Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Meadowcrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Unqualified Food Service Director: The facility failed to employ a qualified FSD to manage daily Dietary operations. The Dietary Supervisor stated she was not certified, and the RD only worked two days a week. The NHA confirmed the RD was not full time and that there was no documented evidence that the Dietary Manager met the qualifications for the FSD role.
Improper Food Storage in Deep Freezer: Food was observed stored directly under the fans of the deep freezer with ice buildup and only about three inches from the ceiling. The Dietary Supervisor confirmed the food was not properly stored in the Main Kitchen, contrary to the facility’s food receiving and storage policy.
Infection control and surveillance deficiencies were identified when an LPN performed wound care without a gown for a resident on EBP, and multiple resident rooms lacked EBP signage. During a dressing change for another resident with paraplegia, neurogenic bladder, and a Stage IV pressure ulcer, sterile saline was opened and partially used, no clean barrier was placed under the wound, soiled bedding was present, and a bath towel was used as a clean field. The facility also lacked documented infection surveillance for the prior 12 months.
Failure to Implement Antibiotic Stewardship Program: The facility failed to carry out its antibiotic stewardship program for 12 of 12 months. The policy called for monitoring antibiotic use and reducing unnecessary or inappropriate antibiotics under the IP's oversight, but the infection control surveillance record did not show antibiotic monitoring was completed. The NHA confirmed the lapse during interview.
Unnecessary Psychotropic Medications: The facility failed to ensure that four residents’ med regimens were free from unnecessary psychotropic meds. One resident with depression and anxiety had a PRN lorazepam order without documentation that the prescriber evaluated its appropriateness, one resident with no psych/neuro dx had a daily Abilify order, and two residents with dementia had PRN haloperidol orders for agitation without documented prescriber evaluation.
A resident with dementia and other significant diagnoses fell out of bed while receiving care and sustained a laceration above the eyebrow that required treatment. The care plan called for fall precautions and bilateral fall mats, but later observations found one mat leaning against the wall and no mat on the other side of the bed. Staff stated the resident required 2-person assistance, and the NHA confirmed the facility failed to thoroughly investigate the injury to rule out possible neglect.
Inaccurate and incomplete MDS assessments were identified for multiple residents. For several residents, the MDS showed they were rarely understood, yet the BIMS and resident mood interviews were not completed as required by the RAI Manual. For another resident, Section GG coding for self-care and bed mobility did not match the nurse aide documentation survey reports, which showed a higher level of dependence. The RNAC confirmed the assessments were inaccurate, and the NHA acknowledged the facility failed to ensure the MDS assessments were accurate and fully completed.
Failure to Provide Ordered Eye Drops and Latex-Free Incontinence Supplies: A resident with a latex allergy reported that the facility did not provide latex-free incontinence supplies and that the brief found for her did not fit properly. The resident and her daughter also stated that ordered eye drops for dry eyes had not been given, and observation showed a reddened eye and no eye drops on the med cart. The RN could not explain why the drops were documented as given but unavailable.
Pressure ulcer treatment and documentation were not provided as ordered for a resident with paraplegia, neurogenic bladder, and a Stage IV PU. An LPN removed a dressing that lacked a documented time or staff name, wound cleansing did not match the ordered treatment, and the resident stated twice-daily dressing changes had not been done in a long time. The TAR also showed incorrect documentation that both dressing changes were completed by an LPN.
Failure to Provide Adequate Supervision and Assistance During Bed Care: A resident with dementia, psychotic and mood disturbances, anxiety, obesity, and dysphagia required substantial/maximal assistance for bed mobility and was identified by staff as needing 2 staff at all times. The resident fell out of bed during care and sustained a laceration above the eyebrow requiring treatment. Observations showed a fall mat on one side of the bed positioned improperly and no mat on the other side, despite the care plan calling for bilateral fall mats.
The facility failed to provide documentation of monthly pharmacist MRRs for three residents. Surveyors requested the records for several months, but the facility could not locate them, and the NHA confirmed the MRR documentation was unavailable for those residents.
Inaccurate Documentation of Wound Treatments: The facility failed to accurately document wound care for two residents. One resident with atrial fibrillation, diabetes, and osteomyelitis had a wound vac dressing change documented as completed on the TAR even though an LPN stated it had not yet been done and another LPN denied completing it. A second resident with paraplegia and neurogenic bladder had ordered sacral dressing changes, but the removed dressing lacked a documented time or staff signature, and the TAR showed dressing changes as completed despite conflicting observations and statements from staff and the resident.
Failure to Offer Pneumococcal Vaccines: The facility did not offer pneumococcal disease vaccines in accordance with its policy for seven of nine residents whose records were reviewed. Clinical record review showed that the residents’ immunization documentation did not include that the vaccine had been offered since admission, and the medical record noted the last pneumococcal vaccine was given in 2013. The NHA confirmed the failure during interview.
Missing Emergency Call Systems in Resident-Accessible Restrooms: The facility failed to maintain an effective call system for two of five resident-accessible restrooms. Two staff restrooms were observed unlocked, with keys accessible to residents, and neither restroom had an emergency call light or call cord attached for emergency use. The NHA confirmed the deficiency during interview.
A resident who was cognitively intact and had Crohn's disease and a hx of stroke said she was uncomfortable using the shower room because a male resident's room opened directly into it through an unlocked door. Surveyors observed the shower room was directly accessed from the male resident's room, and the NHA confirmed the facility failed to uphold the resident's privacy and dignity.
A resident with dementia, depression, and chronic pain had psychotropic drug use triggered on the MDS, and the CAA Worksheet documented that it would be addressed in the care plan. The resident had orders for venlafaxine for depression and haloperidol PRN for agitation, but the care plan did not include a psychotropic drug use plan. The NHA confirmed the facility failed to develop person-centered care plans for one of six residents.
Opened PPD and a nicotine patch box were found without required dates or labels in the med room and a med cart. An RN confirmed the PPD vial appeared accessed with no open date, and another RN confirmed the nicotine patch box and patch used for a resident were unlabeled and undated.
A facility failed to post Medicaid Fraud Unit contact information on two nursing units, the [NAME] unit and Garden unit. Surveyors observed that the information was not posted or accessible to residents, and the NHA later confirmed the omission on both units. The deficiency was cited under 28 Pa. Code: S201.29(i) Resident rights.
The facility failed to display written information on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by Medicare and Medicaid on two nursing units, including the [NAME] and Garden units. Surveyors observed the missing information, and the NHA later confirmed the deficiency.
Failure to post the most recent survey results in the lobby survey binder. Observation showed the binder still contained survey results from an older survey, even though multiple more recent surveys had been completed. The NHA confirmed the survey book was not updated with the latest Federal or State survey results.
