Meadowcrest Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethel Park, Pennsylvania.
- Location
- 1200 Braun Road, Bethel Park, Pennsylvania 15102
- CMS Provider Number
- 395698
- Inspections on file
- 31
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Meadowcrest Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
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.
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.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
