Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain View Rehabilitation And Senior Living Ctr during CMS and state inspections, most recent first.
Failure to Protect Resident from Staff Physical Abuse Resulting in Rib Fracture: A resident with dementia and resistance to care was found with an aide on top of him while the resident was yelling and out of breath during incontinence care. Subsequent skin checks documented bruising, abrasions, swelling, and lip injury across multiple body areas, and x-ray results confirmed an acute displaced fracture of the right 7th rib. The facility substantiated staff-to-resident physical abuse, and records showed the aide and other agency staff lacked evidence of required abuse-prevention training.
Failure to Notify Responsible Party Before Room Change: A resident with Alzheimer's disease and dementia was moved to another room after reporting fear of her roommate following a roommate-on-resident incident. Facility records showed the resident's son was contacted about the incident, but the DON later confirmed staff did not notify the responsible party before the room move, despite policy requiring prior notice.
The facility failed to ensure that active code status orders matched resident or legally authorized representative wishes for multiple residents. Records showed several residents with DNR or Full Code orders but no POLST or advance directive documentation, including residents with severe cognitive impairment, residents rarely or never understood, and one resident adjudicated incompetent with a guardian. For one resident, a POLST was signed without the responsible party’s signature, and staff confirmed there was no evidence the representative participated in advance directive planning.
The facility failed to thoroughly investigate and report a resident-to-resident physical abuse allegation involving two residents after staff found one resident on the floor and heard statements indicating a physical altercation. The DON was notified, but the facility did not complete an investigation, obtain witness statements, or notify law enforcement or the state agency. The facility also failed to follow abuse prevention screening requirements for newly hired staff, including missing registry verification, incomplete employment history, delayed abuse training, and late criminal background verification.
Failure to provide ADL assistance for dependent residents. Two residents were observed with unmet grooming and bathing needs: one resident had unkempt hair and no documented shower assistance for 44 days despite being dependent for bathing and scheduled for baths twice weekly, and another resident was observed with a full beard even though he indicated that was not his preference. Record review showed an ADL self-care deficit care plan and a grooming preference intervention for the second resident.
A facility failed to ensure proper hearing aid access and use for multiple residents with hearing loss. One resident was waiting for hearing aids that had not been released because payment had not been forwarded, another arrived with hearing aids that were later found dead or missing from use, and a third had hearing aids that were not functioning and were sent out for repair. Records, MDS assessments, and MAR/TAR documentation did not consistently match resident observations or interviews, and staff were not always aware of MDS instructions for using a resident’s normal hearing appliance.
A resident with a high fall risk and prior injuries continued to fall after a hip fracture, with no documented new fall interventions after the fracture and return from the hospital. The resident later fell from a wheelchair and again during a bathroom transfer when only one staff member was present despite a 2-assist requirement, and the RN’s note incorrectly stated that two staff were there. The facility also had resident-accessible electrical outlets near sinks in multiple common areas and bathrooms that were not GFCI protected.
The facility failed to provide ordered nutritional supplements as prescribed for several residents, with MARs showing repeated missed doses because Med Pass 2.0 or Juven was unavailable, not in stock, or awaiting delivery, and staff sometimes substituted Boost instead. The facility also failed to timely address significant weight loss for multiple residents, with records showing large drops in body weight and no timely re-weight, physician notification, or documented assessment in several cases.
Dietary orders and resident meal preferences were not consistently followed. A resident reported receiving trays that did not match his current diet order or requested portions, while other residents described menu substitutions, missing items, and incorrect condiments on meal trays. Staff confirmed some trays were served with the wrong entree or without ordered gravy, and the food service director acknowledged the kitchen ran out of a planned entree before all residents were served.
Improper Hair and Beard Net Use During Tray Line Operations: During tray line operations, a dietary cook was observed with long hair extending out from under a hair net and a beard net pulled below the mouth, exposing beard hairs and a mustache. The kitchen supervisor was also observed overseeing the tray line with a beard net pulled below the mouth, exposing a mustache.
An LPN removed gloves after giving an eye drop and did not perform hand hygiene before touching the med cart and computer. In a room with Contact Precautions and EBP signage, an LPN and a nurse aide entered without the correct PPE for all care activities, used a stethoscope that was not effectively disinfected, and handled respiratory equipment and belongings while residents shared the same bathroom. A resident’s daughter also entered and assisted with toileting without PPE or instruction, and a respiratory mask was stored uncovered on a bedside stand.
Failure to maintain staff COVID-19 vaccination documentation. Two nurse aides stated they declined the facility’s offered COVID vaccine, and one had previously received COVID vaccines but also declined the most recent offer. The IP was unable to provide evidence of current vaccination status, and review of both employees’ health files showed no documentation of vaccination status.
A resident’s room was cluttered with possessions that blocked the bathroom door, sink, closets, and much of the floor, and the room’s closet door was broken from its track. Another resident had improperly stored food and drinks in a bedside stand, including undated items and uncleaned containers. The G unit emergency exit door was rusted, had a visible gap to the outside, and had debris, crumbs, candy, and needle cap seals around the threshold.
Failure to monitor psychotropic medication use. A resident had active orders for Lexapro, Trazadone, and Seroquel for depression and psychosis, and a physician order directed staff to monitor behavior related to agitation and anxiety. However, the clinical record had no documentation that staff monitored the resident's behaviors related to psychosis and depression, and there was no evidence of monitoring for potential side effects from the psychotropic medications. An RN regional consultant confirmed the findings.
A resident who was dependent on staff for activities wanted to attend bingo, but staff did not bring them to the activity even though it was scheduled and ongoing. The resident said they enjoyed bingo and often did not get taken to activities, and the activities director confirmed an aide was supposed to bring the resident but did not.
The facility failed to provide ordered care for three residents. One resident with right shoulder pain reported that an ordered lidocaine patch had not been applied, and the MAR showed the patch as completed and later removed without documentation that it had been located or reapplied. Another resident with an adhesive allergy had stoma care documented with adhesive attempted, and a third resident with a neurostimulator had no evidence of a person-centered care plan addressing the device, related assessments, or complications.
Failure to Assess Dialysis Fistula: A resident with CKD stage 4 and dependence on renal dialysis had an AV fistula in the left arm and received hemodialysis 3 times a week. Facility policy required post-dialysis assessment of the access site, including bruit and thrill if a shunt was present, but the record showed only one nursing note documenting a positive bruit and thrill and no routine or post-dialysis documentation of the fistula assessment.
A resident with Alzheimer’s dementia, vascular dementia, and PTSD was found to have a care plan noting childhood trauma and unspecified events the resident did not want to discuss, but the facility did not document efforts to identify triggers through family interviews or review of prior H&P or physician assessments. Surveyors confirmed there was no evidence the facility determined the resident’s triggers to prevent re-traumatization, despite the resident’s severe cognitive impairment and listed emergency contacts.
The facility failed to provide competency documentation for an RN’s tube feeding and resident assessment skills and an LPN’s tube feeding and foley catheter care skills. The surveyor reviewed facility records showing multiple residents with indwelling urinary catheters and tube feedings, and the facility could not produce evidence that the two staff members had completed the requested competency evaluations.
The facility failed to complete annual performance evaluations for two nurse aides reviewed. Personnel record review and interviews with the NHA, DON, and RN regional consultant found no documented evidence that the required evaluations were completed, and it was unclear when the last evaluations had been done.
A resident admitted with dementia was assessed on the MDS as having dementia or cognitive loss, and the facility noted a care plan would be developed. However, review of the care plan showed no documentation that an individualized person-centered plan was developed or implemented to address the resident’s dementia and cognitive loss, and the NHA and regional RN consultant confirmed there was no further documentation before surveyor questioning.
The facility failed to ensure the attending physician addressed pharmacy recommendations for a resident receiving Risperdal without an allowable diagnosis. Consultant pharmacy reviews noted the concern twice, but the clinical record had no documentation that the physician responded appropriately to either recommendation.
A facility failed to ensure drugs were stored and disposed of according to professional standards on the G unit. Surveyors found half of a white oval pill on the floor in a hallway corner next to the emergency exit door, and an LPN said they did not know how it got there and that trash is not taken out through that doorway.