A resident with bipolar disorder, anxiety, and a BIMS score indicating intact cognition had a documented history of sexually inappropriate behaviors over several months, yet a care plan addressing sexual expression and safety was not initiated until after an incident. This resident was observed alone in a dining room with another resident who had schizoaffective disorder, depression, anxiety, and a severely impaired BIMS score, during which he exposed himself and engaged in inappropriate behavior. Staff interviews confirmed prior awareness of this resident’s sexual behaviors, including rumors and observed changes in behavior, but the facility did not implement adequate protections to prevent sexual contact with a cognitively impaired resident, resulting in an Immediate Jeopardy finding for failure to prevent resident-to-resident sexual abuse.
A resident with parkinsonism, bipolar disorder, and anxiety disorder, and an intact BIMS score, had multiple documented episodes of sexual behaviors over several months, but a care plan addressing sexual activity and sexual expression was not initiated until much later. Facility policy required comprehensive assessment and care planning, yet the specific care plan for sexual expression, including goals for safety and interventions such as education, family notification when appropriate, provision of privacy, and staff support and risk assessment, was delayed. The NHA and DON acknowledged that a comprehensive, person-centered care plan to meet this resident’s needs had not been timely developed and implemented.
The facility was cited for failing to protect residents from resident-to-resident sexual abuse when a resident with a known history of sexually inappropriate behavior engaged a non-consenting resident. Review of job descriptions, clinical records, and staff interviews showed that the NHA and DON did not carry out their responsibilities to manage the facility and nursing services in accordance with federal and state regulations and to ensure high-quality care. Both the NHA and DON acknowledged that they did not effectively manage the facility to prevent this incident of sexual abuse.
Two residents with significant medical conditions and intact cognition were not provided the opportunity to formulate an advance directive or have periodic reviews of their advance directive status, as required by facility policy and regulations. Documentation of these actions was absent from their clinical records, and the deficiency was confirmed by the facility administrator.
The facility did not provide required transfer notices to the Office of the Long-Term Care Ombudsman Division for several months, despite policy and regulatory requirements to do so during emergency transfers.
Three residents with complex medical conditions did not receive prescribed therapeutic diets due to missing or incorrect diet orders and assessments. Hospital discharge instructions for cardiac, sodium-restricted, and fluid-restricted diets were not followed, and appropriate diet orders were not entered until after the issue was identified, resulting in noncompliance with dietary and nursing regulations.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences. One resident with celiac disease did not have their gluten intolerance communicated or reflected in meal orders, while others received meals that did not match their documented dislikes or allergies, such as being served chicken, rice, or bananas against their preferences or dietary restrictions.
A resident with a PICC line and a history of diabetes and sepsis did not receive dressing changes as ordered by the physician. Although documentation indicated the dressing was changed, observation showed the dressing was outdated, and staff confirmed the order was not followed, resulting in a deficiency in parenteral fluid administration and nursing services.
Over a 21-day period, facility administrative staff did not provide the minimum required LPN coverage for day, evening, and night shifts, with multiple instances of insufficient or absent LPN hours as confirmed by schedule reviews and staff interviews.
The facility did not notify resident representatives or medical providers of significant changes in condition or care for three residents, including a resident who was found deceased after reporting feeling unwell, a resident whose diet was changed without informing the legal guardian, and a resident transferred to the hospital without family notification. The DON and administrator confirmed these notification failures.
Four residents did not receive accurate or fully completed MDS assessments, as required by the RAI User's Manual. Despite documentation showing that these residents were able to be understood, key sections such as cognitive and mood assessments were left unassessed or incomplete. The facility administrator confirmed these assessment deficiencies.
Surveyors found that the facility did not develop complete, individualized care plans for three residents: one receiving antidepressant and antipsychotic medications, another with a Stage III pressure ulcer, and a third self-administering medication. The care plans lacked specific goals and interventions for these residents' actual conditions and needs, as confirmed by facility leadership.
The facility did not provide adequate training to staff on handling waste from a resident receiving chemotherapy, resulting in confusion among nurse aides about proper toilet flushing procedures and a lack of clear instructions due to the absence of a commode lid. The resident's care plan was not updated with necessary information, and staff confirmed they had not received education on preventing exposure to chemotherapy drug waste.
A resident with metabolic encephalopathy and muscle weakness was admitted with pressure ulcers on both heels. The care plan addressed only the risk of skin integrity issues and did not include interventions for the existing ulcer. Physician-ordered wound care was not consistently documented as completed, and there was no documentation of refusals or reasons for missed treatments. Facility leadership confirmed the failure to provide necessary treatment and services for the pressure ulcer.
A resident receiving chemotherapy was prescribed special waste disposal procedures, but the shared restroom lacked a toilet lid, making compliance impossible. Staff were not educated on proper handling of chemotherapy waste, and care plans did not include necessary instructions, resulting in unsafe conditions for two residents.
The facility did not provide mandatory QAPI training to ten staff members, including nurse aides, an LPN, and other personnel, as required by their policy. The Nursing Home Administrator confirmed that corporate had not included QAPI in the mandatory training, leading to a deficiency under Pennsylvania Code sections related to licensee responsibility, management, and staff development.
The facility failed to maintain a clean, homelike environment on two nursing units, with obstructions in common areas, broken fixtures, and unclean conditions in residents' rooms. The Nursing Home Administrator confirmed these deficiencies during interviews.
The facility failed to provide five residents the opportunity to formulate advance directives upon admission and during their stay, as required by policy. This deficiency was confirmed by the Social Services Director, who confused POLST with advance directives, and the Nursing Home Administrator.
The facility did not conduct QAA meetings with all required members, missing the Infection Preventionist for three of four quarterly meetings from May 2023 to January 2024. The facility's policy requires the QAPI committee to include the administrator, DON, medical director, and infection control representative, but records showed the infection control representative was absent. This was confirmed by the Nursing Home Administrator.
The facility failed to provide required behavioral health training to three staff members, including a housekeeping employee, a dietary aide, and a maintenance director. Despite the facility's policy mandating such training upon hire and annually, their records lacked documentation of this training. This deficiency was confirmed by the Nursing Home Administrator.
A facility failed to accurately complete the MDS assessment for a resident with moderate intellectual disabilities, dementia, and anxiety. The MDS did not reflect the resident's hospice care services, despite a physician's order confirming hospice admission. This inaccuracy was confirmed by the RNAC during an interview.
