Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain Laurel Healthcare And Rehabilitation Ctr during CMS and state inspections, most recent first.
Failure to investigate a Resident Council grievance regarding long call bell response times. Residents reported that some concerns get responses while others do not, and that staffing problems and agency staff not answering call bells were ongoing. Review of grievance logs showed no grievance form or investigation for the concern, and the NHA confirmed the issue had not been investigated.
Homelike Environment Not Maintained in Dining Room: During lunch, four empty wheelchairs were observed stored along the walls of the 2nd-floor dining room instead of in the adjacent closet, and the wallpaper below the windows was peeling. The NHA confirmed empty wheelchairs should not be stored in the dining room, and the DON and Director of Maintenance acknowledged the wall needed repair.
A resident with cognitive impairment, dementia, anxiety, depression, and behaviors of rejecting care and wandering received psychotropic meds that were not transcribed as ordered. The MAR reflected that an olanzapine taper was entered incorrectly, so the resident received more olanzapine than intended while also receiving haloperidol TID, and the ADON confirmed the taper was not followed as ordered.
Late Completion of Comprehensive MDS Assessments: The facility failed to complete required comprehensive MDS assessments and related CAA processes within the required time frames for multiple residents. Review of records showed several assessments were completed one to six days late, and the NHA confirmed the late completions during interview.
A facility failed to develop individualized care plans for several residents with diabetes, anxiety, psychosis, depression, dementia, and anticonvulsant use. Residents were documented as receiving medications such as insulin, Buspirone, Seroquel, Mirtazapine, Olanzapine, Citalopram, Haldol, Sertraline, Zoloft, and Neurontin, but the record lacked care plans addressing those identified needs. The DON/NHA confirmed that multiple residents’ care plans did not address their antidepressant, antipsychotic, or anticonvulsant therapy.
Failure to provide trauma-informed care for residents with PTSD. The facility had a policy requiring identification of trauma triggers and trigger-specific interventions, but records showed no documented trigger assessment or PTSD care plan for three residents. One resident was a Vietnam veteran with PTSD, nightmares, flashbacks, and anxiety; another had diagnoses including anxiety, depression, schizophrenia, and PTSD; and a third had flashbacks related to past sexual abuse and was upset after an aide grabbed and yanked her arm. The DON and NHA acknowledged the missing trigger-focused assessments and care plans.
The facility failed to complete annual performance evaluations for five nurse aides reviewed. Personnel file review showed no evidence of evaluations since 2021 for all five aides, and the NHA and HR Director confirmed that no annual performance evaluations had been completed since 2021.
Unpalatable Food Served at Meal Service A test tray for lunch showed mashed potatoes that were bland, thin in texture, and not palatable, and the Dietary Mgr confirmed the finding. Several residents reported poor taste, limited selection, and food that was often cooked improperly, including raw chicken, mushy or raw vegetables, tough or undercooked meats, and meals that were sometimes cold when delivered to the room.
Dishwasher Wash Cycle Temperature Below Required Range: The main kitchen high-temp dishwasher was observed running at 132 degrees Fahrenheit, below the manufacturer and FDA Food Code range of 150 to 160/165 degrees Fahrenheit. The Dietary Manager confirmed the temp was incorrect for a high-temp wash cycle and stated the thermostat was not set correctly.
Failure to Provide Medicare Non-Coverage Notices: The facility did not provide required ABN/BPN notice after Medicare Part A ended for three residents who remained in LTC. One resident was severely cognitively impaired with metabolic encephalopathy, another had dementia, and the records showed facility-initiated discontinuation before benefit days were exhausted. The NHA confirmed the notices were not provided as required.
Late Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments within the required timeframe for seven residents. The assessments were completed after the allowed deadline, and the NHA confirmed the MDSs were not completed in the required time frames.
A resident admitted with a urostomy, AFib, HTN, DM, anxiety, and depression had no documented baseline care plan addressing her immediate care needs. The record showed orders for multiple meds, including a blood thinner, diuretic, antidiabetic, antidepressant, and anti-anxiety medication, and the ADON confirmed the baseline care plan did not include the resident’s urostomy or other care and treatment needs.
A resident with Type II DM had a conflicting Humulin R U-500 sliding-scale order, but the facility did not clarify which scale to follow before administration. The resident was cognitively intact and needed staff help with daily care, and the DON confirmed the order should have been clarified with the physician.
An LPN did not follow a resident’s wound care order for a pressure ulcer and wound vac treatment. The resident was cognitively intact, needed extensive assistance with daily care, and had a stage II/IV pressure ulcer and a stage IV pressure ulcer. The order directed staff to bridge the wound above the anus, but during observation the LPN bridged it above and below the anus; a wound care RN later confirmed only bridging above the anus was ordered.
Failure to ensure safe supervision and fall precautions for three residents. One resident with severe cognitive impairment and wandering behaviors was found on the floor, but staff did not notify the RN and assisted him up before assessment; another cognitively impaired resident with dementia was pushed in a wheelchair while her foot was sliding on the floor; and a third resident with dementia was observed in bed without the ordered fall mats in place.
Failure to Address Pharmacy Recommendations and Complete Monthly Medication Review: The facility did not address pharmacy consultant recommendations for two residents receiving psychotropic medications, including suggested dose reductions for antipsychotic, antidepressant, and antianxiety drugs. The facility also failed to ensure a monthly pharmacist medication review was completed for another resident whose record showed use of antidepressant, anticoagulant, and antipsychotic medications; the DON and ADON confirmed the omissions.
A facility’s QAPI committee failed to correct recurring deficiencies involving a clean, homelike environment, pressure ulcer prevention, drug regimen reviews, safe food storage/preparation/service, and infection control. Prior plans of correction relied on audits and reporting to QAPI, but the same deficient practices were again cited in the current survey under F584, F686, F756, F812, and F880.
A resident with a stage IV pressure ulcer and EBP signage outside the room received wound care from two LPNs who removed the old dressing, cleansed the wound, and redressed it without wearing gowns. No PPE was visible outside or inside the room, and both the LPN and DON confirmed gowns should have been worn during care.
Failure to Offer Pneumococcal Vaccinations: The facility failed to ensure that four residents were offered and/or received the pneumococcal vaccine. Review of policies, MDS assessments, and clinical records showed that each resident’s pneumonia immunization was not up to date and there was no documented evidence that the vaccine was offered or administered. The NHA confirmed that the residents were not offered the vaccine and should have been.
A resident with dementia and moderate cognitive impairment developed escalating verbal, physical, and sexually inappropriate behaviors toward other residents, including yelling, swearing, refusing care, touching a male resident inappropriately, and multiple altercations that led to psychiatric evaluation and medication changes. The record did not show that staff monitored or analyzed the behaviors for patterns or triggers, and the behavior care plan was not revised or expanded with new interventions. The DON stated there was no behavior policy, individualized behavior plan, or interventions in place to prevent further altercations with wandering residents.
Lack of Activities and Programming on Secured Memory Unit: A resident with dementia and moderate cognitive impairment had ongoing violent, aggressive, and sexual behaviors toward other residents, and her care plan directed staff to keep her away from others when restless or agitated. On the secured memory unit, residents were observed wandering or sitting with no programming available, the activity calendar showed little or no scheduled activity, and staff interviews confirmed there were no evening activities and that residents mostly had nothing to do while staff were occupied with other tasks.
Failure to Complete Required Pre-Employment Screening: The facility did not complete required pre-hire screening for abuse, neglect, theft, and credential verification for several employees reviewed. Personnel records showed missing or delayed PA criminal background checks for two dietary aides, no documented PA nurse aide registry check for one nurse aide, and no documented PA RN licensure verification for two RNs prior to hire. The NHA confirmed the required checks were not completed as required.
Controlled medication accountability failed for multiple residents when narcotic doses were signed out on the controlled drug record but not documented on the MAR as administered. A resident with hospice services and PRN Morphine had missing Morphine with no documented investigation, while another resident with dementia and a third resident with pancreatic disease also had PRN Lorazepam or Morphine signed out without MAR evidence of administration. The DON confirmed the documentation gaps and the unaccounted Morphine.
A resident attempted suicide, was transferred to the hospital, and the facility told the hospital it would not accept the resident back because it could not meet his needs. The record lacked the required physician documentation explaining why the needs could not be met, the facility's attempts to meet those needs, the services available at the receiving facility, and written discharge notice to the resident, resident representative, and State Ombudsman.
Failure to Provide Written Transfer Notification: The facility did not document written notice to two residents and/or their representatives explaining the reason for hospital transfer, and the ombudsman was not notified of the transfers. One resident was sent out after tying a sheet around his neck and stating he did not want to live like this anymore, and another resident with cellulitis and an absent right toes diagnosis was transferred for a worsening foot wound.
