Below average — CMS composite of the measures below.
The next survey window likely opens 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 Perry Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that three of four medication carts on two floors were left unattended and unlocked, contrary to facility policy requiring carts to be locked when out of sight. A resident with dementia and severely impaired cognition, seated next to one cart, was observed taking a personal cell phone from the top of the cart before a speech therapist intervened. Multiple RNs later acknowledged that the Second Floor B/C/G Hall cart, the Third Floor Front Hall cart, and the Third Floor Back Hall cart had been left unlocked, and the DON confirmed these carts were not properly secured.
The facility failed to ensure resident clinical records were readily accessible to State surveyors when records for a resident who had been in the facility during an ownership transition were stored in a prior electronic system (PCC) that current staff could not access. The DON reported that only records from the date of new ownership forward were in the current Matrix system, and that earlier records remained in PCC, which required corporate involvement to access. A Regional RN stated that corporate initially did not have PCC access and had to escalate the issue, leaving surveyors unable to review the needed records for an extended period and delaying the survey process until access was finally obtained.
Surveyors found that the facility did not document communication of essential clinical and care-planning information to receiving hospitals for two residents who were transferred and expected to return, including care plan goals, advance directives, ongoing care instructions, representative contact information, and other details needed to meet their specific needs. The records for these residents, who had conditions such as HTN, COPD, septicemia, cancer, and anemia, also lacked evidence that they or their representatives received written notice of the facility’s bed-hold policy at the time of transfer. The DON confirmed these failures during interview.
Surveyors found that the facility did not respond promptly to call lights for four residents who were dependent on staff for toilet hygiene and, in one case, toilet transfers, and who had diagnoses such as HTN, anxiety, depression, malnutrition, DM, PVD, and atrial fibrillation. Facility policy required prompt response to call lights, and resident council minutes and a written concern documented complaints about waiting to be changed and call lights remaining on for over an hour while staff walked past. In interviews, residents reported waiting from about an hour to an hour and a half for call lights to be answered, especially during the night shift. The NHA and DON acknowledged that the facility failed to ensure timely response to call lights, in violation of applicable Pennsylvania regulations.
Three residents experienced deficiencies in their living environment, including a prolonged ceiling leak with exposed piping, uncleaned privacy curtains, and accumulated debris and dust in a resident room. Additionally, a shower room was found with a detached shower head and visible debris. Facility leadership and staff confirmed these issues and acknowledged the failure to maintain a clean, safe, and homelike environment.
A resident with multiple medical conditions reported acute lower back pain following care by a nurse aide, and both the resident and family raised concerns about the care provided. The facility did not report or investigate the allegation of abuse according to its written policies and procedures, as confirmed by document review and staff interviews.
A resident with multiple medical conditions experienced acute lower back pain after care provided by a nurse aide, and both the resident and family reported concerns about the incident. Despite facility policy requiring immediate reporting of abuse allegations, the incident was not reported to administration or authorities as required, resulting in noncompliance with state regulations.
A resident with multiple medical conditions reported acute lower back pain after care provided by a nurse aide, and the family raised concerns about the incident. Despite facility policy requiring prompt investigation of abuse allegations, the incident was not reported to administration or thoroughly investigated until weeks later, resulting in a deficiency for failure to respond appropriately to an alleged violation.
The facility failed to consistently monitor and log in-room refrigerator temperatures for two residents, with blank temperature logs noted on multiple days and an LPN confirming the logs were not maintained as required. The facility also failed to document Contact Precautions for nine residents with acute GI symptoms or suspected norovirus during an outbreak, despite progress notes and orders referencing viral illness and stool testing. In addition, during wound care for a resident with a left heel wound, staff wore gloves but did not don gowns as required under EBP during dressing change.
Failure to assess self-administration of medications for two residents. One resident with anemia, HTN, and PVD had Dakin's solution, zinc oxide, and Medi Honey in the room without a physician order, assessment, or care plan for self-administration, and an LPN confirmed the meds were stored inappropriately. Another resident with dysphagia, HTN, and constipation had Tums in the room without the required order, assessment, or care plan, and an RN confirmed the same.
A resident with HTN, hemiplegia, and anemia had a touch pad call bell that was supposed to be kept within reach at all times, but staff left it on the dresser out of reach while the resident was lying in bed. An RN confirmed the call bell was not accessible or available for the resident’s use.
The facility failed to ensure the physician was notified when a resident missed ordered levothyroxine doses. The resident had diagnoses including HTN, left knee pain, and difficulty walking, and the MAR showed two missed morning doses. The ADON said the facility had the medication but waited for a dye-free version because of a reported dye allergy, and the DON stated there was no documentation that the MD was informed the medication was unavailable.
The facility failed to provide timely SNF-ABN Form CMS-10055 notice for a resident discharged from skilled services. Review of records showed the form was not in the chart before discharge, and the BOE confirmed the notice was not provided in a timely manner.
Failure to Protect Resident Medical Information: A medication cart on the second floor was left unattended by the nurse's station with a paper nursing report sheet displaying identifiable resident information that could be seen by anyone passing by. An RN confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information as required.
Failure to Recognize Bed Bolsters as a Physical Restraint: A resident with HTN, a right elbow contracture, and decreased WBC count was observed in bed with bilateral raised mattress edges, but the record showed no physician order, no care plan goals or interventions, and no assessments or ongoing evaluations for the bolsters or concave mattress. The MDS indicated no restraints were in use, and the PT stated therapy was not involved in ordering, evaluating, or placing the bolsters; the DON confirmed the facility failed to identify the bolsters as a possible restraint and failed to provide the required documentation and re-evaluation.
The facility failed to ensure that required resident information was sent to the receiving provider for a resident transferred to the hospital. The record showed the resident had HTN, L knee pain, and difficulty walking, but there was no documented evidence that care plan goals, advance directive info, ongoing care instructions, resident representative info, or other needed details were communicated; the DON confirmed the omission.
A resident with HTN, unsteadiness on feet, and malnutrition had bilateral hearing aids ordered for use, removal at HS, and reinsertion in the AM and evening shift. Although the resident was observed wearing the hearing aids, the care plan did not include goals or interventions related to hearing aid use, and the DON confirmed the care plan was not comprehensive.
A resident with a R BKA, anemia, HTN, and HF was ordered PT for therapeutic exercise and gait training and had a care plan directing use of a gel liner and sock when out of bed. Staff did not assist with applying the stump shrinker on consecutive evenings, the limb became swollen, the resident could not apply the prosthetic, and the resident had to refuse ambulation therapy. The resident and the DON confirmed the swelling and the missed assistance.
Failure to Provide Ongoing Resident Activities: A resident with anxiety disorder reported having no relevant activities and said they had no peers close to their age, while relying on reading, sudoku, and walking to stay busy. The MDS showed the resident valued reading, music, news, and going outside for fresh air, but activity records mainly reflected self-directed activity, conversation/social time, family time, and one group party, with clinical notes documenting the resident’s dissatisfaction with the lack of daily activities.
The facility failed to ensure appropriate services, equipment, and assistance to maintain mobility for two residents. One resident with stroke-related impairment and limited hand function was observed without the ordered palm guard, with the fingers of the right hand closed into the palm. Another resident with repeated falls, seizure disorder, muscle weakness, and brain cancer was repeatedly observed improperly positioned in a Geri-chair, and the chart lacked an order or care plan for Geri-chair use; the DON confirmed the deficiency.
The facility failed to provide colostomy care consistent with policy for two residents with colostomies. Their orders and care plans did not include the size or type of appliance to be used, and the DON confirmed staff should have measured the stoma per policy but the facility did not document that measuring was completed or what appliance size and type was being used.
Incomplete Dialysis Communication: The facility failed to provide consistent and complete communication with the dialysis center for two residents receiving dialysis. Both residents had ESRD and orders for dialysis on Monday, Wednesday, and Friday, but multiple dialysis communication sheets were missing for each resident. The DON confirmed the incomplete communication during interview.
Failure to Develop Person-Centered Dementia Care Plans: The facility failed to develop and implement individualized, person-centered care plans for two residents with dementia and cognitive loss. One resident had dementia and Parkinson’s Disease with a BIMS score indicating severe cognitive impairment, and the other had a BIMS score indicating moderate impairment; dementia was documented in provider notes for the second resident, but it was not found in the active diagnosis or admission paperwork. The DON confirmed the care plans did not address the residents’ dementia-related needs.