The facility failed to prevent the storage of food items in a medication refrigerator, as observed in the [NAME] Nursing Unit. Two water bottles and a carton of milk were found in the medication refrigerator, contrary to the facility's policy requiring medications to be stored separately from food. This was confirmed by a nurse and the facility's administration.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department for 12 out of 12 months, from April 2025 through March 2026. During interview, the Dietary Supervisor stated she was not certified and that the Dietitian only worked two days a week. The Nursing Home Administrator stated that the Registered Dietitian was not employed full time and came to the facility two times a week, and that the RD was not on-site full time to oversee kitchen operations in the absence of a full-time qualified dietary manager. The Nursing Home Administrator also confirmed that the facility failed to provide documented evidence that Dietary Manager Employee E1 met the qualifications for the Food Service Director position.
Improper Food Storage in Deep Freezer
Penalty
Summary
The facility failed to properly store food products in the Main Kitchen. Review of the facility policy, Food Receiving and Storage dated 1/8/26, indicated that all food items are to be received and stored in a manner that complies with safe food handling practices. During an observation of the main kitchen on 3/4/26 at 9:40 a.m., food was found stored directly under the fans of the deep freezer, with ice buildup and approximately three inches from the ceiling of the deep freezer. During an interview on 3/4/26 at 9:43 a.m., the Dietary Supervisor confirmed that the facility failed to properly store food products in the Main Kitchen.
Infection control and surveillance deficiencies
Penalty
Summary
The facility failed to ensure an environment free from the spread of infection for five residents and failed to maintain an infection control program with surveillance for communicable diseases or infections for 12 of 12 months. Resident R4 had diagnoses including atrial fibrillation, diabetes, and osteomyelitis, and had physician orders for wound vac dressing changes three times per week and enhanced barrier precautions related to a left foot wound. During wound care observation, an LPN performed the dressing change without using a gown, despite the resident being ordered enhanced barrier precautions. In addition, current physician orders showed seven residents were ordered enhanced barrier precautions, but during unit observation the rooms of Residents R1, R4, R6, R12, and R33 did not have signage at the door indicating those precautions. Resident R1 had paraplegia, neurogenic bladder, cognitive intactness, and a Stage Four pressure ulcer. The resident had a physician order for sacral wound dressing changes, and during observation of the dressing change, sterile saline was opened and partially used, no clean barrier was placed under the wound, the bedding under the wound was soiled with wound drainage, a bath towel was used as a clean field on the overbed table, and 4x4 gauze was placed directly on the bath towel and saturated with normal saline. The soiled dressing removed was dated without a documented time or staff member. Facility policy stated the infection preventionist would conduct ongoing surveillance of healthcare-associated infections and other significant infections, but review of the facility's infection control documentation for the prior 12 months did not reveal surveillance tracking infections for residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 12 of 12 months, from April 2025 through March 2026. Review of the facility's infection control policies and procedures showed that the Antibiotic Stewardship Program, last reviewed on 1/8/26 and previously reviewed on 1/14/25, was intended to monitor antibiotic use and improve antibiotic use by avoiding unnecessary or inappropriate antibiotics, with oversight by the Infection Preventionist in collaboration with the medical director, pharmacist, nursing, and administrative leadership. However, review of the facility's infection control surveillance for April 2025 through March 2026 failed to include documentation showing that antibiotic monitoring was completed. During an interview on 4/6/26 at 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to implement an antibiotic stewardship program during that 12-month period.
Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents’ medication regimens were free from unnecessary psychotropic medications for four of seven residents reviewed: R22, R4, R7, and R41. The facility policy on Psychotropic Medication Use stated that residents should not receive medications that are not clinically indicated, that PRN psychotropic orders are limited to 14 days unless the physician documents the rationale and evaluates the resident for appropriateness, and that antipsychotics should be used at the lowest possible dosage for the shortest period of time with gradual dose reduction and re-review when applicable. Resident R22 had diagnoses including head injury from a fall, parkinsonism, lung disease, depression, and anxiety, and had a physician order for lorazepam 1 mg every six hours PRN for anxiety; the record did not show that the attending physician or prescribing practitioner evaluated the resident for appropriateness of the medication. Resident R4 had diagnoses of atrial fibrillation, diabetes, and osteomyelitis, with no psychiatric or neurologic diagnosis listed in the MDS or facility diagnosis list, yet had an order for Abilify 5 mg daily. Resident R7 had diagnoses of dementia and muscle weakness and an order for haloperidol 0.5 mg every 24 hours PRN for agitation, and Resident R41 had diagnoses of dementia and chronic pain with an order for haloperidol 0.5 mg every twelve hours PRN for agitation; for both residents, the record did not show evaluation by the attending physician or prescribing practitioner for appropriateness of the medication.
Failure to Thoroughly Investigate Injury During Care
Penalty
Summary
The facility failed to conduct a thorough investigation of an injury obtained during care to eliminate possible neglect for Resident R8. Facility policy stated that all accidents and incidents involving residents must be investigated and reported to the Administrator, and that the Nurse Supervisor shall promptly initiate and document the investigation. Resident R8 was admitted with diagnoses including dementia, psychotic and mood disturbances, anxiety, obesity, and dysphagia, and her MDS indicated substantial/maximal assistance for bed mobility. The clinical record showed that on 1/7/26, Resident R8 fell out of bed while being provided care and sustained a laceration above the eyebrow that required treatment. The care plan identified her as a fall risk and directed assistance as required with bilateral fall mats in place. During later observations, the fall mat on the right side of the bed was leaning against the wall and no mat was present on the left side of the bed, while Resident R8 was positioned near the left side of the bed. Staff interviews indicated that substantial/maximal assistance required two staff, and the Therapy Manager stated the resident was not on caseload because she could not understand or follow commands and required two staff at all times due to dementia progression. The Nursing Home Administrator confirmed the facility failed to identify and conduct a thorough investigation of the injury to eliminate possible neglect.
Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for six residents. The RAI User's Manual stated that Section C, Question C0100 should be coded as 0 when a resident is rarely or never understood, or coded as 1 and followed by the Brief Interview for Mental Status when the resident is at least sometimes understood. It also stated that Section D, Question D0100 should be coded as 0 when a resident is rarely or never understood, or coded as 1 and followed by the Resident Mood Interview when the resident is at least sometimes understood. For multiple residents, the MDS documented that the resident was rarely understood, yet the BIMS and Resident Mood Interview were not completed. For one resident, the MDS completed on 12/21/25 showed Section GG functional ability coding that did not match the facility's Documentation Survey Reports, which identified the resident as dependent for bed mobility rolling left to right, while the MDS coded the resident as requiring substantial/maximal assistance. During interview, the Resident Nurse Assessment Coordinator confirmed the MDS assessments were inaccurate, and the Nursing Home Administrator confirmed the facility failed to make certain that comprehensive MDS assessments were accurate and fully completed for five of nine residents.
