Mon Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monongahela, Pennsylvania.
- Location
- 200 Stoops Drive, Monongahela, Pennsylvania 15063
- CMS Provider Number
- 396085
- Inspections on file
- 24
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Mon Valley Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not document that two residents or their representatives were invited to participate in care conferences, despite facility policies requiring resident-centered care planning and advance notice of conferences. One resident with HTN, diabetes, and post-amputation care needs had a discharge plan involving family support and home health, and a care conference note stated the resident and family declined the invite, yet no record of an actual invitation was found; the resident’s family member also reported never being invited and not receiving information on Medicare payment limits and length of stay. Another resident with HF, COPD, and a seizure disorder had a similar note indicating the resident and family declined the invite, but again there was no supporting documentation of an invitation. The DON acknowledged that the facility failed to document invitations for these two residents.
A resident with diabetes, hypertension, and a recent amputation was discharged home after rehab despite documentation that the resident lived alone and would not have supervision. The care plan called for discharge home with family support and home health, but progress notes repeatedly stated the resident lived alone, and the resident had requested an extended rehab stay with a new prosthesis. After an insurance appeal was denied, the resident was discharged home with borrowed DME and a sliding board intended for supervised use, but without the prosthetic leg, which remained at the facility. The DON acknowledged the expectation that the son would help, despite records showing the resident lived alone, and hospital records later documented the resident’s inability to ambulate or care for himself at home without the prosthesis.
A resident with diabetes, hypertension, and a recent amputation was discharged home after losing an insurance appeal, despite living alone and lacking funds for private pay. Although the care plan anticipated discharge with family support and home health, documentation showed that when the resident later wished to extend rehab with a new prosthesis, the SW was unavailable and nursing and rehab staff lacked updated insurance information. The family reported the resident was not offered help with Medicare/Medicaid or Social Security Disability applications, and the record contained no evidence of referrals or assistance with these benefits, reflecting a failure to provide required medically related social services and information on coverage and eligibility.
The facility did not maintain a fully operational call bell system on one nursing unit, as observed when central and room call lights failed to illuminate as expected. This issue was confirmed by the Maintenance Director, indicating residents could not reliably call for staff assistance.
Surveyors observed that several rooms on one nursing unit had soiled floors with black skid marks and cracked floor tiles, compromising the cleanliness and homelike environment required by facility policy. The NHA confirmed these deficiencies during the investigation.
Surveyors found that the facility did not post required Adult Protective Services (APS) contact information, including agency name, address, email, and phone number, in accessible areas for residents and their representatives. The DON confirmed the absence of this information, resulting in non-compliance with regulations requiring the posting of pertinent State agency and advocacy group contacts.
The facility did not display written information for residents or their responsible persons on how to apply for Medicare and Medicaid benefits or obtain refunds for payments covered by these programs, as confirmed by observation and the DON.
The facility did not consistently complete required dialysis communication forms for three residents with end stage renal disease, resulting in incomplete documentation of care and coordination with the dialysis center for multiple treatment dates, as confirmed by the DON.
The facility did not maintain required documentation for automatic sprinkler system inspections, with no records available for inspections in the last two quarters of the previous year. The Facility Maintenance Director confirmed the absence of these inspection records.
The facility did not complete one of the two required semi-annual kitchen exhaust hood cleanings, as documentation showed only one cleaning was performed and staff confirmed the lack of records for the second cleaning. This affected one smoke compartment.
The facility failed to maintain acceptable food storage practices, leading to potential contamination and microbial growth risks. Observations revealed black fuzzy material on the walk-in cooler's fans and ceiling, and significant ice buildup in the deep freezer, affecting stored food. These issues were confirmed by a dietary employee and the DON.
The facility failed to implement a Water Management Program to prevent Legionella and did not follow proper infection control during a dressing change. A nurse contaminated a clean dressing by not changing gloves after cleansing a wound and failed to wash hands before replacing a contaminated dressing.
