pressure was greater than 120 mmHg. Resident 11 had cognitive impairment, needed staff assistance with daily care, and had diagnoses including coronary artery disease and orthostatic hypotension. Review of the MAR showed Midodrine was given on multiple occasions when the resident’s systolic blood pressure was above the ordered hold parameter, including readings of 134/72, 128/72, 123/66, 124/64, and 126/82, with no documented evidence that the medication was held as ordered. Resident 13 was cognitively intact and required assistance with daily care, with diagnoses including coronary artery disease, heart failure, and high blood pressure. The MAR showed Midodrine was administered when systolic blood pressure readings were 126/74, 136/74, 142/80, 130/67, and 130/70, again without documentation that the medication was held. Resident 124, a new admission with orthostatic hypotension, a recent fall, and fluctuating orientation, also received Midodrine when blood pressure readings were above the hold parameter, including 148/96, 122/76, 130/72, 124/83, 126/80, 158/76, 132/78, and 148/76, with no documented evidence that the medication was held as ordered. The DON and NHA confirmed the medication had been given on those occasions and should have been held.
Food Service Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility policy for Dietary Staff Attire, dated November 20, 2025, required all employees to wear approved attire, keep hair off the shoulder and confined in a hair net or cap, and have facial hair properly restrained. During observation on December 10, 2025, at 12:00 p.m., Dietary Aide 2 was preparing lunch meal trays without a beard or mustache cover in place. Assistant Dietary Manager 1 confirmed during interview at that time that Dietary Aide 2 should have had his beard and mustache covered while preparing food. The facility’s Food Receiving and Storage policy, also dated November 20, 2025, required resident food items to be labeled with the resident’s name, the item, and the use-by date, and stated that partially eaten food may not be kept in the refrigerator and beverages must be dated once opened and discarded after twenty-four hours. On December 8, 2025, at 12:20 p.m., the solarium refrigerator on C wing contained resident food items and beverages that were opened and not labeled with resident names or use-by dates, including Kens salad dressing, a partially eaten Three Musketeers candy bar, and two bottles of Gatorade. An LPN on C wing verified that the items should have been labeled and dated once opened, and Assistant Dietary Manager 1 later confirmed that the food should have been labeled and dated once opened.
Failure to Inform Resident/Representative Before Increasing Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or the resident representative in advance of the risks and benefits of psychotropic medication use and the treatment alternatives before increasing the resident’s medications. The facility policy stated that residents, families, and/or representatives are to be involved in medication management, including review of indications, dose, duration, monitoring, and alternatives, and that the resident/representative should understand the intended benefit of the medication and may decline psychotropic treatment. Resident 32 was cognitively intact, able to clearly understand and be understood, and had diagnoses of depression, anxiety, and bipolar disorder. The resident was receiving antidepressant and antianxiety medications. A psychiatric note recommended increasing Prozac from 50 mg to 70 mg daily and Buspar from 15 mg three times daily to 30 mg twice daily, and physician orders were entered for those increased doses. There was no documented evidence in the clinical record that the resident or resident representative was informed in advance of the risks and benefits and treatment alternatives before the increased doses were initiated.
Resident Choice Regarding Diet Consistency Not Honored
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to self-determination regarding diet consistency. Resident 105 had a quarterly MDS that documented she was cognitively intact, understood and was understood by others, received a mechanically altered diet, and had coughing and choking during meals or when swallowing medications. The resident told staff she had been placed on a mechanical food diet because they said she choked, but she denied choking and stated she was to be reassessed by speech therapy. Speech therapy records showed the resident repeatedly stated she did not want the altered diet and wanted a regular diet. On one trial of regular Salisbury steak, she took large bites and had a near choking episode with redness in the face, watery eyes, and forceful coughing that expelled a bite of meat from the airway. Speech therapy removed the steak for safety and educated her about choking risk and possible emergency intervention. Subsequent therapy notes documented that she continued to deny swallowing difficulty, disliked the modified textures, and wanted regular meats, while speech therapy continued to trial different textures and noted improved performance with some regular solids. Interviews confirmed the resident was cognitively able to make her own decisions. The speech therapist stated she would only recommend the safest diet because of safety concerns, while the DON stated that if a resident preferred a regular diet despite speech therapy recommendations, staff would educate the resident, check with the physician, and if the physician agreed, have the resident sign a waiver. The NHA also confirmed the resident was cognizant and that her choices should be honored and that she should have a regular diet if she wanted one.