Failure to Provide Ordered Eye Drops and Latex-Free Incontinence Supplies
Penalty
Summary
The facility failed to provide care and services needed for Resident R26 to attain or maintain the highest practicable physical, mental, and psychosocial well-being. During interview, Resident R26 stated that she had itchiness around her abdomen because the facility had not provided latex-free incontinence pads before the night nurse found her a latex-free brief, and the brief did not fit properly. Resident R26 and her daughter also stated that she had a latex allergy and that the doctor had ordered eye drops to help with dry eyes, but she had not received them. During observation, a tan brief was seen on the windowsill, and an opened package of size large briefs was present, which Resident R26 showed were too small for her. Her left eye appeared reddened. Review of the clinical record showed a latex allergy and an order for Artificial Tears, 2 drops to both eyes twice daily and 1 drop to both eyes every 6 hours as needed. Observation of the nursing unit medication cart showed that Resident R26 did not have eye drops identified in the cart. An RN stated she did not know why the eye drops had been documented as given and were not available, and the NHA confirmed the facility failed to provide care and services needed for Resident R26.
Pressure Ulcer Treatment and Documentation Failure
Penalty
Summary
Failure to provide necessary treatment and services for a pressure ulcer was identified for one resident with paraplegia and neurogenic bladder who was cognitively intact and had a Stage Four pressure ulcer. The resident’s plan of care included treatment per physician order, and the physician ordered sacral wound dressing changes with cleaning using acetic acid 1%, application of zinc oxide to the peri-wound area, collagen, calcium alginate, and an ABD dressing twice daily and as needed. During a dressing change observation, the removed dressing was dated 3/3/26 without a documented time or staff member who performed the dressing change. The observation also showed an LPN using normal saline to clean the wound, while another LPN suggested soap and water. The resident stated that twice-daily dressing changes had not been done in a very long time. Review of the TAR confirmed the resident was ordered to receive twice-daily dressing changes and showed documentation by an LPN that both the morning and evening dressing changes were completed on 3/4/26, which the NHA and DON were informed was incorrect.
Failure to Provide Adequate Supervision and Assistance During Bed Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for one resident who had diagnoses of dementia, psychotic and mood disturbances, anxiety, obesity, and dysphagia. The resident’s MDS indicated substantial/maximal assistance was needed for rolling left to right in bed, while the Documentation Survey Report identified the resident as dependent for that bed mobility task. Staff interviews stated that substantial/maximal assistance required two staff, and therapy staff stated the resident required two staff at all times due to dementia progression and inability to understand and follow commands. The resident’s record included a progress note documenting a fall out of bed during care that resulted in a laceration above the eyebrow requiring treatment. The care plan identified the resident as at risk for falls and directed assistance as required with bilateral fall mats in place. During observations, the fall mat on the right side of the bed was positioned close to and leaning against the wall, and no mat was present on the left side of the bed on two separate observations. The Nursing Home Administrator confirmed the facility failed to make certain the resident received adequate supervision and assistance to prevent accidents.
Missing Monthly Medication Regimen Review Documentation
Penalty
Summary
The facility failed to provide documentation of monthly medication regimen reviews completed by a licensed pharmacist for three of seven residents, identified in the report as R7, R41, and R22. On 3/5/26, surveyors requested the medication regimen reviews for these residents for the period from September 2025 through February 2026, but the facility was unable to locate the records. During interviews on 3/6/26, the Nursing Home Administrator confirmed both that the reviews could not be found and that the facility failed to provide documentation showing medication regimen reviews were completed at least monthly for the three residents.
Inaccurate Documentation of Wound Treatments
Penalty
Summary
The facility failed to appropriately document treatments for two residents. Facility policy required that all services provided to a resident and any changes in condition be documented in the medical record, and that dressing changes include the date and time the dressing was changed. One resident had diagnoses including atrial fibrillation, diabetes, and osteomyelitis, and had a wound vac dressing ordered to be changed three times per week on Monday, Wednesday, and Friday. During an interview, an LPN stated the wound vac dressing change had not yet been completed that day, but the same LPN had already documented on the TAR that the dressing change was completed. When questioned, the LPN stated another LPN had completed the dressing change, but that second LPN stated she had not completed it. A second resident, who was cognitively intact and had paraplegia, neurogenic bladder, and an actual skin impairment related to impaired mobility, had an order for sacral wound dressing changes twice daily and as needed. During an observed dressing change, the removed dressing was dated without a documented time or staff member who performed the dressing change. During the observation, an LPN stated the resident's dressing change was to be completed once daily, and the resident stated he had not had twice daily dressing changes in a very long time. Review of the TAR confirmed the resident was ordered to receive twice daily dressing changes, and that an LPN documented both the morning and evening dressing changes as completed even though the dressing removed during observation was dated several days earlier. The Nursing Home Administrator and DON were informed that incorrect information had been entered on the TAR documenting the dressing changes as completed.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer pneumococcal disease vaccines in accordance with its policy for seven of nine residents whose immunization records were reviewed. The facility policy titled Pneumococcal Vaccine, dated 1/8/26 with a previous review date of 1/14/25, stated that all residents are offered the pneumonia vaccine to aid in the prevention of pneumococcal pneumonia, that residents are assessed for eligibility upon admission, and that when indicated the vaccine will be offered within 30 days of admission. Clinical record review showed that residents R5, R8, R14, R16, R12, R7, and R31 were admitted to the facility, but their immunization documentation records did not include that the pneumococcal vaccine had been offered since admission. The medical record also showed that the last pneumococcal vaccine had been given in 2013. During an interview on 3/6/26 at 2:10 p.m., the Nursing Home Administrator confirmed that the facility failed to offer pneumococcal disease vaccines in accordance with facility policy to these seven residents.
Missing Emergency Call Systems in Resident-Accessible Restrooms
Penalty
Summary
The facility failed to maintain an effective call system for two of five restrooms accessible to residents. During observations on 3/4/26, the staff restroom on the Garden nursing unit was unlocked, and at one point the key was hanging off the door knob and accessible to residents; the restroom had no emergency call light or call cord attached for emergency use. The same restroom was again observed unlocked on 3/6/26 with the key hanging off the door knob, and no emergency call light or call cord was present. The staff restroom on the [NAME] nursing unit was also observed unlocked on 3/5/26 and 3/6/26, with the key hanging on a magnetic hook approximately waist height inside the restroom. On both observations, the restroom had no emergency call light or call cord attached for emergency use. During an interview on 3/6/26, the Nursing Home Administrator confirmed the facility failed to maintain an effective call system for two of five restrooms accessible to residents.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the privacy and dignity of Resident R3, who was admitted to the facility and had Crohn's disease, a history of stroke, and was cognitively intact on the MDS. During interview, R3 stated she was uncomfortable using the shower room on her nursing unit because a male resident's room opened directly into the shower room through an unlocked door. Observation of the Garden unit shower room confirmed it was directly accessed from Resident R20's room through an internal door in the shower room, and R20 was mobile in a wheelchair. The Nursing Home Administrator later confirmed that the facility failed to uphold the privacy and dignity of one of six residents.