Failure to Address Psychosocial and Social Service Needs: A resident with a hx of alcohol dependence, anxiety, and variable BIMS scores repeatedly asked staff for help with housing, AA/12-step services, ID issues, and a safe transfer from the facility. The psychologist’s report recommended AA services, regular meetings, a sponsor, individual psychotherapy, regular work, and monitoring of alcohol dependency, but staff confirmed they received the report and did not act on the recommendations.
Medication carts were not properly secured and opened inhalation meds were not dated. A prefilled Lovenox injection and two nebulizer solution ampules were left unattended on top of a locked cart, opened albuterol ampules, ipratropium bromide, and Trelegy inhalers were found without dates, and another med cart at the nurses' station was left unlocked and unattended; an RN and an LPN confirmed the findings.
Failure to post required state agency and ombudsman contact information. During observations, no accessible posting was found for Adult Protective Services or the State LTC Ombudsman program on the First, Second, or Third Floor. The NHA confirmed the required name, address, email, and phone number information was not posted on any of the three nursing floors.
Staff and resident interviews, along with documentation review, revealed that insufficient nursing staff led to missed showers and delayed care for three residents, including those with high blood pressure, post-polio syndrome, end stage renal disease, and heart failure. Staff reported difficulty providing care requiring two people, such as Hoyer lift transfers, and residents experienced long wait times and incomplete personal care routines. The DON confirmed the staffing shortage and inability to provide necessary services to maintain residents' well-being.
A resident admitted with multiple serious diagnoses did not receive all prescribed medications due to nursing staff failing to transcribe a physician order for Xanax and not administering Diovan as ordered. Facility procedures for handling missing medications and notifying the physician were not followed, as confirmed by the DON.
A resident who required two-person assistance for bed mobility was left unattended and assisted by only one nurse aide during care, resulting in a fall from bed and injuries including a hip fracture and head contusion. The aide was unaware of the resident's assistance requirements, despite this being documented in the care plan and Kardex. Facility policies on fall prevention and resident safety were not followed, leading to actual harm.
Surveyors found that the facility did not maintain a clean, safe, and homelike environment in the first-floor lobby coffee area, with multiple cleanliness issues such as debris, spills, and unclean surfaces confirmed by staff and administration.
Two residents who were dependent on staff for ADL care did not consistently receive scheduled showers or baths, with documentation missing for several dates and one resident reporting extended periods without bathing due to understaffing. The DON confirmed the failure to provide required ADL assistance.
The facility did not provide the required minimum number of nurse aides on certain evening and night shifts, resulting in staff being responsible for more residents than state regulations allow. A resident reported concerns about understaffing, and staffing records confirmed that the facility was below the mandated nurse aide-to-resident ratios on specific shifts.
The facility did not provide the required minimum of one LPN per 40 residents during a night shift, as confirmed by staffing schedules and resident interviews. A resident reported that nurse aides were assigned more residents than usual, highlighting concerns about understaffing.
The facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day on two reviewed days, as confirmed by staffing records and resident interviews indicating understaffing. This deficiency was communicated to facility leadership.
A resident with significant communication and cognitive impairments, identified as at risk for elopement, was able to exit the facility unsupervised after an alarm was silenced by an EVS employee who did not properly check the area or notify staff. The resident was found outside engaged in a physical altercation, and staff failed to update care plans or respond appropriately to the alarm, resulting in immediate jeopardy.
A resident with significant communication and medical needs, identified as an elopement risk, was found outside the facility without staff awareness. The facility's investigation into the incident was incomplete, as it did not include a statement from the EVS employee who silenced the alarm, and the investigation's findings were contradicted by later interviews.
The facility did not complete annual performance evaluations for five nurse aides, as required by their policy. The Wexford Employee Handbook mandates that job descriptions form the basis for these evaluations, which should occur annually. A review of personnel records showed that evaluations were missing for these staff members, a deficiency confirmed by a regional HR employee.
The facility failed to properly label and date food in the Main Kitchen and Third Floor Unit Pantry, as observed by surveyors. Unsealed, unlabeled, and undated food items were found in the Main Kitchen's walk-in freezer and the Third Floor Unit Pantry, confirmed by staff, creating a potential risk for foodborne illness.
The facility failed to maintain an effective QAPI program, as evidenced by 11 repeat deficiencies identified in a recent survey. Despite plans to forward audit results to the QAPI committee, the facility did not implement necessary improvements, as confirmed by the Nursing Home Administrator.
The facility failed to offer residents the opportunity to vote in the May 2024 election and did not provide a dignified dining experience for a resident requiring self-feeding assistance. Residents were not asked about voting, and a nurse aide was observed standing while feeding a resident, which was confirmed as undignified.
The facility failed to assess the ability of three residents to self-administer medications, as required by their policies. One resident was left unattended with medications, another had a medication found on the floor by a family member, and a third had a medication left at the bedside. The Director of Nursing confirmed the facility's failure to adhere to its policies on medication administration.
The facility did not address or resolve resident grievances reported during council meetings over six months. Issues included staff not wearing name tags, rude agency aides, linen and oxygen shortages, and the absence of credit card vending machines. Residents reported ongoing concerns without receiving resolutions, and the Activity Director confirmed no documentation of follow-up actions.
The facility failed to maintain resident confidentiality by displaying medical instructions in three resident rooms and leaving a medication cart unattended with an open computer screen, exposing confidential information. The DON confirmed these breaches of privacy protocols.
The facility failed to communicate necessary information to receiving health care providers for six residents transferred to the hospital. Despite having various medical conditions, including heart failure, anemia, and cancer, the facility did not provide required details such as care plan goals and advance directives. This deficiency was confirmed by the DON, indicating a violation of facility policy and resident rights.
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their policy and state regulations. This deficiency was identified through a review of clinical records and staff interviews, revealing that six residents with various medical conditions were not informed in writing about the bed-hold policy at the time of their hospital transfers. The Director of Nursing confirmed this oversight, which violates residents' rights under state code.
The facility failed to provide necessary ADL assistance for four residents, as required by their care plans. A resident with multiple diagnoses, including diabetes and spinal stenosis, missed several showers in October, while another with dementia and muscle weakness also did not receive scheduled showers. A third resident with neurogenic bladder and quadriplegia reported going weeks without a shower, and a fourth resident with high blood pressure, depression, and dementia had not received any showers since admission. These failures were confirmed by the DON and violated the facility's routine care policy and state regulations.
The facility failed to provide a resident-centered activity program, impacting six residents' physical, mental, and psychosocial well-being. Despite policy requirements for diverse activities, residents reported unmet needs and unannounced schedule changes. Two residents, with specific medical conditions, lacked in-room activities, confirmed by the Activities Director, with no documentation of activities provided.
The facility failed to provide appropriate catheter care for three residents, resulting in deficiencies. A resident's Foley catheter order lacked necessary details, while another resident's catheter collection bag was improperly placed on the floor without a dignity cover, and an open irrigation syringe and sterile water were undated. Additionally, a third resident's urine collection bag lacked a dignity cover. These issues were confirmed by nursing staff and violated facility policy and state regulations.
The facility failed to store refrigerated medications at proper temperatures, secure treatment carts, and lock medication rooms. Medications were improperly labeled and stored, with some lacking resident information. These deficiencies were observed across multiple units and involved several staff members, including RNs and LPNs.
The facility failed to monitor personal refrigerators for four residents, leading to improper food storage. Two residents with indwelling catheters had collection bags on the floor, violating infection control practices. Additionally, the Third Floor Medication Room contained unlabeled ice packs, risking cross-contamination.
Unattended and Unlocked Medication Carts on Multiple Units
Penalty
Summary
The deficiency involves the facility’s failure to keep multiple medication carts locked and attended as required by facility policy and professional standards. The facility’s policy on General Dose Preparation and Medication Administration, last reviewed on 2/8/26, states that medication carts must always be locked when out of sight or unattended. During an observation on 4/7/26 at 12:27 p.m., a resident with dementia, asthma, high blood pressure, and a BIMS score of 04 indicating severely impaired cognition was seated in a wheelchair next to the Second Floor B, C, G Hall medication cart. The resident reached up and removed a personal cell phone from the top of the cart. The Speech Therapist observed this, attempted to redirect the resident, and identified the item as a personal cell phone. The cart was found to be unlocked. At 12:30 p.m., an RN returned to the cart, confirmed the phone was hers, and acknowledged that the cart had been left unattended and unlocked. Additional observations on the same date showed similar failures with other carts. At 12:40 p.m., an unlocked medication cart was observed in the hallway near a resident room and was identified by an RN as the Third Floor Front Hall medication cart; the RN confirmed it had been left unattended and unlocked. At 12:45 p.m., another unlocked medication cart was observed in the hallway near a resident room and was identified by a different RN as the Third Floor Back Hallway medication cart; this RN also confirmed the cart was left unattended and unlocked. At 1:15 p.m., the Director of Nursing confirmed that three of four medication carts (Second Floor B, C, G Hall, Third Floor Front Hall, and Third Floor Back Hall) were not properly secured, in violation of state regulations and the facility’s own policy requiring drugs and biologicals to be stored in locked compartments.
