Pittsburgh Skilled Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 550 South Negley Avenue, Pittsburgh, Pennsylvania 15232
- CMS Provider Number
- 395068
- Inspections on file
- 21
- Latest survey
- April 12, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pittsburgh Skilled Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
The facility failed to label and date food products in the main kitchen and resident refrigerator, and did not maintain sanitary conditions in the dish room. Observations included unlabeled and undated food items, and unsanitary conditions such as debris-covered surfaces. Interviews with staff confirmed these deficiencies.
The facility failed to maintain a clean and homelike environment on the 1st and 3rd floors. Observations included crumbling walls, exposed wiring, dirty floors, and damaged furniture. The Nursing Home Administrator and Environmental Services Director confirmed these deficiencies.
The facility failed to provide an ongoing program of activities to meet resident needs, as residents expressed dissatisfaction with the current activities and desired more outside and varied in-facility activities. Observations and staff interviews confirmed that the activities listed on the calendar were not conducted, and the Nursing Home Administrator acknowledged the deficiency.
The facility failed to ensure that the Activities Department was directed by a qualified professional. A review of the Director of Recreation Services' personnel file revealed that the individual did not have documentation of completing a state-approved program to qualify for overseeing the Activity Program. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to timely assess the nutritional status for four residents, as required by their policy. The clinical records for these residents did not contain documentation of nutritional assessments addressing their specific dietary needs, despite being captured in their MDS assessments. This deficiency was confirmed by the Nursing Home Administrator and Registered Dietitian.
The facility failed to provide consistent and complete communication with the dialysis center for three residents, as required by their policy. The Hemodialysis Communication Forms were often incomplete, which was confirmed by staff interviews.
The facility failed to complete annual performance evaluations for five nurse aides hired on the same date. Personnel records showed that these employees did not have up-to-date evaluations, and the Nursing Home Administrator confirmed this deficiency.
The facility failed to implement an infection control program for four months and did not properly disinfect reusable equipment between residents. An LPN was observed using an alcohol prep pad instead of the approved disinfectant for cleaning a shared glucometer, as confirmed by the Director of Nursing.
The facility failed to offer all residents the opportunity to vote for the May and November 2023 elections. Two residents were unaware of the voting opportunities and expressed interest in voting. The Nursing Home Administrator confirmed the lack of documentation showing that all residents were offered the opportunity to vote.
The facility failed to prevent neglect when a Nurse Aide administered a personal supply of melatonin to a resident without a physician's order. The incident was confirmed through documentation and an interview with the NHA, where the NA admitted to the action.
The facility failed to obtain physician orders for two residents transferred to an acute care facility. One resident with diabetes and other conditions was sent to the hospital for low blood glucose, and another with osteomyelitis and heart failure was sent to the emergency room for lethargy. The clinical records for both residents lacked the required physician orders.
The facility failed to provide a notice of bed hold policy for two residents transferred to an acute care facility. Both residents were sent to the hospital without receiving the required written Bed Hold Policy Notice & Authorization form, as confirmed by the Nursing Home Administrator. This is a violation of resident rights and staff development regulations.
The facility failed to ensure accurate resident assessments for a hospice resident. A resident with stroke, hemiplegia, and metastatic prostate cancer had a physician order and care plan for hospice care, but the MDS did not indicate hospice services as required. This was confirmed by the DON.
The facility failed to provide necessary ADL assistance for two residents. One resident with heart failure and hemiplegia was repeatedly observed in bed without receiving hygiene assistance, while another resident with dementia and blindness was found in an unclean state with an unsanitary room. Staff confirmed the deficiencies, and the Director of Nursing acknowledged the failure to meet care plan requirements.
The facility failed to follow physician's orders for monitoring and reporting decreased blood pressures for a resident and did not provide timely dental care for two residents. These deficiencies were confirmed through a review of facility policies, clinical records, and staff interviews.
The facility failed to ensure a resident with multiple wounds was monitored, assessed, and received necessary preventive measures, as physician orders and treatment records lacked specific interventions for pressure ulcer care. This was confirmed by an RN during an interview.
