Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at John J Kane Regional Center-ro during CMS and state inspections, most recent first.
A facility failed to implement ordered pressure injury prevention and wound care interventions for two residents. One resident with high pressure injury risk developed worsening heel ulcers, including an infected wound with pseudomonas growth, after ordered skin prep and wound treatments were not entered or carried out. Another resident with dementia and BLE contractures did not receive ordered offloading measures such as heel boots, skin prep, or pillow placement, and a left ankle wound progressed from DTI to stage IV and later reopened.
Failure to provide quarterly resident trust fund statements for three residents and to accurately account for one resident's personal funds. Facility records showed active resident fund accounts, but no evidence that quarterly statements were sent to residents or their reps. For one resident, the acct reflected only one month's allowance after a lump-sum payment that covered several months, and the ABOM confirmed the resident fund statement was inaccurate.
Care Plans Missing Required Person-Centered Interventions: The facility failed to include key diagnoses and ordered interventions in the care plans of multiple residents. One resident’s plan omitted pulmonary embolism and bladder mass, another resident’s lymphedema pump orders were not implemented as documented, and two residents’ oxygen-related plans lacked details for humidification and tubing care. Staff interviews confirmed the missing care plan elements and, in one case, that ordered treatment was not being carried out as written.
Incomplete physician orders were found for one resident’s colostomy care and for two residents’ bedside commode use. One resident with HTN, depression, and a right hip fracture had orders for colostomy care, but the orders lacked product type, size, and change frequency details, and no physician order was found for the bedside commode despite staff observations of its use. Another resident with HF, DM, and HLD was also observed with a bedside commode at the bedside, but current orders did not include commode use, and an RN confirmed the missing order.
Insufficient nursing staff on the Third-Floor East unit prevented residents from eating in the dining room. An NA confirmed the unit had only five aides instead of six on observed days, and two residents stated they could not eat in the dining room when staffing was short. The NHA confirmed the facility failed to have enough nursing staff to provide needed nursing and related services for one of three nursing units.
The facility failed to complete annual performance evaluations at least every 12 months for three of five nurse aide records reviewed. Personnel files for three NAs showed a prior performance evaluation, but no subsequent annual evaluation was documented, and the NHA confirmed the lapse during interview.
Cross contamination occurred during a medication pass when an RN handled meds with gloved hands and placed them into a cup after touching them directly. The facility also failed to follow EBP for a resident with an MDRO-related order when a nurse aide emptied a bedside commode without the required PPE and did not understand the isolation precautions. In addition, an LPN failed multiple hand hygiene and PPE steps during a wound dressing change, and the facility did not complete required weekly flushing for a closed unit under its water management plan.
Failure to Obtain Signed Medication Consent: A resident with anxiety, depression, and ALS was ordered Duloxetine for major depressive disorder and Lorazepam for anxiety, but the record lacked a signed consent form showing the resident or responsible party was informed in advance of the proposed meds, including the risks and benefits. An ADON later produced a consent form, but it was unsigned by the resident or responsible party.
A facility failed to keep resident medical information confidential at the Third-floor East nursing station and on a medication cart. Therapy schedules and nurse aide worksheets with personal resident information were left on a counter where they could be viewed by anyone passing by, and an unattended med cart had an open computer screen displaying identifiable resident information. An RN confirmed both observations.
Unnecessary Psychotropic Medication Use: The facility failed to ensure that two residents’ medication regimens were free from unnecessary psychotropic medications. One resident received PRN lorazepam beyond the 14-day limit without a documented rationale for extending the order, and another resident’s record lacked documentation of non-pharmacological interventions, medication effectiveness, and side effect or behavior monitoring for prescribed psychotropics.
Failure to timely investigate an allegation involving a resident being lowered to the floor by a NA. The resident had HTN, DM, anxiety, and required assist of 2 for transfers. Records showed the event was documented as having no injuries, but nursing notes lacked further detail, and the RNAC/former DON stated the investigation did not begin until the grievance was received later. Staff interviews indicated the LPN notified the supervisor at the time, but the timing and completeness of the investigation were unclear.
Missing Transfer Notice and Bed-Hold Policy Documentation: The DON confirmed that the facility failed to document a written transfer notice for one resident who was not responsible for self and failed to document that another resident or the resident's representative received written bed-hold policy information during hospital transfers. The residents had diagnoses including HTN, anemia, adult failure to thrive, anxiety, depression, and ALS.
A resident’s MDS did not accurately reflect the resident’s status because it omitted active diagnoses identified in the hospital discharge summary, including pulmonary embolism, bladder mass, and a history of prostate cancer. The RNAC stated she did not know about the pulmonary embolism and confirmed the missing diagnoses, and the DON confirmed the MDS was inaccurate.
Failure to Provide Baseline Care Plan to Residents or Representatives: The facility did not ensure that two residents or their representatives received and understood the baseline care plan. One resident with HTN, anemia, and adult failure to thrive had a care conference where the resident did not attend and the representative joined by phone, but there was no evidence a written baseline care plan or order summary was provided. Another resident with HTN, DM, and anxiety also had no record of receiving the baseline care plan, and staff confirmed the omission.
Care plans were not updated to match resident-specific needs for two residents. One resident with HTN, depression, and a hip fracture had a bedside commode in use, but the care plan did not include an intervention for it. Another resident with HTN, DM, and anxiety had a transfer care plan that did not specify the required number of staff, even after a physician order changed transfers to assist of 2. The ADON and RNAC confirmed the omissions.
A resident with HTN, CHF, and dementia had significant weight loss documented in the clinical record, but the facility failed to obtain a weight for one month. The RD confirmed the weight loss and the missed weight, showing the resident’s nutrition status was not properly monitored.
Failure to provide appropriate respiratory care for two residents occurred when oxygen equipment was observed with empty humidification containers and, in one case, undated tubing. One resident with continuous oxygen orders and another resident with chronic respiratory failure and oxygen orders were both found receiving oxygen with humidification bottles/canisters empty, and staff confirmed the conditions during observation.
A resident with anxiety, depression, and ALS had multiple pain-related orders, including PRN ibuprofen, scheduled acetaminophen, gabapentin for nerve pain, and a fentanyl patch for a left elbow fracture. The clinical record did not document any non-pharmacological interventions related to pain medication use, and the ADON confirmed the lack of documentation and that pain management was not provided consistent with professional standards of practice.
Failure to Ensure Timely Physician Oversight of Wound Care: A resident with Parkinson’s disease and high pressure-injury risk developed heel wounds that were not promptly assessed by the MD. The record showed missing physician documentation, incomplete or absent wound care orders, and worsening heel wounds with drainage and infection, including a culture with heavy growth of pseudomonas aeruginosa.
The facility failed to ensure monthly MRRs were completed and reviewed for two residents. One resident with diabetes, CVA, and depression had pharmacist recommendations to add Jardiance and consider increasing Metformin, but the record did not show a response from the attending MD; a PA later documented that Jardiance was added and labs would be checked before evaluating Metformin. Another resident with HTN, diabetes, and anxiety had pharmacist recommendations for psych follow-up due to ongoing anxiety despite Buspar, but the chart did not show the recommended psych eval was completed.
Medication storage and labeling deficiencies were observed in two med carts and one med room. Multiple opened eye drops, nasal sprays, inhalers, insulin vials, liquids, and other meds were left without required open-date labeling, and one Advair discus inhaler was missing a resident identifier and was not stored in a box or bag. An ADON and LPNs confirmed the findings.
A resident with Parkinson’s disease and significant muscle weakness did not receive timely dental services after dentures went missing. The resident was observed with no teeth or dentures, the spouse reported the new dentures had disappeared, and staff acknowledged the need for replacement but said the resident was not yet eligible.
Failure to Serve Food in Ordered Form: A resident with HTN, CVA, and anxiety was ordered a soft chopped diet with extra sauce/gravy, but during lunch observation the Salisbury steak on the tray was not chopped as ordered. A nurse aide confirmed the meat was not chopped and that the meal was not served in the ordered form.
The NHA and DON failed to effectively manage the facility when two residents developed avoidable Stage III or Stage IV pressure ulcers due to extensive noncompliance in pressure ulcer care. The facility did not ensure proper preventative wound care or wound treatments, and one resident also developed a wound infection. The deficiency was cited as an IJ.
The facility failed to provide Effective Communication training for one of eight staff members, a nurse aide. Review of the personnel file showed the aide was hired in 2024 and had no documented Effective Communication training during the first year of employment. HR confirmed the training was not provided as required.
Failure to Provide Required QAPI Training: The facility did not provide required QAPI training for one nurse aide. Review of the employee's file showed a hire date of 6/1/24 and no QAPI training documented during the following year, and HR confirmed the training was not provided as required.
Failure to Provide Compliance and Ethics Training: The facility did not document required Compliance and Ethics training for one NA employee. Review of the personnel file showed the employee was hired in 2024 and had no training recorded within the required 1-year period, and HR confirmed the training was not provided.