QAA/QAPI committee records showed the Medical Director or designee did not attend the facility’s meetings, and there was no sign-in evidence of participation. The committee met multiple times, but the facility provided no evidence that the required Medical Director member participated in at least quarterly QAA/QAPI meetings.
An electrical outlet behind a sink in the staff bathrooms outside the main kitchen had a rusted metal cover and was being used for a plugged-in hand dryer, but it was not equipped with GFCI protection. The maintenance director confirmed that both the men's and women's bathrooms lacked GFCI outlets and that the outlets were not on a GFCI circuit at the breaker box.
Two residents were moved from one room or unit to another without receiving complete written notice that included the reason for the room change, and their families or responsible parties were not provided written notification either. In one case, a resident who received dialysis was transferred from one wing to an LTC unit before social services could discuss the move, and the undated written notice lacked any stated reason for the transfer. In the other case, a resident was moved between rooms on the same unit after a voicemail was left for the daughter, but the written notice given to the resident was undated and did not include the reason for the move, and no written notice was sent to the family.
A resident receiving hemodialysis complained of weakness and was found to have a fasting blood sugar of 48 mg/dL, leading to transfer to the ER. The ER physician later reported fluctuating blood sugars and blood pressures, and nursing notes documented that the resident remained hospitalized and ultimately expired there. Review of the clinical record showed no documentation that the resident’s responsible party was notified of the significant change in condition or the hospitalization, a finding confirmed by the NHA and DON.
The facility failed to maintain complete and accurate clinical records for several residents following alleged resident-to-resident sexual incidents. In one case, a resident was found naked in her room with another resident who admitted to sexual contact, and she was sent to the hospital for possible sexual assault evaluation, yet her chart lacked any nursing assessment or documentation of the incident. In another case, a resident was observed rubbing a sleeping resident's genital area over clothing in a common area, but the involved resident's record contained only a vague social services note about recent behaviors with no specific documentation of the event.
A resident with advanced dementia and high fall risk, dependent on staff for mobility, was pushed in a wheelchair at high speed and without leg rests by a nurse aide, despite prior warnings to the aide about safe transport practices. The resident fell forward, sustaining a serious head injury, including a laceration and brain hemorrhage, as a result of staff neglecting required safety interventions.
Surveyors observed multiple areas, including two nursing units, the chapel, a dining area, and the main kitchen, with stained carpets, broken fixtures, lint and debris build-up, improperly managed trash, unlabeled and uncovered food items, and damaged cabinetry. Staff confirmed these areas were used for resident activities and storage, but the deficiencies remained unaddressed during follow-up observations.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A resident with severe dementia and a history of wandering was able to exit the facility unsupervised after following a new dietary aide out the main entrance. Despite care plans and orders for regular wander guard checks, the resident was found outside without a wander guard and had to be retrieved by multiple staff after being seen walking down the road.
A resident with a right heel pressure ulcer had wound care provider recommendations to restrict weight-bearing PT and use offloading devices, but these were not promptly transcribed into the medical record or communicated to PT staff. As a result, the resident continued to participate in ambulation activities contrary to provider instructions, and staff were unaware of the updated care plan until the recommendations were finally entered into the record.
The facility failed to maintain a clean and homelike environment across multiple areas, including nursing units and the Chapel. Observations revealed dirty floors, stained garbage cans, and debris in common areas. Resident rooms were found with uncleaned commodes and soiled furniture. The nourishment refrigerators were also soiled and damaged. These issues were acknowledged by the Nursing Home Administrator and DON.
A resident, requiring two-person assistance, suffered an ankle fracture after a nurse aide provided care alone, despite the resident's reminders. The facility failed to ensure staff adhered to care requirements, resulting in neglect and injury.
A resident suffered a serious injury due to physical abuse by a staff member, resulting in a nasal bone fracture. The facility's policies on abuse prevention were not followed, as the staff member involved had not received necessary training or a criminal background check. The incident was witnessed by another staff member, and facility management confirmed the lack of oversight for contracted agency employees.
Two residents reported grievances about a nurse aide not responding to call bells and engaging in personal phone use. The facility failed to thoroughly investigate these grievances or inform the residents of any resolutions, despite their policy requiring prompt action and communication.
Two residents experienced safety hazards due to facility oversights. A resident fell from a wheelchair during transport as they were not secured with a seatbelt, resulting in pain. Another resident, with cognitive impairment, ingested Dakin's solution left in a cup on their bedside table, mistaking it for water, and was taken to the ER. These incidents highlight the facility's failure to maintain a safe environment.
The facility failed to maintain a clean and homelike environment across four nursing units. Observations included damaged walls in residents' rooms and hallways, unpainted patches, and unclean fall mats with brown smears. Staff interviews revealed uncertainty about the duration of these issues.
The facility failed to implement its abuse policy and conduct thorough investigations for allegations involving five residents. The facility did not submit required PB-22 investigations, failed to identify a nurse aide's non-compliance with a care plan, and did not investigate bruises on two residents. The Director of Nursing confirmed the lack of thorough investigations.
The facility failed to protect residents from an alleged perpetrator of abuse during an investigation. Despite an anonymous allegation against a nurse aide for abusing three residents, the aide continued to work without being removed from resident access. The facility did not adhere to its policy requiring immediate separation of the alleged perpetrator, resulting in a deficiency.
The facility failed to develop and implement individualized person-centered care plans for three residents diagnosed with dementia. Despite assessments indicating the need for such plans, the care plans for these residents did not address their cognitive loss. The Director of Nursing confirmed the lack of documentation for these care plans.
The facility failed to ensure that attending physicians addressed pharmacy recommendations for multiple residents. For several residents, there was no documented evidence that pharmacy recommendations were acted upon, and the facility was unable to locate these recommendations. Additionally, a resident's physician did not provide a stop date or rationale for continued medication use, nor appropriately address an antibiotic change recommendation.
The facility failed to ensure medication regimens were free from unnecessary drugs for three residents. A resident received Haldol and Ativan without a 14-day use limit or clarification on multiple medications for agitation. Another resident's inappropriate diagnosis for Quetiapine was not corrected for over two months. A third resident was prescribed Olanzapine with an unverified diagnosis of schizoaffective disorder. These issues were confirmed by the DON.
The facility's main kitchen had several sanitation issues, including expired spices, grease spills on ovens, undated opened egg noodles, trash in the walk-in freezer, and liquid spills around the juice machine. The certified dietary manager confirmed these findings, noting that machine condensation during hot weather contributed to the leaks.
Two residents with mobility issues were unable to reach their call bells, compromising their ability to request assistance. One resident with hemiplegia was observed twice with the call bell out of reach, while another resident with fall risk and decreased mobility reported waiting two hours for help due to an inaccessible call bell.
A facility failed to establish clear and consistent advance directives for a resident. The resident's POLST form indicated CPR, while physician orders showed conflicting instructions, including limited code and DNR. The inconsistency was confirmed by the assistant director of nursing.
A breach of confidentiality occurred when a non-clinical staff member had visible access to a resident's medical record on a computer left logged in by an LPN who was on break. The incident was observed in the medication/supply room of Nursing Unit F.
A resident was transferred to the hospital after exhibiting violent behavior. The facility decided not to readmit the resident but failed to provide a written discharge notice to the resident, their representative, and the ombudsman. This deficiency was confirmed during an interview with the Nursing Home Administrator and DON.
A resident with a Stage 4 pressure ulcer on the right ischium did not receive the correct treatment as per physician orders. An LPN applied a foam dressing to the left buttock instead of the right ischium. The error was confirmed by a wound nurse, and the facility's management was informed of the deficiency.
