Monroeville Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroeville, Pennsylvania.
- Location
- 885 Macbeth Drive, Monroeville, Pennsylvania 15146
- CMS Provider Number
- 396003
- Inspections on file
- 46
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Monroeville Post Acute during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses and atopic neurodermatitis had a physician order for Clindamycin Phos 1% gel to be applied to the armpit and groin every day and on the evening shift. Review of the MAR showed the evening doses on several consecutive days were not administered, with nursing notes indicating they were awaiting pharmacy. Observation later confirmed the medication was present on-site with a dispense date matching the original order, and the DON acknowledged that staff failed to follow the physician’s medication administration order.
Surveyors found that the facility did not maintain a clean, homelike environment as required by its policies. A resident’s bathroom contained a bedpan with feces in a clear bag left on the floor, contrary to the facility’s bedpan-handling procedures. In a second-floor unit lounge, surveyors observed multiple towels and blankets on the floor, draped over furniture, and spread across tables and chairs, along with visible crumbs on a wooden table. An RN and an LPN confirmed these conditions were inappropriate, and the NHA and DON acknowledged the failure to provide a clean, comfortable, homelike environment in these areas.
The facility did not maintain and post current daily nurse staffing information as required. Over an eight-day period, the nurse staffing hours displayed in the front lobby were several days out of date, with the most recent posting reflecting hours from earlier in the month. During an interview, the DON confirmed that staffing hours were not being updated and posted each day in accordance with regulatory requirements.
Multiple residents and staff reported that insufficient nursing staff resulted in long call light response times, delays in assistance with activities of daily living, and unmet care needs such as pain management, incontinence care, and grooming. Grievances and observations confirmed that residents experienced significant delays and incomplete care, with staff acknowledging increased falls and unaddressed care tasks.
A resident with multiple diagnoses and a history of falls was admitted and identified as high risk for further falls. The care plan included only keeping the call light within reach, with no other fall prevention interventions documented. The resident experienced a fall resulting in a skin tear, and additional interventions such as fall mats were implemented only after the incident. The facility confirmed the care plan was not sufficiently individualized or comprehensive prior to the fall.
A resident with a history of falls and requiring staff assistance for transfers suffered two falls resulting in a hematoma and a facial laceration requiring sutures after a nurse aide failed to follow documented safety interventions, including the use of wheelchair leg rests and proper positioning. Despite prior education on these requirements, the aide did not implement them, leading to the resident being inadequately supervised and positioned, which resulted in actual harm.
A resident with a history of repeated falls and muscle weakness, who required staff assistance and specific wheelchair safety interventions, experienced two falls resulting in a hematoma and a facial laceration requiring sutures. The required use of leg rests and proper wheelchair positioning was not consistently documented or implemented, and not all staff were adequately educated on these safety measures, leading to the resident's injuries.
A resident dependent on two-person assistance for bed mobility suffered a facial laceration requiring sutures after a CNA provided care alone and instructed the resident to hold the headboard, contrary to documented care needs. Staff interviews revealed inconsistent understanding of how to verify required assistance levels, and the DON confirmed the care provided did not align with the resident's assessed dependency.
Seven residents filed grievances about not receiving assistance with showers and, in one case, nail care. Although staff education was documented as the corrective action and the grievances were marked as resolved by the former DON, there was no evidence that the education occurred. The DON and administrator confirmed that corrective actions were not implemented and grievances were not resolved.
The facility did not follow its policies to investigate allegations of abuse and neglect involving two residents. One resident with severe cognitive impairment had unexplained scratches and identified a nurse as the alleged perpetrator, but no investigation was completed. Another resident, who was cognitively intact, reported falling after her call bell was not answered, but the facility did not investigate the possible neglect. Leadership confirmed that required investigations were not conducted in either case.
Several residents with physical and cognitive impairments did not receive scheduled assistance with showers and nail care, despite being able to communicate their needs. Documentation showed missed care and discrepancies in records, with some residents denying refusals that were charted. Observations included a soiled brief left in a room and unanswered call lights, while staff were present but not responding. Facility leadership confirmed that grievances about these issues were not resolved.
Staff failed to accurately document meal intake for two residents with complex medical needs, recording that they consumed 51-75% of their meals when direct observation showed no food was eaten. This practice was confirmed by staff interviews and was also noted in records for several other residents, with the DON acknowledging the documentation failures.
A resident with multiple medical conditions and intact cognition fell while attempting to transfer from bed to wheelchair after using the call bell and not receiving timely staff assistance. The incident, which met criteria for suspected neglect, was not reported to authorities as required by facility policy and state law.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant delay in transfer to an assisted living facility due to the facility's failure to provide timely and complete medically-related social services and required documentation, despite repeated requests from family and advocates.
Staff did not ensure that a medication cart, including its narcotic drawer, was securely locked when out of the nurse's view, contrary to facility policy. This allowed unauthorized access to medications and controlled substances, as confirmed by a nurse and facility leadership.
The facility failed to follow its food safety and hygiene policies, with staff not properly restraining hair or washing hands between handling soiled and clean dishes. Additionally, food items in the nutrition room were improperly labeled and stored, with open and undated packages. These issues were confirmed by the facility's administration.
The facility failed to maintain the dignity of two residents. One resident with severe cognitive and physical impairments was found in the hallway without lower body clothing, exposing her brief. Another resident with intact cognition reported being moved to the television room overnight due to a malfunctioning call light, with no records of the incident or repair. The NHA and DON were unaware of these events.
The facility failed to maintain complete and accurate medical records for two residents. One resident's treatment records for pressure ulcers and abrasions were incomplete, with missing entries on several dates. Another resident's progress notes inaccurately reflected their health status, as they continued to mention nighttime tube feedings despite the removal of the gastrostomy tube. The DON and Nursing Home Administrator confirmed these deficiencies.
The facility failed to maintain required hospice records for three residents, including hospice election documentation, visit records, and care plans. This deficiency was confirmed by the DON, affecting residents with conditions such as cerebral palsy, dementia, and hemiplegia.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and unmet resident needs. Observations and resident interviews revealed that assistance often took an hour or more, with some residents waiting up to five hours. The deficiency was confirmed by the facility's administration, highlighting a systemic issue with staffing levels and response times.
The facility failed to consistently offer evening snacks to residents, as required by policy. During a group interview, several residents expressed frustration over not receiving nourishing snacks and having to buy from vending machines. The Nursing Home Administrator and DON could not explain the shortage, despite confirming the policy to serve snacks according to residents' needs and preferences.
A resident with a cervical fracture and pain reported that nursing staff were uncooperative in administering pain medication, with a night nurse refusing due to workload. The grievance was acknowledged by the DON, but the facility failed to report the neglect allegation to the state field office, violating management responsibilities.