Failure to promptly resolve grievances related to missing clothing was cited after residents raised repeated concerns in council meetings. Meeting minutes showed ongoing reports of missing clothes for multiple residents, but there was no documented evidence the concerns were addressed. The DON said the social worker did not attend the meetings and the activity director did not know she was responsible for filing a grievance; the activity director confirmed she told laundry about the issue but did not complete a grievance form, report it to the grievance officer, or follow up.
Staff failed to follow physician orders and correctly identify residents during medication administration, leading to multiple medication errors. In one case, an LPN gave Metoprolol without first obtaining ordered vital signs. Another resident’s medications were administered at a time different from the physician’s order and the MAR was not updated to reflect the correct times. Additional errors included an LPN giving vitamins to the wrong cognitively impaired resident after relying on the resident’s incorrect self-identification and an outdated photo, a resident receiving Clonazepam instead of Morphine, and another resident receiving Hydrocodone/APAP instead of Oxycodone/APAP. The administrator acknowledged these errors and the failure to update the MAR.
Surveyors observed an LPN leaving an unlocked med cart unattended in a hallway with drawers ajar and multiple pre-poured medication cups, labeled only with first names, sitting unsecured on top while a resident sat nearby. The pre-poured meds included clonazepam, metformin HCl, magnesium oxide, vitamin C, potassium chloride, lactulose, atorvastatin, Pepcid, Ranexa, metoprolol tartrate, and senna for four different residents, including one who was out at the hospital. The LPN reported that she pre-pours meds to accommodate residents going to the dining room and to mix lactulose into a resident’s milk, and acknowledged that the meds and cart should not have been left unsecured or out of her direct line of sight, in violation of facility policy requiring meds to be locked or under direct observation.
An LPN failed to follow facility infection control and medication administration policy by handling oral medications with bare hands during administration to two residents. In one instance, the LPN popped a pill directly into her bare hand before placing it into a medication cup and giving it to a resident. In another instance, when a pill fell from a medication cup onto the medication cart, the LPN picked it up with her bare hand, returned it to the cup, and administered it. The LPN and the Nursing Home Administrator later acknowledged that medications should not have been touched with bare hands before administration.
Two residents experienced deficient wound and pressure ulcer care when staff failed to follow wound vac orders and manufacturer instructions for a Stage 4 pressure ulcer, including not documenting required dressing changes, not routinely checking that the NPWT device was functioning, and not performing timely RN wound assessments while the device was nonfunctional, leading to documented deterioration of the wound. Another resident with paraplegia and diabetes had physician orders for a wound care consult and buttock wound treatment, but there was no evidence the consult was scheduled or completed for several weeks, despite ongoing documentation of moisture-associated skin damage and preventative measures, and the DON confirmed the lack of timely wound consultant involvement and documentation.
The facility did not maintain adequate staffing with appropriate competencies in its food and nutrition services, as the Assistant Dietary Manager lacked full required training and the Certified Dietary Manager position was vacant. There was also a period without a Registered Dietician until a contracted RD began, as confirmed by staff interviews.
Facility management failed to maintain employee health insurance coverage, continuing to deduct premiums from staff paychecks even after the insurance was cancelled for non-payment. Staff were unaware of the cancellation and did not know the status of the deducted funds.
Dirty and damaged STOP signs were observed on the doors of six residents’ rooms, with the signs described as tattered, torn, stained, and in some cases having holes. The D of Housekeeping stated the signs needed replacement, but the order had not been submitted because the facility had not paid the supplier bill.
A resident with severe cognitive impairment and intermittent urinary catheter procedures had repeated urine specimen handling problems and delayed UTI treatment. Nursing notes showed mislabeled, unusable, and inconclusive urine samples, missed culture and sensitivity testing, and multiple antibiotic courses ordered without the ordered urine results being completed. The DON confirmed the resident's UTIs were not treated timely because urine samples were not tested as ordered.
Pharmacy review recommendations were not fully addressed for two residents. One resident’s monthly pharmacist reports contained physician recommendations that were not documented as addressed, and another resident’s pharmacist note recommended a psychiatry referral for behaviors, but the physician response did not include a rationale for not making the referral. The DON confirmed both issues.
Food service staff failed to follow hygiene and labeling requirements in the kitchen. A Dietary Aide worked with sanitized dishes without a beard restraint, and multiple opened food items were found undated, including potato salad, breakfast sausages, and egg noodles. The Dietary Director confirmed the beard restraint and dating requirements were not followed.
The facility failed to ensure that four nurse aides had the required 12 hours of annual in-service training. A review of the aide roster and training records showed no documented evidence that the required training was completed for four reviewed nurse aides, and the NHA confirmed the missing documentation.
Dining Room Closed Despite Resident Preferences: Five residents were observed eating lunch in their rooms instead of the main dining room, which they said they preferred. Residents reported the dining room had been closed for several days because of insufficient nursing staff, and staff confirmed the closure was due to a staffing shortage and the need for nursing presence during meal service.
Insufficient nursing staff prevented several residents from receiving scheduled showers and kept the first-floor main dining room closed. Residents who were cognitively intact or impaired and needed varying levels of assistance were given bed baths instead of preferred showers, and staff said evening shift was especially short. Multiple residents were also observed eating in their rooms because the dining room had been closed due to not having enough nursing staff to safely open it.
Failure to notify the physician after missed insulin doses. A resident with diabetes mellitus was ordered Regular Insulin Concentrate before breakfast, lunch, and supper, but the insulin was not administered for the morning and lunch doses because it was unavailable. Documentation did not show that the MD was notified after the second missed dose, and the ADON confirmed she was aware of the morning omission but not the missed lunch dose.
Failure to Provide Written Transfer and Bed-Hold Notifications: The facility failed to provide written notice to resident representatives regarding hospital transfers and failed to document bed-hold notices for two residents. One resident was transferred after moaning in pain and another after a fall with R shoulder pain, but neither record showed the required written notifications or bed-hold documentation.
Failure to provide ordered tube feeding: A resident who was quadriplegic and dependent on enteral nutrition did not receive the prescribed Osmolite 1.5 via feeding tube as ordered because the formula was not available and the pharmacy delivery did not arrive. The MAR and nursing note confirmed the missed tube feeding, and the DON stated she was unaware the supply had not been delivered.
A resident with diabetes mellitus who was insulin dependent missed scheduled doses of Regular Insulin Concentrate because the medication was not available. The MAR showed two ordered pre-meal doses were not given, the resident reported the facility ran out of his insulin and his blood sugar had risen, and the DON confirmed the missed doses.
An opened Tresiba insulin pen for a resident with diabetes was found undated on a med cart. The facility policy required opened meds to be dated, and both an LPN and the DON confirmed the pen should have been dated after the seal was broken.
Failure to honor resident drink preferences for 2 residents. Two residents stated they wanted soda as a drink choice for meals or snacks, but the facility no longer supplied soda and instead directed them to buy it from vending machines or have it brought in. The Dietary Manager confirmed the facility only had regular and diet ginger ale for sick residents and could not order soda on a regular basis because corporate office stopped it due to cost, despite ongoing resident requests.
A facility’s QAPI committee failed to correct recurring deficiencies cited in prior and current surveys. The same issues were repeated in quality of care, bowel/bladder incontinence, catheter and UTI management, and food procurement, storage, preparation, service, and sanitation, despite prior plans that included audits and reporting results to the QAPI committee.
The facility did not meet the required nurse aide-to-resident staffing ratios during the overnight shift for three consecutive days. With resident censuses of 117 and 116, the facility consistently had fewer nurse aides than required, with no additional higher-level staff to compensate. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to pay outstanding invoices to a staffing agency, leading to the withdrawal of essential nursing staff. Interviews confirmed the facility's inability to maintain required staffing levels without agency support, jeopardizing resident care.
The facility failed to meet the required nurse aide-to-resident staffing ratios on several occasions due to call-offs, as confirmed by the Nursing Home Administrator. On multiple days, the facility did not have enough nurse aides during the evening and overnight shifts, with no additional staff available to compensate for these shortages.
The facility failed to administer medications as ordered for two residents. One resident did not have their blood pressure checked before receiving Midodrine for hypotension, and another did not have their blood pressure or heart rate checked before receiving Metoprolol for hypertension. The DON confirmed these oversights.
Failure to Investigate Resident Council Grievance
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances presented by the Resident Council. Facility policy stated that grievances voiced during resident or family council meetings were to be recorded on a designated grievance form and addressed by the Grievance Official. Resident Council meeting minutes documented that residents raised concern that call bell response times were longer than ten minutes and were causing residents to have accidents. However, review of the grievance logs for June and July 2026 found no documented evidence that a grievance form was created or that the concern was investigated. During an interview, residents stated that some concerns receive responses while others do not, and that staffing remains a problem with agency staff sitting on their phones instead of providing care and answering call bells. The Nursing Home Administrator confirmed that the concern about long call bell wait times had been voiced at the Resident Council meeting and had not been investigated as of the date of interview.