Failure to Include Psychotropic Drug Use in Care Plan
Penalty
Summary
The facility failed to develop person-centered care plans for one of six residents, identified in the report as Resident R41. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual stated that for each triggered care area, the Care Planning Decision in Section V is checked to show whether a new care plan, revision, or continuation of the current care plan is needed. The facility policy on comprehensive person-centered care plans stated that each resident is to have a care plan with measurable objectives and timetables to meet physical, psychosocial, and functional needs. Resident R41 was admitted with diagnoses of dementia, depression, and chronic pain. The resident's comprehensive MDS triggered psychotropic drug use in the Care Area Assessment Summary, and the CAA Worksheet documented that psychotropic drug use would be addressed in the care plan. Physician orders included venlafaxine for depression and haloperidol PRN for agitation. However, the resident's care plan, initiated in 2022 and most recently revised in 2026, did not include a plan of care for psychotropic drug use. During an interview, the Nursing Home Administrator confirmed the facility failed to develop person-centered care plans for one of six residents.
Opened Medications and Biologicals Were Not Properly Labeled
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. Review of the facility policy on Medication Labeling and Storage showed that multi-dose vials that have been opened or accessed must be dated and discarded within 28 days unless the manufacturer specifies otherwise. During observation of the medication storage room, one vial of tuberculosis purified protein derivative solution (PPD) was found opened with no open date written on the vial or the box containing it. A registered nurse confirmed that the vial appeared accessed and that there was no open date on either the vial or the box. In a separate observation, a nicotine patch box used for a resident was found opened, undated, and unlabeled, and the registered nurse confirmed that the box and patch were unlabeled and undated.
Failure to Post Medicaid Fraud Unit Contact Information
Penalty
Summary
The facility failed to post contact information for the Medicaid Fraud Unit on two of two nursing units, identified as the [NAME] and Garden nursing units. During observations on 3/4/25 at approximately 1:30 p.m., surveyors found that the contact information for the Medicaid Fraud Unit was not posted or accessible to residents on either unit. During an interview on 3/6/26 at approximately 12:00 p.m., the Nursing Home Administrator confirmed that the facility had failed to post the Medicaid Fraud Unit contact information on both nursing units. The deficiency was cited under 28 Pa. Code: S201.29(i) Resident rights.
Failure to Display Medicare and Medicaid Benefit Information
Penalty
Summary
The facility failed to display written information on how to apply for Medicare and Medicaid benefits and on receiving refunds for previous payments covered by Medicare and Medicaid on two of two nursing units, identified as the [NAME] and Garden nursing units. During observations on 3/4/25 at approximately 1:30 p.m., surveyors found that the required information was not included on either unit. During an interview on 3/6/26 at approximately 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to display the written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid on both units.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to post the most recent Federal or State survey results in the survey binder located in the main entrance lobby. Observation of the binder on 3/4/26 at 1:30 p.m. showed that the most recent survey results available were dated 9/11/24, even though the facility survey history included surveys dated 1/8/25, 4/30/25, 6/11/25, 7/28/25, 9/3/25, 11/4/25, 12/2/25, 1/14/26, and 2/12/26. During an interview on 3/6/26 at approximately 12:00 p.m., the Nursing Home Administrator confirmed that the facility failed to post the most recent Federal or State survey results for one of one survey books observed.
Failure to Prevent Resident-to-Resident Sexual Abuse by Known Sexually Disinhibited Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident sexual abuse despite having policies defining abuse, neglect, and sexual abuse as non-consensual sexual contact of any type with a resident. The facility’s own policy states that abuse includes the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and that neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility had residents with known psychiatric and behavioral conditions, including one resident with a history of sexually inappropriate behavior, but did not have an adequate care plan in place addressing sexual expression and safety until after an incident occurred. One resident (R1) had diagnoses including parkinsonism, bipolar disorder, and anxiety disorder, and a BIMS score of 15, indicating cognitive intactness. Another resident (R2) had schizoaffective disorder, anxiety, and depression, and a BIMS score of 6, indicating severe cognitive impairment. R2’s care plan identified risk for attention-seeking/manipulative behavior related to psychiatric disease. On a documented date, staff reported that R1 was observed in the dining room alone with R2, acting inappropriately and exposing himself. The residents were separated, and the note stated that the other resident appeared to be consenting, but R2’s low BIMS score and psychiatric diagnoses were known to the facility. The clinical record showed that R1 had exhibited sexually inappropriate behavior on multiple prior dates (7/21/25, 7/23/25, 8/16/25, and 1/3/26). A psychiatric evaluation note for R1 documented that he had been exhibiting inappropriate sexual behaviors with female residents and that staff had observed these behaviors. Staff interviews revealed that some employees had witnessed the incident between R1 and R2 and that at least two staff members had heard rumors or observed changes in R1’s behavior, including sexual behaviors, beginning around the summer of 2025. Despite this history and staff awareness, R1’s care plan addressing sexual expression and protection from unconsented sexual expression was not initiated until after the incident with R2, and the facility failed to prevent R1, a resident with known sexually inappropriate behavior, from having sexual contact with a resident who was not capable of consent, resulting in an Immediate Jeopardy situation.
Removal Plan
- Place Resident R1 on 1:1 supervision and maintain 1:1 supervision.
- Ensure Resident R2 remains safe from resident-initiated sexual abuse by providing 1:1 supervision to Resident R1.
- Update Resident R1's care plan to reflect 1:1 supervision.
- Interview current female residents who are cognitively intact to identify any other residents potentially affected.
- Complete skin assessments for current female residents who are cognitively impaired to identify any other residents potentially affected.
- Provide education to all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee.
- Complete audits for new admissions and current residents for sexual behaviors to ensure resident safety.
- Hold an Ad Hoc Quality Assurance and Process Improvement (QAPI) meeting.
- Monitor the plan of correction at QAPI meetings until consistent substantial compliance is met.
