Below average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Health & Rehab Center during CMS and state inspections, most recent first.
Food Items Left Unlabeled and Undated: The facility failed to properly label and date food products in the main kitchen's standing cooler rack and dry storage area. A Dietary Supervisor confirmed that three chef's salads, seven sandwiches, and an opened container of chicken gravy/bouillon were not labeled or dated, even though the salads were from the prior evening's dinner meal and should have been labeled and dated.
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
Failure to Hold and Notify Residents of Care Plan Conferences: The facility did not conduct required care plan conferences or ensure advance notification to the resident or resident representative for three residents. One resident with DM, HTN, and CAD, one resident with HTN, HF, and DM, and one resident with insomnia, anxiety, and ALS all had missing quarterly care conferences, and one resident stated he had only attended one conference since admission and had not been invited to others.
The facility failed to document that necessary resident information was sent with three hospital transfers, including care plan goals, advance directive information, ongoing care instructions, and resident representative information. It also failed to notify two residents or their representatives of the bed-hold policy and failed to notify the State LTC Ombudsman for three hospital transfers. The DON and Regional Director of Clinical Services confirmed the missing documentation and notifications.
Failure to Follow Ordered Treatments and Weight Monitoring: The facility did not ensure ordered care was carried out for several residents. One resident with Parkinson’s disease and anxiety sustained a skin tear to the hand during an agitated episode, but there was no physician order for the wound treatment that was provided. Two residents had ordered weekly weights that were not obtained as scheduled, and the records did not explain why. Another resident with HTN, depression, and DM had body blisters, but the wound company’s recommendation for skin prep was not entered as an order, and there was no documented evidence that the practitioner was contacted about the missed recommendation.
Inaccurate bedrail care plans and missing ongoing assessments were identified for three residents. Two residents had bilateral enabler bars observed on their beds, but their last enabler-restraint assessments were outdated, and one resident had bilateral enabler bars with no order or ongoing assessment in the record. The residents had diagnoses including HTN, Parkinson's disease, depression, hyperlipidemia, and hemiplegia, and the facility policy required risk evaluation for bed rail use.
The facility failed to complete annual performance evaluations for three nurse aides. Personnel record review showed each aide was hired on 7/1/23, and none of the three files contained the required yearly performance evaluation. The NHA confirmed the missing evaluations during interview.
The facility failed to provide evidence that MRRs were reviewed by the attending physician for three residents. One resident with HTN, Parkinson's disease, and anxiety had an MRR recommending a GDR of quetiapine, but the record only showed a CRNP note without physician response. Another resident with DM, MS, and depression had multiple MRRs citing missing PRN details, stop dates, and pain reassessment, and a third resident with HTN, anxiety, and arthritis had an MRR noting multiple antidepressants and recommending evaluation for a single agent; in both cases, staff confirmed there was no evidence the attending physician reviewed the MRRs.
Medication carts and a resident room had multiple storage and labeling deficiencies. An RN left a medication cart unlocked and unattended, a narcotic drawer on another cart was unsecured, and a third cart contained unopened insulin that was not refrigerated before opening plus multiple insulin pens, inhalers, and eye drops with no open date noted. Two bedside eye drop bottles in a resident room were also unlabeled.
The facility failed to maintain infection control practices during meal assistance, medication administration, and contact isolation. An aide handled a resident’s food with bare hands, an RN handled medications onto an ungloved hand before placing them in a cup, and an LPN entered a resident’s contact isolation room without the required PPE. The facility also lacked documented infection surveillance and tracking for several months, and the DON and NHA confirmed the missing records.
Failure to Implement Antibiotic Stewardship Program: The facility failed to implement an antibiotic stewardship program for eight of 12 months. Review of the infection control records showed no documented antibiotic monitoring or appropriate use tracking during that period. The DON stated she had not been overseeing infection control until May and that if the binders did not contain the information, then the facility did not have it. A Regional Director later found an antibiotic stewardship binder with lab reports and prior survey information, but no facility antibiotic tracking, and the NHA and DON confirmed the lapse.
Incomplete pneumococcal vaccine documentation was identified for three residents. The facility policy required admission review of prior immunizations and documentation in the EHR, but records for residents with DM, HTN, CAD, MS, and COPD showed pneumococcal status coded as not up to date and not offered, while the immunization entries listed consent not obtained or status to be determined, with education not checked for two residents and no documented evidence that vaccine status was discussed with the attending physician for one resident. The DON acknowledged the facility failed to provide accurate and timely documentation related to the pneumonia vaccine.
Failure to provide requested enabler bars: A resident with HF, HTN, and renal insufficiency was assessed by OT as needing assist bars for bed mobility, but the resident remained without enabler bars despite stating she had requested them since admission. Nursing and OT staff confirmed the bars were not in place, and OT indicated the observation/order process likely was never entered.
Failure to support resident family group meetings: A facility handbook stated residents have the right to organize and participate in resident/family groups, but family council minutes did not show that families chose to stop meetings or that the facility formally told families the meetings would end. Family representatives said the meetings had previously occurred monthly or quarterly but were no longer being held, and the NHA and Activities Director confirmed the prior administration stopped them and that there was no formal communication to families.
Failure to Provide SNF-ABN for Medicare Non-Covered Services: The facility failed to provide a SNF-ABN to a resident when Medicare Part A coverage ended and the payor source changed to private pay. Records showed the resident had diagnoses including an artificial hip joint, cellulitis, and dysphagia, and staff documented only a NOMNC review with the resident’s wife; the chart did not show that the resident or family received the SNF-ABN for services no longer covered under Medicare Part A.
Failure to protect resident medical information on the 2B med cart. During a med pass, an RN left the cart unattended in the hallway with the computer screen open and displaying identifiable resident information, and later confirmed that anyone passing by could see residents' personal and confidential data.
A resident’s room and the second-floor hallway had missing baseboards, including under the window in the room and periodically along both sides of the hall. During interview, an Mnt. employee stated the machine must be hitting them and that they had been taken off.
Failure to Assess Bolsters as Possible Restraints: The facility failed to identify a bolster as a possible physical restraint and did not assess whether bolster use was a restraint for two residents. One resident had Parkinson’s disease, anxiety, and limited transfer ability, and the other had hemiplegia, anxiety, depression, and a history of falls related to decreased safety awareness, altered cognition, and impulsivity. Both residents were observed in bed with mattresses that had bilateral raised edges, and their records did not show assessments or ongoing evaluations for bolster use.
Missing FBI Background Check for Agency Nurse Aide: The facility failed to complete an updated FBI background check for an agency NA before allowing the aide to work on the nursing unit. The aide had lived outside PA within the past two years, but the personnel file only contained an older FBI check and no updated check before the aide worked two shifts. The facility policy required background checks for all employees in accordance with State law.
Failure to Report Allegation of Verbal Abuse: A resident with HTN, anxiety disorder, and hyperlipidemia reported that a staff member yelled at her during resident council. Facility records showed a nurse aide was disciplined and retrained on communication, but the allegation was not included in the abuse reports submitted to the State. The DON confirmed the required report was not filed.
A resident’s MDS was inaccurate because suctioning was not checked in Section O0110 D1 even though the resident had a tracheostomy and suction trach care was ordered and documented in the MAR. The resident’s care plan called for suction trach and oral care every shift and as needed, and the RNAC confirmed the omission on the MDS.
Baseline Care Plan Missing Enteral Feeding Instructions: A resident admitted with pneumonitis, stroke, and hemiplegia had an order for Isosource 1.5 via enteral feeding, but the admission observation and baseline care plan failed to identify the gastric/enteral tube and did not include instructions for gastrostomy tube or enteral feeding care. The RN consultant confirmed the baseline care plan was not developed and implemented to include the needed instructions for effective, person-centered care.
Failure to provide proper pressure injury care for two residents. One resident with a coccyx pressure injury had an ordered daily dressing change missed, and the MAR lacked a clear reason for the omission. Another resident had a documented heel pressure injury, but the record lacked measurements, staging, wound description, preventive measures, and treatment. The DON confirmed the ordered care was not followed, and an RN confirmed the second resident did not receive proper pressure injury treatment.