Inaccurate Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents' specific care needs for two residents reviewed. Facility policy stated that care plans should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and that assessments are ongoing and care plans are revised as resident information and conditions change. For one resident with an indwelling Foley catheter, the quarterly MDS showed cognitive impairment, assistance needs, and a catheter in place, but the care plan dated earlier still listed an 18F 10cc Foley catheter even though physician orders later specified a 16F 10cc Foley catheter and observation confirmed a 16F 10cc Foley in place. For another resident, the quarterly MDS showed cognitive impairment with a BIMS score of 6 and partial assistance needs, but the falls care plan still stated the resident had a BIMS of 13 and was alert and oriented. The DON confirmed that both care plans were inaccurate and should have been updated.
Incomplete Blood Sugar Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one resident. The resident’s admission MDS dated October 9, 2025 showed the resident was cognitively intact and had diabetes. Physician’s orders in October directed blood sugars to be checked twice daily, with the hypoglycemia protocol to be followed if blood sugar was less than 70 mg/dL and the medical doctor and RN supervisor to be notified if blood sugar was greater than 400 mg/dL. Review of the MAR for October and November showed no documented blood sugar results from October 6, 2025 at 2000 through November 15, 2025 at 0630. The DON confirmed in interview on December 11, 2025 that the blood sugars were obtained but were not documented in the MAR and should have been.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies identified in prior and current surveys. The report states that the facility’s plans of correction for the annual survey ending January 17, 2025 included quality assurance systems intended to maintain compliance with cited nursing home regulations, but the current survey ending December 11, 2025 found repeated deficiencies involving failure to revise care plans, prepare and store food safely, and follow infection prevention policies. For the care plan revision deficiency cited under F657, the prior plan of correction said the facility would complete audits and report the results to the QAPI committee for review, but the current survey found the QAPI committee failed to successfully implement that plan to ensure care plans were revised as needed. Similar findings were reported for food storage and food storage, preparation, and serving under F812, where the prior plans also relied on audits and QAPI review, yet the current survey found the committee failed to ensure food was stored safely and properly stored, prepared, and served. For infection control under F880, the prior plan of correction likewise called for audits and QAPI review, but the current survey found the QAPI committee failed to successfully implement the infection control program.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for one resident. The facility’s medication administration policy dated November 20, 2025 stated that staff were to follow established infection control procedures, including handwashing, antiseptic technique, gloves, and isolation precautions, as applicable. Physician orders for the resident dated May 14, 2025 included multiple medications, including oxycodone, azithromycin, prednisone, Lasix, Sinemet, Trelegy inhaler, senna, Pepcid, Vitamin B-12, and Cymbalta. During observation of medication administration on December 10, 2025 at 8:05 a.m., an LPN did not perform hand hygiene before preparing the resident’s medication or after administration when she began preparing medication for the next resident. When interviewed at 8:11 a.m., the LPN stated she does not perform hand hygiene after each resident and does it after three residents. The DON confirmed at 10:37 a.m. that the LPN should have performed hand hygiene between each resident.
Failure to Discontinue Medications as Ordered
Penalty
Summary
The facility failed to ensure that physician orders were written and followed for one resident. According to facility policy, verbal orders from a physician must be communicated to the nurse and followed through with appropriate documentation. For one resident, an admission MDS assessment indicated the resident was cognitively intact and required assistance with daily care. A pharmacist's recommendation to discontinue aspirin and famotidine was reviewed and signed by the physician, but there was no documentation in the clinical record that these medications were discontinued as ordered. The DON confirmed that the orders to discontinue the medications were not carried out as required.
Unsanitary Fan Blowing on Clean Dishes in Kitchen Dishroom
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and sanitary environment in the main kitchen dishroom. During an observation, a large, upright fan with a heavy accumulation of visible dirt and debris on its blade cover was found blowing directly onto the dish dry rack, which held several clean pots, pans, and dishes. The fan was noted to have several half-inch tendrils of dirt and debris flowing from the cover as it operated, potentially contaminating the clean kitchenware. The Dietary Manager and the Nursing Home Administrator both confirmed the presence of the dirty fan blowing on the clean dishes and acknowledged that it should not have been there. The facility's policy required that dish cleaning areas be kept sanitary, but this was not followed in this instance.
Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to formulate an advance directive or were offered assistance in doing so. This deficiency was identified for six residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated November 26, 2024, mandates that upon admission, the facility should determine if a resident has executed an advance directive and provide information about the right to refuse medical or surgical treatment and formulate an advance directive. However, there was no documented evidence in the medical records of the six residents reviewed that these steps were taken. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with care needs. For instance, one resident had mild cognitive impairment and required supervision to moderate assistance, while others were cognitively impaired with diagnoses such as dementia and hemiplegia. Despite these conditions, the facility did not document any efforts to discuss or assist with advance directives, as confirmed by the Director of Nursing during an interview. This lack of documentation and action indicates a failure to comply with the regulatory requirements regarding advance directives.
Plan Of Correction
1. Assistance with completing advanced directives was offered to residents 37, 62, 81, 88, 90. Resident 100 has been discharged from the facility. 2. Audit of all residents in the facility was completed to ensure all residents had been offered the opportunity to formulate an advanced directive. All residents without a current advanced directive are offered the opportunity to complete one. 3. Education completed with the Interdisciplinary team to ensure the opportunity to formulate an advanced directive is being offered during the residents' initial care plan meeting and the opportunity to update/change at a minimum of each care plan meeting thereafter. 4. Audits will be completed on all new admissions weekly x 4 weeks and monthly x 2 months to ensure the opportunity to formulate an advanced directive is being completed. 5. Date of compliance 3/5/2025
Failure to Follow Planned Menu and Provide Complete Meal Trays
Penalty
Summary
The facility failed to follow their planned menu, as evidenced by observations and interviews with residents and staff. A facility policy dated November 25, 2024, required service staff to inspect food trays to ensure the correct meal was provided to each resident. However, on January 13, 2025, a resident's lunch tray was missing margarine for her roll, which she stated made her unwilling to eat it. The resident also reported that her meal trays routinely lacked sugar packets, condiments, napkins, or flatware. An interview with a nurse aide confirmed that no margarine was available on any trays in A wing, and the kitchen was contacted but had none available. Further interviews with a group of residents on January 14, 2025, revealed that they often did not receive the correct menu items or were missing items on their trays. The facility's written and printed menu for January 13, 2025, specified that residents were to receive beef meatloaf with glaze, green beans, scalloped potatoes, a buttered dinner roll, margarine, pound cake, and a choice of beverage. However, the dietary manager confirmed that while the kitchen had margarine available, it was not placed on the trays. The facility did not have individual packets but could provide small lidded cups of margarine, which were not utilized by the kitchen staff.
Plan Of Correction
1. The Dietary Manager immediately educated line staff on the importance of adding the condiments that are listed on the menu. 2. The dietary department will add an extra bowl of condiments to each tray cart sent to the units to ensure there is extra available. 3. The Dietary Manager or designee will review the Food Preparation and Service Policy and Menus. The Dietary Manager or designee will educate the Dietary staff on the importance of following the menus as listed to include condiments. 4. The Dietary Manager or designee will randomly audit daily for 4 weeks, then weekly for 3 months to ensure that the food delivered to residents matches the menu posted. The Dietary Manager or designee will report the results of this audit monthly to the Quality Assurance Performance Improvement (QAPI). 5. The completion date will be 03/5/202.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to meet the requirements for serving food at appropriate temperatures, as evidenced by multiple observations and interviews. The policy for food service temperatures, dated November 26, 2024, stated that hot foods should be served at 140 degrees Fahrenheit or above, and cold foods at 40 degrees Fahrenheit or below. However, interviews with residents revealed that meals served in their rooms were often cold, overcooked, and not palatable. Additionally, residents reported missing items such as sugar packets, condiments, napkins, or flatware on their meal trays. During an observation in the kitchen, a test tray was placed on a meal cart destined for the A wing. The cart arrived at the unit, and the last resident was served approximately 19 minutes later. At that time, the temperature of the mashed potatoes was recorded at 129 degrees Fahrenheit, and the mixed vegetables at 122 degrees Fahrenheit, both below the required temperature for hot foods. The milk was also found to be at 51 degrees Fahrenheit, above the required temperature for cold foods. The Dietary Manager confirmed that the foods were not served at the proper temperatures, corroborating the residents' complaints.
