Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Hollidaysburg Veterans Home during CMS and state inspections, most recent first.
Failure to provide adequate supervision after repeated falls. A resident with cognitive impairment, urinary incontinence, and a care plan for bedside urinal use fell while trying to toilet, was found with bruising and later hit his head in another fall. After returning from the hospital, ordered 15-minute checks were not documented as started, and he later fell again, sustaining a hip fracture.
A resident with COPD who used CPAP was left without his machine when maintenance removed it for repairs, and there was no timely communication to the RN or physician about the change in condition. The RN supervisor learned of the issue only after a computer alert, and the DON confirmed there was no documented evidence that the physician was notified when the CPAP became unavailable.
Failure to Provide Scheduled Toileting and Incontinent Care Documentation: A resident with urinary incontinence and substantial toileting assistance needs was care planned for pull-ups and 2-hour checks, but records showed toileting was not documented every 2 hours as planned. After repeated falls while trying to use a bedside urinal and difficulty removing clothing, the resident was found incontinent, sustained bruising, a skin tear, head injury, and later a hip fracture. The DON confirmed there was no documented evidence of toileting every 2 hours as a fall intervention.
A resident with Parkinson’s, dementia, orthostatic hypotension, and cognitive impairment, care planned for all transfers with a full mechanical lift using a large sling, was being transferred by two nurse aides for a shower when the resident fell backward out of the sling. The resident was found on the floor between the lift’s legs with a bleeding head laceration and complaints of head, neck, and back pain, and was later diagnosed with a scalp laceration, closed head injury, and T6 vertebral fracture. Investigation showed an extra-large sling was used instead of the ordered large sling, and the leg straps were attached incorrectly (not crisscrossed), leading the facility and the DON to substantiate neglect for failure to follow the care plan.
Two residents experienced serious injuries due to failures in fall prevention and safe transfer practices. One resident with dementia, confusion, wandering, and a history of falls had physician orders and a care plan requiring hip savers at all times, yet was found on the floor after an unwitnessed fall without hip savers in place and was later diagnosed with a left hip fracture. Another cognitively impaired resident with Parkinson’s disease, orthostatic hypotension, and dependence for transfers was care planned for use of a full mechanical lift with a large sling, but during a transfer for a shower, two CNAs used an incorrect sling size and attached the leg straps improperly (not crisscrossed), causing the resident to fall backward out of the sling, sustain a scalp laceration, closed head injury, and a T6 vertebral fracture.
A resident with dementia, wandering behavior, a history of falls, and an order to wear hip savers at all times was found on the floor between two nightstands in another resident’s room with head, arm, and elbow injuries and severe left hip pain, later diagnosed as a hip fracture. Facility policy required detailed fall documentation and a thorough abuse/neglect investigation, including interviews with all involved staff. The internal investigation documented that hip savers were in place, but an RN and an RN Supervisor both observed that the resident was not wearing hip savers and this discrepancy was not captured in the written investigation, and leadership was unaware of the missing hip savers, demonstrating that a thorough investigation was not completed.
A resident with kidney failure who received dialysis did not have required post-dialysis assessments or vital sign checks documented on multiple occasions, as mandated by facility policy. The DON confirmed that the necessary monitoring and documentation were not completed after the resident returned from dialysis.
Surveyors found that large plastic containers of flour, sugar, and thickening powder in the kitchen were being used to store the original paper packaging of these ingredients, rather than transferring the contents directly into the plastic containers. The Dietary Manager was unaware of any issue with this practice.
Three residents experienced deficiencies in clinical record documentation, including inconsistent recording of enteral feeding and flushes, an unsupported PTSD diagnosis, and a delayed entry for a speech therapy follow-up after a fall. These lapses resulted in incomplete and inaccurate medical records, as confirmed by facility staff.
A deficiency occurred when a medication cart was left unattended with a computer screen displaying a resident's personal health information, contrary to facility policy requiring confidentiality. Both the LPN and DON confirmed that the information should have been covered when the nurse was not present.
A resident with cognitive and physical impairments was subjected to neglect and mental abuse by a nurse aide, who refused to provide required care, made dismissive remarks, and turned off the resident's call bell without assisting. The resident reported feeling fearful and anxious due to the aide's actions, and facility investigation substantiated the abuse and neglect.
A resident with heart failure and Alzheimer's disease experienced a fall resulting in head staples, and the care plan was updated to include staple care. After the staples were removed, the care plan was not revised to discontinue staple care interventions, despite facility policy requiring such updates. Staff confirmed the care plan should have been updated to reflect the change.