Incomplete Posting of Required State Agency and Complaint Information A facility failed to post complete contact information for the Office of the State LTC Ombudsman program and the Medicaid Fraud Unit, and failed to post a statement that residents may file a complaint with the State Survey Agency. During observations and an interview, Case Work Supervisor E18 confirmed the required information was missing on all three floors, including the First, Second, and Third Floors.
Failure to report an allegation of verbal abuse involving a resident. The resident reported that a staff member on evening shift had been mean and told her to shut up. The allegation was not included in the reports submitted to the State, and the DON confirmed the facility failed to report it as required by policy.
A cognitively impaired resident with multiple sclerosis, dementia, and a cognitive communication deficit, and a BIMS score indicating severe impairment, had physician orders for a wander guard to be checked each shift and was permitted to ambulate on the unit but not to exit the safe area without supervision. Despite facility policies on abuse, neglect, and elopement prevention, and documentation that a wander/elopement alarm was used daily, the resident was found on another floor by staff there while original unit staff were performing morning rounds. The wander guard remained in place, and the resident was redirected back to the unit, but the DON at the time later reported being unaware of the incident until months afterward, demonstrating a failure to supervise and protect the resident from neglect related to elopement.
A resident with severe cognitive impairment and diagnoses including MS and dementia was found on a different floor while looking for breakfast, with a wander guard in place, and was redirected and monitored by staff. Facility policy required that any suspected abuse or neglect, including such incidents, be promptly reported to designated authorities and fully investigated. The DON at the time was unaware of the event until months later, and no complete, thorough investigation was conducted, demonstrating a failure to implement the written abuse/neglect prevention and investigation procedures.
The facility failed to follow its abuse/neglect reporting policy when an elopement-type incident involving a cognitively impaired resident with MS, dementia, and a cognitive communication deficit was not reported to required authorities. Nursing documentation showed the resident, who had a severe BIMS impairment score and wore a wander guard, was found on a different floor while staff were doing morning rounds and was redirected without noted distress. However, the DON later stated she was unaware of the incident at the time and only learned of it months later, and the event was not included in the facility’s reports to the State Survey Agency as an elopement or neglect incident.
A resident with severe cognitive impairment, dementia, and multiple sclerosis had physician orders for a wander guard to be checked each shift and was permitted to move about the unit but not to exit the safe area without supervision. One morning, staff from another floor found the resident on their unit looking for breakfast and returned the resident to the assigned unit, with documentation noting the wander guard was still in place and the resident was redirected and monitored. Despite facility policies requiring prompt reporting and full investigation of all alleged abuse, neglect, and elopement incidents, the event was not reported to leadership or the State Survey Agency, and no investigation was initiated, as later confirmed by interviews with the RNAC/former DON and the NHA.
A resident with multiple sclerosis, dementia, and a cognitive communication deficit had an MDS assessment that inaccurately coded a wander/elopement alarm as not used, despite physician orders, the MAR, and the care plan all documenting that a wander guard was to be in place at all times and checked every shift. The RAI Manual requires coding alarms based on actual use during the 7‑day look‑back period, and facility policy requires incorporating physician orders and clinical records into the MDS. The RNAC confirmed that the MDS did not accurately reflect the resident’s status, constituting a failure to ensure an accurate assessment.
A resident with multiple sclerosis, dementia, and severe cognitive impairment, who had a daily wander/elopement alarm and orders restricting unsupervised exit from the unit, was found on another floor while staff were performing morning rounds. Documentation showed the resident’s wander guard was in place and the resident was redirected and monitored, but the existing elopement care plan, initiated earlier in the month, was not revised or updated after this elopement event. The RNAC/DON later reported being unaware of the incident at the time, and the facility did not ensure the resident’s person-centered care plan was individualized and updated to reflect the elopement.
A resident with multiple sclerosis, dementia, severe cognitive impairment (BIMS score of 3), and a cognitive communication deficit had physician orders for a wander guard to be in place and checked each shift, and the MAR showed daily use of a wander/elopement alarm. An elopement evaluation nonetheless classified the resident as minimal risk, indicated no elopement care plan was needed, and the MDS did not reflect use of a wander/elopement alarm. The resident, who was ambulatory or independent in wheelchair locomotion, left her room on an upper floor, entered an elevator alone, and arrived on the first floor without staff supervision, where ancillary staff found her confused and lost and waited with her until nursing staff escorted her back, demonstrating a failure to provide adequate supervision to prevent elopement.
A resident with neurogenic bladder, lymphedema, and frail skin sustained a significant skin tear when staff improperly placed a Foley catheter bag down her pants during dressing, contrary to the care plan. The catheter bag hook caught the resident's leg, causing a laceration that required emergency room care. Staff interviews and documentation confirmed the injury resulted from improper catheter bag handling.
A resident with traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema suffered a significant leg wound during care, yet the care plan was not updated to include interventions for lymphedema or skin integrity. Staff and administration confirmed the care plan did not reflect the resident's current needs.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
A resident who required two-person assistance for bed mobility due to an air mattress was left unattended by a nursing assistant, resulting in a fall and injuries including a forehead hematoma, laceration above the eye, and knee hematoma. The care plan and assignment sheet specified the need for two staff, but the NA was unaware and left the resident near the bed's edge, leading to the incident. Staff interviews confirmed the assistance requirement was documented, and the DON acknowledged the failure as neglect.
Two residents experienced actual harm when staff failed to provide necessary equipment and supervision: one resident with dementia and a fractured foot was transported in a wheelchair without footrests, resulting in further injury, while another resident requiring two-person assistance for bed mobility was left unattended and fell from bed, sustaining multiple injuries. Staff interviews and observations revealed inconsistent use of safety equipment and lack of awareness of care plan requirements.
Two residents with cognitive impairments and histories of confusion and wandering were able to elope to unsupervised or unauthorized areas due to the facility's failure to update elopement assessments and care plans after significant changes or incidents. Despite the use of wanderguards and supervision requirements, staff did not consistently monitor or revise interventions, and there were gaps in communication and documentation regarding residents at risk for elopement.
Surveyors observed that food items in the Main Kitchen were not properly stored, labeled, or dated, and expired food products were present in the walk-in cooler. The Food Service Director confirmed that these practices did not follow facility policy and that expired items, including bologna, pepperoni, turkey, and pureed egg salad, were not removed.
The facility failed to provide adequate supervision and implement person-centered care plan interventions, resulting in two residents at risk for elopement exiting to unsupervised or unauthorized areas without staff knowledge. This lack of effective management by the Administrator and DON created an immediate jeopardy situation and did not meet professional standards of care.
Four residents with diabetes and other chronic conditions had physician orders for FreeStyle Libre devices, but their care plans did not include instructions for the care and management of these devices, as confirmed by the RN Assessment Coordinator and review of clinical records.
The facility did not ensure proper care for residents with enteral feeding tubes, including failing to label and date feeding and flush bags, and not verifying tube placement before medication administration. These deficiencies were observed in three residents with complex medical conditions, and staff confirmed the lapses in required procedures.
Three residents did not receive proper respiratory care, including one receiving oxygen at an incorrect rate with an empty humidification bottle, another whose BiPAP mask was not stored in a bag as required, and a third using an undated nasal cannula. Nursing staff and the DON confirmed these failures to follow respiratory care protocols.
Essential emergency equipment, including two crash carts and three AEDs, were not properly maintained, with missing documentation of required checks and expired AED electrodes. Interviews with the DON and NHA confirmed that regular maintenance and testing were not consistently performed, leaving critical equipment potentially non-operational.
Staff failed to provide a dignified dining experience by standing while assisting a resident with lunch, contrary to facility policy. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, failing to respect their privacy. Both the DON and the involved staff confirmed these lapses.
