Lafayette Manor, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 147 Lafayette Manor Road, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395795
- Inspections on file
- 21
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Lafayette Manor, Inc during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, unsteadiness on feet, and muscle weakness was admitted and noted to be alert with confusion and not always following commands. On the evening of admission, CNAs repeatedly redirected the resident, who kept getting up, but later found the resident missing during a room check. Staff initiated a search of the unit, basement, and outside areas, while an RN coordinated the response and notified the attached personal care home and law enforcement. The resident was ultimately found in the basement of the attached assisted living building, having left the unit without detection. Facility leadership confirmed that adequate supervision had not been provided to prevent the elopement.
Surveyors found that staff and management provided torn towels, ripped washcloths, and pieces of blankets as linens for resident care, despite facility policy requiring clean linens in good condition. LPNs, nurse aides, and the Maintenance Director confirmed this practice, and the Nursing Home Administrator acknowledged that these were the linens being supplied, even though new washcloths were available but unused.
The facility failed to provide adequate incontinence care supplies, limiting each resident to eight diapers per day regardless of individual needs, and sometimes providing the wrong size. Staff reported difficulty obtaining additional supplies and a lack of proper wipes, leading to the use of potentially unclean washcloths. As a result, several residents developed incontinence-associated dermatitis or other complications related to inadequate incontinence care.
Surveyors found that staff inaccurately documented meal consumption for six residents, with records often completed before meals were finished and amounts recorded that did not match what was actually consumed. Staff interviews confirmed premature charting, and the administrator acknowledged the documentation failures.
The facility failed to verify the washing temperature of the dish machine in the main kitchen, creating a potential for foodborne illness. The dish machine did not reach the required temperatures for proper sanitation, as confirmed by the Dietary Manager.
A facility failed to maintain infection control during a dressing change, as LPNs did not clean the bedside table, improperly handled soiled gloves, and reused gauze on multiple wounds. Additionally, unclean scissors were used, and the bedside table was not sanitized post-procedure. These actions were confirmed by the involved LPN and the Nursing Home Administrator.
A facility failed to protect residents from misappropriation of controlled medications. An LPN signed out medications but did not administer them to three residents, leading to discrepancies in medication records. The issue was discovered after residents reported not receiving their pain medications, prompting an investigation that resulted in the LPN's suspension and termination.
The facility failed to provide meals according to resident preferences, as observed during a survey. A resident did not receive requested scrambled eggs and cranberry juice, another received cold cereal instead of oatmeal, and a third did not get cheese curls with their hotdog. Resident Council feedback confirmed that menus often did not match the food served, highlighting a violation of dietary service regulations.
The facility's QAPI program failed to correct previously cited deficiencies related to the misappropriation of property and the implementation of policies to prohibit abuse. This repeated deficiency affected three residents, as identified in a survey. The facility's QAPI Committee did not effectively review and approve necessary policies and procedures, and the Nursing Home Administrator confirmed the failure to maintain the plan of correction.
The facility did not provide required training on Abuse, Neglect, and Exploitation for five staff members, including an NA, two RNs, and two LPNs. This was confirmed by the Nursing Home Administrator and violates specific state codes regarding staff development and management responsibilities.
The facility failed to provide mandatory infection control training for six staff members, including NAs, RNs, and LPNs. This deficiency was confirmed by the Nursing Home Administrator, who acknowledged the absence of training documentation for these employees.
The facility failed to promote dignity for two residents by placing them in rooms with a shared bathroom, leading to a grievance from a resident upset about sharing with a male. The facility's resolution of providing a bedside commode did not address the dignity and privacy concerns, as confirmed by the Nursing Home Administrator.
The facility failed to provide the required 12 hours of annual in-service education for nurse aides within 12 months of their hire date anniversary. Two nurse aides did not receive the necessary training, with one completing only 4.97 hours and the other none at all. The Nursing Home Administrator confirmed the deficiency and noted the absence of an education process for annual trainings prior to her arrival.