A resident with a cervical fracture and high blood pressure reported neglect due to staff's refusal to administer pain medication, citing workload. Despite the grievance being acknowledged by the DON, no investigation was conducted, violating the facility's policy and state regulations.
The facility failed to properly store and dispose of expired medications and biologicals in the First Floor medication room. Observations revealed expired vacutainers, an I.V. start kit, bacterial collection culture bottles, glucose monitoring control solutions, and a wound vacuum dressing package. These findings were confirmed by staff, indicating non-compliance with the facility's medication labeling and storage policy.
The facility failed to maintain a clean and homelike environment on one nursing unit, where two residents experienced a persistent ceiling leak above their toilet. Despite multiple attempts to replace the ceiling tile, the issue persisted, leading to water leaking down the wall and onto the floor. The Nursing Home Administrator confirmed the deficiency.
A resident with multiple health issues, including paraplegia and severe malnutrition, experienced inadequate respiratory care due to empty portable oxygen tanks and a malfunctioning concentrator. The facility's failure to adhere to its oxygen administration policy was confirmed by staff and acknowledged by the DON.
The facility did not post contact information for the Medicaid Fraud Unit and Adult Protective Services on the first and second floor nursing units. Observations confirmed the absence of these postings, and the Nursing Home Administrator acknowledged the oversight. This is a violation of state regulations regarding the responsibilities of the licensee and management.
The facility did not post notice of the availability of survey results in a prominent location on both nursing units. During an observation, no signage was found, and in a resident group interview, all residents were unaware of the survey results' location. The Nursing Home Administrator confirmed the failure to post the required notice.
The facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by these programs on both the first and second floor nursing units. This deficiency was confirmed by the Nursing Home Administrator and is a violation of resident rights.
The facility did not provide mandatory Effective Communication training to four staff members, including NAs and nurses, as required by their policy. This deficiency was confirmed by the Nursing Home Administrator and the DON.
The facility did not provide mandatory in-service training on Resident Rights for four staff members, including a Nurse Aide, two LPNs, and a Therapy Employee, as required by policy. This was confirmed by the Nursing Home Administrator and the DON.
The facility failed to provide mandatory QAPI training for six staff members, as required by its policy. Documentation showed that a Nurse Aide, a Registered Nurse, and several LPNs did not receive the necessary training within their annual periods. The Nursing Home Administrator and the DON confirmed this deficiency.
The facility failed to provide mandatory Compliance and Ethics training for two staff members, an NA and an LPN, as required by facility policy. The NA and LPN did not receive the necessary training within the specified timeframes, which was confirmed by the Nursing Home Administrator and the DON.
The facility did not provide required Behavioral Health training to a Nurse Aide, an LPN, and a Therapy Employee, as per the facility's policy. This was confirmed by reviewing training records and through interviews with the Nursing Home Administrator and the DON.
The facility failed to provide a dignified dining experience by using disposable styrofoam bowls for serving dessert during lunch. This was observed and confirmed by staff, including the Food Service Director, who admitted the lack of china or thermal serving bowls, violating resident rights under PA Code: 201.29(k).
The facility did not provide a method for visitors to access the building during off hours, as required. The intercom system was non-operational, and calls to the main telephone number were disconnected without being answered. Staff were aware of these issues, and notices did not specify off hours, hindering visitor access.
The facility did not notify the State Ombudsman Office of resident transfers and discharges for 42 months, from March 2021 to September 2024. This was confirmed through a document review, an audit by the State Ombudsman Office, and staff interviews. The Nursing Home Administrator admitted to the oversight, which violated PA Code: 201.29(f)(g) on resident rights.
The facility failed to provide a homelike environment by not repairing a leaking ceiling in a resident's bathroom and using common areas for storage, thus denying residents access. An LPN confirmed the ceiling issue, and the Nursing Home Administrator acknowledged the deficiencies.
The facility failed to maintain its intercom and telephone systems, which are essential for visitor access during off hours. The intercom was removed, leaving exposed wires and preventing staff from responding to visitors. Additionally, the telephone system did not transfer unanswered calls, further hindering visitor access. The Nursing Home Administrator and DON confirmed these issues.
A facility failed to notify a resident's responsible party about two room changes, as required. The resident's census record showed two room changes, but there was no evidence in the progress notes that the guardian was informed. This was confirmed by the guardian during an interview, and the issue was later addressed with the Nursing Home Administrator and DON.
The facility failed to complete the grievance process for two residents who reported misappropriation of personal property. One resident alleged that her glasses were thrown away, but the grievance form lacked investigation documentation and resolution. Another resident reported missing items, but no grievance form or investigation was initiated. This was confirmed by staff and management, acknowledging the failure to resolve the allegations as required.
The facility failed to provide proper wound care for several residents, resulting in neglect of services. Documentation discrepancies were found in the Treatment Administration Records, where wound care was either not scheduled, not documented, or not completed as required. Staff interviews confirmed these issues, with the Wound Care Nurse acknowledging that dressings were not changed as documented. The Nursing Home Administrator and DON confirmed the neglect, violating resident rights and nursing service regulations.
The facility failed to provide prescribed wound care for three residents, as documented in their treatment administration records. A resident with hemiplegia and wound infection did not receive documented care on multiple dates, and dressings were not changed as scheduled. Another resident with chronic surgical wounds had missing documentation of care, particularly during evening shifts. A third resident with a left groin abrasion also had lapses in documented care. The Nursing Home Administrator confirmed these deficiencies, violating state regulations.
The facility failed to provide consistent wound care for two residents with pressure ulcers. One resident with a deep tissue injury and another with a Stage IV pressure wound did not receive care as per physician's orders, with missing documentation and unchanged dressings noted.
The facility failed to provide sufficient nursing staff, resulting in unmet resident needs and compromised well-being. Residents reported long wait times for call light responses, with some waiting up to an hour. Observations revealed signs of neglect, such as matted hair and malodorous conditions. The Nursing Home Administrator confirmed the facility's failure to maintain adequate staffing levels, violating Pennsylvania Code regulations.
The facility failed to provide substantial evening snacks, resulting in a meal span of up to 16 hours between supper and breakfast. Meals were distributed earlier than scheduled, leading to resident dissatisfaction. Staff confirmed the lack of substantial snacks, with only limited options like graham cookies available.
The facility failed to schedule ordered follow-up appointments for three residents, leading to a deficiency in providing medically-related social services. The deficiency was confirmed through clinical record reviews and staff interviews, highlighting a lapse in ensuring residents receive necessary medical follow-ups.
The facility failed to maintain resident safety during a transfer, resulting in a laceration of a resident's left leg. The resident, who had Myasthenia Gravis and required maximal aid for transfers, was incorrectly assessed and transferred using improper techniques. The leg rests of the wheelchair were removed, causing the injury. Staff interviews revealed inconsistencies in the assessment and communication of the resident's transfer needs.