A resident with a G-tube and diagnoses including stroke and pneumonitis had tube feeding ordered at 60 ml/hr, and the care plan identified increased nutritional risk related to gastric tube use. Staff observed the tube feeding bag hanging with an additional water bag, and both bags were not labeled with the resident’s name, formula, rate, date, or time hung; an RN and an LPN confirmed the unlabeled setup.
Failure to Include PICC Line Care and Management: A resident with pneumonitis, stroke, and hemiplegia had a PICC line observed in the L upper arm, but the admission orders and care plan did not include PICC line care and management. Facility policy required a prescriber order with specific flushing/locking details and documentation of the procedure, and an RN later confirmed the omission.
Respiratory care was not provided as ordered for one resident receiving O2, as the NC tubing was not dated. Tracheostomy care was also not provided as ordered for another resident: heavy thick mucus was visible under the trach, the ATM mask was soiled with mucus, the ATM and nebulizer tubing were not dated or stored in a bag, and the suction catheter tubing end was not stored in a bag. An RN confirmed the findings.
The facility failed to accurately complete its Facility Assessment. The assessment did not reflect the skill sets needed for the resident population or list medical equipment in use, including an AED, tracheostomy care and management, a Life Vest, wound vac machines, and glucometer devices. The NHA confirmed the omission during interview.
The facility QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve care and services effectively addressed them. A prior survey had cited the facility and included QAPI-related plans of correction, but the current survey found multiple repeat deficiencies, including F604, F609, F628, F700, F880, F883, and PA1020. The NHA confirmed the facility had multiple repeat deficiencies and had not corrected the quality issues.
Expired supplies were found in two crash carts on nursing units 1B and 2B. An opened Ambu bag in the 2B cart was expired, and the 1B cart contained two expired Ambu bags and expired Assure Prism glucometer strips. RN staff confirmed the items were expired and should not have been in the carts.
The facility failed to provide annual QAPI in-service training for an RN whose personnel file lacked documentation of the required training. The ADON confirmed the missing training during interview, and the record review showed the RN had been hired in 2023 but did not have QAPI training documented for the review period.
A resident with diabetes, CKD, and anxiety had escalating behaviors, including aggression, refusal of meds, throwing items, and spitting on staff. The family requested a UA to rule out a UTI, but the record did not show the test was completed or that the resident’s representative was informed why it was not done before the resident was sent to the ER and later returned with a UTI diagnosis and an order for Cefuroxime.
A resident with DM, CKD, and anxiety developed aggressive and combative behaviors, refused meds and drinks, threw food and objects, and had poor intake with swallowing difficulty. Although staff documented these changes in CRNP notes and nursing notes, the care plan was not revised to include the resident’s behaviors, food/drink refusals, or swallowing issues.
Failure to complete a comprehensive activity assessment for a resident. The resident had CHF, DM, CKD, and depression, and the record showed she was oriented, denied pain, and had no acute distress, but there was no documented life enrichment or activity assessment to identify her interests and preferences. The care plan also did not include activity preferences, despite facility policy stating the life enrichment director would complete interviews, assessments, and documentation.
A resident with dementia and Alzheimer’s disease, admitted for respite hospice care, repeatedly expressed wanting to leave and was identified as an elopement risk. Staff documented agitation and wandering, but the resident later exited through the front door and was found about 0.5 miles away after being missing. A receptionist thought he was a visitor, and the root cause analysis cited a breakdown in secured access control and monitoring in the Memory Care Unit elevator area.
Failure to employ a qualified full-time social worker. Review of the employee file showed a BS degree and a Certified Therapeutic Recreation Specialist certificate, with coursework in Recreational Therapy. The NHA stated these credentials qualified the employee for the social worker role and did not confirm that the employee lacked the required bachelor’s degree in social work or a human services field.
A facility failed to develop person-centered comprehensive care plans with measurable goals and timetables for three residents identified as elopement risks. The residents had diagnoses including anxiety, depression, cognitive decline, intellectual disabilities, and Alzheimer’s disease, and each had elopement assessments showing potential risk with immediate interventions such as wander guards and floor placement, but the care plans did not include person-centered interventions related to their elopement risk status.
A resident eloped from the facility after staff failed to ensure proper supervision, and the event was identified as an IJ for all residents at risk for elopement. The NHA and DON were found to have failed to effectively manage the facility and to fulfill their job duties related to overseeing operations and nursing services.
A resident with diabetes, hypertension, and a history of falls did not receive three ordered bedtime medications (Seroquel, Atorvastatin, and Lantus) after a verbal altercation with an agency RN over access to a kitchenette. The MAR documented the medications as not administered/resident refused, but the resident later reported that the nurse never came to give the medications and denied leaving the facility during the relevant time. An RN supervisor reported witnessing the argument and offering to pass the medications, which the agency RN refused, while another staff member stated that the agency RN asked other nurses to administer the medications but they declined. Conflicting accounts about the resident’s whereabouts and the refusal status, combined with the lack of medication administration as ordered, led surveyors to determine that the facility failed to provide necessary goods and services to the resident.
A resident with diabetes, hypertension, and a history of falls did not receive ordered bedtime doses of Seroquel, Atorvastatin, and Lantus on an evening shift. Facility policy required verification and administration of medications as ordered, and the resident’s care plan directed staff to give medications per MD orders. The MAR showed the agency RN documented the medications as refused, but the resident later reported he had not been offered or given them. Staff interviews and facility documentation described a verbal altercation between the agency RN and the resident over access to a kitchenette, the RN’s refusal of assistance from the RN supervisor to pass the medications, and conflicting accounts about whether and when the resident left and returned to the unit, resulting in the missed administration of significant medications.
A resident with hypertension, osteoporosis, and diabetes had physician orders for showers twice weekly during the 3 p.m. to 11 p.m. shift, but review of electronic Point of Care documentation over several months showed only six showers were completed. The admission materials stated that residents have the right to have their personal needs and preferences provided for, yet the ordered shower frequency was not followed. The DON confirmed that the resident received only six showers during the review period, demonstrating a failure to accommodate the resident’s shower needs and preferences.
A resident with anemia, diabetes, and late-onset Alzheimer’s disease, identified as a fall risk, experienced two unwitnessed falls with head strike, back pain, and a 4 x 4 cm head laceration. A provider ordered neurochecks with vital signs at frequent, specified intervals over a 24-hour period, but documentation showed these assessments were performed only a few times and did not follow the ordered schedule. The DON confirmed that staff failed to complete the neurochecks and vital signs as ordered, resulting in a failure to provide appropriate post-fall care and treatment.
A resident with a history of stroke and hemiplegia had a physician order for a left shoulder subluxation sling to be applied in the morning and removed in the evening, but the device was not included in the resident's care plan and was not in use during multiple observations. The resident reported that staff never applied the splint, did not know where it was, and stated that it helped reduce pain. An LPN confirmed the splint was not in place as ordered, and the DON acknowledged that the facility failed to provide the necessary services, equipment, and assistance to maintain or improve the resident's mobility.
Several residents with dementia, depression, diabetes, and neurocognitive disorders did not have individualized, measurable care plans addressing their specific medical and psychosocial needs. Care plans were missing for residents receiving psychotherapy, insulin therapy, and those exhibiting behavioral symptoms, despite documented diagnoses and physician orders. Staff interviews and record reviews confirmed these omissions.
The facility failed to notify physicians of abnormal blood glucose readings for a resident with diabetes, did not provide comprehensive skin assessments or timely wound care for two residents with skin conditions, and did not follow physician orders for vital sign monitoring or medication continuation for a resident with a seizure disorder. Staff interviews and record reviews confirmed lapses in documentation and adherence to care protocols.
The facility did not properly identify or assess two residents for smoking safety, omitting required risk assessments and care plan interventions, even though both were known to smoke. Additionally, after a resident eloped from the facility, staff failed to reassess the resident for elopement risk, update the care plan with appropriate interventions, or include the resident's information in the elopement binder, despite the resident being cognitively intact and non-compliant. Staff interviews and documentation confirmed these lapses in required procedures.