The facility did not provide required transfer notices to the Office of the Long-Term Care Ombudsman Division. Federal regulations mandate that before transferring or discharging a resident, the facility must notify the resident and their representative(s) in writing and send a copy to the Ombudsman. This includes emergency transfers to acute care facilities. The Nursing Home Administrator confirmed the omission of these notices since September 2023.
The facility failed to provide required annual in-service education to its nursing staff, affecting 10 personnel, including NAs, LPNs, and RNs. The deficiency was confirmed through personnel record reviews and an interview with the Nursing Home Administrator, revealing missing trainings on essential topics like infection control and behavioral health.
The facility failed to conduct annual performance evaluations for five nurse aides, as required by policy and state regulations. The nurse aides, hired on various dates, did not receive evaluations within the specified time frames. This deficiency was confirmed by the DON during an interview.
The facility did not provide communication training to five direct care staff members, including an NA, two RNs, and two LPNs. This deficiency was confirmed by the Nursing Home Administrator and violates specific state codes regarding staff development and licensee responsibility.
The facility failed to provide training on resident rights for six staff members, including NAs, RNs, and LPNs, as identified through document reviews and staff interviews. This deficiency was confirmed by the Nursing Home Administrator and violates several Pennsylvania Code regulations related to licensee responsibility, management, and staff development.
The facility did not provide mandatory QAPI training to five staff members, including an NA, two RNs, and two LPNs. This deficiency was confirmed by the Nursing Home Administrator, violating staff development regulations.
The facility failed to provide compliance and ethics training for six staff members, including NAs, RNs, and LPNs. A review of facility documents and staff interviews confirmed the absence of such training, which was acknowledged by the Nursing Home Administrator. This deficiency violates several Pennsylvania Code regulations related to licensee responsibility, management, and staff development.
The facility did not provide behavioral health training for ten staff members, including NAs, LPNs, and RNs. A review of documents showed that employees E8 through E17 lacked the required training. This was confirmed by the Nursing Home Administrator, indicating a breach in staff development responsibilities.
An LPN in a facility failed to administer controlled medications to 12 residents, despite signing them out. Discrepancies were found between the narcotic book and the eMar, indicating potential narcotic diversion. The issue was discovered by an RN supervisor, and the state police were notified for investigation.
The facility was found to have insufficient nursing staff, impacting resident care. Several residents reported long wait times for call light responses, delayed medications, and inadequate assistance with ADLs. Observations included unkempt grooming and prolonged periods on the commode. Resident Council minutes and grievances further highlighted these issues, which were confirmed by the Nursing Home Administrator.
A resident undergoing treatment for anemia, chronic kidney disease, and cancer did not receive medications as prescribed on multiple occasions. The facility failed to administer medications when the resident was out for chemotherapy and did not address missed medications upon the resident's return from a PET scan. The Nursing Home Administrator confirmed these failures, indicating a lack of adherence to physician orders for medication administration.
A facility failed to implement proper infection control procedures for a resident undergoing chemotherapy, who required neutropenic precautions. The facility's policy did not include specific guidelines for such precautions, and the resident's care plan and Kardex lacked necessary information. Observations showed that protective equipment was not available at the resident's doorway, and staff entered the room without wearing gloves or a mask. The Nursing Home Administrator confirmed the deficiency.
Failure to Adequately Supervise Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for one resident. The resident was admitted with diagnoses including atrial fibrillation, unsteadiness on feet, muscle weakness, and Alzheimer’s disease, and the MDS dated 5/29/24 documented severe cognitive impairment. A progress note from the day of admission stated the resident was alert with confusion and did not always follow commands. On the evening of admission, a nurse aide reported seeing the resident in her room at approximately 9:10 p.m., noting that the resident kept getting up and that aides repeatedly redirected her back to her room. Around 9:30 p.m., during a room check and inventory, the aide discovered the resident was no longer in bed or in the bathroom and could not be located in nearby rooms. The aide alerted other staff that the resident was missing, and a search of the unit, basement, laundry room, fire exits, outside areas, and around other campus buildings was initiated. During this time, the RN was notified and documented that the resident had eloped and that staff were instructed to conduct a thorough search of the facility and surrounding areas. The facility also notified the attached personal care home and law enforcement after the resident was not located within 15 minutes. The resident was ultimately found off the unit in the basement area of the attached personal care/assisted living building, sitting by the time clock, and was then returned to the facility. The facility later acknowledged they were unable to determine the exact exit path, but indicated an obvious route would have been through the front doors into the attached personal care home and down an elevator to the lower level. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to provide adequate supervision to prevent this elopement.