Plan Of Correction
The policy on palatable food temperatures was reviewed with all members of the dietary department by the Registered Dietician and/or designee. All nursing staff re-educated on serving meal trays timely to residents eating in their rooms. Test trays will be completed by the Registered Dietician dietary manager twice weekly x 4 weeks, then monthly x 2 months, and at random afterwards to ensure that served foods are within facility policy temperatures and palatable. Results for test trays will be reviewed during facilities Quality Assurance committee meetings. Date of compliance 3/5/2025
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage and sanitation practices. Observations in the walk-in freezer revealed a plastic bag of pizza crusts that were not labeled or dated, contrary to the facility's policy requiring all items to have a received date and an expiration date. Additionally, there was a significant build-up of ice on the freezer's condenser, and a ceiling vent above the tray line in the kitchen was covered with a large accumulation of black debris and dust. The ice machine was found to have a pink, removable build-up on the top plastic piece and was dripping water onto the ice, indicating unsanitary conditions. Further observations in the kitchen showed that the ceiling vent above the tray line remained uncleaned, and the three-compartment sink contained water with utensils and pans drying on the counter. The facility's sanitizer log for January 2025 lacked documentation of the sanitizer strength for each meal from January 1 through January 17, 2025, which was confirmed by the Dietary Manager. These findings highlight the facility's failure to maintain sanitary conditions in food storage and preparation areas, as well as a lack of adherence to their own policies regarding food labeling and sanitation practices.
Plan Of Correction
Dietary manager immediately verified no other items in the walk-in freezer was not labeled and completed on the spot education to the dietary staff on recording chemical sanitizer strength. Both the ice storage machine and the kitchen vents were cleaned and the buildup of ice on the freezer condenser was removed. Administrator or designee educated all dietary staff on the policy for food storage and record keeping for the strength of chemical sanitizers. Administrator or designee educated both dietary staff and maintenance on cleaning of kitchen equipment and vents. Audits will be completed by dietary manager or designee 2 x week for 2 weeks and monthly for 2 months for food labeling and buildup of ice in the walk-in freezer. Audits of the record sheets for chemical sanitizer strength will be completed 2 x week for 2 weeks and monthly for 2 months to ensure documentation is accurate and available. Audits for the ice machine and kitchen ceiling vents will be completed weekly for 4 weeks then monthly for 2 months. All results of findings will be reported and trended through the facilities Quality Assurance Committee. Date of compliance 3/5/2025.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control guidelines as outlined by the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC), resulting in deficiencies in the implementation of Enhanced Barrier Precautions (EBP) for several residents. The report highlights that the facility did not implement EBP for residents with indwelling medical devices or chronic wounds until November 27, 2024, despite having residents with conditions that warranted such precautions. This oversight affected multiple residents, including those with indwelling catheters, pressure ulcers, and infections with multidrug-resistant organisms (MDROs). Observations and staff interviews revealed specific instances of non-compliance with infection control practices. For example, a Licensed Practical Nurse (LPN) failed to perform hand hygiene between glove changes during wound care for a resident with pressure ulcers, which is a critical step in preventing cross-contamination. Additionally, there was a lack of proper signage and personal protective equipment (PPE) availability for residents on transmission-based precautions, as evidenced by the case of a resident with a methicillin-resistant Staphylococcus aureus (MRSA) infection. The facility's infection preventionist and Director of Nursing confirmed the lapses in implementing EBP and maintaining proper infection control measures. These deficiencies were identified through a review of clinical records, facility policies, and direct observations, indicating a systemic issue in the facility's infection prevention and control program. The report underscores the need for adherence to established guidelines to prevent the spread of infections and protect both residents and staff.
Plan Of Correction
1. Residents 7, 8, 11, 12, 34, 63, 70, and 80 suffered no ill effects. EBP for residents 7, 11, 12, 63, 70, and 80 was implemented on 11.27.2024. Signage for Enhanced Barrier Precautions was replaced for resident 34. 2. Baseline audit done on all residents needing Enhanced Barrier Precautions to ensure all needed signage is posted. 3. Education completed with all nursing staff on hand hygiene to include demonstration and with housekeeping and nursing to ensure EBP signage stays in place at all times. Nursing staff reeducated on residents that require the need for enhanced barrier precautions. 4. Audits will be completed 2 x week for 2 weeks and monthly for 2 months to ensure all residents' doors that require EBP signage is up and current. Audit on staff hand hygiene will be done 5 x a week for 2 weeks. 5. Date of compliance 3/5/2025.