Failure to Provide Surveyors Timely Access to Electronic Clinical Records
Penalty
Summary
The facility failed to ensure that resident clinical records were readily accessible to the State Survey Agency, resulting in a delay in the survey process for one of three sampled residents (R3). During an interview on 4/7/26 around midday, the DON explained that the facility began using the Matrix electronic record system when new ownership took over on 12/1/25, and that residents present during the ownership transition had their records in the prior system, Point Click Care (PCC), to which the facility no longer had access. The DON stated that to obtain records prior to 12/1/25, corporate would need to be contacted for PCC access. Later that day, the Regional RN reported that corporate did not have access to PCC and would need to contact PCC again, and then further reported that corporate had to involve legal in an effort to gain access, leaving the PCC system still unavailable to the State Agency throughout multiple attempts on 4/7/26. As of 3:15 p.m. that day, the PCC program remained inaccessible, causing the State Agency to delay its record review and return the following day. On 4/8/26 at 8:45 a.m., the State Agency finally received access to PCC, and the DON confirmed that the prior ownership company had taken everything and would not initially provide access, resulting in the failure to maintain resident records in a manner that made them readily accessible for surveyor review. No additional clinical details or medical history for the affected resident were provided in the report.
Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to receiving health care providers for two residents who experienced facility-initiated transfers to the hospital and were expected to return. For Resident R1, who had diagnoses including high blood pressure, septicemia, and chronic obstructive pulmonary disease per an MDS dated 3/9/26, the clinical record showed a transfer to the hospital on 3/21/26 with no documented evidence that the facility communicated required information to the hospital. Missing documentation included the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident’s specific needs at the receiving facility. Similarly, Resident R4, with diagnoses including cancer, anemia, and high blood pressure, was transferred to the hospital on 3/17/26, and the clinical record lacked documentation that the facility communicated the same categories of essential information to the receiving provider. In addition, for both residents R1 and R4, their clinical records did not contain documented evidence that the residents or their representatives were provided written information about the facility’s bed-hold policy at the time of transfer to the hospital. During an interview, the Director of Nursing confirmed that the facility did not ensure necessary resident information was communicated to the receiving health care providers and did not notify the residents or their representatives of the facility bed-hold policy for these hospital transfers.
Failure to Respond Promptly to Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were answered in a timely manner for four residents who were dependent on staff for toilet hygiene and, in one case, toilet transfers. The facility’s Call Light Resident Communication System Policy dated 2/8/26 stated that staff would respond to call lights promptly. Resident Council Meeting Minutes from 2/18/26 documented a concern about residents waiting to be changed. A written concern from one resident dated 3/12/26 reported having a call light on for over an hour while staff walked past the room without stopping. Clinical records showed that these residents had multiple diagnoses, including high blood pressure, anxiety, depression, malnutrition, diabetes, peripheral vascular disease, and atrial fibrillation, and that each was assessed as dependent in Section GG0130 for toilet hygiene, with one also dependent in Section GG0170 for toilet transfers. During individual interviews, all four residents reported prolonged delays in call light response, particularly during the night shift. One resident stated that call lights take a long time to be answered at night. Another resident reported that response time is slow after midnight and that they had waited an hour. A third resident stated it sometimes takes an hour and a half for staff to answer the call bell at night. A fourth resident reported having to wait an hour to an hour and a half for staff to respond and stated that staff do not always come, especially at night. In an interview on 3/18/26 at 2:05 p.m., the Nursing Home Administrator and DON confirmed that the facility failed to ensure call lights were answered in a timely manner, in violation of 28 Pa. Code 211.10(c)(d) and 211.12(d)(1)(2)(3)(5).
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three residents and one shower room. Specifically, two residents' room had a water leak from a ceiling pipe, resulting in a missing ceiling tile and an exposed pipe above the bathroom entrance. Water was observed dripping into a bin placed under the leak, and staff had to sop up water to allow bathroom access. One resident was relocated when the plumber arrived to fix the pipe, but the other resident remained in the affected room. The leak persisted for several days before being repaired, and the administrator confirmed that both residents should have been relocated until the issue was resolved. Additionally, another resident reported that their privacy curtain had not been cleaned, and observations confirmed a dirty curtain with stains, debris along the walls and under the bed, and dust on the windowsill and blinds. The large shower room on the second floor was found with a detached hose/shower head lying on the floor and a brown spot on the shower stall floor. Housekeeping staff confirmed these conditions. The administrator acknowledged the facility's failure to maintain cleanliness and a homelike environment in these areas.
Failure to Implement Abuse Investigation Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to ensure a complete and thorough investigation of an allegation of abuse involving one resident. According to the facility's own policy, all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation, misappropriation of resident property, and injuries of unknown source are to be investigated. However, documentation and staff interviews revealed that an allegation of abuse was not reported to administration and was not investigated in accordance with these policies. The resident involved had diagnoses including cachexia, dysphagia, and hypothyroidism, and was assessed as cognitively intact. Progress notes indicated that the resident experienced acute lower back pain following care provided by a nurse aide, with the resident and family both raising concerns about the care received. Despite these complaints and the facility's policy requirements, the incident was not promptly reported or investigated by administration as an abuse allegation. The deficiency was identified through review of facility documents, clinical records, and staff interviews, which confirmed that the required procedures for investigating abuse allegations were not followed for this resident. The Director of Nursing acknowledged that the facility failed to implement its written policies and procedures in this case.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident, despite having a policy that requires immediate reporting and investigation of all allegations, suspicions, and incidents of abuse, neglect, or misappropriation of resident property. The policy mandates that such allegations be reported to the Administrator, who must then notify local and state agencies. In this case, the required reporting did not occur when a resident complained of pain following care provided by a nurse aide. The resident in question had diagnoses including cachexia, dysphagia, and hypothyroidism, and was assessed as cognitively intact. Progress notes documented that the resident experienced acute lower back pain after being turned during incontinence care by a nurse aide. The resident and their family reported the incident, stating that the pain began when the aide elevated the resident's legs during care. Medical evaluations, including x-rays and a CT scan, were performed, with findings that did not confirm an acute injury but did note an indeterminate compression fracture. Despite these reports and the facility's policy, the allegation of abuse was not reported to administration or to the appropriate authorities in a timely manner. The Director of Nursing later confirmed that the required reporting did not occur for this incident, resulting in noncompliance with state regulations regarding the reporting of alleged violations.
Failure to Investigate Alleged Abuse Following Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of abuse involving one resident. The resident, who was cognitively intact and had diagnoses including cachexia, dysphagia, and hypothyroidism, reported experiencing acute lower back pain after being turned by a nurse aide during incontinence care. The resident's family later inquired about the incident after receiving a phone call from the resident describing the care provided by the aide. Progress notes documented the resident's complaints of pain originating during care, and subsequent medical evaluations noted persistent lower back pain, with imaging revealing an indeterminate L4 compression fracture. Despite these reports and the facility's policy requiring investigation of all allegations and incidents of abuse, the allegation was not reported to administration, and a thorough investigation was not initiated until weeks after the incident, when the DON became aware through communication with the resident's family. The delay in reporting and investigating the allegation constituted a failure to respond appropriately to an alleged violation, as required by facility policy and regulatory standards.