Use of Damaged Linens Fails to Meet Homelike Environment Standards
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on both the first and second floor nursing units. Observations revealed that linen carts contained torn towels, bed blankets, and ripped washcloths, which were being provided to residents for their care. Staff interviews confirmed that these damaged linens were used in place of proper washcloths and wipes, as the facility did not supply adequate alternatives. The facility's own policy indicated that clean bed and bath linens in good condition should be provided, but this standard was not met. Further interviews with LPNs, nurse aides, and the Maintenance Director corroborated that the use of ripped and torn linens was a common practice, and that although new washcloths were available, they remained unused and still packaged. The Nursing Home Administrator also confirmed that the damaged linens were what was being provided to residents. These actions resulted in the failure to maintain a safe, comfortable, and homelike environment as required by federal and state regulations.
Plan Of Correction
1. Resident rooms inspected by NHA/designee and torn blankets, washcloths, and towels removed and replaced if necessary. 2. Torn linens were removed from laundry; facility ordered new linen for resident care. Audit performed to ensure adequate supply of linens available for resident care. 3. NHA/designee educated housekeeping and nursing staff on home-like environment. Housekeeping educated on sufficient and appropriate supplies availability for resident care. 4. Housekeeping will complete audit of linens and remove torn linens weekly for 4 weeks and monthly for 2 months. Director of Nursing/designee will complete audits of resident care supplies in residents' rooms to ensure linens are in good repair weekly for 4 weeks and monthly for 2 months. 5. Findings of audits will be reviewed through QAPI.
Failure to Provide Adequate Incontinence Supplies and Reasonable Accommodation
Penalty
Summary
Lafayette Manor failed to provide reasonable accommodation of resident needs and preferences regarding incontinence care supplies for five of 25 residents reviewed. Observations and staff interviews revealed that the facility imposed a limit of eight incontinence diapers per resident per 24 hours, regardless of individual needs. Staff reported that if additional diapers were needed, they had to wait for a supervisor, and some residents received the wrong size of incontinence products. Additionally, there were reports of insufficient wipes, leading to the use of washcloths that were sometimes not clean, with concerns that these cloths may have been used on multiple residents for different purposes. Clinical record reviews indicated that one resident with a history of incontinence and a recently healed sacral pressure ulcer developed a urinary tract infection, while four other residents developed incontinence-associated dermatitis during their stay. The facility's supply practices and lack of appropriate incontinence care products contributed to these conditions. The Nursing Home Administrator confirmed the failure to provide reasonable accommodation for the affected residents.
Plan Of Correction
1. R1, 2, 3, 4, and 5 were assessed for incontinence and brief size. 2. Current residents will be assessed for incontinence episodes by the director of nursing / designee by 8/25/2025. 3. Current residents will be measured for appropriate size briefs by the director of nursing / designee by 8/25/2025. The Director of Nursing/Designee will complete an audit of current residents to ensure an adequate amount of incontinence supplies are available. 4. The Director of Nursing / designee will educate nursing staff and agency on inventory control, supplies, and storage location of incontinence supplies. 5. The Director of Nursing / designee will complete an audit to ensure sufficient incontinence supplies and appropriate brief size are stored in resident rooms weekly for 4 weeks and monthly for 2 months. 6. Findings of audits will be reviewed in QAPI.