Failure to Timely Develop Person-Centered Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s sexual behaviors despite multiple documented incidents. Facility policy dated 1/4/25 required comprehensive assessments, care planning, and care delivery to include collecting and analyzing information, choosing and initiating interventions, and then monitoring and adjusting interventions. The resident, who had diagnoses including parkinsonism, bipolar disorder, and anxiety disorder, had a BIMS score of 15 on the 10/26/25 MDS, indicating intact cognition. The clinical record showed that the resident exhibited sexual behaviors on 7/21/25, 7/23/25, 8/16/25, and 1/3/26. Despite these documented behaviors, the resident’s care plan addressing sexual activity and sexual expression was not initiated until 1/5/26. When it was initiated, the goal was for the resident to be safe during the stay and protected from unconsented sexual expression, with interventions including education to the resident/responsible party as needed, notifying family as needed for cognitively impaired residents, providing privacy if both residents were deemed capable of consenting, and staff providing comfort, reassurance, support, and risk assessment. During an interview on 1/14/2 at approximately 4:00 p.m., the Nursing Home Administrator and the DON confirmed that the facility failed to develop and implement comprehensive care plans to meet resident care needs for one of five residents, in violation of 28 Pa. Code 211.11(d) Resident Care Plan.
Failure of Administration and Nursing Leadership to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to protect residents from resident-to-resident sexual abuse. The NHA job description requires managing the facility in accordance with applicable federal, state, and local standards and regulations, following all facility policies uniformly, and ensuring the highest degree of quality care for residents at all times. The DON job description requires planning, organizing, developing, and directing the overall operation of the nursing service department in accordance with current standards, guidelines, and regulations, and as directed by the Administrator and Medical Director, to ensure the highest degree of quality care is maintained. Based on review of job descriptions, clinical records, and staff interviews, surveyors determined that the NHA and DON did not fulfill these essential duties, as the facility failed to prevent and protect residents from resident-to-resident sexual abuse. Specifically, a resident with a known history of sexually inappropriate behavior engaged a non-consenting resident, affecting one of 44 residents (identified as Resident R2). During an interview, the NHA and DON confirmed that they failed to effectively manage the facility to protect residents from resident-to-resident sexual abuse for this resident. The cited regulatory references include 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Failure to Provide Opportunity for Advance Directive Formulation and Review
Penalty
Summary
The facility failed to provide two residents with the opportunity to formulate an advance directive or to conduct periodic reviews of their advance directive status, as required by facility policy and state regulations. Review of the clinical records for both residents, who were cognitively intact with BIMS scores of 15, showed no documentation that they had been given written information about their right to accept or refuse medical treatment or to create an advance directive upon admission. Additionally, there was no evidence in their records that periodic reviews of advance directive instructions had occurred. Both residents had significant medical histories, including diagnoses such as adult failure to thrive, anxiety, depression, diabetes mellitus, osteomyelitis, and toe amputation. Despite these conditions and their cognitive ability to participate in care planning, the facility did not document any discussion or provision of information regarding advance directives. The deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging the lack of compliance for these two residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide required transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division for four months, from July through October 2025. According to the facility's own policy, when an emergency transfer or discharge to a hospital or related institution occurs, several steps must be followed, including notifying the resident's attending physician, the receiving facility, the resident's representative or family member, and preparing necessary documentation. However, during staff interviews and policy review, it was confirmed that the facility did not send transfer notices to the Ombudsman Division representatives during the specified period, as required by regulation 28 Pa. Code 201.18(b)(3)(e)(2).
Failure to Provide Prescribed Therapeutic Diets to Multiple Residents
Penalty
Summary
The facility failed to meet the dietary needs of three out of eight residents by not ensuring that prescribed diets were accurately ordered and provided according to each resident's medical requirements. For one resident with diagnoses including heart failure, chronic kidney disease, and high blood pressure, the hospital discharge paperwork specified a cardiac, 2 gm sodium-restricted diet. However, upon admission, the appropriate dietary restriction was not selected in the assessment, and the resident initially received a regular diet without restrictions. The diet order was later changed to a no added salt (NAS) diet only after the deficiency was identified. Another resident with chronic obstructive pulmonary disease, pulmonary fibrosis, and high blood pressure was admitted with no diet order included in the physician's orders, despite the assessment indicating a regular diet. A third resident, admitted with muscle weakness and gait abnormalities, had hospital discharge instructions for a cardiac, moderate carbohydrate, 2 gm sodium, and 1800 mL fluid-restricted diet, but the facility's assessment only indicated a controlled carbohydrate diet, and no diet order was present in the physician's orders until after the issue was raised. These deficiencies were confirmed through review of clinical records, hospital discharge paperwork, admission assessments, and physician orders, as well as interviews with facility administration. The lack of timely and accurate diet orders resulted in residents not receiving diets that met their specific medical and nutritional needs as prescribed, in violation of federal and state regulations regarding food and nutrition services, management, nursing services, resident rights, and dietary services.
Plan Of Correction
Resident R2, R3, and R4 were assessed. No negative outcome resulted from not including diet orders in physician orders. Diets were added in per hospital de records for each resident. An audit was completed to ensure all residents have accurate diet orders in physician orders. Don, or designee, will educate licensed staff on following the physicians' orders policy and verifying orders. The DON, or designee, will conduct an audit to ensure that all new admissions have accurate diet orders per hospital de summary added into physician orders weekly for 2 weeks, then monthly for 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
Failure to Accommodate Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to provide food items that accommodated resident allergies, intolerances, and preferences for four out of nine residents reviewed. Specifically, one resident with a documented history of celiac disease did not have gluten intolerance noted on their admission assessment, diet order, or meal slips, despite multiple references to this condition in their hospital referral. The resident's dietary communication slip also lacked information about gluten intolerance, and their meal orders did not reflect this critical dietary need. Additionally, meal observations revealed that another resident was served chicken despite a documented dislike, a third resident received their meal on a regular plate instead of the required plastic bowls, and a fourth resident was served rice and bananas despite a documented dislike of rice and an allergy to bananas. The facility's policy required individual food preferences to be assessed and communicated upon admission, but this was not consistently implemented, resulting in residents not receiving their selected or appropriate menu items.
Plan Of Correction
Resident R4, R5, and R6 had no negative outcome for not following preference. Resident was offered a replacement meal which was accepted. Audit completed that all residents' preferences are listed. Dietary Manager or designee will educate dietary staff on following Resident Food Preference. Dietary Manager will audit tray line to ensure all preference tickets are being followed 2x a week by 2 weeks and monthly by 2 months.
Failure to Follow Physician Orders for PICC Line Dressing Change
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of a peripherally inserted central catheter (PICC) line for one resident. The resident, who had a history of diabetes and sepsis, was admitted with a PICC line in place. According to a physician's order, the PICC dressing and caps were to be changed every seven days, specifically on Wednesdays during the day shift. However, documentation in the treatment administration record indicated that the dressing was changed as ordered, but direct observation revealed that the dressing was dated from a previous week, indicating the order was not followed. Further review and staff interviews confirmed that the PICC dressing had not been changed according to the physician's order. The discrepancy between the documented care and the actual condition of the dressing was verified by both a registered nurse and the nursing home administrator. This failure to follow physician orders and facility policy for PICC line care constituted a deficiency in the administration of parenteral fluids and related nursing services.