Homelike Environment Not Maintained in Dining Room
Penalty
Summary
The facility failed to provide a homelike environment in the second-floor dining room. During lunch, four empty wheelchairs were observed stored along the walls of the dining room, and a nurse aide confirmed they should have been kept in the closet adjacent to the dining room before moving them there. In addition, the wallpaper in the second-floor dining room was observed peeling off the wall below the windows. The Director of Maintenance stated the wall was already on the repair list and was aware it was a problem, and the DON confirmed the dining room wall needed repair.
Psychotropic Medication Order Transcription Error
Penalty
Summary
The facility failed to ensure one resident’s medication regimen was free from unnecessary psychotropic medications when Resident 59 did not receive the ordered olanzapine taper as intended. Resident 59 was cognitively impaired, had behaviors of rejecting care and wandering, and had diagnoses that included anxiety, depression, and dementia. The resident’s physician orders included olanzapine 10 mg twice daily and haloperidol 2 mg twice daily, and a later verbal order from the psychiatry provider increased haloperidol to three times daily and directed olanzapine to taper to a bedtime dose ending on July 6. A review of the MAR showed the olanzapine taper was transcribed in a way that resulted in higher doses being administered than intended during the taper. Resident 59 received haloperidol 2 mg three times daily from July 2 through July 7, 2026, and received olanzapine 10 mg twice daily from July 2 through July 7, 2026, with an additional 10 mg bedtime dose from July 3 through July 5, 2026. The Assistant Director of Nursing confirmed that the resident did not receive the olanzapine taper as ordered by the physician, resulting in a medication error of receiving more olanzapine than intended.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments and the associated Care Area Assessment process were completed within the required time frames for 16 of 87 residents reviewed. The report cites the RAI User’s Manual requirement that admission MDS assessments and CAA completion be finished no later than the admission date plus 13 calendar days, and that an MDS assessment be completed every 92 days. Review of the CMS MDS validation report and clinical records showed that multiple residents had comprehensive assessments completed after the required deadline, including residents whose ARDs ranged from May through July 2026 and whose assessments were completed one to six days late. Specific examples included residents 9, 57, 83, 97, 98, 129, 152, 153, 157, 159, 162, 163, 165, 170, 171, and 172, with late completion documented for each. The Nursing Home Administrator confirmed in interview on July 23, 2026, at 11:15 a.m. that the comprehensive MDS assessments were not completed in the required time frames. The deficiency was cited under 28 Pa. Code 211.5(f), Clinical records.
Failure to Develop Individualized Care Plans for Residents’ Medication and Chronic Care Needs
Penalty
Summary
The facility failed to develop individualized care plans for multiple residents with identified care needs related to diabetes, psychotropic medication use, and anticonvulsant therapy. Resident 4 was cognitively intact, required assistance with daily care, and had diabetes with orders for Insulin Glargine and Jardiance, but there was no documented care plan addressing the resident’s diabetic needs. Resident 25 was slightly cognitively impaired, required assistance with daily care, and was receiving an antipsychotic, antidepressant, and anticonvulsant medication, yet no care plan was documented for psychosis, seizures, or depression. Resident 129 was cognitively intact, required assistance with daily care, and had diabetes, with orders for Buspirone and Seroquel, but no care plan was documented for anxiety or psychosis. Additional residents also lacked documented care plans for their medication-related needs. Resident 56 was cognitively intact and receiving Mirtazapine and Olanzapine, but there was no care plan for antidepressant or antipsychotic use. Resident 59 was cognitively impaired and receiving Citalopram and Haldol, but no care plan was documented for antidepressant or antipsychotic use. Resident 135 was cognitively impaired and receiving Sertraline and Seroquel, and Resident 162 was cognitively impaired with dementia and receiving Zoloft and Haldol; neither had a documented care plan for antidepressant or antipsychotic use. Resident 171 was cognitively impaired and receiving Neurontin for neuropathy, but there was no documented care plan for anticonvulsant use. The Nursing Home Administrator confirmed that the care plans for Residents 56, 59, 135, 162, and 171 did not address their use of antidepressant, antipsychotic, or anticonvulsant medications and should have. The report cited 28 Pa. Code 211.10(a)(c)(d) and 28 Pa. Code 211.12(d)(1)(3)(5).
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure that residents with PTSD were assessed and received trauma-informed care to identify and minimize triggers for three residents. The facility policy stated that trauma-informed care should account for resident experiences and preferences, identify triggers that may retraumatize residents with a history of trauma, and add trigger-specific interventions to the care plan. However, the record review showed no documented evidence that specific triggers were identified or that measures were implemented to prevent or minimize triggers for Residents 7, 25, and 129. Resident 7 had a quarterly MDS showing moderate cognitive impairment, need for staff assistance with daily care, and diagnoses including PTSD, with medications including antipsychotic, antianxiety, and antidepressant drugs. His care plan noted he was a trauma survivor, including service in the Vietnam War, the loss of his wife to suicide, and a history of physical and verbal abuse from his father. He reported anxiety related to Vietnam, loss of his best friend, and problems at night with PTSD, and a PTSD trauma assessment documented intrusive memories, flashbacks, upsetting dreams, and nightmares. Resident 25 had diagnoses including anxiety, depression, schizophrenia, and PTSD, but there was no documented evidence of specific triggers or a PTSD care plan. Resident 129 was cognitively intact and required assistance with daily care; nursing notes showed she was upset after a nurse aide grabbed and yanked her arm and that she had occasional flashbacks related to a past sexual abuse incident, but there was no documented evidence of identified triggers or a PTSD care plan. The DON and Regional Consultant stated that Resident 7's care plan did not address triggers or nightmares and flashbacks, and the NHA stated that Residents 25 and 129 did not have PTSD trauma assessments or care plans and should have.
Missing Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to ensure that nurse aide performance evaluations were completed at least annually for five of five nurse aides reviewed. Review of personnel files showed that Nurse Aide 1, hired October 29, 2015; Nurse Aide 2, hired March 20, 2014; Nurse Aide 3, hired August 18, 2021; Nurse Aide 4, hired October 16, 2012; and Nurse Aide 5, hired November 15, 2011, all had no evidence of a performance evaluation completed since 2021. Interviews with the Nursing Home Administrator and the Director of Human Resources confirmed that there had been no annual performance evaluations since 2021.
Unpalatable Food Served at Meal Service
Penalty
Summary
The facility failed to serve food that was palatable. Review of the posted lunch menu for Wednesday, July 22, 2026 showed that residents were to receive a ham steak, mashed potatoes with gravy, green beans, ice cream, and a beverage. A test tray for the B wing lunch meal showed the cart left the kitchen at 12:38 p.m., arrived on the nursing unit at 12:40 p.m., and the last resident was served at 12:47 p.m.; when the tray was tasted at 12:47 p.m., the mashed potatoes were bland, thin in texture, and not palatable. Multiple resident interviews on July 20, 2026 reflected dissatisfaction with the food, including limited selection, poor taste, food that was rarely cooked properly, chicken that was raw, vegetables that were either mushy or raw, meats that were overcooked and tough or undercooked and raw, and meals that were sometimes cold when they arrived to the room. The Dietary Manager confirmed that the mashed potatoes were bland, thin in texture, and not palatable.
Dishwasher Wash Cycle Temperature Below Required Range
Penalty
Summary
The facility failed to ensure that the main kitchen high-temperature dishwasher was operating at the proper wash cycle temperature to provide sanitary dishwashing conditions. Manufacturer instructions for the CMA Dish Machine EST-44H called for a wash cycle temperature between 150 and 160 degrees Fahrenheit, and the FDA Food Code cited a high-temperature dishwasher wash cycle range of 150 to 165 degrees Fahrenheit. During observation in the main kitchen, the dishwasher wash cycle temperature was only 132 degrees Fahrenheit. The Dietary Manager confirmed at the time of the observation that this was not the correct temperature for a high-temperature wash cycle, stated that the dishwasher was only registering 132 degrees Fahrenheit, and confirmed that it should register at least 150 degrees Fahrenheit. She also confirmed that the thermostat was not set correctly.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required notice to residents or their representatives after Medicare Part A coverage ended for three residents who remained in the facility for long-term care. For Resident 10, the clinical record showed severe cognitive impairment, need for staff assistance with daily care, and a diagnosis of metabolic encephalopathy. The facility’s SNF Beneficiary Protection Notification Review form showed Medicare coverage began on March 18, 2026, and the last covered day was June 1, 2026, with the discontinuation initiated by the facility before benefit days were exhausted. Resident 10 signed the Beneficiary Protection Notification himself, but the record indicated he could not understand the form due to his cognitive impairment, and there was no documented evidence that he was provided an ABN of non-coverage. For Resident 14, the facility’s SNF Beneficiary Protection Notification Review form showed Medicare coverage began on January 27, 2026, and the last covered day was March 5, 2026, with facility-initiated discontinuation before benefit days were exhausted, but there was no documented evidence that an ABN of non-coverage was provided. For Resident 46, the clinical record showed cognitive intactness, need for staff assistance with daily care, and a diagnosis of dementia. The facility’s SNF Beneficiary Protection Notification Review form showed Medicare coverage began on February 14, 2026, and the last covered day was March 4, 2026, with facility-initiated discontinuation before benefit days were exhausted. There was no documentation that Resident 46 or her Power of Attorney was aware of the form, and she remained in the facility for long-term care while unaware she was now private pay. The Nursing Home Administrator confirmed that an ABN was not provided to Residents 10, 14, or 46 as required.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed within the required time frame for seven of 87 residents reviewed: Residents 56, 74, 85, 96, 119, 130, and 141. The RAI User's Manual stated that the ARD for a quarterly MDS must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment completion date must be no later than the ARD plus 14 calendar days. For Resident 56, the quarterly MDS had an ARD of May 26, 2026, but was completed on June 10, 2026, two days late. Resident 74's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 85's quarterly MDS had an ARD of June 28, 2026, but was completed on July 13, 2026, two days late. Resident 96's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 119's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. Resident 130's quarterly MDS had an ARD of June 3, 2026, but was completed on June 18, 2026, two days late. Resident 141's quarterly MDS had an ARD of June 24, 2026, but was completed on July 9, 2026, two days late. The Nursing Home Administrator confirmed in interview that these comprehensive MDS assessments were not completed in the required time frames.