Failure to Maintain a Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a clean and homelike environment for one resident, identified as Resident 8, who was cognitively intact and dependent on staff for all care needs due to quadriplegia and depression. During an observation, it was noted that Resident 8's room had areas of broken drywall near the closet and bathroom entrance. The damage was reportedly caused by the footrest of the resident's electric wheelchair scraping the wall when staff forgot to put the footrest up while parking the wheelchair. Interviews with staff revealed that the damage had been reported to the maintenance department, but no work order was found in the system, and the former maintenance director had recently resigned. Maintenance Employee 2 confirmed the need for repairs and acknowledged that the room was not homelike. The deficiency was noted as a failure to maintain a safe, clean, and homelike environment as required by regulations.
Plan Of Correction
1. Repair of both areas of the drywall in resident 8's room was completed. 2. Audit of all resident rooms was done and any other holes found were repaired. 3. Education with all staff completed on completing a work order on any holes observed. 4. Weekly audits x 4 weeks and monthly times 2 months will be completed to check and repair any holes observed in resident rooms. 5. Date of compliance 3/5/2025
Quarterly MDS Assessment Not Completed Timely
Penalty
Summary
The facility failed to complete the quarterly Minimum Data Set (MDS) assessments within the required time frame for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type. However, for Resident 81, the quarterly MDS assessment had an ARD of December 13, 2024, which was 116 days after the previous annual MDS assessment with an ARD of August 19, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on January 17, 2025.
Plan Of Correction
1. Resident 81 suffered no ill effects. 2. Baseline audit completed to ensure all other Minimum Data Sets were completed timely by the registered nurse assessment coordinator/designee. 3. Review of the Resident Assessment Instrument manual was completed with Registered Nurse Assessment Coordinator to ensure understanding of the completion dates. 4. Audits will be completed by RNAC weekly x 2 weeks and monthly x 2 months checking for timeliness of assessments. 5. Date of compliance 3/5/2025.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs. For one resident, the care plan was not updated to indicate the discontinuation of Coumadin and the initiation of Apixaban for anticoagulation therapy. Additionally, the care plan did not document the resident's use of a foley catheter leg bag, which was preferred for dignity. These omissions were confirmed by the Director of Nursing during interviews. For another resident, the care plan inaccurately documented surgical wounds on the palms, which were actually scars from previous surgeries. This error was identified during a skin and wound assessment shortly after the resident's admission, but the care plan was not revised to reflect the correct information. The Director of Nursing confirmed that the care plan should have been updated to remove the incorrect information about surgical wounds.
Plan Of Correction
1. Care plan for resident 7 and resident 11 were reviewed and updated by the Director of Nursing. Neither resident suffered any adverse effects. 2. The Director of Nursing or designee will review the care plans for all current residents with catheters, have wounds or on anticoagulation medication for accuracy in anticoagulation medication, for residents with catheters who preference leg bags along with correct wound documentation. Any identified care plans will be updated upon discovery. 3. The Director of Nursing or designee will educate all staff who are responsible for completing and updating the care plan so that to reflect a resident's new orders, treatments, and interventions. 4. The Director of Nursing or designee will audit any changes to resident preferences to ensure comprehensive care plans are updated to reflect changes 2 times a week for 2 weeks then monthly for 2 months to assure the resident's anticoagulant therapy/catheter bag preferences wound changes are reflected. The Director of Nursing or designee will report on the results of the audit to the facility's Quality Assurance Committee. 5. Date of compliance 3/5/2025.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that Resident 24, who was dependent on staff for bathing and showering, received showers as per her preference and schedule. The resident, who was cognitively intact and had chronic congestive heart failure and diabetes, had a documented preference for showers twice a week on Wednesdays and Sundays during the day shift. However, a review of the Bath/Shower record from October to December 2024 revealed that the resident was consistently provided with bed baths instead of showers on multiple occasions, including all of November and specific dates in October and December. Interviews with Resident 24 and the Director of Nursing highlighted that the resident was not receiving her preferred showers due to various excuses provided by the staff, such as the lack of hot water or the shower room being too cold. Furthermore, there was no documented evidence that the resident was offered or refused a shower on her scheduled days when bed baths were given instead. This lack of adherence to the resident's bathing preferences and schedule constitutes a failure to meet the requirement of providing necessary services to maintain good personal hygiene.