A resident room was found unlocked and unattended, containing a large maintenance cart with tools, exposed wires where lights had been removed, and a light bulb on the floor. The room, which lacked beds or furniture, shared a bathroom with an occupied room. The Environmental Services Director and the Nursing Home Administrator confirmed the safety risk and the failure to maintain a clean, safe, and homelike environment.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide preventative interventions and wound treatments for two residents, resulting in avoidable pressure ulcers, and one resident’s wound became infected. Resident R5 had diagnoses including muscle weakness, muscle wasting and atrophy, and Parkinson’s disease, and was identified as high risk for pressure injuries on the Braden Scale. After readmission from the hospital, a deep tissue injury was observed on the left heel, but the record did not include a complete skin assessment documenting the wound’s characteristics. The resident’s care plan identified high risk for pressure injuries and included interventions such as floating heels, using heel protectors, and reducing friction and shear. For Resident R5, wound care recommendations from the CRNP included Cavilon to the left heel, then later skin prep to both heels as a prophylactic measure. The record showed the facility did not enter or implement the ordered skin prep intervention, and the resident later developed a right heel stage III pressure ulcer that progressed to an unstageable ulcer. The record also showed the facility failed to enter and carry out ordered treatment for the worsening right heel wound, including cleansing with normal saline, applying xeroform, and covering with a dry clean dressing. The wound continued to deteriorate, developed copious green drainage and signs of infection, and a wound culture later showed heavy growth of pseudomonas aeruginosa. The DON confirmed the facility failed to provide the preventative measures and wound care as ordered. Resident R13 was admitted with diagnoses including hypertension, dysphagia, and dementia, and was identified as high risk for pressure injuries. Wound care assessments repeatedly documented BLE contractures, that the resident tended to pull the left leg up underneath herself, and that a pillow under the left knee and skin prep to both heels were recommended as preventative measures. The record failed to show that these interventions were implemented or documented over an extended period. The resident also did not have the ordered Medi helix boots in place during observations, and staff confirmed the boots were not on and were not in the room. The left lateral ankle wound progressed from a DTI to a stage III ulcer, later to a stage IV ulcer with muscle and bone exposed, and the wound later reopened as a stage III pressure ulcer.
Failure to Provide Quarterly Resident Trust Fund Statements and Accurately Account for Resident Funds
Penalty
Summary
The facility failed to provide quarterly resident trust fund statements for three residents with active resident fund accounts, identified in the facility trust fund account as Residents R12, R23, and R48. Review of facility business records and resident records did not show evidence that quarterly statements were provided to the residents or their representatives. During interviews, the Revenue Accounting Manager and the Assistant Business Office Manager confirmed that quarter one statements were not sent out and that the facility could not provide documented evidence for the previous quarters as well. The facility also failed to accurately account for Resident R48's personal funds. Resident R48 was admitted to the facility on [DATE], and review of the resident fund statement showed the facility received one payment on 4/17/26. On 5/13/26, the resident fund account reflected only one month's worth of the allotted money, although the Assistant Business Office Manager stated the payment represented a lump sum covering the resident's stay from September 2025 through April 2026. The Assistant Business Office Manager confirmed that the facility should have transferred eight months of monthly allowance into the account and that the facility failed to have an accurate resident personal fund statement for Resident R48.
Care Plans Missing Required Person-Centered Interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents. Review of the facility policy stated that comprehensive person-centered care plans were to be documented, developed, and implemented for all residents, and that practitioner orders, medication and treatment administration records, and progress notes were part of the overall care plan. The survey found that the care plans for the identified residents did not include required instructions related to their current diagnoses and ordered treatments. For one resident admitted with diagnoses including high blood pressure, anemia, and adult failure to thrive, the hospital discharge summary also documented a bladder mass, a plan to monitor for hematuria, possible urology follow-up, acute pulmonary embolism, continued Eliquis, Lasix for five days with monitoring of input and output, and continuation of a dysphagia diet. The resident’s MDS did not include pulmonary embolism or bladder mass as active diagnoses, and the care plan did not include goals or interventions for those conditions. The RNAC stated she did not know the resident had a pulmonary embolism and confirmed the care plan lacked related interventions. For another resident with lymphedema, morbid obesity, and muscle wasting and atrophy, the care plan included use of lymphedema pumps and later lymphedema wraps, and a physician order required the left-leg pump at bedtime as tolerated for no more than 60 minutes, with nursing to call the resident’s brother if the resident refused. The treatment record showed repeated refusals and statements that the pump was broken or not working properly, and the resident stated the pumps had not been usable for a long time. The record did not show that the resident was educated on the importance of the pumps when refused or that the brother was notified when the resident refused. Staff interviews confirmed the facility was aware of the issue and that the pumps were not being implemented as ordered. Two additional residents had oxygen-related care plan omissions. One resident with lymphedema, morbid obesity, and muscle wasting and atrophy had a care plan addressing behavioral symptoms and oxygen use, but it did not include interventions related to humidification or oxygen tubing despite an order for continuous 2 L oxygen and observation of oxygen with humidification. Another resident with chronic respiratory failure with hypoxia, lymphedema, and anxiety had a care plan for respiratory distress and oxygen use, but it did not include interventions related to humidification or how often to change oxygen tubing, despite orders for 3 L oxygen during the day and for the humidifier bottle to be filled appropriately. The DON stated that residents using oxygen were expected to be care planned for oxygen, and the RNAC confirmed the care plans lacked these specific interventions.
Incomplete Physician Orders for Ostomy Care and Bedside Commode Use
Penalty
Summary
The facility failed to procure complete physician orders for Resident R7’s colostomy care and for the use of a bedside commode, and also failed to have physician orders for a bedside commode for Resident R126. Facility policy on transcription-reconciliation of practitioner orders stated that all new, changed, and discontinued orders are to be entered into facility approved forms. Resident R7 was admitted on 11/9/19 and had diagnoses including hypertension, depression, and right hip fracture. Her physician orders dated 5/1/26 directed colostomy care every shift and to ensure the site was clean, dry, and intact, but did not include specific information such as product type, product size, or how often the products were to be changed. During observation, Resident R7 was seen sitting on the edge of her bed with a bedside commode at the foot of the bed, and later a nurse aide was observed emptying the bedside commode. Review of current physician orders did not show an order for bedside commode use. The Assistant Director of Nursing confirmed that Resident R7 did not have specific colostomy orders with product details or frequency and did not have physician orders for the bedside commode. Resident R126, admitted on 11/30/22 with diagnoses including heart failure, diabetes, and hyperlipidemia, was observed in bed with a bedside commode beside the bed on two separate occasions, but current physician orders also failed to show an order for bedside commode use. A registered nurse confirmed that Resident R126 did not have physician orders for the bedside commode and that the facility failed to procure complete physician orders for that equipment.
Insufficient Nursing Staff on Third-Floor East Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on the Third-Floor East unit and to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of two residents. During lunch observations on 7/13/26 and 7/14/26, no residents were eating in the Third-Floor East Dining Room, and Nurse Aide Employee E20 confirmed that the dining room was not being used because the unit had only five aides instead of six, stating that extra aides were needed to get residents up and ready for transport to the dining room. In a group interview on 7/15/26, two residents stated that they could not eat in the dining room when there was not enough staff. On 7/18/26, the Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services for one of three nursing units.
Missed Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three of five nurse aide personnel records reviewed: NA Employee E23, E25, and E26. E23’s record showed a hire date of 6/7/21 and a performance evaluation completed on 5/29/25, with no additional evaluation documented after that date. E25’s record showed a hire date of 6/27/16 and a performance evaluation completed on 6/6/25, with no additional evaluation documented after that date. E26’s record showed a hire date of 1/16/24 and a performance evaluation completed on 2/6/25, with no additional evaluation documented after that date. During an interview on 7/18/26 at 10:11 a.m., the Nursing Home Administrator confirmed that the facility failed to complete annual performance evaluations at least every 12 months for these three nurse aides.
Cross Contamination During Medication Pass and Wound Care; Failure to Follow EBP and Water Management Plan
Penalty
Summary
The facility failed to prevent cross contamination during a medication pass for a resident receiving morning medications. During observation, an RN preparing medications for a resident applied gloves, punched medication directly into her right hand, and then used her left hand to pluck the medication from her gloved hand and place it into the medication cup. The RN continued this process with all scheduled morning medications and confirmed that she touched the medications before placing them into the cup. The facility also failed to follow Enhanced Barrier Precautions for a resident with an MDRO-related order. The resident had diagnoses including anemia, urinary tract infection, and right hip fracture, and physician orders identified MDRO related to ESBL E. coli with special instructions for a purple isolation bin and stocked PPE on the resident’s door. During observation, a nurse aide emptied the resident’s bedside commode without using the required PPE. When asked about the purple sticker on the door, the nurse aide stated she did not know why it was there and said she would wear a gown only for ostomy care, confirming she did not understand the MDRO-related precautions. The facility failed to prevent cross contamination during a wound dressing change for a resident with a left lateral ankle pressure injury. The resident had physician orders for cleansing the wound with Dakin’s solution and applying mupirocin and Santyl, covered with a foam dressing daily. During the dressing change, the LPN did not wash hands before donning gown and gloves, entered the hallway with doffed gown and gloves, failed to wash hands before opening supplies, placed wound dressing supplies on an unclean surface, placed contaminated supplies on a clean surface, failed to wash hands for 15 seconds, failed to turn off the faucet with a hand, entered the hallway before doffing the gown, and did not clean the bedside table after the dressing change. The facility also failed to conduct weekly flushing for the closed unit on the 2nd floor from April 2025 through April 2026, and the epidemiologist confirmed the water management plan was not implemented as required.