Failure to Protect Resident from Staff Physical Abuse Resulting in Rib Fracture
Penalty
Summary
The facility failed to protect a resident from physical abuse by staff, resulting in actual harm that included an acute displaced fracture of the right 7th rib. The resident had diagnoses including dementia with behavioral disturbance and required assistance with personal care. His plan of care addressed resistance to care by directing staff to reassure him, leave, and return 5 to 10 minutes later, but the bedside Kardex available to direct care staff did not include that instruction at the time of the incident. Nursing documentation stated that a nurse aide observed the resident upside down on the bed with a nurse aide on top of him while the resident was yelling, out of breath, and shaking, as the aide attempted to put on his incontinence brief. Another nurse aide asked the staff member to leave the room, and the resident’s care was then completed. The resident was escorted from the facility by the RN. A skin assessment documented red raised welts on the abdomen and back and lower extremities, and a follow-up skin observation identified bruising, abrasions, redness, swelling, tenderness, and a bruise to the right inner lip across multiple body areas, including the scalp, chest, abdomen, back of head, shoulders, back, buttock, wrist, rib area, and lip. The physician was notified of the skin findings and right rib discomfort, and an x-ray was ordered. The x-ray results showed an acute displaced fracture of the lateral right seventh rib. The facility substantiated the allegation of staff-to-resident physical abuse and removed the nurse aide from the facility. Review of personnel records showed no evidence that the nurse aide completed education related to the facility’s Abuse Prevention and Prohibition Program, and the DON confirmed that several agency staff on the deployment schedule also lacked evidence of completing that training. The DON and NHA confirmed that contracted staffing agency personnel were considered contractors subject to orientation training, but the facility did not have evidence of that training for the nurse aide or other agency staff until after surveyor questioning.
Failure to Notify Responsible Party Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident's responsible party before changing the resident's room. The resident had diagnoses of Alzheimer's disease and dementia and lived on the secured nursing unit for residents with dementia-type diagnoses. Facility policy stated that when a room change occurs, the patient will be notified prior to the move, and the facility form included signature lines for the resident or responsible party. After a roommate incident in which staff found the roommate on top of the resident in bed, assessed a bite mark on the resident's left hand without broken skin, and documented the resident's report that her hair had been pulled and she had been slapped in the face, the resident's son was contacted about the incident and the roommate was placed on one-to-one supervision. Later documentation showed the resident stated she was scared of the roommate and did not want to remain in the room with her because of the recent incidents. The facility then moved the resident to another room on the A nursing unit without notifying the responsible party beforehand, and the responsible party later expressed being very upset about the move and requested that the resident be returned to the previous room.
Advance directive and POLST documentation not aligned with resident or representative wishes
Penalty
Summary
The facility failed to ensure that active physician orders reflected the resident or appropriate resident representative’s wishes related to end-of-life care for seven residents reviewed for advance directive concerns. The cited residents included individuals with varying cognitive and decision-making status, including residents with severe cognitive impairment, residents who were rarely or never understood, and a resident who had been adjudicated incompetent with a guardian appointed. In several cases, the clinical record contained active code status orders such as DNR or Full Code, but no POLST or advance directive documentation was present to show that the resident or legally authorized representative participated in the planning. For Resident 3, the record showed admission on February 23, 2026, with a BIMS score of 4 indicating severe impairment, and an MDS stating the resident only sometimes understood others and was only sometimes understood by others. The resident’s niece was listed as responsible party, health care representative, and power of attorney. A POLST signed by the medical practitioner on February 26, 2026, contained only Resident 3’s signature and not the responsible party’s signature, and it implemented DNR and limited additional interventions. The active physician orders also reflected DNR status. Employee 1 confirmed that the facility had no evidence that the responsible party participated in advance directive planning on the POLST form. For Resident 14 and Resident 71, the records contained active Full Code orders but no POLST or advance directive documentation. Resident 71’s record also showed a court adjudication of incompetence on August 8, 2023, with guardianship awarded to another party. For Residents 2, 6, and 13, the records showed active code status orders but no POLST or advance directive documentation at the time of survey review; Resident 2 had a DNR order, Resident 6 had a Full Code order and an MDS indicating the resident was rarely or never understood, and Resident 13 had a DNR order with an MDS indicating the resident was rarely or never understood. Nursing documentation entered after the surveyor’s questioning indicated staff later spoke with family members to review POLSTs for Residents 2, 6, and 14, but no documentation was provided during the onsite survey for Residents 6 and 13, and the Nursing Home Administrator and Employee 1 confirmed that no documentation could be located.
Failure to Investigate Resident Abuse and Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to thoroughly investigate and report a resident-to-resident physical abuse allegation involving a resident who was admitted on December 3, 2025. Nursing documentation dated March 17, 2026, with a late entry on March 20, 2026, stated that a nurse heard one resident say something about the other resident being on his bed, then heard a thud and found one resident standing in the doorway while the other was lying on his back on the floor. One resident stated, "I am not a wussy, he kicked me and swung at me, so I put him down," and the other resident stated, "he hit me once and I went down." A resident witness stated the two residents were wrestling and that one resident was hunched over and then started to fall. The documentation also stated that everything was reported to the DON. Interview with the regional RN consultant confirmed that the facility did not complete an investigation, obtain witness statements, notify law enforcement, or notify the Department of Health related to the allegation of physical abuse. The facility policy required alleged abuse and neglect to be thoroughly investigated and reported to the appropriate agencies, including immediate reporting when abuse is alleged. The record review and interview showed that these required actions were not completed for the incident involving the two residents. The facility also failed to implement abuse prevention policies related to pre-employment screening for three newly hired employees. One nurse aide had no evidence in the personnel record of nurse aide registry verification or abuse prevention training, and the residency attestation did not show that the employee had lived in Pennsylvania for the previous two consecutive years. A licensed practical nurse’s file did not include the dates of prior employment, preventing verification of employment history. A social worker received abuse prevention education one week after hire, and the facility could not show that the employee had no resident contact before that training. The social worker’s Pennsylvania criminal background verification was not obtained until after the surveyor requested the record, and the facility could not show an attempt to obtain it within 30 days of hire.
Failure to Provide ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide ADL assistance for two dependent residents. Resident 84 was observed with unkempt hair, and record review showed she was admitted on October 3, 2025, was assessed on the most recent quarterly MDS dated March 30, 2026 as dependent on staff for bathing, and had a Kardex directing that she receive a bath every Wednesday and Saturday. Review of the Documentation Survey Report from January 1 to May 1, 2026 showed no documentation that staff assisted Resident 84 with a shower after March 19, 2026, a span of 44 days. Resident 64 was observed with a full beard, and when asked if this was his preference, the resident shook his head no. Record review showed Resident 64 had a care plan with a focus on ADL Self Care Performance Deficit initiated on April 28, 2023, with an intervention initiated on May 19, 2025 stating that the resident prefers to have a mustache. The findings for both residents were reviewed with the Nursing Home Administrator, the DON, and an RN regional consultant.
Failure to Provide and Track Hearing Aid Use
Penalty
Summary
The facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for three residents with documented hearing concerns. Resident 68 had a diagnosis of bilateral hearing loss and a care plan directing staff to place bilateral hearing aids in the morning and remove them at bedtime, but during interview she stated she was deaf and had been waiting for hearing aids. She was observed without hearing aids, and staff documentation showed refusals to use old hearing aids while waiting for new ones. The resident’s daughter reported that the hearing aid company would not release the hearing aids because the facility had not forwarded payment. Resident 3 arrived with bilateral hearing aids, but nursing documentation showed the devices were locked in the medication cart because both were dead, then later that one aid worked and the other did not. On observation and attempted interview, Resident 3 was hard of hearing and had no hearing aids in use, and staff confirmed none were in the medication cart. The MDS assessed Resident 3’s hearing as adequate with a hearing aid, yet the care plan did not include hearing aid use, and a quarterly MDS was completed without the use of a hearing aid. The MDS staff member stated she was not aware of the RAI instruction to ensure the resident was using a normal hearing appliance during the hearing assessment. Resident 14 had a long-standing diagnosis of hearing loss and an order to use hearing aids every morning and at bedtime. Although records showed staff initialed hearing aid use, the resident was very hard of hearing during interview, required loud repeated questions, and pointed to a charger while stating the hearing aids needed battery replacement. Nursing documentation later showed the batteries were changed, then the hearing aids were not functioning and were sent out for repair. Additional documentation showed the hearing aids were removed and sent for repair, while MAR/TAR entries indicated use on days when observation and resident interview showed they were not actually in use.
