Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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 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to the wrong cognitively impaired resident after relying on the resident’s incorrect self-identification and an outdated photo, a resident receiving Clonazepam instead of Morphine, and another resident receiving Hydrocodone/APAP instead of Oxycodone/APAP.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.
A facility failed to document catheter care for a resident with an indwelling urinary catheter, leading to a urinary tract infection. Despite the facility's policy requiring regular catheter care, there was no evidence of care being provided during night shifts on several occasions. The resident, who was cognitively impaired and required assistance, developed a UTI, and the lack of documentation was confirmed by the DON.
A facility failed to provide trauma-informed care for a resident with PTSD, who had a history of significant traumatic events. Despite the resident's cognitive impairment and known trauma history, there was no documented assessment to identify triggers that could re-traumatize the resident. The DON confirmed the absence of such an assessment, highlighting a deficiency in care.
A resident with dementia exhibited wandering and rummaging behaviors, leading to multiple altercations with other residents. Despite documented care plans, interventions like redirection and stop signs were ineffective, resulting in physical altercations. Staff interviews indicated that strategies to manage the resident's behaviors were not consistently effective, and there was no documented evidence of revised interventions when initial measures failed.
The facility failed to provide enough dietary staff to keep the main dining room open during meal times, leaving residents unable to dine there. Several residents expressed their desire to eat in the dining room for socialization and hot meals, but staffing shortages prevented this. The Dietary Manager and Nursing Home Administrator confirmed the closure due to insufficient staff.
The facility failed to maintain sanitary conditions in the second floor kitchenette's ice machine and the first floor kitchenette's refrigerator. The ice machine's drain pipe lacked an air gap, and the refrigerator contained an expired sherbet, unlabeled popsicles, and a dark substance. These issues were confirmed by the Maintenance Director and Nursing Home Administrator.
The facility's QAPI committee failed to address recurring deficiencies, including providing an environment free from abuse, developing comprehensive care plans, and ensuring quality care. Despite previous plans of correction involving audits and QAPI reviews, the same issues were repeatedly cited, indicating ineffective implementation of corrective measures.
A resident's rights were violated when staff removed personal food items from her room without her knowledge or consent. The resident, who was cognitively intact and able to communicate, was taken to the dining room, during which time her belongings were removed. Interviews with staff confirmed that the resident was not informed prior to the removal, violating the facility's policy on resident rights.
A resident with dementia was subjected to abuse by an agency nurse aide, who was reported by the resident's wife for being rough and causing fear during care. The aide's actions were confirmed through an investigation, leading to her termination and placement on the Do Not Return list.
The facility failed to provide written notification to the state ombudsman, residents, and/or their representatives regarding the reasons for hospital transfers for five residents. These residents, with varying cognitive and medical conditions, were transferred to the hospital without the required documentation. The Nursing Home Administrator confirmed the lack of written notices.
The facility failed to develop and implement care plans for three residents, neglecting to address PTSD, dialysis catheter care, and smoking needs. A resident with PTSD had no care plan despite a significant trauma history. Another resident with a central venous catheter for dialysis lacked a care plan for catheter care, and a resident with metastatic lung cancer had no care plan for smoking needs. The DON confirmed these oversights.
The facility failed to update care plans for three residents, leading to outdated care instructions. A resident's care plan still included potential complications for a PICC line and urinary catheter that were removed, while another resident's care plan was not updated after a PICC line removal. Additionally, a resident's care plan required 15-minute checks due to cognitive impairment, but there was no evidence these checks were conducted.
A facility failed to ensure a safe smoking environment for a resident who was cognitively impaired and required supervision. The resident's ability to smoke was not re-evaluated quarterly as per facility policy, with the last evaluation conducted several months prior. The DON confirmed the oversight in completing the required smoking assessment.
A facility failed to maintain a medication administration error rate below five percent, with an error rate of eight percent observed. An LPN did not follow the manufacturer's instructions when administering Fluticasone nasal spray to a resident, as confirmed by the DON.
A facility failed to document that a resident was offered the influenza vaccine for the 2022-2023 season. The resident, who was cognitively impaired and dependent on staff, had a history of receiving the vaccine annually. However, there was no evidence of an offer for the current season, as confirmed by the DON.
The facility did not notify the responsible parties of two residents about changes in their medication and treatment. One resident, with dementia, was prescribed Macrobid for a UTI and Tamiflu for flu exposure without notifying their responsible party. Another resident, who tested positive for the flu, was given Tamiflu and guaifenesin without notification. The DON confirmed the lack of documentation for these notifications.