Failure to Administer Ordered Topical Antibiotic as Prescribed
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident when prescribed topical Clindamycin Phos 1% gel was not given as ordered. Facility policy dated 3/6/26 required that medications be administered as prescribed in accordance with good nursing principles and practices. The resident, who had diagnoses including bipolar disorder, paranoid personality disorder, adjustment disorder, conduct disorder, and atopic neurodermatitis, was documented on an MDS dated 11/2/25 as alert, oriented, and independent with all ADLs. A physician order dated 3/23/26 directed staff to apply Clindamycin Phos 1% gel to the armpit and groin every day and evening shift. Review of the March 2026 MAR showed the medication was not administered on the evening shifts of 3/27, 3/28, and 3/29, with nurse progress notes stating they were awaiting pharmacy. However, observation on 3/30/26 at 3:30 p.m. showed the Clindamycin gel was available with a dispense date of 3/23/26 on the label, and the DON confirmed the facility failed to follow the physician’s order for this resident. This deficiency centers on the missed evening doses of the ordered topical antibiotic despite its documented availability in the facility during the period when staff charted that they were awaiting pharmacy, in contradiction to facility policy and the physician’s written order.
Failure to Maintain Clean, Homelike Resident Bathroom and Unit Lounge
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in accordance with its own policies. Facility policies titled “Homelike Environment,” “Bathrooms,” and “Bedpan/Urinal, Offering/Removing,” all dated 6/20/25, require that resident areas, including bathrooms, be kept clean, sanitary, and orderly, and that bedpans be emptied into the commode, the commode flushed, the bedpan cleaned, dried, and stored properly, not left in the bathroom or on the floor. During an observation on 3/3/26 at 9:15 a.m., surveyors observed a bedpan containing feces in a clear bag on the floor of Resident 100’s bathroom. At 9:20 a.m., an RN confirmed that the bedpan should not have been left soiled and on the floor. Additional observations on 3/3/26 at 9:30 a.m. showed that the second-floor unit lounge was not maintained in a clean, homelike condition. The lounge contained a white blanket and approximately two white towels on the floor beside a wheelchair, three or four white towels draped across the wheelchair armrests, a white blanket loosely folded on a wooden stand next to a lamp, a towel spread across an end table with another towel draped over it, a towel spread across a visitor chair seat, and a towel draped over the back of a couch. A round wooden table in the lounge had visible crumbs, and the area also contained two additional visitor chairs, a large resident scale, and a vending machine. At 9:35 a.m., an LPN confirmed that the lounge should not be dirty and that dirty linens should not be left there. At 1:00 p.m., the NHA and DON acknowledged that the facility failed to provide a clean, comfortable, homelike environment for the resident and the second-floor lounge, in violation of 28 Pa. Code 207.2(a) regarding the administrator’s responsibility.
Failure to Maintain and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to prominently display and maintain accurate daily nurse staffing hours for eight consecutive days. Observations on 3/3/26 at 8:30 a.m. showed that the nursing hours posted in the front lobby were for 2/23/26, and the previously posted nursing hours were for 2/19/26, indicating that the required daily updates had not been made. During an interview on 3/3/26 at 8:35 a.m., the Director of Nursing confirmed that the facility had not updated and posted the staffing hours on a daily basis as required by 28 Pa. Code: 201.14(a) regarding the responsibility of the licensee.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, as well as grievance reviews. Fourteen out of twenty residents reported long wait times for call light responses, delays in receiving assistance for activities of daily living such as getting out of bed, incontinence care, grooming, and pain medication administration. Several residents described waiting up to an hour or more for help, with one resident specifically stating that she was left in excruciating pain due to delayed pain medication. Another resident was observed to be malodorous, confirming her report of infrequent showers and inadequate incontinence care. Grievances also documented issues such as lack of fresh water, failure to apply protective booties, and unaddressed requests for assistance. Staff interviews corroborated these concerns, with one staff member stating that there was not enough staff to meet resident needs and describing increased falls, wounds, and incomplete care tasks. Documentation from resident council meetings and individual grievances further supported the pattern of insufficient staffing, with multiple reports of call light response times exceeding 30 minutes and unresolved complaints. The Nursing Home Administrator confirmed that the facility did not have enough nursing staff to provide necessary care to maintain residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Develop Person-Centered Fall Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan related to falls for one of five residents. The resident in question was admitted following hospitalization due to falls and was identified as high risk for further falls, with multiple diagnoses including anemia, cancer, and multiple fractures. Despite the facility's policy requiring a resident-centered falls prevention plan based on assessment information, the care plan for this resident only included the intervention to keep the call light within reach, with no other documented fall prevention measures. The resident experienced a fall, resulting in a skin tear, and was found on the floor next to the bed with the call light in reach but not activated. Fall mats were only added as an intervention after the incident. Documentation showed that the resident had terminal restlessness and agitation, and experienced new or worsening pain and urinary incontinence following the fall. The care plan had not been updated with additional fall prevention interventions prior to the incident, despite the resident's high risk status and recent fall history. The lack of a robust, individualized fall care plan was confirmed by the facility, and the deficiency was identified as past non-compliance.
Failure to Implement Wheelchair Safety Measures Results in Resident Harm
Penalty
Summary
A resident with a history of achondroplasia, muscle weakness, and repeated falls, who was dependent on staff for transfers and used a wheelchair, experienced two significant falls resulting in actual harm. The resident's care plan and Kardex specified the use of wheelchair leg rests and proper positioning as safety interventions. Despite these documented requirements, a nurse aide failed to apply the leg rests when transferring the resident to the wheelchair, citing that the leg rests caused the resident pain. The aide positioned the resident in front of the television without the required safety measures in place. The first incident involved the resident being found on the floor in front of the wheelchair with a hematoma on the forehead, necessitating hospital evaluation. The second incident occurred when the resident was again found on the floor in a pool of blood, having sustained a head injury that required sutures for a 3.5 cm laceration and treatment for a hematoma. In both cases, documentation indicated that the resident had been last seen by staff within a short period prior to the falls, and that the required safety interventions were not followed. Staff interviews and facility documentation confirmed that the nurse aide responsible had received education on the use of the Kardex and the necessity of using leg rests for this resident. However, the aide did not follow these instructions, resulting in the resident not being adequately supervised or positioned, which directly led to the falls and subsequent injuries. The facility acknowledged that the failure to implement the prescribed safety measures constituted neglect and resulted in actual harm to the resident.