The facility failed to ensure appropriate treatment and services for two residents receiving enteral feedings, lacking necessary physician orders for aspiration precautions and not following orders for medication administration through feeding tubes. This was confirmed through staff interviews and clinical record reviews.
The facility failed to provide appropriate respiratory care for three residents, as evidenced by undated nasal cannula tubing, empty humidifiers, and visibly soiled oxygen concentrator filters. Staff confirmed these observations, and the Director of Nursing acknowledged the deficiencies.
A facility failed to provide culturally appropriate, trauma-informed care for a resident with PTSD, depression, and anxiety disorder. The resident's clinical record lacked documentation addressing PTSD care plans for psychiatric or social services, despite the care plans indicating risks for behavior symptoms and mood changes. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to accurately label and date open medications for a medication cart and a medication room. Observations revealed undated medications and inappropriate storage of a beverage in the medication refrigerator. These findings were confirmed by staff and the Director of Nursing.
The facility failed to conduct Quality Assessment and Assurance and Performance Improvement (QAPI) meetings at least quarterly for one of the required quarterly meetings. The QA Committee, which includes the administrator, DON, Medical Director, and Infection Preventionist, did not meet between April 2024 and June 2024, as confirmed by the Nursing Home Administrator.
The facility failed to implement an antibiotic stewardship program for four months. The policy required antibiotic use protocols and monitoring systems, but a review of Infection Control surveillance revealed missing documentation for the specified months. This was confirmed by the DON.
The facility failed to provide adequate dining areas for two out of four nursing units. Observations revealed no dining room for breakfast on the 3rd floor nursing unit and insufficient seating and tables in the 3rd floor secured unit's dining room. The NHA confirmed these deficiencies.
Failure to Label and Date Food Products and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to properly label and date food products in the walk-in cooler in the main kitchen and resident refrigerator, and failed to maintain sanitary conditions in the dish room. Observations included unlabeled and undated bags of coleslaw mix, packages of American cheese, grilled cheese, a bag of coconut, and a container of dinner rolls in the main kitchen. Additionally, an industrial-size fan was covered with brown debris, and the wall beside the dirty side of the dishwasher was covered with food debris and a black-like substance. In the first-floor resident refrigerator, there were items such as pizza, applesauce, coleslaw, and cake that were either undated or lacked resident names. Interviews with the Dietary Manager and Nursing Home Administrator confirmed these deficiencies, which created the potential for foodborne illness.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two of its three floors, specifically the 1st and 3rd floors. During a tour of the 1 North Nursing Unit, several deficiencies were observed, including crumbling wall surfaces, white chips and gouges in walls, exposed wiring from a phone jack, and a large hole in the wall with broken plaster and exposed brick. Additionally, the main elevator door grates were full of debris and grime, and the shower room was missing a door handle. Several resident rooms had floors covered in grime and debris, and the Environmental Services Director confirmed these findings. The Nursing Home Administrator also confirmed the facility's failure to maintain a clean and homelike environment during interviews conducted on different dates. On the 3rd floor secured unit, multiple issues were observed, including marks on closet doors, holes in bathroom doors, chipped walls, exposed sockets, dirty air units, and ripped furniture. The dining room lacked seating and had few dining tables available for residents during meals. The Nursing Home Administrator confirmed the facility's failure to maintain a clean and homelike environment for both the 1st and 3rd floors during interviews. These observations and confirmations indicate a significant lapse in housekeeping and maintenance services necessary to provide a safe, clean, and comfortable environment for the residents.
Failure to Provide Ongoing Program of Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs of residents, which are designed and based on their interests and support their physical, mental, and psychosocial well-being. During a group meeting, residents expressed dissatisfaction with the current activities, stating that they wanted outside activities such as shopping trips, restaurant visits, and park outings. They also desired different in-facility activities, including various games and outdoor activities like cookouts and picnics. The review of the facility's activity calendar confirmed the absence of these requested activities, and residents indicated that they had not participated in any outside activities for over a year. Observations on the secured unit over several days revealed that none of the activities listed on the April calendar were conducted. Staff interviews indicated that only three activities were done with residents: playing Elvis music, an Easter-themed activity, and an art activity. However, these activities were not listed on the activity calendar, nor was there any clarification on what activities were offered to residents in the secured unit. The Nursing Home Administrator confirmed that the facility failed to provide an ongoing program of activities to meet resident needs, as required by regulations, thereby not supporting the physical, mental, and psychosocial well-being of each resident and failing to encourage both independence and community interaction.