Infection Control Failures With Refrigerator Monitoring, Contact Precautions, and Wound Care
Penalty
Summary
The facility failed to properly monitor and document in-room personal refrigerator temperatures for two residents. Facility policy required staff to monitor and log refrigerator temperatures and expiration dates of food items, but the temperature logs for one resident were blank on multiple days in October and the log for another resident was blank from 10/5/25 through 10/20/25. During interview, an LPN confirmed the temperature logs were not consistently monitored and logged as required. The report stated this created the potential for food borne illness. The facility also failed to implement appropriate transmission-based precautions for nine residents during a gastrointestinal illness outbreak. Clinical records showed multiple residents had acute nausea, vomiting, diarrhea, loose stools, or suspected norovirus, and several progress notes and physician orders referenced viral illness or stool testing for norovirus. However, the records for these residents did not contain documentation showing they had been placed on Contact Precautions. During interview, the Infection Preventionist stated it was not clear whether residents were placed on contact precautions and confirmed the facility failed to implement appropriate transmission-based precautions for these residents. The facility further failed to follow infection control practices during wound care for one resident with a left heel wound. Physician orders required enhanced barrier precautions during wound care and other high-contact care activities. During observation of a dressing change, the wound care nurse and an LPN wore gloves but did not don gowns while providing care. The wound care nurse later confirmed the resident was ordered EBP during wound care and that the facility failed to implement infection control practices to prevent cross contamination during the dressing change.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to determine whether it was safe for two residents to self-administer medications. The facility policy for Resident Self-Administration of Medications stated that residents may self-administer only if the interdisciplinary team determines the practice is clinically appropriate, with assessment and care plan documentation addressing medication storage, who is responsible for storage, documentation of administration, and where the drugs will be administered. For one resident, the clinical record did not contain a physician order, assessment, or plan of care for self-administration, yet the resident room contained Dakin's solution, zinc oxide, and Medi Honey during observation. The LPN confirmed the medications were stored in the room inappropriately and that no assessment, physician order, or plan of care was present. For the second resident, the clinical record also lacked a physician order, assessment, or plan of care addressing self-administration of medications. During observation, a bottle of Tums was found in the resident's room. The RN confirmed the medication was stored in the room inappropriately and that the resident did not have an assessment, physician order, or plan of care for self-administration. The residents' records included diagnoses such as anemia, high blood pressure, peripheral vascular disease, dysphagia, hypertension, and constipation.
Call Bell Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to accommodate the call bell needs for one resident who had diagnoses of high blood pressure, hemiplegia, and anemia. The resident’s care plan directed staff to place the touch pad call bell within reach at all times, and the facility policy stated that call light or bell access would be within reach of the resident as one method to communicate needs to staff. During an observation, the resident was lying in bed while the touch pad call bell was observed on the dresser, out of reach. A registered nurse confirmed that the call bell was not accessible and unavailable for the resident’s use.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
The facility failed to ensure the physician was appropriately notified of missed levothyroxine doses for Resident R1. Resident R1 was admitted to the facility with diagnoses including high blood pressure, left knee pain, and difficulty walking. A physician order dated 9/8/25 directed levothyroxine 100 micrograms by mouth every morning on Tuesday through Sunday, but the September 2025 MAR showed the medication was not administered on Tuesday 9/9/25 and Wednesday 9/10/25. During an interview, the ADON stated the facility had the medication in the building, but because the resident had a reported allergy to dyes used in the medication, the facility waited for the pharmacy to obtain an appropriate dye-free medication and the doses were missed as ordered. The DON later stated the facility could not provide documentation that the physician was made aware that the medication was unavailable and confirmed that the physician was not appropriately notified of the missed doses.
Failure to Provide Timely SNF-ABN Notice
Penalty
Summary
The facility failed to provide timely notice of Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN), Form CMS-10055, for one of two residents reviewed, Resident R142. Clinical documentation showed that Resident R142 was discharged from skilled services on 5/11/25, but facility records did not include a SNF-ABN form prior to discharge from skilled services. During an interview on 10/24/25 at 12:32 p.m., Business Office Employee E16 confirmed that the facility failed to provide the SNF-ABN form in a timely manner for Resident R142.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of eight medication carts, specifically the second floor cart. The facility's HIPAA policy dated 3/14/25 stated that HIPAA requires providers and others to implement security measures to guard the integrity and confidentiality of medical information. During an observation on 10/21/25 at 11:16 a.m., a medication cart by the nurse's station was left unattended with a paper nursing report sheet containing identifiable resident information that any passerby could see. During an interview on 10/22/25 at 8:51 a.m., Registered Nurse Employee E5 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information as required.
Failure to Recognize Bed Bolsters as a Physical Restraint
Penalty
Summary
The facility failed to identify the use of bolsters on a bed as a possible physical restraint for one resident, failed to obtain a physician's order, failed to develop a person-centered plan of care for the use of the restraint, and failed to provide ongoing re-evaluation of the need for the restraint. Resident R15 was admitted to the facility with diagnoses including high blood pressure, right elbow contracture, and decreased white blood cell count. The resident's MDS dated 8/31/25 indicated that no restraints were in use, yet on 10/21/25 at 8:54 a.m., the resident was observed lying in bed with the mattress having bilateral raised edges on the top and bottom portions. Review of the resident's active physician orders on 10/22/25 did not include an order for bolsters or a concave mattress, and the comprehensive care plan did not include goals or interventions related to the use of bolsters or a concave mattress. The clinical record also failed to identify any assessments or ongoing evaluations for the use of bolsters or a concave mattress. During interview, the PT stated therapy was not involved in ordering, evaluating, or placing bolsters on the resident's bed and explained that some air mattresses come with bolsters zipped into the mattress. The DON confirmed that the facility failed to identify the bolsters as a possible restraint, failed to obtain a physician's order, failed to develop a person-centered care plan, and failed to provide ongoing re-evaluation for one of two residents reviewed.
Failure to Send Required Transfer Information
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for one of two residents sampled with facility-initiated transfers. Resident R1 was admitted to the facility on [DATE], and the MDS dated 9/10/25 identified diagnoses of high blood pressure, left knee pain, and difficulty walking. The clinical record showed that Resident R1 was transferred to the hospital on 9/10/25, but there was no documented evidence that the facility communicated the resident’s care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, or other information necessary to meet the resident’s specific needs at the receiving facility. During an interview on 10/24/25 at 11:40 a.m., the DON confirmed that the facility failed to make certain the necessary resident information was communicated for this transfer.
Incomplete Care Plan for Hearing Aid Use
Penalty
Summary
The facility failed to develop a comprehensive care plan to meet the care needs of Resident R119. Review of the clinical record showed the resident was admitted to the facility and had an MDS dated 10/7/25 with diagnoses of high blood pressure, unsteadiness on feet, and malnutrition. The MDS also indicated that the resident used hearing aids. A physician order dated 7/1/25 directed bilateral hearing aids to be removed at HS and placed in a container, then inserted in the ears in the AM and evening shift. During an observation on 10/20/25 at 10:52 a.m., Resident R119 was observed wearing bilateral hearing aids. Review of the current care plan showed it did not include goals or interventions related to the resident's bilateral hearing aid use. During an interview on 10/24/25 at 11:56 a.m., the DON confirmed that the facility failed to develop a comprehensive care plan to meet the resident's care needs.
Failure to Assist With Stump Shrinker Application
Penalty
Summary
The facility failed to provide assistance with application of a stump shrinker for a resident with a right below the knee amputation, resulting in the resident being unable to attend therapy for ambulation. The resident was admitted with diagnoses including anemia, high blood pressure, and heart failure, and had a BIMS score of 15, indicating cognitive intactness. The care plan identified an ADL self-care performance deficit related to weakness, deconditioning, and the amputation, and directed that the resident wear a gel liner and sock when out of bed at all times, with the prosthetic used only for transfers. The resident stated that staff on the evening shift did not apply the stump shrinker when requested on two consecutive days, and as a result the limb became swollen and the resident could not apply the prosthetic leg. Because the prosthetic was not in place, the resident had to refuse therapy for the day since therapy was focused on ambulation. The resident and the DON confirmed that the limb was swollen and that the facility failed to provide the needed assistance.
Failure to Provide Ongoing Resident Activities
Penalty
Summary
The facility failed to provide an on-going program of activities to meet the interests of and support the physical, mental, psychosocial, and well-being needs of Resident R128. Facility documentation showed the resident was admitted with a diagnosis of anxiety disorder, and the MDS identified that reading books and newspapers, magazines, listening to music, keeping up with the news, and going outside for fresh air were very important to the resident. During interview, the resident stated they had no relevant activities to do, did not have peers close to their age, and kept busy by reading, doing sudoku, and walking around the facility. Clinical documentation also reflected the resident’s dissatisfaction with living in the facility and a discussion with the therapist about the resident’s report of the drone of daily activities, or lack thereof. Facility activity records for July, August, and September 2025 showed the resident did activities by themselves, with entries limited to conversation/social time/family time, relaxation/self-directed activity, and one group men/women party in September. The surveyor determined that the facility failed to provide an on-going program of activities for this resident.