Failure to Provide Adequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary safety interventions to prevent falls for a resident with a history of repeated falls, muscle weakness, and achondroplasia. The resident was dependent on staff for transfers and required the use of a high back wheelchair with fitted leg rests and a foot buddy, as documented in the care plan. However, the Kardex did not consistently include these interventions, and staff were not uniformly educated on their use. On two separate occasions, the resident was found on the floor after falling from the wheelchair, resulting in a hematoma and a facial laceration that required sutures. Documentation revealed that on one occasion, the resident was last seen approximately 20 minutes prior to the fall, and on another, about an hour prior. In both incidents, it was noted that the leg rests were not applied as indicated in the care plan, and a nurse aide admitted to not using the leg rests due to the resident's complaints of pain. Staff interviews confirmed reliance on the Kardex for care instructions, but not all staff received direct education on the required safety measures. Only eight staff members were formally educated on proper wheelchair positioning and use of leg rests, with the expectation that they would inform others. The lack of consistent documentation, incomplete staff education, and failure to follow prescribed safety interventions directly contributed to the resident's falls and resulting injuries.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with a history of morbid obesity, muscle weakness, and osteoarthritis, who was assessed as dependent for bed mobility and required the assistance of two staff members, experienced a fall resulting in a facial laceration requiring sutures. The resident's clinical records and Minimum Data Set (MDS) assessments consistently indicated the need for two-person assistance for bed mobility, with the resident being unable to assist in the activity. However, during care, a nurse aide provided care alone and instructed the resident to hold onto the headboard to maintain position, despite the resident's indication that she had been told not to do so by others. The resident subsequently rolled out of bed and sustained a head injury. Staff interviews and documentation review revealed inconsistencies in staff understanding and adherence to the resident's required assistance level for bed mobility. The nurse aide's actions were contrary to the resident's documented care needs, as the resident was dependent and unable to assist with bed mobility. The Director of Nursing confirmed that the expectation for the resident to assist in her care was inconsistent with her MDS level of dependency. Further interviews with staff demonstrated a lack of consistent knowledge regarding how to verify a resident's bed mobility status, with some staff referencing different sources and one staff member unable to describe the process. The facility failed to provide adequate supervision and did not ensure that staff followed the resident's care plan, resulting in a preventable fall and actual harm to the resident.
Failure to Resolve Resident Grievances and Implement Corrective Actions
Penalty
Summary
The facility failed to resolve and implement corrective actions for grievances filed by seven residents regarding lack of assistance with showers and, in one case, nail care. According to the facility's grievance policy, the administrator and staff are required to make prompt efforts to resolve grievances to the satisfaction of residents and/or their representatives, and to determine and implement necessary corrective actions. However, documentation showed that the recommended corrective action for each grievance was staff education, and the grievances were marked as resolved by the former DON. Upon review, the current DON was unable to provide evidence that the staff education had occurred as documented. Both the Nursing Home Administrator and the DON confirmed that the facility did not institute the corrective actions or resolve the grievances as required. This deficiency affected seven of fifteen residents who had filed grievances about not receiving assistance with showers and, for one resident, nail care.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures to investigate possible abuse and/or neglect for two of four residents reviewed. For one resident with a history of cerebral palsy and autistic disorder, who was severely cognitively impaired (BIMS score of 00), there were multiple instances of scratches observed on his body. Despite a police report indicating that the resident, through yes/no questioning, identified a registered nurse as the alleged perpetrator of the injuries, the facility did not complete an investigation to rule out possible abuse. The resident's care plan did not mention self-inflicted behaviors until after the incident, and documentation of behaviors was inconsistent or absent. Another resident, who was cognitively intact and required moderate assistance for transfers, reported that after her call bell was not answered for an extended period, she attempted to transfer herself and subsequently fell. Progress notes and incident reports provided conflicting accounts of the circumstances surrounding the fall, and the resident stated she had called for help but no one responded. Despite this allegation of neglect, the facility did not conduct a further investigation to determine if neglect had occurred. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that in both cases, allegations of abuse and neglect were not properly investigated according to facility policy. The lack of timely and thorough investigations into these incidents represents a failure to respond appropriately to alleged violations, as required by both facility policy and state regulations.
Failure to Provide Adequate Assistance with Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal hygiene for nine out of sixteen residents who were unable to perform activities of daily living (ADLs) independently. Multiple residents voiced grievances about not being assisted with showers and nail care, and documentation showed discrepancies between scheduled and actual care provided. For example, several residents were scheduled for regular showers but received fewer than scheduled, with some records indicating refusals that residents denied making. One resident was observed with long, dirty fingernails and expressed a desire for assistance with nail care. Clinical records revealed that the affected residents had various medical conditions, including weakness, gait abnormalities, history of stroke, multiple sclerosis, diabetes, muscle wasting, hemiplegia, morbid obesity, dementia, osteoporosis, and frequent incontinence. Cognitive assessments indicated that most of these residents were cognitively intact or only moderately impaired, suggesting they were able to communicate their needs and preferences. Despite this, their care records and personal accounts indicated that their hygiene and grooming needs were not consistently met according to their care plans. Observations during the survey included a soiled brief left on the floor in a resident's room and a call light left unanswered for an extended period while staff were present at the nurses' station but not responding. Interviews with facility leadership confirmed that corrective actions had not been instituted to resolve resident grievances related to these deficiencies. The findings were cited under state regulations for management and resident rights.
Inaccurate Documentation of Meal Consumption
Penalty
Summary
The facility failed to accurately document meal consumption for two residents who were observed during a meal period. Both residents had care plans requiring close monitoring of their nutritional intake due to conditions such as dementia, anemia, diabetes, and dysphagia. Observations revealed that meal trays for both residents remained untouched, yet staff documented that each had consumed 51-75% of their meals. Staff interviews confirmed that documentation was based on typical consumption rather than actual intake, with one nursing assistant stating she recorded what the resident usually ate, not what was actually consumed during the observed meal. Further review of documentation practices showed a pattern, as ten additional residents had identical meal consumption percentages recorded for both breakfast and lunch, regardless of actual intake. The Director of Nursing confirmed the failure to accurately document meal consumption for the observed residents. These findings were in violation of facility policy and state regulations requiring accurate clinical records.
Failure to Report Alleged Neglect Following Resident Fall
Penalty
Summary
The facility failed to implement its policies and procedures for reporting allegations of neglect for one of four residents. According to the report, a resident with diagnoses including diabetes, heart failure, and muscle weakness, and who was cognitively intact, experienced a fall while attempting to transfer from bed to wheelchair. Documentation indicated that the resident had used her call bell but, after an extended period without staff response, attempted the transfer independently and slid to the floor. Multiple clinical notes and assessments confirmed the resident's account that she called for assistance but did not receive help in a timely manner. Despite the resident's report and the facility's own policies and state law requiring immediate reporting of suspected neglect, the incident was not reported as an allegation of neglect to the appropriate authorities. Facility records and interviews with the Nursing Home Administrator and Director of Nursing confirmed that the required reporting procedures were not followed for this incident.