Unqualified Director of Recreation Services
Penalty
Summary
The facility failed to ensure that the Activities Department was directed by a qualified professional. A review of the Director of Recreation Services' personnel file revealed that the individual, identified as Employee E20, did not have documentation of completing a state-approved program to qualify for overseeing the Activity Program. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the Director of Recreational Services had not completed the necessary state-approved program.
Failure to Timely Assess Nutritional Status for Residents
Penalty
Summary
The facility failed to timely assess the nutritional status for four of five residents reviewed. According to the facility's policy, residents are to be assessed upon admission and routinely thereafter by a dietitian or a non-dietitian designee. However, the clinical records for Residents R1, R24, R25, and R82 did not contain documentation of nutritional assessments addressing their nutritional status and specific dietary needs as captured by their Minimum Data Set (MDS) assessments. For instance, Resident R1, who has diagnoses of epilepsy, breast cancer, and depression, had no nutritional assessment documentation despite being on a therapeutic diet. Similarly, Resident R24, with high blood pressure, diabetes mellitus, and cerebral infarction, lacked documentation for her nutritional status, feeding tube, and therapeutic diet. Resident R25, diagnosed with multiple sclerosis, dysphagia, and failure to thrive, also had no documentation for her mechanically altered diet. Lastly, Resident R82, with Alzheimer's disease, dysphagia, and aphasia, had no documentation for her feeding tube and mechanically altered diet. During an interview, the Nursing Home Administrator and Registered Dietitian confirmed the facility's failure to timely assess the nutritional status for these residents. This deficiency was found to be in violation of 28 Pa. Code: 201.18(b)(1)(e)(1) Management and 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. The lack of timely nutritional assessments could potentially impact the health and well-being of the residents, as their specific dietary needs were not adequately documented or addressed in their clinical records.
Incomplete Hemodialysis Communication Forms
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents (R5, R8, and R11). The facility's policy required communication with the dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis treatments. However, the review of clinical records indicated that the Hemodialysis Communication Forms for these residents were often incomplete. For Resident R5, 24 out of 25 forms were incomplete, for Resident R8, all 11 forms were incomplete, and for Resident R11, 13 out of 29 forms were incomplete. These forms were supposed to document the dialysis facility's report to the facility and the facility's licensed nurse's post-hemodialysis monitoring. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the forms were not completed as required. The residents involved had significant medical conditions, including hypertension, renal failure, heart failure, and diabetes mellitus, which necessitated regular dialysis treatments. The failure to complete these forms as required indicates a lack of proper communication and documentation, which is essential for monitoring the residents' conditions and ensuring their safety during and after dialysis treatments.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for five nurse aides (NA Employee E2, E3, E4, E5, and E6). Personnel records revealed that these employees, all hired on 12/10/22, did not have up-to-date performance evaluations. Specifically, NA Employee E2 had no performance evaluations on file, while NA Employees E3 and E4 had their last evaluations completed between 5/2/19 and 5/1/20. NA Employees E5 and E6 had their last evaluations completed between 2/8/20 and 2/7/21. During an interview, the Nursing Home Administrator confirmed the lack of current performance appraisals for these employees.
Failure to Implement Infection Control Program and Properly Disinfect Equipment
Penalty
Summary
The facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for four of ten months (October 2023, January 2024, February 2024, and March 2024). This was confirmed by the Director of Nursing during an interview. The facility's Infection Control documentation for the previous ten months did not reveal surveillance for tracking infections for residents during these months, indicating a lapse in the infection control program's implementation. Additionally, the facility failed to properly disinfect reusable equipment between residents. During an observation, an LPN was seen cleaning a shared glucometer machine with an alcohol prep pad instead of the approved disinfectant as per facility policy and manufacturer guidelines. The LPN confirmed that she was instructed by the facility to use an alcohol swab to clean the glucometer before and after each resident, which is not in compliance with the manufacturer's instructions. This failure was also confirmed by the Director of Nursing.