The facility did not maintain accurate care plans or conduct ongoing assessments for bedrail or enabler bar use for three residents, despite their medical conditions and physician orders. Clinical records lacked documentation of ongoing assessment, goals, and interventions related to bedrail use, and observations confirmed the use of bedrails or enabler bars without proper care plan updates.
Surveyors identified multiple failures in medication storage and labeling, including expired medications, unlocked and improperly monitored medication refrigerators, missing temperature logs, and insulin pens without open dates or with expired use on a medication cart. Staff confirmed these deficiencies, which involved improper storage, lack of security, and inadequate documentation for medications and biologicals.
The facility failed to prevent cross contamination by storing milk in a medication refrigerator and did not follow proper infection control practices during a dressing change for a resident with multiple diagnoses. An LPN did not cleanse the bedside table, used gloves from her pocket, and did not perform hand hygiene or change gloves between steps. Additionally, the facility did not conduct infection surveillance for four months, as confirmed by the Infection Preventionist.
A resident with multiple chronic conditions was not offered the influenza vaccine, and two residents with significant medical histories did not have documentation that the pneumococcal vaccine was offered, administered, or declined. Facility policy required proper documentation and offering of these vaccines, but clinical records and staff interview confirmed these steps were not completed.
A resident with multiple medical conditions, including a pressure ulcer, did not have their dignity maintained when an LPN wrote on a dressing after it was applied during wound care. This action was confirmed by the LPN and was found to be inconsistent with the resident's right to dignity and respect.
Food Items Left Unlabeled and Undated
Penalty
Summary
The facility failed to properly label and date food products in the main kitchen's standing cooler rack and dry storage area. Review of the facility's Food Preparation and Handling Policy dated 5/4/26 indicated that potentially hazardous foods are to be kept refrigerated except when being handled, and refrigerated foods are to be covered for storage, cooked timely following defrosting, and appropriately labeled and dated. During observation in the Main Kitchen on 8/3/26 at 9:20 a.m., a tray in the standing cooler rack contained three separate chef's salads and seven sandwiches that were not labeled and dated. In the dry storage area, a container of chicken gravy/bouillon was found opened and not labeled or dated. During interview on 8/3/26 at 9:30 a.m., the Dietary Supervisor confirmed the salads were from the prior evening's dinner meal and stated they, along with the sandwiches, should have been labeled and dated; the Dietary Supervisor also confirmed the chicken gravy/bouillon should have been labeled and dated.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring privacy covers were applied to urinary catheter drainage bags for three residents. Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a physician order for catheter care to provide a privacy cover for the drainage bag every shift. During observation, the catheter drainage bag was hanging on the bedframe without a privacy cover. Resident R178, with diagnoses of diabetes, high blood pressure, and depression, also had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. Resident R179, diagnosed with COPD, atrial fibrillation, and heart failure, likewise had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. An RN confirmed that the bags should be covered and that the residents' dignity was not maintained. The facility also failed to provide a dignified dining experience for one resident who was ordered to be fed by staff. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had a care plan and physician order for staff to feed all meals. During lunch observation on the 2B nursing unit, the resident was sitting upright in bed while a nurse aide stood beside the bed feeding the resident. The nurse aide stated that they should have been sitting down while feeding but did not know where the resident's chair was. The DON later confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed on 2B.
Failure to Hold and Notify Residents of Care Plan Conferences
Penalty
Summary
The facility failed to conduct care plan conferences and failed to ensure that residents or their resident representatives were notified in advance of care conference meetings for three residents. Review of the facility policy showed that an interdisciplinary plan of care was to be established and updated as indicated for every resident, with resident or representative participation included unless participation was not practicable and documented in the medical record. However, review of care plan conference records showed that Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a last documented care conference on 1/29/26 and no documented quarterly care conferences in April 2026 or July 2026. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had an admission care conference on 10/1/25 with no attendee list except the staff member and no documented quarterly care conferences in January 2026 or May 2026. Resident R91, who had diagnoses of insomnia, anxiety, and ALS, stated during interview that he had only been to one care conference since admission and had not been invited to any others; records showed an admission care conference on 6/4/25 and no documented quarterly care conferences in September 2025, December 2025, March 2026, or June 2026. The Social Worker Aide confirmed the missing quarterly care conferences for all three residents, and the Nursing Home Administrator confirmed the facility failed to conduct care plan conferences and failed to ensure advance notification to the resident or resident representative.
Failure to Communicate Transfer Information and Notify of Bed-Hold and Ombudsman
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers. For Residents R4, R10, and R72, the clinical record did not show documentation that the facility sent specific information to the acute hospital, including care plan goals, advance directive information, specific instructions for ongoing care, resident representative information, and other information needed to meet the resident’s specific needs at the receiving facility. Staff interviews confirmed that the resident information sent with these transfers was not documented. The facility also failed to notify the resident or the resident’s representative of the bed-hold policy for two hospital transfers, Residents R4 and R10, and failed to notify the Office of the State Long-Term Care Ombudsman for three hospital transfers, Residents R4, R10, and R72. Resident R4 had diagnoses including diabetes, depression, and multiple sclerosis and was transferred to the hospital and later returned to the facility. Resident R10 had diagnoses including diabetes, cerebral infarction, and depression and was also transferred to the hospital and returned. Resident R72 had diagnoses including high blood pressure, chronic pain, and COPD and was transferred to the hospital and returned the same day. The DON and Regional Director of Clinical Services confirmed the missing documentation and the lack of Ombudsman notification.
Failure to Follow Ordered Treatments and Weight Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with orders and professional standards for four residents. Facility policy stated that weights were to be obtained routinely to monitor nutritional health, including weekly for the first four weeks after admission or readmission and more often if risk was identified or as ordered. For one resident with diagnoses including high blood pressure, Parkinson’s disease, and anxiety, a nursing note documented that the resident sustained a skin tear to the right hand during an episode of agitation and attempted physical aggression toward staff while being assisted out of bed. The wound nurse confirmed there was no physician order for treatment of the right hand skin tear, although steri-strips had been applied and the wound nurse stated steri-strips are the preferred treatment for skin tears. For two residents, physician orders required weekly weights, but the clinical record did not show that the ordered weights were obtained as directed. One resident had weights not obtained on two scheduled dates, and the record lacked additional documentation explaining why the weights could not be obtained. Another resident had one missed weekly weight, and the record also lacked additional documentation explaining why the weight was not obtained. The DON confirmed that the facility failed to make certain these residents were provided appropriate treatment and care. For another resident with diagnoses including hypertension, depression, and diabetes, the record showed the resident was admitted with marks and blisters on the body and no treatment was ordered. A contracted wound company later recommended skin prep to the blisters, but physician orders did not include skin prep. A wound nurse stated there was no order for skin prep and confirmed the facility did not follow the wound company’s recommendations. An RN stated the recommendations were not followed, but the facility had no documented evidence of speaking with the practitioner about treatment for the blisters or the reason the recommendations were not followed.
Inaccurate Bedrail Care Plans and Missing Ongoing Assessments
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments for bedrail use for three residents. Facility policy stated that if a bed rail or side rail is used, the facility will evaluate the potential risks associated with bed rail use, including entrapment, before installation using the Bed and Bed Rail Safety Inspection Checklist. The report identified that the facility did not keep current assessments for Residents R2 and R14, whose beds had bilateral enabler bars observed during survey, and the last Enabler-Restraint Observation 2 assessment for each resident had been completed on 10/6/25. Resident R2 had diagnoses including high blood pressure, Parkinson's Disease, and anxiety, and had a physician order for a bariatric bed with bariatric mattress and bolster overlay and bilateral assistive handrails to aid with positioning, with placement checks every shift. Resident R14 had diagnoses including high blood pressure, hyperlipidemia, and depression, and had a physician order allowing grab/assist bars on the bed to promote independence and a sense of safety/security. Resident R160 had diagnoses including high blood pressure, hyperlipidemia, and hemiplegia, and bilateral enabler bars were observed on the bed, but the clinical record did not include an order or ongoing assessment for the enabler bar use, and the comprehensive care plan did not include measurable objectives, timetables, or specific interventions/services for the enabler bars.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations at least once every 12 months for three of three nurse aide personnel records, including NA Employee E23, NA Employee E24, and NA Employee E25. Review of each personnel file showed a date of hire of 7/1/23, and each record lacked an annual performance evaluation at least every 12 months as required. During an interview on 8/4/26 at 1:55 p.m., the Nursing Home Administrator confirmed that the facility failed to complete the required annual performance evaluations for all three nurse aides.