A resident with cognitive impairment and kidney failure, who attended early morning dialysis, was scheduled to receive multiple medications at 9:00 a.m. on dialysis days. Instead, an LPN administered these medications before 6:00 a.m., without physician clarification or documentation of order changes. The DON confirmed that the medication orders should have been clarified.
The facility did not ensure that a resident with left-sided paralysis had a required positioning wedge in place while in bed, as ordered by the physician and care plan. Additionally, during a transfer of another resident using a Hoyer lift, staff failed to engage the brakes as required, causing the lift to move slightly. Both deficiencies were confirmed by staff interviews and observations.
Staff failed to document the administration of Oxycontin, a controlled medication, for a resident despite signing out doses on multiple occasions. The MAR and clinical record contained no evidence that the medication was actually given, as confirmed by the ADON.
A medication cart was found unlocked and unattended in a hallway while the responsible LPN was away at the nurse's station. Facility policy requires medication carts to be locked when not in view, and both the LPN and DON confirmed this expectation during interviews.
The QAPI committee failed to correct recurring deficiencies, resulting in repeated issues with resident abuse/neglect, accountability for controlled medications, proper food storage and serving, and accurate medical records. Despite previous plans to conduct audits and review results, the same problems were identified again during the most recent survey.
A resident with a history of stroke and COPD did not receive showers on their preferred and ordered days, as per their care plan and physician's orders. Instead, the resident was given showers on different days, and there was no documented reason for this deviation, as confirmed by the Assistant Director of Nursing.
An LPN failed to ensure three residents swallowed their medications, leaving the medication cups on the table and walking away, contrary to facility policy. Additionally, the facility did not clarify physician's orders for a resident's venous access device, failing to document the required flushing of the port every 30 to 90 days.
The facility failed to follow physician's orders for two residents. One resident did not receive magnesium hydroxide as ordered for constipation, despite extended periods without a bowel movement. Another resident received Carvedilol without the required blood pressure or heart rate checks prior to administration. These deficiencies were confirmed by the Assistant Director of Nursing.
A facility failed to maintain accountability for controlled medications for a resident with breast cancer, who was prescribed Oxycodone for pain management. The facility's policy required accurate documentation of narcotic administration, but discrepancies were found in the records, indicating that doses were signed out without documented evidence of administration. This deficiency was confirmed by the Quality Assurance Coordinator, violating pharmacy and nursing service regulations.
The facility failed to maintain sanitary conditions for food storage and preparation. In the main kitchen, an undated beef broth and standing water were found in the refrigerator. In the kitchenettes, unlabeled frozen items and expired magic cups were discovered. Staff confirmed these deficiencies.
A facility failed to obtain necessary hospice documentation for a resident with breast cancer receiving hospice services. Despite the care plan requiring hospice staff to provide reports, there was no evidence of essential hospice forms or progress notes in the clinical records. This deficiency was confirmed by the Assistant Director of Nursing and the Nursing Home Administrator.
The facility did not maintain the main kitchen walk-in freezer properly, as a large accumulation of ice was observed on the fans. The Dietary Director confirmed that this ice buildup should not occur.
A resident with Alzheimer's disease was left without timely assistance for toileting needs during a dental appointment, resulting in incontinence and embarrassment. Despite expressing the need to use the bathroom, the resident was not assisted appropriately, leading to a lack of dignity in care.
A resident with Alzheimer's disease was left incontinent while awaiting a dental visit due to a failure in providing necessary toileting assistance. Despite expressing the need to use the bathroom, the resident was not assisted, resulting in incontinence. The dental hygienist managed the situation by placing a towel on the chair, but proper care was not provided until the resident was returned to his room.
A resident with Waldenstrom macroglobulinemia, who was cognitively intact, did not receive the prescribed built-up utensils for meals, as per the care plan and physician's orders. The resident reported frequently not receiving the assistive devices, which was confirmed by staff interviews.
A facility failed to ensure accurate documentation of narcotic administration for a resident. The policy required recording the date, time, and amount of narcotic administered, but discrepancies were found between the MAR and narcotic sign-out sheets. The resident, who was cognitively impaired, received NORCO at times that did not match the sign-out records, as confirmed by the DON.
The facility failed to follow infection control guidelines for two residents. A nurse aide did not perform hand hygiene after glove removal while caring for a resident with incontinence. Additionally, staff did not wear gowns as required by Enhanced Barrier Precautions when accessing a feeding tube for another resident. These actions were contrary to the facility's policies and CDC guidelines.