Failure to Offer Voting Opportunity to Residents
Penalty
Summary
The facility failed to offer all residents the opportunity to vote for the May and November 2023 elections. This deficiency was identified based on resident and staff interviews, as well as a review of facility documentation. The review of Resident Council minutes for six months (March, February, January 2024, and December, November, and October 2023) did not include information about how the facility asked residents if they were interested in voting. During a resident group meeting, two residents stated they were unaware of the voting opportunities for the May and November 2023 elections and expressed interest in voting. The Nursing Home Administrator confirmed that there was no documentation showing that all residents were offered the opportunity to vote for these elections.
Unlicensed Employee Administers Non-Ordered Medication
Penalty
Summary
The facility failed to prevent neglect when an unlicensed employee administered a non-ordered medication to a resident. Specifically, a Nurse Aide (NA) provided a personal supply of melatonin to Resident R62 without a physician's order. The incident was confirmed through a review of facility documentation and an interview with the Nursing Home Administrator (NHA). The NA admitted to administering the medication, which constitutes a violation of state regulations that define the scope of practice for Nurse Aides and the requirement for proper medication administration protocols.
Failure to Obtain Physician Orders for Resident Transfers
Penalty
Summary
The facility failed to obtain a physician order for residents transferred to an acute care facility. This deficiency was identified for two of three residents reviewed. Resident R10, who had diagnoses including diabetes, high blood pressure, and depression, was sent to the hospital for low blood glucose and decreased responsiveness on 3/29/24. However, the clinical record for Resident R10 did not include a physician order for this transfer. Similarly, Resident R126, who had diagnoses including osteomyelitis of the right ankle and foot, peripheral vascular disease, and heart failure, was sent to the emergency room due to lethargy on 1/2/24. The clinical record for Resident R126 also lacked a physician order for this transfer. The Director of Nursing confirmed the facility's failure to obtain the necessary physician orders for these transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a notice of bed hold policy for residents transferred to an acute care facility. This deficiency was identified through clinical record reviews and staff interviews. Specifically, two residents, Resident R10 and Resident R126, were transferred to a hospital without receiving the required written Bed Hold Policy Notice & Authorization form. Resident R10, who had diagnoses including diabetes, high blood pressure, and depression, was sent to the hospital for low blood glucose and decreased responsiveness. Similarly, Resident R126, with diagnoses including osteomyelitis, peripheral vascular disease, and heart failure, was sent to the emergency room due to lethargy. In both cases, the clinical records did not include the necessary bed hold policy notice forms as mandated by the facility's policy dated 11/1/23. Interviews with the Nursing Home Administrator confirmed the absence of the required notices for both residents. The administrator acknowledged that the facility failed to provide the bed hold policy notice for two of the three residents reviewed. This failure is a violation of resident rights and staff development regulations as outlined in 28 PA Code: 201.29(j), 201.20(a)(b)(c)(d), 201.14(a), and 201.18(b)(1).
Failure to Accurately Document Hospice Services in MDS
Penalty
Summary
The facility failed to ensure that resident assessments were accurate for one of three hospice residents. Specifically, Resident R30, who was admitted with diagnoses of stroke, hemiplegia, and metastatic prostate cancer, had a physician order for hospice care dated 3/4/23 and a care plan indicating hospice care dated 1/25/24. However, the Minimum Data Set (MDS) for Resident R30, dated [DATE], did not indicate hospice services in Section O as required. This deficiency was confirmed by the Director of Nursing during an interview on 4/12/24.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance for two residents, R26 and R45. Resident R26, diagnosed with heart failure, high blood pressure, and hemiplegia, was observed in bed multiple times without having received assistance for daily hygiene and grooming as per their care plan. Despite the resident's request to be washed and out of bed early in the morning, staff interviews confirmed that the resident remained in bed due to challenges in staff assignments. The resident's care plan indicated the need for substantial assistance with transfers and hygiene, which was not provided consistently, as observed on multiple occasions. Resident R45, diagnosed with Non-Alzheimer's Dementia, left eye blindness, and high blood pressure, was found in an unclean state with dried brown substances on their shoes and leg. The resident's room was also observed to be in an unsanitary condition with an unmade bed and gnats present. Staff interviews confirmed the observations, and the Director of Nursing acknowledged the failure to provide adequate ADL assistance. The care plan for Resident R45 indicated the need for assistance with daily hygiene and grooming, which was not met, leading to the resident's unkempt appearance and unsanitary living conditions.
