Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Maple Heights Health & Rehab Center, Llc during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer's disease, dependent on staff for all care needs, attempted to self-propel out of a room by grabbing another resident's bed. A nurse aide repeatedly grabbed and pushed the resident's hands off the bed, after which the resident became agitated and grabbed the aide's arm. The aide then struck the resident's left wrist with a fist, causing the resident to verbalize pain and later be found with small, deep purple bruises on both hands. Another aide witnessed the event and reported it, and the allegation of abuse was subsequently substantiated by facility leadership.
A resident admitted after a fall with a traumatic brain bleed consistently expressed a goal of remaining for LTC due to inability to manage stairs, living alone, and needing assistance with daily care, and this goal was documented by the IDT, social services, therapy, and a CRNP. Despite this, the resident later received a NOMNC and was discharged home without documented follow-up to address the change in plan or ensure safety. Therapy services were not timely updated about the shift from LTC to home discharge and did not provide training on home-related tasks or stair negotiation, even though the resident had multiple stairs at home. The case manager did not notify the insurer of the goal change, and the resident was discharged without written medication instructions specifying which medications to take, at what times and dosages, or which to discontinue.
The facility failed to secure water-absorbing beads, a known ingestion hazard, in an activity room on a dementia unit where residents wander, contrary to its own policy requiring supervised items to be locked. A cognitively impaired resident with dementia, dysphagia, and a care plan for wandering was independently mobile and later found in bed with the floor covered in water beads, coughing and spitting beads from the mouth. Around the same time, staff observed the activity room door open and the cabinet containing the beads unlocked. An LPN and RN assessed the resident, noting coughing, mucus, and abnormal lung sounds, and the resident was transferred to the hospital and admitted to the ICU.
Facility administration, including the NHA and DON, failed to carry out their defined responsibilities to organize and direct resources to ensure resident safety and quality care. Surveyors found that water-absorbing beads were not secured on a dementia unit, based on review of job descriptions, observations, and staff interviews. This failure meant the environment was not kept free of accident hazards as required under F689 and related state regulations, placing residents on the dementia unit at risk for serious harm and resulting in an Immediate Jeopardy finding.
The facility failed to keep essential kitchen equipment in safe operating condition when the dishwasher was observed out of service and not functioning properly. The ADM confirmed it had not been used since late October and that meals were being served on Styrofoam products.
A resident reported that meals were often served cold and of poor quality. During observation, food was delivered in Styrofoam containers and measured below the required temperature, with fried chicken at 127.0°F and spinach at 122.9°F. The meal components lacked seasoning and flavor, and the Assistant Dietary Manager confirmed food should be served at correct temperatures and be palatable.
Failure to Report Medication Omission Incidents as Alleged Abuse: The facility did not report multiple medication omission events to the DOH as required by policy and state law. Residents with conditions including BPH, glaucoma, seizures, MS on hospice, diabetes, Parkinson’s disease, stroke, CKD on dialysis, and pain management needs missed scheduled meds or blood glucose checks due to nurse omission. The DON confirmed the errors were not reported and should have been.
Inaccurate MDS coding was found for multiple residents after review of clinical records, MARs, physician orders, and the RAI manual. Errors included coding a trunk restraint without documentation, failing to code antiplatelet medication and dialysis, incorrectly coding antipsychotic, antibiotic, insulin, and wander/elopement alarm use, and omitting dialysis and alarm use when they were documented. The DON and NHA confirmed several of the coding errors during interview.
QAPI Committee Failed to Correct Repeated Deficiencies: The facility’s QAPI committee did not successfully implement prior plans of correction tied to repeated deficiencies involving resident rights, environment, reporting of alleged violations, MDS accuracy, care planning, quality of care, accident hazards, and essential equipment. Prior plans relied on audits and reporting results to QAPI, but the current survey found the same issues remained unresolved.
Failure to Inform Before Psychotropic Medication Use: Two residents had psychotropic medications started without documented evidence that the resident or representative was informed in advance of the risks, benefits, and treatment alternatives. One resident with COPD and anxiety was started on hydroxyzine, and another resident with schizophrenia and moderate cognitive impairment was started on Secuado. The NHA confirmed the lack of documentation.
Call Bell Not Within Resident’s Reach: A resident who required staff assistance for daily care needs was observed leaning forward across her bed from a chair to reach a call bell that was placed out of reach. The resident told the surveyor she could not reach the call box and needed to call for a nurse. An RN stated the resident could not self-propel in her chair and the call bell should have been within reach; the NHA confirmed it should have been within reach while she was in her room.
Dirty Bed Enablers: A resident who was cognitively intact, highly hearing impaired, and had a stroke with residual R-sided weakness was observed resting in bed while the bilateral enablers on the bed had a thick blackish/brown removable substance on them, especially the inside of the left enabler. An LPN confirmed the enablers had a large amount of removable dirt and grime, and the DON confirmed they should have been clean.
Failure to develop a baseline care plan within 48 hours of admission for a resident with seizure meds, PRN pain medication, and a wanderguard. The resident was admitted from the hospital and received levetiracetam, tramadol, and daily wanderguard use, but there was no documented individualized interim care plan for these immediate needs; the DON confirmed the baseline care plans were not completed.
Failure to Develop Individualized Care Plans for Pain and Antidepressant Use: The facility did not have active, individualized care plans for two residents’ identified needs. One resident had chronic pain, almost constant pain, and orders for scheduled and PRN opioid analgesics, but no documented care plan for pain management or pain meds. Another resident had cognitive impairment and dementia with an order for sertraline, but no documented care plan for antidepressant use. The NHA confirmed the missing care plans.
Care plans were not revised to match the current care needs of four residents. One resident’s plan did not include a bed positioning wedge ordered for use in bed, another resident’s plan did not reflect dycem added after a fall and tibia fracture, and two residents’ plans still listed antipsychotic, antianxiety, antidepressant, and oxygen therapy interventions that were no longer being provided. The DON and NHA confirmed the discrepancies.
Failure to Follow Medication and Treatment Orders: Multiple residents had missed scheduled meds, meds given when they should have been held, and treatments not completed as ordered. Examples included a resident receiving Midodrine despite SBP being above the hold parameter, several residents missing afternoon doses of ordered meds such as tamsulosin, Neurontin, buspirone, Parkinson’s meds, insulin, Lyrica, and oxycodone, and one resident not receiving ordered skin treatments or documented barrier cream application; the DON and NHA confirmed the order failures.
Fall Prevention Interventions Missing for Two Residents: Two residents with documented fall risk, cognitive impairment, and other medical conditions did not have ordered fall-prevention measures in place. One resident’s bed was not in the lowest position and lacked ordered mats and other safety devices, while another resident did not have the ordered positioning wedge or bilateral fall mats. The RN Supervisor, Nurse Aide, and DON confirmed the missing interventions.
A facility failed to ensure dialysis emergency kits were at the bedside for two residents receiving hemodialysis. One resident was cognitively intact and had a hemodialysis port in the chest, and the other was cognitively impaired with a hemodialysis port in the chest; both were observed without emergency equipment at bedside. An LPN and the DON confirmed the kits should have been in place.
Medication administration error rate exceeded the allowed threshold after surveyors observed two errors in 27 opportunities. An LPN gave a resident Breo Ellipta without having the resident rinse his mouth as ordered and directed by the manufacturer, and another LPN gave a resident 10 mg of Citalopram instead of the ordered 20 mg. The DON confirmed both errors.
Failure to Obtain Ordered Laboratory Tests: Staff did not obtain ordered lab studies for three residents. One resident with dementia, urinary incontinence, anticoagulant use, and hematuria had a UA C&S ordered after blood was noted in the toilet and blood-tinged urine was documented, but there was no evidence the test was completed. Two other residents had standing orders for periodic LFTs, but there was no documented evidence that the tests were obtained.
Food storage and kitchen sanitation were not maintained in accordance with policy. A block of sliced cheese was found in the freezer without a date or label, and the Dietary Manager confirmed it should have been labeled and dated. Surveyors also observed loose ceiling tile, peeling paint above clean pans, dust on a fan blowing onto clean cups, and unlabeled food in pantry refrigerators/freezers with missing thermometers and temperature logs; the DON confirmed refrigerator temps should have been logged.
The facility failed to obtain required hospice records from the contracted hospice provider for four residents receiving hospice services. Missing items included the hospice election of benefits, physician certification of terminal illness, hospice POC, and current nursing or nurse aide documentation; the DON and NHA confirmed the records were not in the chart.
Improper medication handling and soiled linen storage: An LPN dropped a gabapentin capsule on a medication cart, picked it up with a bare hand, and administered it to a resident despite the cart surface being unclean and drinks being on the cart. In a separate observation, soiled linen and clothing were found on the floor in a resident room instead of being bagged and placed in the soiled linen container.
A resident who was cognitively impaired, required staff assistance for eating, and was on a texture modified diet did not have meal intake documented for multiple breakfast meals as required by facility policy. The lack of documentation was confirmed by the administrator and was not in accordance with established procedures.