Failure to Provide Adequate Supervision After Repeated Falls
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for one resident who had a history of falls, cognitive impairment, occasional urinary incontinence, and substantial assistance needs with toileting hygiene. The resident’s care plan identified potential for falls and directed that his urinal be kept at the bedside. After an unwitnessed fall in which the resident said he was trying to use his urinal but could not get his pants down, he was noted to be without socks, incontinent of urine, and to have abrasions/bruising to the left knee and multiple bruises to the left arm. Following that fall, the resident was found on the floor again while attempting to use the bedside urinal and reaching forward from the bed. He was found perpendicular to the bed, had urinated on himself, and had a purple quarter-sized mark on his forehead after hitting his head. He was sent to the hospital for evaluation and treatment. The fall investigation documented that neurological checks were started and that the resident would be placed on frequent checks upon return from the hospital. After the resident returned from the hospital, there was no documented evidence that the ordered 15-minute checks were initiated. Later that same night, the resident was found on the floor again with his pants around his knees after apparently trying to stand to use his urinal. He had a skin tear to his right elbow and reported right hip pain. Hospital records showed a right hip fracture due to a ground-level fall. Staff statements and record review showed that the resident’s neurological checks were not fully documented and that the frequent checks were not initiated as planned after the earlier fall.
Delayed Physician Notification for Unavailable CPAP Machine
Penalty
Summary
The facility failed to ensure that the physician was notified timely about a change in condition for one resident who was cognitively intact, had chronic obstructive pulmonary disease, and used a CPAP machine. The facility policy dated January 1, 2026 stated that when there was a change in condition, staff would notify the covering RN, who would then update the supervisor, physician, and family. For Resident 2, an admission MDS dated April 29, 2026 documented the resident’s diagnoses and CPAP use, and a progress note dated May 18, 2026 at 1:19 a.m. indicated that the CPAP machine was unavailable. Resident 2 stated that he used his oxygen at night but that it was not the same as his CPAP machine and that it bothered him very much not to have it because he could not sleep well. The RN Supervisor reported that on May 13, 2026, maintenance took the CPAP machine to change filters and fix a broken magnet on the strap, but there was no communication between the LPN and RN about the removal. She stated the resident was without the CPAP machine until approximately May 22, 2026, and that she did not become aware of the situation until the computer flagged it on May 18, 2026, at which time she notified the physician. The DON confirmed there was no documented evidence that the physician was notified timely when the CPAP machine became unavailable.
Failure to Provide Scheduled Toileting and Document Incontinent Care
Penalty
Summary
The facility failed to provide scheduled toileting for a resident with urinary incontinence and substantial assistance needs for toileting hygiene. The resident’s care plan directed staff to keep pull-ups on at all times and to check the pull-up every two hours, with assistance for perineal hygiene and changing soiled or wet incontinence products or clothing. A facility email also instructed nursing supervisors that incontinent care and toileting documentation needed to be entered in point of care, and that staff could not block chart at the beginning of a shift and then have documentation appear as though the resident had not been changed all shift. After a fall on April 14, 2026, the resident stated he was trying to use his urinal but could not get his pull-up brief off. He was noted to be incontinent of urine and had bruising and abrasions to his left knee and left arm. The fall investigation stated the resident was getting up to use his urinal and was unable to get his pants down. The immediate intervention was to have staff offer toileting assistance on rounds, start a bowel and bladder program, and encourage him to use his bedside urinal. The resident fell again on May 3, 2026, while attempting to use the bedside urinal and reaching forward, and he urinated on himself. He was sent to the hospital after hitting his head. He returned from the hospital early the next morning and was found on the floor again later that morning with his pants around his knees from apparently trying to stand to use his urinal; he had a skin tear to his right elbow and reported right hip pain. Hospital records showed a right hip fracture from a ground-level fall. Review of toileting documentation showed staff did not document every two hours as care planned, with some staff documenting only once per shift. The DON confirmed there was no documented evidence that the resident was toileted every two hours as a fall intervention.
Neglect Due to Improper Mechanical Lift Sling Use Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan for safe transfers using a mechanical lift. The resident had a quarterly MDS showing cognitive impairment, dependence on staff for daily care needs and transfers, and diagnoses including Parkinson’s disease, dementia, and orthostatic hypotension. The resident’s care plan identified a potential for falls related to a new environment, adjustment to nursing home placement, tremors, orthostatic hypotension, Parkinson’s, and impaired mobility, and specified that all transfers were to be completed with a full mechanical lift using a large sling size. On the day of the incident, two nurse aides attempted to transfer the resident out of bed for a shower using a mechanical lift. During this transfer, the resident fell backwards out of the sling and hit the floor. A nursing note documented that the nurse entered the room and found the resident lying on his right side between the legs of the mechanical lift, with his head near the center post of the lift at the doorway. The lift’s legs were in the closed position, the lift arm was in a high position, and the sling remained on the hooks of the lift while it was moved. Blood was observed along the occipital region of the resident’s head extending to the left ear and on the floor from a head laceration, and the resident complained of headache, back-of-head pain, neck pain, and back pain. The resident was sent to the hospital and was diagnosed with a scalp laceration requiring staples, a closed head injury, and a fracture of the sixth thoracic vertebra. During the facility’s investigation, a registered nurse observed that the sling used for the transfer was marked as extra-large and had long leg straps that were supposed to be placed between the legs, crisscrossed, and then attached to the lift. Instead, the straps had been attached with the two right straps together and the two left straps together, not crisscrossed. The investigation determined that the fall was caused by the use of the wrong sling size, and the DON confirmed that neglect was substantiated because the nurse aides did not follow the resident’s care plan requiring use of a large sling size for transfers with the mechanical lift.