A resident with COPD and heart conditions was not provided appropriate respiratory care as prescribed. The care plan lacked specific interventions for oxygen therapy, and observations revealed the resident's nasal cannula was not reapplied after a transfer, and the humidification cannister was repeatedly found empty. A nurse aide confirmed it was their responsibility to maintain the cannister, and the DON acknowledged the deficiency.
The facility did not inform residents or their representatives that signing the arbitration agreement was voluntary and failed to allow a 30-day rescission period. Instead, the agreement misleadingly stated a three-day revocation period and required immediate vacating if canceled. This affected all 20 admitted residents, as confirmed by the NHA.
A resident with multiple diagnoses, including a history of cancer and dizziness, exhibited slurred speech and nonsensical talking after receiving Lorazepam. An LPN noted the change but failed to notify the physician or document further assessment, contrary to facility policy. The DON confirmed the lack of notification, highlighting a deficiency in adhering to professional standards.
A facility failed to ensure a medication regime was free from unnecessary medications for a resident. Despite the facility's policy requiring clinical indications for psychotropic medication use, a resident was administered Haloperidol and Lorazepam without documented symptoms such as anxiety or nausea. The Director of Nursing confirmed the lack of documentation, and the MAR showed multiple administrations of these medications without corresponding symptom documentation.
A resident with hypertensive heart disease and macular degeneration continued to receive an ineffective antibiotic, Nitrofurantoin, despite lab results showing bacterial resistance. The facility's failure to act on these results and modify the treatment was confirmed by the DON and Nursing Home Administrator, highlighting a deficiency in monitoring antibiotic use.
The facility failed to provide training on Resident Rights to its staff, as revealed by a review of policy documents and staff interviews. The policy on in-service training, dated March 2024, aimed to ensure staff competency in enhancing residents' quality of life and care. However, no evidence of training on Resident Rights was found. The Nursing Home Administrator confirmed this deficiency, violating several Pennsylvania Codes related to licensee responsibility, management, and staff development.
The facility failed to provide effective communication training for two staff members, a Nurse Aide and an LPN, as required by their in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory QAPI training to four staff members, including a Nurse Aide, an administrative employee, an LPN, and a dietary employee, as required by the facility's in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
The facility did not provide required behavioral health training for three staff members, including two nurse aides and a dietary employee, as per the facility's in-service training policy. The deficiency was confirmed by the Nursing Home Administrator.
Failure to Document Resident/Representative Invitations to Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to document that residents or their representatives were invited to participate in care conferences for two of five reviewed residents. Facility policies titled “Care Planning - Interdisciplinary Team” and “Care Plans, Comprehensive [NAME]-Centered,” both dated 4/14/25, state that residents, families, and/or legal representatives are encouraged to participate in care plan development and revisions, and that residents are informed of their right to participate and provided advance notice of care planning conferences. For one resident, admitted on an unspecified date with diagnoses including hypertension, diabetes, and post-surgical amputation care needs, the plan of care dated 1/14/26 included discharge planning to home with family support and home health services. A care conference note dated 12/23/25 stated that a care conference was held and that the resident and family declined the invite, but review of the clinical and paper records did not show documentation that the resident or family member had actually been invited. For a second resident, admitted on an unspecified date with diagnoses including heart failure, COPD, and a seizure disorder, a care conference note dated 12/2/25 similarly documented that a care conference was held and that the resident and family declined the invite. However, review of this resident’s clinical record also failed to show documentation that the resident or family member had been invited to the care conference. During an interview, a family member of the first resident reported that the facility did not provide information related to Medicare payment limitations and allowed time in the facility and stated that he was never invited to a care plan conference. In a separate interview, the DON confirmed that the facility failed to document the invitation of the resident or their representative to care conference meetings for two of five residents reviewed, in violation of cited Pennsylvania regulatory codes regarding resident rights, resident care policies, and nursing services.