Failure to Maintain Mobility Supports and Positioning
Penalty
Summary
The facility failed to ensure that two residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Facility policy for routine resident care required certified nursing assistants with specialized rehabilitation/restorative training to maintain proper body position and alignment, encourage maximum function, and assist with special devices. Resident R56 had diagnoses including high blood pressure, stroke, and heart failure, and had a physician order and care plan for a palm guard to the right hand on with morning care and off with bedtime care. During observation on 10/20/25, R56 was in bed without the splint on either hand, and the right hand fingers were closed into the palm; an LPN later confirmed the palm guard was not on the resident as ordered. Resident R57 had diagnoses including repeated falls, seizure disorder, and muscle weakness. On 10/20/25, R57 was observed in a Geri-chair with the right leg dangling over the right side of the chair arm, and an NA stated staff had a hard time keeping the resident in the chair. On 10/22/25, R57 was again observed in the Geri-chair with both legs dangling over the right side of the chair arm and then turning so the feet were at the head area and the back and head were where the feet should be. An RN repositioned the resident and stated the resident had brain cancer and little safety awareness. Review of the physician orders and care plan did not include an order or care plan for use of the Geri-chair, and the DON confirmed the facility failed to have physician orders or a care plan for the resident to be in the Geri-chair.
Colostomy Care Orders and Documentation Missing Appliance Size and Type
Penalty
Summary
The facility failed to provide colostomy care and services consistent with professional standards of practice for two residents, R13 and R77. Facility policy for colostomy appliance bag changes stated that staff should position an appropriately sized appliance to fit well around the stoma, measure the stoma with a stoma measuring guide, remove the paper backing, and check the opening in the new pouch to ensure it was large enough to fit the diameter of the stoma. However, review of the clinical record showed that the physician orders for both residents directed staff to monitor the colostomy site for discoloration and change the ostomy bag as needed, but did not include the size or type of colostomy appliance to be used. Resident R13 had diagnoses including high blood pressure, muscle wasting, and colostomy, and Resident R77 had diagnoses including ulcerative colitis, diverticulitis of the large intestine, and diabetes mellitus. Their current care plans also failed to include the size and type of colostomy appliance being used. During interview, the DON confirmed that the colostomy orders for both residents did not include the size and type of appliance, stated that staff should measure the opening per policy to determine what should be used, and confirmed that the facility failed to document that measuring was being completed and failed to document what size and type of appliance was being used for both residents.
Incomplete Dialysis Communication
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required dialysis services. Facility policy titled Hemodialysis Care and Monitoring, dated 3/14/25, stated the facility would provide a method for ongoing communication and collaboration. Review of the clinical record showed that Resident R17 was admitted to the facility and had diagnoses of end stage kidney disease, dependence on renal dialysis, and high blood pressure. A physician order dated 10/8/25 indicated dialysis one time a day every Monday, Wednesday, and Friday. Review of Resident R17's Dialysis Communication Records from 10/10/25-10/20/25 revealed five missing completed communication sheets on 10/10/25, 10/13/25, 10/15/25, 10/17/25, and 10/20/25. Review of Resident R65's record showed diagnoses of end stage kidney disease, dependence on renal dialysis, and heart failure, with a physician order dated 10/6/25 for dialysis one time a day every Monday, Wednesday, and Friday. Review of R65's Dialysis Communication Records from 10/1/25-10/21/25 revealed three missing communication sheets on 10/3/25, 10/15/25, and 10/17/25. During interview on 10/23/25 at 11:15 a.m., the DON confirmed the facility failed to provide consistent and complete communication with the dialysis center for both residents.
Failure to Develop Person-Centered Dementia Care Plans
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss for two residents reviewed. Facility policy stated that residents with dementia and/or dementia-related diagnoses are to be treated with the same respect and dignity and that individual goals should be addressed on the care plan to meet the resident’s needs for quality of life, quality of care, safety, and to maximize independence and functioning. The Resident Assessment Instrument guidance identified the BIMS as a screening test for cognitive impairment, with scores of 0-7 indicating severe impairment and 8-12 indicating moderate impairment. Resident R111 was admitted with diagnoses including high blood pressure, dementia, and Parkinson’s Disease, and had a BIMS score of 4, indicating severe impairment. Review of the care plan showed no person-centered care plan addressing dementia and cognitive loss. Resident R119 was admitted with diagnoses including high blood pressure, unsteadiness on feet, and malnutrition, and had a BIMS score of 9, indicating moderate impairment. A PA progress note and a physician progress note both documented dementia, but the active diagnosis and admission paperwork did not include dementia, and the DON stated the facility could not locate documentation of a dementia diagnosis. The DON also reported that the PA said, "You can just walk in the room and tell she has it. I'll write a diagnosis if you need me to." Resident R119’s care plan also failed to address dementia and cognitive loss, and the DON confirmed the facility failed to develop and implement individualized person-centered care plans for both residents.
Failure to Address Psychosocial and Social Service Needs
Penalty
Summary
The facility failed to provide medically related social services to help a resident achieve the highest practicable psychosocial well-being by not addressing recommendations from a psychologist report. Resident R128 had been in the facility since 2021 and reported a history of alcohol use, anxiety, frustration, and repeated requests for help with leaving the facility in a safe and appropriate manner. The resident stated they had spoken with multiple staff members about housing, support services, AA/12-step meetings, and assistance with obtaining identification and understanding income, but said follow-up never occurred and no meaningful help was provided. The resident’s record showed varying BIMS scores of 10, 13, and 15, and the expert report completed for a competency hearing stated diagnoses of alcohol dependence with alcohol-induced persisting dementia by another clinician, alcohol dependence with another alcohol-induced disorder by another clinician, and anxiety disorder. The psychologist’s recommendations included connection to AA services and regular AA meetings, a sponsor, individual psychotherapy, regular work, and monitoring of alcohol dependency. During interview, the psychologist confirmed the resident was alert and oriented, did not diagnose dementia, and stated the resident should be assisted by the facility with transfer to a different facility to meet their needs. Facility staff, including the Social Service Director, Assistant, Business Office staff, and NHA, confirmed the facility knew the resident wanted to leave and had received the psychologist’s expert report, but failed to act on the recommendations. The report also noted the resident had not been assisted with AA/12-step meetings, housing or placement options, or obtaining a current ID, despite the resident’s repeated requests and stated desire to leave the facility with appropriate support.
Medication carts left unsecured and opened inhalation medications not dated
Penalty
Summary
The facility failed to properly secure medications on one of eight medication carts, failed to properly label medications after opening on one of eight medication carts, and failed to properly secure a medication cart while it was not in use on one of eight medication carts. Review of the facility policy dated 3/14/25 stated that medications and biologicals are to be stored safely, securely, and properly, and that medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. During an observation on 10/21/25 at 11:16 a.m., the Dover Medication Cart had a prefilled injection of Lovenox and two clear nebulizer solution ampules sitting on top of the cart and unattended. RN E5 confirmed at 11:18 a.m. that the medications were not securely stored in the locked medication cart. During an inspection of the Royal Pavilion Back Hall Medication Cart on 10/22/25 at 10:25 a.m., opened inhalation medications were found without dates, including a box of albuterol ampules, two boxes of ipratropium bromide, and two Trelegy inhalers; RN E8 confirmed they were not dated when opened. During an observation on 10/24/25 at 9:42 a.m., the [NAME] Gardens Medication Cart at the nurses' station was left unlocked and unattended, and LPN E8 confirmed the cart was not properly secured while not in use.
Failure to Post Required State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post contact information for Adult Protective Services and the State Long-Term Care Ombudsman program in a form and manner accessible and understandable to residents or resident representatives. During observations on 10/24/25, no posted contact information, including name, address, email address, and phone number, was found for either agency on the First Floor, Second Floor, or Third Floor. During interview on 10/24/25 at 12:38 p.m., the Nursing Home Administrator confirmed that the required contact information was not posted on any of the three nursing floors.
