Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadows Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete controlled medication count documentation was found on three medication carts after review of shift narcotic count records and facility policy. The records for Clover, Bluebell, and Dogwood Units had multiple missing signatures from incoming and outgoing nurses, and two LPNs confirmed the omissions. The DON acknowledged the facility did not consistently follow its policy for shift-to-shift controlled med counts.
Failure to Protect a Resident from Sexual Contact by Another Resident: A resident with dementia and prior sexually inappropriate behaviors was found in another resident’s room with the resident’s pants partially removed and genitals exposed. Staff reports described the resident with hands in the other resident’s groin area and refusing to leave when directed, while the affected resident later described unwanted touching and said the behavior made him feel disgusted. The record lacked documented assessments, behavioral review, or psychosocial follow-up after the incident.
Failure to investigate resident-to-resident sexual abuse allegation: Two residents with dementia, one moderately cognitively impaired and the other severely cognitively impaired, were involved in an incident where a nurse aide observed one resident with his hands inside the other resident’s brief in the genital area. Staff did not obtain timely written statements, did not document resident assessments or investigative findings at the time, and there was no documented evidence that physicians or resident representatives were notified or that protective interventions were implemented until the resident was later moved to another unit.
A facility failed to consistently implement ordered pressure injury prevention measures for two residents with impaired mobility and cognitive impairment. One resident with dementia and CKD was observed in a Broda chair without ordered calf bumpers, and another resident with dysphagia and malnutrition was observed without ordered calf bumpers or a foot buddy board; staff confirmed the ordered devices were not applied.
A resident at high fall risk with CHF, COPD, and vertigo was left without timely staff assistance while toileting, then fell forward in the bathroom and sustained a large head laceration requiring staples and hospital admission. In a separate event, a severely cognitively impaired resident with a history of wandering did not have the ordered Wander guard device in place during observation, and the required photo was not maintained at the receptionist area, despite ongoing elopement risk and documented wandering behavior.
Failure to Maintain Ordered Oxygen Humidification: A resident with respiratory failure and hypoxia was ordered oxygen at 5.0 L/min via NC with humidified water and routine checks of the humidifier bottle. Staff documentation showed the bottle was filled and checked, but surveyors observed the resident receiving oxygen with no water in the humidifier bottle and later with only a partial water level. The DON confirmed the findings and the facility's responsibility to follow the physician's order.
Failure to assess and manage worsening pain: A resident with diabetes and mid-back fractures had moderate cognitive impairment and documented pain that progressed beyond the existing acetaminophen order for mild pain. The MAR showed repeated pain assessments, but there was no comprehensive pain re-evaluation, no physician notification, no revised pain regimen, and the care plan did not identify the resident's pain or interventions. The resident later reported severe neck and mid-back pain, and the DON could not provide evidence of timely pain reassessment or physician intervention.
A resident with CHF and oropharyngeal dysphagia had a physician order for a puree diet, but an LPN served a peanut butter and jelly sandwich as a snack without checking the diet order. The resident began coughing, a piece of sandwich was found in the throat, and an RN performed the Heimlich maneuver to remove it.
A resident with dementia, peripheral vascular disease, and ongoing lower extremity vascular wounds did not receive timely, comprehensive wound assessments as required by facility policy and best practices. Over several months, nursing progress notes repeatedly documented the same limited descriptions of a left shin wound, including slough, open areas, scattered scabs, granulation tissue, and scant serous drainage, but lacked measurements, staging, and complete weekly assessments. Despite a change in treatment orders and instructions to document the wound condition daily, the record contained no evidence of full wound assessments with location, stage, length, width, depth, or exudate/necrotic tissue details until an outside wound management provider conducted a full-body skin assessment, and the facility could not show that an RN had completed timely, comprehensive assessments of the venous ulcer before that time.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A nurse aide transported a resident with peripheral vascular disease in a shower chair through a hallway while the resident's buttocks and gluteal cleft were exposed due to inadequate covering. The aide was unaware of the exposure, and the facility did not ensure the resident's dignity was maintained during care.
A resident's bed linens remained visibly soiled with large tan stains and dark red streaks over multiple days, despite staff being responsible for changing bedding when soiled. Interviews with a nurse aide and the DON confirmed that the facility did not maintain a clean, safe, and sanitary environment in the resident's room.