Baseline Care Plan Missing Immediate Needs
Penalty
Summary
The facility failed to ensure that Resident 155’s baseline care plan included information about the resident’s immediate care needs within 48 hours of admission. Resident 155’s physician orders dated July 15, 2026 showed a urostomy and medications including Diltiazem, Lasix, Apixaban, glipizide, Sertraline, and Clonazepam. An admission note dated July 15, 2026 at 5:00 p.m. documented that the resident arrived alert and oriented, was crying and anxious/depressed, had bladder cancer with bladder removal and a urostomy in place, atrial fibrillation, high blood pressure, and diabetes. There was no documented evidence that a baseline care plan was developed or individualized for the resident’s urostomy, irregular heartbeat, water pill, blood thinner, diabetes, depression, or anxiety. The Assistant Director of Nursing confirmed that the baseline care plan did not include these care and treatment needs.
Unclear insulin order not clarified
Penalty
Summary
The facility failed to clarify a provider’s insulin orders for one resident with Type II diabetes mellitus. The resident’s quarterly MDS dated May 9, 2026 indicated the resident was cognitively intact and required assistance from staff for daily care needs. Physician’s orders dated June 22, 2026 included Humulin R U-500 to be injected per sliding scale, but the order contained conflicting directions, including one scale stating blood sugar 0-300 give 0 units, 301-450 give 40 units, and 451 or more call the provider, and another scale stating 0-300 give 0 units, 301-450 give 5 units, and 451 give 7 units and call the provider. The facility did not clarify which sliding scale was to be followed before administering the medication. The DON confirmed in interview that the medication order should have been clarified with the physician prior to administration and was not.
Improper Wound Vac Bridging During Pressure Ulcer Care
Penalty
Summary
Pressure ulcer care and prevention treatments were not provided as ordered for one resident who was cognitively intact, required extensive assistance with daily care tasks, and was at risk for pressure ulcer development. The resident had a stage II/IV pressure ulcer and a stage IV pressure ulcer documented on the annual MDS assessment. A physician’s order dated July 15, 2026 directed staff to cleanse the wound with soap and water, apply skin prep, cut black foam to size, loosely pack the tunnel of the right buttocks at the 2 o’clock position, cover the wound bed with transparent dressing, and set the wound vac to 125 mmHG continuous suction. During wound care observation on July 21, 2026, an LPN bridged the wound together above and below the anus, although the order specifically stated to bridge above the anus. The LPN stated after the treatment that she thought it was necessary to bridge above and below the anus. A wound care RN from the resident’s wound care center later stated that staff should have only bridged the wound above the anus.
Failure to Ensure Safe Supervision and Fall Precautions
Penalty
Summary
The facility failed to ensure a safe environment for three residents by not providing adequate supervision and by not following its own fall-related procedures. Resident 133 had severe cognitive impairment, wandering behaviors, dementia, and required assistance with daily care. He was found lying on the floor on his right side near his bed, but the LPN and RN on duty were not informed at the time, and he was assisted off the floor before being assessed by nursing staff. Staff statements about how he ended up on the floor were inconsistent, with one aide stating she lowered him to the floor after care and another stating he was already on the floor when she entered the room. The interim DON confirmed that Resident 133 was not assessed by an RN after being found on the floor and should not have been assisted off the floor before assessment. Resident 169, who was cognitively impaired, dependent on staff for wheelchair use, and had dementia, was observed sitting in her wheelchair with her left foot positioned behind the footrest and sliding on the floor while a nurse aide pushed her down the hallway. The aide stated she was not aware the resident's foot was off the footrest, and the DON confirmed the aide should not have pushed the resident in that condition. Resident 171, who was cognitively impaired, dependent on staff for daily care, and had dementia, had previously been found on the floor beside her bed and her care plan was updated to include fall mats on both sides of the bed. However, later observation showed the resident in bed without fall mats on either side, and an LPN confirmed the mats were supposed to be in place when the resident was in bed.
Failure to Address Pharmacy Recommendations and Complete Monthly Medication Review
Penalty
Summary
The facility failed to respond to pharmacy recommendations for two residents and failed to ensure that monthly pharmacy medication reviews were completed for one resident. Facility policy stated that each resident was to be reviewed at least monthly by a licensed pharmacist and that staff were to act on all recommendations according to procedures for assessing medication regimen review irregularities. One resident had a quarterly MDS showing cognitive impairment, need for assistance with daily care, and use of antipsychotic, antianxiety, and antidepressant medications. Pharmacy medication regimen review reports recommended that the physician consider gradual dose reductions of ziprasidone, venlafaxine, lorazepam, risperidone, and citalopram, but there was no documented evidence that the recommendations were addressed by the physician. Another resident had a quarterly MDS showing cognitive intactness and use of antidepressant, anticoagulant, and antipsychotic medications, but the clinical record contained no documented evidence that a monthly pharmacist medication review was completed for one month. Interviews with the interim DON and the ADON confirmed that the pharmacy consultant reports were not addressed and that the monthly pharmacy review was not completed.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring deficient practices identified in prior surveys and complaint investigations. The report states that previous plans of correction for deficiencies involving a clean, homelike environment, pressure ulcer development/prevention, drug regime reviews, food storage/preparation/service, and infection control included quality assurance systems and audits to be reported to the QAPI committee, but the current survey found those same areas remained deficient. The current survey ending July 23, 2026 cited repeated deficiencies under F584, F686, F756, F812, and F880, showing that the committee was ineffective in correcting the cited practices. The report also notes that the facility’s prior survey ending August 14, 2025 and complaint surveys ending March 19, 2026 and April 28, 2026 had already identified these issues and that the facility’s plans of correction relied on audits and QAPI review. Despite those plans, the current survey again found deficiencies related to the clean/homelike environment, pressure ulcer development/prevention, drug regime reviews, food store/prepare/serve safely, and infection control. The cited regulatory references included 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(e)(1) Management.
Failure to Use Required PPE During Wound Care
Penalty
Summary
The facility failed to use proper infection control practices during incontinent care for one resident who was cognitively intact, required assistance with daily care needs, had limited range of motion to the lower extremity, and had a stage IV pressure ulcer with exposed bone, tendon, or muscle. The facility’s policy on enhanced barrier precautions stated that EBP may be indicated for residents with wounds and that staff must wear appropriate PPE, including a gown and gloves, when providing care. During observation, the resident had a sign outside the room indicating enhanced barrier precautions, but there was no PPE visible outside or inside the room. Two LPNs entered the room to perform wound care, removed the old dressing, cleansed the wound, and dressed the wound without wearing gowns. One LPN confirmed she did not have on a gown while performing wound care, and both LPNs should have worn gowns during care. The DON also confirmed that both LPNs should have worn gowns when performing wound care.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered and/or received for four of 87 residents reviewed: Residents 1, 4, 113, and 171. The facility’s influenza and pneumonia vaccination policies, dated April 10, 2026, stated that all residents would be offered the influenza and pneumonia vaccines. However, review of the clinical records showed that Resident 1’s quarterly MDS dated July 6, 2026, indicated the resident’s pneumonia vaccine was not up to date and that she was not offered the vaccine, with no documented evidence that it was offered or administered. Resident 4’s quarterly MDS dated June 24, 2026, showed the same findings: the pneumonia vaccine was not up to date, the resident was not offered the vaccine, and there was no documented evidence that it was offered or administered. Resident 113’s comprehensive MDS dated June 30, 2026, showed that he was cognitively intact, his pneumonia vaccine was not up to date, and he was not offered the vaccine, with no documented evidence that it was offered. Resident 171’s admission MDS dated May 19, 2026, showed that her pneumonia vaccine was not up to date and that she was not offered the vaccine, with no documented evidence that it was offered or administered. During an interview on July 23, 2026, the Nursing Home Administrator stated that Residents 1, 4, 113, and 171 were not offered the pneumonia vaccine and that they should have been.