Failure to Prevent Recurrent Falls and Remove Electrical Hazards
Penalty
Summary
The facility failed to implement interventions to prevent recurrence of falls for a resident who was admitted with a high fall risk score and had already sustained injuries from prior falls. After admission, the resident was found on the floor with a hip fracture and later returned from the hospital requiring assistance of two staff and a roller walker for ambulation and transfers with weight bearing as tolerated on the left lower extremity. The care plan initiated for fall risk did not show new fall prevention interventions after the fracture and return to the facility, and the resident was later found on the floor again in front of her wheelchair by the nurses’ desk. The resident fell again in the hallway from her wheelchair, and later in the bathroom while two staff were supposed to be present for transfers. The facility’s investigation determined that only one staff member was actually present during the bathroom transfer, and that the resident threw herself backward, knocking the wheelchair out of reach. The Nursing Home Administrator confirmed there was no evidence that care plan revisions had been implemented after the earlier fall and fracture, and also confirmed that the staff member suspended after the bathroom fall did not have evidence of the required education upon return to work. The administrator also confirmed that the registered nurse’s documentation incorrectly stated that two staff were present during the fall. The facility also failed to ensure an environment free from potential accident hazards on multiple units. Observation showed electrical outlets near sinks in the F Unit bathrooms for residents in several rooms, as well as in the B and E common lounge area and the Cranberry common dining area, were not GFCI protected. The maintenance director confirmed that outlets located near water sources should be equipped with GFCI protection, and staff observed that the outlets in these resident-accessible areas were not GFCI outlets.
Failure to Provide Ordered Supplements and Address Significant Weight Loss
Penalty
Summary
The facility failed to implement interventions to maintain acceptable nutritional status for three residents with documented weight loss and failed to provide physician-ordered nutritional supplements for three residents. The report identified missed or undocumented supplement administrations for residents ordered Med Pass 2.0 and Juven, with multiple doses not documented as given and repeated administration notes stating the supplements were unavailable, not in the building, awaiting delivery, or otherwise not available. In several instances, staff documented that Boost was given instead, and some notes stated the physician was aware, but the record did not show that the ordered supplements were administered as prescribed. For one resident, the physician ordered Med Pass 2.0 four times daily, but the MAR showed numerous missed doses across the month, including morning, afternoon, evening, and bedtime doses. The administration notes repeatedly documented that the supplement was unavailable or not available in the facility, and one nutrition progress note later referenced the intervention without addressing the repeated unavailability or the missed doses. For another resident, Med Pass 2.0 was ordered twice daily, yet the MAR showed multiple missed doses over several days, with notes again stating the supplement was unavailable, not in the building, or awaiting delivery. For a third resident, Juven was ordered twice daily and then discontinued, but the MAR showed many missed doses before discontinuation, with notes indicating awaiting delivery, not available, none in house, or substitution with Boost because Juven was not available. The report also identified failure to address significant weight loss for three residents. One resident had a 10.55 percent weight loss from January to February 2026, with no evidence that staff obtained a re-weight or notified the physician after the significant loss. Another resident had a 19.62 percent weight loss from February to March 2026, with no evidence of a re-weight or physician notification after the loss. A third resident had a 29.41 percent severe weight loss over the documented period, and the record showed no assessment of the severe weight loss or interventions until several days later; the registered dietitian later documented the cause as unknown and added health shakes and weekly weights, but there was no documentation that the physician was notified timely of the severe weight loss.
Dietary Orders and Resident Meal Preferences Not Followed
Penalty
Summary
The facility failed to provide food in accordance with resident preferences and physician-ordered diets for residents on one nursing unit. Resident 175 reported that meals frequently arrived from the kitchen not matching his preferences or diet order, including a tray ticket that still listed a 2000 milliliter fluid restriction even though that order had been discontinued months earlier. He also stated that he often did not receive the double portions listed on his tray ticket. Clinical record review confirmed the fluid restriction order had been discontinued and was no longer active, and the concern was reviewed with the RN regional consultant and the Nursing Home Administrator. Resident 127 stated he stopped attending resident council or food committee meetings because the facility did not make changes, and Resident 71 reported that menu items promised on the planned menu did not arrive on his tray, including oatmeal being replaced with grits and cinnamon buns not being served. Resident 4 stated that kitchen staff switched menu items and that she was supposed to receive only cauliflower as a vegetable, yet her lunch tray contained green beans; her tray ticket did not indicate vegetables were to be omitted except cauliflower. The same resident later received beef covered in gravy even though her tray ticket instructed no gravy. Resident 26 reported receiving a ham entree instead of the turkey entree she was supposed to receive, and she did not receive gravy on the side as ordered; nurse aides confirmed the missing gravy and stated they often had to call the kitchen for it. The food service director confirmed the kitchen ran out of turkey before all residents were served and that Resident 26 received the ham substitute, and the log for meal concerns documented only one gravy-related call despite repeated reports from staff and the resident.
Improper Hair and Beard Net Use During Tray Line Operations
Penalty
Summary
The facility failed to prepare and serve food items in accordance with professional standards of practice in the main kitchen. During an observation of the tray line on May 1, 2026, at 11:15 AM, Employee 16, a dietary cook, was seen walking between the tray line and the food preparation area wearing a hair net and beard net, but with long hair extending out from under the net and the beard net pulled down under the mouth, exposing long beard hairs and a mustache above the netting. During the same observation, Employee 17, the kitchen supervisor, was observed overseeing the tray line with a beard net pulled down under the mouth, exposing a mustache above the netting. The findings were reviewed with the Nursing Home Administrator later that day.
Infection Control Failures During PPE Use and Shared Room Care
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection on one open nursing unit. During a medication pass for a resident, an LPN donned gloves to administer an eye drop, removed the gloves afterward, placed the medication back in the cart, typed on the medication cart computer, and moved the cart to the nurses’ station without performing hand hygiene after glove removal. The LPN confirmed she did not clean her hands after removing the gloves and pointed to the alcohol hand sanitizer on the cart, stating she had been trained to perform hand hygiene after glove removal. On a room housing two residents with transmission-based precautions signage posted at the doorway, one resident had an active physician order for enhanced barrier precautions related to ESBL in urine, and the other resident had active orders for enhanced barrier precautions related to ESBL resistance and contact precautions for C. diff diarrhea. Observation showed an LPN entered the room without gown or gloves to administer medications, sorted through the resident’s belongings to find respiratory treatment equipment, used a stethoscope kept on her person, and did not wash her hands with soap and water before leaving the room. The LPN later used alcohol-based sanitizer after adjusting the other resident’s oxygen tubing, even though the room also had contact precautions posted and the resident had C. diff-related precautions. The room was shared by three residents, and staff confirmed that all three used the same bathroom. One resident had no diagnosis of C. diff or ESBL history, yet staff did not consider that resident’s use of the shared bathroom in relation to the precautions in place for the other two residents. A nurse aide entered the room to change an incontinence pad on one resident’s bed wearing gloves but no gown, stating she believed the PPE signage and equipment were for the other resident only. The daughter of one resident was observed in the room without gown or gloves, assisted her mother to the bathroom, and stated she had received no education or instruction from facility staff regarding special precautions such as handwashing, avoiding contact with environmental surfaces, or wearing gloves. In addition, a respiratory mask used by one resident was stored on top of the bedside stand when not in use and was not bagged or otherwise protected from environmental contamination, and the facility’s oxygen storage policy did not address protecting oxygen equipment such as face masks when not in use.
Failure to Maintain Staff COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of staff COVID-19 vaccination status for two of two staff reviewed, Employees 27 and 28. Employee 27, a nurse aide, stated during interview that she declined the COVID vaccination offered by the facility last year. Employee 28, a nurse aide, stated during interview that he had received COVID vaccinations in the past but declined the COVID vaccination offered by the facility last year. The infection preventionist stated that she was unable to provide evidence that staff documentation of current COVID-19 vaccination status was maintained, and review of the two employees’ health files showed no evidence of their vaccination status. The surveyor reviewed these findings with the Nursing Home Administrator.