Failure to Provide Medically-Related Social Services for Resident Transfer
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident with a transfer to an assisted living facility. The resident, who had diagnoses of cerebral palsy, autistic disorder, and a seizure disorder, was assessed as having severe cognitive impairment with a BIMS score of 00. The resident’s care plan indicated a preference for discharge to an assisted living facility, and the family, along with external advocates, actively sought to facilitate this transition. However, the facility did not complete or provide the necessary documentation in a timely manner, resulting in significant delays. Key documents, including the annual physical examination, medication and treatment records, screening forms, and various health evaluation forms, were either incomplete, missing, or unsigned. Despite the assisted living facility having a bed available and the resident’s family and advocates repeatedly requesting the required paperwork, the facility did not send the majority of the necessary documents until nearly two months after the initial acceptance of the transfer. Interviews with facility staff and external parties confirmed that the lack of timely and complete documentation directly delayed the resident’s transfer. The deficiency was acknowledged by the facility’s Nursing Home Administrator and Director of Nursing, who confirmed the failure to provide the required medically-related social services for the resident’s transition.
Failure to Secure Medications and Narcotics in Medication Cart
Penalty
Summary
Facility staff failed to ensure that medications, including controlled substances, were properly secured in one of the medication carts assigned to rooms 100-117. According to facility policy, medication carts must be securely locked at all times when not in the nurse's view. During an observation, a surveyor found the medication cart unlocked and unattended. Upon further inspection, the narcotic drawer within the cart was also found unsecured, and the surveyor was able to access the narcotic book and narcotic cards. The issue was confirmed by a registered nurse and later acknowledged by the Nursing Home Administrator and the Director of Nursing during interviews. No specific residents or patient medical histories were mentioned in relation to this deficiency. The report cites violations of state codes regarding the responsibility of the licensee, management, pharmacy services, and nursing services.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to its own policies regarding food safety and hygiene, as evidenced by several observations in the kitchen. During a survey, it was noted that a kitchen aide did not have her hair fully covered by a hair net, and another kitchen aide was working without a beard guard. Additionally, an employee was observed handling soiled dishes and then clean dishes without washing her hands in between, which was confirmed by the employee herself. The dietary manager also acknowledged these lapses in hygiene practices. Further observations in the first-floor nutrition room revealed improperly labeled and stored food items. There were several open and undated food packages, including cereal boxes, bags of tortilla chips, and a package of cookies. Additionally, there were containers with no names or dates, such as a glass jar with soup and a partially consumed bottle of strawberry lemonade. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing, indicating a failure to maintain proper food labeling and storage practices.
Failure to Maintain Resident Dignity and Address Call Light Malfunction
Penalty
Summary
The facility failed to maintain the dignity and quality of life for two residents, as evidenced by observations and interviews. Resident R47, who has severe cognitive impairment and physical impairments requiring assistance with dressing, was observed in the hallway without clothing on the lower body, exposing her brief. This incident was confirmed by the Unit Manager and a Nurse Aide, who stated that Resident R47 was unable to dress herself. This lack of appropriate clothing compromised the resident's dignity and sense of well-being. Additionally, Resident R36, who has intact cognition and is dependent for mobility, reported an incident where his call light malfunctioned, leading to a staff member threatening to place him in the television room for the night. The resident was subsequently moved to the television room from 1:30 a.m. to 7:30 a.m. without his consent. The facility's electronic work order system was not functioning, and there were no records of the call light repair or the incident in the facility's complaint and grievance files. The Nursing Home Administrator and Director of Nursing were unaware of the event until it was reported during the survey.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurately documented. For Resident R106, the clinical record showed a lack of documentation for prescribed treatments for pressure ulcers and abrasions. Specifically, the Treatment Administration Record (TAR) lacked entries for the left hip treatment on multiple dates in December 2024, and similarly, there were missing entries for the left buttock treatment. The Director of Nursing (DON) confirmed these findings, indicating a failure in maintaining complete and accurate medical records for Resident R106. For Resident R42, the facility's documentation inaccurately reflected the resident's current health status. Despite hospital discharge paperwork indicating the removal of the resident's gastrostomy tube, the physician and nurse practitioner progress notes from July to December 2024 continued to include information about nighttime tube feedings. The DON confirmed that the progress notes did not accurately represent Resident R42's health status. The Nursing Home Administrator and the DON acknowledged the facility's failure to maintain complete and accurate medical records for these two residents.
Failure to Maintain Hospice Records for Residents
Penalty
Summary
The facility failed to maintain hospice records for three residents receiving hospice services, as required by their policies and regulations. The facility's Hospice Services Agreement policy mandates that hospice services must meet professional standards and that specific documentation must be maintained, including the most recent plan of care, hospice election form, physician certification, and contact information for hospice personnel. However, upon review, it was found that the hospice records for Residents R2, R72, and R92 were incomplete. For Resident R2, the hospice election documentation, hospice visit documents, and hospice plan of care documents after a certain date were missing. Similarly, Resident R72's records lacked the hospice election documentation, hospice visit documentation, medications, hospice providers, and current hospice plan of care. Resident R92's records were also missing the hospice election documentation, hospice visit documentation, medications, hospice providers, and current hospice plan of care. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the facility's failure to maintain the required hospice records for the residents. The residents involved had various medical conditions, including cerebral palsy, high blood pressure, dementia, anxiety, and hemiplegia following cerebral infarction. The lack of proper documentation could potentially impact the coordination and quality of hospice care provided to these residents, as the necessary information to ensure continuity of care was not adequately maintained.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by observations, interviews, and grievance reviews. The facility's policy on call system response times was not adhered to, as calls for assistance were not answered promptly. During an observation, a call light for a resident was noted to be alarming, and it took several minutes before a registered nurse entered the room to assist. Interviews with residents revealed that it often took an hour or more for call lights to be answered, with some residents reporting waiting up to five hours for assistance. Residents expressed dissatisfaction with the staffing levels, describing them as insufficient and leading to long waits for help, medications, and other services. The deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to maintain adequate staffing levels to ensure the highest practicable physical, mental, and psychosocial well-being of the residents. The report highlights the experiences of multiple residents who consistently faced delays in receiving care, indicating a systemic issue with staffing and response times. The facility's non-compliance with state regulations regarding staffing and management was noted, further emphasizing the need for improvement in these areas.