Failure to assess and manage escalating resident aggression and inappropriate behaviors
Penalty
Summary
The facility failed to monitor, assess, analyze, and develop new interventions for a resident with dementia and moderate cognitive impairment who developed escalating verbal, physical, and sexually inappropriate behaviors toward other residents. The resident’s record showed repeated episodes of aggression and agitation after admission for long-term care, including altercations with other residents, hitting and pushing another resident down, screaming, swearing, making rude and negative remarks, refusing care, and not allowing her roommate into the room. Her care plan directed staff to keep her away from other residents when restless or agitated, but the record did not show that her behaviors were analyzed for patterns or precipitating factors. The resident’s behaviors continued to worsen over time. Nursing and psychiatry notes documented refusal of medications, combative behavior with care, intrusive and inappropriate touching of a male resident, threats toward staff and residents, and an emergency room transfer for psychiatric evaluation and admission. After readmission, she was again observed screaming at male residents, refusing care and assessments, entering another resident’s room shouting, lunging at a male resident, yelling at wandering residents, and being verbally abusive and physically aggressive, including swinging at one resident, scratching another resident’s arm, and using her hip in an attempt to make another resident fall. The record also showed that her psychiatric medications were increased and she received intramuscular antipsychotic medication due to violent and aggressive behaviors, but there was no documented evidence that staff monitored her behaviors in a way that identified patterns or triggers, and no documented evidence that the behavior care plan was revised or that new interventions were developed. During observation, she stood in the hallway watching and commenting on residents as they passed, while there was no programming on the unit and no behavior plan in place to prevent further aggression toward wandering residents. The Nursing Home Administrator stated there was no behavior policy, individualized behavior plan, or interventions in place to prevent further altercations with residents who wandered freely on the secured unit.
Lack of Activities and Programming on Secured Memory Unit
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents on the secured memory impaired unit, including a resident with dementia who was moderately cognitively impaired and had a history of violent, aggressive, and sexual behaviors toward other residents. Her care plan directed staff to keep her away from other residents when she was restless or agitated, and nursing notes documented ongoing violent and aggressive behaviors, wandering, and a psychiatric hospitalization from June 4 through June 17, 2026 for increased violent, aggressive, and sexual behaviors with other residents. After returning to the facility, she continued to display violent and aggressive behaviors on the secured unit. Observations of the secured unit on July 9, 2026 showed no programming or activities for residents on the unit. The activity calendar showed bingo on another unit, but nothing scheduled for the secured unit. Residents were observed wandering the hallway, sitting in the area outside the dining room, and sitting in or moving in and out of the dining room while staff were occupied with resident care or medication pass and were not available to interact with residents. The activity calendar for June and July 2026 showed days with no activities on the secured unit and other days with only one scheduled activity at 10:30 a.m. Staff interviews confirmed there were no evening activities and that residents mostly wandered or sat in lounge chairs, with the Director of Activities stating there was not enough staff to provide activities or programming on the secured unit every day.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to complete required pre-employment screening for abuse, neglect, theft, and credential verification for several employees reviewed. Based on review of policies and personnel files, the facility did not complete a Pennsylvania State Board of Nursing licensure verification prior to hire for two of five employees reviewed, did not complete a Pennsylvania Nurse Aide registry check prior to hire for one of five employees reviewed, and did not perform a Pennsylvania criminal background check for two of five employees reviewed. The facility’s abuse policy, dated April 10, 2026, stated that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Personnel records showed that Dietary Aide 1 was hired on May 26, 2026, and the Pennsylvania criminal background check was completed on July 9, 2026; Dietary Aide 2 was hired on May 28, 2026, and there was no documented evidence of a Pennsylvania criminal background check until July 9, 2026. Nurse Aide 3 was hired on May 11, 2026, with no documented evidence of a Pennsylvania nurse aide registry check prior to hire. Registered Nurse 4 was hired on June 16, 2026, and Registered Nurse 5 was hired on May 12, 2026, with no documented evidence that Pennsylvania RN licensure verification was completed prior to hire. The Nursing Home Administrator confirmed these licensure verifications, nurse aide registry check, and criminal background checks were not completed as required.
Controlled Medication Accountability Failure
Penalty
Summary
The facility failed to ensure accountability of controlled medications for three residents. Resident 5, who was cognitively intact, required assistance with daily care needs, received hospice services, and had an order for Morphine 0.25 ml orally every 2 hours as needed for moderate pain/anxiety. The controlled drug record showed Morphine signed out on May 18, 2026 at 11:00 p.m. and 2:00 a.m., but the MAR did not document administration on those dates. The record also showed Morphine available on May 29, 2026 at 12:09 p.m. as 12.75 ml, but only 6.0 ml was present when the first shift nurse and second shift nurse counted narcotics, and there was no documented investigation for the missing amount. Resident 7 was cognitively impaired, required assistance with daily care needs, and had diagnoses including heart failure and dementia. The resident had an order for Lorazepam 0.5 mg orally every 4 hours as needed for anxiety, but the controlled drug record showed doses signed out on multiple dates in May 2026 with no MAR documentation that the medication was administered. Resident 8 was moderately cognitively impaired, required assistance with daily care needs, had pain occasionally, received PRN pain medication, and had pancreatic disease. The resident had an order for Morphine 0.5 ml orally every 1 hour as needed for severe pain or respiratory distress, but the controlled drug record showed doses signed out on several occasions in May 2026 with no MAR documentation that the medication was administered. The DON confirmed there was no documented evidence that the signed-out doses for Residents 5, 7, and 8 were actually given, and confirmed Resident 5's Morphine was unaccounted for with no investigation initiated.
Failure to Complete Required Discharge Documentation After Hospital Transfer
Penalty
Summary
The facility failed to readmit a resident after hospitalization following a suicide attempt. The resident was admitted to the facility and later tied a sheet around his neck and stated, "I don't want to live like this anymore." Police and EMS were present, and the resident was transferred to the hospital for treatment. A nursing note later documented that the hospital was told the facility would be unable to accept the resident back because it could not meet his needs. The facility's policy required physician documentation when the facility determined it could not meet a resident's needs, including the specific needs that could not be met, the facility's attempts to meet those needs, and the specific services available at the receiving facility. The policy also required written discharge notice to the resident, resident representative, and the State Ombudsman when discharge was decided while the resident was hospitalized. The Nursing Home Administrator confirmed there was no written physician reason, no documentation of the facility's attempts to meet the resident's needs, no documentation of services available at the receiving facility, and no written discharge notice provided to the resident, resident representative, or State Ombudsman.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing regarding the reason for transfer to the hospital for two residents reviewed. The report states that the facility's policy regarding transfers and discharges required that transfer notice and bed hold policy be provided to residents and representatives when indicated, but there was no documented evidence that this occurred for either resident. Resident 1 was admitted to the facility and later tied a sheet around his neck and stated, "I don't want to live like this anymore." Police and EMS were present, and the resident was transferred to the hospital for treatment. Resident 6 had an admission MDS showing cognitive intactness, need for assistance with daily care needs, and diagnoses including cellulitis of the right lower limb and acquired absence of right toes. The resident was later transferred to the hospital with a worsening foot wound. For both residents, the clinical record lacked documented evidence that the resident and legal guardian were notified in writing of the purpose for the hospitalization, and the Nursing Home Administrator confirmed this during interview. The report also states that the ombudsman was not notified of the transfers.
Failure to Resolve Resident Council Grievances About Missing Clothing
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances related to residents’ concerns voiced during resident council meetings. A facility policy for Resident and Family Grievances, dated April 10, 2026, stated that grievances may be voiced during resident or family council meetings and that the staff member receiving the grievance will record the nature and specifics on a grievance form or assist with completing the form. The policy also stated that the grievance official will take steps to resolve the grievance and document the grievance and actions taken on the grievance form. Resident council meeting minutes dated February 16, 2026, showed a general concern that many clothes were missing. Minutes dated March 16, 2026, indicated clothes were still missing for three residents, and minutes dated April 20, 2026, showed one resident still had missing clothes. There was no documented evidence that these concerns were addressed. The DON stated on May 12, 2026, that the social worker did not attend resident council meetings and the activity director was unaware she was responsible for filing a grievance for concerns identified in those meetings. The Activity Director confirmed that residents raised concerns about missing clothing, reported the concern to laundry, but did not complete a grievance form, report it to the grievance officer, or follow up on the concern.