Unsafe and Unclean Resident Areas and Emergency Exit Doorway
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment on two open nursing units, involving Resident 4 on the F unit and the G unit emergency exit doorway. Resident 4’s room contained personal possessions that blocked the bathroom door, blocked access to the handwashing sink, blocked access to both residents’ closets, covered most dresser and furniture surfaces, and occupied a large portion of the floor space. Resident 4 stated she needed staff assistance to organize the room and remove two storage totes. Her manual wheelchair was stored on her roommate’s side of the room, and the closet bifold door was broken from its track and hung open into the room. The housekeeping/laundry director stated she had twice made a list over two months for activities staff to review Resident 4’s possessions with her and confirmed the amount of items prevented housekeeping staff from effectively cleaning the room. The report also identified unsafe food storage in Resident 95’s bedside stand. A sandwich bun with ketchup was stored loosely in a napkin in the drawer, along with undated mayonnaise packets, an uncleaned bowl that appeared to have contained fruit, two bowls of prepared hot cereal with no date of preparation or expiration, two containers of apple juice with no expiration date, a container of lemonade with no expiration date, and a lidded cup containing liquid believed to be cold coffee. In addition, the G unit emergency exit door was rusted at the base on both sides, had a 0.5-inch gap with the outdoor sidewalk visible, had peeling and bubbling drywall near the threshold, and had dust, debris, food crumbs, a piece of chocolate candy, and three needle cap seals around the threshold.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the use of psychotropic medications for one resident reviewed for potentially unnecessary medications. The resident had active physician orders for Lexapro 10 mg, two tablets in the morning for depression; Trazadone 50 mg, half a tablet in the morning and one tablet at bedtime for depression; and Seroquel 25 mg, one tablet two times a day for psychosis. A physician order dated January 9, 2026, directed staff to monitor the resident's behavior related to agitation and anxiety, but there was no documentation in the clinical record that staff monitored the resident's behaviors related to psychosis and depression. The clinical record also did not provide evidence that the facility monitored for potential side effects from the resident's use of these psychotropic medications. An RN regional consultant confirmed these findings during interview.
Failure to Assist Resident to Attend Desired Activity
Penalty
Summary
The facility failed to provide resident assistance to attend activities of interest for Resident 140, who stated they enjoyed activities, especially bingo, and were dependent on staff to take them because staff often did not come to get them. On April 28, 2026, Resident 140 said they still wanted to attend bingo at 2:00 PM, but at 3:15 PM bingo was ongoing and the resident was not present. Review of the clinical record showed a care plan focus initiated on August 18, 2020, stating the resident is dependent on staff for activities. The activities director later stated that Resident 140 was supposed to be brought to bingo by an aide, but the aide did not bring them.
Failure to Follow Orders, Allergy Precautions, and Device Care
Penalty
Summary
The facility failed to provide the highest practical care related to physician-ordered medications, allergies, and devices for three residents. One resident with right shoulder pain reported increased pain because the nurse had not applied the ordered pain patch. The resident allowed assessment of both shoulders, and no patch was found. The clinical record showed an active order for Aspercreme Lidocaine External Patch 4% to be applied to the right shoulder once daily for right shoulder pain and removed per schedule, and the MAR documented the patch as completed at the 9:00 AM medication pass and removed at the 9:00 PM medication pass, but there was no documentation showing the patch was not present or that it had been located and applied or reapplied during the day. The same resident later reported severe pain and received PRN oxycodone 5 mg. Another resident had a documented adhesive allergy, yet a progress note stated that ileostomy leakage continued and that stoma powder and adhesive were attempted. A third resident had a diagnosis of a neurostimulator, and hospital documentation listed an implantable pulse generator and a kit pulse generator, but the clinical record contained no evidence that the facility addressed the neurostimulator or developed a person-centered care plan related to the device, including the type of neurostimulator, assessments, or complications.
Failure to Assess Dialysis Fistula
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident who required dialysis services. Resident 7 had diagnoses including chronic kidney disease stage four and dependence on renal dialysis, and the care plan noted the resident received hemodialysis three times a week at a dialysis center and had an AV fistula in the left arm. Facility policy for post-dialysis care required staff to evaluate the dialysis access site for bleeding, signs or symptoms of infection, intact placement, and to document the observation of the access site, including assessment for bruit and thrill if a shunt was present. Clinical record review showed a nursing progress note on April 21, 2026, documenting the left arm fistula as pulsatile with a positive bruit and thrill. However, there was no documentation that staff routinely assessed the AV fistula site for bruit and thrill or performed such assessment as part of post-dialysis care as required by the facility policy. The facility's failure to provide appropriate assessment for the dialysis fistula for Resident 7 was confirmed by the Nursing Home Administrator and Director of Nursing on May 1, 2026.
Failure to Identify PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to identify triggers related to a resident’s diagnosis of Post-Traumatic Stress Disorder and failed to provide culturally competent, trauma-informed care for one resident reviewed for mood and behaviors. The resident was admitted with diagnoses including Alzheimer’s dementia and PTSD, and the care plan noted a history of unspecified childhood trauma, multiple childhood events the resident did not like to discuss, and that the resident had Alzheimer’s and vascular dementia. A MDS assessment later showed the resident had severe cognitive impairment. The clinical record showed four family members listed as emergency contacts, but there was no evidence the facility attempted to determine the resident’s triggers by interviewing family members or reviewing prior history and physical reports or physician assessments. Surveyors reviewed these findings with the NHA and DON, and an RN regional consultant confirmed the findings and was unable to provide additional documentation.
Staff Competency Documentation Missing for Catheter, Tube Feeding, and Assessment Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to care for residents with indwelling urinary catheters and to complete resident assessments. Facility documentation showed that the Resident Matrix identified 15 residents with indwelling urinary catheters and 6 residents with tube feedings. The facility’s competency check-off records listed foley catheter care and PEG/G-tube care for LPNs, and PEG/G-tube care and resident assessment for RNs. During review, the surveyor requested competency documentation for an RN related to tube feeding and resident assessment/change in condition, and for an LPN related to tube feeding and foley/indwelling catheter care. These requests were made with the NHA, DON, and a regional RN consultant. The facility did not provide documentation showing that either employee had completed the requested competency evaluations in those areas.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for two of three nurse aides reviewed, Employees 29 and 30. Employee 29 had a hire date of May 20, 2018, and Employee 30 had a hire date of April 28, 2025. During review of personnel records with the Nursing Home Administrator, Employee 1 (RN regional consultant), and later with the Nursing Home Administrator and DON, no documented evidence was provided showing that annual performance evaluations were being completed for these employees. Employee 1 confirmed in interview that the facility could not provide documentation that performance evaluations had been completed for the two nurse aides, and it was unclear when the last evaluations were performed.
Failure to Develop Person-Centered Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss for one resident. The resident was admitted with a diagnosis of dementia, and the admission MDS dated December 10, 2025, indicated that the facility assessed the resident as having dementia or cognitive loss and determined that a care plan for dementia and cognitive loss would be developed. However, review of the resident’s care plan showed no indication that the facility had developed or implemented a person-centered care plan to address the resident’s dementia and cognitive loss. During the survey meeting, the Nursing Home Administrator and the regional RN consultant confirmed there was no further documentation that such an individualized care plan had been developed and implemented prior to surveyor questioning.
Failure to Address Pharmacy Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the resident's attending physician addressed and responded appropriately to pharmacy recommendations for Resident 18. The resident was admitted on May 22, 2025, and a consultant pharmacy review dated June 30, 2025, noted that Resident 18 was receiving Risperdal, an antipsychotic medication, but lacked an allowable diagnosis to support its use. A second pharmacy recommendation dated December 30, 2025, again stated that Resident 18 was receiving Risperdal without an allowable diagnosis to support its use. The clinical record contained no documentation that the physician addressed or responded appropriately to either pharmacy recommendation. An interview with Employee 1, a registered nurse regional consultant, on May 1, 2026, at 12:49 PM confirmed these findings.