Failure to Provide Consistent Evening Snacks
Penalty
Summary
The facility failed to consistently offer or make available evening snacks to residents, as required by their policy. During a review of the facility's policy on snacks, it was noted that the purpose is to provide residents with adequate nutrition and to report any problems or complaints related to snacks. However, the facility's snack audits for August and September 2024 only documented the volume and itemized list of snacks delivered to nursing units, without addressing whether residents' needs and preferences were met. In a resident group interview, nine out of ten residents expressed that they were not consistently offered nourishing evening snacks and that there were insufficient snacks for those who requested them. The residents expressed frustration and reported resorting to purchasing snacks from vending machines. They also mentioned that they no longer bring up this issue in Resident Council Meetings due to a lack of improvement. The Nursing Home Administrator and Director of Nursing were unable to explain the shortage of evening snacks, despite confirming that it is the facility's policy to offer and serve snacks according to residents' needs and preferences.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident, identified as R166, who was admitted with diagnoses including a fracture of the cervical vertebrae, high blood pressure, and pain. The resident was alert, oriented, and cognitively intact according to the Minimum Data Set assessment. On 11/12/24, the resident filed a grievance stating that the nursing staff was giving her a hard time about administering pain medication, and a night nurse refused to provide the medication, citing the need to care for 30 other residents. This grievance was acknowledged by the Director of Nursing (DON). Despite the facility's policy requiring thorough investigation and reporting of all allegations of abuse or neglect, the allegation made by Resident R166 was not reported to the local state field office. The Director of Nursing confirmed during an interview that the facility did not report the allegation as required. This failure to report constitutes a deficiency in the facility's management responsibilities as outlined in 28 Pa Code: 201.14 (a) and 28 Pa Code: 201.18 (e)(1).
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility failed to investigate an alleged incident of neglect involving a resident, identified as R166, who was admitted with diagnoses including a fracture of the cervical vertebrae, high blood pressure, and pain. The resident, who was alert, oriented, and cognitively intact, reported experiencing a high level of pain while at the facility. A grievance form dated 11/12/24 indicated that the resident complained about the nursing staff's reluctance to administer pain medication, with a night nurse refusing to provide the medication, citing the need to care for 30 other residents. This grievance was acknowledged by the Director of Nursing (DON), but there was no documented evidence of an investigation into the alleged neglect. During an interview on 12/17/24, the DON confirmed that the facility did not investigate the alleged incident of neglect for the resident. The facility's policy on Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, dated 11/1/24, mandates thorough investigation of all allegations and reporting to the Administrator and other officials as required. The failure to investigate and report the incident as per the policy and state regulations constitutes a deficiency in the facility's management and staff development responsibilities.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and disposed of in the First Floor medication room. During an observation, it was found that several vacutainers, an I.V. start kit, bacterial collection culture bottles, glucose monitoring control solutions, and a package of wound vacuum dressing were past their expiration dates. These items were not removed or disposed of according to the facility's policy, which requires contacting the dispensing pharmacy for instructions on returning or destroying discontinued, outdated, or deteriorated medications or biologicals. The observations were confirmed by Unit Manager Employee E3 and later by the Nursing Home Administrator and the Director of Nursing. The facility's failure to adhere to its medication labeling and storage policy resulted in the presence of expired medical supplies in the medication room, which is a violation of the regulations outlined in 28 Pa. Code sections related to the responsibility of the licensee, management, pharmacy services, and nursing services.
Facility Fails to Maintain Clean Environment Due to Persistent Leak
Penalty
Summary
The facility failed to provide a clean and homelike environment on the One East nursing unit, specifically in the room shared by two residents. During an observation, a large brown stain was noted on the ceiling tile above the toilet, indicating a persistent leak. Resident interviews revealed that the ceiling had been leaking down the wall and onto the floor for an extended period, despite attempts to replace the tile multiple times. The Nursing Home Administrator confirmed these findings, acknowledging the failure to maintain a clean and comfortable environment for the residents.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and oxygen services consistent with professional standards of practice for Resident R106. The facility's policy on oxygen administration, which includes verification of a physician order, equipment checks, and periodic assessments, was not adhered to. Resident R106, who has diagnoses including pressure ulcers, paraplegia, and severe protein-calorie malnutrition, was found using an oxygen concentrator and had two portable oxygen tanks at the bedside. However, during a subsequent interview, the resident reported that the portable oxygen tanks were empty and the concentrator malfunctioned, causing intermittent breathing difficulties. An employee confirmed the resident's report, noting that the portable oxygen tanks were indeed empty and the concentrator required replacement. The Director of Nursing acknowledged the facility's failure to provide adequate respiratory care and oxygen services for Resident R106, as per professional standards. This deficiency was identified during a review of the facility's policies, clinical records, and through staff interviews.
Failure to Post Required Contact Information
Penalty
Summary
The facility failed to post the required contact information for the Medicaid Fraud Unit and Adult Protective Services on both the first and second floor nursing units. This deficiency was identified during observations conducted on December 17, 2024, at 9:30 a.m., where it was noted that the contact information was not accessible to residents. During an interview later that day at 2:40 p.m., the Nursing Home Administrator confirmed the absence of the required postings. This failure is a violation of 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.18(e), which outline the responsibilities of the licensee and management.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to post notice of the availability of survey results in a prominent location on both the first and second floors, as required. During an observation, no signage was identified indicating that survey results were available. In a resident group interview, all 10 residents interviewed were unaware of the location of the survey results. The Nursing Home Administrator confirmed that the facility did not post notice of the location of survey results, which is a requirement under 28 Pa. Code 201.13(g) for the issuance of a license.
Failure to Display Medicare and Medicaid Information
Penalty
Summary
The facility was found to be deficient in displaying written information on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs. This deficiency was observed on both the first and second floor nursing units during a survey conducted on December 17, 2024. The absence of this information was confirmed by the Nursing Home Administrator during an interview on the same day. The failure to provide this information is a violation of resident rights as outlined in 28 Pa. Code: S201.29(i).
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide mandatory in-service training on Effective Communication for four out of ten staff members, as required by their policy. The policy, dated 11/1/24, mandates regular in-service education for all staff, with all mandatory in-services to be completed annually as a condition of employment. However, documentation revealed that Nurse Aide Employee E9, Nurse Aide Employee E10, Registered Nurse Employee E11, and Licensed Practical Nurse Employee E12 did not receive this training within the specified time frames corresponding to their hire dates. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide mandatory in-service training on Resident Rights for four out of ten staff members, as required by their policy. The policy mandates that all staff participate in regular in-service education, with all mandatory in-services to be completed annually as a condition of employment. However, documentation revealed that Nurse Aide Employee E9, LPN Employee E13, LPN Employee E14, and Therapy Employee E15 did not receive the required training within their respective annual periods. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for six out of ten staff members. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, dated 11/1/24, mandates that all staff participate in regular in-service education, with all mandatory in-services to be completed annually as a condition of employment. However, documentation revealed that Nurse Aide Employee E9, Registered Nurse Employee E11, and Licensed Practical Nurses Employees E12, E13, and E14 did not receive the required QAPI training within their respective annual periods. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the lack of QAPI training for these staff members. The facility's failure to adhere to its policy on mandatory in-service training was noted as a deficiency under the Pennsylvania Code sections 201.14 (a), 201.18 (b)(1), and 201.20 (a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide mandatory in-service training on Compliance and Ethics for two staff members, a Nurse Aide (NA) and a Licensed Practical Nurse (LPN). According to the facility's policy, all staff are required to participate in regular in-service education, with all mandatory in-services to be completed annually as a condition of employment. However, the training records revealed that the NA, hired on 7/5/11, did not receive Compliance and Ethics training between 7/5/23 and 7/5/24. Similarly, the LPN, hired on 11/29/22, did not receive the required training between 11/29/23 and 11/29/24. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the oversight, acknowledging that the facility did not provide the necessary training for these two staff members. This deficiency was identified under the regulations 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a)(c) Staff development.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required Behavioral Health training to three staff members, as determined by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy mandates regular in-service education for all staff, with mandatory sessions to be completed annually. However, documentation revealed that a Nurse Aide, an LPN, and a Therapy Employee did not receive Behavioral Health in-service education within the specified time frames. This deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience to residents during the lunch meal service on October 15, 2024. Observations revealed that the facility was using disposable styrofoam bowls to serve dessert, specifically cinnamon apples, to the residents. This practice was confirmed by Employee E1 during an interview on November 15, 2024, and by the Food Service Director, Employee E2, on the same day as the observation. Employee E2 acknowledged that the facility did not maintain a supply of china or thermal serving bowls, which resulted in the use of disposable styrofoam bowls, thereby failing to meet the requirement for a dignified dining experience as per PA Code: 201.29(k) Resident rights.