A resident with multiple medical conditions experienced a fall and was subjected to verbal abuse by an LPN, who told the resident they could remain on the floor using inappropriate language. The incident was witnessed and confirmed by staff and the resident, violating the facility's abuse prevention policy and resident rights.
A resident with multiple medical conditions experienced a fall and was subjected to abusive language by an LPN, as witnessed by staff and reported by the resident. The incident, which met the criteria for mandatory reporting under state law and facility policy, was not reported to the Department of Health or other required agencies, and the DON was unaware of the reporting obligation.
A resident with dementia and cognitive impairment, who required staff assistance, was transported in a wheelchair without the physician-ordered bilateral elevating leg rests. The nurse aide responsible confirmed the leg rests were not applied as required, and the administrator acknowledged this failure to follow the care plan.
A resident with recent hospital admission and a history of substance use was able to leave the facility undetected after being last seen around noon. Staff did not notice the absence until a lunch tray was untouched for over two hours, and the receptionist had seen the resident leave but mistook him for an employee. The facility's elopement protocol was not activated promptly, and the resident was later found several miles away and taken to the hospital.
The facility did not meet required nurse aide and LPN staffing ratios on several shifts, with multiple days where the number of NAs and LPNs scheduled was below regulatory minimums. Additionally, the facility failed to provide the minimum required hours of direct resident care per day on several occasions, as confirmed by the Nursing Home Administrator and facility records.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
A resident with anxiety and behavioral concerns was not monitored according to physician-ordered 15-minute safety checks. Staff failed to visually observe and document the resident's status as required, and an agency nurse aide was unaware of the safety check order due to incomplete shift reporting and lack of computer access.
Soiled linen and a soiled brief were found on the floor in a resident room without staff present. Facility policy requires all used linen to be bagged at the point of care and placed in a soiled linen container. Both an RN and the DON confirmed that the items should not have been left on the floor and should have been handled according to infection control protocols.
Due to inadequate dietary staffing, several residents reported receiving meals on styrofoam plates with plastic silverware on random occasions, including during breakfast, as confirmed by the Assistant Nursing Home Administrator. This practice was directly linked to low kitchen staffing levels.
A resident with quadriplegia and cognitive impairment developed a new open area on the buttock, initially treated for moisture-associated skin damage. When the wound worsened, new orders for Hydrofera blue were not promptly implemented, and the resident continued to receive the previous treatment for two days. Nursing staff confirmed the delay in updating the treatment orders, resulting in the resident receiving incorrect wound care.
Multiple residents' wheelchairs were found with significant accumulations of removable dust, dirt, and grime on their metal supports, wheels, and seat cushions. Staff interviews confirmed that cleaning these wheelchairs was the responsibility of housekeeping, but a reduction in staff made it difficult to maintain cleanliness. Facility leadership acknowledged that the wheelchairs should have been clean.
A resident was observed self-administering multiple medications at bedside without staff supervision, despite lacking a physician's order, evaluation, or care plan for self-administration. Nursing staff and the administrator confirmed that the required assessment and authorization were not completed, and medications should not have been left at the bedside.
A resident with cognitive impairment was placed at risk when a van driver, who appeared drowsy and was later found to have a blood alcohol level of 0.122 percent, began to fall asleep and swerve off the road during transport to a medical appointment. The nurse aide escorting the resident intervened and returned to the facility, where the incident was reported to supervisory staff.
A resident with a history of heart issues and dementia was mistakenly given another resident's medications by an LPN, leading to a significant drop in blood pressure and subsequent ICU admission. The error involved multiple medications not prescribed to the resident, highlighting a failure to follow the facility's medication administration policy.
The facility failed to prevent abuse and neglect among residents, as evidenced by incidents involving three residents. A resident with dementia reported neglect by a nurse aide, which was substantiated. Another resident with severe dementia was involved in multiple altercations with other residents, leading to substantiated abuse findings. A third resident, with cognitive impairment, hit another resident with a wheelchair footrest, also resulting in a substantiated abuse finding.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in recorded treatments and medications. For example, a resident's assessment did not reflect the administration of gabapentin, while another's failed to indicate hemodialysis treatments. Additionally, inaccuracies were found in the documentation of vaccine offerings and the administration of anti-anxiety and anticonvulsant medications.
The facility failed to update care plans for several residents to reflect changes in their care needs, such as code status, infection control precautions, medication changes, and hospice services. Staff interviews confirmed the lack of documentation in the care plans.
A facility failed to provide adequate activities for a resident with hemiplegia and dysphagia following a stroke. Despite a care plan requiring one-to-one in-room activities, there was no documentation of such activities occurring over several weeks. The resident's spouse noted a lack of in-room activities, and the Activities Director confirmed the absence of documented visits.
The facility failed to document the disposal of controlled medications for two residents. One resident's fentanyl patch disposal was not properly documented by two nurses as required, and another resident's Ativan disposition was not documented upon discharge. These actions were confirmed by the facility's nursing leadership.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies such as failure to prevent resident abuse, timely assessments, and proper medication management. Despite plans of correction, the committee was ineffective in addressing these issues.
The facility failed to maintain essential kitchen equipment in safe operating condition, with issues such as a leaking dishwasher and steam kettle, and several other pieces of equipment out of service for extended periods. Despite these problems, alternate cooking equipment was used, and there were no adverse effects on meal service.
The facility failed to maintain the fire alarm system according to NFPA standards, as they could not provide documentation for a required semiannual visual inspection. An interview with the Facility Administrator and Maintenance Director confirmed the absence of this documentation, indicating a lapse in adherence to fire safety maintenance protocols.
Maple Heights Health and Rehab Center failed to maintain the dignity of a resident by not ensuring proper hygiene assistance. A resident, who required help with daily living activities, was observed with visible facial hair that had not been addressed. The facility lacked a policy for facial hair removal preferences, and staff did not document any inquiry into the resident's preferences. The DON confirmed the absence of a specific protocol for such situations.
A resident was not informed of their medical appointments in advance, despite previous concerns and agreements to provide notice. The resident discovered an appointment through their patient portal, and the DON confirmed the lack of documentation and communication with the resident.
A resident filed a grievance about not receiving medication and care, which was not addressed in a timely manner. The grievance was filed on one date but not assigned until much later, with no evidence of a thorough investigation or resolution communicated to the resident until over a month later. The facility failed to document ongoing efforts to resolve the grievance, leading to a deficiency in grievance handling procedures.
Physical Abuse of Cognitively Impaired Resident by Nurse Aide
Penalty
Summary
The facility failed to protect a resident from abuse when a nurse aide physically struck the resident during an interaction in the resident's room. Facility policy dated September 23, 2025, stated that abuse, neglect, mistreatment, exploitation, and misappropriation of resident property would not be tolerated. Resident 2 had an admission MDS dated December 7, 2025, indicating cognitive impairment, dependence on staff for all care needs, and a diagnosis of Alzheimer's disease. On December 15, 2025, at approximately 6:11 p.m., during supper, the resident attempted to self-propel out of the room and grabbed another resident's bed to assist with movement. According to a nurse's note and an event report, Nurse Aide 2 responded by grabbing the resident's hands to make him let go of the bed and pushing him away, which caused the resident to become agitated and again grab the bed. A witness statement and interview with Nurse Aide 1, who observed the incident, revealed that after the resident again grabbed the bed, Nurse Aide 2 forcefully removed the resident's hands, leading the resident to grab the aide's arm and tell him to stop. Nurse Aide 2 then removed the resident's hands from his arm and struck the resident's left wrist with his fist, after which the resident said, "ouch that hurt" and held his arm. Nurse Aide 2 then pushed the resident out of the room into the lounge. A subsequent skin check documented small, deep purple bruises on both of the resident's hands, though the resident was able to move both hands without signs or symptoms of pain or swelling. The regional director of clinical services later confirmed that the allegation of abuse by Nurse Aide 2 toward this resident was investigated and substantiated.
Failure to Align Discharge Planning With Resident Goals and Provide Complete Discharge Instructions
Penalty
Summary
The facility failed to develop and implement a discharge planning process that aligned with a resident's stated goal of remaining for LTC and failed to provide complete discharge instructions, including medication times and dosages. The resident was admitted after a fall at home resulting in a traumatic brain bleed and was assessed as cognitively intact but needing assistance with daily care. A comprehensive MDS and care plan documented that his goal was LTC placement. Social services notes, a CRNP note, and an interdisciplinary team meeting all recorded that the resident did not want to return to his prior living arrangement due to inability to manage stairs, living alone, and being unable to care for himself, and that he was willing to apply for state insurance to stay for LTC. Subsequently, social services documented that the resident was issued a NOMNC and would discharge home, but there was no evidence in the clinical record that the facility followed up with the resident or family regarding this change in plan to ensure his safety upon discharge. Therapy assessments and goals remained focused on LTC, and the Rehab Program Manager confirmed that therapy was not notified of the change in goal until shortly before discharge and had not worked with the resident on home-related tasks such as housework, cooking, laundry, or stair training, despite knowing he had 12 stairs at home. The case manager did not inform the insurer that the resident’s goal had changed from LTC to going home, and the Nursing Home Administrator acknowledged that the resident was discharged without written instructions listing his medications, including times, dosages, and which medications to discontinue.