Improper Storage and Disposal of Medication Found on Hallway Floor
Penalty
Summary
The facility failed to ensure that drugs used in the facility were stored and disposed of in accordance with professional standards on one of four nursing units, the G nursing unit. During an observation on the G nursing unit, a half of a white oval pill, marked with a 2 on one side and an F on the other side, was found on the floor in a corner at the end of the hallway next to the emergency exit G door. During a concurrent interview, an LPN stated they did not know how the pill came to be on the floor in that location and said no trash is taken out through that doorway. The finding was reviewed with the NHA and DON later that day.
QAPI Committee Missing Required Medical Director Participation
Penalty
Summary
The facility failed to ensure the Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAA/QAPI) committee included the required Medical Director member and met at least quarterly. Review of the facility’s QAPI Committee Members documentation from March 4, 2025 through the current survey ending May 1, 2026 showed the most recent QAPI committee meeting occurred in March 2026. Attendance records for meetings dated March 4, 2025; April 2025; July 2025; October 2025; November 2025; December 2025; January 2026; and March 2026 showed no attendance by the Medical Director or designee, and there was no associated sign-in for the Medical Director on the meeting sign-in sheets provided by the facility. The Nursing Home Administrator reviewed this information with the surveyor on May 1, 2026, at 9:46 AM, and the facility provided no further evidence that the Medical Director or designee participated in at least quarterly QAA/QAPI committee meetings.
Electrical outlet near sink lacked GFCI protection
Penalty
Summary
The facility failed to ensure that electrical equipment in the staff bathrooms outside the main kitchen was in safe operating condition. During observations on April 30, 2026, surveyors found an electrical outlet on the wall behind the sink, about a foot from the faucet, with a metal cover that appeared rusted. A hot air hand dryer was plugged into the outlet and functioning, but the outlet was not equipped with a GFCI. Employee 18, the maintenance director, confirmed that both the men's and women's bathrooms were not equipped with a GFCI outlet and stated that an outlet located near a water source should be equipped with GFCI. In a later interview, Employee 18 stated the outlets were not on a GFCI circuit at the breaker box. The findings were reviewed with the Nursing Home Administrator and Employee 1, RN Regional Consultant.
Failure to Provide Proper Written Notice for Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice, including the reason for a room change, prior to moving residents to different rooms. For one resident admitted to the B‑wing unit in late September 2025, a social service progress note in mid‑January 2026 documented that the interdisciplinary team had requested social services to discuss a room move to an LTC unit. When social services attempted to speak with the resident after his dialysis treatment, staff reported he had already been moved to the F‑wing LTC unit. The Nursing Home Administrator later produced a written notice addressed to this resident that stated he was being moved to F‑wing, but the notice was not dated and did not include the reason for the room move. The Administrator also confirmed that the resident’s family or responsible party did not receive written notification of the room move or the reason for it. For another resident admitted in May 2025 to room F15‑2, a social service progress note in mid‑February 2026 showed that a message was left for the resident’s daughter about moving the resident to room F25‑1, asking her to call with any questions or concerns. The Nursing Home Administrator stated that this resident was provided with a written notice of the room move and provided a printed notice indicating the resident was being moved to room F25‑1, as discussed with her and/or her family or responsible party. However, this notice was also not dated and did not state the reason for the room move. The Administrator confirmed that the facility did not provide the resident’s family or responsible party with written notification of the room move and the reason for the move. As a result, for both residents, the facility failed to provide written notice that included the reason for the room change to the residents and their family/responsible parties.
Failure to Notify Responsible Party of Resident’s Change in Condition and Hospitalization
Penalty
Summary
The facility failed to notify a resident’s responsible party of a significant change in condition and hospitalization. Clinical record review showed that the resident, who was receiving hemodialysis, was reported by the dialysis provider to be complaining of weakness prior to treatment, and a fasting blood sugar of 48 mg/dL was documented. The resident was sent to the emergency room for evaluation. Nursing documentation indicated that at 11:30 AM the facility received a call from the emergency room physician, who reported that the resident’s blood sugars and blood pressures were rising and dropping, and nursing notes later documented that the resident remained hospitalized and subsequently expired at the hospital. There was no documented evidence that the resident’s responsible party was notified of the significant change in condition or the admission to the hospital, and the Nursing Home Administrator and Director of Nursing confirmed these findings. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services, based on the lack of documentation and confirmation of responsible party notification for the resident’s change in condition and hospitalization.
Failure to Maintain Complete and Accurate Clinical Records After Resident-to-Resident Sexual Incidents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents involved in alleged resident-to-resident sexual incidents. For one incident, facility documentation and an Event Reporting System (ERS) submission indicated that a resident (CR1) was found in another resident's (8) room, where the second resident was completely naked. Witness statements documented that the first resident admitted to removing the second resident's clothing, removing his own pants, and rubbing his penis against the second resident's side after stating he wanted to have sex with her. ERS and hospital records showed that the second resident was sent to the hospital for possible evaluation of sexual assault and remained overnight for observation in the emergency room. Despite these events, review of the second resident's clinical record revealed no nursing assessment documented after the alleged sexual abuse and prior to her transfer to the hospital, and no documentation in her clinical record related to the incident itself. In a separate incident reported through ERS, another resident was observed rubbing a sleeping resident's genital area over her clothing while she was in a geri-lounger in a common area. Review of the first resident's clinical record showed only a social services note referencing follow-up for "recent behaviors" but no documentation specifically describing or relating to the observed genital touching incident. These omissions demonstrated that the facility did not ensure clinical records were complete and accurate for the residents involved.
Failure to Prevent Resident Fall Due to Neglect of Wheelchair Safety Precautions
Penalty
Summary
A deficiency occurred when facility staff failed to protect a resident with vascular dementia and significant cognitive and physical impairments from neglect, resulting in a serious fall from a wheelchair. The resident was assessed as high risk for falls, with documented poor recall, judgment, and safety awareness, and was dependent on staff for all mobility and transfers. Physical therapy and nursing assessments consistently indicated the resident required two-person assistance and the use of leg rests and other safety precautions when being transported in a wheelchair. On the day of the incident, a nurse aide was observed pushing the resident in a wheelchair at a high speed and without leg rests. Multiple staff statements confirmed that the resident was being transported in this unsafe manner, despite prior education and warnings given to the aide the previous day regarding the necessity of using leg rests and not pushing residents quickly. During transport, the resident fell forward out of the wheelchair, sustaining a laceration to the forehead and a serious brain injury, including intraparenchymal and subarachnoid hemorrhages, as confirmed by hospital documentation. The facility's documentation and staff interviews revealed that concerns about the aide's unsafe transport practices had been identified the day before the incident, and the aide had been instructed on proper procedures. However, these interventions were not effectively implemented, and the resident was subsequently injured due to the same unsafe practices. The failure to ensure staff followed required safety interventions directly led to the resident's fall and serious injury.
Failure to Maintain Clean, Comfortable, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across multiple areas, including two nursing units, the chapel, a common dining area, and the main kitchen. Observations revealed heavily stained carpeting, broken and loose floor transition strips, lint accumulation in the laundry area, water-stained ceiling tiles, overflowing and improperly managed trash receptacles, and used food items left in inappropriate locations. In the A Nursing Unit, an electrical receptacle was coming out of the wall, and a pantry shelf and surrounding floor were covered in dirt and debris. Refrigerators in both the A and B Nursing Units contained unlabeled, undated, and uncovered food items, and there was a significant build-up of dirt and debris behind equipment and on storage containers. Damaged cabinetry and improper storage of resident snacks were also noted. In the main kitchen, used linens were placed directly into a lidded receptacle without a bag. Throughout the observed areas, issues such as dust accumulation, food debris, and improper waste management persisted despite follow-up observations later in the day. Staff interviews confirmed the use of these areas for resident-related activities and storage, but did not indicate any corrective actions taken at the time of observation. These findings were reviewed with facility leadership during the survey.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Elopement for Resident with Dementia
Penalty
Summary
The facility failed to provide the highest practicable care regarding elopement prevention for a resident with severe cognitive impairment and a known history of wandering and exit-seeking behaviors. The resident, diagnosed with dementia and assessed as an elopement risk, was moved from a locked memory care unit to another nursing unit. Despite care plans and physician orders requiring staff to check the resident's wander guard placement every shift, documentation and staff interviews revealed lapses in monitoring and intervention. The resident exhibited multiple episodes of exit-seeking, including attempts to leave the facility and being found at the main entrance on several occasions. On one occasion, a new dietary aide exited the building, followed by the resident, who stated he was going to the police station. The aide, unsure of protocol, asked a visitor to watch the resident while she sought help. By the time staff responded, the resident had left the parking lot and was found walking down the road, requiring several staff members to return him to the facility. It was noted that the resident did not have a wander guard on at the time of the incident, despite orders for its use and regular checks. These failures to follow established policies and care plans resulted in the resident's elopement and demonstrated a lack of adequate supervision and monitoring.