Insufficient Nursing Staff Resulting in Missed Care and Delayed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by staff and resident interviews, documentation review, and direct observations. Nurse aides and licensed nurses reported that staffing levels were inadequate, particularly on the second and third floors, resulting in residents not receiving routine care such as showers and timely assistance with activities of daily living. Staff described working twelve-hour shifts with only three aides for 37 residents, making it difficult to provide care that required two staff members, such as Hoyer lift transfers, and leading to residents waiting longer than appropriate for care. Three residents were specifically affected by the staffing shortage. One resident with high blood pressure, post-polio syndrome, and vitamin D deficiency reported not receiving scheduled showers and described an incident where an aide attempted a transfer without proper equipment or assistance, resulting in discomfort and feelings of disrespect. Documentation confirmed that this resident received only three showers in the past 30 days, with the last one occurring over two weeks prior to the interview. Another resident with end stage renal disease, heart failure, and high blood pressure stated they had not received a shower in over a month, despite a scheduled shower routine, and documentation showed only one shower in the past 30 days. A third resident with similar diagnoses also reported not receiving showers as scheduled, with records indicating only three showers in the same period. Interviews with registered nurses and the Director of Nursing confirmed the lack of sufficient staff to provide necessary care, with staff acknowledging that residents had to wait for assistance and that it was often difficult to find a second person for required two-person transfers. The Director of Nursing was unable to locate complete shower documentation for the affected residents and confirmed the facility's failure to provide adequate nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being for the residents involved.
Failure to Transcribe and Administer Admission Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received the correct medications upon admission, as required by physician orders and facility policy. Upon review, it was found that the resident, who had diagnoses including respiratory failure, abdominal aortic aneurysm without rupture, and high blood pressure, was admitted with hospital discharge orders for Xanax 0.25mg four times a day for five days and Diovan 80mg every evening. However, the nursing staff did not transcribe the Xanax order into the facility's physician orders or Medication Administration Record (MAR), resulting in the medication not being administered as prescribed. Additionally, the Diovan was not administered on the evening of admission because it was not available from the pharmacy, and the nursing staff did not follow facility procedures for handling a missing medication. Specifically, the staff failed to notify the physician regarding the missed dose of Diovan. The Director of Nursing confirmed these omissions, acknowledging that the required procedures for medication transcription and notification were not followed.
Failure to Provide Required Assistance for Bed Mobility Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was identified as being at risk for falls and required the assistance of two persons for bed mobility, was left unattended and assisted by only one nurse aide during a routine care activity. The resident's care plan and assessment tools clearly indicated the need for two-person assistance and the use of a mechanical lift for all transfers due to the resident being non-ambulatory and on bedrest. Despite these documented requirements, the nurse aide proceeded to provide care alone and left the resident on their side while reaching for linens, resulting in the resident rolling off the bed and falling to the floor. The incident led to the resident sustaining significant injuries, including a right hip fracture, a head contusion, and multiple skin tears. The resident was sent to the emergency department, where further evaluation confirmed a right lateral impacted sub capital fracture of the hip, a temporal laceration, and additional abrasions. The resident experienced new pain following the fall, and the injuries required medical intervention, including sutures and hospital assessment. Interviews with staff revealed that the nurse aide involved was unaware of the resident's requirement for two-person assistance, despite this information being available in the resident's Kardex and care plan. Other staff members confirmed that the standard protocol is to always use two people for residents requiring such assistance and to never leave them unattended on their side. The facility's policies on fall prevention, incident management, and routine care all emphasized the importance of providing care according to individualized resident needs and minimizing accident hazards, but these protocols were not followed in this instance.
Failure to Maintain Clean and Homelike Environment in Coffee Area
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean, safe, and homelike environment in the first-floor lobby coffee area. During an observation, multiple cleanliness issues were noted, including a white substance on the ice machine catch tray and counter, brown splatter debris inside the microwave, and yellow and brown substances on the sink's plastic shield. Additional findings included a basket, washcloth, and debris under the sink, a white fuzzy substance and a grape under the coffee machine, a step stool with a brownish tan substance, and tan debris, paper wrappers, and coffee stirrers on the floor. The windowsill also had leaf debris under a plant. Staff interviews confirmed these observations. The receptionist acknowledged the unclean conditions and indicated that housekeeping had not yet attended to the area that morning. The Nursing Home Administrator also confirmed the findings and acknowledged the failure to maintain a clean, safe, and homelike environment in the coffee area. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
F 0584 1. Following the surveyor's feedback, facility housekeeping initiated a thorough cleaning of the main lobby coffee bar. 2. The Director of Environmental Services will educate housekeeping staff on the cleaning processes and procedures for the main lobby coffee bar. 3. The main lobby coffee bar cleanliness will be audited by the Director of Environmental Services or designee daily, 7 days a week, for the next three weeks, then weekly for the next three weeks, then monthly for the next two months. 4. Results of the findings will be reviewed during the Monthly QAPI for the next two months for any recommendations.
Failure to Provide Consistent ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide consistent assistance with activities of daily living (ADLs), specifically showers or baths, for two residents who were dependent on staff for these services. One resident, admitted with diagnoses including anemia, gastroesophageal reflux disease, and anxiety, was scheduled to receive showers on specific days but did not have documentation indicating receipt or refusal of a shower or bed bath on one of the scheduled days. The Director of Nursing confirmed that the resident did not receive the required care on that date. Another resident, diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and anxiety disorder, was also dependent on staff for bathing. Documentation for this resident failed to show that showers or bed baths were provided or refused on multiple scheduled dates. The resident reported significant delays in receiving showers, citing understaffing as a contributing factor. The Director of Nursing confirmed the lack of consistent ADL assistance for this resident as well.
Plan Of Correction
1. Resident R1 has been discharged, and Resident R3 has received a shower as of 07/11/2025. 2. All residents have the potential to be affected by the alleged deficient practice. 15 residents on each unit have been interviewed regarding if they are receiving showers. 3. The Director of Nursing or Designee will in-service nursing staff on residents receiving showers at least twice weekly. The Director of Nursing or Designee will audit 10 residents' shower documentation 5 times weekly for 2 weeks and 3 times weekly for 2 weeks. 4. The Director of Nursing or Designee will report in monthly QAPI meetings the results of findings monthly for the next three months and randomly thereafter.
Failure to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet state-mandated minimum nurse aide staffing levels on specific evening and night shifts, as evidenced by a review of three weeks of nurse staffing schedules. On one evening shift, the number of nurse aides present did not meet the required ratio of one nurse aide per 11 residents, and on one night shift, the number of nurse aides did not meet the required ratio of one nurse aide per 15 residents. The census and required staffing numbers were documented, showing that the facility was understaffed on these particular shifts. Additionally, during interviews, a resident reported that nurse aides were responsible for more residents than the expected ratio, specifically noting that there were more residents per aide than the standard of 10-12 residents per nurse aide. This concern was communicated to the Nursing Home Administrator and the Director of Nursing during the exit interview, confirming the facility's failure to provide the required minimum nurse aide staffing on the identified shifts.
Plan Of Correction
1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for CNAs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of CNAs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate CNA coverage is scheduled to meet the minimum ratio of CNAs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. --- 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the minimum state ratio requirements for LPNs. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum ratio of LPNs are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate LPN coverage is scheduled to meet the minimum ratio of LPNs. 4. Facility recruitment/retention efforts include utilizing job postings on company's career website, Indeed, and LinkedIn. Company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met.
Failure to Meet Minimum LPN Staffing Requirement on Night Shift
Penalty
Summary
The facility failed to meet the state-required minimum staffing level of one licensed practical nurse (LPN) per 40 residents during the night shift on one of 21 reviewed days. Review of three weeks of nurse staffing schedules revealed that on 5/31/25, the facility did not have the required number of LPNs scheduled for the night shift, with a census of 124 residents and only 3.00 LPNs present instead of the required 3.10. During interviews, a resident reported that nurse aides were responsible for more residents than expected, indicating concerns about understaffing on the hallway. This deficiency was communicated to the Nursing Home Administrator and Director of Nursing during the exit interview.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state-mandated minimum of 3.2 hours of direct nursing care per resident per day on two out of twenty-one days reviewed. Specifically, staffing documents and nurse schedules showed that on 5/30/25 and 6/30/25, the provided hours of care were 3.15 and 3.14 PPD, respectively, which is below the required threshold. During interviews, a resident reported that nurse aides were responsible for more residents than expected, indicating issues with understaffing on the affected days. These findings were confirmed and communicated to the Nursing Home Administrator and Director of Nursing during the exit interview.