A resident with moderately impaired cognition and on a mechanically altered diet experienced a choking incident with pizza due to inadequate assessment of swallowing ability. Despite previous reports of difficulty, the resident was served pizza, leading to a Heimlich maneuver intervention. Communication lapses prevented timely assessment by the Speech Therapist.
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.
Failure to Document Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy required that the resident's care plan be reviewed for any special needs related to the urinary catheter. The resident, who was cognitively impaired and required assistance for daily care activities, had a diagnosis of obstructive uropathy and a physician's order for a 20 French urinary catheter with a 5 cc balloon for urinary retention. Despite these requirements, there was no documented evidence of catheter care being provided during the night shift on multiple dates across July, August, and September 2024. A nursing note from September 7, 2024, indicated that the resident developed a urinary tract infection, and orders were given to start antibiotic treatment and maintain proper Foley catheter care. However, the lack of documentation for catheter care during the night shifts was confirmed by the Director of Nursing, indicating a failure to adhere to the facility's policy and potentially contributing to the resident's urinary tract infection.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate triggers associated with their condition. The resident, who was cognitively impaired, had a history of significant traumatic events, including witnessing a friend's death in war, his wife's suicide, and abuse from his father. Despite these known factors, there was no documented evidence that the facility conducted an assessment to identify specific triggers that could re-traumatize the resident. An interview with the resident revealed the emotional impact of these traumatic events, with the resident expressing feelings of guilt and distress. The Director of Nursing confirmed the absence of a documented trauma history assessment for the resident, indicating a lapse in the facility's responsibility to provide appropriate care for individuals with PTSD. This deficiency was identified during a review of clinical records and interviews with the resident and staff.
Inadequate Management of Dementia-Related Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, leading to multiple incidents of resident-to-resident altercations. Resident 109, who has Alzheimer's disease and dementia, exhibited wandering and rummaging behaviors, entering other residents' rooms and taking their belongings. Despite these behaviors being documented in care plans, interventions such as redirection and the use of stop signs were ineffective in preventing the resident from entering others' rooms, resulting in several altercations with other residents. On multiple occasions, Resident 109 was involved in physical altercations with other residents who reacted negatively to her entering their personal spaces. For instance, Resident 94 hit Resident 109 after she entered his room, and Resident 70 struck her in the common area. These incidents highlight the facility's failure to adequately assess and adjust interventions for Resident 109's wandering behaviors, as the measures in place did not prevent her from entering other residents' rooms or protect her from harm. Interviews with staff revealed that while they attempted to redirect Resident 109 and used stop signs to deter her from entering rooms, these strategies were not consistently effective. The facility's documentation lacked evidence of a thorough assessment or revision of person-centered interventions when initial strategies failed. This oversight contributed to ongoing safety risks for Resident 109 and other residents, as her behaviors continued to disrupt the unit and lead to altercations.
Dining Room Closure Due to Insufficient Dietary Staff
Penalty
Summary
The facility failed to provide sufficient dietary staff to operate the main dining room during meal times, resulting in residents being unable to eat there. Observations on September 23, 2024, revealed that the dining room was empty during lunch hours. Multiple residents expressed their desire to eat in the dining room for socialization and to enjoy hot meals, including coffee, but were unable to do so due to staffing shortages. Interviews with residents confirmed their preference for dining room meals, highlighting the impact of the deficiency on their dining experience. The Dietary Manager acknowledged the issue, stating plans to reopen the dining room in the future but confirming the current closure due to insufficient staff. The Nursing Home Administrator also confirmed the dining room's closure, acknowledging awareness of residents' wishes to have it open, particularly for lunch. The deficiency was noted under several Pennsylvania Code regulations, indicating a failure in management, staff development, and dietary services.
Sanitation Deficiencies in Ice Machine and Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the preparation and storage of food and ice, as evidenced by deficiencies found in the second floor kitchenette's ice machine and the first floor kitchenette's refrigerator. The ice machine's drain pipe was observed to be in direct contact with the floor drain due to a clear tube installed over the pipe, eliminating the necessary air gap required for sanitary conditions. This was confirmed by the Maintenance Director, who acknowledged the absence of the air gap. Additionally, the refrigerator in the first floor kitchenette was found to contain a dark, removable substance at the bottom of the freezer, an expired carton of orange sherbet, and several popsicles that were undated, unlabeled, and one that was open to air. The Nursing Home Administrator confirmed that these items should have been discarded and that the freezer should have been clean. These findings indicate a failure to adhere to the facility's policy for resident personal food storage, which mandates labeling and dating of all food and beverages.