Plan Of Correction
1. Resident 24 suffered no adverse effects. Education was provided to all nursing staff on following resident preferences. 2. The Director of Nursing or designee will review residents' tasks to ensure preferences on bathing/showering are being met or documented as completed. 3. The Director of Nursing or designee will educate all staff on documentation of tasks and refusals, making sure resident preferences are followed. 4. The Director of Nursing or designee will do random audits on bathing preferences for a minimum of 10% of the population 2 times a week for 4 weeks, monthly for 2 months to ensure showers/bathing preferences are followed. The Director of Nursing or designee will report the results of the audit to the facility's Quality Assurance Committee. 5. Date of Compliance: 3/5/2025
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of Midodrine Hydrochloride for a resident diagnosed with Parkinson's Disease. The resident, who was cognitively intact and required assistance with personal care, had a physician's order to receive 2.5 mg of Midodrine Hydrochloride twice daily, with the stipulation to hold the medication if the resident's systolic blood pressure (SBP) exceeded 120. However, the medication was administered multiple times over several months when the resident's SBP was above the specified threshold. The Medication Administration Record (MAR) for the resident showed instances in October, November, December, and January where the medication was given despite the SBP readings being higher than 120, with values ranging from 122 to 150. An interview with the Director of Nursing confirmed that the medication was improperly administered on these occasions, contrary to the physician's orders. This oversight indicates a failure in following professional standards of practice and the resident's care plan, as required by the quality of care regulations.
Plan Of Correction
1. Resident 9 suffered no ill effects. The Medical Director was notified of resident 9 receiving medication outside of parameters. No new orders given. 2. A baseline audit was completed on all residents currently receiving the medication Midodrine to check for error in documentation. 3. All licensed nursing staff were educated on the process of documenting medications not given due resident being outside of parameters. 4. Audits on residents receiving medications with parameters will be completed weekly x4 weeks and monthly x 2 months to ensure compliance. Results will be reported and trended through the facility's Quality Assurance Committee. 5. Date of compliance 4/5/2024
Failure to Document Gastric Residual Volumes for Enteral Feeding
Penalty
Summary
The facility failed to adhere to its policy regarding the documentation of gastric residual volumes (GRV) for a resident with an enteral feeding tube. According to the facility's policy, staff were required to check and document the GRV every shift to assess the resident's tolerance to enteral feeding and minimize the risk of aspiration. If the GRV exceeded 250 mL, the physician was to be notified, and the resident was to be assessed for feeding intolerance. However, a review of the clinical records for Resident 70, who was cognitively impaired and had an enteral feeding tube, revealed that there was no documented evidence of GRV checks from January 1 to January 17, 2025. Physician's orders for Resident 70 specified that the GRV should be checked every shift, and specific actions were to be taken if the GRV exceeded certain thresholds. Despite these orders, the facility did not document the GRV checks as required. An interview with the Director of Nursing confirmed the absence of documentation for the GRV checks in the resident's clinical record, indicating a failure to comply with the facility's policy and the physician's orders.
Plan Of Correction
1. Medical Director was immediately notified of staff not documenting residuals. Electronic Medication Administration Record updated to reflect spot for documentation of residual amount. Resident 70 suffered no ill effects. 2. Audit completed for all residents receiving feedings completed to ensure that residual is being documented. 3. Director of nursing/designee completed Education with licensed nursing staff on the facility policy for checking residual every shift. 4. Director of nursing or designee will audit Electronic Medication Administration Record for all residents receiving feedings 2 x week for 4 weeks and monthly for 2 months to ensure residual is being documented. 5. Date of compliance 3/5/2025
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The survey ending January 17, 2025, identified repeated deficiencies related to maintaining a homelike environment, accuracy of assessments, updating/revising care plans, quality of care, and food service standards. These deficiencies were previously cited in a survey ending February 1, 2024, indicating a lack of effective implementation of corrective actions. The facility's plan of correction for maintaining a homelike environment included completing audits and reporting results to the QAPI committee. However, the current survey revealed that the QAPI committee failed to implement the plan successfully, resulting in ongoing non-compliance with regulations. Similarly, deficiencies in the accuracy of assessments and updating/revising residents' care plans were not addressed effectively, as the QAPI committee did not ensure compliance with the established corrective plans. Additionally, the facility's plans to address quality of care and food service issues, such as ensuring food was palatable and served at proper temperatures, were not successfully implemented. The QAPI committee's failure to ensure compliance with these plans resulted in repeated citations under various F-tags, including F584, F641, F657, F684, F804, and F812. This indicates a systemic issue in the facility's ability to sustain improvements and adhere to regulatory standards.