Plan Of Correction
NotSpecified Resident R1 was assessed no negative outcome for not following physician order for dressing change. R1 dressing immediately changed. Facility residents with current PICC Line dressings treatment orders were audited to ensure appropriate and current order in place for treatment. Don, or designee will educate licensed staff on treatment and following physicians orders policy, and verifying orders. DON, or designee will conduct an audit to ensure that treatment orders are being followed, for PICC Line dressing changes are being completed per physicians orders weekly times 2 weeks, then monthly times 2 months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
Failure to Meet Minimum LPN Staffing Requirements Across All Shifts
Penalty
Summary
Facility administrative staff failed to provide the minimum required number of LPNs per state regulations for all shifts over a 21-day period. Review of nursing schedules and census information revealed that on multiple occasions, the number of LPN hours provided during day, evening, and night shifts did not meet the required staffing ratios. Specific shortfalls included shifts where no LPN hours were provided at all, as well as shifts where the hours provided were consistently below the required minimums based on the resident census. This deficiency was confirmed through both documentation review and staff interviews, including confirmation from the Nursing Home Administrator. The report details each day and shift where the required LPN coverage was not met, with deficiencies occurring on every day reviewed. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
The residents had no negative outcome for not meeting the minimum of one LPN per 25 residents on day shift, one LPN per 30 residents on the evening shift, and one LPN to 40 residents on the night shift. The facility is attempting to hire additional staff, hold daily staffing meetings to track staffing, and has added additional agencies to utilize for staffing needs. The DON/designee will provide the Staffing Coordinator/HR with re-education on the Pennsylvania staffing requirements for ratios. Staffing coordinator/designee will audit the ratios five times weekly for two weeks and monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met.
Failure to Notify Representatives and Providers of Resident Condition Changes
Penalty
Summary
The facility failed to notify resident representatives and/or medical providers of changes in condition or care for three residents. In one case, a resident with cirrhosis and a hip fracture complained of feeling unwell and cold throughout the night, but there was no documentation that the provider was notified of these symptoms prior to the resident being found unresponsive and subsequently pronounced deceased. The resident's son and physician were only notified after the resident's death. In another instance, a resident with schizophrenia and paraplegia had a diet change from mechanical soft to pureed, but the legal guardian and responsible party was not informed of this change, leading to questions from the family about the resident's medications and dietary modifications. Additionally, a resident with COPD, lung cancer, and dementia was transferred to the hospital for altered mental status and behavioral concerns without notification to the emergency contact or legal guardian. Documentation failed to show that the family was informed of the transfer, and family-submitted information confirmed they were not notified. The Nursing Home Administrator and Director of Nursing confirmed these failures to notify the appropriate parties regarding changes in condition or care for these residents.
Incomplete and Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for four out of eight residents reviewed. According to the Resident Assessment Instrument (RAI) User's Manual, specific sections of the MDS, including Section C: Cognitive Patterns and Section D: Mood, require completion based on the resident's ability to be understood. For several residents, documentation indicated that they were not in a persistent vegetative state and were at least sometimes understood, which should have triggered the completion of the Brief Interview for Mental Status (BIMS) and Resident Mood Interview. However, these sections were marked as 'Not Assessed' for the affected residents. Review of clinical records showed that for each of the four residents, key assessment sections were either left incomplete or not assessed at all, despite documentation that indicated the assessments should have been conducted. This included residents who were documented as being understood or usually understood, yet their cognitive and mood assessments were not performed as required. The Nursing Home Administrator confirmed during an interview that the facility did not ensure the comprehensive MDS assessments were accurate and fully completed for these residents.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three of eight residents reviewed. For one resident with diagnoses of diabetes and bipolar disorder, the care plan did not include goals or interventions related to the use of prescribed antidepressant and antipsychotic medications, despite multiple physician orders for these medications. Another resident, admitted with pressure ulcers on both heels and diagnosed with metabolic encephalopathy and muscle weakness, had a care plan that addressed only the risk of developing skin integrity issues, but did not include a plan of care with goals and interventions for the actual presence of a Stage III pressure ulcer. A third resident, with osteoporosis, muscle weakness, and hypercalcemia, was observed self-administering medication but did not have a care plan addressing self-administration of medication, despite being cognitively intact and reporting difficulty swallowing pills. The Nursing Home Administrator and Director of Nursing confirmed that comprehensive care plans addressing all resident care needs were not completed for these residents, as required by facility policy and state regulations.
Failure to Train Staff on Chemotherapy Waste Management Procedures
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff, specifically regarding care procedures for residents receiving chemotherapy. Despite a physician's order for a resident diagnosed with B-cell lymphoma to flush the toilet twice with the lid down after use, the facility did not update the resident's Kardex with this information. Additionally, the shared restroom used by the resident and another individual did not have a commode lid, and the posted instructions were unclear. Nurse aides interviewed were not provided with education on proper waste disposal or on preventing exposure to chemotherapy drug waste, and they expressed confusion about the instructions due to the absence of a commode lid. The facility assessment indicated that care for chemotherapy patients was not previously common, and both the Nursing Home Administrator and Director of Nursing confirmed that staff had not received training on this topic. The lack of training and clear procedures resulted in staff being unprepared to safely manage waste from a resident undergoing chemotherapy, as evidenced by their inability to interpret or follow the posted instructions and the absence of relevant information in the resident's care documentation.
Failure to Provide Consistent Pressure Ulcer Treatment and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. The resident was admitted with pressure ulcers on both heels and had a diagnosis of metabolic encephalopathy and muscle weakness. The care plan developed addressed only the risk of developing skin integrity issues but did not include specific goals or interventions for the resident's existing pressure ulcer. Physician orders were in place for wound care, including cleansing and dressing changes, but the care plan did not reflect the actual presence of a pressure ulcer. Documentation review revealed multiple dates where wound treatments were not completed as ordered, with no documentation of refusals or reasons for missed treatments. Progress notes did not provide explanations for the lack of completed dressing changes. During interviews, facility leadership confirmed that necessary treatment and services were not consistently provided for the resident's pressure ulcer.