The facility did not update comprehensive care plans for two residents to reflect current physician orders, including insulin administration, fluid restrictions, and oxygen therapy. This deficiency was identified through clinical record reviews and staff interviews, showing that care plans were not revised to address the residents' individualized needs.
A resident with inflammatory polyarthropathy was not consistently provided with restorative ambulation services as outlined in their care plan. Although records indicated that ambulation with a rollator walker was completed regularly, the resident reported only walking once in the past month. A nurse aide admitted to documenting the task as completed before actually performing it, leading to discrepancies between documentation and actual care provided.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, as observed by surveyors during their review.
The facility did not provide required written notices of facility-initiated hospital transfers to the State LTC Ombudsman for two residents. Although the residents and their representatives received the notices, there was no documentation that the Ombudsman was notified, as confirmed by the Nursing Home Administrator.
A resident with multiple orthopedic conditions and a non-weight bearing order suffered a right tibia and fibula fracture requiring surgery after three nurse aides transferred her without using the required mechanical lift, despite being aware of the physician's order and care plan. The aides manually transferred the resident during a shower, leading to severe pain and injury, and the facility's investigation substantiated neglect due to failure to follow safety protocols.
The facility failed to provide restorative ambulation services to residents, as evidenced by the experiences of three residents with various medical conditions. Changes in staffing and budgeting led to the removal of designated restorative aides, placing the responsibility on nurse aides. Residents expressed that they were not receiving their scheduled ambulation programs, and records confirmed limited participation. Interviews with facility leadership revealed an inability to explain the lack of services, despite acknowledging the facility's responsibility.
A resident with severe cognitive impairment and a history of skin tears was not provided with prescribed Geri Sleeves to protect her arms, despite a physician's order. Observations confirmed the absence of these protective devices, and staff were unable to explain or locate them, indicating a failure to adhere to professional standards of practice.
A resident with dementia and congestive heart failure exceeded their physician-ordered fluid restriction multiple times over several weeks. The facility's policy required notifying the physician if fluid restrictions were exceeded, but there was no documentation of such notifications. An interview with the DON confirmed the lack of adherence to the fluid restriction order, indicating a deficiency in maintaining the resident's care plan.
The facility failed to monitor and document IV therapy according to professional standards for two residents. One resident's IV site was not labeled with the date of insertion, and the catheter was not removed after completing medication. Another resident's IV site dressing was not dated, and there was no documented evidence of a dressing change. The DON confirmed these deficiencies.
A facility failed to communicate necessary resident information to a receiving health care provider during a transfer. A resident was transferred to a hospital with the expectation of returning, but there was no documented evidence that the resident's care plan goals and necessary information were communicated. The Nursing Home Administrator confirmed this deficiency during an interview.
The facility did not provide written notification of its bed-hold policy to two residents or their representatives upon hospital transfer, as required. This deficiency was confirmed through a review of clinical records and an interview with the administrator, which revealed a lack of documented evidence for the provision of the necessary information.
A resident with a history of kidney transplant received incorrect doses of Tacrolimus due to a transcription error by a nurse, leading to Tacrolimus toxicity and subsequent hospitalization. The error was discovered after the resident showed symptoms of altered mental status and low blood oxygen saturation.
Two residents suffered injuries due to neglect in a facility. One resident with severe cognitive impairment fell because an LPN failed to lower the bed as per the care plan, resulting in a head injury. Another resident was injured during transport when the van driver did not secure the wheelchair properly, causing it to flip. Both incidents were confirmed by the DON.