Inaccurate Documentation of Meal Consumption
Penalty
Summary
The facility failed to accurately document meal consumption for six of seven residents observed. According to the facility's policy, documentation in the medical record must be objective, complete, and accurate. However, observations revealed discrepancies between the actual amount of food consumed by residents and what was recorded in their clinical records. For example, one resident was observed to have consumed approximately 25% of their meal, but the record indicated 75% consumption. Similar inconsistencies were found for five other residents, with documentation often completed before the meal was finished or with amounts that did not match direct observation. Staff interviews confirmed that documentation was sometimes completed prematurely, with one nursing assistant admitting to charting meal consumption too quickly. The Nursing Home Administrator acknowledged that the facility did not accurately document meal consumption for the majority of residents observed during the survey. These findings were determined to be non-compliant with the facility's own documentation policy and state regulations regarding clinical records.
Dish Machine Temperature Verification Failure
Penalty
Summary
The facility failed to verify the washing temperature of the dish machine in the main kitchen, which created the potential for foodborne illness. The facility's Automated Ware Washing Policy and Dish Machine Temperature Log required that the dish machine be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitation. The policy specified that the wash temperature should be at least 160 degrees, and the final rinse temperature should be at least 180 degrees. However, during an observation of the main kitchen, it was identified that the dish machine valves did not function during the wash and rinse cycles. A subsequent observation confirmed that the dish machine did not reach the required temperatures for proper sanitation, as confirmed by the Dietary Manager.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed by surveyors. LPN Employees E1 and E2 did not follow the facility's infection control policy, which included not cleaning the bedside table before placing a clean drape and not removing the resident's belongings from the table. Additionally, LPN Employee E2 did not wash her hands after pulling the drapes for privacy and placed soiled gloves on the resident's bed without washing hands afterward. The same piece of gauze was used multiple times to cleanse and dry the wounds, and soiled gloves were improperly handled and disposed of. Further observations revealed that LPN Employee E1 used unclean scissors from his pocket to cut treatment materials and returned them to his pocket without cleaning them after use. The bedside table was not cleansed after the procedure, and the wound cleanser spray bottle was returned to the storage room without proper sanitation. These actions were confirmed by LPN Employee E1 during an interview, who was training LPN Employee E2 as a new employee. The Nursing Home Administrator also confirmed the facility's failure to maintain infection control to prevent potential cross-contamination during the dressing change.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of property, specifically controlled medications, for three residents. The facility's policy on abuse prevention, which includes protection against misappropriation of property, was not adhered to. Medications were signed out by an LPN but not administered to the residents. Specifically, one resident had three pills of Oxycodone signed out but not given, another had four pills of Hydrocodone/APAP signed out but not administered, and a third resident had three pills of Oxycodone signed out but not administered. This discrepancy was identified during a review of medication records and was linked to one LPN who failed to complete documentation on the electronic medication administration record but signed off on the controlled substance count sheet. The issue was discovered when the LPN in question was investigated after residents reported not receiving their pain medications. The Director of Nursing and supervisors conducted an audit and found ten discrepancies involving controlled substances over a two-day period. The investigation led to the suspension and eventual termination of the LPN involved. The state police and other relevant authorities were notified, and residents were interviewed as part of the investigation.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to adhere to the food preferences of its residents, as evidenced by observations and interviews conducted during a survey. During a tray accuracy observation, it was noted that Resident R63 did not receive the requested scrambled eggs and cranberry juice for breakfast, instead receiving pancakes. Similarly, Resident R92 requested oatmeal but was served cold cereal. Resident R700, who requested a hotdog and cheese curls for lunch, received a chopped hotdog without the cheese curls. Interviews with the residents and their representatives confirmed these discrepancies, with Resident R63 expressing dissatisfaction with the meal choices provided and Resident R92's representative noting that meal items were often missing. Further evidence of the facility's failure to meet resident food preferences was found in the Resident Council Minutes and Meeting. On 8/29/24, residents reported that the menus did not match the food provided, and during a meeting on 9/4/24, 12 out of 16 residents in attendance confirmed this issue. The concern regarding the dietary staff's failure to provide or substitute preferred food items was discussed with the Nursing Home Administrator. This deficiency is a violation of Pa Code: 211.6(a) Dietary Services, which mandates that facilities accommodate resident food preferences.