Failure to Apply Ordered Hip Protectors and Incorrect Mechanical Lift Sling Use Resulting in Resident Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered protective devices were applied as care planned for one resident and failure to maintain an environment free of accident hazards during a mechanical lift transfer for another resident, resulting in falls with fractures for both residents. For Resident 2, the facility’s own policy on incidents and accidents required individualized preventive measures, including hip savers, for residents at high risk for falls. Resident 2’s quarterly MDS showed confusion, wandering, a history of falls, and dementia, and the physician’s orders and care plan directed that hip savers be worn at all times due to fall risk. Multiple witness statements from nursing staff and nurse aides on the night and day shifts indicated that the hip savers were reportedly in place during care earlier in the day, including during incontinent care, morning skin checks, and after a shower. On the afternoon of January 22, 2026, Resident 2 was found on the floor on his left side between two nightstands in another resident’s room, with an open area on the left side of the head, an abrasion on the left upper arm, and a skin tear on the left elbow. The resident yelled out in pain when the left leg was straightened, and the leg could not be fully straightened due to pain. The facility’s investigation report documented that the resident had non-skid socks and hip savers on at the time of the fall, and that the resident had last been observed by staff at 3:15 p.m. and last toileted at 7:47 a.m. However, when Registered Nurse 5 responded to the fall and assessed the resident, she confirmed that the hip savers were not on the resident, contrary to the care plan and physician’s order, and she reported this to the Registered Nurse Supervisor. The Registered Nurse Supervisor also observed that the hip savers were not in place and, upon reviewing the clinical record, confirmed that hip savers were ordered and care planned to be on at all times. The resident was sent to the hospital and diagnosed with a left hip fracture. For Resident 3, the deficiency centers on improper use of a mechanical lift and incorrect sling size and attachment during a transfer. Resident 3’s quarterly MDS documented cognitive impairment, dependence on staff for daily care needs, dependence with transfers, and diagnoses including Parkinson’s disease, dementia, and orthostatic hypotension. The care plan identified a potential for falls related to new environment, adjustment to nursing home placement, tremor, orthostatic hypotension, Parkinson’s, and impaired mobility, and specified that a full mechanical lift with a large sling size was to be used for all transfers. On the evening of January 19, 2026, staff informed the nurse that the resident had fallen from the mechanical body lift during a transfer for a shower. The nurse found the resident lying on the right side between the legs of the lift, with the head near the center post at the doorway, the lift legs in the closed position, the lift arm in a high position, and blood along the occipital region of the head and on the floor from a head laceration. The resident complained of headache, neck pain, and back pain and was later admitted to the hospital with a scalp laceration requiring staples, a closed head injury, and a fracture of the sixth thoracic vertebra. Statements from the two nurse aides involved in the transfer indicated that the resident fell backwards out of the sling and hit the floor while they were getting him out of bed for a shower, and that the lift pad had been positioned up his back. A Registered Nurse who reviewed the sling after the incident observed that it was an extra-large sling with long leg straps that required crisscrossing between the legs before attachment to the lift, but the straps had been connected incorrectly, with the two right straps together and the two left straps together, and not crisscrossed. The Registered Nurse Supervisor later observed the extra-large sling on the resident’s bed, noting that the material and straps appeared in good condition. The facility’s investigative documents concluded that the fall occurred because the wrong sling size was used, and the Director of Nursing confirmed that the investigation substantiated that the nurse aides used an incorrect sling size per the resident’s care plan and that the leg straps were not crisscrossed as required.