Incomplete Controlled Medication Count Documentation
Penalty
Summary
The facility failed to consistently maintain accurate controlled medication accountability records on three of three medication carts reviewed: Clover Unit, Bluebell Unit, and Dogwood Unit. A review of the facility policy on Controlled Medication-Receipt, Count, and Secure Storage showed that controlled drug counts were to be completed at the beginning of each shift by the outgoing nurse and the incoming nurse, with paperwork completed using legible dates and initials. However, the Shift Narcotic Count Signature Sheets for the Clover Unit showed missing signatures from the incoming and outgoing nurses on May 20, 2026, and a missing signature from the day shift incoming nurse on May 28, 2026. Employee 6, an LPN, confirmed the missing signatures during an interview on May 28, 2026. The Bluebell Unit Shift Narcotic Count Signature Sheet also showed incomplete documentation, including missing signatures from the night shift incoming nurse on May 23, 2026, the day shift outgoing nurse on May 24, 2026, and the day shift incoming nurse on May 28, 2026. The Dogwood Unit record contained multiple missing signatures across several dates in March, April, and May 2026, including missing signatures from incoming and outgoing nurses on multiple shifts. Employee 7, an LPN, confirmed the missing signatures for the Bluebell Unit and Dogwood Unit records, and the DON later confirmed the facility failed to consistently implement its policy requiring outgoing and incoming nursing staff to complete and sign shift-to-shift controlled medication count records.
Failure to Protect a Cognitively Impaired Resident from Sexual Contact
Penalty
Summary
The facility failed to protect one resident from non-consensual sexual contact by another resident. The deficiency involved a resident with dementia and a history of sexually inappropriate behavior, including prior documented vulgar sexual comments toward staff, invading another resident’s personal space, and entering other residents’ rooms. His care plan identified behaviors such as inappropriate sexual statements, entering other residents’ rooms, and making inappropriate statements and gestures, with interventions including redirection, removal from situations, and 1:1 support as needed. The affected resident had dementia and severe cognitive impairment, with a BIMS score of 03. He was dependent on staff for lower body dressing and toileting hygiene. On the day of the incident, staff entered the room and observed the other resident with his hands in the affected resident’s groin area while the affected resident’s pants were partially removed, his brief was open or torn, and his penis was exposed. One staff member documented that the resident appeared to be attempting to remove the brief and stated he was trying to help change the resident, while another staff member observed the resident seated beside the affected resident with a hand on his upper thigh and reported that the resident refused to leave when directed. Staff accounts differed regarding whether direct touching occurred, but one aide stated it appeared the resident was touching the affected resident’s penis and groin area and that the resident did not comply when told to stop. The registered nurse supervisor responded, observed the resident seated next to the affected resident with exposed genitals, and directed him to leave, but did not debrief or interview the aides who had witnessed the event. The clinical record contained no documented assessments, evaluations, behavioral reviews, or nursing documentation regarding the incident, and no documentation of follow-up observations or psychosocial impact. During interview, the affected resident described unwanted interactions with a male resident, stating the resident was trying to feel him up, that the behavior made him feel disgusted, and that he did not want the resident’s attention.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement abuse prevention and investigation procedures after an allegation of resident-to-resident sexual abuse involving two residents. One resident had diagnoses including dementia and was assessed as moderately cognitively impaired with a BIMS score of 11, while the other resident also had dementia and was assessed as severely cognitively impaired with a BIMS score of 03. Facility policy required staff to immediately separate residents, assess for injury, initiate an investigation, obtain written statements from staff on duty, notify the administrator, physician, resident representative, law enforcement, and report the incident to the Pennsylvania Department of Health and local Area on Aging within 24 hours. Facility documentation and staff interviews showed that two nurse aides observed one resident with his hands inside the other resident’s brief in the area of the resident’s genitals, creating an allegation of sexual abuse. The nurse aides stated they were not asked to provide written statements at the time of the incident, and a registered nurse supervisor stated she did not interview or debrief them. The clinical records contained no documented evidence of resident-specific observations, evaluations, assessments, or investigative documentation at the time of the incident, and there was no documented evidence that physicians or resident representatives were notified. The records also lacked evidence of additional interventions to address the resident’s behavior or to protect the other resident and others from further unwanted contact until the resident was transferred to another nursing unit approximately 16 days later.