MRRs Not Reviewed by Attending Physician
Penalty
Summary
The facility failed to provide evidence that medication regimen reviews (MRRs) were reviewed by the resident's attending physician for three residents. Facility policy stated the consultant pharmacist would provide MRRs to identified facility personnel so the attending physician, medical director, DON, and other necessary staff would receive the recommendations. Review of the clinical record for Resident R2 showed diagnoses of high blood pressure, Parkinson's disease, and anxiety, and an MRR dated 1/23/26 recommended a gradual dose reduction of quetiapine fumarate. The record did not include a response from the attending physician, and a CRNP note stated, "Already being done," without indicating whether the recommendation was accepted or declined. Medical Records staff confirmed the MRR was addressed by the CRNP and that there was no evidence the attending physician reviewed it. Resident R4's record showed diagnoses of diabetes, multiple sclerosis, and depression. Multiple MRRs dated 9/12/25, 11/18/25, 1/2/26, and 7/29/26 included pharmacist recommendations regarding missing PRN pain severity, missing stop dates, PRN orders not used in the previous 30 days, and reevaluation of pain status. The record did not include a response from the attending physician for these recommendations, and Medical Records staff confirmed there was no evidence the attending physician reviewed the MRRs. Resident R7's record showed diagnoses of high blood pressure, anxiety, and arthritis, and an MRR dated 1/27/26 identified concomitant use of multiple antidepressants and recommended evaluation for a single agent. The record lacked a response from the attending physician, and a CRNP note stated, "accepted and decreased the duloxetine to 40mg," with Medical Records staff confirming there was no evidence the attending physician reviewed the MRR.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in four medication carts and one resident room, with observations showing unsecured carts and improperly labeled or stored medications. During a medication pass, an RN walked into a resident room and left the 2B Medication Cart unlocked and unattended, and later the narcotic drawer on the 2C2 Medication Cart was observed unlocked and unsecured while the cart sat unattended in the hallway. An RN confirmed both conditions during interview. On another observation, the 2A Medication Cart contained multiple medication storage issues, including unopened insulin vials and pens that were not refrigerated before opening, several insulin pens and inhalers with no open date noted, and eye drops with no date noted. The cart also contained an open Lantus vial with no open date. In the 1B Medication Cart, Latanoprost eye drops were dated 6/8/26. In a resident room, two bottles of eye drops at bedside were not labeled with an open date, and an RN confirmed the bottles failed to be labeled as required.
Infection Control Failures During Food Handling, Medication Administration, Isolation, and Surveillance
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified through multiple observations and record reviews. During the lunch meal in the main dining area, Transportation Aide Employee E9 assisted Resident R97 by opening a dinner roll from its package and opening a sandwich wrapped in plastic wrap without using gloves and while touching the food directly with her hands. During a medication pass observation on the 2B hallway, RN Employee E13 pushed medications out of blister packs onto an ungloved hand and then placed the medication into a medicine cup for administration, and later confirmed that gloves were not worn during the handling of resident medications. The facility also failed to follow ordered contact isolation precautions for Resident R91. Resident R91’s record showed diagnoses of insomnia, anxiety, and ALS, and physician orders included contact isolation. During observation, contact isolation signage and PPE were present at the room, but LPN Employee E12 entered the room without applying the required PPE and later confirmed the failure. In addition, review of the facility’s infection control program showed no documented surveillance and tracking of infections for eight months, from September 2025 through April 2026, and the DON and NHA confirmed the lack of surveillance documentation during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for eight of 12 months, from September 2025 through April 2026. Review of the facility’s Antimicrobial Stewardship Program policy dated 5/4/26 showed the program was intended to focus on avoiding unnecessary or inappropriate antibiotic use and was to be overseen by the Infection Preventionist, Medical Director, Pharmacist, nursing, and leadership. Review of the Infection Prevention and Control Program policy dated 5/4/26 also stated the program included promoting antibiotic stewardship. Review of the facility’s Infection Control Program records for September 2025 through July 2026 found no documented evidence that antibiotic monitoring and appropriate antibiotic use were completed from September 2025 through April 2026. During interview, the DON stated she had not been overseeing infection control until May and said that if the binders did not contain the information, then the facility did not have it. A Regional Director of Clinical Services later found an antibiotic stewardship binder in an office that contained lab reports and prior survey information, but no facility tracking of antibiotics. The NHA and DON then confirmed the facility failed to implement an antibiotic stewardship program for eight of 12 months.
Incomplete Pneumococcal Vaccine Documentation
Penalty
Summary
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations was identified after review of facility policy, clinical records, and staff interview. The facility policy dated 5/4/26 stated that residents or responsible parties would be asked about prior vaccinations at admission, prior doses of influenza, pneumococcal, COVID, and other vaccines would be documented in the immunization portal in the electronic health record, and vaccinations would be administered by provider orders. For Resident R4, who was admitted with diabetes, depression, and multiple sclerosis, the MDS dated 6/19/26 coded pneumococcal vaccine status as not up to date and reason as not offered. The immunization record showed consent was not obtained and the reason was status to be determined, with education to the resident or representative not checked. For Resident R26, admitted with diabetes, high blood pressure, and coronary artery disease, the MDS also coded pneumococcal vaccine status as not up to date and reason as not offered, but the immunization record showed consent was not obtained and the reason was unable to obtain data, with no documented evidence that the vaccine status was discussed with the attending physician. For Resident R72, admitted with high blood pressure, chronic pain, and COPD, the MDS coded pneumococcal vaccine status as not up to date and reason as not offered, and the immunization record showed consent was not obtained and the reason was status to be determined, with education to the resident or representative not checked. The DON stated the facility should have followed up with vaccinations and confirmed the facility failed to provide accurate and timely documentation related to the pneumonia vaccine for these residents.
Failure to Provide Requested Enabler Bars
Penalty
Summary
The facility failed to reasonably accommodate Resident R105’s need and preference for enabler bars on the bed. The resident was admitted with diagnoses including heart failure, high blood pressure, and renal insufficiency. An OT evaluation dated 7/22/26 documented that the resident required assistance with bed mobility and could complete it with stand-by assistance if assist bars were present, but the resident’s clinical record on 8/5/26 did not include an observation for enabler bars. During an observation on 8/3/26, Resident R105 was lying in bed and stated she wanted enabler bars to help position herself in bed and had asked for them since admission but had not heard back. An RN confirmed the resident did not have enabler bars and said she would look into it. On 8/5/26, the resident was again observed resting in bed without enabler bars. An OT employee stated the process was for therapy to determine whether residents could use their upper extremities, then nursing would enter an observation for enabler bars and maintenance would be notified, and another OT employee stated the resident would benefit from enabler bars and that the observation probably never got entered into the computer.
Failure to Support Resident Family Group Meetings
Penalty
Summary
The facility failed to assist resident families with forming and continuing a family group for three of three resident families identified in the report. The facility handbook stated residents have the right to organize and participate in resident groups, and that the facility must provide a resident or family group with private space and take reasonable steps, with the group’s approval, to make residents and family members aware of upcoming meetings. However, review of the family council minutes dated 8/20/25 showed families were informed of upcoming events, shared suggestions, and were told the next meeting would be announced later, while the minutes did not document that families had decided not to continue meetings or that the facility had communicated it would stop conducting Family Group meetings. Resident family interviews indicated the meetings were no longer being held. Two resident family representatives stated the facility no longer provided family meetings and had previously held them monthly, while another family representative stated the prior administrator stopped the quarterly meetings and that there had been no formal communication to families that the meetings were no longer occurring. The NHA stated August 2025 was the last Family Council meeting and that the prior administration did not want to continue the meetings, while the Activities Director stated the prior administrator stopped the meetings and that there was no formal communication to families. The report also states that information was disseminated to the NHA, DON, and Regional Director of Clinical Services that the facility failed to assist a resident family with forming a family group for four of four resident families as required.