Failure to Obtain Signed Medication Consent
Penalty
Summary
The facility failed to inform a resident or the resident’s representative in advance of the proposed care, including the risks and benefits of prescribed medications, for Resident R103. The clinical record showed that R103 was admitted to the facility and had diagnoses of anxiety, depression, and amyotrophic lateral sclerosis (ALS), a progressive disease affecting nerve cells that control voluntary muscles. Physician orders included Duloxetine 30 mg twice daily for major depressive disorder and Lorazepam 0.5 mg three times daily for anxiety. Review of the record did not include a signed consent form for Duloxetine or Lorazepam with the risks and benefits of the medications. During interview, the Assistant Director of Nursing provided a consent form for the two medications, but the form did not contain a signature from the resident or the resident’s responsible party, and confirmed that the facility failed to inform the resident or resident representative in advance of the proposed care, including the risk and benefits of the prescribed medication.
Failure to Protect Resident Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information at the Third-floor East Nursing Station and at medication cart number ten. During an observation on 7/15/26 at 1:12 p.m., therapy schedules and nurse aide worksheets containing resident personal and confidential information were left on the counter at the Third-floor East Nursing Station and were available for anyone passing the area to view. During an interview at 1:19 p.m., an RN confirmed that the documents were visible on the counter and acknowledged that the facility failed to maintain confidentiality at that nursing station. During another observation on 7/15/26 at 1:17 p.m. in the Third-Floor East hallway, medication cart number ten was left unattended with the computer screen open, displaying identifiable, personal, and confidential resident information that any passerby could see. The same RN confirmed this observation during interview and acknowledged the confidentiality failure involving the resident medical information.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents’ medication regimens were free from unnecessary psychotropic medications for two residents, including one resident with muscle weakness, anxiety, and depression and another resident with anxiety, depression, and ALS. For one resident, the record showed a PRN lorazepam order started for anxiety and continued beyond 14 days without a documented stop date or a documented rationale for extending the PRN psychotropic order past 14 days. The record also showed psychiatric notes referencing the PRN lorazepam as having been added by the medical doctor, but the clinical record from the start of the order through discontinuation did not include the prescribing practitioner’s rationale for the extended use. For the second resident, the record showed orders for Wellbutrin XL, duloxetine, and lorazepam for major depressive disorder and anxiety, but the clinical record did not include documented non-pharmacological interventions, evidence of effectiveness of pharmacological interventions, or evidence of side effect or behavior monitoring related to psychotropic medication use. During interview, the Assistant Director of Nursing confirmed the missing rationale for the extended PRN lorazepam order for the first resident and confirmed that the second resident’s record lacked documentation of non-pharmacological interventions, effectiveness of medications, and monitoring for psychotropic use.
Failure to Timely Investigate Resident Lowering-to-Floor Incident
Penalty
Summary
The facility failed to implement written policies and procedures to ensure a complete, thorough, and timely investigation of an allegation involving a resident being lowered to the floor by a nurse aide. The facility policy stated that every complaint or allegation of resident abuse must be promptly reported to the Administrator and investigated, with the house RN supervisor/designee initiating the investigation, notifying the NHA and DON, interviewing the complaining party and witnesses, completing an incident report, notifying the practitioner, updating the resident’s care plan, and consulting the interdisciplinary team as needed. Resident R72 was admitted with diagnoses including hypertension, diabetes, and anxiety, and had an order indicating transfers with assistance of two. Nursing documentation showed that on 1/5/26 the resident was lowered to the floor by herself with no injuries noted, and later notes referenced a minor fall in which she was assisted to the floor while transferring into bed. However, the nursing progress notes did not contain further documentation about the event, and the RNAC/former DON stated the investigation did not begin until 1/23/26 after a grievance was received. Staff interviews indicated the LPN notified the supervisor at the time of the event, but the DON stated she was not employed at the facility when it occurred and the RNAC was unsure whether administration had been notified.
Missing Transfer Notice and Bed-Hold Policy Documentation
Penalty
Summary
The facility failed to ensure that the resident's representative was provided with a written notice of transfer for one resident who was admitted with diagnoses of high blood pressure, anemia, and adult failure to thrive and later transferred to the hospital on 5/23/26. The clinical record showed the resident was not responsible for self, but it did not include documented evidence that the resident's representative received the required written notice of transfer. During interview, the DON confirmed the facility failed to maintain documentation that the resident's representative was provided a written notice of transfer. The facility also failed to document that a resident or the resident's representative was provided written information about the facility's bed-hold policy at the time of hospital transfer for another resident admitted with anxiety, depression, and ALS. The record showed the resident was transferred to the hospital for a change in condition on 12/30/25 and again on 12/28/26, but it did not include evidence that the resident or representative received the bed-hold policy information at either transfer. The DON confirmed during interview that the clinical record lacked documentation of written information about the facility's bed-hold policy at the time of those transfers.
MDS Did Not Include Active Diagnoses
Penalty
Summary
The facility failed to ensure Resident R1’s MDS accurately reflected the resident’s status. Resident R1 was admitted with diagnoses of high blood pressure, anemia, and adult failure to thrive, then transferred to the hospital and later readmitted to the facility. The hospital discharge summary identified pulmonary embolism, bladder mass, and a history of prostate cancer, but the resident’s MDS dated [DATE] did not include those diagnoses in Section I, Active Diagnoses. During interview, the RNAC stated she did not know the resident had a pulmonary embolism and confirmed the MDS failed to include pulmonary embolism, bladder mass, and history of prostate cancer. The DON also confirmed the facility failed to ensure the MDS accurately reflected the resident’s status for one of six residents reviewed.
Failure to Provide Baseline Care Plan to Residents or Representatives
Penalty
Summary
The facility failed to ensure that the resident or the resident representative received a copy of the baseline care plan and understood the baseline care plan for two residents. The facility’s Assessment Comprehensive Person-Centered care planning policy stated that the interdisciplinary team develops and implements a baseline care plan for each resident within 48 hours of admission, including instructions needed to provide effective and person-centered care. One resident was admitted with diagnoses of high blood pressure, anemia, and adult failure to thrive. A care conference was held, the resident was invited but did not attend, and the resident’s representative participated by phone; however, the clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident or representative. Another resident, admitted earlier and later assessed with hypertension, diabetes, and anxiety, also had no evidence in the clinical record that a baseline care plan was received by the resident or resident representative. Staff interviews confirmed that the facility did not have evidence that the baseline care plan was provided for either resident.
Care plans not updated to reflect resident-specific needs
Penalty
Summary
The facility failed to ensure that residents’ care plans were updated and revised to reflect their specific care needs for 2 of 3 residents reviewed, Residents R7 and R72. The facility’s Assessment Comprehensive Person-Centered care planning policy stated that the interdisciplinary team develops, reviews, revises, and implements a comprehensive person-centered care plan for each resident. Review of R7’s record showed an admission date of 11/9/19 and an MDS dated 4/21/26 listing hypertension, depression, and a right hip fracture. During observations on 7/13/26 and 7/14/26, R7 was seen sitting on the edge of the bed getting ready to eat lunch, and a bedside commode was observed at the foot of the bed and later being emptied by a nurse aide. R7’s current care plan did not include an intervention for the bedside commode, and the Assistant Director of Nursing confirmed this omission during interview. Review of R72’s record showed an admission date of 9/23/25 and an MDS listing hypertension, diabetes, and anxiety. R72’s care plan, with an approach start date of 10/24/25, indicated ADL assistance and transfer training with sit-to-stand and supine-to-sit MOD/MAX assist, but it did not specify the number of staff required for transfers. A physician order dated 11/25/25 directed ADL transfers with assist of 2. During interview, the RNAC confirmed that R72’s transfer status was not updated in the care plan when the order changed and that the facility failed to ensure the care plan reflected the resident’s specific care needs.
Failure to Monitor Resident Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor Resident R12’s weight and nutrition status by not obtaining a weight in April 2026. Resident R12 was admitted to the facility with diagnoses including high blood pressure, heart failure, and dementia. The clinical record showed weights of 117.1 pounds on 1/14/26, 117.4 pounds on 2/1/26, 109.1 pounds on 3/1/26, 110.0 pounds on 3/4/26, and 111.8 pounds on 5/11/26, with a Nutrition progress note dated 3/20/26 confirming significant weight loss in March 2026. During interview, the RD confirmed that Resident R12 had significant weight loss in March 2026 and that the facility failed to obtain her weight in April 2026.
Failure to Provide Appropriate Oxygen Humidification
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who were ordered to receive oxygen. One resident had diagnoses including lymphedema, morbid obesity, and muscle wasting and atrophy, and had a physician order to receive 2 L of oxygen at all times. The resident’s care plan noted continuous oxygen use and included interventions to monitor for tolerance to activities and to ensure oxygen was placed and oxygen saturation checked as needed for shortness of breath. During an observation, the resident was using oxygen, but the humidification canister was empty and there was no date on the nasal cannula tubing. An LPN confirmed the empty humidification canister and undated tubing. Another resident had diagnoses including chronic respiratory failure with hypoxia, lymphedema, and anxiety, and had orders to receive 3 L of oxygen from 8:00 a.m. to 8:00 p.m. with titration to keep oxygen saturation above 92%, as well as an order to ensure the oxygen humidifier bottle was filled appropriately. The resident’s care plan identified a potential for respiratory distress due to oxygen use and sleep apnea. During an observation, the resident was receiving oxygen via nasal cannula and the humidification bottle was empty. A nurse aide confirmed the empty humidification bottle. The report also cited the facility’s oxygen guideline policy, which stated humidification bottles should be filled with distilled water and checked every shift, and oxygen setups should be changed at least every seven days and labeled with the date of change.