Failure to Apply Ordered Pressure Injury Prevention Devices
Penalty
Summary
The facility failed to consistently implement physician-ordered pressure injury prevention interventions for two residents with impaired mobility and cognitive impairment. Resident 18 was admitted with chronic kidney disease and dementia, had a care plan identifying potential for pressure-related skin failure related to impaired mobility, and had an order to be out of bed in a Broda chair with calf bumpers at all times. During observation, Resident 18 was sitting in the Broda chair with the leg rest brackets exposed and no calf bumpers applied, and the RN confirmed the ordered calf bumpers were not in place. The resident’s MDS indicated severe impairment in daily decision-making, and the BIMS was not completed because the resident was rarely or never understood. Resident 126 was admitted with dysphagia and moderate protein-calorie malnutrition, had a baseline care plan identifying potential for pressure-related skin failure related to impaired mobility, and had an order to be out of bed in a Broda chair with a padded foot buddy board and calf bumpers at all times. During observation, Resident 126 was in the Broda chair with the leg rest brackets exposed, no calf bumpers applied, and the foot buddy board not in place. The nurse aide confirmed that the ordered calf bumpers and foot buddy board were not applied. The resident’s admission MDS showed severe cognitive impairment with a BIMS score of 7.
Failure to Provide Adequate Supervision and Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and timely staff assistance for a resident identified as high risk for falls. Resident 63 was admitted with CHF, COPD, benign paroxysmal vertigo, and atrial fibrillation. The resident’s admission MDS showed intact cognition with a BIMS score of 14, required partial to moderate assistance with toileting hygiene, and required supervision or touching assistance to get on and off the toilet or commode. The resident’s fall risk evaluation scored 20, indicating high fall risk, and the care plan directed staff to ambulate the resident to and from the bathroom with one staff member using a rolling walker and gait belt. On the evening of the incident, nursing documentation showed staff found Resident 63 lying face down on the floor partially inside the bathroom doorway with significant bleeding from a large head laceration. The note described a wound approximately 12 cm by 12 cm deep with a skin flap on the top of the head extending toward the forehead. Staff repositioned the skin flap, approximated the wound edges, applied Steri-Strips and gauze dressings, and maintained pressure and ice until EMS arrived. The documentation indicated blood on the inside of the bathroom door suggested the resident fell forward and struck her head on the door. Hospital records showed the resident reported dizziness from vertigo, tripping over her own foot, and falling forward with a head strike, and the laceration required ten staples. The emergency department also diagnosed acute respiratory failure with hypoxia and admitted the resident. Facility investigation records showed the resident had been placed on the toilet about five minutes before the fall. Although the call bell was documented as within reach, it was not activated when staff found the resident on the floor. The resident stated she rang the call bell before the fall but no one responded, and she believed she waited long enough before attempting to transfer herself from the toilet. She also stated that some staff stayed with her during toileting while others did not, and that she knew she was not supposed to get up by herself. A nurse aide stated the resident was assisted to the bathroom, told to use the call bell when finished, and had been reported as not herself before the fall. The DON confirmed the facility failed to provide the supervision necessary to ensure the resident’s safety and prevent the avoidable fall. The facility also failed to consistently implement planned safety interventions for Resident 108. The resident had vascular dementia and depression, a BIMS score of 03 indicating severe cognitive impairment, and an elopement risk assessment identifying the resident as high risk for elopement. The resident had a history of wandering in the community before admission and had required relocation twice before placement in the facility. A physician order required a Wander guard bracelet on the resident’s right lower extremity and wheelchair, with staff to verify placement and proper functioning every shift. Clinical notes documented wandering through hallways and into other residents’ rooms, including nighttime wandering. However, during observation, no Wander guard device was present on the resident’s right leg or any other extremity, and the resident did not have a personal wheelchair in the room. The receptionist’s monitoring log still listed the resident for Wander guard monitoring, but no resident photograph was maintained as required by facility policy. The DON confirmed the facility failed to consistently implement and monitor the resident’s planned elopement prevention interventions.
Failure to Maintain Ordered Oxygen Humidification
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to a physician's order for one resident. The resident was admitted with respiratory failure and hypoxia and had moderately impaired cognition with a BIMS score of 11. Physician orders dated May 21, 2026 directed oxygen at 5.0 L/min by nasal cannula with humidified water, with staff to check the humidification every shift, refill as needed, and have nightshift fill the humidifier bottle daily. A review of the TAR showed the humidifier bottle was signed off as filled on May 26, 2026 at 11:00 PM and the water level was checked on May 27, 2026 at 7:00 AM. However, an observation on May 27, 2026 at 11:15 AM found the resident receiving oxygen at 5.0 L/min via nasal cannula with no water in the humidifier bottle attached to the oxygen flowmeter. The humidification bottle was dated May 24, 2026. A later observation on May 29, 2026 at 8:00 AM found the resident still receiving oxygen at 5.0 L/min via nasal cannula with only a quarter of the humidifier bottle filled with water. The DON confirmed the findings and stated it was the facility's responsibility to ensure oxygen therapy was administered in accordance with the physician's order.