Failure to Provide SNF-ABN for Medicare Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that would be charged for one of three sampled residents, Resident R120. Review of the admission record showed the resident was originally admitted on [DATE]. His MDS dated 6/18/26 listed diagnoses including an artificial hip joint, cellulitis, and dysphagia. The census document showed he was admitted under Medicare Part A on 3/27/26 and changed to private pay on 4/19/26. A social services note dated 4/17/26 documented that Resident R120 was given a NOMNC form and that it was verbally reviewed with his wife, since he was unable to sign. The note stated that both the resident and his family acknowledged and agreed with the NOMNC and did not intend to appeal. However, review of the social services notes and clinical nurse notes did not show that Resident R120 or his wife were provided with a SNF-ABN form for services no longer covered under Medicare Part A. During interview on 8/5/26 at 10:19 a.m., the Regional Director of Clinical Services confirmed that the facility failed to provide the SNF-ABN form to inform the resident or his family of items and services no longer deemed eligible under Medicare Part A.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of five medication carts, the 2B Medication Cart. During a medication pass observation, the Registered Nurse left the medication cart unattended in the hallway with the computer screen open and displaying resident information. In an interview shortly afterward, the RN confirmed that the cart had been left unattended with the screen open and that identifiable resident information could be seen by anyone passing by, resulting in a failure to keep residents' personal and confidential medical information private.
Missing Baseboards on Second-Floor Hallway and Resident Room
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment on the second floor. During a tour with Maintenance Employee E9, Resident R171’s room was observed to have a missing part of a baseboard under the window, and the left side of the hallway had baseboards missing periodically down the hall. The right side of the hallway also had baseboards missing periodically down the hall. During an interview, Maintenance Employee E15 stated that the machine must be hitting the baseboards and that they had been taken off.
Failure to Assess Bolsters as Possible Restraints
Penalty
Summary
The facility failed to identify a bolster as a possible physical restraint and failed to assess the functional status of two residents to determine whether the use of a bolster was a restraint. The facility’s restraint policy stated that a physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body. Resident R2 had diagnoses including high blood pressure, Parkinson’s disease, and anxiety. The clinical record showed a physician order for a bariatric bed with bariatric mattress and bolster overlay, along with bilateral assistive handrails to aid positioning, and the care plan included the same interventions. During observation, R2 was lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. Resident R87 had diagnoses including hemiplegia, anxiety, and depression. The record showed an order for bilateral bed rail bolsters while in bed as tolerated, and the care plan included a contour mattress with bolster overlay and bilateral foam wedges for positioning. During observation, R87 was also lying in bed with a mattress that had bilateral raised edges on the top and bottom portions. For both residents, the clinical record did not identify assessments or ongoing evaluations for the use of bolsters, and the Regional Director of Clinical Services confirmed the facility failed to assess whether the bolster was a restraint.
Missing FBI Background Check for Agency Nurse Aide
Penalty
Summary
The facility failed to conduct an FBI background check on an agency nurse aide before allowing the aide to work on the nursing unit. The facility’s personnel abuse policy stated that it would not employ or otherwise engage individuals found guilty of abuse, neglect, or mistreatment of residents and that it would undertake background checks of all employees in accordance with State law. Review of the agency nurse aide’s personnel record showed the aide was hired and completed orientation at the facility on 7/15/26, and then worked two shifts on 7/26/26 and 8/1/26. The personnel record also showed that the agency nurse aide had lived outside Pennsylvania within the past two years, but the file contained only an FBI background check dated 6/1/23 and did not include an updated FBI background check before the aide started at the facility. During interview, the Director of Human Resources confirmed that the aide had lived outside Pennsylvania within the past two years. The deficiency was discussed with the NHA, DON, and Regional Director of Clinical Services, who were informed that the facility had failed to conduct the required FBI background check prior to the aide working on the nursing unit.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to submit a report of an allegation of verbal abuse involving one resident. Facility policy stated that all allegations of abuse must be reported immediately to the Administrator and the applicable State agency, and verbal abuse was defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. Review of the resident’s record showed diagnoses including hypertension, anxiety disorder, and hyperlipidemia. Resident council minutes documented that the resident told staff that a staff member had yelled at her, and facility investigation documents showed a disciplinary action for a nurse aide related to the incident along with retraining on effective communication. The allegation was discussed in resident council, but the grievance documentation did not show a related grievance and the reported incidents submitted to the State did not include the verbal abuse allegation. During interviews, the Activities Director stated the incident happened and that the Director of Human Resources spoke with the aide, while the Director of Human Resources did not recall retraining or discussing the allegation. The resident stated the matter had been taken care of and that she had cursed the aide back. The DON confirmed that the facility failed to submit the required report of the verbal abuse allegation.
MDS Did Not Accurately Reflect Suctioning
Penalty
Summary
Resident R164’s assessment was inaccurate because Section O0110 D1, suctioning, was not indicated on the MDS even though the resident had a tracheostomy and suctioning was being performed. The resident’s record showed diagnoses of diabetes, heart failure, and stroke, and the admission record confirmed the resident was admitted to the facility. The RAI User’s Manual stated that suctioning performed while a resident is in the facility and within the last 14 days must be checked in Section O0110 D1. The resident had a physician order dated 7/20/26 to check that the trach mask and oxygen were in place and to check the need for suctioning, trach care, and oral care four times a day. The care plan directed suction trach and oral care every shift and every two hours as needed. The MAR from 7/20/26 through 7/26/26 showed suction tracheostomy was performed on 7/22/26, 7/23/26, 7/24/26, 7/25/26, and 7/26/26. During interview on 8/5/26, the RNAC confirmed the MDS for Resident R164 did not indicate suctioning in Section O0110 D1.
Baseline Care Plan Missing Enteral Feeding Instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, R181, to include instructions needed to provide effective and person-centered care. The facility’s Interim Baseline Care Plan Policy dated 5/4/26 stated that an interim/baseline care plan would be developed and implemented within 48 hours of admission for each resident until a comprehensive assessment could be completed. R181 was admitted with diagnoses of pneumonitis, stroke, and hemiplegia. A physician order dated 7/31/26 indicated Isosource 1.5 enteral feeding at 60 ml/hr with confirmation of total volume to infuse. However, the Nursing-Admission/readmission Observation 3 document dated 7/31/26 at 2:39 p.m. documented that the resident did not have a gastric/enteral tube, and the GI appliances section failed to mark a gastrostomy tube as present. The baseline care plan section stated dietary needs would be met as ordered but did not specify the need for gastrostomy tube and/or enteral feedings. During interview on 8/7/26 at 11:10 a.m., the Regional Nurse Consultant confirmed the facility failed to develop and implement a baseline care plan to include instructions needed to provide effective and person-centered care for R181.
Failure to Provide Proper Pressure Injury Care
Penalty
Summary
The facility failed to ensure proper treatment of pressure injuries for two residents. One resident was admitted with malnutrition, cancer, and chronic pain, and had an impaired skin integrity care plan for a coccyx pressure injury with goals that the ulcer would not increase in size and would not show signs of infection. Physician orders directed daily cleansing with normal saline, application of Santyl, calcium alginate, and a dry dressing. During a dressing change observation, the old coccyx dressing was found dated 8/3/26, and the LPN confirmed that the dressing change ordered for 8/4/26 had not been completed. The MAR also showed the dressing was not changed on 8/4/26 and was marked as other, with no explanation documented for why the ordered treatment was not provided. A second resident was admitted with pneumonitis, stroke, and hemiplegia, and the admission observation documented a pressure injury/ulcer on the left heel. However, the clinical record did not include measurements, stage, wound description, preventive measures, or treatment for the heel pressure injury. The facility policy required pressure injuries to be assessed initially and at least weekly, with documentation of location, stage, size, drainage, pain, wound bed, surrounding tissue, infection, and treatment orders. An RN confirmed the facility failed to make certain the resident received proper treatment for the pressure injury.