Unsecured Water Beads on Dementia Unit Lead to Resident Ingestion and ICU Transfer
Penalty
Summary
The deficiency involved the facility’s failure to keep water-absorbing beads, an identified choking and obstruction hazard, securely stored on a dementia unit where residents wander. Facility policy required that items needing close supervision be stored in locked cabinets or other secure areas, with cabinets locked when not in active use. Manufacturer instructions and a U.S. Consumer Product Safety Division warning specified that water beads can expand significantly when ingested and pose a serious medical emergency, including life-threatening intestinal blockages or choking. Despite these known hazards and policies, the water beads used for activities were kept in a cabinet in the north lounge activity/dining room on the dementia unit and were not secured. Resident 1, who had dementia, cognitive impairment, dysphagia, and a care plan indicating wandering behavior and the need for a secure environment, was independently mobile on the unit. On the night of the incident, a nurse aide observed the resident in bed at approximately 2:15 a.m. with nothing unusual noted. During 5:00 a.m. rounds, two nurse aides entered the resident’s room and found the resident in bed with the floor covered in water beads. The resident was coughing and spitting water beads out of his mouth. One aide went to get the LPN, and neither aide reported seeing the resident access any items. At about the same time, one of the nurse aides noticed that the north lounge activity room door was open, the light was on, and the cabinet where the water beads were kept was open. When the LPN arrived to assess the resident, she observed the resident coughing up water beads and mucus, with stable vital signs but bilateral rattling lung sounds, and notified the RN. The RN’s assessment documented that the resident was awake, alert with confusion, spitting up water beads, with even, unlabored respirations, cough, and diminished lung sounds with congestion. The DON later confirmed that the water beads had been unsecured in the north lounge activity/dining room on the dementia unit and that it was unknown how many beads the resident had ingested. The resident was transferred to the hospital and admitted to the intensive care unit.
Removal Plan
- Removed the water beads from the facility.
- Identified residents that have the potential to be affected.
- Completed a house review of rooms and lounges for any foreign objects and any other items that would pose a similar issue.
- Provided education to nursing and activities staff on removing items that would pose a potential risk for residents to ingest.
- Locked and secured all activity cabinets.
- Educated newly hired staff on removing items that would pose a potential risk for residents to ingest.
- Will monitor and maintain ongoing compliance.
- Director of Nursing or designee will complete observation audits to ensure items that have potential to be ingested are removed and activity cabinets are locked.
Failure of Administration to Control Environmental Hazard on Dementia Unit
Penalty
Summary
The deficiency involves the facility administration, specifically the Nursing Home Administrator (NHA) and Director of Nursing (DON), failing to effectively use facility resources to promote resident safety and maintain residents’ highest practicable physical well-being. Review of the NHA’s job description, dated September 23, 2025, showed that the NHA is responsible for leading, directing, and managing overall operations in accordance with applicable federal, state, and local regulations, and for organizing and directing resources to ensure quality care for each resident at all times. The DON’s job description, also dated September 23, 2025, indicated responsibility for organizing, developing, managing, and directing the Nursing Service Department in compliance with regulatory standards, and working directly with the Administrator and Medical Director to ensure the highest degree of quality care, including following all health, sanitary, and infection control policies and established nursing standards of practice. Based on review of employee job descriptions, observations, and staff interviews, surveyors determined that the NHA and DON did not fulfill these essential duties because they failed to ensure that water-absorbing beads were secured. This failure occurred on the dementia unit and resulted in the residents’ environment not being kept free of accident hazards, as required under 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices). The unsecured water-absorbing beads placed residents on the dementia unit at risk for serious harm and created an Immediate Jeopardy situation. The deficiency was also cited under 28 Pa. Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Kitchen Dishwasher Not Functioning Properly
Penalty
Summary
The facility failed to ensure that essential equipment was in safe operating condition in the kitchen. During observation of the kitchen, the dishwasher was not in use and was not functioning properly, and there was no evidence of a confirmed plan to repair or replace it before the initial kitchen tour. In an interview, the Assistant Dietary Manager confirmed that the dishwasher had not been used because it was not functioning properly and stated that it had been out of service since October 25, 2025, with meals being served on Styrofoam products since then.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food that was both palatable and at appetizing temperatures, as required by its own policy. The policy specified that hot foods should be at least 135 degrees Fahrenheit when plated and remain palatable at the point of delivery, with the use of appropriate hot/cold holding equipment and prompt transportation to maintain temperature. However, observations during a lunch meal service revealed that food was served in Styrofoam containers, and a test tray delivered to the third floor showed the fried chicken at 127.0 degrees F and the spinach at 122.9 degrees F, both below the required temperature. Additionally, the fried chicken had a hard border, and the mashed potatoes, seasoned spinach, and cornbread were noted to lack seasoning and flavor. A resident interviewed reported that the quality and quantity of food served was poor, and that hot foods were often served cold. The recipes used for the meal in question were minimal in seasoning, with the seasoned spinach only containing salt, the mashed potatoes containing minced garlic, margarine, and salt, and the cornbread being made from a mix with water added. The Assistant Dietary Manager confirmed that food should be served at correct temperatures and be palatable, but the observations and resident feedback indicated that this standard was not met.
Failure to Report Medication Omission Incidents as Alleged Abuse
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported to the State Survey Agency and other required state agencies in accordance with state law for 10 residents. The report cites the Older Adult Protective Services Act and the facility’s abuse policy, which required immediate reporting of suspected abuse, neglect, injuries of unknown source, and misappropriation of resident property to the appropriate authorities. The facility’s policy also stated that the administrator or designee would provide a written report to the Department of Health within five calendar days of the incident. The cited events involved medication omissions for multiple residents with significant medical needs. Resident 3, who was cognitively intact and had benign prostatic hyperplasia, did not receive scheduled tamsulosin. Resident 40, who was cognitively intact and dependent for care with seizures and glaucoma, missed doses of artificial tears, brimonidine eye drops, and Neurontin. Resident 44, who was cognitively impaired and had stroke, seizure disorder, dysphagia, and GERD, did not receive a scheduled dose of metoclopramide. Resident 46, who was cognitively impaired, dependent for care, on hospice, and had multiple sclerosis, missed scheduled acetaminophen, diazepam, promethazine, and senna. Additional residents were also affected by omitted medications. Resident 52, who was cognitively intact with stroke, anxiety, and depression, missed an afternoon dose of buspirone. Resident 87, who was severely cognitively impaired and dependent for care with coronary artery disease, heart failure, diabetes, and Parkinson’s disease, missed afternoon doses of baclofen, carbidopa-levodopa-entacapone, entacapone, carvedilol, and tums. Resident 96, who was cognitively intact and dependent for care with diabetes, did not have blood sugar checked and did not receive sliding-scale Humalog at the scheduled time. Resident 99, who was cognitively intact and dependent for care with osteoarthritis and stroke, missed afternoon doses of carbidopa-levodopa and clonazepam. Resident 115, who was cognitively intact and had end-stage kidney disease, diabetes, and dialysis, missed an afternoon dose of Lyrica. Resident 158, who was cognitively intact and had Parkinson’s disease and scheduled pain medication, missed an afternoon dose of oxycodone. The facility’s investigation determined the medication errors were due to omission by the nurse, and the DON confirmed that these errors were not reported to the Department of Health and should have been.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to complete accurate MDS assessments for seven residents, with survey review of the RAI User’s Manual, clinical records, and staff interviews showing multiple coding errors in sections related to restraints, medications, dialysis, and alarms. For Resident 2, the quarterly MDS coded trunk restraint use even though the medical record contained no documented evidence that a trunk restraint was used during the lookback period. The DON confirmed the coding error during interview. For Resident 4, physician orders and the MAR showed daily 81 mg aspirin use and no antipsychotic medication during the lookback period, yet the quarterly MDS did not code antiplatelet medication and instead coded antipsychotic use. For Resident 11 and Resident 115, physician orders included dialysis services, but their quarterly MDS assessments did not code dialysis in Section O0110J1. For Resident 16, the physician ordered use of a wanderguard and the MAR showed use throughout the month, but the quarterly MDS coded the wander/elopement alarm as not used. For Resident 17, the MAR showed no antibiotic during the lookback period, but the significant change MDS coded antibiotic use. For Resident 157, there was no documented evidence of insulin administration during the lookback period, but the quarterly MDS coded insulin use. Staff interviews confirmed the inaccurate coding for each of these residents. The cited regulation was 28 Pa. Code 211.5(f), Clinical records.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed recurring problems identified in prior surveys. Based on review of the facility’s plans of correction from the annual survey ending January 30, 2024, and complaint surveys ending January 26, April 8, June 16, July 2, July 31, and August 27, 2025, the facility had developed plans that called for quality assurance systems and audits to maintain compliance with cited nursing home regulations, with results to be reported to the QAPI committee for review. The current survey ending November 20, 2025 identified repeated deficiencies related to the right to be informed/make treatment decisions, safe, clean, comfortable homelike environment, reporting of alleged violations, accuracy of assessments, development and implementation of comprehensive care plans, care plan timing and revision, quality of care, free of accident hazards/supervision/devices, and essential equipment safe operating condition. The survey found that the QAPI committee failed to successfully implement the facility’s prior plans regarding the safe, clean, comfortable and homelike environment, reporting of alleged violations, accurate MDS assessments, comprehensive care plans, care plan timing and revision, quality of care, safety/accident hazards, and essential equipment safe operating condition.