Failure to assess and manage worsening pain
Penalty
Summary
The facility failed to comprehensively evaluate, monitor, communicate, and implement appropriate interventions for new onset and worsening pain for Resident 41. The resident was admitted with diabetes and fractures of the mid-back area, and the admission MDS dated May 18, 2026, identified moderate cognitive impairment with a BIMS score of 11 and moderate pain over the prior 5 days. The admission pain evaluation documented that the resident was able to respond appropriately and reported no pain during the five days before admission. Physician orders initiated on admission included acetaminophen for resident-reported pain levels of 1 through 3, consistent with mild pain. The May 2026 MAR documented pain assessments on May 14, May 21, May 22, and May 28, 2026, showing pain that had not been identified on admission. The resident reported pain levels of 4 on May 21 and May 22, which exceeded the parameters of the existing order, but there was no documented comprehensive pain re-evaluation, no evidence the physician was notified, no evidence the pain regimen was re-evaluated, and no new or revised orders were obtained at that time. During interviews on May 28 and May 29, 2026, the resident reported neck and mid-back pain rated 8/10 and stated staff occasionally gave something for pain, but it was not effective. The comprehensive care plan did not identify the resident's pain, its location, or interventions to monitor or relieve it, and pain-related information was not added until after surveyor inquiry. The DON was unable to provide evidence of timely re-evaluation, physician notification, or timely physician intervention for the resident's ongoing pain complaints.
Pureed Diet Not Followed When Snack Was Served
Penalty
Summary
The facility failed to ensure that food was provided in a form that matched a resident’s ordered diet. Resident 94 had diagnoses including CHF and oropharyngeal dysphagia, and the physician order dated March 24, 2026 specified a puree diet with thin liquids. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11 and that the resident required setup or clean-up assistance for meals. A health status note documented that the resident was eating a peanut butter and jelly sandwich at the nurses station when the resident started coughing and was found to have a piece of sandwich in the throat. An LPN and RN assessed the resident, and the RN performed the Heimlich maneuver until the sandwich piece was expelled. Facility documentation stated that the sandwich had been provided as a snack by the LPN even though it was not a pureed food item and the LPN did not check the resident’s diet order before serving it.
Failure to Perform and Document Comprehensive Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, comprehensive assessment and monitoring of a resident’s lower extremity vascular wounds and to implement necessary practices to prevent worsening skin breakdown. The resident was admitted with dementia and peripheral vascular disease and had ongoing skin integrity issues related to vascular wounds on both lower extremities. An Annual MDS showed the resident was cognitively moderately impaired and required substantial/maximal assistance with mobility-related ADLs and used a wheelchair for mobility. Progress notes showed that from late October through late January, wound documentation for the resident’s left lower extremity was repetitive and lacked comprehensive assessment details. Entries on October 30 and November 7 documented a left lower extremity wound partially covered with slough, scant serous drainage, no infection, and stated wounds were improving with a directive to continue treatment, but did not include measurements or staging. On December 24, a new treatment order for the left shin wound was documented, including cleansing with antiseptic spray and application of Silvadene, with instructions to document the wound condition daily. Subsequent notes on January 6 and January 14 described five open areas with scattered scabs and scant serous drainage without signs of infection, but again did not include measurements or staging. Further progress notes dated January 15, 20, 22, and 27 repeated essentially identical descriptions of the left shin wound as vascular in appearance with five open areas, scattered scabs, pink granulation tissue, scant serous drainage, and no signs of infection, without additional or updated assessment information. The clinical record lacked documentation of required wound measurements, staging, or complete weekly assessments between October and early February, despite facility policy requiring assessment and documentation of location, stage, length, width, depth, and presence of exudate or necrotic tissue. Interviews with the NHA and the designated wound nurse confirmed that an outside wound management provider performed full-body skin assessments on all residents on February 2, and the wound nurse acknowledged that weekly full wound assessments with all required elements were expected but had not been fully documented for this resident’s venous ulcer prior to that date. The facility was unable to provide documentation that an RN completed timely and comprehensive wound assessments for the resident’s venous ulcer before February 2.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming.