Repeated Deficiency in Misappropriation of Property
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address and correct previously cited deficiencies, as identified in the abbreviated survey conducted on May 24, 2024. The deficiencies were related to the misappropriation of property and the implementation of policies and procedures to prohibit abuse and misappropriation of resident property. These issues were found to affect three residents, indicating a repeated deficiency in the facility's ability to maintain compliance with nursing home regulations. During the survey ending on September 6, 2024, it was determined that the facility's QAPI Committee did not effectively review and approve facility policies, procedures, and guidelines, which are required to be assessed annually. The Nursing Home Administrator confirmed that the facility failed to maintain their plan of correction for the deficient practices. This failure was noted in the context of federal and state deficiencies, demonstrating that the facility did not have an effective Quality Assurance Committee to ensure that the concerns related to abuse and misappropriation of resident property were adequately addressed.
Failure to Provide Training on Abuse, Neglect, and Exploitation
Penalty
Summary
The facility failed to provide mandatory training on Abuse, Neglect, and Exploitation for five out of ten staff members, specifically Employees E12, E14, E15, E16, and E17. This deficiency was identified through a review of facility policy and documents, as well as staff interviews. The records for a Nurse Aid (NA), two Registered Nurses (RNs), and two Licensed Practical Nurses (LPNs) did not include the required training. During an interview, the Nursing Home Administrator confirmed the lack of training for these employees, which is a violation of the facility's responsibilities under 28 Pa Code: 201.14 (a), 201.18 (b)(1), and 201.20 (a)(c).
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for six out of ten staff members reviewed. Specifically, the facility's records for Nurse Aide (NA) Employees E8 and E12, Registered Nurse (RN) Employees E14 and E17, and Licensed Practical Nurse (LPN) Employees E15 and E16 did not include documentation of training on infection control. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of infection control training for these employees.
Failure to Promote Resident Dignity in Shared Bathroom Arrangement
Penalty
Summary
The facility failed to provide an environment and care that promoted dignity for two residents, identified as R500 and R501. Resident R500, who was cognitively intact with a BIMS score of 15, was admitted with diagnoses including diabetes, depression, and cervical spine fusion. Resident R501, with a BIMS score of 11 indicating moderate cognitive impairment, was admitted with diagnoses including diabetes, depression, and dementia. Both residents were placed in rooms with a shared bathroom. A grievance was filed by Resident R500, who was upset about sharing a bathroom with a male resident, as the bathroom door was often locked from the other side. The facility's resolution to the grievance was to provide Resident R500 with a bedside commode, which did not address the underlying issue of dignity and privacy. The Nursing Home Administrator confirmed that the facility failed to provide an environment that promoted dignity for Resident R500. The facility policies on resident rights, dignity, and a homelike environment emphasize treating residents with respect and ensuring their comfort and personal needs are met, which was not upheld in this situation.
Deficiency in Nurse Aide In-Service Education
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education for nurse aides within 12 months of their hire date anniversary, as mandated by regulations. Specifically, two nurse aides, Employees E8 and E12, did not receive the necessary training. Employee E8, hired on February 28, 2022, completed only approximately 4.97 hours of in-service education between February 28, 2023, and February 28, 2024. Employee E12, hired on November 14, 2022, had not completed any in-service education between November 14, 2022, and November 14, 2023, and had not participated in any in-services for 2024 as of the survey exit date. The Nursing Home Administrator confirmed the deficiency and noted the absence of an education process for annual trainings prior to her arrival at the facility.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division, as required by federal regulations. According to Title 42 Code of Federal Regulations S483.15(c)(3), before a facility transfers or discharges a resident, it must notify the resident and their representative(s) in writing, and send a copy of the notice to a representative of the State Long-Term Care Ombudsman. This requirement applies even in cases of emergency transfers to acute care facilities, which are considered facility-initiated transfers. During an interview, the Nursing Home Administrator confirmed that the facility had not been providing these notices since September 20, 2023.
