Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
A resident with diabetes, heart flutter, and pneumonia required assistance of two for bed mobility, but a call light was left unanswered for 21 minutes while the resident waited to use the bedpan and then needed cleaning up. In a resident group meeting, residents reported staff often do not respond to call bells in a timely manner and sometimes turn them off and say they will return later, but do not come back for an hour or longer. The ADON confirmed the facility failed to accommodate the resident’s call bell needs.
Surveyors found multiple damaged and uneven surfaces on the first floor nursing unit, including broken shower room tiles, lifting hallway flooring, loose and missing floor tiles in resident rooms, warped tiles, and exposed broken wall areas. An NHA confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment.
Expired medications and supplies were found stored in a medication room, including IV pole strips, COVID-19 antigen self-tests, infusion sets, PICC stabilization devices, and dressing change trays with expiration dates ranging from 2022 through 2025. The NHA and DON confirmed the facility failed to properly store medications and/or biologicals in one of two medication rooms, contrary to the facility policy on medication storage.
The facility failed to follow infection control guidance on the first-floor nursing unit after two staff tested positive for COVID-19 and masking was required for staff, visitors, and residents due to potential exposure. During observation, three NAs were seen wearing masks that did not fully cover their faces while entering and exiting resident rooms, and the ADON/Infection Control Preventionist confirmed the lapse.
Failure to provide adequate supervision to prevent elopement for two residents. One resident with TBI, hemiplegia, and impulse disorder was found in the dining room after leaving his room via wheelchair without being seen, despite being assessed as not at risk for elopement. Another resident with dysphagia after CVA, hemiplegia, and muscle weakness was found in the parking lot after a visitor assisted him outside; he stated he was trying to go home and his spouse believed he followed her out. The NHA confirmed the supervision failure.
Missing Order and Care Plan Interventions for Urostomy: A resident with cancer, scoliosis, and anxiety had an indwelling catheter and urostomy on admission, but the facility did not obtain a physician order for the urostomy and did not include resident-centered urostomy interventions in the care plan. The care plan only addressed intake/output monitoring and reporting s/sx of UTI, and the ADON confirmed the omissions.
A facility failed to complete a significant change MDS for a resident after hospice admission. The resident had diagnoses including cancer, scoliosis, and anxiety, and the LPN Assessment Coordinator confirmed the MDS was not completed within 14 days of the hospice admission.
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.
Delayed Response to Resident Call Bell Needs
Penalty
Summary
The facility failed to accommodate the call bell needs of one resident. The resident had diagnoses including diabetes, heart flutter, and pneumonia, and the most recent MDS indicated the resident required assistance of two for bed mobility. During observation, the resident’s call light above the door was illuminated at 8:31 a.m. and was not answered until 8:52 a.m., 21 minutes later, when the ADON responded. At that time, the resident stated she had been waiting to use the bedpan and now needed cleaned up because she could not wait any longer. In the resident group meeting, residents stated staff do not respond to call bells in a timely manner, that they often have to wait, and that staff sometimes turn off the call bell and say they will come back, but it is often an hour or longer before they return. The ADON confirmed the facility failed to accommodate the resident’s call bell needs.
Unsafe and Damaged Conditions on First Floor Nursing Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on one of two nursing units, the first floor nursing unit. Survey observations found multiple environmental deficiencies, including broken wall and floor border tiles in the left shower room, uneven flooring and broken wall tiles in the right shower room, uneven and lifting flooring in the hall of the 100-room numbers, broken loose floor tiles under the sink in one resident room, warped tiles behind a bed with a cable wire hanging in a way that could be pulled down, missing floor trim near a bathroom leaving broken wall exposed in another resident room, loose and missing floor tiles by a heater and in the bathroom area of another room, and a loose bathroom panel under a heater in another resident room. The Nursing Home Administrator confirmed the facility failed to provide the required environment on the first floor nursing unit.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to properly store medications and biologicals in one of two medication rooms, identified as the Second Floor Medication Room. Review of the facility policy titled Medication Storage in the Facility, dated 1/28/25, indicated that medications and biologicals are to be removed from active supply and destroyed in the facility. During an observation on 9/23/25 at 10:25 a.m. in the First Floor Medication Room, surveyors observed multiple expired items stored in the room, including DualCap IV Pole Strips disinfecting caps for male connectors with an expiration date of 5/4/22, Binax Now Covid-19 Antigen self-test 2-packs with an expiration date of 5/15/23, several Volumat VL PR72-11 Primary Infusion Sets with 0.2-micron filters with expiration dates ranging from 3/8/25 through 5/4/25, Statlock PICC Plus Stabilization Devices with an expiration date of 5/28/2025, and dressing change trays with an expiration date of 8/31/25. During an interview on 9/23/25 at approximately 2:30 p.m., the Nursing Home Administrator and the DON confirmed that the facility failed to properly store medications and/or biologicals in one of two medication rooms. The cited deficiency referenced 28 Pa. Code: 211.9(a)(1)(j.1)(k) Pharmacy services and 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Failure to Follow Infection Control and Masking Requirements
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC to reduce the spread of infections and prevent cross-contamination on the first-floor nursing unit. Facility policy stated that staff with a confirmed or suspected viral respiratory infection would be restricted from work until 3 days had passed since symptoms, and another policy stated the facility would minimize exposures to respiratory pathogens and use universal source control and masks, especially with close contact. During the entrance conference, the Nursing Home Administrator stated that two staff tested positive for COVID-19 and that staff, visitors, and residents on the first-floor nursing unit were to wear masks due to potential exposure. However, during observation on the first-floor nursing unit, Nurse Aide employees E9, E10, and E11 were seen with masks not fully covering their faces while going in and out of resident rooms. The Assistant DON and Infection Control Preventionist confirmed that the facility failed to follow infection control guidelines from CMS and CDC on that unit.