Medication Administration Errors and Failure to Follow Physician Orders
Penalty
Summary
The deficiency involves failures to follow physician medication orders and to ensure correct resident identification during medication administration, resulting in multiple medication errors. For one cognitively intact resident who required assistance with all daily care needs, the physician had ordered Metoprolol Tartrate 50 mg twice daily with instructions to hold the dose if systolic blood pressure was less than 100 or heart rate was less than 60. During an observed medication pass, an LPN administered the Metoprolol without obtaining the resident’s blood pressure or heart rate beforehand, contrary to the order and facility policy requiring vital signs to be obtained and medications held when parameters were not met. Another cognitively impaired resident who required assistance with all daily care needs had physician orders for Synthroid 25 mg at 8:00 a.m. and Oxycodone 10 mg at 8:00 a.m. and 4:00 p.m. A nursing note documented that this resident became upset when the 8:00 a.m. medications were given at 6:00 a.m., stating he had requested medications at 8:00 a.m. and 8:00 p.m., and the MAR was not updated to reflect the ordered administration times. Additional medication errors occurred when medications were administered to the wrong residents or the wrong medications were given. A cognitively impaired resident with dementia, anxiety, and depression was sitting in a wheelchair outside another resident’s room and, when asked her name, identified herself as that other resident. An LPN, unfamiliar with the resident, relied on this verbal identification and a computer photo that did not resemble the resident’s current appearance, assumed it was an old picture, and did not seek staff assistance to verify identity. As a result, calcium with Vitamin D and magnesium intended for another resident were administered to this resident in pudding. In another incident, a cognitively impaired, dependent resident was given 0.5 mg Clonazepam instead of the ordered 60 mg Morphine during a morning medication pass. In a separate case, a cognitively intact, independent resident was given Hydrocodone/APAP 5-325 mg instead of the ordered Oxycodone/APAP 5-325 mg. The Nursing Home Administrator confirmed that these medication errors should not have occurred and that the MAR for the resident with time-specific medication orders had not been updated to reflect the correct administration times.
Unsecured and Pre-Poured Medications Left on Unlocked Med Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were properly secured and not pre-poured in advance, contrary to facility policy and professional standards. The facility’s medication policy dated March 19, 2026, required all drugs and biologicals to be stored in locked compartments and to remain under the direct observation of the person administering them or locked in the storage area/cart during medication pass. During an observation of medication administration on April 28, 2026, five pre-poured medication cups containing pills and liquids, labeled only with first names, were found sitting unsecured on top of an unlocked medication cart with three drawers ajar. These medications corresponded to physician orders for four residents: one receiving clonazepam, metformin hydrochlorothiazide, magnesium oxide, and Vitamin C; another receiving potassium chloride and lactulose; a third receiving atorvastatin, Pepcid, and Ranexa; and a fourth receiving metoprolol tartrate and senna. During the observation period, the LPN responsible for the cart left it unattended and out of her direct line of sight multiple times while a resident sat near the unsecured cart. She administered pre-poured medications to two residents at different times, and also left the cart in the hallway with pre-poured medications on top and drawers ajar while entering residents’ rooms to administer medications. In an interview, the LPN stated that she pre-pours medications for some residents because they like to go to the dining room for supper and that she prepared lactulose in advance to mix it into a resident’s milk because the resident does not like to take it. She also acknowledged that she had prepared medications for a resident who was out at the hospital before realizing the resident had not yet returned. The LPN and the Nursing Home Administrator both confirmed that medications should not have been pre-poured or left unsecured and that the medication cart should have been locked with all drawers closed when not in the nurse’s direct sight.
Improper Handling of Oral Medications During Administration
Penalty
Summary
Facility staff failed to follow its infection prevention and control and medication administration policy, which required staff to remove medications from their source without touching them with bare hands. During medication administration for Resident 2, an LPN preparing the medications was observed popping a pill into her bare hand and then dropping it into a medication cup before administering it to the resident. In a separate observation during medication administration for Resident 3, while the LPN was popping medications into a medication cup, a pill fell out of the cup onto the medication cart; the LPN picked up the pill with her bare hand, placed it back into the cup, and then administered it to the resident. In a subsequent interview, the LPN acknowledged that she should not have touched the pills with her bare hands before administering them, and the Nursing Home Administrator confirmed that the LPN should not have handled the pills in this manner, in violation of the facility’s policy and 28 Pa. Code 211.12(d)(1) regarding nursing services.
Failure to Provide Timely and Appropriate Wound and Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services for an existing Stage 3/4 pressure ulcer for one resident and failure to follow physician orders in a timely manner for another resident. Facility policies required physician orders for wound care, detailed documentation of each treatment, weekly head-to-toe skin assessments, and adherence to negative pressure wound therapy (NPWT/wound vac) orders and manufacturer instructions, including frequent monitoring of the pump and changing dressings at least every 72 hours. The wound vac manufacturer’s instructions specified that the machine should be frequently checked to ensure it was on and delivering negative pressure and that dressings should not remain in place longer than 72 hours. Resident 4, who was cognitively intact, dependent for care, frequently bowel incontinent, and diagnosed with paraplegia, had a Stage 4 pressure ulcer on the right buttock/ischium. Physician orders and a wound clinic consultation directed cleansing with soap and water, placement of white foam in tunnels, black foam to the wound bed, wound vac pressure at 125 mmHg, and dressing changes on specified days. Documentation showed the wound vac treatment was completed at the wound clinic on one date, and the resident later requested that wound vac changes be done in the morning instead of the evening. However, there was no documented evidence that the wound vac treatment was completed on the specified mornings following the resident’s requests. There was also no documentation that the wound vac was changed between several consecutive days, no evidence of routine checks to ensure the wound vac was functioning, and no RN wound assessment documented during that period, despite the wound vac not charging and ultimately going completely dead. By the next wound clinic visit, the wound on Resident 4’s right buttock/ischium was documented as significantly worse, with markedly increased measurements, tunneling, undermining, and the presence of necrotic tissue, slough, and exudate requiring debridement. Interviews with wound clinic staff, LPNs, an RN, and the DON confirmed that the resident did not arrive at the clinic with a wound vac, that the wound vac had not been functioning properly, that there were necrotic areas and foul odor, that the wound was the worst it had ever been, and that no wound assessment had been completed during the time the wound vac was not working. Staff also confirmed that the wound clinic physician was not informed that the wound vac was not in use, that wet-to-dry dressings were being used instead, or that the wound condition had changed. Resident 3 was admitted with an abrasion on the left calf, a friction area on the left buttock, and reddened heels requiring elevation. Physician orders included cleansing the left buttock wound with soap and water and applying zinc barrier cream every shift. The resident was cognitively intact, required extensive assistance, and had diagnoses including paraplegia and diabetes, and was care planned as being at risk for skin breakdown. A physician order for a wound care consultation was entered, and nursing documentation noted that the rounding provider updated orders, including the wound care consult. Subsequent clinical notes over several days documented moisture-associated skin damage to the buttocks with preventative skin measures in place. Despite the physician’s order for a wound care consultation for Resident 3, there was no documented evidence that the resident was seen by a wound consultant from the date the consult was ordered until several weeks later, when a wound care consultation finally occurred and new treatment orders for bilateral buttocks were written. There was also no documentation that an appointment had been made for the consult or that the resident refused to be seen. The DON confirmed that Resident 3 was not seen by a wound consultant during that interval and that there was no documentation of scheduling or refusal. These omissions reflect the facility’s failure to follow physician orders in a timely manner for wound care consultation and treatment for Resident 3.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Assistant Dietary Manager, who was originally hired as a dietary aide, was promoted to the assistant manager position after the previous dietary manager resigned, despite not having completed all required training and only having finished one Serve Safe training course. The Certified Dietary Manager position remained vacant during this period. Additionally, the facility did not have a Registered Dietician from October 11, 2025, through November 17, 2025, with the current Registered Dietician only starting on November 17, 2025, through a contracted agency. These findings were confirmed through interviews with the Assistant Dietary Manager and the Director of Nursing.
Failure to Maintain Employee Health Insurance and Mismanagement of Payroll Deductions
Penalty
Summary
The governing body and owners failed to ensure effective management of the facility by not maintaining compliance with state regulations regarding employee health insurance. Interviews with the Assistant Director of Nursing and a Registered Nurse Supervisor revealed that although money was being deducted from staff paychecks for health insurance premiums, the insurance had actually been cancelled due to non-payment by the facility. Staff were unaware of the cancellation and did not know where the deducted funds were going. Facility records confirmed that deductions continued for several months after the insurance was cancelled, and the Director of Nursing was unable to specify when payments to the insurance company had stopped.
Dirty and Damaged STOP Signs on Resident Room Doors
Penalty
Summary
The facility failed to provide a clean and homelike environment in residents’ rooms for six residents. During observations on August 11, 2025, the STOP signs posted on the doors of Residents 23, 24, 40, 48, 90, and 105 were observed to be tattered, torn, and stained. These signs were being used to prevent wandering residents from entering the rooms, but each observed sign was in poor condition. During an interview on August 14, 2025, the Director of Housekeeping stated that the STOP signs were dirty/stained and had holes in them. She said they needed to be replaced, but the order for new signs had not been submitted because the facility had not paid the bill with the supplier. She stated that once the bill was settled, she would order more and they would be replaced.