Failure to Maintain Accurate and Complete Clinical Records for Wound Care
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible clinical records for one resident with a right heel pressure ulcer. The resident's diagnoses, care plan, and physician orders included specific instructions for wound care and offloading of the affected heel. Wound care consultation appointments documented clear recommendations to hold off on weight-bearing physical therapy (PT) until the wound healed and to use specialized offloading devices. However, these recommendations were not transcribed into the resident's medical record or communicated to the PT staff in a timely manner. Despite the wound care provider's instructions, physical therapy documentation over several weeks continued to list the resident as weight bearing as tolerated on the right lower extremity, and the resident participated in ambulation activities. The resident repeatedly reported to PT staff that he was instructed by his doctor to avoid weight bearing and remain in bed, but nursing staff indicated that no such orders were present in the record. This discrepancy persisted until the recommendations from the wound care consultations were finally received and entered into the record, and PT staff were made aware of the restrictions. Interviews with facility staff, including the Director of Rehabilitation and the DON, confirmed that the wound care provider's recommendations were not transcribed into the electronic medical record or communicated to the appropriate staff upon the resident's return from appointments. The lack of timely transcription and communication resulted in incomplete and inaccurate clinical records, as well as a failure to ensure that all staff were aware of and following the current care instructions for the resident.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across multiple areas, including three nursing units and the Chapel. Observations on the F Wing Nursing Unit revealed a scuffed and dirty hallway floor, a garbage can with dried liquid stains, and a dining area with debris on a vent, unidentified drinks and backpacks, and stained tables. Additionally, the room for four residents had a peeling cove base with visible concrete. The Chapel had water-stained ceiling panels, dusty ceiling fans, and a garbage can with dried stains. A dirty linen container was also found with used medical gloves on top. In Resident 1's room, a chair had a pad with smears, and a commode was left uncleaned with feces and toilet paper. The resident had been discharged earlier, but the room remained in disarray. The nourishment refrigerators on the A and B nursing units were found with soiled shelves, debris, and a broken drawer with a sticky substance. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, who acknowledged the issues, particularly noting that staff should have emptied the commode as the resident prepared for discharge.
Neglect Leads to Resident's Ankle Fracture
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in actual harm with a serious injury. A resident, who was cognitively intact and required the assistance of two staff members for all care, was left in the care of a single nurse aide. Despite the resident's repeated reminders of her need for two caregivers, the aide proceeded to provide a shower alone. During the process, the resident was asked to stand, leading to a fall and subsequent ankle fracture. The facility's investigation revealed that the nurse aide was aware of the requirement for two caregivers but chose to act alone. The resident's clinical records indicated that she was admitted in May 2024 and had been assessed to need two-person assistance since then. The incident occurred in October 2024, and the facility did not implement measures to ensure staff training on the required number of caregivers for residents, resulting in a failure to provide safe care.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in actual harm with a serious injury. The incident involved a resident who was found with fresh bruising, swelling, and bleeding from the nose, indicating potential abuse. The resident was later diagnosed with an acute, displaced nasal bone fracture, confirming the severity of the injury. The abuse was witnessed by another staff member who reported seeing the resident being forcefully handled and thrown onto a bed by a nurse aide. The facility's policies and procedures, as outlined in their Resident Abuse and Neglect Prevention Program, were not adequately followed. The program includes components such as screening, training, prevention, identification, investigation, protection, reporting, and conclusion of the investigation. However, the facility failed to ensure that the staff member involved in the incident had received the necessary training on abuse prevention before providing care. Additionally, there was no evidence of a criminal background check being conducted for the staff member prior to their employment. Interviews with facility management confirmed that the staff member was a contracted agency employee, and the facility did not implement measures to ensure that contracted staff received training on the facility's abuse prevention program. This lack of oversight and failure to adhere to established policies contributed to the incident, resulting in harm to the resident and a deficiency in the facility's care standards.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve grievances reported by two residents, identified as Residents 8 and 9, regarding the conduct of a nurse aide, Employee 7. The grievances involved allegations that Employee 7 was not responding to call bells and was engaging in personal phone conversations while on duty. Despite these grievances being logged as resolved on the same day they were reported, interviews with the residents revealed that they were not informed of any interventions or resolutions regarding their concerns. The facility's grievance policy requires immediate action to prevent further violations of resident rights and mandates that grievances be thoroughly investigated, with findings reported to the concerned parties within five working days. The investigation into the grievances lacked thoroughness, as there was no evidence that statements were obtained from the residents who reported the issues, nor were they kept informed of the investigation's progress. The facility only collected statements from staff members, including Employee 7, and failed to include any resident statements from the Unit B nursing unit. Interviews with the Nursing Home Administrator and other staff confirmed that the residents were cognitively intact and capable of providing statements, yet this was not done. The facility was unable to demonstrate that the grievances were thoroughly investigated or reported to appropriate agencies, as required by their policy.
Failure to Ensure Resident Safety During Transport and Wound Care
Penalty
Summary
The facility failed to ensure a safe environment for Resident 1 during transport to and from dialysis appointments. Resident 1, who is dependent on renal dialysis and uses a wheelchair, was not properly secured with a seatbelt during transport. This oversight led to an incident where the resident fell out of the wheelchair, resulting in pain in the lower back and neck. Interviews with the transport driver and aide revealed uncertainty about whether the resident was secured, and facility documentation confirmed that the seatbelt was not attached to the resident. Resident 2, who has a Stage 4 pressure ulcer and some cognitive impairment, was exposed to an accident hazard when Dakin's solution, an antiseptic for external use, was left on her bedside table in a Styrofoam cup. Mistaking it for water, Resident 2 ingested a sip of the solution, which caused a burning sensation in her mouth. The resident was subsequently taken to the emergency room for evaluation. Witness statements from staff indicated that the solution was left within the resident's reach, leading to the accidental ingestion. Both incidents highlight the facility's failure to maintain a safe environment free from accident hazards for its residents. The lack of proper supervision and adherence to safety protocols during transport and wound care contributed to these deficiencies, as evidenced by the residents' experiences and staff interviews.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment across four nursing units, as observed during a survey. In Resident 54's room on the F unit, an eight-inch by eight-inch section of the wall at the head of the bed was damaged, with the cove base separating and dust accumulating on the floor. Employee 1, a nurse aide, was unable to specify how long the damage had been present. On the G unit, the hallway walls between rooms 10-18 were patched but not painted, and the Nursing Home Administrator acknowledged that the patches had been there for at least a week. In Resident 122's room on the B unit, the wall separating the beds was severely marred, with the white drywall exposed and the cove basing either missing or peeling. Resident 122 confirmed that the wall had been in this condition since her admission. In Resident 95's room on the A unit, fall mats on the floor had multiple brown smears, and the wall behind the bed was marred. The brown smears on the fall mat remained even after the mats were folded and leaned against the wall when Resident 95 was out of the room.