Unlabeled Tube Feeding Bags
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an enteral feeding tube. Resident R181 was admitted with diagnoses including pneumonitis, stroke, and hemiplegia, and had a physician order for Isosource 1.5 tube feeding at 60 ml/hr. The resident’s care plan identified increased nutritional risk related to gastric tube use and included enteral feeding/supplements to support normal lab levels. During observation, Resident R181’s tube feeding bag was hanging on a pole with another bag of water. On both observations, the bags were not labeled with the resident’s name, the formula, the rate, the date, or the time it was hung; one observation also noted the bags were not labeled with the resident’s name, formula, or rate. RN E4 and LPN E17 both confirmed the unlabeled tube feeding setup and the presence of the additional water bag on the pole.
Failure to Include PICC Line Care and Management
Penalty
Summary
The facility failed to include care and management of a PICC line for one resident, identified in the report as Resident R181, consistent with professional standards of practice. Facility policy for Central Vascular Access Device Flushing and Locking required a prescriber order for flushing and locking a catheter, including the flushing/locking agent, strength/concentration, volume, and frequency, and required documentation of the date and time, prescribed agent, site assessment, resident response, and teaching. Review of the admission record showed the resident was admitted with pneumonitis, stroke, and hemiplegia, but the admission orders and care plan did not include orders for PICC line care and management. A progress note dated 7/31/26 documented that the resident had a midline in the left upper extremity. On 8/3/26 at 10:30 a.m., the resident was observed lying in bed with a PICC line in the left upper arm, and RN Employee E4 confirmed the PICC line was present during the observation. A later progress note dated 8/6/26 indicated the PICC line was removed from the left upper arm per order. On 8/7/26, RN Employee E4 confirmed the facility failed to include care and management of the PICC line consistent with professional standards of practice for the resident.
Respiratory Care and Tracheostomy Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for a resident receiving oxygen. The resident had diagnoses including depression, low blood pressure, and atrial fibrillation, and the MDS indicated oxygen therapy while a resident. During observation, the resident was lying in bed with oxygen on, and the nasal cannula was not dated. The physician order required oxygen at 3 liters per minute via nasal cannula at night or as needed, and another order directed that the oxygen concentrator and filter be cleaned and the tubing changed weekly. During interview, the RN confirmed that the oxygen tubing did not have a date on it and confirmed the facility failed to provide appropriate respiratory care for the resident. Tracheostomy care was also not provided consistent with professional standards of practice for another resident. The resident had diagnoses including diabetes, heart failure, and stroke. Physician orders directed staff to check that the trach mask and oxygen were in place and to assess the need for suctioning, trach care, and oral care four times a day. The care plan directed suctioning of the trach and oral care every shift and every two hours as needed, and to provide oxygen via aerosolized trach mask with tubing and filters changed weekly. During observation, the resident was connected to oxygen via ATM, but heavy thick mucus was visible under the trach, the inside of the trach mask was soiled with mucus, the ATM tubing and nebulizer tubing were not dated, and the tubing was not stored in a bag as required. The suction catheter tubing end was also not stored in a bag as required, and the RN confirmed these findings during interview.
Incomplete Facility Assessment Missing Required Care Resources
Penalty
Summary
The facility failed to accurately complete the Facility Assessment. A review of the Facility Assessment dated 7/15/26 found that the template was not completed to show accurate information about the skill sets necessary to provide the level and types of care needed for the resident population, including specific medical equipment currently in use. The medical equipment section did not include an AED, tracheostomy care and management, a Life Vest, wound vac machines, or glucometer devices. During an interview on 8/7/26 at approximately 12:07 p.m., the Nursing Home Administrator confirmed that the facility failed to accurately complete the Facility Assessment.
QAPI Committee Failed to Correct Repeat Deficiencies
Penalty
Summary
The facility QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed those deficiencies. A prior State Survey and Certification survey ending August 22, 2025, cited the facility and included plans of correction with quality assurance systems intended to maintain compliance with nursing home regulations. However, the current survey ending August 7, 2026, found repeated deficiencies from the prior survey, including F604, F609, F628, F700, F880, F883, and PA1020. During an interview on 8/6/26 at 3:00 p.m., the Nursing Home Administrator confirmed that the facility had multiple repeat deficiencies from the previous survey and that the facility failed to correct the quality deficiencies and ensure that plans to improve care and services effectively addressed them.
Expired Supplies Found in Crash Carts
Penalty
Summary
The facility failed to keep crash cart equipment in safe operating condition for two of two crash carts on nursing units 1B and 2B. The facility’s Emergency Equipment Check Policy stated that emergency equipment carts are to be checked daily, outdated or opened items are to be replaced, and contents are to be checked monthly for expired items if the cart is not accessed in the interim. During observation of the crash cart on 2B, an opened Ambu bag was found stored in the cart with an expired date, and RN E14 confirmed it was expired. During observation of the crash cart on 1B, two Ambu bags and a bottle of Assure Prism glucometer strips were found with expired dates, and RN E4 confirmed the Ambu bags and glucometer strips were expired and should not have been in the crash cart.
Missing QAPI Training for RN Staff Member
Penalty
Summary
The facility failed to provide annual in-service training on Quality Assurance and Performance Improvement (QAPI) for one of five staff members reviewed, RN Employee E22. Review of the RN’s personnel file showed a hire date of 7/1/23, but the file did not include annual QAPI training for the period from 1/1/25 through 12/31/25. During an interview on 8/5/26 at 2:17 p.m., the Assistant Director of Nursing, Employee E10, confirmed that the facility failed to provide QAPI training for this staff member.
Failure to Communicate Testing Decision With Resident Representative
Penalty
Summary
The facility failed to involve the resident’s representative in a treatment decision and failed to communicate the decision regarding testing for a closed resident with diabetes, chronic kidney disease, and an anxiety disorder. After the resident was admitted, staff documented that he was aggressive, combative, refusing care and medications, throwing food and objects, and not allowing staff to examine him. On 5/13/26, the resident’s family requested a urinary analysis to rule out a UTI because of his increased behaviors, but the record did not indicate that a urinary analysis was completed between 5/13/26 and 5/18/26. Clinical notes documented ongoing behaviors, including refusal of medications, slapping a nurse, pushing staff away, yelling out, throwing cups and other items in the dining room, and spitting on staff. The physician note on 5/18/26 stated the family was adamant that the resident go to the emergency room despite counseling that he might return within a few hours if no acute problems were found. The resident was sent to the hospital and returned the next day with a new order for Cefuroxime 500 mg twice daily for seven days and a diagnosis of UTI. The resident’s clinical nurse and physician notes did not show any communication with the family representative explaining why the urinary analysis was not done before the hospital transfer.
Care Plan Not Updated for Resident’s Behavioral and Eating Changes
Penalty
Summary
The facility failed to ensure that Closed Resident Record CR1’s care plan was updated and revised to reflect his specific care needs. The facility’s comprehensive care planning policy stated that a plan of care would be established and updated as indicated for every resident, and that the care plan would be reviewed on an ongoing basis and revised as indicated by the resident’s needs, wishes, or change in condition. CR1 was admitted with diagnoses including diabetes, chronic kidney disease, and anxiety disorder, and his care plans addressed assistance with activities of daily living, dressing, grooming, toileting, feeding, and oral care. Clinical notes and CRNP documentation showed that CR1 developed significant behavioral and eating-related issues after admission. He was documented as aggressive and combative, refusing medications, slapping a nurse, pushing staff away, yelling out, throwing food and objects at staff, refusing drinks, and not allowing staff to examine him. He also had poor intake and difficulty swallowing, with speech therapy notified. Despite these documented changes, the care plans dated 5/26/26 did not include revisions for his behaviors, food refusals, drink refusals, or swallowing difficulties.