Deficiency in Annual In-Service Education for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff received the required annual in-service education, as evidenced by a review of personnel records and interviews. The deficiency affected 10 out of 10 nursing personnel, including Nurse Aides, Licensed Practical Nurses, and Registered Nurses. The facility's policy mandates in-service training upon hire and regularly scheduled sessions covering various essential topics such as infection control, fire prevention, emergency preparedness, and resident rights. However, the personnel records reviewed showed that these mandatory trainings were not completed for the staff members in question. Specifically, the records indicated missing annual in-services on critical topics like infection prevention, behavioral health, and restorative nursing techniques, among others. During an interview, the Nursing Home Administrator confirmed the oversight, acknowledging the facility's failure to provide the necessary education to its nursing staff. This lack of training could potentially impact the quality of care provided to residents, as staff may not be adequately prepared to handle various situations that arise in the care environment.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by their policy and state regulations. The nurse aides in question, identified as Employees E8, E9, E10, E11, and E12, did not receive their evaluations within the specified time frames based on their hire dates. Employee E8, hired on 2/28/22, did not have an evaluation between 2/28/23 and 2/28/24. Employee E9, hired on 6/12/23, did not have an evaluation by 6/12/24. Employee E10, hired on 11/17/16, did not have an evaluation between 11/17/22 and 11/17/23. Employee E11, hired on 1/27/23, did not have an evaluation by 1/27/24. Employee E12, hired on 11/14/22, did not have an evaluation by 11/14/23. This deficiency was confirmed during an interview with the Director of Nursing on 9/4/24.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide communication training to five out of ten direct care staff members reviewed, specifically Employees E12, E14, E15, E16, and E17. This deficiency was identified through a review of facility education documents, which revealed that the facility did not offer communication education to its direct care staff. The specific employees affected included a Nurse Aide (NA), two Registered Nurses (RNs), and two Licensed Practical Nurses (LPNs), none of whom had received training on effective communication as per the facility-provided information. During an interview, the Nursing Home Administrator confirmed the lack of communication training for the direct care staff. This failure to provide necessary training is a violation of the 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(c) Staff Development.
Failure to Provide Training on Resident Rights
Penalty
Summary
The facility failed to provide training on resident rights for six out of ten staff members, which was identified through a review of facility documents and staff interviews. Specifically, the facility-provided information for Nurse Aide (NA) Employees E8 and E12, Registered Nurse (RN) Employees E14 and E17, and Licensed Practical Nurse (LPN) Employees E15 and E16 did not include training on resident rights. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of training for these staff members. The deficiency is in violation of several Pennsylvania Code regulations, including 28 Pa Code: 201.14 (a) regarding the responsibility of the licensee, 28 Pa Code: 201.18 (b)(1) concerning management, and 28 Pa Code: 201.20 (a)(c) related to staff development.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to five out of ten staff members reviewed. Specifically, the facility's records for a Nurse Aid (NA), two Registered Nurses (RNs), and two Licensed Practical Nurses (LPNs) did not include documentation of QAPI training. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of QAPI training for these employees. The failure to conduct this training is a violation of the facility's responsibility under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(c) regarding staff development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on compliance and ethics for six out of ten staff members, specifically Employees E8, E12, E14, E15, E16, and E17. This deficiency was identified through a review of facility policies, documents, and staff interviews. The review revealed that the facility-provided information for these employees did not include any record of training on compliance and ethics. During an interview, the Nursing Home Administrator confirmed the lack of training for these employees, acknowledging the facility's failure in this regard. The deficiency is in violation of several Pennsylvania Code regulations, including 28 Pa Code: 201.14 (a) regarding the responsibility of the licensee, 28 Pa Code: 201.18 (b)(1) concerning management, and 28 Pa Code: 201.20 (a)(c) related to staff development.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training for ten staff members, including nurse aides, licensed practical nurses, and registered nurses. A review of facility documents revealed that none of the employees, identified as E8 through E17, had received the required training on behavioral health. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of training for these employees. The failure to provide this training is a violation of the facility's responsibility for staff development and management as outlined in the relevant state codes.