Failure to Thoroughly Investigate Unwitnessed Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation to rule out abuse or neglect as the cause of a resident’s fracture following an unwitnessed fall. The resident had dementia, was confused, exhibited wandering behaviors, had a history of falls, and required maximum assistance with dressing. The resident had physician orders and a care plan requiring hip savers to be worn at all times due to fall risk. On the day of the incident, the resident was found on the floor on his left side between two nightstands in another resident’s room, with an open area on the left side of the head, an abrasion on the left upper arm, a skin tear on the left elbow, and severe pain in the left hip and leg when the leg was straightened. The resident was sent to the hospital and diagnosed with a left hip fracture. The facility’s fall and abuse/neglect policies required immediate notification of the RN Supervisor, detailed documentation of fall circumstances, and a thorough investigation of any alleged violations, including identifying and interviewing all involved persons and witnesses. The facility’s investigation documented that the resident had an unwitnessed fall and indicated that hip savers were in place at the time of the fall. However, the RN who first assessed the resident and the RN Supervisor both observed and confirmed that the resident was not wearing hip savers at that time, and the RN reported this to the RN Supervisor. These observations and statements were not included in the written investigation, and the ADON and DON later confirmed they were not aware that the resident did not have hip savers on at the time of the fall. There was no documented evidence that the investigation incorporated these witness observations or fully explored the lack of hip savers as a potential factor, resulting in a failure to conduct a thorough investigation as required by facility policy and state regulations.
Failure to Follow Post-Dialysis Assessment and Monitoring Policy
Penalty
Summary
The facility failed to follow its own policy for the care and monitoring of a resident receiving dialysis. According to the facility's policy, a registered nurse was required to assess the resident with a complete set of vital signs and check the dialysis access site for bleeding every 15 minutes for two hours upon the resident's return from dialysis. Review of the clinical record for a cognitively impaired resident with kidney failure who received dialysis revealed that, on multiple occasions across several months, there was no documented evidence that these assessments or vital sign checks were performed as required. The Director of Nursing confirmed the lack of documentation for the required post-dialysis assessments and monitoring on the specified dates.
Improper Storage of Food Ingredients in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store and prepare food under sanitary conditions in the main kitchen. Specifically, large plastic containers used for flour, sugar, and thickening powder were found to contain the original paper packaging of these ingredients inside the plastic containers. This practice was noted during an inspection of the preparation area. During an interview, the Dietary Manager stated she was not aware of any reason why the original paper containers should not be stored inside the larger plastic containers. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as evidenced by documentation errors and omissions. For one resident receiving enteral feeding, the Medication Administration Record (MAR) did not consistently reflect the correct amounts of tube feeding formula and pre- and post-administration flushes as ordered by the physician. Documentation was inconsistent, with varying amounts recorded and no clear indication of whether flushes were administered as required. Another resident was noted in a physician's progress note to have a diagnosis of Post Traumatic Stress Disorder (PTSD), but a review of the clinical record, including psychiatric notes and care plans, revealed no supporting documentation for this diagnosis. The Social Service Director confirmed that there was no evidence of PTSD in the resident's history or assessments, and subsequent review by a Certified Registered Nurse Practitioner (CRNP) determined that the diagnosis was not warranted. A third resident experienced an unwitnessed fall resulting in a neck abrasion, after which a speech therapy screening was ordered and conducted. The initial speech therapy note recommended vocal rest and a follow-up assessment, but there was no timely documentation of the follow-up visit in the clinical record. The speech therapist later confirmed that the follow-up had occurred but was not documented until a late entry was made after the omission was discovered. The Nursing Home Administrator acknowledged that the clinical record should have been complete and accurate.
Resident Health Information Left Visible on Unattended Medication Cart
Penalty
Summary
A deficiency was identified when a medication cart was observed unattended in the North Hall, with the computer on top displaying a resident's personal health information on the screen. The facility's policy required the protection of residents' health information, but the information was left visible when the nurse was not present at the cart. This was confirmed by both the LPN responsible for the cart and the Director of Nursing, who acknowledged that the screen should have been covered to maintain confidentiality. The incident involved one resident whose personal and medical records were not kept private during medication administration, as required by facility policy and state regulations. No information about the resident's medical history or condition at the time of the deficiency was provided in the report.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, glaucoma, and Parkinson's disease was not protected from abuse and neglect by facility staff. The resident required moderate assistance with activities of daily living, including toileting and perineal hygiene, as documented in their care plan. Multiple statements from staff and the resident indicated that a nurse aide repeatedly refused to provide necessary care, told the resident to stop ringing the call bell, and insisted the resident could manage personal care independently despite the resident's visual impairment. The nurse aide also turned off the resident's call bell without providing assistance and made dismissive and intimidating remarks, causing the resident to feel fearful and anxious. Facility investigation confirmed that the nurse aide's actions constituted neglect and mental abuse, as the resident was deprived of essential care and subjected to verbal intimidation. The resident reported feeling nervous and afraid of the staff member, and expressed concerns about retaliation. Documentation and interviews substantiated that the resident's rights to be free from abuse and neglect were not upheld, as required by facility policy and state regulations.