Failure to Complete Activity Assessment
Penalty
Summary
The facility failed to complete a comprehensive activity assessment to determine a resident's activity interests and preferences for one of three closed resident records. The facility policy for life enrichment interviews, assessment documentation, and care planning stated that the life enrichment director would complete interviews, periodic assessments, care planning, and documentation, and that a welcome note would be completed within 24 business hours. However, the closed record for the resident admitted on [DATE] did not contain an activity or life enrichment assessment in the clinical nurse notes or staff assessments, and the care plan dated 6/8/26 did not include activity preferences. The resident's MDS dated 6/5/26 documented diagnoses of CHF, diabetes, CKD, and depression. Clinical nurse notes dated 5/30/26 stated the resident was oriented to her room, hearing was adequate, she denied pain, and no acute distress was noted, but there was no documented assessment of activity interests or preferences. During interview, the activity director stated that initial activity assessments were kept in activity observations and completed within the first five days of admission, and refusals were documented in the plan of care report. On 7/9/26, the NHA, interim NHA, regional clinical coordinator, and infection control preventionist were informed that the facility failed to complete a comprehensive activity assessment for the resident as required.
Resident Eloped After Inadequate Supervision and Recognition
Penalty
Summary
The facility failed to ensure proper supervision for a resident with dementia and Alzheimer’s disease, resulting in an elopement from the facility. The resident was admitted for a 5-day respite stay under hospice services and had expressed that he did not want to be there, including statements about wanting to go home and leave the facility. An admission elopement observation identified him as a potential elopement risk based on those statements, and his baseline care plan noted he was at risk for wandering with monitoring interventions in place. Progress notes documented that the resident was agitated about being in the facility, yelled at his caregiver, and continued to express that he wanted to leave. Another note stated that he wandered the hallways ad lib. On the day of the event, staff last saw him at the third-floor nursing station around noon, and he was later found missing. Staff searched the center and surrounding grounds, and the resident was eventually located seated on the porch of a residence about 0.5 miles away from the facility and returned without incident. A receptionist stated she saw a shorter gentleman near the front entrance who said, “Well I think I will go out for a while,” and exited through the front door, but she believed he was a visitor and did not recognize him as a resident. The facility’s root cause analysis stated the resident was able to follow through the elevator access point unnoticed during visitor/family movement through the Memory Care Unit. The report also documented that staff interviews reflected inconsistent understanding of elopement assessment scoring and that some staff stated they had not completed elopement assessments themselves.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified social worker in a facility with more than 120 beds from February 16, 2026, through the present. Review of Social Worker Employee E12’s personnel file showed a Bachelor of Science degree and a Certified Therapeutic Recreation Specialist certificate, and the resume showed education that included bachelor’s degree coursework in Recreational Therapy. During an interview on 5/21/26 at 1:30 p.m., the Nursing Home Administrator stated that the Bachelor of Science degree and the Certified Therapeutic Recreation Specialist certificate qualified the employee for the social worker position. During a later interview on 5/21/26 at 1:33 p.m., the Nursing Home Administrator refused to confirm that Social Worker Employee E12 did not have at least a bachelor’s degree in social work or a bachelor’s degree in a human services field such as sociology, gerontology, special education, rehabilitation counseling, or psychology as required.
Failure to Develop Person-Centered Elopement Care Plans
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans with measurable goals and timetables for three residents identified as at risk for elopement. Facility policy required comprehensive person-centered care plans to address each resident’s medical, nursing, mental, and psychosocial needs based on the comprehensive assessment, but the care plans reviewed did not include person-centered interventions related to the residents’ elopement risk status. Resident R2 had diagnoses of anxiety, depression, and age-related cognitive decline, and an elopement observation assessment scored a risk for elopement of 10 with immediate intervention of a wander guard. Resident R3 had diagnoses of high blood pressure, anxiety, and mild intellectual disabilities, and an elopement observation assessment scored 8 with immediate intervention of a wander guard. Resident R4 had diagnoses of Alzheimer’s Disease, depression, and unspecified lack of coordination, and an elopement observation assessment scored 10 with immediate interventions of a wander guard and placement on the 3rd floor. During interview, the Nursing Home Administrator confirmed the facility failed to develop person-centered comprehensive care plans for these three residents.
Failure to Supervise Resident Resulted in Elopement
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility by not ensuring proper supervision for Resident R1, who eloped from the facility on 5/10/26. The report states that the resident exited to an unsupervised and unauthorized location without staff's knowledge, and this event was identified by surveyors as creating an immediate jeopardy situation for all residents identified as an elopement risk. The job description for the NHA stated responsibility for leading, directing, and managing overall operations in accordance with applicable policies, procedures, and regulations, while the DON was responsible for organizing, developing, managing, and directing the Nursing Service Department and working with the Administrator and Medical Director to ensure the highest degree of quality care. Based on the findings, the facility failed to ensure proper supervision for the resident, and the NHA and DON were notified on 5/20/26 that they had failed to effectively manage the facility to prevent the elopement.
Failure to Administer Ordered Medications After Staff–Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary medications to a resident as ordered, constituting neglect under the facility’s abuse and neglect policy. The facility’s policy defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required staff to verify correct medication, dose, route, rate, time, and resident with each administration. The resident involved had an MDS dated 11/26/25 showing diagnoses including a history of falls, diabetes, and hypertension, and a care plan directing that medications be administered per physician orders. On a specific evening shift, the resident’s January MAR showed that three ordered medications—Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneous at bedtime—were not administered. The MAR entries for that date documented these medications as “not administered/resident refused” by an agency RN. However, the following day, the resident reported to nursing staff that he had not received his scheduled medications for that shift. This discrepancy between the MAR documentation and the resident’s report prompted a facility investigation. During the investigation, multiple staff statements described a verbal altercation between the resident and the agency RN after the RN told the resident he was not permitted in the kitchenette. The RN supervisor reported witnessing the altercation and offering to pass the resident’s medications, but the agency RN refused this assistance. A nurse aide stated that the agency RN asked another nurse or the RN supervisor to provide the medications because the resident was being rude and calling her names, but nursing staff refused to assist. The agency RN stated that after the argument, the resident sat near the nurse station, called her the B-word, then left the unit; she reported she intended to have another nurse administer or witness the medications when the resident returned, but the resident did not return until early morning and did not request medications. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room, and that she never came to give his medications, and he denied being out of the facility until 1 a.m. These events led surveyors to determine that the facility neglected to provide required goods and services to the resident when his ordered medications were not administered as required.
Failure to Administer Ordered Bedtime Medications After Staff–Resident Altercation
Penalty
Summary
Facility staff failed to ensure that significant medications were administered as ordered for one resident. The facility’s medication administration policy required staff to verify the correct medication, dose, route, rate, time, and resident with each administration. The resident, who had a history of falls, diabetes, and hypertension, had care plans directing staff to administer medications per physician orders. Review of the January MAR showed that on the evening shift of 1/6/26, the resident did not receive ordered doses of Seroquel 150 mg, Atorvastatin 10 mg at bedtime, and Lantus Solostar 28 units subcutaneously at bedtime. These medications were documented in the MAR by an agency RN as not administered due to resident refusal. Subsequent documentation and interviews conflicted with the refusal notation. A clinical progress note the next day recorded that the resident approached staff and reported not receiving his scheduled medications for the 3–11 p.m. shift. Facility investigation statements indicated that during the shift, the agency RN and the resident had a verbal altercation after the RN told the resident he was not permitted in the kitchenette, and the RN supervisor intervened. The RN supervisor reported offering to pass the resident’s medications, but the agency RN refused this assistance. Another staff statement indicated the agency RN asked another nurse or the RN supervisor to give the medications because the resident was being rude, but nursing staff refused to assist. The agency RN stated she intended to have another nurse witness medication administration when the resident returned to the unit, but documented that the resident left and did not return until early morning. In a later interview, the resident stated the nurse was not around between approximately 8 and 9 p.m., that he went to his room and did not receive his medications, and that he did not leave the facility until about 1 a.m., and reported having no ill effects.