Repeated Deficiencies in Quality Assurance and Care
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated citations in multiple surveys. The deficiencies identified in the current survey include failure to provide an environment free from abuse, inadequate development and revision of comprehensive care plans, and failure to provide quality care. Additionally, the facility was cited for not maintaining a safe environment free of accident hazards, improper management of indwelling urinary catheters, and inappropriate food preparation and serving. The facility had previously developed plans of correction for these deficiencies, which included conducting audits and reporting the results to the QAPI committee. However, the current survey results indicate that these plans were not successfully implemented, as the same issues were repeatedly cited. The QAPI committee's inability to maintain compliance with regulations highlights a significant gap in the facility's quality assurance processes.
Resident Rights Violation: Unauthorized Removal of Personal Items
Penalty
Summary
The facility failed to protect the rights of a resident, identified as Resident 47, by removing personal food items from her room without her knowledge or consent. According to the facility's policy on resident rights, residents have the right to retain and use personal possessions, including food items, and should be informed in advance of any changes to their care plan. Resident 47, who was cognitively intact and able to communicate her needs, was taken to the dining room by a nurse aide on August 20, 2024. During her absence, staff removed all food items from her room, including non-perishable items, without notifying her beforehand. Interviews with staff members, including a nurse aide, the Director of Nursing, and the Nursing Home Administrator, confirmed that the resident was not informed prior to the removal of her belongings. The nurse aide stated that she was instructed by the Director of Nursing to remove the food items, and both the Director of Nursing and the Nursing Home Administrator acknowledged that they did not notify the resident before the action was taken. This incident was found to be in violation of the resident's rights as outlined in the facility's policy and the 28 Pa. Code 201.29(j) regarding resident rights.
Resident Abuse by Agency Nurse Aide
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a resident with dementia who was sometimes understood and could sometimes understand others. The resident's care plan indicated that they were resistive to care and required extensive assistance with dressing. On a particular shift, the resident's wife reported witnessing Agency Nurse Aide 2 being rough with the resident, pushing him over, causing fear, and handling him in a manner that resulted in his arm getting caught and his head stuck while changing his shirt. The aide's actions were so forceful that a TV was knocked off its stand, and the resident attempted to hit the aide out of fear. The investigation confirmed the abuse allegations after reviewing interviews with residents, families, and staff. The resident's wife also noted that another resident was dissatisfied with the care provided by the same aide. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse and neglect, which was violated in this instance. The investigation substantiated the abuse, leading to the termination of Agency Nurse Aide 2's contract and her placement on the Do Not Return list for the facility.
Failure to Notify Ombudsman and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the state ombudsman, residents, and/or their representatives regarding the reasons for hospital transfers for five residents. Resident 30, who had dementia, was transferred to the hospital for a femur fracture without documented notification. Resident 44, who was cognitively intact and had respiratory failure, requested a transfer due to breathing difficulties, but no written notice was provided. Similarly, Resident 48, also with respiratory failure, requested a transfer to the emergency department without documented notification. Resident 56, who was moderately cognitively impaired and had obstructive uropathy, was transferred to the hospital with symptoms of sepsis and a urinary tract infection, yet no written notice was documented. Resident 118, who was cognitively impaired and had dementia, was transferred to the hospital for an open fracture on his finger without documented notification. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Failure to Develop Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in addressing their specific care needs. Resident 4, who was cognitively impaired and diagnosed with PTSD, did not have a care plan addressing his PTSD despite a psychological evaluation indicating significant trauma history. The Director of Nursing confirmed the absence of a care plan for PTSD, acknowledging it should have been in place. Similarly, Resident 47, who required dialysis and had a central venous catheter, lacked a care plan addressing the catheter's care needs. Despite physician orders for post-dialysis weighing and the presence of an emergency kit, no documented care plan was found. Additionally, Resident 111, diagnosed with metastatic lung cancer and requesting to smoke, did not have a care plan addressing her smoking needs, even though staff reviewed the smoking policy with her. The Director of Nursing confirmed the absence of care plans for both residents, acknowledging the oversight.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs of three residents. For Resident 44, the care plan was not updated to remove references to a PICC line and an indwelling urinary catheter after these devices were removed on September 3, 2024. Despite the removal, the care plan continued to indicate potential complications related to these devices. This oversight was confirmed by the Director of Nursing during an interview. Similarly, Resident 90's care plan was not updated to reflect the removal of a PICC line, which had been removed without issues as noted in a nursing entry dated March 14, 2024. Observations confirmed the absence of the PICC line, yet the care plan still included potential complications related to it. Additionally, Resident 109's care plan required 15-minute checks due to cognitive impairment and behavior issues, but there was no documented evidence that these checks were conducted from August 8, 2024, through September 26, 2024. Interviews with staff confirmed that the care plan was not revised to reflect the current status of the checks.