Failure to Properly Process Urine Samples and Treat UTIs
Penalty
Summary
Proper care to prevent infection was not provided for one resident who had severe cognitive impairment, required extensive assistance with daily care tasks, and had intermittent urinary catheter procedures. Clinical notes showed repeated problems with urine specimen collection and processing in February 2025: a urine sample was not labeled, another could not be flexed and had to be redrawn, and a later sample was inconclusive, after which the physician ordered an antibiotic without urinary test results. The record also showed that the resident received multiple straight catheter procedures to obtain urine during this period. In April 2025, the resident was again ordered an antibiotic for a UTI, but there was no indication that a urine sample was obtained or cultured. A later note stated the resident had finished an antibiotic, but the provider ordered another urine sample because the culture and sensitivity had not been run as ordered. Another note documented bacteria in the urine and a second antibiotic order, yet the culture and sensitivity still was not run as ordered. A subsequent urine sample was obtained and sent to the lab, and the sensitivity was finally run, after which the physician ordered an additional seven days of antibiotics. The DON confirmed that the resident's UTIs were not treated timely because the urine samples were not tested according to physician orders in February and April 2025.
Pharmacy Review Recommendations Not Addressed
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review recommendations were addressed and documented in the medical record for one resident, and failed to provide a rationale for not referring another resident to psychiatric care as recommended by the pharmacist. For Resident 46, an annual MDS dated August 14, 2025 showed the resident was cognitively intact and required moderate assistance with daily care needs, and pharmacy medication regimen review reports dated January 31, 2025, March 26, 2025, April 29, 2025, June 29, 2025, and July 30, 2025 contained physician recommendations, but there was no documented evidence that they were addressed by the physician. The DON confirmed on August 13, 2025 that these pharmacy consultant reports were not addressed. For Resident 8, an admission MDS dated May 30, 2025 showed the resident was cognitively intact, dependent on staff for daily care needs, had diabetes, and received insulin; a pharmacy note dated May 19, 2025 recommended referral to psychiatry for behaviors, and although the medication regimen review was addressed by the physician on May 22, 2025, it did not include any rationale for not referring the resident to psychiatry. The DON confirmed that the medical director did not provide a rationale for not making the referral.
Food Storage and Personal Hygiene Lapses
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for food service safety. The dietary policy required staff to cover all hair, including facial hair, with a restraint such as a hairnet, cap, hat, or beard restraint. During kitchen observations, a Dietary Aide was seen working at the dishwasher with sanitized dishes without a beard restraint, and the Dietary Director confirmed the aide should have been wearing one while in the kitchen. The facility’s food labeling policy also required opened food items to be securely closed, labeled, and dated before being returned to the refrigerator or freezer. Observations in the main kitchen found an opened and undated three-quarter full gallon container of potato salad in the refrigerator, an opened and undated one-quarter full bag of breakfast sausages in the main freezer, and an opened and undated one-quarter full bag of egg noodles in the pantry. The Dietary Director confirmed these items should have been dated when opened for use.
Failure to Document Required Annual Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that four of four nurse aides reviewed had at least 12 hours of annual in-service training. Based on the facility’s list of nurse aides, Nurse Aide 6, Nurse Aide 7, Nurse Aide 2, and Nurse Aide 8 each had hire dates that required them to complete 12 hours of in-service training within their respective annual periods, but there was no documented evidence that any of the four received the required training. The Nursing Home Administrator confirmed during interview that there was no documented evidence that these nurse aides completed the 12 hours of in-service training as required.
Dining Room Closed Despite Resident Preferences
Penalty
Summary
The facility failed to reasonably accommodate resident dining preferences for 5 of 50 residents reviewed. On August 11, 2025, Residents 46, 69, 81, 83, and 95 were observed eating lunch in their rooms at bedside tables or on their beds. Each of these residents stated that they preferred to eat in the main dining room, but it had been closed for several days to about a week, and they were not allowed to eat there during that time. Resident interviews showed that the residents were not given a clear reason for the closure, other than being told the dining room was not open or that it could not be safely opened. Staff interviews confirmed that the main dining rooms on the first floor had not been opened since the previous week because there was not enough nursing staff, and that nursing staff were required to be present during meal service. The Dietary Director confirmed the dining room had been closed since Monday, August 11, 2025, due to a shortage of nursing staff and stated that residents should be able to eat where they prefer.
Insufficient Nursing Staff Prevented Scheduled Showers and Dining Room Access
Penalty
Summary
The facility failed to provide sufficient nursing staff to complete residents’ scheduled showers for multiple residents whose care plans called for showers on specific days and shifts. Resident 17, who was cognitively intact and required maximum assistance with personal care, received only one shower in the last 34 days and did not refuse any showers. Resident 71, who was cognitively intact and required moderate assistance with bathing, received a bed bath instead of a shower. Resident 77, who was cognitively impaired and required maximum assistance with showering, received bed baths instead of showers on multiple dates in July and August. Resident 86, who was cognitively intact and dependent on staff for showering, received a bed bath instead of a shower. Resident 100, who was cognitively intact and required moderate assistance with showers, received multiple bed baths instead of showers across June, July, and August. Resident and staff interviews described that the facility did not have enough staff to provide the preferred showers and that evening shift was especially affected. Resident 71 stated she preferred showers to bed baths and was not aware why she did not receive showers all the time. Resident 77 stated he preferred showers and that there had not been enough staff to provide them. Resident 86 stated they did not have enough staff to provide the care she should be receiving. Resident 100 stated the facility was very short staffed, that he was unable to receive his preferred showers, and that he was concerned about odor because he did not get as clean from a bed bath. The facility also failed to keep the first floor main dining room open for residents because of insufficient nursing staff. A group of residents stated the dining room had been closed due to lack of nursing staff and that they preferred to eat there for socialization. Residents 46, 69, 81, 83, and 95 were observed eating lunch in their rooms instead of the main dining room, and each stated they preferred the dining room but had been unable to use it because it was closed. Nursing staff and the Dietary Director confirmed the main dining room had been closed since the previous week, and that it was closed because there was not enough nursing staff to safely open it.
Failure to Notify Physician After Missed Insulin Doses
Penalty
Summary
The facility failed to ensure that the physician was notified timely about a change in condition for one resident, identified in the record as Resident 58. The facility’s policy on changes in condition stated that the nurse would notify the attending physician when there was a change in the resident’s medical or mental condition or status, and when there was refusal of treatment or medications two or more consecutive times. Resident 58’s quarterly MDS showed that he was cognitively intact, understood and was understood, was independent with care needs, used insulin medication, and had a diagnosis of diabetes mellitus. His care plan indicated that he was insulin dependent and that staff were to administer medications per physician order. Physician orders required Regular Insulin Concentrate 500 units/ml to be given subcutaneously daily before breakfast, lunch, and supper. Medication administration documentation showed that the insulin was not given at 9:10 a.m. and again at 2:03 p.m. on the same day because it was unavailable. There was no documented evidence that the physician was notified after the resident’s second missed dose of insulin. The Assistant DON confirmed that she was aware the medication was not available for the morning dose, but she was not aware that the resident also missed the lunch dose, and therefore the physician was not notified when the second dose was missed.
Failure to Provide Written Transfer and Bed-Hold Notifications
Penalty
Summary
The facility failed to notify the resident representative in writing of the reason for transfer to the hospital and failed to ensure that a bed-hold notice was provided for two residents reviewed. For one resident, a nursing note documented that the resident was moaning in pain, staff attempted to contact the resident’s son three times without response, and the physician ordered transfer to the emergency room; however, there was no documented evidence that the resident representative was notified in writing of the hospital transfer and no documented evidence that a bed-hold notice was provided. For a second resident, a nursing note documented a fall followed by transfer to the emergency room with complaints of pain in the right shoulder. Review of the clinical record again found no documented evidence that the resident representative was notified in writing of the hospital transfer and no documented evidence that a bed-hold notice was provided. The Nursing Home Administrator confirmed that there was no documented evidence in either resident’s record of written notification to the resident representative regarding the transfer to the hospital and no documentation that a bed-hold notice was provided.
Failure to Provide Ordered Tube Feeding
Penalty
Summary
The facility failed to follow a physician’s order for enteral tube feeding for one resident who was quadriplegic and required enteral feedings due to a decreased appetite. The resident’s quarterly MDS indicated the need for assistance with care, and the physician ordered Osmolite 1.5, or Diabetisource as a substitute, to be administered via feeding tube at 90 milliliters per hour from 8:00 p.m. for 11 hours, totaling 990 milliliters. A review of the MAR showed the resident did not receive the ordered tube feeding on the evening of August 11, 2025. A nursing note documented that the Osmolite 1.5 was not available, and the DON contacted the pharmacy and was told it would arrive on the night run, but it did not arrive. The resident stated he knew he did not receive the tube feeding that evening and reported that he had a bowl of cereal. The DON later stated she was unaware the Osmolite 1.5 was not delivered and was not notified that the resident missed the 11-hour tube feeding.