Failure to Update Care Plan After Change in Resident's Condition
Penalty
Summary
The facility failed to update a resident's care plan to reflect changes in the resident's care needs following a significant medical event. Specifically, a resident with a history of heart failure and Alzheimer's disease, who was moderately cognitively impaired and required supervision for showering and bathing, experienced a fall at his daughter's home that resulted in a brain bleed and the placement of five sutures in the back of his head. The care plan was updated to include monitoring of the staples to the head and instructions to notify the medical provider if the condition worsened. However, after the staples were removed, the care plan was not revised to discontinue the intervention related to staple care. Observations confirmed that the resident no longer had staples, and staff interviews verified that the care plan should have been updated to reflect this change. The facility's policy required proper documentation in the care plan for discontinued interventions, but this was not completed for this resident.
Failure to Clarify Medication Orders for Dialysis Patient
Penalty
Summary
The facility failed to clarify physician's orders for a resident who was cognitively impaired, diagnosed with kidney failure, and received dialysis. The resident had a care plan indicating scheduled dialysis sessions at 6:00 a.m. on specific days, while physician's orders required administration of multiple medications at 9:00 a.m. on those same days. Review of the Medication Administration Records showed that the resident was marked as having received the 9:00 a.m. medications on dialysis days, despite being off-site at dialysis during that time. Further review of nursing notes revealed that the third shift LPN administered the resident's 9:00 a.m. medications before the resident left for dialysis at 6:00 a.m., rather than at the prescribed time. There was no documentation that the physician was notified or that the medication administration times were clarified for dialysis days. The DON confirmed that the orders should have been clarified with the physician.
Failure to Implement Fall Interventions and Safe Mechanical Lift Use
Penalty
Summary
The facility failed to implement required fall prevention interventions and proper use of mechanical lift equipment for two residents. For one resident with a history of stroke resulting in left-sided hemiplegia and hemiparesis, both the care plan and physician's orders specified the use of a long positioning wedge to the left side at all times when in bed. However, during two separate observations, the resident was found in bed without the required wedge in place. Interviews with nursing staff revealed uncertainty about the intervention, and the wedge could not be located in the resident's room. The Assistant Director of Nursing confirmed that the wedge should have been in place but was not. In a separate incident, another resident who was cognitively impaired and required extensive assistance for transfers was observed being moved from the floor to bed using a Hoyer mechanical lift. During this transfer, staff failed to engage the brakes on the lift as required by both facility policy and the manufacturer's instructions, resulting in the lift rolling slightly. Both staff involved and the Director of Nursing confirmed that the brakes should have been engaged during the transfer process.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. According to the facility's policy, staff are required to document medication administration on the Medication Administration Record (MAR). For one resident with a physician's order for Oxycontin 10 mg every four hours as needed, the controlled drug records showed that doses were signed out for administration on several dates. However, there was no documented evidence in the resident's clinical record or MAR that the Oxycontin was actually administered on those occasions. This was confirmed by the Assistant Director of Nursing during an interview, who acknowledged the lack of documentation for the administration of the medication.
Unattended and Unlocked Medication Cart
Penalty
Summary
A deficiency was identified when a medication cart was observed unlocked and unattended in the hallway while the responsible Licensed Practical Nurse (LPN) was at the nurse's station. The facility's policy, dated July 2, 2025, requires that medication carts be securely locked at all times when not in the nurse's view. Both the LPN and the Director of Nursing confirmed that the cart should have been locked when unattended. This incident was documented during observations and staff interviews, and it was found to be out of compliance with the facility's medication storage policy and relevant state regulations.
Recurring Deficiencies Due to Ineffective QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effectively implemented. Despite developing plans of correction after a previous survey, the facility continued to have repeated deficiencies in several key areas, including protection of residents from abuse and neglect, accountability for controlled medications, proper food storage and serving, and maintenance of complete and accurate medical records. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were identified again in the most recent survey. Specifically, the facility had previously committed to conducting audits and reporting the results to the QAPI committee for review in response to deficiencies related to abuse/neglect, controlled medication accountability, food storage/serving, and medical record accuracy. However, the current survey found that these plans were not successfully implemented, as evidenced by the recurrence of the same issues. The report cites deficiencies under F600 (abuse/neglect), F755 (controlled medications), F812 (food storage/serving), and F842 (medical records), indicating ongoing noncompliance in these areas.