Failure to Re-evaluate Smoking Ability for Resident
Penalty
Summary
The facility failed to ensure a safe environment related to smoking for a resident, identified as Resident 46. According to the facility's policy, a resident's ability to smoke should be re-evaluated quarterly, upon a significant change, or as determined by staff. However, there was no documented evidence that Resident 46's ability to smoke was evaluated quarterly as required. The resident, who was cognitively impaired and required supervision for daily care needs, was last evaluated for smoking in March 2024, indicating she was an at-risk smoker needing supervision or physical support. The Director of Nursing confirmed that a smoking assessment was not completed with the quarterly Minimum Data Set (MDS) assessment, which was a mandated assessment of the resident's abilities and care needs.
Medication Administration Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as evidenced by observations during medication administration. On September 25, 2024, two medication administration errors were identified during 25 opportunities for error, resulting in an error rate of eight percent. Specifically, the administration of Fluticasone nasal spray to Resident 60 did not adhere to the manufacturer's instructions. The instructions required the user to blow their nose before use and to close off the other nostril during administration, which was not done. Licensed Practical Nurse 7 administered the Fluticasone nasal spray to Resident 60 without instructing the resident to blow his nose or close off the other nostril, as confirmed by an interview with the nurse. The Director of Nursing also confirmed that the nurse should have followed the manufacturer's instructions. This oversight contributed to the facility's failure to maintain the required medication administration error rate.
Failure to Document Influenza Vaccine Offer
Penalty
Summary
The facility failed to ensure that each resident was offered and/or received the influenza immunizations, specifically for one resident reviewed. The facility's policy, dated October 2023, stated that the Infection Preventionist is responsible for promoting and administering the seasonal influenza vaccine. However, a review of the Minimum Data Set (MDS) assessment for a resident, dated August 3, 2024, indicated that the resident, who was cognitively impaired and dependent on staff for daily care tasks, did not receive the influenza vaccine for the current season due to being offered but declining it. Despite this, there was no documented evidence that the resident was offered the vaccine for the 2022-2023 flu season, as confirmed by the Director of Nursing. The resident had a history of receiving the influenza vaccine annually from 2017 to 2022, but there was a lack of documentation for the 2022-2023 season.
Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about changes in their treatment and medication, as required by their policy. Resident 2, who had moderately impaired cognition and a diagnosis of dementia, experienced a decline in condition, leading to a urinalysis and subsequent prescription of Macrobid for a urinary tract infection. Additionally, Resident 2 was exposed to Influenza A and was prescribed Tamiflu. In both instances, there was no documented evidence that the resident's responsible party was informed of these changes in medication. Similarly, Resident 5, who also had moderately impaired cognition, tested positive for the flu and was prescribed Tamiflu and guaifenesin. Again, there was no documented evidence that the responsible party was notified of these new medication orders. The Director of Nursing confirmed the lack of documentation regarding the notification of responsible parties for both residents, which was a requirement according to the facility's policy and state regulations.
Failure to Assess Resident's Swallowing Ability Leads to Choking Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not adequately assessing the resident's ability to safely consume certain foods, specifically pizza. The resident, who had moderately impaired cognition and was on a mechanically altered diet, experienced a choking incident during dinner when a piece of pizza obstructed his airway. Despite being on a mechanical soft, ground texture diet, the resident was served pizza, which led to the incident where a Licensed Practical Nurse had to perform the Heimlich maneuver to dislodge the food. Prior to the incident, there were indications that the resident had difficulty eating pizza, as noted by a Nurse Aide who had observed the resident's struggles and communicated this to the kitchen and a nurse. However, there was no documented assessment of the resident's ability to safely eat pizza in the months leading up to the incident. The Speech Therapist, who was responsible for the resident's case, was not informed of these difficulties, indicating a breakdown in communication and assessment processes within the facility.
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) |
|---|---|---|---|---|
| Ridgeview Healthcare And Rehabilitation Center | 6.8 mi | ★★★★★ | 21 | 0 |
| Heritage Ridge Senior Living At Windy Hill | 13.4 mi | ★★★★★ | 0 | 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 |
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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 July 2026) and official state health department websites.