Failure to Document Non-Pharmacological Pain Interventions
Penalty
Summary
Safe, appropriate pain management was not provided for Resident R103, who was admitted to the facility and had diagnoses of anxiety, depression, and ALS. The resident’s physician orders included ibuprofen 800 mg every 8 hours as needed for left elbow pain, acetaminophen 1,000 mg three times a day for pain, gabapentin 100 mg twice a day for nerve pain, and a fentanyl 75 mcg/hr patch every three days for pain related to a left elbow fracture. Review of the clinical record found no documented non-pharmacological interventions associated with the resident’s pain medication use. During interview, the Assistant Director of Nursing confirmed that Resident R103’s record lacked documentation of non-pharmacological interventions for pain medication and that the facility failed to provide pain management consistent with professional standards of practice for this resident.
Failure to Ensure Timely Physician Oversight of Wound Care
Penalty
Summary
The facility failed to ensure that a physician supervised care in a timely manner for one resident with significant wound care needs. The resident was admitted and later readmitted with diagnoses including muscle weakness, muscle wasting and atrophy, and Parkinson’s disease. The care plan identified the resident as high risk for pressure injuries due to decreased mobility, incontinence, decreased nutrition, and decline in overall medical condition. On arrival to the facility, a deep tissue injury was observed on the left heel, but the physician progress note the next day did not include evidence that the physician assessed or evaluated the heel wound or skin, and no measurements were obtained at that time. The record also showed ongoing wound care problems involving the resident’s heels. The MDS later indicated one unstageable deep tissue injury present on admission/reentry and stated the resident was not at risk for pressure ulcers. Physician orders from one period failed to include skin prep to bilateral heels, and later orders failed to include treatment for a right heel stage 3 pressure ulcer and then failed to include ordered wound care treatments such as cleansing with normal saline, applying xeroform, and covering with a dry clean dressing. A subsequent wound assessment documented a worsening right heel wound with increasing size, drainage, signs and symptoms of infection, and a wound culture later showed heavy growth of pseudomonas aeruginosa. The physician progress notes reviewed during this period did not show evidence of assessment or oversight of the resident’s wound care and treatment, and the ADON confirmed the facility failed to ensure timely physician supervision.
Failure to Complete and Follow Up on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure medication regimen reviews (MRR) were completed and reviewed by the attending physician for two residents. For one resident with diagnoses of diabetes, cerebral infarction, and depression, the pharmacist’s MRR included recommendations to add Jardiance and to consider increasing Metformin based on blood sugars, but the clinical record did not include a response from the attending physician for either recommendation. Instead, documentation showed a physician assistant addressed the MRR entries on later dates, including noting that Jardiance was added and that labs would be checked before evaluating Metformin. For another resident with diagnoses of hypertension, diabetes, and anxiety, the pharmacist’s MRRs stated that the resident remained anxious despite Buspar and was due for a psych follow-up evaluation to determine whether additional psychiatric medication might help with anxiety or possible depression. The clinical record did not include documentation that the resident completed the recommended psych evaluation for either MRR. During interview, the Assistant Director of Nursing confirmed that the MRRs were not followed up with the psych recommendations and that the facility failed to ensure medication reviews were completed for this resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in two medication carts and one medication room, with multiple opened drugs and biologicals left without required open-date labeling. In the 9 East Medication Cart, surveyors observed opened bottles of genteal eye drops, refresh tears eye drops, ipratropium bromide nasal inhalers, calcitonin nasal spray, lispro insulin, Novolog insulin, nasal decongestion spray, and lactulose liquid that were not labeled with a date as required. An LPN confirmed these observations during the cart review. In the 10 East Medication Cart, surveyors observed opened bottles of Peridex mouth rinse, Celexa liquid, Robitussin liquid, lactulose liquid, refresh tears, Flonase nasal sprays, Anoro Ellipta inhalers, Lumigan eye drops, latanoprost eye drops, ipratropium nasal spray, liquid senna, Pataday eye drops, and an Advair discus inhaler that was not labeled with a resident identifier, not stored in a box or bag, and not labeled with an opened date. In the 3 East Medication Room, a tuberculin vial was observed opened without an open date or expiration date. An LPN and the ADON confirmed the observations in their respective areas.
Delayed Dental Services and Missing Dentures
Penalty
Summary
The facility failed to ensure timely and necessary dental services for one Medicaid resident, R5, out of three residents reviewed. The facility policy stated that oral hygiene and dental needs were to be adequately met, including prostheses such as dentures, and that the facility would assume responsibility for replacing dentures when loss or damage was determined to have been caused by the facility. R5’s record showed diagnoses including muscle weakness, muscle wasting and atrophy, and Parkinson’s disease, and the care plan directed staff to monitor for difficulty chewing and swallowing and consult the dental clinic as needed. R5 was seen by the dentist on multiple occasions. In August 2025, the resident’s upper and lower dentures were delivered and adjusted, with the dentist noting very dry mouth and a low upper anterior muscle attachment that tended to dislodge the denture, and that adhesive would likely be needed. In April 2026, the resident was documented as completely edentulous with only a lower complete denture, and the upper denture was missing; the resident wanted a new upper denture if the missing one could not be found. A later progress note stated the family reported the resident needed new upper and lower dentures, and during observation the resident had no teeth or dentures in the mouth. The spouse stated the resident had received a new set of dentures that later went missing, and staff interviews confirmed the facility knew the dentures needed replacement but said the resident was not yet eligible.
Failure to Serve Food in Ordered Form
Penalty
Summary
The facility failed to prepare food in a form that matched a physician-ordered diet for Resident R25, who was admitted with diagnoses of high blood pressure, stroke, and anxiety. The resident’s MDS dated 6/9/26 showed the diagnoses were current, and the care plan dated 7/6/26 directed staff to provide a soft chopped diet with extra sauce/gravy, with interventions to adjust diet orders to promote appropriate nutritional status. The active physician’s order dated 7/6/26 also required a soft chopped diet with extra sauce and gravy. During lunch observation on 7/13/26 at 11:58 a.m., the resident’s tray included Salisbury steak meat that was not chopped, even though the tray ticket indicated it was to be served soft chopped with extra gravy. At 12:00 p.m., a nurse aide confirmed the meat was not chopped and that the facility failed to serve the food in its ordered form.
Failure to Manage Pressure Ulcer Care
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility when the facility had extensive noncompliance in multiple areas of pressure ulcer care. Based on review of job descriptions, clinical records, and staff interviews, the facility did not ensure proper preventative wound care or wound treatments for two residents, identified as R5 and R13, and both residents developed avoidable Stage III or Stage IV pressure ulcers. The report states that one of the two residents, R5, also developed an infection related to the wound. The signed job descriptions for the NHA and DON described their responsibilities for directing facility operations and the nursing department in accordance with applicable regulations and standards. During an interview on 7/18/26 at 3:30 p.m., the NHA and DON were notified that they failed to effectively manage the facility to ensure proper preventative wound care and treatments, which resulted in avoidable pressure ulcers and a wound infection. The deficiency was cited as an immediate jeopardy.
Missing Effective Communication Training for Nurse Aide
Penalty
Summary
The facility failed to provide Effective Communication training for one of eight staff members, a nurse aide identified as Employee E27. Review of the employee’s personnel file showed a hire date of 6/1/24 and no Effective Communication training documented between 6/1/24 and 6/1/25. During an interview on 7/18/26 at 9:50 a.m., Human Resources Employee E29 confirmed that the facility had failed to provide the required Effective Communication training for one of eight staff members as required by facility policy and regulation.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for one of eight staff members, a nurse aide identified as Employee E27. Review of Employee E27's personnel file showed a hire date of 6/1/24 and did not include QAPI program training between 6/1/24 and 6/1/25. During an interview on 7/18/26 at 9:50 a.m., Human Resources Employee E29 confirmed that the facility had failed to provide QAPI program training for one of eight staff members as required.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide Compliance and Ethics training for one of eight staff members, nurse aide Employee E27. Review of Employee E27's personnel file showed a hire date of 6/1/24 and no Compliance and Ethics training documented between 6/1/24 and 6/1/25. During an interview on 7/18/26 at 9:50 a.m., Human Resources Employee E29 confirmed that the facility failed to provide the required training for one of eight staff members.