Resident Exposed During Hallway Transport
Penalty
Summary
A nurse aide was observed transporting a resident with peripheral vascular disease in a shower chair through a public hallway while the resident was only wearing a black t-shirt that extended to the waist and was not wearing pants. A white cloth was loosely draped across the resident's lap, but the resident's buttocks and approximately four inches of the gluteal cleft were visibly exposed during the transport to the shower room. The nurse aide was unaware of the exposure at the time. The Nursing Home Administrator confirmed that residents have the right to be provided care with dignity and acknowledged that the resident should have been properly covered and provided with appropriate clothing to prevent exposure. The facility failed to ensure that the resident received care in a manner that maintained his dignity, as required by regulations.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to provide necessary housekeeping and maintenance services to ensure a clean, safe, and sanitary environment for a resident. Multiple observations over two consecutive days revealed that the resident's fitted bed sheet had large tan stains and several long streaks of a dark red substance. These stains were consistently present on the bed sheet during each observation, indicating that the bedding had not been changed despite being visibly soiled. A nurse aide confirmed during an interview that bedding is typically changed on shower days or when visibly soiled, and acknowledged responsibility for the resident's care on the day in question but did not notice the soiled sheets. The DON also confirmed the failure to maintain a safe, sanitary, and orderly environment in the resident's room. The deficiency was cited under relevant state codes for management and licensee responsibility.
Failure to Update Comprehensive Care Plans with Current Medical Orders
Penalty
Summary
The facility failed to fully develop and revise person-centered comprehensive care plans to address the individualized needs of two residents. For one resident with diagnoses including congestive heart failure and diabetes, the clinical record showed recent physician orders for both short-acting and long-acting insulin, as well as a specific daily fluid restriction. However, the resident's comprehensive care plan, last revised after these orders were issued, did not reflect these updated medical treatments and interventions. Similarly, another resident with hypertension and hypoxemia had a physician's order for oxygen therapy due to shortness of breath. Despite this, the resident's comprehensive care plan, last revised after the order, did not include the updated intervention. These findings were confirmed through clinical record reviews and staff interviews, indicating that the facility did not ensure care plans were updated to reflect current physician orders and resident needs.
Failure to Provide and Accurately Document Restorative Nursing Services
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain or improve mobility for a resident diagnosed with inflammatory polyarthropathy. According to the resident's care plan, a restorative nursing walking program was initiated, requiring staff to assist the resident in walking with a rollator walker for distances up to 350 feet or as tolerated. Despite this plan, the resident reported that she had only walked once in the past month and was not regularly asked to participate in the walking program, contrary to the documented interventions. Clinical record review showed that the ambulation task was marked as completed multiple times, but the resident denied receiving the service on those occasions. Further investigation revealed that a nurse aide admitted to documenting the ambulation task as completed before actually performing it, intending to provide the service later. The facility's policy requires ongoing monitoring and accurate documentation of restorative nursing programs, but there was a discrepancy between the documentation and the resident's account. The Nursing Home Administrator confirmed that staff should not document care tasks as completed if they have not occurred and was unable to explain the inconsistency between the records and the resident's statements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the potential for accidents to occur. The deficiency was based on direct observations and findings by surveyors during their review of the facility's practices and physical environment. No additional details regarding the specific hazards, the number of residents affected, or the medical conditions of those involved were provided in the report.
Failure to Notify Ombudsman of Facility-Initiated Transfers
Penalty
Summary
The facility failed to provide copies of written notices of facility-initiated hospital transfers to the representative of the Office of the State Long-Term Care Ombudsman for two residents. Clinical record reviews showed that both residents were transferred to the hospital and later readmitted to the facility. While written notices of the transfers were given to the residents and their representatives, there was no documented evidence that these notices were also sent to the Ombudsman as required. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documentation for sending the required notices to the Ombudsman.