Failure to Inform Residents or Representatives Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform the resident representative in advance of the risks and benefits of psychotropic medication use and the treatment alternatives prior to initiating medication for two residents. One resident was cognitively intact, required staff assistance with daily care needs, and had a diagnosis of COPD. That resident had an order for hydroxyzine hydrochloride 25 mg three times a day as needed for anxiety after a nurse documented increased anxiety and inability to be redirected with therapeutic distraction activities. The record did not contain documented evidence that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives before hydroxyzine hydrochloride was started. A second resident was moderately cognitively impaired, could usually make needs known, received antipsychotic medications, and had a diagnosis of schizophrenia. Physician orders included Secuado 3.8 mg/24 hours transdermal patch daily. The clinical record did not contain documented evidence that the resident or the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Secuado. The Nursing Home Administrator confirmed that there was no documented evidence in either resident's record showing that this information had been provided before the medications were started.
Call Bell Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that a call bell was within reach for one resident. The facility policy titled Call Light Resident Communication System stated that residents should be provided a means of communicating with staff and that when a resident is in bed or confined to a chair, the call light should be within easy reach. Resident 18’s admission MDS dated October 30, 2025, indicated that the resident could make herself understood, could understand others, required staff assistance for daily care needs, and had a diagnosis of noninfective gastroenteritis and colitis. During observation on November 17, 2025, at 1:44 p.m., Resident 18 was sitting in a chair on the left side of her bed facing the wall and leaning forward across the bed to reach her call bell, which was on the upper right side of the bed. When the surveyor entered the room, the resident asked for help reaching her call box because she could not reach it and needed to call for a nurse. RN 1 stated that Resident 18 could not self-propel in her chair and that the call bell should have been within her reach. The NHA later confirmed that Resident 18 should have had a call bell within reach while in her room.
Dirty Bed Enablers
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident. Resident 142 had a quarterly MDS assessment dated September 5, 2025, showing the resident was cognitively intact, usually understood and understands, was highly hearing impaired, and had diagnoses including a stroke with residual right-sided weakness. During observations on November 17, 2025, at 12:17 p.m. and on November 18, 2025, at 8:45 a.m. and 2:35 p.m., the resident was lying in bed resting, and the bilateral enablers on the bed were observed to have a thick amount of blackish/brown removable substance on them, especially on the inside aspect of the left enabler. An LPN stated that the resident frequently used the enablers to assist in positioning herself and confirmed that both enablers, especially the left one, had a large amount of removable dirt and grime on them. The DON also confirmed that the resident's bilateral enablers should be clean and were not.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for one resident after admission. The facility policy on Comprehensive Care Plans, dated September 23, 2025, stated that an interdisciplinary plan of care was to be established and updated as indicated for every resident in accordance with state and federal regulatory requirements, and that an interim care plan was to be developed within 48 hours of admission so the resident's needs would be met until a comprehensive care plan was completed. A nursing note documented that the resident was admitted from the hospital on November 13, 2025, at 7:45 p.m. Physician orders dated November 13 and 14, 2025 included levetiracetam 500 mg twice daily for seizures, tramadol 50 mg every six hours as needed for pain, and a wanderguard bracelet for safety. The MAR showed the resident received levetiracetam from November 13 through 20, tramadol as needed from November 14 through 20, and used a wanderguard daily from November 14 through 20, but there was no documented evidence of individualized interventions developed within 48 hours of admission to address seizure/anticonvulsant medication needs, pain, or wanderguard use. The DON confirmed there were no baseline care plans for these needs and that they should have been.
Failure to Develop Individualized Care Plans for Pain and Antidepressant Use
Penalty
Summary
The facility failed to develop comprehensive care plans with specific, individualized interventions for two residents. For Resident 18, the admission MDS dated October 30, 2025, showed the resident could make herself understood and understand others, needed staff assistance with daily care needs, received routine and PRN pain medication, had almost constant pain, and had a diagnosis of noninfective gastroenteritis and colitis. Physician orders dated October 24, 2025, directed Belbuca 450 mcg twice daily for chronic pain and hydrocodone-acetaminophen 5-325 mg every eight hours as needed for pain, but there was no documented care plan addressing the resident’s chronic pain or use of pain medications. For Resident 38, the significant change MDS dated August 29, 2025, indicated cognitive impairment, need for assistance with daily care needs, and a diagnosis of dementia. Physician orders dated October 15, 2025, directed sertraline 100 mg daily, but there was no documented care plan addressing the resident’s care and treatment needs related to antidepressant use. The Nursing Home Administrator confirmed on November 19, 2025, that there was no active care plan for either resident’s identified needs.
Care Plans Not Updated to Match Residents’ Current Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents’ specific care needs for four residents. Resident 23 had a quarterly MDS showing moderate cognitive impairment, needed staff assistance with daily care tasks, and had diagnoses including malignant melanoma of the left upper limb and shoulder. Physician orders included a bed positioning wedge along the resident’s left side from the hip down while lying in bed, but the resident’s care plan, last reviewed and revised before that order, only addressed fall risk related to muscle wasting and weakness and was not updated to include the wedge. Resident 28 had moderate cognitive impairment, used a wheelchair, had recent falls, and had dementia. After an unwitnessed fall in the bathroom, the resident slid out of the wheelchair, complained of knee pain, and was diagnosed with a left tibia fracture; dycem was added to the top of the wheelchair cushion to prevent further sliding, but the care plan did not include this intervention. Resident 38 had cognitive impairment and dementia, and the care plan stated the resident was receiving an antipsychotic medication, but the MAR and nurses’ notes showed no evidence the resident was receiving it. Resident 129 was cognitively intact, needed assistance with daily care, and had diabetes and cancer; the care plan listed antianxiety medication, antidepressant medication, and supplemental oxygen therapy, but the MAR and nurses’ notes showed no evidence the resident was receiving those medications or oxygen therapy.
Failure to Follow Medication and Treatment Orders
Penalty
Summary
The facility failed to follow physician’s orders for medications and treatments for 12 of 51 residents reviewed. The deficiencies involved missed doses of scheduled medications, medications given when they should have been held, and treatments that were not completed as ordered. The report states that the Nursing Home Administrator and Director of Nursing confirmed multiple instances in which medications and treatments were not administered per the physician’s orders. Resident 4 had orders for Midodrine 5 mg three times daily with instructions to hold the medication if systolic blood pressure was greater than 110. The MAR showed Midodrine was administered on multiple occasions when the resident’s systolic blood pressure was above that threshold, including readings of 136, 124, 114, 118, 114, 124, 125, 115, 132, 126, 126, 123, 112, and 120. The Nursing Home Administrator confirmed that Midodrine was given on those dates and times when it should have been held. Several residents missed ordered medications during scheduled medication passes. Resident 3 did not receive tamsulosin; Resident 40 did not receive artificial tears, brimonidine eye drops, or Neurontin during an afternoon medication pass; Resident 44 missed a dose of metoclopramide; Resident 46 missed acetaminophen, diazepam, promethazine, and senna during an afternoon medication pass; Resident 52 missed an afternoon dose of buspirone; Resident 87 missed afternoon doses of baclofen, carbidopa-levodopa-entacapone, entacapone, carvedilol, and Tums; Resident 96 did not have blood sugar checked and did not receive sliding-scale Humalog at 4:00 p.m.; Resident 99 missed afternoon doses of carbidopa-levodopa and clonazepam; Resident 115 missed an afternoon dose of Lyrica; Resident 157 had no documented evidence of receiving scheduled oxycodone-acetaminophen on several ordered times; and Resident 158 missed an afternoon dose of oxycodone. For Resident 46, the TAR also showed the pressure ulcer preventative foam dressing was completed on dates that were not every 5 days as ordered, and there was no documented evidence that barrier cream was applied to prevent MASD. The resident later developed MASD. The DON confirmed that the medications and treatments for the 12 residents were not administered per the physician’s orders.