Plan Of Correction
The facility Quality Assurance Performance Improvement committee will continue to be held on a monthly basis and meet the expectations as outlined in the facilities policy. The Quality Assurance Performance Improvement committee has not been following the appropriate policy guidelines as outlined in the policy and therefore, the Administrator will provide re-education on the Quality Assurance Performance Improvement committee process and the expectations to active committee participants as outlined in the above-mentioned policy. The committee failed to successfully implement plan of corrections for previously identified areas by not reviewing audit findings and making any corrective recommendations. To assure compliance of the plan of correction, participating members (department heads) of the committee will present their specified areas at the committee meetings for discussion, committee recommendations, effectiveness and implementation of corrective actions. These presentations will include audit tools utilized to address areas of the plan of correction and will be reported on a monthly basis. Committee members will implement recommendations as discussed and detailed by the committee. Participating committee members will follow up on recommendations to assure continued compliance. Any outlying findings will be corrected and reported back to the committee for further discussion/recommendations. Monthly minutes from the Quality Assurance Performance Improvement committee will be forwarded to the Director of Clinical Operations for review and recommendations. Date of compliance 3/5/2025
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in the documentation of their medical conditions. For one resident with an ostomy, the MDS inaccurately indicated bowel continence, despite physician orders confirming the presence of an ostomy. Another resident's MDS failed to reflect a Stage 4 pressure ulcer, as documented in a skin and wound note, leading to an inaccurate assessment of the resident's skin condition. Additionally, the MDS for a resident receiving Trazadone, an antidepressant, did not record the medication during the assessment period, despite physician orders and the Medication Administration Record confirming its administration. Furthermore, a resident receiving Seroquel for dementia with agitation had an MDS that inaccurately indicated no physician-documented Gradual Dose Reduction (GDR) as clinically contraindicated, despite a pharmacy recommendation and physician's decision against a GDR.
Plan Of Correction
Plan of Correction: 1. The Minimum Data Set assessments for residents 7, 63, 75, and 85 have been reviewed and modified to correctly reflect the residents' condition at the time of the assessment periods. Modifications have been completed and submitted to MDS. 2. Sections H, M, and N were reviewed for accuracy on current residents' most recent Minimum Data Set based on his/her most recent Assessment Reference Date (ARD) and corrected where applicable. 3. The Registered Nurse Assessment Coordinator was educated by the Director of Nursing on assessment accuracy. 4. Registered Nurse Assessment Coordinator(s) and/or designee will audit 10% or a minimum of 5 completed Minimum Data Set(s) section H, M, and N weekly for 2 weeks and then monthly for 2 months. The results of the audits will be addressed at the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions. 5. Date of compliance: 3/5/2025.
Deficiency in Emergency Generator Maintenance Documentation
Penalty
Summary
The facility was found to be deficient in maintaining proper documentation for the emergency generator's annual preventative maintenance and testing for the year 2024. During a document review conducted on January 15, 2025, it was revealed that the facility could not provide the necessary documentation to confirm that the required maintenance and testing had been performed. This deficiency affects the entire facility as the emergency generator is a critical component of the essential electrical system, which is required to supply power within 10 seconds in the event of an outage. An interview with the Facilities Administrator and Assistant Maintenance Director on the same day confirmed the absence of documentation for the emergency generator's maintenance and testing. This lack of documentation indicates a failure to comply with the standards set forth by NFPA 101, NFPA 110, and NFPA 111, which require regular inspection, testing, and maintenance of emergency power systems to ensure their reliability and functionality in emergencies.
Plan Of Correction
1. Documentation for the emergency generator annual preventive maintenance was found and added to the life safety binder. 2. Review of life safety binder will be completed monthly by maintenance director/designee to ensure all needed paperwork is available. 3. Maintenance Director will bring results of monthly audit to the facility's Quality Assurance Committee for review.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, as evidenced by an observation on January 15, 2025. During the inspection, it was noted that the door to the storage closet in the Rehabilitation Room did not latch properly because tape was placed on the striker plate. This deficiency affected one of the eight smoke compartments in the facility. The issue was confirmed through an interview with the Facility Administrator and Assistant Maintenance Director on the same day, who acknowledged the hazardous area enclosure deficiencies.