Incomplete Posting of Required State Agency and Complaint Information
Penalty
Summary
The facility failed to post complete contact information for the Office of the State Long-Term Care Ombudsman program and the Medicaid Fraud Unit, and failed to post a statement that residents may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation. During observations and an interview completed on 7/17/26 at 9:50 a.m., Case Work Supervisor E18 confirmed that this required information was not posted on three of three floors, including the First, Second, and Third Floors, as required by 28 Pa. Code 201.14(a) and 201.18(e).
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving one resident. The facility policy titled "Abuse- Resident and Reasonable Suspicion of a Crime" stated that verbal abuse includes disparaging or derogatory oral, written, or gestured language directed to a resident or within the resident's hearing distance, and that alleged violations, whether confirmed or not, must be reported to the Administrator, Department of Health, Area Agency on Aging, Compliance Officer, and Executive Director, with a full investigation conducted. Resident R1 was admitted to the facility and had diagnoses including diabetes, dysphagia, and muscle weakness. A Concern Form documented that the resident reported a staff member on evening shift had been mean to her and would tell her to shut up. Review of the allegations submitted to the State field office did not include this verbal abuse incident, and the DON confirmed in interview that the facility failed to report the allegation as required.
Failure to Prevent Elopement of Cognitively Impaired Resident with Wander Guard
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to inadequate supervision and elopement prevention. Facility policies on abuse, neglect, and elopement required that residents be protected from neglect, that alleged violations be promptly reported and investigated, and that safety measures be implemented for residents who wander or are at risk for elopement. Neglect was defined as the failure of the facility, staff, or service provider to provide necessary goods and services to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. The Wanderguard and Elopement Policy specified that safety measures were to be implemented for residents at risk for elopement to attempt to prevent such events. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s MDS indicated that a wander/elopement alarm was used daily, and physician orders directed staff to check the function of the wander guard daily on the night shift and to check and document wander guard placement every shift. Another physician order stated that the resident could move about the floor without supervision but could not exit the unit or safe area without supervision. A physician progress note documented that staff had previously reported possible UTI due to altered mental status and wandering, indicating that wandering behavior had been observed by staff despite the MDS section indicating no wandering behavior. On the date of the incident, a nurse progress note documented that while staff on the resident’s unit were performing morning rounds with other residents, staff from the second floor brought the resident back to the unit after finding the resident on their floor looking for breakfast. At that time, the resident’s right lower extremity wander guard monitor was still in place, and the resident was cooperative with redirection. The note indicated that a nurse aide was monitoring and redirecting the resident by her room after the incident. During a later interview, the RNAC, who was the DON at the time of the incident, stated she had been unaware that the resident had been found on the second floor on that date and only became aware of the incident months later, confirming that the facility failed to protect the resident from neglect due to lack of supervision resulting in an elopement from the designated safe area.
Failure to Investigate Elopement Incident as Required by Abuse/Neglect Policy
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse and neglect by not conducting a complete and thorough investigation of an elopement incident. The facility’s abuse/neglect policy, dated 1/2/25, states that abuse or neglect of residents will not be tolerated, that any suspected occurrence will be promptly investigated, and that alleged violations must be reported to the Administrator, the PA Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director, with a full investigation conducted. Despite these requirements, an incident in which a resident was found on a different floor than their own, without the facility’s knowledge, was not recognized or investigated as a potential neglect or elopement event in accordance with policy. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. A nurse progress note documented that during morning rounds, staff from the second floor brought the resident to their unit after finding the resident there looking for breakfast, with a wander guard still in place, and that the resident was redirected and monitored by a nurse aide. The Resident Nurse Assessment Coordinator, who was the DON at the time of the incident, reported being unaware of this event until months later and confirmed that the facility failed to implement its abuse/neglect policies by not conducting a complete and thorough investigation of this elopement incident for the resident.
Failure to Report Elopement Incident as Neglect
Penalty
Summary
The facility failed to implement its abuse and neglect reporting policies by not reporting an incident of potential neglect involving one resident. Facility policy titled "Abuse - Resident and Reasonable Suspicion of a Crime" dated 1/2/25 required that any suspected abuse or neglect be promptly investigated and reported to the Administrator, the PA Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director. Neglect was defined as the failure of the facility, staff, or service provider to provide goods and services necessary to avoid or that may result in physical harm, pain, mental anguish, or emotional distress. Despite this policy, documentation submitted by the facility to the State Survey Agency did not include a report of an elopement incident for one resident on 12/23/25. The resident involved (CR1) had diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment, per the MDS dated 12/3/25. A nurse clinical progress note dated 12/23/25 at 6:34 a.m. documented that while staff were doing morning rounds with other residents, second floor staff brought this resident to the unit, noting the resident was on their unit looking for breakfast. The note indicated the resident denied pain or discomfort, had no complaints, and still had a right lower extremity wander guard monitor in place, and that a nurse aide was monitoring and redirecting the resident. However, the former DON (now RNAC) stated in an interview that she was unaware of the resident being found on the second floor on that date and only became aware of the incident months later, adding that it would have been reported if she had known. This sequence of events demonstrated that the facility did not follow its own procedures to recognize and report the incident as neglect.
Failure to Investigate Elopement Incident for Cognitively Impaired Resident
Penalty
Summary
The facility failed to initiate a thorough investigation into an incident of elopement involving one resident (CR1). Facility policies on Abuse - Resident and Reasonable Suspicion of a Crime and on Wanderguard and Elopement required that all suspected abuse or neglect, including elopement, be promptly investigated and reported to the Administrator, the Department of Health, the Area Agency on Aging, the Compliance Officer, and the Executive Director. These policies defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and defined elopement as a resident leaving the premises or safe area without the facility’s knowledge and supervision. The policies also required implementation of safety measures for residents who wander or are at risk for elopement and an evaluation to identify root causes of non-goal-directed wandering. Resident CR1 had multiple diagnoses including multiple sclerosis, dementia, and a cognitive communication deficit, and had a BIMS score of 3, indicating severe cognitive impairment. The resident’s MDS indicated that a wander/elopement alarm was used daily, and physician orders directed staff to check the function of the wander guard daily on the night shift and to check and document its placement every shift. Another physician order specified that the resident could move about the floor without supervision but could not exit the unit or safe area without supervision, and an ADL order required assist/supervision for ambulation every shift. A physician progress note documented that staff had previously reported possible UTI due to altered mental status and wandering. On the date of the incident, a nurse progress note documented that while staff were doing morning rounds, staff from the second floor brought the resident back to the unit, reporting that the resident had been on their unit looking for breakfast. The note indicated that the wander guard monitor remained in place on the resident’s right lower extremity, and that a nurse aide was monitoring and redirecting the resident, with the resident cooperative and safety maintained. However, documentation submitted by the facility to the State Survey Agency did not include any report of an investigation into an elopement for this resident related to that incident. During interviews, the RNAC and former DON stated she was unaware of the resident being found on the second floor at that time and only became aware months later, acknowledging that an investigation would have been conducted if she had known. The surveyors concluded that the facility failed to initiate a thorough investigation of the elopement incident for this resident, in violation of state regulatory requirements for licensee responsibility, management, and nursing services.
Inaccurate MDS Coding of Wander/Elopement Alarm Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s actual status regarding the use of a wander/elopement alarm. The RAI User’s Manual requires that staff review the medical record and code alarms in Section P based on their use during the 7‑day look‑back period, with specific codes for not used, used less than daily, or used daily. The facility’s own policy on MDS/RAI and care planning states that MDS assessments must comply with federal and state requirements and incorporate physician orders, medication and treatment records, practitioner notes, and therapy plans. Despite these requirements, the MDS dated 3/5/26 for one resident with multiple sclerosis, dementia, and a cognitive communication deficit coded the wander/elopement alarm as “0 – not used,” indicating the device was not used during the look‑back period. Clinical documentation and orders showed that this coding was inaccurate. Physician orders dated 5/16/25 directed staff to check the function of the wander guard daily on the night shift, and a subsequent order dated 7/9/25 required the wander guard to be in place at all times, with placement and function checked and documented every shift. The medication administration record from 2/19/26 through 3/18/26 documented daily use of the wander/elopement alarm, and the resident’s care plan, initiated 12/4/25, included an intervention for a wander guard at all times with function and placement checks every shift due to potential for elopement. During an interview, the RN Assessment Coordinator confirmed that the facility failed to ensure the MDS accurately reflected the resident’s status, resulting in an inaccurate assessment for this resident under 28 Pa. Code 211.12(c)(d)(5) Nursing services.