Facility Fails to Ensure Visitor Access During Off Hours
Penalty
Summary
The facility failed to provide a method for resident visitors to easily access the facility during off hours, as required by regulations. On a Saturday morning, the State Agency (SA) attempted to enter the facility and found secured double doors preventing access. The SA activated the intercom, which triggered a doorbell sound, but no staff responded. A notice instructed visitors to call the facility's main telephone number during off hours, but the call was disconnected after ringing for two minutes without being answered or allowing a voicemail message. The SA eventually gained access through the service entrance after encountering staff members outside. Further observations revealed that the intercom system was non-operational, with equipment removed and wires exposed. The receptionist confirmed uncertainty about visitor access outside her working hours. The Nursing Home Administrator and Director of Nursing acknowledged awareness of the non-operational intercom and the issue with the main telephone number. Additionally, the facility failed to specify off hours on the posted notices, contributing to the difficulty in visitor access.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman Office of resident transfers and discharges for a period of 42 months, from March 2021 through September 2024. This deficiency was identified through a review of facility documents, an audit conducted by the State Ombudsman Office, and staff interviews. The facility was unable to provide documented evidence of compliance with the notification requirement during this time frame. An audit conducted by the State Ombudsman Office on August 1, 2024, confirmed the lack of notifications since February 10, 2021. The Nursing Home Administrator acknowledged the failure to report these transfers and discharges as required by PA Code: 201.29(f)(g) regarding resident rights.
Failure to Maintain Homelike Environment and Access to Common Areas
Penalty
Summary
The facility failed to provide a homelike environment for its residents, as evidenced by several observations and staff interviews. In room [ROOM NUMBER], a ceiling tile in the bathroom was observed to have a wet spot and brown markings, indicating prior water leakage. This issue was confirmed by an LPN, who acknowledged the presence of the brown marks and wet spot. A review of the facility's maintenance work orders showed that a work order had been submitted for the repair of the leak and replacement of the ceiling tile after a resident reported feeling water dripping on them while using the bathroom facilities. Additionally, the facility was found to be using the second-floor dining room as a storage area, which prevented residents from having a designated area to dine. The dining room contained various items, including oxygen concentrators, bed frames, wheelchairs, and other equipment. Furthermore, the second-floor resident lounge was blocked by a broken utility cart and locked, preventing resident access, and was also used for storage. Similarly, the first-floor resident lounge was locked, denying residents access to this common area. The Nursing Home Administrator confirmed these deficiencies, acknowledging the failure to repair the leak, permit resident access to common areas, and the inappropriate use of these areas for storage.
Failure to Maintain Visitor Access Systems
Penalty
Summary
The facility failed to maintain essential equipment used for visitor access during off hours, specifically the intercom and telephone systems. During an observation, it was found that the intercom system, which notifies staff of a visitor requesting access, was not functioning properly. The intercom located at the first-floor nursing unit had been removed, leaving exposed wires and rendering the staff unable to respond to visitors. Additionally, the facility's telephone system failed to transfer calls to another extension when unanswered, further preventing visitor access. The Nursing Home Administrator and Director of Nursing confirmed these deficiencies during an interview.
Failure to Notify Responsible Party of Room Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident regarding two room changes, as required by regulations. The review of the resident's census record showed that the resident experienced two room changes on the same day. However, the progress notes did not provide evidence that the resident's guardian or responsible party was informed of these changes. This was confirmed during an interview with the resident's guardian, who stated that they were not notified of the room changes. The issue was later addressed with the Nursing Home Administrator and Director of Nursing.
Failure to Complete Grievance Process for Misappropriation Allegations
Penalty
Summary
The facility failed to properly complete the grievance process for two residents who reported the misappropriation of their personal property. The facility's Grievances/Concerns policy requires the creation of a grievance form, documentation of investigation steps, a summary of findings, a decision on the allegations, and documentation of corrective actions and resolution dates. However, for Resident R1, who alleged that the maintenance department threw away her glasses, the grievance form lacked documentation of the investigation findings, a summary, a decision on the allegations, corrective actions, and the resolution date. This was confirmed by the Assistant Director of Nursing during an interview. Similarly, Resident R3 reported missing personal items, including teeth, a cell phone, and clothing, during a care conference. The facility failed to create a grievance form or begin an investigation into these allegations. This was confirmed by Resident R3 and further corroborated by the Nursing Home Administrator and Director of Nursing, who acknowledged the facility's failure to implement the grievance process and resolve the allegations in a timely manner, as required by the PA Code: 201.18(e)(4) Management.
Neglect in Wound Care Services
Penalty
Summary
The facility failed to protect residents from neglect of services, as evidenced by the lack of proper wound care for seven residents. The facility's policy on abuse prohibition, which includes neglect, was not adhered to, resulting in multiple instances where wound care was either not documented or not completed as scheduled. The Wound Care Report and Treatment Administration Records (TAR) revealed discrepancies in wound care documentation and actual care provided. For instance, Resident R1 had wound care documented as completed on several occasions, but the handwritten notes on the Wound Care Report indicated that the dressings were not changed as documented. Similar issues were found with Residents R2, R3, R4, R5, R6, and R7, where wound care was either not scheduled, not documented, or not completed as per the records. Interviews with staff, including the Wound Care Nurse and the Nursing Home Administrator, confirmed these discrepancies. The Wound Care Nurse admitted that the handwritten dates on the Wound Care Report were the dates she removed the dressings, which were not changed as per the documented schedule. The Nursing Home Administrator and the Director of Nursing acknowledged the failure to provide necessary wound care services, confirming that the facility did not protect residents from neglect. This neglect was in violation of several Pennsylvania Code regulations related to resident rights, management, and nursing services.