Inappropriate Discharge of Resident Without Prosthesis and Adequate Support
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to remain in the facility and not transfer or discharge the resident unless the transfer or discharge was appropriate based on the resident’s health status. Facility policy stated that discharge planning must ensure a safe transition to a post-discharge setting that meets the resident’s health and safety needs and preferences. The resident had diagnoses including hypertension, diabetes, and a need for care following a surgical amputation, and the care plan identified discharge home with family support and home health services. However, multiple progress notes documented that the resident lived alone in an apartment and planned to discharge home after rehab, with no indication of consistent in-home supervision. Care conference documentation showed that a care conference was held, but the resident and family declined the invitation, and the plan of care was reviewed only with the IDT. Progress notes repeatedly recorded that the resident lived alone, and one note indicated the resident expressed a desire to extend the rehab stay with a new prosthesis, while staff lacked updated insurance information. Another note documented that the resident lost an insurance appeal and that the family chose to take the resident home that day, with arrangements for transportation and some DME (wheelchair cushion and sliding board) to be borrowed until ordered items were delivered. Interviews and hospital records further described that the resident was discharged home without his prosthetic leg and was instead provided a sliding board intended for use with supervision/assistance, despite documentation that he would be alone at home. The DON acknowledged that it was thought the resident’s son would help, but could not explain this expectation in light of the record showing the resident lived alone. The resident’s family member reported that the appeal for continued care was denied, that the resident was discharged only hours before a major snowstorm, that the resident was sent home without his prosthesis despite pleas not to discharge him without it, and that he lacked funds to pay out of pocket. Hospital documentation indicated the resident presented requesting placement, reporting inability to ambulate and care for himself at home without his prosthesis, and that the facility still had the prosthetic leg. The DON confirmed that the facility failed to permit the resident to remain in the facility and not transfer or discharge him unless the transfer or discharge was appropriate because his health had improved sufficiently so he no longer needed facility services.
Failure to Provide Medically Related Social Services and Benefits Assistance
Penalty
Summary
The facility failed to provide medically related social services to assist a resident in understanding and accessing insurance and public benefits needed to continue necessary care. Federal regulations at 42 CFR 483.10(g)(4) require that residents receive notices and information regarding Medicare and Medicaid eligibility and coverage in a format and language they understand, and the facility’s Director of Social Services job description included assisting discharged residents and families with placement options. The resident, who had diagnoses including hypertension, diabetes, and a need for care after a surgical amputation, was admitted for rehabilitation and had a care plan goal for discharge home with family support and home health services. A progress note documented that the resident lost an insurance appeal, the family chose to take the resident home that day, and arrangements were made for transportation and durable medical equipment, with the facility temporarily lending a wheelchair cushion and sliding board. Subsequent documentation showed that the resident later expressed a desire to extend the rehab stay with a new prosthesis, but the social worker was not available and nursing and rehab staff did not have updated insurance information. Another note indicated that personal care and continued stay at the SNF level without insurance coverage were offered to the resident’s son, who declined. During interview, the resident’s family member stated that the facility had been informed the resident lived alone without supervision upon discharge and lacked funds to remain as a private pay resident, and further stated the resident was not offered assistance with completing Medicare/Medicaid or Social Security Disability applications. Review of the clinical record confirmed there was no documentation of referrals or assistance with such applications, and the DON acknowledged that the facility failed to provide medically related social services to this resident.
Failure to Maintain Fully Functioning Resident Call Bell System
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system on the second-floor nursing unit, as required by facility policy. Observations revealed that when the central call light was activated in the North Hall, no resident room lights were illuminated above the doors. Additionally, in multiple instances, individual resident room call lights were illuminated above the doors, but the corresponding central hall lights for the South Hall and another hall were not illuminated. The Maintenance Director confirmed that the call bell system was not fully operational, preventing residents from reliably calling for staff assistance through the communication system.