Fall Prevention Interventions Not in Place for Two Residents
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards by not having fall-prevention interventions in place for two residents whose care plans and physician orders identified them as being at risk for falls. The facility policy stated that residents at risk for falls were to be identified on admission, readmission, and quarterly, with interventions added to the care plan to address resident-specific safety needs. For Resident 15, the quarterly MDS showed severe cognitive impairment, use of a mechanical lift for transfers, a recent fall, and diagnoses including Alzheimer's dementia. Physician orders directed staff to keep the bed in the lowest position, use bilateral floor mats, bilateral assistive handrails, a bolster overlay, and a gap filler for the mattress, and the fall risk care plan identified the resident as at risk for falls related to dementia, psychotic disturbances, and anxiety. When Resident 15 was observed in bed, the bed was not in the lowest position and none of the ordered interventions were in place, including bilateral fall mats, bilateral assistive handrails, the bolster overlay, or the gap filler. The RN Supervisor confirmed the resident had been moved to a different room and verified that the ordered equipment was not present. For Resident 23, the quarterly MDS showed moderate cognitive impairment, use of a bariatric bed, need for assistance with bed mobility, and diagnoses including muscle weakness and malignant melanoma of the left upper limb and shoulder. Physician orders required a wedge for bed positioning along the left side from hip to foot while in bed and bilateral fall mats on either side of the bed, but observation showed the wedge was on the floor and no bilateral fall mats were in place. The Nurse Aide confirmed the wedge was not in the bed as ordered and that no fall mats were present, and the DON confirmed both residents should have had all fall-prevention interventions in place as ordered and care planned.
Dialysis Emergency Kits Missing at Bedside
Penalty
Summary
The facility failed to ensure that a dialysis emergency kit was at the bedside for two residents who required hemodialysis. A hemodialysis care policy dated September 23, 2025, stated that a smooth clamp should be kept at the bedside of a resident with a dialysis vascular access catheter in place. Resident 10’s admission MDS dated October 24, 2025, showed that she was cognitively intact and required hemodialysis, and physician orders dated October 18, 2025, included dialysis. When observed on November 20, 2025, Resident 10 was sitting beside her bed in a wheelchair with a hemodialysis port in her left chest, and there was no emergency equipment at her bedside. An LPN confirmed that the equipment was not in place and should have been. Resident 11’s quarterly MDS dated October 2, 2025, showed that she was cognitively impaired and required hemodialysis, and physician orders dated June 26, 2025, included hemodialysis. When observed on November 20, 2025, Resident 11 was sitting up in a broda chair with a hemodialysis port on her chest, and there was no emergency equipment at her bedside. An LPN confirmed that the equipment was not in place and should have been. The DON also confirmed that there should have been a dialysis emergency kit at the bedsides of Residents 10 and 11.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent. During observation of medication administration, surveyors identified two medication errors in 27 opportunities for error, resulting in a 7.41 percent medication administration error rate. The facility policy required staff to verify the correct medication, dose, route, rate, time, resident, and technique each time a medication was administered. For Resident 49, physician orders included Breo Ellipta 100 mcg/25 mcg inhalation powder, 1 puff orally daily, with instructions to rinse the mouth after each use. Manufacturer instructions and the printed box directions also stated to rinse the mouth with water and spit it out after administration. During observation, an LPN administered the inhaler but did not have the resident rinse his mouth afterward. For Resident 135, physician orders included Citalopram 20 mg once daily, but during observation an LPN administered only 10 mg. Both nurses confirmed the errors, and the DON confirmed that Resident 49 should have rinsed his mouth after the inhaler and Resident 135 should have received the ordered dose.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for three residents. Resident 12 had an admission MDS that showed cognitive impairment, frequent urinary incontinence, anticoagulant use, and a diagnosis of dementia. After nursing documented a moderate amount of bright red blood in the toilet and later blood-tinged urine, the CRNP was notified and a verbal order was received to hold Xarelto because of hematuria and obtain a UA C&S. There was no documented evidence that the UA C&S was obtained. Resident 46 had an MDS that showed cognitive impairment, dependence on staff for daily care, and diagnoses including high blood pressure, peripheral vascular disease, and multiple sclerosis. A physician ordered liver function tests to be completed on the 3rd day of January, April, July, and October, but there was no documented evidence that the tests were obtained. Resident 157 had an MDS showing cognitive intactness, independence with daily care, and a diagnosis of high cholesterol. A physician ordered liver function tests to be completed on the 1st Tuesday of March and September, but there was no documented evidence that the tests were obtained.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions. Review of the facility policy for refrigerated foods showed that foods prepared and held more than 24 hours were to be marked with the date they would be consumed or discarded, and that refrigerators used to store facility-purchased food were to have internal thermometers checked at least twice daily with temperature logs retained for one year. During observation of the main kitchen, a block of sliced cheese in a plastic bag was found in the reach-in freezer without a date or label indicating when it was opened, and the Dietary Manager confirmed that staff should have labeled and dated the bag. Additional observations in the main kitchen found a loose hanging ceiling tile, large pieces of loose paint hanging from the bulk head/duct work in the dishwasher room with clean pans stored below it, another large piece of loose paint hanging near the double doors leading to the hallway, and a large fan with dust and debris on the back cage blowing onto clean cups. In the fourth floor pantry, there was no temperature log for the refrigerator. In the third floor pantry, a full Dairy Queen Blizzard was in the freezer and a full box of pizza was in the refrigerator without labels or dates, and there was no thermometer in the refrigerator or temperature log for that unit. The DON confirmed that staff should have been logging the refrigerator temperatures.
Missing Hospice Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained required hospice information from the contracted hospice provider for four residents receiving hospice services. The report states that the facility and hospice provider were expected to work collaboratively and that the hospice provider would supply the most recent hospice plan of care, physician certification or recertification, the hospice election of benefits form, and updated nursing documentation, but these records were not present in the residents’ clinical records or the hospice provider’s records for the residents reviewed. Resident 17 was receiving hospice for protein malnutrition, Resident 23 for malignant melanoma of the left upper limb and shoulder, Resident 36 for hypertensive heart disease without heart failure, and Resident 46 for hospice services with a current certification period. For Resident 17, the election of benefits, certification of terminal illness, hospice plan of care, and current nursing documentation were not documented; for Resident 23, the election of benefits, certification of terminal illness, hospice plan of care, and up-to-date nurse aide charting were missing; for Resident 36, hospice nursing notes were not available; and for Resident 46, the election of benefits, certification of terminal illness, and most recent hospice plan of care were not documented. Interviews with the DON and NHA confirmed these records were not in the clinical record.
Improper medication handling and soiled linen storage
Penalty
Summary
The facility failed to ensure proper medication handling and infection control practices for one resident who was severely cognitively impaired and receiving gabapentin 300 mg in the morning. During medication administration, an LPN dropped the yellow gabapentin capsule onto the medication cart, picked it up with a bare hand, placed it in a medication cup, and administered it to the resident. The medication cart’s preparation area had a white removable substance on it, and there was a lidded iced coffee and a closed plastic bottle of iced coffee on the cart at the time of administration. When questioned, the LPN did not identify the handling of the capsule or the condition of the cart as a concern. The facility also failed to follow its linen handling practices. Soiled linen and clothing were observed lying on the floor inside a resident room with no staff present in the room or hallway. Staff interviews confirmed that the soiled items should not have been on the floor and should have been bagged and placed in the soiled linen container and taken to the dirty utility room. The nursing home administrator also confirmed that the soiled linen and clothing should not have been on the floor and that staff should place all laundry in bags and take them to the dirty utility room.
Failure to Document Meal Intake for Dependent Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who was cognitively impaired, dependent on staff for personal care, and had a diagnosis of dysphagia. According to facility policy, staff are required to document the provision of Activities of Daily Living (ADL) care, including actual meal consumption, each shift. However, a review of the resident's records showed that meal intakes were not documented for several breakfast meals in August and September 2025. The care plan specified that the resident required a texture modified diet and staff assistance at meals, but there was no evidence that meal intakes were recorded on the specified dates. The Nursing Home Administrator confirmed the lack of documentation for these meals, which was not in accordance with the facility's policy.
Failure to Protect Resident from Verbal Abuse by LPN
Penalty
Summary
A facility failed to protect a resident from verbal abuse by a staff member. According to the facility's abuse policy, all forms of abuse, neglect, and mistreatment are prohibited, and all allegations must be investigated. A cognitively intact resident with a history of falls, diabetes, atrial fibrillation, and seizures experienced a witnessed fall in the bathroom. Documentation and witness statements revealed that after the fall, an LPN told the resident that they could "stay on the f******g floor" and made similar statements, which were corroborated by both the resident and a nurse aide. The resident expressed that they did not want the LPN to care for them anymore. Interviews with the resident and facility staff confirmed the incident and the use of inappropriate language by the LPN following the resident's fall. The interim administrator substantiated that the LPN made the abusive statement. The facility's failure to ensure the resident was free from verbal abuse constituted a violation of resident rights and facility policy.
Failure to Report Alleged Abuse to State Agencies
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the required state agencies, including the Department of Health, Ombudsman, Protective Services, the resident's representative, and law enforcement, as mandated by state law and facility policy. The incident involved a resident who was cognitively intact and required staff assistance for daily care, with medical conditions including diabetes, atrial fibrillation, and seizures. After a witnessed fall in the bathroom, the resident and a nurse aide reported that an LPN told the resident to stay on the floor, using profane language, and the resident expressed that he did not want the LPN to care for him anymore. Despite the facility's policy requiring immediate reporting of all abuse allegations and the state law mandating such reports, the Director of Nursing was unaware of the reporting requirement, and the incident was not reported to any of the appropriate authorities. The deficiency was confirmed through review of facility policies, state law, clinical records, and staff and resident interviews.