Failure to Follow Transfer Protocols Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order requiring the use of a mechanical lift for all transfers of a resident with significant mobility and orthopedic issues. The resident, who had diagnoses including osteoarthritis, rheumatoid arthritis, osteoporosis, and a periprosthetic fracture around a right knee prosthesis, was documented as non-weight bearing on the right lower extremity and required total staff assistance for transfers and showers. The care plan and physician's order specifically mandated the use of a Hoyer lift with a green sling for all transfers. Despite these clear directives, three nurse aides transferred the resident from her wheelchair to a shower chair without using the mechanical lift. Witness statements from the aides confirmed that they were aware of the requirement to use the lift but chose to manually transfer the resident instead. The aides cited reasons such as time constraints and the resident's position in the wheelchair, and one aide admitted to not wanting to upset coworkers. During the transfer, the resident experienced severe pain and reported feeling as though her leg was giving out. She subsequently complained of right leg pain, which was documented by nursing staff. An X-ray revealed a comminuted fracture of the right tibia and a displaced fracture of the right fibula, necessitating hospital transfer and surgical intervention. The facility's internal investigation substantiated that the aides knowingly failed to implement the required safety protocols, directly resulting in serious physical injury to the resident. The incident was classified as neglect, as the staff did not provide the necessary goods and services to avoid physical harm, as required by facility policy and physician orders.
Failure to Provide Restorative Ambulation Services
Penalty
Summary
The facility failed to ensure that residents received appropriate services and assistance to maintain or improve mobility, as evidenced by the experiences of three residents. The facility's policy, last reviewed on April 3, 2024, mandates a restorative nursing program to help residents achieve and maintain optimal function. However, changes in staffing and budgeting led to the removal of designated restorative aides, placing the responsibility of ambulation programs on nurse aides. This change was communicated to residents, who were instructed to inform staff if they were not being walked. Resident 79, who has a history of cerebral infarction and moderate cognitive impairment, was discharged from physical therapy with instructions to continue a restorative nursing program for ambulation. Despite this, records show that Resident 79 declined participation in the program 36 times and participated only 19 times between August 22, 2024, and September 20, 2024. Similarly, Resident 78, with diagnoses of muscle wasting and inflammatory polyarthropathy, also declined participation 30 times and participated 25 times in the same period. Both residents expressed during a group interview that they were not receiving their scheduled ambulation programs, attributing this to staff changes. Resident 40, with conditions including polyosteoarthritis and diabetes with neuropathy, also reported not receiving restorative ambulation services. Her records indicated that she was only provided with the ambulation program 5 times out of 36 opportunities in September 2024. Interviews with the Nursing Home Administrator and Director of Nursing revealed an inability to explain why residents were not receiving their restorative programs, despite acknowledging the facility's responsibility to provide such services.
Failure to Implement Physician's Orders for Skin Protection
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for Resident 34, who was admitted with diagnoses including degenerative disease of the nervous system and ataxia. The resident was severely cognitively impaired, as indicated by a BIMS score of 4. A physician's order was in place for the resident to wear Geri Sleeves on both arms at all times to protect against skin tears, following incidents where the resident had sustained skin tears on her arms. Despite the physician's order and care plan intervention, observations on multiple occasions revealed that Resident 34 was not wearing the protective skin devices. The resident was seen with bare arms during these observations, and staff interviews confirmed the absence of the protective sleeves. The registered nurse and the Nursing Home Administrator acknowledged the facility's responsibility to implement physician's orders and maintain the resident's skin integrity, yet the protective devices were not in use, and the staff could not explain or locate them.
Failure to Maintain Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to maintain a physician-ordered fluid restriction for a resident diagnosed with dementia and congestive heart failure. The resident was admitted with a fluid restriction order of 1500 mL per 24 hours, divided between dietary and nursing staff. However, a review of the resident's daily fluid intake records from late August to mid-September revealed multiple instances where the resident's fluid intake exceeded the prescribed limit, with no documented evidence that the physician was notified of these excesses as required by the facility's policy. The facility's Intake and Output Monitoring Policy mandates that intake and output be documented in the Electronic Medical Record and reviewed daily by the RN Charge Nurse. If a resident exceeds fluid restrictions for two days, the physician must be informed. Despite this policy, there was no documentation indicating that the physician was notified of the resident's repeated excess fluid intake. An interview with the Director of Nursing confirmed the lack of documentation and adherence to the fluid restriction order, highlighting a deficiency in maintaining the resident's prescribed care plan.