Failure to Accommodate Resident's Shower Preferences
Penalty
Summary
The facility failed to accommodate a resident's preference for showering, as evidenced by a review of clinical records and staff interviews. The resident, who had a history of stroke with hemiplegia and Chronic Obstructive Pulmonary Disease (COPD), was understood and could understand others. The care plan and physician's orders specified that the resident should receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift, as per the resident's request. However, the bathing records for May, June, and July 2024 showed that the resident received showers on Tuesdays and Fridays instead of the preferred and ordered days. There were also instances where the resident did not receive a shower on the specified days. An interview with the Assistant Director of Nursing confirmed that there was no documented reason for the deviation from the resident's preferred shower schedule.
Medication Administration and Physician Order Clarification Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse provided care and services according to accepted standards of clinical practice for three residents. Observations revealed that a Licensed Practical Nurse (LPN) placed medication cups on the tables of three cognitively intact residents during lunch and walked away without ensuring the residents swallowed their medications. This action was contrary to the facility's medication administration policy, which required staff to remain with the resident until the medication was swallowed. Interviews with the LPN and the Director of Nursing confirmed the deviation from the policy. Additionally, the facility did not clarify physician's orders for one resident with a venous access device. The resident's care plan required the port to be checked every shift, but there was no documented evidence that physician's orders were obtained to flush the port every 30 to 90 days as per facility policy. An interview with the Assistant Director of Nursing confirmed that the physician's orders should have been clarified but were not.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration for two residents. For Resident 118, who was cognitively intact and diagnosed with Waldenstrom macroglobulinemia, the physician's orders included administering magnesium hydroxide if no bowel movement occurred for 72 hours, followed by a Dulcolax suppository if no bowel movement occurred within 24 hours after the magnesium hydroxide. However, the facility did not administer the magnesium hydroxide as ordered on multiple occasions in April, May, and June 2024, despite the resident not having a bowel movement for extended periods. For Resident 152, who was cognitively impaired and diagnosed with atrial fibrillation, the physician's orders required administering Carvedilol every 12 hours, with the condition that the medication should be held if the systolic blood pressure was less than 95 mmHg or the heart rate was less than 55 beats per minute. The facility administered the medication twice daily from January 2024 without documenting any blood pressure or heart rate checks prior to administration, as required by the physician's orders. These deficiencies were confirmed through interviews with the Assistant Director of Nursing.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for a resident, identified as Resident 160, who was cognitively impaired and required assistance for daily care needs. The resident had a diagnosis of breast cancer and was prescribed Oxycodone concentrate for pain or shortness of breath. The facility's policy required that when administering a narcotic, the medication nurse must compare the amount recorded on the narcotic administration and disposition record with the electronic Medication Administration Record (eMAR) to ensure accuracy. However, discrepancies were found in the records for Resident 160, indicating that doses of Oxycodone were signed out as administered on specific dates, but there was no documented evidence in the eMAR that these doses were actually given. The Quality Assurance Coordinator confirmed the lack of documentation for the administration of Oxycodone on the specified dates. This deficiency was identified during a review of the narcotic administration and disposition records and the eMAR for the months of May, June, and July 2024. The failure to document the administration of controlled medications as per the facility's policy led to a violation of the regulations governing pharmacy and nursing services, as outlined in 28 Pa. Code 211.9(h) and 28 Pa. Code 211.12(d)(1)(5).
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as evidenced by several observations and staff interviews. In the main kitchen, an opened and undated container of beef broth was found, along with a puddle of standing water inside the refrigerator. The Dietary Manager confirmed that the beef broth should have been dated upon opening and acknowledged the inappropriate presence of water in the refrigerator. Further observations in the facility's kitchenettes revealed additional deficiencies. On the first floor, a frozen coffee drink and a strawberry sundae were found in the freezer without any labeling of the resident's name or date. A Registered Nurse confirmed the lack of labeling. On the second floor, two expired wildberry magic cups were discovered, with an expiration date of February 2024. A Licensed Practical Nurse confirmed that these items were expired and should have been discarded. The Dietary Manager also confirmed the labeling and expiration issues in both kitchenettes.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. The resident, who was cognitively impaired and required assistance for daily care needs, had a diagnosis of breast cancer and was receiving hospice services. The care plan indicated that hospice staff were to provide written and oral reports to the facility after each visit with the resident. Despite the resident being admitted to hospice services, there was no documented evidence in the clinical records that the facility obtained essential hospice documentation, including the hospice benefit of elections form, certification of terminal illness form, the resident's hospice plan of care, or the hospice registered nurse and nurse aide progress notes. This lack of documentation was confirmed during an interview with the Assistant Director of Nursing and the Nursing Home Administrator.