Failure to Use Required Wheelchair Leg Rests During Resident Transport
Penalty
Summary
A deficiency was identified when a resident with cognitive impairment and a diagnosis of dementia, who required staff assistance for personal care, was transported in a wheelchair without the physician-ordered bilateral elevating leg rests. The resident's care plan specified the use of these leg rests for transport and when outside. During an observation, a nurse aide transported the resident from a common area to the resident's bedroom for lunch without applying the leg rests. The nurse aide confirmed that the leg rests were not used as required, and the nursing home administrator also acknowledged that the leg rests should have been applied according to the physician's order but were not.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Delayed Response
Penalty
Summary
Maple Heights Health and Rehab was found noncompliant with federal and state regulations after a complaint survey revealed that the facility failed to maintain an environment free of accident hazards for one resident. The facility's elopement policy required staff to conduct a head count and announce a code green if a resident was missing, with subsequent notifications to administration, the DON, and the attending physician, and to contact emergency responders if the resident was not found in a reasonable time. Despite these procedures, a resident with a recent history of hospital admission, housing instability, and substance use was able to leave the facility undetected. On the day of the incident, the resident was last seen by a nurse aide around noon. At 2:30 p.m., staff noticed the resident's lunch tray was untouched and that he had not been seen for over two hours. A search was initiated, and it was discovered that the receptionist had seen the resident leave the building at 12:30 p.m., mistaking him for an employee. The code green protocol was not activated until after this discovery, and the local police were notified. The resident was eventually found several miles away and taken to the hospital for evaluation. Interviews with staff revealed delays in recognizing the resident's absence and in activating the facility's elopement protocol. The administrator stated that the resident left against medical advice and did not consider it an elopement. However, the sequence of events and staff interviews indicated that the required supervision and timely response to a missing resident were not provided, resulting in the resident's unsupervised departure from the facility.
Plan Of Correction
Preparation and submission of this Plan of Correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding. Resident R2 no longer resides in the facility. To identify residents who have the potential to be affected, a review of resident elopement risk evaluations done in the last quarter will be conducted to ensure those at risk for elopement have appropriate interventions. To prevent recurrence, nursing staff was educated on the elopement policy and licensed nurses were educated on the Against Medical Advice discharge policy at the time of the event by the Director of Nursing/designee. To monitor and maintain compliance, the Director of Nursing/designee will audit 5 residents at risk of exit seeking to ensure interventions are in place weekly x 4 weeks and monthly x 2 months. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Meet Minimum Staffing Ratios and Direct Care Hours
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of nursing schedules, staffing information, and staff interviews. Specifically, there were eight days where the day shift did not meet the minimum of one NA per 10 residents, four days where the evening shift did not meet the minimum of one NA per 11 residents, and nine days where the night shift did not meet the minimum of one NA per 15 residents. On these days, the number of NAs scheduled was consistently below the required ratios based on the facility census, and no additional higher-level staff were available to compensate for the shortfall. The Nursing Home Administrator confirmed that all staffing hours were provided as documented and acknowledged the failure to meet the required ratios on the specified days. Additionally, the facility did not meet the minimum required Licensed Practical Nurse (LPN) staffing ratios for the night shift on two days. The census data indicated that the number of LPNs scheduled was below the required minimum of one LPN per 40 residents for the night shift, and again, no excess higher-level staff were available to make up for the deficiency. The Nursing Home Administrator confirmed the shortfall in LPN staffing for the identified days. The facility also failed to provide the minimum required hours of direct resident care per day for nine days within the review period. The nursing time schedules showed that the facility provided less than the required 3.20 hours of direct care per resident on these days, with the lowest being 2.84 hours. The Nursing Home Administrator confirmed the accuracy of the staffing information and acknowledged that the facility did not meet the required daily direct care hours on the specified days.
Plan Of Correction
There is no evidence that any resident was adversely affected. Current residents have the potential to be affected. The facility will schedule, monitor, and manage the nursing assistant staff ratios to meet the requirements. To prevent recurrence, the Nursing Home Administrator will review the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings will be held to review the scheduled staffing ratios and hours per patient day for the upcoming day(s) to ensure the facility plans to meet the requirements. To maintain and monitor compliance, the Nursing Home Administrator/designee will conduct audits of the nursing assistant staffing ratios to determine minimums were met weekly x4 and monthly x2. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations. There is no evidence that any resident was adversely affected. Current residents have the potential to be affected. The facility will schedule, monitor, and manage the hours per patient day to meet the requirements. To prevent recurrence, the Nursing Home Administrator will review the required ratios with the Director of Nursing and other staff responsible for nursing staff scheduling. Daily staffing meetings will be held to review the scheduled staffing ratios and hours per patient day for the upcoming day(s) to ensure the facility plans to meet the requirements. To maintain and monitor compliance, the Nursing Home Administrator/designee will conduct audits of the hours per patient day to determine minimums were met weekly x4 and monthly x2. Results of the audits will be forwarded to the center Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Complete Physician-Ordered 15-Minute Safety Checks
Penalty
Summary
The facility failed to ensure that physician-ordered 15-minute safety checks were completed for a resident with a diagnosis of anxiety and a history of behavioral issues, including inappropriate interactions with female residents. According to facility policy, staff are required to visually observe residents on 15-minute checks and document their status using an observation tool. The resident in question had a physician's order and nursing documentation indicating the need for 15-minute safety checks due to ongoing behavioral concerns. On the day of observation, the resident was seen resting in his room for a period of 44 minutes without any staff conducting the required safety checks. An agency nurse aide, who entered the room during this time, was unaware of the safety check requirement and reported that this information was not provided during shift report. The aide also noted she was unable to access the computer system to review orders. The Director of Nursing confirmed that staff should have been conducting and documenting the 15-minute checks as per policy and physician orders.
Improper Handling of Soiled Linen
Penalty
Summary
Surveyors observed soiled linen and a soiled brief lying on the floor inside a resident room, with no staff present in the room or hallway at the time. According to the facility's environmental services policy for laundry, all used linen is to be handled as potentially contaminated, bagged at the point of care, and placed in a soiled linen container in the soiled utility room or laundry chute. Interviews with a registered nurse and the Director of Nursing confirmed that the soiled linen and brief should not have been left on the floor and should have been properly bagged and transported according to policy. This failure to follow established infection control practices for handling linen constituted a deficiency under the cited regulation.
Insufficient Dietary Staffing Led to Use of Disposable Meal Service Items
Penalty
Summary
The facility failed to provide sufficient dietary staff to perform essential kitchen duties, resulting in residents being served meals on styrofoam plates with plastic silverware on random days without explanation. Multiple residents reported receiving their meals in this manner, with one resident stating it occurred about half the time and specifically noting it happened during breakfast on the day of the interview. The Assistant Nursing Home Administrator confirmed that plastic silverware was provided for breakfast due to low staffing in the kitchen. These findings indicate that inadequate staffing in the dietary department led to the use of disposable meal service items for residents.
Failure to Timely Update Pressure Ulcer Treatment Orders
Penalty
Summary
A resident with quadriplegia, traumatic brain injury, and cognitive impairment was identified as having a new open area on the right lower buttock, initially assessed as moisture-associated skin damage. The care plan included cleansing the wound, applying medihoney, and covering with an adhesive foam dressing. Despite a wound healing consult noting the area was worsening, there was no documented evidence that the new treatment order to use Hydrofera blue was initiated promptly. The Treatment Administration Record showed that the wound treatment was not updated in a timely manner, and the resident continued to receive the previous treatment for two days after the new order was given. Interviews with the Director of Nursing and a Registered Nurse confirmed that the orders for the resident's worsening wound were not updated as required, resulting in the resident receiving the incorrect treatment. This failure to provide timely and appropriate pressure ulcer care was identified during a review of clinical records and staff interviews, constituting a deficiency under 28 Pa. Code 211.12(d)(5) Nursing Services.
Failure to Maintain Clean and Homelike Environment Due to Unclean Wheelchairs
Penalty
Summary
The facility failed to provide a clean and homelike environment for five residents, as evidenced by observations of their wheelchairs, which were found to have moderate to large accumulations of removable, dried-on debris, dust, dirt, and grime on various parts including the metal supports, wheels, and seat cushions. These conditions were directly observed by surveyors during their review, with each of the five residents' wheelchairs exhibiting visible, removable contaminants that had not been addressed. Interviews with staff, including LPNs, nurse aides, and housekeepers, confirmed that the wheelchairs should have been clean and that it was the responsibility of housekeeping to maintain their cleanliness. Staff indicated that a reduction in housekeeping personnel had made it difficult to keep up with cleaning tasks, and the nursing home administrator acknowledged that the wheelchairs should not have had dust, dirt, or debris present.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
Facility staff failed to determine if a resident was safe to self-administer medications, as required by facility policy and regulatory standards. The policy stated that residents wishing to self-administer medications must have a physician's order and an evaluation to determine their capability. Review of the resident's clinical record showed no physician's order for self-administration, no documented evaluation of the resident's ability to self-administer medications, and no care plan addressing this issue. During an observation, the resident was found taking medications at her bedside without staff supervision. The medications included several tablets of varying shapes and colors. Interviews with nursing staff and the Nursing Home Administrator confirmed that the resident had not been evaluated for self-administration and did not have the necessary physician's order, and that medications should not have been left at the bedside.