Failure to Follow Physician's Orders and Provide Timely Dental Care
Penalty
Summary
The facility failed to follow physician's orders and notify the physician of decreased blood pressures for Resident R11. Despite having a physician order to monitor vital signs every shift and notify the provider of a systolic blood pressure less than 95 mmHg, there were 14 instances in March 2024 where Resident R11's systolic blood pressure was less than 95 mmHg or not documented. Out of these, 11 instances were not reported to the physician as required. This failure was confirmed by the Registered Nurse Clinical Lead during an interview on April 11, 2024. Additionally, the facility failed to provide timely dental care for Resident R11 and Resident R87. Resident R11 experienced right upper gum pain and had a broken tooth that required extraction. Despite multiple physician orders and consultations with dental services, there were delays in addressing her dental needs, including a flagged Physician Clearance for Dental Treatment form that remained unaddressed from March 28, 2024, to April 11, 2024. Similarly, Resident R87 had a dental abscess and required extractions, but there were no additional measures implemented between the dentist's recommendation on March 12, 2024, and the physician's orders for antibiotic treatment on March 21, 2024. The Director of Nursing confirmed that the facility failed to follow physician's orders and notify the physician of decreased blood pressures for Resident R11 and failed to provide timely care and services for the dental needs of both Resident R11 and Resident R87. These deficiencies were identified through a review of facility policies, clinical records, and staff interviews, highlighting significant lapses in the facility's adherence to medical and dental care protocols.
Failure to Prevent and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to ensure that Resident R23 was monitored, assessed, and received necessary services to prevent pressure ulcers from developing or worsening. Resident R23, who was admitted with diagnoses including neurogenic bladder, diabetes, and anxiety disorder, had multiple wounds documented, including stage 3 and 4 ulcers and unstageable wounds on various parts of the body. The physician orders did not include preventive measures such as a specific type of mattress, off-loading on a pillow, or specialized boots. Additionally, the Medication Administration Record/Treatment Administration Record for March and April 2024 did not include preventive measures for the seven wounds. This deficiency was confirmed by a Registered Nurse during an interview.
Failure to Ensure Appropriate Enteral Feeding Care
Penalty
Summary
The facility failed to ensure that residents receiving enteral feedings received appropriate treatment and services to prevent potential complications. For Resident R25, the facility did not have the necessary physician orders for aspiration precautions, including elevating the head-of-bed, checking gastric residual volume, and providing care for the feeding tube. This deficiency was confirmed during an interview with the Registered Nurse Clinical Lead, who acknowledged the lack of appropriate physician orders for nursing care regarding enteral feedings for Resident R25. Similarly, Resident R83 also did not have the required physician orders for aspiration precautions and other necessary care related to the feeding tube. The Registered Nurse Clinical Lead confirmed this deficiency as well. Additionally, there was a failure to follow physician's orders for administering medications through the enteral feeding tube for Resident R83. Instead, medications were being given orally, crushed in applesauce, which was confirmed by both the Licensed Practical Nurse and Resident R83 during interviews. The Nursing Home Administrator confirmed that the facility failed to follow physician's orders for one of the residents receiving medications through an enteral feeding tube. The deficiencies were identified through a review of facility policies, clinical records, and staff interviews, highlighting the facility's failure to provide appropriate treatment and services for residents with feeding tubes, thereby increasing the risk of potential complications.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by observations, staff interviews, and clinical record reviews. Resident R9, who had diagnoses of high blood pressure, diabetes, and asthma, was observed with her nasal cannula tubing on the floor, an empty humidifier dated 3/30/34, and a visibly soiled oxygen concentrator filter. The nasal cannula tubing was not dated, and the resident reported smelling dust when using the oxygen. RN Employee E14 confirmed these observations. Resident R13, diagnosed with COPD, stroke, and pain, was observed with a soiled oxygen concentrator filter, which was confirmed by NA Employee E16. Resident R45, diagnosed with Non-Alzheimer's Dementia, left eye blindness, and high blood pressure, was observed with an outdated humidifier and oxygen cannula on the floor, despite having no physician order for oxygen use. RN Employee E7 confirmed these observations. The Director of Nursing confirmed the lack of a physician order for Resident R45's oxygen and acknowledged the facility's failure to provide appropriate respiratory care for the three residents. The facility policy required the replacement of disposable oxygen setups every seven days, dating and storing cannulas in treatment bags when not in use, and labeling humidifiers with the date. These requirements were not met, leading to the deficiencies observed during the survey.