Missed Insulin Doses Due to Medication Unavailability
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one resident who was insulin dependent and had a diagnosis of diabetes mellitus. Facility policy stated that insulin medication given to a resident shall be prescribed by the physician. The resident’s quarterly MDS indicated that he was cognitively intact, independent with care needs, and used insulin medication to manage blood glucose levels. His care plan directed staff to administer medications per physician’s order, and the physician’s orders required Regular Insulin Concentrate before meals, including 160 units before breakfast, 50 units before lunch, and 125 units before supper. On review of the August 2025 MAR, the resident’s ordered insulin was not administered at 7:00 a.m. when his blood sugar was 178 mg/dl and was not administered again at 12:00 p.m. when his blood sugar was 309 mg/dl. The resident stated that the facility ran out of his insulin and that he missed two doses and his blood sugar had risen. The DON confirmed that the medication was not available and that the resident did not receive the scheduled doses.
Undated opened insulin pen
Penalty
Summary
The facility failed to date an opened Tresiba insulin pen for one resident. The facility policy for medication storage and labeling stated that when the original seal of a manufacturer's container or vial is broken, the container or vial must be dated, with a date-opened sticker placed on the medication and the date opened and new expiration date entered. Manufacturer instructions for Tresiba insulin stated that after first opening, it may be kept at room temperature for up to 8 weeks (56 days). Resident 18 had diabetes mellitus and an order for 64 units of Tresiba insulin subcutaneously in the afternoon. During observation of Medication Cart 2, surveyors found an opened and undated Tresiba insulin pen labeled with the resident's name. An LPN confirmed that the insulin pen should have been dated once the seal was broken, and the DON also confirmed that the Tresiba insulin pen should have been dated once the seal had been broken.
Failure to Honor Resident Drink Preferences
Penalty
Summary
The facility failed to ensure that drink preferences were honored for 2 of 50 residents reviewed. One resident stated that she wanted soda as a drink choice for meals or snacks, but was told she could only purchase soda from vending machines or have someone bring it in, and that the facility would no longer supply it; she was told she would be provided ginger ale if sick. Another resident stated that he wanted soda as a drink choice and was having to spend his own money out of pocket for soda because he wanted something besides ginger ale when sick and wanted different sodas as a choice for meals or snacks. The Dietary Manager confirmed that the facility had regular and diet ginger ale for residents who were sick, but she was not permitted to order soda on a regular basis because corporate office decided soda would no longer be ordered due to cost, even though residents continued to request soda as a drink choice for meals and snacks.
QAPI Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior and current surveys. A State Survey and Certification survey ending September 26, 2024, had already cited deficiencies involving quality of care, bowel/bladder incontinence, catheter use, urinary tract infection, and food procurement, storage, preparation, service, and sanitation. The facility’s plans of correction for those deficiencies included quality assurance systems, audits, and reporting audit results to the QAPI committee for review. The current survey ending August 14, 2025, found repeated deficiencies in the same areas, including quality of care under F684, bowel/bladder incontinence, catheter, and UTI under F690, and food procurement, storage, preparation, service, and sanitation under F812. Survey findings showed that the QAPI committee failed to successfully implement the prior plans to ensure ongoing compliance with the cited regulations.
Failure to Meet Overnight Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios during the overnight shift for three consecutive days. On January 28, 2025, with a census of 117 residents, the facility required 7.80 nurse aides but only had 7.25 on duty. On January 29, 2025, with a census of 116 residents, 7.73 nurse aides were needed, but only 7.09 were present. Similarly, on January 30, 2025, with the same census of 116, 7.73 nurse aides were required, but only 7.17 were available. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the failure to meet the staffing requirements during an interview on January 31, 2025.
Plan Of Correction
1. The administrator and/or designee will conduct a review of the last 14-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews for least 5-days per week for two weeks then 3-days per week for one month to ensure compliance. In the event of extensive call-offs, higher level nursing will staff fill, if possible, we ask for volunteers with bonuses, then in extreme case, we will mandate and will stop admissions. We continue to recruit all levels of staff, Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census. We have created a shift differential for evenings and night shifts and a weekend differential - this program is for all our nursing staff. We have increased our Registered Nurse Licensed Practical Nurse wages. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurser's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class thru an outside contractor to develop more Certified Nurse's Aide. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.
Failure to Pay Staffing Agency Jeopardizes Resident Care
Penalty
Summary
The facility failed to pay bills incurred for services essential to the residents' health and safety in a timely manner. A review of unpaid invoices from the National Healthcare Staffing agency revealed significant outstanding balances dating from September 2024 to January 2025. The total amount owed was $324,648.00, with individual invoices ranging from $10,817.18 to $46,143.11. The facility's inability to settle these debts led to the staffing agency withdrawing their personnel from the facility. Interviews with the Nursing Home Administrator and the owner of the staffing agency confirmed the outstanding balance and the agency's decision to pull their staff due to non-payment. The Nursing Home Administrator acknowledged that the facility could not maintain the required nursing staff levels without the agency's support. A payment was sent for the oldest invoice, but the remaining invoices remained unpaid, jeopardizing the facility's ability to provide adequate care to its residents.
Plan Of Correction
National Healthcare Staffing has agreed to a payment schedule. The facility Scheduler will receive, review and process each National Healthcare Staffing invoice and forward to the Nursing Home Administrator for approval. Then the Business Office Manager/designee will forward electronically to the Accounts Payable for payment. Facility administrator will review the Accounts Payable relative to National Healthcare Staffing to ensure timely payments as follows: weekly x2, monthly x2 for timely processing of National Healthcare Staffing with results to the facility Quality Assessment and Assurance Committee.
Staffing Deficiency Due to Inadequate Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios on multiple occasions, as evidenced by a review of nursing schedules and staffing information. On December 20, 2024, the facility had a census of 119 residents, necessitating 10.82 nurse aides for the evening shift, but only 9.37 nurse aides were available. Similarly, on December 19, 2024, with a census of 120 residents, the overnight shift required 7.93 nurse aides, yet only 7.07 were present. This pattern continued over the following days, with the facility consistently falling short of the required number of nurse aides during the overnight shifts. The deficiency was confirmed through an interview with the Nursing Home Administrator, who acknowledged that the facility did not meet the staffing ratios due to call-offs. No additional higher-level staff were available to compensate for these deficiencies, indicating a lack of contingency planning to address unexpected staff shortages. The report highlights specific instances where the facility's staffing levels were inadequate, leading to non-compliance with the regulatory requirements for nurse aide-to-resident ratios.
Plan Of Correction
1. The administrator and/or designee will conduct a review of the last 14-days of nursing schedules to determine compliance with proper nursing hours. 2. The administrator and/or designee will conduct reviews at least 5-days per week for two weeks, then 3-days per week for one month to ensure compliance. In the event of extensive call-offs, higher level nursing will staff fill, if possible. We ask for volunteers with bonuses, then in extreme cases, we will mandate and will stop admissions. We continue to recruit all levels of staff: Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. We also have a schedule/staffing meeting each day to discuss staffing and census. We have created a shift differential for evenings and night shifts and a weekend differential - this program is for all our nursing staff. We have increased our Registered Nurse and Licensed Practical Nurse wages. We continue a bonus for: Open Shift Bonus 4hrs 8hrs Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. Referral and Sign on Bonuses for: Registered Nurses, Licensed Practical Nurses, Certified Nurse's Aides. While we continue recruitment, we have established a Certified Nurse's Aide class through an outside contractor to develop more Certified Nurse's Aides. 3. The results of the audits, along with a Root Cause Analysis of any identified issues, will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective action.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to administer medications as ordered by the physician for two residents. Resident 55, who was cognitively intact and dependent on staff for daily care, had a physician's order to receive Midodrine for hypotension, with specific instructions to hold the medication if the systolic blood pressure exceeded 130. However, the staff did not obtain or record the resident's blood pressure before administering the medication, as confirmed by the Director of Nursing. Similarly, Resident 84, who was cognitively impaired and also dependent on staff, had a physician's order to receive Metoprolol Succinate Extended Release for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. The staff failed to obtain or record the resident's blood pressure or heart rate prior to administering the medication. This oversight was also confirmed by the Director of Nursing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clearfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ava Nursing And Rehab Center | 6.8 mi | ★★★★★ | 1 | 0 |
| Heritage Ridge Senior Living At Windy Hill | 13.4 mi | ★★★★★ | 20 | 0 |
| Dubois Nursing Home | 18.5 mi | ★★★★★ | 22 | 0 |
| Christ The King Manor | 20.7 mi | ★★★★★ | 4 | 0 |
| Highland View Rehabilitation & Healthcare Center | 25.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.