Failure to Provide Adequate Supervision to Prevent Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for two residents. The facility policy stated residents would be assessed for wandering behavior or elopement within eight hours of admission and quarterly, and defined elopement as leaving the premises or a safe area without authorization. Resident R71 was admitted with diagnoses including history of traumatic brain injury, hemiplegia, and impulse disorder. An elopement risk assessment completed in March indicated the resident was not at risk because he was unable to leave the building without staff help, required assistance with locomotion, and did not wander. Despite this, a facility incident on August 18 documented the resident sitting in the dining room in front of his wheelchair, and the facility investigation later stated it was unknown how he got there and that he left his room via wheelchair and exited the floor without being seen. Resident R73 was admitted with diagnoses including dysphagia following cerebral infarction, hemiplegia, and muscle weakness. An elopement risk assessment completed in August also indicated the resident was not at risk because he was unable to leave the building without staff help, required assistance with locomotion, and did not wander. A facility incident on August 27 documented the resident sitting in the parking lot in front of his wheelchair. The investigation found he was assisted outside by a visitor who then informed staff that he was outside. During interview, the resident stated he was trying to go home when he left the facility, and his spouse stated she thought he followed her out after she left. The nursing home administrator confirmed the facility failed to provide adequate supervision to prevent elopement for these two residents.
Missing Order and Care Plan Interventions for Urostomy
Penalty
Summary
The facility failed to obtain a physician order for Resident R8’s urostomy and failed to include resident-centered interventions for the urostomy in the care plan. Facility policy for Suprapubic Catheter / Urological Device Care and Management dated 1/28/25 indicated that a physician order for the urological device is to be obtained, including the catheter size, frequency of catheter change, flushes, and routine care. Facility policy for Comprehensive Person-Centered Care Planning dated 1/28/25 indicated that a comprehensive person-centered care plan should include necessary and appropriate care, attending physician orders, services, and accommodations of resident needs and preferences within 21 days of admission. Resident R8 was admitted with diagnoses including cancer, scoliosis, and anxiety. The MDS dated 7/22/25 indicated that Resident R8 had an indwelling catheter and urostomy on admission. The care plan initiated 7/16/25 included interventions to monitor and document intake and output and to monitor, record, and report signs and symptoms of UTI, but it did not include interventions specific to the urostomy. During an interview on 9/26/25, the ADON confirmed that the facility failed to obtain a physician order for the resident’s urostomy and failed to provide a person-centered care plan with interventions for the urostomy.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS assessment for one hospice resident after the resident was admitted to hospice services. The resident was admitted to the facility with diagnoses including cancer, scoliosis, and anxiety, and a physician order dated 8/18/25 indicated the resident was admitted to hospice on 8/15/25. Review of the MDS record showed that a significant change MDS was not completed following the hospice admission. The RAI 3.0 User’s Manual states that a comprehensive assessment must be completed within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. During interview, the LPN Assessment Coordinator confirmed the facility failed to complete the significant change MDS within 14 days of the resident’s hospice admission.
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.
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 122 citations issued within 25 miles in the last 12 months — including the 2 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 Uniontown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Macrina Manor | 0.8 mi | ★★★★★ | 14 | 0 |
| Terrace Health & Rehab Center | 0.9 mi | ★★★★★ | 10 | 0 |
| Laurel Ridge Center | 2.2 mi | ★★★★★ | 2 | 1 |
| Uniontown Nursing And Rehab | 2.2 mi | ★★★★★ | 1 | 0 |
| Scottdale Healthcare & Rehabilitation Center | 16.9 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.