Improper Maintenance of Kitchen Walk-in Freezer
Penalty
Summary
The facility failed to maintain the main kitchen walk-in freezer in good condition. During an observation on July 15, 2024, at 9:12 a.m., a large accumulation of ice was noted on the fans inside the freezer. This observation was confirmed through an interview with the Dietary Director, who acknowledged that the ice buildup should not be present on the fans.
Failure to Maintain Resident Dignity During Incontinent Care
Penalty
Summary
The facility failed to provide assistance with incontinent care in a manner that maintained the dignity of a resident, identified as Resident 106. The resident, who had Alzheimer's disease and was frequently incontinent, expressed a need to use the bathroom while being transported to a dental appointment by Nurse Aide 3. Despite the resident's request, Nurse Aide 3 asked if he could hold it, to which he replied yes, but no further action was taken to address his need. The resident was left with the dental hygienist, and during this time, he became incontinent, soaking his clothing and the dental chair. The dental hygienist attempted to manage the situation by placing a towel on the chair and covering the resident with another towel, rather than arranging for immediate incontinent care. Nurse Aide 3 returned the resident to his unit without addressing the incontinence and left at the end of her shift, passing the responsibility to the second shift staff. This series of actions and inactions resulted in the resident experiencing embarrassment and a lack of dignity, as his need for timely assistance with toileting was not met.
Neglect in Toileting Assistance for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, specifically in providing assistance with toileting. Resident 106, who had Alzheimer's disease and required assistance with toileting hygiene, was left incontinent of bladder while awaiting a dental visit. The resident expressed the need to use the bathroom to Nurse Aide 3, who asked if he could hold it, to which the resident replied yes. However, Nurse Aide 3 did not follow up on the resident's need or check his transfer status, leaving him with the dental hygienist without ensuring his toileting needs were met. The incident resulted in the resident being incontinent, soaking through his clothing and onto the dental chair. The dental hygienist attempted to manage the situation by placing a towel on the chair and covering the resident, rather than providing proper incontinent care. The resident was later returned to his room by Nurse Aide 2, who found him soaked and changed him. The facility's policies on abuse prevention and resident rights emphasize the importance of respecting residents' dignity and providing necessary care, which was not adhered to in this case.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive eating devices as per the care plan for a resident diagnosed with Waldenstrom macroglobulinemia, who was cognitively intact and independent with personal hygiene and eating. The resident had a physician's order and a care plan directive to use built-up utensils for meals due to potential altered nutrition. However, during an observation, the resident was found using regular utensils instead of the prescribed built-up utensils. The resident confirmed that he frequently did not receive the built-up utensils for meals, which was corroborated by interviews with a registered nurse and the assistant director of nursing.
Inaccurate Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented, specifically for one resident. The facility's policy for Medication Administration required that after administering a narcotic, the medication nurse must record the date, sign their name, record the amount and time of administration, and the remaining balance on the Narcotic Administration and Disposition Record. Additionally, the specific time the narcotic was given should be reflected on the eMAR. However, discrepancies were found in the documentation for Resident 154, who was cognitively impaired and received pain medication as needed. For Resident 154, the Medication Administration Record (MAR) indicated that NORCO was administered at different times than those recorded on the narcotic sign-out sheets. On one occasion, the MAR showed administration at 8:45 p.m., while the narcotic was signed out at 5:17 p.m. On another occasion, the MAR showed administration at 9:00 a.m. and 7:58 p.m., but the narcotic was signed out at 9:00 a.m. and 6:00 p.m. An interview with the Director of Nursing confirmed that the narcotic should have been administered at the same time it was signed out, indicating a failure to adhere to the facility's medication administration policy.
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 for two residents. For Resident 87, who was cognitively intact and dependent on staff for care due to incontinence and chronic kidney disease, a nurse aide did not perform hand hygiene after removing gloves following urinary incontinence care. This lapse occurred despite the facility's policy requiring hand hygiene after glove removal, and the nurse aide acknowledged the oversight during an interview. For Resident 128, who was cognitively impaired and required extensive assistance due to a feeding tube, the facility's Enhanced Barrier Precautions (EBP) policy was not followed. Although signage indicated EBP measures were in place, staff members accessing the feeding tube wore gloves but failed to wear gowns as required. Interviews with the involved staff and the Director of Nursing confirmed the oversight, acknowledging that both gloves and gowns should have been used during the procedure.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 186 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hollidaysburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Home At Hollidaysburg | 0.2 mi | ★★★★★ | 14 | 0 |
| Presbyterian Homes-presby | 0.8 mi | ★★★★★ | 8 | 0 |
| Garvey Manor | 0.9 mi | ★★★★★ | 0 | 0 |
| Hilltop Healthcare And Rehabilitation Center | 3.7 mi | ★★★★★ | 14 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 5.5 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.