Failure to Maintain Safe and Homelike Environment Due to Damaged and Soiled Flooring
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the second floor nursing unit. Observations revealed that one room had black skid marks and soiled floor tiles, another room had cracks in the tiles at the entrance, and a third room had multiple cracked floor tiles. These conditions were confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to maintain the required environment as outlined in the facility's housekeeping policy.
Failure to Post Required APS Contact Information
Penalty
Summary
The facility failed to post the required contact information for Adult Protective Services (APS) in areas accessible and understandable to residents and their representatives. Observations conducted in the first-floor lobby and the second-floor nursing unit revealed that no elements of the APS contact information, including agency name, address, email, or phone number, were posted or accessible. This omission was confirmed during an interview and rounds with the Director of Nursing, who acknowledged that the required information was not displayed in the building. The deficiency was identified during a survey, which found that the facility did not comply with regulations mandating the posting of a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups. This list must include the State Survey Agency, State licensure office, APS, the Office of the State Long-Term Care Ombudsman, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit, along with a statement informing residents of their right to file complaints. The lack of posted APS contact information constituted non-compliance with state code requirements.
Failure to Display Required Medicare and Medicaid Information
Penalty
Summary
The facility failed to display written information for residents and/or their responsible persons regarding how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs. During observations of the first-floor lobby and the second-floor nursing unit posting locations, it was noted that this required information was not posted. In an interview, the Director of Nursing confirmed that the facility did not have the necessary written information displayed as required by regulations. No specific residents or medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for three residents with end stage renal disease who required regular dialysis treatments. According to the facility's own policy, licensed nurses are required to communicate with the dialysis center using a designated communication form or other written/telephonic means, documenting information such as medication administration, treatment orders, laboratory values, vital signs, advanced directives, nutrition/fluid management, treatments provided, adverse reactions, changes in condition, injuries, and transportation concerns. However, review of the clinical records and dialysis communication forms for the three residents revealed multiple instances where these forms were incomplete on several treatment dates. The affected residents had complex medical histories, including diagnoses of end stage renal disease, hypertension, diabetes, heart disease, and bladder cancer, and were scheduled for dialysis at specific times and days each week. Despite these needs, the required communication forms were not fully completed for numerous dialysis sessions, as confirmed by the Director of Nursing. This failure to ensure ongoing and thorough communication with the dialysis center was identified through review of facility policy, clinical records, and staff interviews.
Failure to Maintain Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by missing documentation for sprinkler system inspections in two instances. During a documentation review, it was found that there was no verification of any sprinkler inspections being performed in the last two quarters of the previous twelve months. The last recorded inspection was on October 15, 2024. This lack of documentation was confirmed in an interview with the Facility Maintenance Director, who acknowledged the absence of records for the required inspections.
Plan Of Correction
The quarterly sprinkler inspection will be scheduled by the Maintenance Director with completion expectation sprinkler inspection vendor by 8-8-25. I certify this document to be a true and correct statement of deficiencies and approved facility plan of correction for the above-identified facility survey.