Failure to Implement Abuse Policy and Conduct Thorough Investigations
Penalty
Summary
The facility failed to implement its abuse policy regarding the completion of thorough investigations and reporting for allegations of abuse involving five residents. The policy required the separation of the alleged perpetrator from the victim, obtaining a written statement from the suspect, and completing a PB-22 form within five working days. However, the facility did not submit the PB-22 investigation for allegations involving three residents, despite being instructed to do so by the Department of Health. In one instance, a resident's roommate alleged that a nurse aide manhandled the resident, resulting in red discoloration under her arms. The facility obtained a statement from the aide but failed to identify that the aide did not follow the resident's care plan, which required assistance from two caregivers for transfers. The facility did not implement an educational action plan for the aide until the issue was highlighted by a surveyor. Additionally, the facility did not conduct a complete investigation into the cause of a bruise on another resident's lower extremity, nor did it investigate bruises found on a different resident's abdomen, thigh, and shoulder. The facility had no investigation to rule out abuse for these bruises, and the Director of Nursing confirmed the lack of a thorough investigation into these incidents.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from an alleged perpetrator of abuse during an investigation. The facility's policy requires immediate separation of the alleged perpetrator from access to the alleged victim upon discovery of an abuse allegation. However, the facility did not adhere to this policy. An anonymous allegation was made against Employee 2, a nurse aide, for abusing three residents who had bruises. Despite the allegation, Employee 2 continued to work every day, including double shifts, from May 29, 2024, to June 7, 2024, totaling 124 hours in 10 days. There was no documented evidence that the facility removed Employee 2 from having access to vulnerable residents during the investigation. Interviews with the Director of Nursing confirmed that the facility did not take the necessary steps to separate Employee 2 from the residents during the investigation. The facility's failure to act according to its policy resulted in a deficiency, as it did not protect the residents from potential harm. The report highlights the facility's non-compliance with its own Resident Abuse and Neglect Prevention Program, as well as state regulations regarding the responsibility of the licensee, management, and nursing services.
Failure to Implement Person-Centered Care Plans for Dementia
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for residents diagnosed with dementia, as required by regulations. Three residents, identified as Residents 32, 90, and 163, were reviewed, and it was found that their care plans did not address their dementia and cognitive loss. Resident 32 was admitted with a diagnosis of dementia and other behavioral disturbances, yet the care plan lacked any person-centered strategies to manage these conditions. Similarly, Resident 90, who had been diagnosed with dementia, also did not have a care plan that addressed his cognitive needs. Resident 163 was admitted with a diagnosis of dementia, but her care plan similarly lacked any individualized approach to manage her condition. The Director of Nursing confirmed that there was no documentation of individualized care plans for these residents. This deficiency was previously cited on July 14, 2023, indicating a recurring issue with the facility's compliance with dementia treatment and services regulations.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physicians addressed pharmacy recommendations for five out of seven residents reviewed. For Resident 130, the pharmacist made recommendations on three separate occasions, but there was no documented evidence that these recommendations were acted upon. The Director of Nursing (DON) confirmed that the facility could not locate the recommendations. Similarly, for Resident 43, the pharmacist made recommendations on two occasions, but there was no evidence in the clinical record that these were addressed, and the DON confirmed the facility's inability to find the recommendations. Resident 165's clinical record showed a pharmacy recommendation regarding the use of Alprazolam and Cipro, but the physician's response did not provide a stop date or rationale for the continued use of Alprazolam, nor did it appropriately address the recommendation to change the antibiotic. The DON and Administrator confirmed these findings. Additionally, for Residents 32 and 55, there were multiple instances where pharmacy recommendations were not documented as acted upon, and the facility was unable to find the recommendations. These deficiencies indicate a systemic issue in the facility's handling of pharmacy recommendations.
Failure to Ensure Medication Regimens are Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from potentially unnecessary medications, as evidenced by the cases of three residents. For Resident 130, the clinical record showed a physician's order for Haldol and Ativan to be administered as needed for agitation, but there was no documentation of the required 14-day use limit or clarification on the use of multiple medications for the same indication. This was confirmed by the Director of Nursing during an interview. Resident 163 was admitted with diagnoses including anxiety, spinal stenosis, and hypertension. A drug regimen review identified an inappropriate diagnosis for Quetiapine, which was not corrected until over two months later, despite a pharmacy recommendation to change the diagnosis. Similarly, Resident 55 was receiving Olanzapine with a diagnosis listed as preventative measures, which was later changed to schizoaffective disorder without evidence of a proper diagnosis by a qualified practitioner. These findings were confirmed through interviews with the Director of Nursing.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store food and maintain equipment in a sanitary manner in the main kitchen, potentially leading to the spread of foodborne illness. During an observation with the certified dietary manager, several issues were noted: expired spices were found on the spice rack, including parsley dated June 22, 2022, and ground cumin dated March 2021, contrary to the facility's policy requiring disposal six months after opening. The first oven had grease spills, and the second oven had water on the floor with pink rags on a tray below. In the dry storage room, two bags of egg noodles were opened and undated. The walk-in freezer had scraps of trash and spilled peas on the floor. The juice machine area had liquid on the counter, wet rags, and water on the floor. Employee 9 confirmed these findings, attributing the leaks to machine condensation during hot weather.
Inaccessible Call Bells for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents, specifically regarding the accessibility of their call bells. Resident 54, who has muscle weakness and hemiplegia following a cerebrovascular accident, was observed on two occasions with the call bell out of reach. The resident was seated in a broda-chair at the foot of the bed, facing away from the bed, while the call bell was positioned at least five feet away near the head of the bed. This was confirmed by a nurse aide who acknowledged the call bell was out of reach for the resident. Similarly, Resident 17, who is at risk for falls due to gait and balance problems, reported decreased mobility and difficulty reaching the call bell. During an interview and observation, the resident was found sitting at the foot of the bed in a wheeled chair, unable to reach the call bell, which was clipped to the side of the mattress on the opposite side of the bed. The resident expressed having waited two hours for assistance to get back into bed, highlighting the inaccessibility of the call bell. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Inconsistency in Advance Directives for a Resident
Penalty
Summary
The facility failed to establish clear and consistent resident wishes regarding advance directives for one of the residents reviewed. Clinical record review revealed that the facility admitted the resident on a specific date. The resident's POLST form, dated on two separate occasions, indicated that the responsible party chose CPR. However, a review of the resident's physician orders revealed a current order indicating the resident was a limited code, no CPR, and a previous order indicating the resident was a DNR. An interview with the assistant director of nursing verified that the POLST in the resident's medical record did not match the physician orders.
Confidentiality Breach of Resident's Medical Record
Penalty
Summary
The facility failed to ensure the confidentiality of personal health information and a resident's right to privacy on Nursing Unit F. During an observation, it was noted that the medication/supply room was being restocked by a non-clinical staff member, Employee 4, while an LPN, Employee 5, was present. A computer on top of a medication cart was logged into Resident 23's medical record and was clearly visible to Employee 4. The computer belonged to another LPN, Employee 6, who was on break at the time, leaving the resident's chart unsecured. The incident was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated hospital transfer and discharge to the resident, the resident's representative, and the ombudsman for one of the residents. The clinical record review showed that the resident was admitted on January 12, 2024, and on March 12, 2024, the resident exhibited violent behavior by striking another resident multiple times. The local police were involved, and the resident was transferred to the hospital for evaluation and treatment. Subsequently, the facility decided not to readmit the resident due to the risk posed to other residents. However, the facility did not send an updated discharge notice to the relevant parties. This was confirmed during an interview with the Nursing Home Administrator and Director of Nursing on June 7, 2024.
Failure in Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer treatment for a resident with a Stage 4 pressure ulcer on the right ischium. The resident was under the care of a wound care consultant, and the physician's orders specified the application of a foam dressing with a border to the right ischium. However, during an observation of wound care, an LPN applied the dressing to an open area on the resident's left buttock instead of the right ischium, which was the area specified in the physician's orders. Further review and interviews confirmed that the treatment was incorrectly applied to the left buttock, which had new open areas, rather than the right ischium, which was almost healed. The registered nurse and wound nurse verified that the treatment order was for the right ischium. The Nursing Home Administrator and the Director of Nursing were informed of the issue, highlighting the facility's failure to adhere to professional standards of practice in pressure ulcer treatment for the resident.
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 258 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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 Coal Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Carmel Senior Living Community | 6.2 mi | ★★★★★ | 27 | 0 |
| Grandview Nursing And Rehabilitation | 12 mi | — | 25 | 1 |
| Emmanuel Center For Nursing | 12.1 mi | ★★★★★ | 1 | 0 |
| Nursing And Rehabilitation At The Mansion | 12.4 mi | ★★★★★ | 9 | 0 |
| Sunbury Skilled Nursing And Rehabilitation Center | 12.5 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.