Failure to Monitor and Document IV Therapy
Penalty
Summary
The facility failed to provide person-centered care by not monitoring intravenous (IV) therapy according to professional standards for two residents. Resident 94, who was admitted with conditions including pleural effusion and suspected pneumonia, had an IV catheter inserted for antibiotic administration. However, the IV site was not labeled with the date of insertion, and there was no documented evidence of dressing changes. The IV catheter was not removed after the completion of the prescribed medication, and there was no documented physician order for the care and monitoring of the IV site. Similarly, Resident 1, admitted with dementia and suspected septic arthritis, had an IV catheter inserted for antibiotic treatment. Observations revealed that the IV site dressing was not dated, and there was no documented evidence of a dressing change on a specific date, despite the dressing being labeled with that date. Additionally, there was no documented physician order for the care and monitoring of Resident 1's IV. The Director of Nursing confirmed the deficiencies in labeling and documentation as per facility policy.
Failure to Communicate Resident Information During Transfer
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. This deficiency was identified through a clinical record review and staff interview, which revealed that a resident was transferred to a hospital and expected to return to the original facility. However, there was no documented evidence that the facility communicated the resident's care plan goals and all necessary information to meet the resident's specific needs at the receiving facility. During an interview, the Nursing Home Administrator confirmed the lack of evidence that the necessary information was communicated to the receiving health care institution or provider for the resident's transfer. This failure to communicate essential information was a violation of the regulatory requirements outlined in 28 Pa. Code 211.12 (d)(3)(5) regarding nursing services.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives upon transfer to a hospital, as required by regulations. This deficiency was identified during a review of clinical records and staff interviews, which revealed that two residents, identified as Residents 96 and 27, were transferred to the hospital without receiving the necessary written information about the facility's bed-hold policy. Resident 96 was transferred on July 4, 2024, and Resident 27 on August 28, 2024. In both cases, there was no documented evidence that the facility provided the required written notice at the time of transfer. An interview with the administrator confirmed the absence of such documentation.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which compromised the resident's clinical condition and health due to Tacrolimus toxicity. The resident, who had a history of a kidney transplant, was admitted from the hospital with discharge instructions to continue Tacrolimus at a specific dosage. However, upon admission to the facility, the physician orders incorrectly transcribed the dosage, leading to the administration of significantly higher doses of Tacrolimus than prescribed. The error was discovered after the resident exhibited symptoms of altered mental status and low blood oxygen saturation, prompting a transfer to the emergency room. The resident was later admitted to the hospital, where they expired, with Tacrolimus toxicity listed as a preliminary cause of death. The facility's investigation revealed that the medication was verified correctly but transcribed incorrectly by a registered nurse, leading to the administration of the wrong dosage.
Neglect Leads to Resident Injuries
Penalty
Summary
The facility failed to prevent physical injury or harm to two residents due to neglect. Resident CR2, who has severe cognitive impairment and Parkinson's disease, was at risk for falls. Despite having a care plan that required the bed to be in the lowest position to prevent falls, an LPN neglected to implement this intervention. As a result, Resident CR2 fell and sustained an open hematoma to the forehead, requiring emergency room treatment. The director of nursing confirmed that the LPN did not follow the care plan, leading to the resident's injury. Resident 26, who is cognitively intact and has diabetes and peripheral vascular disease, was injured during transport to a medical appointment. The resident's wheelchair flipped backward in the van because the front tie downs were not properly secured by the van driver. This negligence resulted in the resident striking his head on the van floor, causing a soft protrusion on the back of the head. The director of nursing confirmed that the van driver failed to ensure the resident's safety during transport.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Ridge Rehabilitation & Healthcare Center | 4.4 mi | ★★★★★ | 7 | 0 |
| Kadima Rehabilitation & Nursing At Lakeside | 4.8 mi | ★★★★★ | 9 | 0 |
| Third Avenue Health & Rehab Center | 5.1 mi | ★★★★★ | 13 | 0 |
| Edenbrook On Second Ave | 5.2 mi | ★★★★★ | 15 | 0 |
| Highland Manor Rehabilitation And Nursing Center | 5.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.