Missed Semi-Annual Kitchen Hood Cleaning
Penalty
Summary
The facility failed to complete one of the two required semi-annual cleanings of the kitchen exhaust hood, as mandated by NFPA 101 and NFPA 96 standards for cooking facilities. Documentation and observation on July 2, 2025, revealed that the last hood cleaning was performed on December 22, 2024, and there was no documentation available for the subsequent required cleaning. This deficiency affected one of nine smoke compartments within the facility. During interviews, both the Facility Administrator and Maintenance Director confirmed the absence of documentation for the missed semi-annual hood cleaning. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission and or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. The semi-annual hood cleaning will be scheduled by the Maintenance Director with completion expectation from hood cleaning vendor by 8-8-25.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to maintain acceptable practices for food storage, which increased the risk of food-borne illness in the main kitchen. During an observation, the walk-in cooler was found to have black fuzzy material throughout the fans and on the ceiling, with a cart of several trays of food stored underneath. Additionally, the deep freezer had abundant ice buildup on the ceiling, fan areas, and shelving, with several boxes of frozen food having blocks of ice buildup. These conditions were confirmed by a dietary employee and the Director of Nursing and Director of Maintenance during interviews.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement an effective Water Management Program to prevent and control water-borne contaminants, such as Legionella. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged that the facility had not had a Water Management Program in place since 2023. The absence of this program poses a risk of exposure to water-borne bacteria, which can lead to serious health conditions like Legionnaires' Disease. Additionally, the facility did not adhere to proper infection control practices during a dressing change for a resident. During an observation, a registered nurse placed wound care items on a resident's overbed table alongside personal items, potentially contaminating the clean field. The nurse then failed to change gloves after cleansing the wound and placed a clean dressing with the same soiled gloves, contaminating it. After leaving the room to obtain a new dressing, the nurse did not wash hands before donning new gloves and replacing the contaminated dressing. This lapse in infection control was confirmed by the nurse involved.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident R1, who was admitted with diagnoses including hypertensive heart disease, heart failure, and COPD. The resident was prescribed continuous oxygen therapy at 3 LPM via nasal cannula. However, the care plan did not include specific interventions for oxygen therapy, such as maintenance of humidification cannisters, changing of tubing, monitoring for skin breakdown, and recognizing signs and symptoms related to oxygen therapy that should be reported to a provider. During observations, it was noted that the resident's nasal cannula was removed during a transfer and not reapplied, and the humidification cannister on the oxygen concentrator was empty. Despite the presence of a water jug next to the concentrator, the cannister remained unfilled. A nurse aide confirmed that maintaining water in the humidification cannister was part of their responsibilities, yet it was found empty on multiple occasions. The Director of Nursing acknowledged the facility's failure to provide appropriate respiratory care for the resident.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to uphold residents' rights regarding binding arbitration agreements. Specifically, the facility did not inform residents or their representatives that signing the arbitration agreement was voluntary, nor did it allow them the right to rescind the agreement within 30 calendar days of signing. Instead, the agreement misleadingly stated that residents had only a three-day revocation period and required them to make immediate arrangements to vacate the facility if they chose to cancel the agreement. This deficiency affected all 20 residents admitted to the facility, as confirmed by the Nursing Home Administrator during an interview.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for Resident R21, who was admitted with multiple diagnoses including a history of colon cancer, aneurysm of the aorta, cancer of the parotid gland, dizziness, and unsteadiness on feet. On a specific date, a progress note by an LPN indicated that Resident R21 exhibited slurred speech and nonsensical talking after being administered Lorazepam. The LPN documented that the oncoming shift should monitor the resident due to the medication administration but did not document any further assessment or notification of the physician regarding the resident's change in condition. The facility's policy on changes in a resident's condition requires staff to notify the attending physician of any significant changes, such as adverse reactions to medication or changes in mental status. However, the clinical record lacked documentation of any notification or further assessment following the observed change in Resident R21's condition. During an interview, the Director of Nursing confirmed that the LPN did not notify anyone about the resident's condition change, which is a failure to adhere to the facility's policy and professional standards of practice.
Failure to Ensure Medication Regime Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure a medication regime was free from potentially unnecessary medication for a resident, identified as Resident R21. The facility's policy on psychotropic medication use requires that residents do not receive medications that are not clinically indicated to treat a specific condition. However, a review of Resident R21's clinical records and interviews with staff revealed that there was no documentation of diagnoses or symptoms such as anxiety, hallucinations, or nausea that would justify the use of psychotropic medications. Despite this, Resident R21 was administered Haloperidol and Lorazepam without proper documentation of the symptoms these medications were intended to treat. The Director of Nursing confirmed the lack of documentation for Resident R21's symptoms, and it was noted that the facility had to contact the Hospice office to obtain relevant notes. The Medication Administration Record (MAR) indicated that Haloperidol and Lorazepam were administered multiple times without corresponding documentation of the symptoms they were prescribed for. This oversight was further confirmed during interviews with the Nurse Practitioner and the Director of Nursing, highlighting a failure in the facility's medication management practices.