Misappropriation of Controlled Medications by LPN
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, specifically controlled substances, by an LPN. The incident involved 12 out of 15 residents who were prescribed opioid pain medications such as oxycodone, tramadol, and hydrocodone. These medications were signed out by the LPN but were not administered to the residents, as confirmed by discrepancies in the electronic medication administration record (eMar) and the controlled substance count sheet. The issue was discovered when an RN supervisor noticed that narcotics were signed out in the narcotic book but not documented as administered in the eMar. Further investigation revealed multiple discrepancies over two shifts worked by the LPN, who had signed out narcotics for several residents without administering them. Interviews with alert and oriented residents confirmed that they did not receive the medications, indicating a potential diversion of narcotics by the LPN. The facility's Director of Nursing and Nursing Home Administrator were notified of the discrepancies, and the state police were involved in the investigation. The LPN was suspended pending the investigation, and the state board of licensure was notified. The facility identified 21 discrepancies involving 12 residents, highlighting a significant failure in ensuring the proper administration and documentation of controlled medications.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Several residents reported issues related to inadequate care, such as long wait times for call light responses, delayed medication administration, and insufficient assistance with activities of daily living (ADLs). For instance, one resident was observed with long, jagged fingernails, indicating a lack of grooming assistance, while another resident reported only receiving one shower per week despite preferring two. Additionally, a resident was left on a bedside commode for an hour, resulting in discomfort and pain, and another resident's grievance highlighted a delay in receiving pain medication and assistance for therapy. The Resident Council minutes from February, March, and April further corroborated these concerns, documenting issues with call light response times, long waits for bathroom assistance, and instances where call lights were turned off without addressing the residents' needs. The Nursing Home Administrator confirmed the facility's failure to maintain adequate staffing levels to ensure the highest practicable physical, mental, and psychosocial well-being of the residents. This deficiency was noted to affect six out of twelve residents reviewed, highlighting a systemic issue with staffing and care provision within the facility.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to follow physician orders for medication administration for a resident, identified as R14, who was undergoing treatment for anemia, chronic kidney disease, and cancer. The resident's medication administration record (MAR) showed that on multiple occasions, medications were not administered as prescribed. On April 2, 2024, medications Gabapentin and Rytary were not given because the resident was out for chemotherapy, and there was no documentation indicating whether the physician was contacted or if the missed medications were administered later. Additionally, on April 9 and 10, 2024, the MAR indicated that the resident refused medications, but the resident was not present in the facility to refuse them. Further issues were noted on May 7, 2024, when the resident did not receive several morning medications after returning from a PET scan. The resident's daughter reported the missed medications, and it was confirmed that the resident had not received Lasix, Tums, a vitamin D supplement, and Lexapro. The facility failed to address whether the resident could have received medications before the PET scan or what could be administered upon return. The Nursing Home Administrator confirmed these failures during an interview, acknowledging that the facility did not follow physician orders for medication administration for the resident.
Failure to Implement Neutropenic Precautions for Resident
Penalty
Summary
The facility failed to maintain infection control procedures to prevent the possible transmission of communicable diseases for Resident R14, who was undergoing chemotherapy and had a physician's order for neutropenic precautions. The facility's policy on Transmission-Based Precautions did not include specific information related to neutropenic isolation precautions, which are necessary for residents with suppressed immune systems. Resident R14's care plan and Kardex also lacked information on neutropenic precautions, despite the resident's recent chemotherapy treatment and the associated increased risk of infection. Observations revealed that signage on Resident R14's door indicated the need for gloves and a mask, but the necessary protective equipment was not available at the doorway. A face shield was present, but it was confirmed by LPN Employee E5 that it would not be effective in preventing infection transmission to the resident. Additionally, Nurse Aide Employee E6 was observed entering Resident R14's room without wearing gloves or a mask. The Nursing Home Administrator confirmed the facility's failure to maintain proper infection control procedures for Resident R14.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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