Failure to Provide Culturally Appropriate, Trauma-Informed Care
Penalty
Summary
The facility failed to provide culturally appropriate, trauma-informed care in accordance with professional standards of practice for a resident with a history of PTSD, depression, and anxiety disorder. The clinical record for the resident, who was admitted with diagnoses including diabetes and major depression disorder, lacked documentation addressing PTSD care plans for psychiatric or social services. The care plans indicated risks for behavior symptoms and changes in mood related to depression, PTSD, and anxiety disorder, but there was no follow-up or implementation of these plans. This deficiency was confirmed by the Nursing Home Administrator during an interview.
Failure to Label and Date Open Medications
Penalty
Summary
The facility failed to accurately label and date open medications for one of four sampled medication carts (MedBridge Med Cart) and one of four sampled medication rooms (1 South Med Room). During an observation of the MedBridge medication cart, it was found that several medications, including Trelegy inhaler, Lantus pen, Stiolto inhaler, and Lispro pen, were not dated upon opening. This was confirmed by an LPN. Additionally, an observation of the One South Medication Room revealed an opened and undated Tuberculin vial, an opened and undated Trulicity pen, and a can of Red Bull sugar-free beverage stored inappropriately in the medication refrigerator. This was confirmed by an RN. The Director of Nursing confirmed that the facility failed to accurately label and date open medications for the MedBridge Med Cart and the One South Medication Room. The facility's policy on Storage and Expiration Dating of Medications, Biologicals, dated 11/1/23, requires that opened medications be dated and discarded according to manufacturer guidelines. The policy also prohibits the storage of food in areas where medications and biologicals are stored. The failure to adhere to these policies was confirmed through staff interviews and observations.
Failure to Conduct Quarterly QAPI Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance and Performance Improvement (QAPI) meetings at least quarterly for one of the four required quarterly meetings from April 2024 through June 2024. The facility's policy, dated 11/9/23, mandates that the QA Committee, which includes the administrator, Director of Nursing, Medical Director, and Infection Preventionist, meets at least quarterly to review data and input from various stakeholders. However, a review of the Quality Assurance and Performance Improvement sign-in sheets and attendance records from May 2023 through March 2024 revealed no documentation for the required meeting between April 2024 and June 2024. This deficiency was confirmed by the Nursing Home Administrator during an interview on 4/11/24 at 10:10 a.m.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for four of ten months (October 2023, January 2024, February 2024, and March 2024). The facility's policy on Antibiotic Stewardship, dated November 1, 2023, required the implementation of an Antibiotic Stewardship Program that includes antibiotic use protocols and systems for monitoring antibiotic use. However, a review of the facility's Infection Control surveillance from June 2023 through March 2024 revealed a lack of documentation indicating that antibiotic monitoring was completed for the specified months. This deficiency was confirmed by the Director of Nursing during an interview on April 10, 2024, at 12:45 p.m.
Inadequate Dining Areas in Two Nursing Units
Penalty
Summary
The facility failed to provide adequate dining areas for two out of four nursing units, specifically the 3rd floor secured unit and the 3rd floor pavilion. Observations on the 3rd floor nursing unit revealed that no dining room was available for residents to eat their breakfast, and the activity room was locked, limiting resident access to times when activity staff were present, which did not include breakfast or dinner on most days. Additionally, the 3rd floor secured unit lacked sufficient seating and tables in the dining room. The Nursing Home Administrator confirmed these deficiencies, acknowledging the absence of a dining area in the 3rd floor pavilion and inadequate furniture in the 3rd floor secured unit's dining area.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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