Failure to Provide Prescribed Wound Care
Penalty
Summary
The facility failed to provide prescribed treatment and services related to wound care for three residents, as identified through a review of facility policies, clinical records, and staff interviews. Resident R1, who had diagnoses of hemiplegia, lymphedema, and wound infection, did not receive documented wound care on several occasions in July 2024, despite having specific physician orders for wound treatment. The Wound Care Report indicated that dressings were not changed as scheduled, with a dressing dated 7/26/24 still in place on 7/29/24. Resident R3, diagnosed with anemia and osteoarthritis, was being followed for chronic surgical wounds. The treatment administration record for July 2024 showed multiple instances where wound care was not documented as provided, particularly during evening shifts. The Wound Care Report noted that a dressing dated 7/24/24 was still in place on 7/29/24, indicating a lapse in the prescribed wound care regimen. Resident R4, with peripheral vascular disease and high blood pressure, was followed for a left groin abrasion. The treatment administration record for July 2024 revealed missing documentation of wound care on several dates, both before and after a change in the physician's order. The Nursing Home Administrator confirmed the facility's failure to provide the prescribed wound care for these residents, which was a violation of several Pennsylvania Code regulations regarding resident care policies and nursing services.
Inconsistent Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of pressure ulcers for two residents. Resident R1, who was at risk for pressure ulcer development and had a deep tissue injury, did not receive consistent wound care as per the physician's orders. The documentation showed gaps in care, with several days missing records of wound care being provided. Additionally, a wound dressing removed on 7/29/24 had a date of 7/26/24, indicating that the dressing had not been changed as frequently as required. Similarly, Resident R2, who had a Stage IV pressure wound, also did not receive consistent wound care according to the physician's orders. The treatment records for Resident R2 showed missing documentation on specific days, indicating that wound care was not provided. The wound dressing for Resident R2, removed on 7/29/24, also had a date of 7/26/24, suggesting a lapse in the prescribed wound care regimen. These deficiencies were confirmed by the Wound Care Nurse and the Nursing Home Administrator during interviews.
Insufficient Nursing Staff Leads to Resident Care Deficiencies
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident interviews and observations. Residents reported long wait times for call light responses, with some waiting up to an hour or more. One resident described an incident where a leaking colostomy bag went unattended for 40 minutes after calling for help. Another resident reported that the lack of staff resulted in missed showers, with documentation showing only one shower provided since admission. Observations of residents revealed signs of neglect, such as matted hair, malodorous conditions, and unclean fingernails. Several residents expressed dissatisfaction with the level of personal care they received, citing insufficient staff as the primary reason. The facility's staffing policy, which mandates appropriate staffing levels for all shifts, was not adhered to, leading to unmet care needs and compromised resident well-being. The Nursing Home Administrator confirmed the facility's failure to provide adequate nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of the residents. The deficiency was noted in the context of Pennsylvania Code regulations, highlighting the facility's responsibility for ensuring sufficient staffing and staff development to meet resident needs.
Failure to Provide Substantial Evening Snacks
Penalty
Summary
The facility failed to provide a substantial evening snack to residents, resulting in a meal span of up to 16 hours between the supper meal and breakfast the next day. The facility's policy, dated 7/24/24, mandates that meals should not be spaced more than 14 hours apart. However, observations and interviews revealed that the evening meal was distributed as early as 3:53 p.m., with meal trays typically arriving between 4:00 p.m. and 4:15 p.m., which is earlier than the scheduled time of 4:45 p.m. This early meal distribution led to a prolonged period without substantial nourishment for the residents. Interviews with staff and residents highlighted dissatisfaction with the early meal times and the lack of substantial evening snacks. A resident expressed discontent with the early dinner time, and a nurse aide confirmed that the facility did not consistently provide substantial evening snacks, with only limited snacks like graham cookies available. The dietary worker corroborated the early meal distribution, and the nursing home administrator acknowledged the failure to adhere to the policy of providing a substantial evening snack and maintaining a meal span of no more than 14 hours.
Failure to Schedule Follow-Up Appointments
Penalty
Summary
The facility failed to schedule ordered follow-up appointments for three residents, leading to a deficiency in providing medically-related social services. Resident R1, diagnosed with end-stage renal disease, atrial fibrillation, and dementia, was discharged from the hospital with instructions to follow up with a pulmonologist in four weeks. However, the clinical record showed no evidence that this appointment was scheduled, which was confirmed by the scheduler. Similarly, Resident R2, with diagnoses including heart failure, diabetes, and an indwelling urinary catheter, was discharged with instructions to follow up with a urologist. The clinical record also lacked evidence of this appointment being scheduled, as confirmed by the scheduler. Resident R3, diagnosed with hemiplegia, heart failure, and Parkinson's disease, was discharged with instructions to follow up with a cardiologist and a surgeon within two weeks. The appointments were not scheduled until after the due date, following a discussion with the resident's family member. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility failed to schedule the ordered appointments for these three residents. The failure to schedule these follow-up appointments was identified through a review of clinical records and staff interviews, highlighting a lapse in the facility's responsibility to ensure residents receive necessary medical follow-ups as part of their care plan. This deficiency is a violation of 28 Pa. Code: 211.16(a) Social services.
Failure to Maintain Resident Safety During Transfer
Penalty
Summary
The facility failed to consistently maintain resident safety during a transfer, resulting in a laceration of the left leg for Resident R1. The facility's policy on accidents/incidents requires staff to report, review, and investigate all accidents/incidents, and the Director of Nursing (DON) and Administrator are responsible for reviewing and reporting the incident. However, the initial assessment of Resident R1 upon admission was inaccurate, leading to improper transfer methods being used. Resident R1, who had Myasthenia Gravis and required maximal aid for transfers, was incorrectly assessed as being able to perform a stand-to-pivot transfer with contact guard, when in fact, she required a Hoyer lift with two staff assistance. On the date of the incident, Resident R1 sustained a laceration on her left leg during a transfer from her wheelchair to her bed. The leg rests of the wheelchair were removed, and the sharp edges where they were attached caused the injury. Interviews with staff revealed that there was confusion regarding the transfer status of residents admitted on Fridays, and the accurate transfer information was not effectively communicated to all staff members. The DON confirmed that Resident R1 should have been transferred using a Hoyer lift from the beginning, and the failure to do so resulted in the injury. The facility's documentation and staff interviews indicated that there were inconsistencies in the assessment and communication of Resident R1's transfer needs. The therapy department and nurse aides had different understandings of Resident R1's transfer requirements, leading to the use of improper transfer techniques. The incident report and subsequent interviews confirmed that the facility did not maintain resident safety during the transfer, resulting in the laceration of Resident R1's left leg.
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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