Plan Of Correction
Tape was removed from the striker plate on the storage room doors in the rehab department. Maintenance director/designee educated rehab staff on not attaching foreign objects that would obstruct closing of any doors. Audit will be completed by maintenance director/designee weekly x 2 months and then randomly thereafter to ensure nothing is obstructing closet door from latching. Date of compliance 2/28/2025.
Deficiency in Kitchen Fire Safety Maintenance
Penalty
Summary
The facility failed to maintain cooking facilities in compliance with NFPA 101 standards, specifically affecting one of eight smoke compartments. During a review of documentation and observation on January 15, 2025, it was found that the facility lacked necessary documentation for semiannual kitchen fire suppression testing and maintenance for the second half of 2024. Additionally, there was no record of semiannual kitchen exhaust hood and duct cleanings for the same period. An interview with the Facility Administrator and Assistant Maintenance Director confirmed these deficiencies in the kitchen fire suppression system and hood maintenance.
Plan Of Correction
Semiannual kitchen fire suppression testing was located and added to the life safety binder. The cleaning of the kitchen exhaust hood/duct was scheduled for completion on 1/27/2025. Review of the life safety binder will be completed monthly by the maintenance director/designee to ensure all needed paperwork is easily accessible. The facility obtained contracted services to ensure kitchen exhaust hood/duct cleaning is completed as required. Semiannual cleaning will be monitored by the facility maintenance director/designee to ensure completion and brought to the facility's Quality Assurance Committee meeting for confirmation and review. Date of compliance: 2/28/2025.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for two residents, both of whom were cognitively impaired and receiving opioids for pain management. For one resident, the controlled drug record indicated that doses of oxycodone were signed out for administration on specific dates and times, but there was no documented evidence in the Medication Administration Record (MAR) or clinical record to confirm that the medication was administered. Similarly, for the second resident, doses of oxycodone were signed out, but there was no documentation to show that the medication was administered as ordered, nor was there evidence that the remaining medication was properly wasted by two licensed nurses as required. The facility's policy for controlled substances requires that the charge nurse maintains the keys to controlled substance containers and that controlled medications are wasted or disposed of in the presence of a nurse and a witness who signs the disposition sheet. An interview with the Director of Nursing confirmed the lack of documentation for the administration of the signed-out doses of oxycodone for both residents. This deficiency was identified during a review of policies, clinical records, and staff interviews, highlighting a failure in the facility's processes for managing and documenting the use of controlled substances.
Inaccurate MDS Assessment for Wander/Elopement Alarm
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for one resident. Specifically, the quarterly MDS assessment for a resident, dated December 5, 2023, incorrectly indicated that the resident did not use a wander/elopement alarm, despite the resident having a physician's order and care plan for the use of a Wanderguard from November 2 through December 31, 2023. This discrepancy was confirmed by the Director of Nursing during an interview on January 25, 2024. The Resident Assessment Instrument (RAI) User's Manual specifies that if a wander/elopement alarm is used, it should be coded accordingly in Section P0200E of the MDS assessment.
Failure to Document Resident Elopement Incident
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed. Specifically, Resident 1, who was cognitively intact, was able to leave the building without staff knowledge. The resident observed staff exiting the building and used this knowledge to exit the door without triggering an alarm. She walked around the building until staff found her and returned her to the facility. This incident was not documented in the resident's clinical record, nor was there any evidence that the resident was assessed upon her return to the building. Interviews with the Social Services Director, a Registered Nurse, and a Nurse Aide confirmed that the incident occurred and that it was not documented in the resident's clinical record. The Social Services Director learned about the incident during a morning meeting, and the Registered Nurse and Nurse Aide described their actions in response to the resident's elopement. The Nursing Home Administrator and the Director of Nursing also confirmed that there was no documentation of the incident in the resident's clinical record, although there should have been.
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What surveyors actually found near you
We read the 178 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Altoona
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midtown Oaks Health & Rehab Center | 1.9 mi | ★★★★★ | 24 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 2.2 mi | ★★★★★ | 3 | 0 |
| Garvey Manor | 2.8 mi | ★★★★★ | 0 | 0 |
| Hollidaysburg Veterans Home | 3.7 mi | ★★★★★ | 6 | 0 |
| Lutheran Home At Hollidaysburg | 3.8 mi | ★★★★★ | 14 | 0 |
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