Failure to Ensure Safe Handling of Chemotherapy Waste
Penalty
Summary
The facility failed to provide a safe environment for a resident receiving chemotherapy, resulting in a deficiency related to accident hazards and supervision. Facility documentation showed that a resident was prescribed chemotherapy and required special handling of bodily waste, including flushing the toilet twice with the lid down after use. However, the shared restroom used by this resident and another was not equipped with a toilet lid, making it impossible to follow the physician's order. Additionally, the resident's care plan (Kardex) did not include instructions regarding the special waste disposal procedure. Staff interviews revealed that nursing assistants were not educated on the proper procedures for handling waste from a resident receiving chemotherapy. Both staff members interviewed were confused by the posted instructions, as there was no lid to close, and they had not received training on how to prevent exposure to chemotherapy drug waste. Facility leadership confirmed the failure to provide a safe environment for the residents involved.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for all ten staff members reviewed. The facility's policy, dated 1/4/24, mandates that all staff, including new hires, existing employees, individuals providing services under contractual arrangements, and volunteers, participate in regular in-service education, including training on the facility's QAPI program. However, upon reviewing the training records, it was found that none of the ten staff members, including nurse aides, a licensed practical nurse, a housekeeping employee, a dietary aide, a maintenance director, and an assistant director of nursing/infection control preventionist, had documented QAPI training within the specified timeframe. During an interview, the Nursing Home Administrator confirmed the lack of QAPI training for these staff members and stated that corporate had not included QAPI in the mandatory training for all staff. This oversight was identified as a deficiency under the Pennsylvania Code, specifically sections 201.14 (a) regarding the responsibility of the licensee, 201.18 (b)(1) concerning management, and 201.20 (a)(c) related to staff development.
Failure to Maintain a Clean, Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, homelike environment on two nursing units, [NAME] Lane and Garden Lane, as observed during a survey. In the main resident lounge on [NAME] Lane, six wheelchairs, a Hoyer lift, and a floor scale obstructed resident access. The dining room at the end of [NAME] hall had a broken baseboard heating unit with sharp edges protruding. On Garden Lane, the dining room contained two wheelchairs marked for cleaning since 4/21/24, with debris and broken armrests. Additionally, a closet with personal items was left open and accessible to residents, and the emergency exit near the therapy room was blocked by six wheelchairs, both at the exit and in the hall leading to the outer exit. The Nursing Home Administrator confirmed these observations during an interview on 5/14/24 at 7:22 a.m. Further observations on 5/14/24 revealed additional deficiencies in the Garden Lane nursing unit. Resident R24's room had broken plastered walls behind the dresser, closet, bed, and nightstand. Residents R4 and R22 had broken plaster behind their beds, a broken baseboard heater unit, a tripping hazard due to a lifted bathroom transition strip, and clothes piled on the floor in their shared closet. Residents R34 and R25 had holes in the wall behind their beds, soiled floors with food debris and liquids, and clothes piled on the floor in their shared closet. Residents R16 and R17's floor had debris, including a marker lying in the middle. The Nursing Home Administrator confirmed these findings during an interview on 5/14/24 at 10:45 a.m.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care, for five out of six residents reviewed. The facility's policy, which was reviewed on two occasions, indicated that residents should be provided with written information about their rights to refuse or accept medical treatment and to formulate an advance directive upon admission. However, the clinical records for Residents R1, R2, R12, R20, and R35 did not contain an advance directive or documentation that they were given the opportunity to formulate one. The deficiency was confirmed during interviews with the Social Services Director and the Nursing Home Administrator. The Social Services Director admitted to confusing POLST with advance directives, acknowledging that the residents were not afforded the opportunity to formulate advance directives upon admission and periodically during their stay. The Nursing Home Administrator also confirmed the facility's failure to provide this opportunity, which is a violation of the residents' rights as outlined in the state code.
Failure to Include Required Members in QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all required committee members, specifically the Infection Preventionist, for three of four quarterly meetings from May 2023 through January 2024. The facility's policy, reviewed on January 4, 2024, mandates that the QAPI committee must include the administrator, director of nursing, medical director, and an infection control representative. However, a review of QAPI sign-in sheets and attendance records revealed that the infection control representative did not attend any of the meetings during the specified period. This deficiency was confirmed during an interview with the Nursing Home Administrator on May 17, 2024, who acknowledged the failure to include all required members in the QAA meetings as stipulated by the facility's policy and regulatory requirements.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health training to three out of ten staff members reviewed, as required by their policy and facility assessment. The policy, dated 1/4/24, mandates that all staff, including those under contractual arrangements and volunteers, participate in regular in-service education upon hire and annually. This training includes communication, abuse, neglect, the facility's QAPI program, and behavioral health. However, upon reviewing the education records, it was found that Housekeeping Employee E4, Dietary Aide Employee E5, and Maintenance Director Employee E8 did not have current behavioral health training documented. Housekeeping Employee E4 was hired on 12/29/23, Dietary Aide Employee E5 on 7/10/23, and Maintenance Director Employee E8 on 9/1/20. Despite these employment dates, their training records lacked evidence of behavioral health training. This deficiency was confirmed during an interview with the Nursing Home Administrator on 5/15/24, who acknowledged the facility's failure to provide the necessary training. The report cites violations of specific Pennsylvania Code sections related to the responsibility of the licensee, management, and staff development.
Inaccurate MDS Assessment for Hospice Care
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status for one of the residents, identified as Resident R23. The Resident Assessment Instrument (RAI) User's Manual provides instructions for completing MDS assessments, including Section O, which requires documentation of special treatments, procedures, and programs performed in the last 14 days. Resident R23 was readmitted to the facility with diagnoses of moderate intellectual disabilities, dementia, and anxiety. The MDS assessment for Resident R23 did not indicate hospice care services, despite a physician's order dated 12/14/23, confirming the resident's admission to hospice services. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), Employee E13, who acknowledged the inaccuracy in the MDS assessment.
Improper Storage of Food in Medication Refrigerator
Penalty
Summary
The facility failed to adhere to its policy on medication labeling and storage, which mandates that medications requiring refrigeration be stored separately from food and drinks. During an observation on May 15, 2024, it was found that two Fuji brand water bottles, one sparkling water bottle, and a small carton of whole milk were stored in the medication refrigerator in the [NAME] Nursing Unit medication room. This was confirmed by a Registered Nurse, Employee E13, who acknowledged that food and drinks should not be stored in the medication refrigerator. Further confirmation of this deficiency was provided by the Nursing Home Administrator and Director of Nursing during an interview on May 16, 2024. The facility's failure to prevent the storage of food items in a medication refrigerator is a violation of 28 Pa Code: 211.9 (a) Pharmacy services and 28 Pa code: 211.12 (d) (1) (5) Nursing services.
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Illustrative
What surveyors actually found near you
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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
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Nursing homes near Bethel Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Of South Hi | 3.9 mi | ★★★★★ | 16 | 0 |
| South Hills Post Acute | 4 mi | ★★★★★ | 3 | 0 |
| Peters Township Post Acute | 4.7 mi | ★★★★★ | 11 | 0 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 4.9 mi | ★★★★★ | 21 | 0 |
| Mcmurray Hills Rehabilitation And Healthcare Cente | 4.9 mi | ★★★★★ | 3 | 0 |
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