Plan Of Correction
P 5640 1. NHA or designee to educate staffing coordinator, DON, ADON, Unit Managers, and Nursing Supervisors on the state-required minimum staffing levels of 3.2 hours per patient day. 2. NHA or designee will conduct daily staffing meetings five times per week for the next two months to ensure the state minimum number of general nursing care hours are met. 3. NHA or designee will review staffing sheets once per week for the next two months to ensure adequate nursing coverage is scheduled to meet the minimum number of general nursing care hours. 4. Facility recruitment/retention efforts include utilizing job postings on the company's career website, Indeed, and LinkedIn. The company offers competitive wages, benefits within 30 days of employment, tuition reimbursement program, etc. Facility administration holds weekly retention events with activities and food and also has a quarterly employee recognition program. 5. Results of findings will be reviewed during Monthly QAPI for recommendations and until compliance is met. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for elopement or unsafe wandering. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was noted to rarely understand or be understood and had been assessed as at risk for elopement on multiple nursing admission evaluations. However, a wandering observation tool completed shortly before the incident indicated no history of wandering, and physician orders did not include interventions related to wandering or elopement risk. On the day of the incident, the resident was observed to be agitated, pacing the halls, and not at his baseline. Staff last saw the resident at the nurses' station, and shortly thereafter, the resident exited the facility through a side door. The stairwell alarm sounded but was silenced by an Environmental Services employee who did not properly check the stairwell or notify other staff. The resident was later found outside the building on the road, engaged in a physical altercation with a passerby. Staff intervened and escorted the resident back into the facility, where a small open area was found on his wrist. Interviews and documentation revealed that staff did not respond appropriately to the alarm, and the resident was able to leave the premises without supervision. The facility's investigation confirmed that the alarm was silenced without ensuring resident safety, and the resident's care plan and risk assessments were not updated in a timely manner to reflect his increased agitation and risk of elopement. This failure resulted in an immediate jeopardy situation for the resident.
Removal Plan
- Affected Resident was escorted back into the facility. Wanderguard was then placed on resident. Physician was notified. Body assessment completed and skin tear to resident's right wrist was discovered. Treatment applied. Resident was transferred to ED for evaluation and treatment. Resident returned with a positive UA but not being treated.
- Facility Wide Headcount was conducted by nursing department and all residents were accounted for.
- All Alarming Doors were audited to ensure functionality.
- After return from hospital immediate intervention of 1:1 was placed on resident and will be until adjustment to new medications is accomplished.
- Elopement Books were updated to include affected resident.
- Elopement Care plan and Orders were updated on all like residents.
- Whole House Education was completed on Elopement Policy, Responding to Alarms, Code [NAME] and inspecting any stairwells or any exit path by Nurse Educator/designee.
- Pharmacist Consultant reviewed medications, no medication changes.
- Psychiatric consultation was made, and medication adjustments were made. Resident was prescribed Lexapro.
- Newly admitted residents are screened for elopement risk upon admission, quarterly and as needed and care plans and assessments done accordingly. Any resident deemed at risk for elopement will have a Wanderguard placed.
- Facility Medical Director was notified of the Immediate Jeopardy and Abatement Plan.
- Daily Door Alarm Audits will continue by Maintenance Department or designee.
- Elopement Drills will be conducting weekly for two months, alternating shifts for two months.
- The Plan of Correction will be monitored at the Monthly QAPI Committee Meetings monthly for the next three months. Reviewing all door audits, elopement drills, new admissions for elopement assessments and reviewing the Elopement Policy as needed.
- Results will be submitted to QAPI.
Failure to Fully Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to fully investigate an incident involving a resident who was at risk for elopement and was found outside the facility without staff awareness. The resident, who had diagnoses including aphasia, heart failure, and a history of stroke, was rarely able to understand or be understood and had been identified as an elopement risk in the care plan. Despite this, there were no physician orders related to wandering or elopement risk, and documentation of the resident's wandering history was inconsistent. On the day of the incident, the resident was discovered outside the building on the road, interacting with a passerby, and was subsequently returned to the facility and sent to the emergency department for evaluation. The facility's investigation into the incident was incomplete, as it failed to gather a statement from the Environmental Services (EVS) employee who had silenced the alarm without ensuring no residents were present in the stairwell. The DON and Nursing Home Administrator later confirmed that the investigation did not include an interview with this key employee, and the surveyor's interview with the EVS employee contradicted the facility's initial findings. This lack of a thorough investigation prevented the facility from eliminating possible neglect in the incident.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides, as required by their policy. The Wexford Employee Handbook specifies that job descriptions form the basis for annual performance evaluations, which should be conducted at least once a year. However, a review of personnel records for Nurse Aides E26, E27, E30, E31, and E33 revealed that these evaluations were not completed based on their respective hire dates. This deficiency was confirmed during an interview with Regional Human Resource Employee E12, who acknowledged the facility's failure to conduct the required evaluations for these staff members.
Failure to Properly Label and Date Food
Penalty
Summary
The facility failed to adhere to its policy on food storage, which requires all foods to be wrapped or stored in covered containers, labeled, and dated to prevent cross-contamination. During an observation in the Main Kitchen's walk-in freezer, an open bag of chicken breast and an open package of ravioli were found unsealed, unlabeled, and undated. This was confirmed by the Assistant Food Service Supervisor, indicating a failure to properly store, label, and date opened food packages, which could lead to foodborne illness. Additionally, in the Third Floor Unit Pantry, several food items were found without proper labeling or dating. These included two containers of vanilla reduced sugar Med pass 2.0, a container of thickened lemon water, a container of Panera broccoli cheddar soup, and a box of cheddar biscuits in the freezer. An LPN confirmed these observations, further highlighting the facility's failure to properly label and date food in the nursing unit pantry, creating a potential risk for foodborne illness.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program, which is essential for focusing on outcomes. This deficiency was identified through a review of facility documentation and staff interviews, revealing that the facility did not implement a QAPI for 11 previously cited citations. These citations were identified during a Full Health Survey ending on October 27, 2023, and included issues such as resident rights, quality of care, and infection control, among others. Despite the facility's indication that audit results would be forwarded to the QAPI committee for further review and recommendation, the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies and failed to maintain an effective QAPI program.
Failure to Facilitate Voting and Provide Dignified Dining Experience
Penalty
Summary
The facility failed to uphold residents' rights to participate in the electoral process and to have a dignified dining experience. The review of facility documentation, observations, and interviews revealed that the facility did not offer residents the opportunity to vote in the May 2024 election. The resident council meeting minutes for six months did not include any information about the facility asking residents about voting. During a resident group meeting, residents indicated they were not offered the ability to vote in the November 2024 election, and four residents expressed a desire to vote. The Activity Director confirmed the lack of documentation showing that all residents were asked about voting and acknowledged the facility's failure to offer voting to all residents. Additionally, the facility did not provide a dignified dining experience for one resident, identified as Resident R43. The resident, who has diagnoses of high blood pressure, dementia, and muscle weakness, requires self-feeding assistance during meals. An observation noted that Resident R43 was being fed by a nurse aide who was standing beside her, which was confirmed by the nurse aide as not providing a dignified dining experience. This incident highlights the facility's failure to adhere to its policy of providing care in a safe and respectful manner.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess and determine the ability of three residents to self-administer medications, as required by their policies. Resident R17 was observed holding a medication cup full of medications without any nursing staff present, and there was no physician's order or care plan for self-administration of medications. Additionally, there was no Self-Administration of Medication assessment in Resident R17's clinical record. Similarly, Resident R50's physician orders and care plan did not include self-administration of medications, and there was no assessment for this ability. An incident occurred where Resident R50's granddaughter found an Ativan pill on the floor, raising concerns about whether the resident was receiving her medication properly. The nurse had left the medication with the resident while she was visiting with her granddaughter, contrary to the facility's policy. Resident R71 also did not have a physician's order or care plan for self-administration of medications, nor was there an assessment for this ability. A bottle of Biofreeze was left on Resident R71's bedside table, which was confirmed by a nurse. The Director of Nursing acknowledged that the facility failed to determine the ability to self-administer medications for these three residents. The facility's policies emphasize the importance of remaining with residents during medication administration to ensure safety and avoid adverse effects, which was not adhered to in these cases.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve resident concerns and grievances raised during resident council meetings over a six-month period from May 2024 to October 2024. The resident council minutes documented recurring issues such as staff not wearing name tags, agency aides being unfamiliar and rude to residents, shortages in linens and oxygen, and the lack of vending machines that accept credit cards. Despite these concerns being consistently reported, residents expressed during a group meeting that they did not receive answers or resolutions, only being told that the facility was working on their concerns. The Activity Director confirmed the absence of documentation for follow-up actions on these grievances, indicating a lack of response from the facility to the residents' issues.