Failure to Update Person-Centered Care Plan After Elopement Incident
Penalty
Summary
The deficiency involves the facility’s failure to update and individualize a resident’s person-centered care plan following an elopement incident. Facility policies on Wanderguard and Elopement, Assessment – MDS/RAI and Care Planning, and Comprehensive Person-Centered Care Planning require implementation of safety measures for residents at risk for elopement, compliance with MDS/RAI requirements, and development, review, and revision of comprehensive person-centered care plans by an interdisciplinary team. The Resident Assessment Instrument (RAI) manual guidance on the BIMS was cited, and the resident’s MDS dated 12/3/25 documented diagnoses of multiple sclerosis, dementia, and cognitive communication deficit, with a BIMS score of 3 indicating severe cognitive impairment. The same MDS showed no documented wandering behavior in Section E, but Section P indicated daily use of a wander/elopement alarm. Physician orders included a directive for a wander guard to be in place at all times with placement checked and documented every shift, and another order allowing the resident to move about the floor without supervision but not to exit the unit/safe area without supervision. A physician progress note later referenced staff reports of possible UTI due to altered mental status and wandering. On 12/23/25, a nurse progress note documented that while staff were doing morning rounds on other residents, staff from the second floor brought the resident back to the unit after finding the resident on their floor looking for breakfast. The note indicated the resident denied pain or discomfort, had the right lower extremity wander guard monitor still in place, and was being monitored and redirected by a nurse aide, with the resident cooperative and safety maintained. Despite this event, review of the resident’s elopement care plan, initiated on 12/4/25, showed no updates or revisions to goals and interventions after the elopement incident. During an interview, the RN Assessment Coordinator, who was the DON at the time of the incident, stated she was unaware of the resident being found on the second floor on 12/23/25 until months later and confirmed that the facility failed to ensure the resident had an updated, person-centered care plan individualized to specific needs after the elopement.
Failure to Adequately Supervise Resident With Severe Cognitive Impairment, Resulting in Unsupervised Elevator Travel
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident, identified as CR1, who had severe cognitive impairment and was ordered to have a wander guard in place at all times. The resident’s MDS dated 3/5/26 documented diagnoses of multiple sclerosis, dementia, and a cognitive communication deficit, with a BIMS score of 3 indicating severe impairment. Although the MDS Section E indicated the resident had not exhibited wandering behavior and Section P indicated no wander/elopement alarm was used, physician orders from 5/16/25 and 7/9/25 required daily function checks of a wander guard on the night shift and verification of wander guard placement and documentation every shift. The MAR from 2/19/26 through 3/18/26 showed that a wander/elopement alarm was used daily during that period. An Elopement Evaluation dated 2/13/26 documented that the resident was ambulatory or independent in wheelchair locomotion, but indicated no elopement risk factors were identified or verbalized and concluded the resident was at minimal risk for elopement, stating that an elopement care plan was not needed at that time. The same evaluation note added that the resident made no further statements about leaving that night and that she had a wander guard on and did not leave her room that night. Despite the presence of severe cognitive impairment and the use of a wander guard as reflected in orders and the MAR, the resident was not care planned for elopement risk at that time, and the facility’s documentation did not align the resident’s cognitive status and safety device use with an appropriate elopement risk assessment and care plan. On 3/17/26, the resident left her room on the third floor at approximately 12:02 p.m., entered the elevator at 12:03 p.m., and arrived on the first floor at 12:05 p.m. without staff supervision. A late-entry clinical progress note recorded that the resident got onto the elevator and was found on the first floor, then escorted back to the unit without incident. Employee statements from the DON’s secretary and the EVS manager indicated they saw the resident exiting the elevator on the first floor alone, described her as confused and lost, and noted that she stated she had an appointment but could not recall with whom. They contacted nursing, confirmed there were no scheduled appointments, and waited with the resident until an aide arrived to escort her back to the unit. The NHA and DON later confirmed that the facility failed to provide adequate supervision to prevent elopement for this resident, constituting the cited deficiency.
Failure to Protect Resident from Neglect During Catheter Care and Dressing
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from neglect during the provision of catheter care and dressing. The resident, who had a history of traumatic spinal cord dysfunction, anemia, neurogenic bladder, lymphedema, and frail skin, was dependent on staff for all toileting and hygiene needs. According to the care plan, a string was to be used to hang the Foley catheter bag, not a plastic clip. However, staff placed the catheter bag down the leg of the resident's pants while dressing her, contrary to the care plan instructions. During the dressing process, the hook from the urine bag caught the resident's leg, resulting in a laceration on the right anterior medial shin. The wound was described as a v-shaped skin flap with visible fatty tissue and serosanguinous discharge, and the surrounding skin was noted to be shiny, fragile, and edematous. The injury required assessment by a physician assistant and transfer to the emergency room, where it was determined that the wound was non-reparable and was closed with steri-strips. Staff interviews and documentation confirmed that the injury occurred as a direct result of improper handling of the catheter bag during dressing. The resident reported that staff continued to use the same technique despite her daughter's request for a different approach. The facility's own investigation acknowledged that the catheter bag should not have been threaded through the resident's pants, and staff were subsequently educated on safer practices.
Failure to Update Care Plan for Resident with Lymphedema and Skin Integrity Issues
Penalty
Summary
The facility failed to revise and update the care plan to accurately reflect the current status and care needs of a resident with multiple medical conditions. Upon review, it was found that the resident had diagnoses including traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema with frail skin. The resident sustained a laceration to the right anterior medial shin when staff were assisting with dressing, which was attributed to the hook from a urine bag catching the leg. Documentation indicated the wound was significant, with a v-shaped skin flap, visible fatty tissue, and serosanguinous drainage, and the resident's skin was described as shiny, fragile, and edematous. Despite these findings and the resident's history of lymphedema and skin integrity issues, the current care plan did not include any interventions for lymphedema or preventative measures for impaired skin integrity. Interviews with staff, including a nurse aide and a registered nurse, confirmed that the care plan lacked these necessary interventions. The Nursing Home Administrator also acknowledged that the care plan had not been revised to reflect the resident's current needs, resulting in a deficiency under the cited regulations.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Required Two-Person Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide the required two-person assistance for bed mobility to a resident with an air mattress, as specified in the resident's care plan and assignment sheet. The resident, who was cognitively intact and had diagnoses including depression, hypertension, and diabetes, required total assistance for toileting and bed mobility, and substantial assistance for bathing. The care plan clearly indicated that two staff members were needed for bed mobility tasks due to the increased risk of injury associated with the air mattress. On the day of the incident, the NA placed the resident in a lateral position near the edge of the bed and left the resident unattended while stepping out to consult with a nurse about a spinal cord stimulator. During this time, the resident rolled out of bed and sustained injuries, including a hematoma on the left side of the forehead, a laceration above the left eye, and a hematoma to the right knee with associated pain. The NA later stated that she was unaware of the two-person assistance requirement, despite the assignment sheet reflecting this instruction. Multiple staff interviews confirmed that the assignment sheets contained information about required assistance levels and that residents on air mattresses or with similar needs should not be left unattended during care. The incident resulted in actual harm to the resident, as documented by physical assessments and progress notes, and was acknowledged by the Director of Nursing as a failure to provide appropriate goods and services to prevent falls, constituting neglect.
Failure to Prevent Accidents Due to Lack of Equipment and Supervision
Penalty
Summary
The facility failed to provide appropriate equipment and supervision to prevent accidents for two residents, resulting in actual harm. One resident with severe cognitive impairment and a history of right foot fracture was transported in a wheelchair without footrests by nursing assistants. During transport, the resident's foot dropped to the floor, her shoe came off, and she sustained a bruise and an acute fracture of the right fifth toe. Staff interviews revealed a lack of awareness and inconsistent use of wheelchair leg rests, with some staff stating they would ask residents to hold their legs up if footrests were unavailable. Observations confirmed multiple residents being pushed in wheelchairs without leg rests, and the DON acknowledged that staff were not informed about which residents required leg rests, relying instead on whether the equipment was present on the chair. Another resident, who was cognitively intact but required two-person assistance for bed mobility due to an air mattress, was left unattended by a nursing assistant during care. The assistant placed the resident near the edge of the bed in a lateral position and stepped out of the room to consult with a nurse, leaving the resident unsupervised. The resident subsequently rolled out of bed, sustaining a hematoma and laceration above the left eye, a hematoma to the right knee, and reported pain. Documentation and staff interviews confirmed that the resident's care plan and assignment sheet specified the need for two-person assistance, but the nursing assistant was unaware of this requirement despite having access to the assignment sheet. Facility policies required maintaining an environment free from accident hazards and providing adequate supervision and assistive devices. However, the facility did not ensure staff were aware of or followed these requirements, resulting in residents being exposed to preventable harm. Staff interviews and observations highlighted gaps in communication and adherence to care plans, directly contributing to the incidents of injury.