Resident Placed at Risk During Transport by Impaired Van Driver
Penalty
Summary
A deficiency occurred when a resident, who was cognitively impaired and had communication limitations, was being transported to an orthopedic appointment. The nurse aide escorting the resident reported that the van driver arrived late, appeared drowsy, and drove the van at an unusually slow speed. During the trip, the driver began to fall asleep and swerved off the road, prompting the nurse aide to fabricate a story about the appointment being canceled in order to return safely to the facility. Upon return, the nurse aide immediately reported the incident to supervisory staff. A reasonable suspicion report documented that the van driver exhibited signs of intoxication, including sleepiness, bloodshot and droopy eyes, slurred speech, and difficulty standing. A subsequent blood alcohol test confirmed the driver had a blood alcohol level of 0.122 percent while responsible for transporting the resident. This incident demonstrated a failure to maintain an environment free of accident hazards and to provide adequate supervision to prevent accidents during resident transportation.
Medication Error Leads to ICU Admission
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who received another resident's medications. This error occurred when an LPN confused the resident with another and administered a series of medications not prescribed to them. The medications included aspirin, tamsulosin, vitamin-b, depakote, buspar, Plavix, Cymbalta, folic acid, docusate, gabapentin, lisinopril, memantine, ingrezza, Seroquel, and lopressor. The facility's policy for medication administration required that medications be administered according to physician orders, which was not followed in this instance. The resident involved had a medical history that included non-ischemic myocardial injury, dementia, encephalopathy, atrial fibrillation, and heart failure. Following the administration of the incorrect medications, the resident's blood pressure dropped significantly, and their pulse rate decreased, prompting the physician to order an evaluation at the emergency department. The resident was subsequently admitted to the intensive care unit for low blood pressure and required vasopressors. Interviews with the hospital's medical doctor and the nursing home administrator confirmed that the resident's condition was a direct result of receiving the wrong medications.
Failure to Prevent Abuse and Neglect Among Residents
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by incidents involving three residents. Resident 58, who has dementia and is dependent on staff for toileting needs, reported that a nurse aide pulled her call bell out and left her without assistance. This allegation was substantiated, and the nurse aide was terminated. The Director of Nursing confirmed the substantiation of the abuse/neglect allegation. Resident 130, who is cognitively impaired and has severe dementia with anxiety, was involved in multiple resident-to-resident altercations. In one incident, Resident 130 flipped a supper tray on another resident, leading to a physical altercation. In another incident, Resident 130 was kicked by another resident while wandering the hall. These incidents were investigated, and the resident-to-resident abuse was substantiated. Resident 130 was subsequently admitted to a Behavioral Health Unit for further evaluation. Resident 134, who is cognitively impaired and has a history of physical behavioral symptoms, was involved in an altercation where he hit another resident with a footrest from his wheelchair. The incident was a result of a misunderstanding due to Resident 134's mental state. The facility's investigation confirmed the occurrence of resident-to-resident abuse. These incidents highlight the facility's failure to prevent abuse and neglect among residents, as evidenced by the substantiated cases of abuse and neglect.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, as determined through a review of clinical records and staff interviews. The inaccuracies were found in various sections of the MDS assessments, which are crucial for reflecting the residents' medical and treatment statuses. For instance, Resident 12's assessment inaccurately indicated that the influenza vaccine was not offered, despite documentation showing the resident refused it. Similarly, Resident 17's assessment failed to record the administration of gabapentin, an anticonvulsant medication, which was given as per the physician's orders. Further discrepancies were noted in the assessments of other residents. Resident 18's MDS assessment did not reflect the administration of bumetanide, a diuretic medication, despite records showing it was administered daily. Resident 25, who required hemodialysis, had an assessment that did not indicate the receipt of dialysis treatments, contrary to nursing notes. Additionally, Resident 41's assessment failed to record the administration of diazepam, an anti-anxiety medication, which was given daily as ordered. The inaccuracies extended to Resident 93, whose assessment incorrectly stated that vaccines were not offered, despite declination forms indicating refusal. Resident 122's assessment did not reflect the administration of Tramadol and Topiramate, despite records showing these medications were given. Interviews with the Licensed Practical Nurse Assessment Coordinator confirmed these coding errors, highlighting a failure in accurately documenting the residents' treatment and medication administration in the MDS assessments.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #12 will have a corrected Minimum Data Set (MDS). Resident #17 will have a corrected MDS. Resident #18 will have a corrected MDS. Resident #25 will have a corrected MDS. Resident #41 will have a corrected MDS. Resident #93 will have a corrected MDS. Resident #122 will have a corrected MDS. To identify other residents with the potential to be affected, the MDS nurse/designee will audit the most recent MDS assessment of residents to ensure they are coded correctly. Modifications will be made as necessary. To prevent a future occurrence, the Nursing Home administrator/designee provided education to the MDS nurses on proper coding of the MDS items. To monitor and maintain ongoing compliance, the MDS team/designee will complete an audit weekly x4 then monthly x2 to ensure MDS assessments are being properly coded. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Care Plan Updates Not Reflecting Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for seven residents. For Resident 2, the care plan was not updated to reflect a change in code status from full code to Do Not Resuscitate (DNR), despite a physician's order indicating the change. The Director of Nursing confirmed that the care plan should have been updated to reflect this change. Resident 25's care plan was not revised to include Enhanced Barrier Precautions (EBP), contact, and droplet precautions, even though there was signage indicating these precautions were in place. Similarly, Resident 79's care plan was not updated to include EBP, despite signage indicating the precautions. Interviews with staff confirmed the lack of documentation in the care plans for these precautions. Other deficiencies included Resident 41's care plan not being updated to reflect the discontinuation of an antibiotic, Resident 64's care plan not reflecting a change in out-of-bed orders to an evolution chair, Resident 106's care plan not being updated to reflect hospice services, and Resident 130's care plan not reflecting the discontinuation of a diuretic. These omissions were confirmed through interviews with the Director of Nursing and other staff members.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This Plan of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #2 careplan changes were completed and are accurate. Resident #25 careplan changes were completed and are accurate. Resident #41 careplan changes were completed and are accurate. Resident #64 careplan changes were completed and are accurate. Resident #79 careplan changes were completed and are accurate. Resident #106 careplan changes were completed and are accurate. Resident #130 careplan changes were completed and are accurate. To identify other residents with the potential to be affected, the Director of Nursing/designee will review care plans to ensure any changes to code status, Enhanced Barrier Precautions, antibiotics, out of bed orders, hospice care and residents on diuretic medication within the last two weeks were reviewed/revised correctly on the care plan. To prevent a future occurrence, the Director of Nursing/designee provided education to the interdisciplinary team on the comprehensive care planning policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure any changes to orders are reflected on the care plan. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide adequate, ongoing activities designed to meet the needs of a resident, identified as Resident 9, as required by §483.24(c)(1). The facility's life enrichment programming policy mandates an ongoing resident-centered program based on comprehensive assessments and care plans, which should cater to the interests and abilities of each resident. However, for Resident 9, who has hemiplegia and dysphagia following a stroke, there was no documented evidence of participation or refusal of activities during several weeks across November 2024 to January 2025. Interviews revealed that Resident 9's spouse indicated the resident does not like to get out of bed and is not provided with in-room activities, leaving television as the only option. The Activities Director confirmed that Resident 9 was scheduled for weekly one-to-one bedside/in-room visits and activities, but there was no documentation to support that these activities occurred during the specified weeks. This lack of documentation and activity provision indicates a failure to meet the resident's needs as outlined in their care plan.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #9 activity preferences and care plan were updated. To identify other residents with the potential to be affected, the Life Enrichment Director/designee will complete 100% audit of all residents to identify those at risk and in need of a 1:1 visit. To prevent a future occurrence, Life Enrichment Director will create a separate calendar listing the residents who trigger for a 1:1 visit based on the observation completed. Life Enrichment Director/designee will educate Life Enrichment Staff on how this process designed will work moving forward within the department and facility. To monitor and maintain ongoing compliance, Life Enrichment Director/designee will monitor the monthly activity logs for residents with Care plans for 1 to 1 visit weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Document Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents. For one resident, the facility's policy required that two licensed nurses witness and document the disposal of fentanyl patches. However, there was no documented evidence that two staff members signed off on the destruction of the old fentanyl patches on multiple occasions. The Director of Nursing confirmed the lack of documentation for the destruction of the patches. For another resident, who was discharged to another nursing facility, there was no documented evidence of the disposition of Ativan, a controlled drug, upon discharge. The Assistant Nursing Home Administrator confirmed the absence of documentation regarding the medication's disposition. These deficiencies indicate a failure to adhere to the facility's procedures for managing controlled substances, as required by regulations.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility could not go back and fix Resident #44 destruction log. The facility could not go back and fix the accountability log for Resident #149 narcotic at time of discharge. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit Fentanyl destruction logs for the last 30 days to ensure two signatures are present and review residents discharged over the last 2 weeks to ensure accountability of narcotics if resident was to be discharged with them. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on the proper destruction of medications and medication disposition of discharged residents. To monitor and maintain ongoing compliance, the Director of Nursing/designee will audit Fentanyl destruction logs and accountability of narcotics on discharge weekly x4 and then monthly x2 to ensure two signatures are present and residents are discharged with narcotics if ordered by Medical Director (MD). Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Repeated Deficiencies in QAPI Implementation