Breach of Resident Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information, as observed during a tour and interviews. In three out of six resident rooms, signs were posted that disclosed specific medical instructions for the residents. For instance, one resident had a sign indicating the need to float heels when in bed, while another had instructions for food intake and assistance during meals. These signs were visible to anyone entering the rooms, thus compromising the residents' privacy. The Licensed Practical Nurse interviewed was unaware of who placed the signs, and the Director of Nursing confirmed the breach of confidentiality. Additionally, during a medication administration observation, a Registered Nurse left a medication cart unattended with the computer screen open, exposing confidential information to passersby. This occurred with one out of four medication carts, further indicating a lapse in maintaining the confidentiality of residents' medical records. The Director of Nursing acknowledged this failure, confirming the breach of privacy protocols as per the facility's HIPAA policy.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for six residents who were transferred from the facility. The facility's policy required that specific information, including the contact information of the practitioner responsible for the resident's care, resident representative information, advance directive information, care plan goals, and any special instructions or precautions for ongoing care, be provided to the receiving provider. However, the clinical records for these residents showed no documented evidence that such information was communicated. The residents involved in this deficiency had various medical conditions. One resident had high blood pressure, depression, and heart failure, while another had high blood pressure, hyponatremia, and unsteadiness on feet. Other residents had conditions such as peripheral vascular disease, dependence on supplemental oxygen, anemia, atrial fibrillation, neurogenic bladder, quadriplegia, depression, muscle weakness, and cancer. Despite these complex medical needs, the facility did not provide the necessary information to ensure a safe and effective transition of care when these residents were transferred to the hospital. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that there was no evidence of the required communication to the receiving health care institution or provider for the six residents with facility-initiated transfers. This lack of communication violated the facility's policy and the residents' rights as outlined in the applicable regulations.
Failure to Notify Residents of Bed-Hold Policy
Penalty
Summary
The facility failed to notify residents or their representatives about the bed-hold policy during hospital transfers, as required by their own policy and state regulations. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy, last reviewed on 10/24/24, mandates that residents or their representatives be informed in writing about the bed-hold policy within 24 hours of a hospital transfer, or the next business day if the transfer occurs on a weekend or holiday. However, this procedure was not followed for six residents who were transferred to the hospital. The clinical records of six residents, identified as R20, R36, R41, R42, R48, and R101, were reviewed, and it was found that none of them contained documented evidence that the residents or their representatives were provided with written information about the facility's bed-hold policy at the time of their hospital transfers. These residents had various medical conditions, including high blood pressure, depression, heart failure, hyponatremia, peripheral vascular disease, anemia, atrial fibrillation, neurogenic bladder, quadriplegia, muscle weakness, and cancer. Despite these conditions, the facility did not comply with its policy to inform them about the bed-hold arrangements. The Director of Nursing confirmed during an interview that the facility did not notify the residents or their representatives about the bed-hold policy for any of the six hospital transfers. This lack of notification is a violation of the residents' rights as outlined in 28 Pa. Code 201.29 (a) (c.3) (2). The failure to provide this information could potentially impact the residents' understanding of their rights and the financial implications of their hospital stays.
Failure to Provide ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for four residents, as required by their care plans. Resident R27, who has multiple diagnoses including diabetes and spinal stenosis, was dependent on staff for bathing. However, documentation showed missed showers on several dates in October 2024, and the resident reported not receiving a shower or beard trim as needed. Similarly, Resident R46, diagnosed with dementia and muscle weakness, required assistance for bathing but did not receive showers on multiple occasions in October 2024. Resident R48, with neurogenic bladder and quadriplegia, was also dependent on staff for bathing. The resident reported going weeks without a shower, despite being scheduled for showers twice a week, and documentation confirmed missed showers on several dates. Resident R87, who has high blood pressure, depression, and dementia, was admitted in September 2024 and had not received any showers since admission, as confirmed by the Director of Nursing. These failures were in violation of the facility's routine care policy and state regulations.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the interests and support the physical, mental, and psychosocial well-being of six residents. The facility's policy requires a resident-centered care approach, including a variety of activities such as social, indoor, outdoor, religious, creative, intellectual, educational, exercise, individualized, in-room, and community activities. However, during a resident group interview, several residents expressed dissatisfaction, stating that activities often do not meet their needs, and changes to the activity calendar occur without prior notice. Specific cases highlighted include Resident R1, who was admitted with high blood pressure, muscle weakness, and dependence on a wheelchair, and Resident R112, diagnosed with cerebral palsy and epilepsy. Both residents reported a lack of in-room activities despite their preferences and needs. The Activities Director confirmed that activities were not consistently offered to these residents, and there was no documentation to support that activities were provided during the specified months. This lack of adherence to the activity program policy resulted in a deficiency in meeting the residents' psychosocial, physical, and emotional needs.
Deficiencies in Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling urinary catheters, as evidenced by deficiencies found in the care of three residents. Resident R42 had a physician order for a Foley catheter that lacked essential details, such as the amount of fluid needed for balloon inflation and a diagnosis for the catheter. This omission was confirmed by a registered nurse during an interview. Resident R48's care was compromised by the improper placement of the catheter collection bag on the floor without a dignity cover, and the use of an open, undated irrigation syringe and bottle of sterile water. These issues were observed and confirmed by a registered nurse. Resident R107 was also found to have inadequate catheter care, as her urine collection bag lacked a dignity cover while she was resting in bed. This was confirmed by a registered nurse during an interview. The facility's failure to adhere to its catheter care policy, which mandates twice-daily care and proper placement of collection bags, resulted in these deficiencies. The report cites violations of several Pennsylvania codes related to the responsibility of the licensee, resident rights, resident care policies, and nursing services.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that refrigerated medications were stored at proper temperatures in one of the four medication rooms, specifically the Third Floor Medication Room. The temperature logs for the medication refrigerator were found to be incomplete for several dates, and a vial of Tuberculin was not labeled with the date it was opened. Additionally, the facility did not properly label open medications with a date on one of the medication carts and in the medication refrigerator. The facility also failed to secure medications and treatment carts properly. On the C1 nursing unit and the Second Floor D Unit, treatment carts were observed to be unlocked. Furthermore, the Second Floor D Wing Medication Room was found propped open with a garbage can, allowing unauthorized access. Medications and biologicals were not stored securely, as evidenced by the presence of a white jar of nystatin/Silvadene cream on a resident's nightstand and multiple used tubes of treatments on medication carts. The facility did not adhere to its policy of storing medications and biologicals safely and securely. Medications were found improperly stored on medication carts, with some lacking resident information. The Director of Nursing confirmed these deficiencies, acknowledging the failure to secure medication rooms and carts, and to prevent cross-contamination of treatments. These lapses in protocol were observed across multiple units and involved several staff members, including RNs and LPNs.
Deficiencies in Food Storage, Catheter Care, and Medication Room Sanitation
Penalty
Summary
The facility failed to properly monitor and maintain the personal refrigerators of four residents, leading to improper storage of food items. Observations revealed that residents had personal refrigerators with food items that were not dated or labeled, and there was no evidence of daily temperature monitoring. This lack of monitoring was confirmed by staff interviews, indicating a failure to adhere to the facility's policy on safe food storage. Additionally, the facility did not maintain proper infection control practices for residents with indwelling urinary catheters. Two residents were observed with catheter collection bags placed on the floor, which is against the facility's policy. Staff interviews confirmed these observations, highlighting a failure to ensure that catheter care was conducted in a manner that prevents infection. The facility also failed to provide a safe and sanitary environment in one of its medication rooms. Observations in the Third Floor Medication Room revealed the presence of ice packs without proper labeling or identification, which could lead to cross-contamination. Staff interviews confirmed the lack of awareness and proper management of these items, indicating a breach in maintaining a sanitary environment.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,361 citations issued within 25 miles in the last 12 months — including the 28 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wexford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vincentian Home | 2.3 mi | ★★★★★ | 4 | 0 |
| Highland Hills Post Acute | 3 mi | ★★★★★ | 35 | 1 |
| John J Kane Regional Center-ro | 3.1 mi | ★★★★★ | 9 | 0 |
| Harmony Hills Healthcare And Rehabilitation Center | 3.5 mi | ★★★★★ | 1 | 0 |
| St Barnabas Nursing Home | 6.3 mi | ★★★★★ | 15 | 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.