Failure to Provide Adequate Supervision and Person-Centered Interventions Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and person-centered care plan interventions, resulting in elopement incidents for two residents identified as at risk for elopement. Both residents had documented cognitive impairments and histories of confusion, agitation, and wandering behaviors. Despite these risk factors, the facility did not consistently update or revise elopement assessments or care plans following significant changes in the residents' conditions or after incidents indicating increased risk. One resident, with diagnoses including metabolic encephalopathy, repeated falls, and diabetes, exhibited fluctuating cognition, periods of confusion, and a history of wandering and falls. The resident was found unsupervised in restricted areas of the facility on multiple occasions, including the basement and another floor, despite care plan interventions such as a wanderguard and supervision requirements. Documentation showed that after these incidents, the facility did not complete timely elopement observations or update the care plan to reflect the increased risk or necessary interventions. Another resident, diagnosed with dementia and severe cognitive impairment, was found unsupervised in a closed and unstaffed unit's break room. The resident's care plan and elopement risk assessment were not updated after documented episodes of increased confusion, sundowning, and behavioral changes. The care plan failed to reflect a resident-centered approach or include appropriate interventions until several months after the incident. Staff interviews revealed inconsistencies in the identification and monitoring of residents at risk for elopement, lack of updated wander lists, and unclear responsibilities for the wander management program.
Removal Plan
- DON/Designee will immediately re-evaluate Resident R6 and Resident R111 for elopement risk.
- DON/Designee will re-evaluate all residents for exit seeking behaviors.
- Nursing staff/Designee will provide every one-hour safety checks on all residents. Residents who are at risk of elopement will have every one-hour safety checks ongoing to ensure resident safety.
- DON/Designee will provide appropriate supervision levels for all residents in their orders and person-centered care plans to include interventions such as resident specific activities such as 1:1 interactions, cards, outside to courtyard with supervision, etc. Review and update quarterly, annually or with any significant changes or with any event where elopement is an identified risk.
- DON/Designee will audit appropriate supervision levels.
- DON/Designee will thoroughly investigate all incidents for root cause analysis and follow up with interventions.
- DON/Designee will audit all incidents.
- DON/Designee will implement interventions for residents identified as an elopement risk to prevent residents from eloping.
- DON/Designee will audit all interventions.
- DON/Designee will update elopement assessments quarterly, annually or with any significant change or with any event where elopement is an identified risk.
- Security/Designee to take photographs of residents upon admission to the facility to ensure updated wander books, if they are at risk of elopement. Security providing all nursing units with wander books, with photographs and names/room numbers of residents, and will be updated upon resident's admission and/or discharge.
- Policy for Wanderguard and elopement has been reviewed and facility will add addendum regarding supervision levels and also Security/Designee taking photos of residents upon admission to the facility to ensure resident at risk of elopement are placed in wander books are updated with names/room numbers. Wander books to be updated upon resident admission/discharge and with room changes.
- Staff Educator/Designee will educate all staff on policies for Elopements, Assessments, Care Plan, Supervision, and Accidents.
- Facility will review incidents at QI/QAPI.
Failure to Properly Store, Label, and Date Food in Main Kitchen
Penalty
Summary
The facility failed to properly store, label, and date food items and did not monitor expiration dates of food products in the Main Kitchen. During an observation in the Main Kitchen Walk-in Cooler, an opened bag of French fries was found unsealed, unlabeled, and undated. Additionally, a plastic bag containing bologna, a plastic bag of pepperoni, and a plastic bag of turkey were all marked with use-by dates that had already passed. A container of pureed egg salad was also found with a use-by date that had expired. The Food Service Director confirmed these findings and acknowledged that the facility did not adhere to its own policies regarding food storage, labeling, dating, and monitoring of expiration dates.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that necessary care and services were provided to residents requiring adequate supervision to prevent elopement. Review of job descriptions, clinical records, and staff interviews revealed that the facility failed to maintain necessary supervision and implement person-centered care plan interventions, resulting in two residents exiting to unsupervised or unauthorized areas without the facility's knowledge. This failure constituted an immediate jeopardy situation for two of the 21 residents identified as at risk for elopement. The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy.
Failure to Include FreeStyle Libre Device Management in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing the care and management of the FreeStyle Libre 2 Sensor or Reader for four residents. Each of these residents had physician orders specifying the use and scheduled changes of the FreeStyle Libre device as part of their diabetes management. However, reviews of their care plans revealed that none included instructions or interventions related to the care and management of these devices, despite the orders being present in their clinical records. The residents involved had diagnoses including high blood pressure, diabetes, muscle weakness, heart failure, and arthritis. The deficiency was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the care plans for these residents did not reflect the required care and management of the FreeStyle Libre devices. This failure was found to be inconsistent with the facility's own policy on comprehensive person-centered care planning and relevant state regulations.
Failure to Provide Appropriate Care for Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications, as evidenced by multiple deficiencies in labeling, dating, and verifying feeding tube placement. For one resident with diagnoses including high blood pressure, dementia, and diabetes, the enteral feeding bag in use was observed to be outdated and not properly labeled with the resident's name or the formula, and the water bag for flushes was not dated. Staff interviews confirmed that feeding and flush bags should be changed daily and properly labeled, but this was not done. Another resident with a history of stroke and difficulty swallowing had a care plan requiring verification of feeding tube placement before medication administration. However, during observation, an LPN failed to check the tube's placement prior to administering medication, a lapse confirmed by the DON. A third resident with Alzheimer's disease and muscle weakness was also observed receiving enteral feeding from an unlabeled bag, with staff confirming the lack of labeling. The DON acknowledged that the facility did not provide appropriate treatment and services for these residents, as required by policy and physician orders.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents as evidenced by multiple observations and staff confirmations. One resident with diagnoses including high blood pressure and muscle weakness was observed receiving oxygen at a rate higher than ordered by the physician, and the humidification bottle attached to the oxygen setup was empty. A registered nurse confirmed that the resident was not receiving oxygen at the prescribed rate and that the humidification bottle was not filled as required. Another resident with chronic obstructive pulmonary disease, anemia, and obstructive sleep apnea had a physician's order and care plan for BiPAP use at night. However, the BiPAP mask was repeatedly observed left on the bed and not stored in a bag as required by facility policy, with two different LPNs confirming this failure. A third resident, diagnosed with Alzheimer's disease, difficulty swallowing, and muscle weakness, was observed receiving oxygen via nasal cannula that was not dated as required. A registered nurse confirmed the lack of dating on the nasal cannula. The Director of Nursing acknowledged that the facility failed to provide appropriate respiratory care for these three residents.
Failure to Maintain Crash Carts and AEDs in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that essential emergency equipment, specifically crash carts and Automated External Defibrillators (AEDs), were maintained in safe operating condition. Observations revealed that two of four crash carts did not have completed documentation verifying that they had been checked as required, and the associated AEDs had not been tested or confirmed operational on multiple occasions. One crash cart was found with a blank emergency cart log, indicating no checks had been performed or recorded for an extended period. Additionally, three of six AEDs were found with expired electrodes, and there was no evidence that these had been replaced or that the devices were fully operational. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these lapses, with the NHA noting that AEDs were only serviced annually by an external safety officer. Facility policy requires regular checks and maintenance of emergency equipment, but documentation and observations showed these procedures were not consistently followed, resulting in equipment that may not have been ready for use in an emergency.
Failure to Ensure Dignified Dining and Respect Resident Privacy
Penalty
Summary
The facility failed to ensure a dignified dining experience and respect for residents' private space on the Three East unit. During a dining observation, a nurse assistant was seen standing while feeding a resident lunch, rather than sitting as required by facility policy. The nurse assistant acknowledged awareness of the expectation to sit while assisting with meals. Additionally, a housekeeping employee entered two residents' rooms without knocking or requesting permission, which did not protect or value the residents' private space. The Director of Nursing and the housekeeping employee both confirmed these failures during interviews.
Unsafe and Unattended Maintenance Area in Resident Room
Penalty
Summary
Facility staff failed to maintain a clean, safe, comfortable, and homelike environment in one of three resident areas, specifically in an unoccupied resident room. During an observation, a large maintenance cart containing handheld drills, scraping tools, a caulk gun, screws, wires, and other maintenance equipment was found left in the room, which had no beds or furniture. The lights above the bed areas had been removed, leaving wires visibly protruding from the wall, and a light bulb was found on the floor near the closet. The room was unlocked and unattended, and it shared a bathroom with an occupied resident room. The Environmental Services Director confirmed these observations and acknowledged the safety risk posed by the situation. The Nursing Home Administrator also confirmed the facility's failure to provide a safe and homelike environment in this area.
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 1,446 citations issued within 25 miles in the last 12 months — including the 27 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 Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Hills Post Acute | 1.1 mi | ★★★★★ | 25 | 0 |
| Vincentian Home | 1.3 mi | ★★★★★ | 13 | 0 |
| Perry Health & Rehab Center | 3.1 mi | ★★★★★ | 30 | 0 |
| Little Sisters Of The Poor | 4.5 mi | ★★★★★ | 15 | 0 |
| Concordia At Rp Home | 5.9 mi | ★★★★★ | 7 | 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 October 2026) and official state health department websites.