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in multiple surveys. These deficiencies included a failure to prevent resident abuse and neglect, timely completion of comprehensive assessments, and inaccuracies in Minimum Data Set (MDS) assessments. Additionally, the facility struggled with developing comprehensive care plans and providing professional nursing services. The survey results also highlighted issues with ensuring a safe environment free of accident hazards, as well as failures in accountability for controlled medications and proper storage and labeling of medications. The facility was cited for not ensuring that physicians and certified registered nurse practitioners wrote, signed, and dated progress notes with each visit. Furthermore, the facility's infection control practices were found to be deficient. Despite the facility's plans of correction, which included completing audits and reporting results to the QAPI committee, the committee was ineffective in addressing and correcting these deficiencies. The repeated nature of these issues across multiple surveys indicates a systemic problem in the facility's ability to implement and sustain effective quality assurance measures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility is unable to fix the Quality Assurance audits at the time of the survey. There were no other issues identified at the time of the survey. To prevent a future occurrence, the Nursing Home Administrator will educate department heads on the Quality Assurance and Process Improvement Policy. To monitor and maintain ongoing compliance, the Nursing Home Administrator/designee will complete an audit weekly x4 then monthly x2 to ensure that audits are being completed, reviewed and have process improvement plans put into place if necessary. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Facility Fails to Maintain Safe Operating Condition of Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed during a survey. The dishwashing machine was not registering a temperature during the first rinse cycle and was leaking water onto the floor. Additionally, a steam kettle was leaking water, which was being caught by a plastic bucket placed underneath it. These issues were observed during a kitchen inspection. Interviews with the Dietary Manager and the Nursing Home Administrator revealed that several pieces of kitchen equipment had been malfunctioning for extended periods. The dishwasher had been leaking and not functioning to full capacity since September 2024. The steam kettle required a new seal since June 2024, and an upright cooler had been out of service since May 2024. The garbage disposal was not in use due to a loud noise, and one oven was unusable since March 2024 because of a broken door pin. The second oven had a broken on/off switch but was still in use. One pressure cooker had been out of service since August 2024, and the second pressure cooker was irreparable since September 2024. Despite these issues, alternate cooking equipment was used, and there were no adverse effects on meal service.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. No residents had any adverse reactions. To prevent a future occurrence, the Administrator/designee will work with Maintenance staff on the processing repair orders to assure kitchen equipment repairs are fixed timely. Work orders have been initiated for the equipment listed in deficiency. To monitor and maintain ongoing compliance, the Maintenance Director/designee will complete an audit weekly x4 and then monthly x2 to ensure kitchen equipment parts have been ordered, then internally fixed or vendor has fixed the equipment. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Document Semiannual Fire Alarm Inspection
Penalty
Summary
The facility failed to maintain the fire alarm system as required by NFPA 101, NFPA 70, and NFPA 72 standards. During a documentation review on January 30, 2025, it was discovered that the facility could not provide documentation for a semiannual visual inspection of the fire alarm system. This lack of documentation indicates that the required inspection was not conducted or recorded, which is a violation of the fire safety standards that mandate regular testing and maintenance of fire alarm systems. An interview with the Facility Administrator and Maintenance Director on the same day confirmed the absence of documentation for the semiannual inspection of the fire alarm system and devices. This deficiency highlights a lapse in the facility's adherence to the approved program for fire alarm system maintenance, as the records of system acceptance, maintenance, and testing were not readily available as required.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Vendor was contacted when survey ended to schedule the semi annual visual inspection of the fire alarm system. 2. To prevent recurrence, Maintenance manager/designee will preschedule twice a year for the visual inspection to be completed. Administrator will be notified of those inspection dates and monitor them for completion. 3. To maintain and monitor compliance, Administrator or designee will review inspection dates and have them reported to monthly safety committee meeting, then turned into Monthly QAPI meeting.
Failure to Maintain Resident Dignity in Hygiene Assistance
Penalty
Summary
Maple Heights Health and Rehab Center was found to be non-compliant with certain resident rights requirements as per 42 CFR Part 483, Subpart B, and the 28 PA Code. The deficiency involved a failure to maintain the dignity of a resident, identified as Resident 84, in the provision of hygiene assistance. The resident, who was capable of understanding and communicating, had a care plan indicating a need for assistance with activities of daily living, including morning and evening care. The facility's bath schedule specified that the resident was to receive showers on certain evenings, but on one occasion, the resident refused a shower and accepted a bed bath instead. Observations made on two separate days revealed that Resident 84 had visible facial hair, which had not been addressed by the staff. There was no documented evidence that the staff had asked the resident about her preference regarding facial hair removal, nor was there a policy in place for such preferences. An interview with the Director of Nursing confirmed that the staff did not have a specific protocol for addressing facial hair removal for female residents, and it was left to the discretion of the staff based on the resident's response at the time of their shower.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #84 had facial hair removed at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit female residents to see if they have a preference on facial hair removal and will add it to their shower day order and plan of care. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff on the resident right policy/in-service as well as the importance of following female resident's preference on facial hair removal. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 random female residents to ensure there is no facial hair present weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Inform Resident of Medical Appointments
Penalty
Summary
The facility failed to honor a resident's right to be informed and participate in their treatment decisions, as required by regulations. Specifically, the facility did not notify a resident of their medical appointments in advance, despite the resident's expressed desire to be informed. The resident, who was capable of understanding and communicating, had previously raised concerns about not being informed of appointments, and it was agreed that they would receive at least a week's notice. However, the resident was sent to a procedure without prior notification, as confirmed by interviews and clinical records. The deficiency was further evidenced by the lack of documentation in the resident's clinical record indicating that they were informed of appointments on two specific dates. The Director of Nursing confirmed the absence of such documentation and acknowledged that the resident's sister was notified instead, as she had requested to be informed. This oversight in communication and documentation led to the resident discovering an upcoming appointment through their patient portal rather than being informed by the facility staff.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Facility could not go back and notify Resident #79 of a previous appointment. Facility clarified Resident #79 preference of notification at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit appointments for the previous month to see if notifications were made and documented. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff/transportation on the resident right to make informed choices and participate in his/her treatment. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 appointments (if applicable) to ensure notifications are completed and documented weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
Failure to Resolve Resident Grievance Timely
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances for a resident, identified as Resident 18, who was cognitively intact and required assistance from staff for care. The resident filed a grievance on December 25, 2024, regarding not receiving her gas pill and not being washed up for the day. Despite asking for assistance from a nurse aide and an LPN at 1:00 p.m., the resident was not attended to until 3:00 p.m. by two unknown nurse aides. The grievance was not assigned until January 7, 2025, and there was no documented evidence of a thorough investigation, including interviews or written statements from the staff involved. The grievance form indicated that nursing was to review medication changes with the resident, but there was no documentation of whether the grievance was confirmed or not. Additionally, there was no evidence of ongoing efforts to resolve the resident's concerns until January 28, 2025, when the Nursing Home Administrator met with the resident to discuss changes to her care. The resident was not informed of the grievance resolution until January 29, 2025, over a month after the grievance was filed. An interview with the Nursing Home Administrator confirmed the lack of documented evidence of ongoing efforts to resolve the grievance and the delay in informing the resident of the resolution. This failure to address the grievance in a timely manner and to keep the resident informed of the resolution process is a deficiency in the facility's grievance handling procedures.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #18 grievance was resolved and reviewed with the resident at the time of the survey. To identify other residents with the potential to be affected, the Social Service Department/designee will audit grievances for the month of January to ensure they were addressed and to resolve per policy. To prevent a future occurrence, the Director of Nursing/designee will educate department heads on the grievance policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of current grievances to ensure they are addressed and resolved timely weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.
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 227 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ebensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Winds Healthcare And Rehabilitation, Llc | 8.9 mi | ★★★★★ | 23 | 0 |
| Haida Nursing And Rehab | 12 mi | ★★★★★ | 11 | 0 |
| Hilltop Healthcare And Rehabilitation Center | 15.8 mi | ★★★★★ | 14 | 0 |
| Midtown Oaks Health & Rehab Center | 16 mi | ★★★★★ | 24 | 0 |
| Conemaugh Memorial Medical Center Tcu | 16.1 mi | ★★★★★ | 2 | 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.