Failure to Monitor Antibiotic Use for a Resident
Penalty
Summary
The facility failed to monitor antibiotic use for a resident, identified as Resident R8, which led to the continuation of an ineffective antibiotic treatment. The facility's policy on Antibiotic Stewardship, dated March 2024, mandates that lab results and the current clinical situation be communicated to the provider to determine appropriate antibiotic therapy. However, this protocol was not followed for Resident R8. The resident, who had diagnoses of hypertensive heart disease and macular degeneration, was initially prescribed Nitrofurantoin for a urinary tract infection. A urine culture and sensitivity report later revealed that the bacteria causing the infection were resistant to Nitrofurantoin, but the resident continued to receive this medication until the original end date of the order. The failure to act on the lab results was confirmed during interviews with the Director of Nursing and the Nursing Home Administrator. They acknowledged that the facility did not respond to the lab results indicating resistance to the prescribed antibiotic and did not modify the treatment to an effective antibiotic. This oversight was identified as a deficiency in the facility's monitoring of antibiotic use, as per the facility's policy and state regulations.
Failure to Provide Training on Resident Rights
Penalty
Summary
The facility was found to have a deficiency due to its failure to provide training on Resident Rights to its staff. This was determined through a review of the facility's policy and documents, as well as staff interviews. The policy titled 'Inservice Training, All Staff,' dated March 2024 and previously reviewed in March 2023, stated that the primary objective of in-service training is to ensure staff can interact in a manner that enhances residents' quality of life and care, demonstrating competency in training topics. However, the review of the facility's education documents did not show any evidence that training on Resident Rights was offered. During an interview conducted on June 17, 2024, the Nursing Home Administrator confirmed the facility's failure to provide this essential training. This deficiency is in violation of several Pennsylvania Codes, including 28 Pa Code: 201.14 (a) regarding the responsibility of the licensee, 28 Pa Code: 201.18 (b)(1) concerning management, and 28 Pa Code: 201.20 (a)(c) related to staff development.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication for two staff members, Nurse Aide Employee E7 and Licensed Practical Nurse Employee E10. The facility's policy on in-service training, last reviewed in March 2023, mandates that all staff participate in training to enhance residents' quality of life and care. However, a review of training records revealed that Employee E7, hired on May 21, 2019, did not receive effective communication training between May 21, 2023, and May 21, 2024. Similarly, Employee E10, hired on May 11, 2008, lacked documented training in effective communication between May 11, 2023, and May 11, 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on June 11, 2024.
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 four out of ten staff members, specifically Employees E7, E9, E10, and E11. According to the facility's policy on in-service training, all staff are required to participate in training to ensure they can enhance residents' quality of life and care. However, a review of the training records revealed that these employees did not have documented QAPI training within the specified time frames. Employee E7, a Nurse Aide, did not receive QAPI training between May 21, 2023, and May 21, 2024. Employee E9, an administrative staff member, lacked training between February 12, 2023, and February 12, 2024. Employee E10, an LPN, did not have training between May 11, 2023, and May 11, 2024. Lastly, Employee E11, a dietary staff member, was not trained between March 1, 2023, and March 1, 2024. The Nursing Home Administrator confirmed this deficiency during an interview.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for three staff members, identified as Employees E7, E8, and E11. The facility's policy on in-service training, last reviewed in March 2023, mandates that all staff participate in training to enhance residents' quality of life and care. However, a review of training records revealed that Nurse Aide Employee E7, hired on 5/21/19, did not receive behavioral health or dementia training between 5/21/23 and 5/21/24. Similarly, Nurse Aide Employee E8, hired on 1/23/08, and Dietary Employee E11, hired on 3/1/18, also lacked documented training in these areas for the specified periods. The Nursing Home Administrator confirmed this deficiency during an interview on 6/17/24.
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.
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