Failure to Provide Ordered Twice-Weekly Showers for a Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s shower needs and preferences as outlined in the admission notice packet, which states that residents have the right to have their personal needs and preferences provided for as long as they do not interfere with the rights of others. The resident, who was admitted on an unspecified date, had an MDS dated 11/19/25 reflecting diagnoses of hypertension, osteoporosis, and diabetes, and had current physician orders for showers twice weekly on Sunday and Thursday during the 3:00 p.m. to 11:00 p.m. shift. Review of the Point of Care History from 9/1/25 through 1/5/25 showed only six showers documented as completed on 9/4/25, 10/4/25, 10/5/25, 10/26/25, 11/23/25, and 12/28/25, despite the standing order for twice-weekly showers. During an observation on 1/5/26, the resident was on the telephone and declined interaction with the survey agency, and in a subsequent interview the Director of Nursing confirmed that the resident had received only six showers during the review period, confirming the failure to accommodate the resident’s ordered shower schedule.
Failure to Follow Ordered Post-Fall Neurochecks and Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered post-fall neurological monitoring and vital signs for a resident following two unwitnessed falls with head impact. The resident had diagnoses including anemia, diabetes, and late-onset Alzheimer’s disease, with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and was care planned as a fall risk related to impaired cognition, decreased safety awareness, Alzheimer’s, age-related cognitive decline, and sarcopenia. Facility documentation showed that on 12/27/25 the resident was found lying on the bedroom floor between the recliner and the bed after an unwitnessed fall, with moderate pain to the right side of the back and head, and later the same day had another unwitnessed fall with moderate head pain and an abrasion. A Third Eye Health note documented that the resident had two unwitnessed falls with head strike, reported back pain, and a 4 x 4 cm head laceration, and included specific provider orders for neurochecks with vital signs every 15 minutes for one hour, every 30 minutes for one hour, hourly for four hours, and then every four hours for 24 hours. Review of the Continuity of Care Document showed that neurochecks and vital signs were only completed at 2:41 p.m. and 8:48 p.m. on 12/27/25, and at 12:23 a.m., 8:13 a.m., and 3:53 p.m. on 12/28/25, which did not meet the ordered frequency. In interviews, the Director of Nursing confirmed that the facility did not complete the neurochecks and vital signs as ordered by the provider and acknowledged that the facility failed to provide appropriate care and treatment post fall for this resident.
Failure to Implement and Care Plan Ordered Shoulder Subluxation Splint
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility as ordered. Facility policy required that splints be issued or fabricated with a provider's order, that a therapist evaluate the patient for need, fit, and issuance, and that the splint schedule be communicated to the multidisciplinary team and documented in the care plan. The resident in question had diagnoses including high blood pressure, stroke, and hemiplegia, and had a physician's order to wear a left shoulder subluxation sling on with morning care and off with evening care, as tolerated twice a day. However, the resident's current care plan did not include management and treatment of the left shoulder subluxation splint. During observations, the resident was seen in a wheelchair without the ordered left shoulder subluxation splint in place. The resident reported that staff never put the splint on, was unsure of its location, and stated that the splint reduced pain. An LPN confirmed that the splint was not in place as ordered. Later observation showed the resident still in the wheelchair without the splint, and the resident indicated that staff could not find it. The DON confirmed that the facility failed to ensure the resident with limited mobility received the appropriate services, equipment, and assistance to maintain or improve mobility.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with complex medical and psychosocial needs. Specifically, care plans for residents with diagnoses such as dementia, depression, diabetes, and neurocognitive disorders did not include individualized instructions or measurable goals and timetables as required by facility policy and regulatory standards. For example, residents with dementia or related symptoms did not have care plans addressing appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Additionally, a resident with ongoing psychotherapy for anxiety and depression did not have a care plan addressing their psychosocial concerns or monitoring for depressive symptoms, despite multiple psychiatry visits and recommendations. Another resident receiving insulin for diabetes lacked a care plan that included the use of insulin and protocols for managing hyperglycemia and hypoglycemia, even though physician orders and medication administration records indicated ongoing insulin therapy. Furthermore, a resident with a neurocognitive disorder and behavioral issues did not have a care plan addressing their cognitive decline, behavioral symptoms, or interventions to manage these behaviors. These deficiencies were confirmed through staff interviews and review of clinical records, demonstrating a pattern of incomplete or missing care plans for residents with significant medical and behavioral needs.
Failure to Follow Physician Orders and Provide Comprehensive Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with diabetes, the facility did not notify the physician of abnormal capillary blood glucose (CBG) readings as required by the physician's order. Specifically, there were instances of both hyperglycemia and hypoglycemia where the clinical records did not show any physician notification or documented interventions, despite clear orders to do so. Interviews with nursing staff confirmed a lack of consistent understanding and adherence to the notification protocol for abnormal blood glucose levels. Two residents with skin condition concerns did not receive comprehensive skin assessments or appropriate care and treatment. One resident had wounds that were not assessed or had dressings changed for several days, resulting in the wounds increasing in size and worsening. Documentation was lacking regarding wound care between dressing changes, and staff interviews confirmed that the wounds were not addressed as needed. Another resident at risk for pressure ulcers did not have a Braden Scale assessment completed for several months, and when fluid-filled blisters were observed, there was no comprehensive skin assessment, care, or notification to appropriate parties documented in the clinical record. Additionally, the facility failed to follow physician orders for vital sign monitoring for a resident with a history of seizures and recent hospitalization. The hospital discharge instructions required vital signs to be taken every four hours, but the clinical record did not show that this was done. The resident's family reported concerns about the discontinuation of an anti-epileptic medication (Keppra) after a 30-day order expired, and the facility did not continue the medication or document a reason for not following the order. Interviews with facility leadership confirmed these failures to follow physician orders and provide the required care.
Failure to Identify, Assess, and Care Plan for Smoking and Elopement Risks
Penalty
Summary
The facility failed to properly identify, assess, and care plan for residents who smoke and those at risk for elopement, as required by facility policy. For two residents, the facility did not timely identify or assess for smoking safety. One resident was not recognized as a smoker during admission, had no completed Smoking Risk Assessment, and lacked a care plan addressing safe smoking, despite being observed smoking in the designated area. Another resident, known by staff to smoke daily and with a diagnosis of nicotine dependence, was not included on the facility's list of current smokers and did not receive required quarterly Smoking Risk Assessments after a certain date. Additionally, the facility failed to reassess a resident after an elopement event and did not develop a comprehensive care plan with interventions to address the risk of elopement. This resident, who was cognitively intact and had a history of non-compliance, was found outside the facility on a motorized scooter without staff knowledge. Although a wanderguard was ordered, the care plan did not include interventions related to the device or address elopement risk, and the resident's information was not included in the elopement binder accessible to staff. Interviews with staff and residents confirmed these deficiencies, with staff acknowledging the lack of timely assessments and care planning. Facility documentation and policy reviews further substantiated that required procedures for identifying, assessing, and care planning for smoking and elopement risks were not followed for the affected residents.
Failure to Maintain Accurate Care Plans and Assessments for Bedrail Use
Penalty
Summary
The facility failed to maintain accurate resident care plans and conduct ongoing assessments regarding the use of bedrails for three residents. For each resident, the clinical records did not include ongoing assessments for bedrail or enabler bar usage, nor did they contain the development of goals and interventions related to this equipment in the care plans. Observations confirmed the presence of bedrails or enabler bars in use, but physician orders were either missing or not reflected in the care plans. Specifically, one resident with diagnoses including high blood pressure, hemiplegia, and depression was observed with enabler bars on the bed, but there was no physician order or care plan documentation for their use. Another resident with cancer, high blood pressure, and anxiety had a physician order for bilateral assistive handrails, but the care plan lacked ongoing assessment and interventions. A third resident with high blood pressure, dementia, and anxiety also had physician orders for assistive handrails, but again, the care plan did not include ongoing assessment or related interventions. Facility policy required evaluation of potential risks associated with bedrail use, including entrapment, prior to installation, and ongoing assessment using a safety checklist. However, review of the clinical records and staff interviews confirmed that these requirements were not met for the three residents in question. The deficiencies were identified through observations, policy review, clinical record review, and staff interviews, and were communicated to the facility's Director.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications and biologicals in multiple medication rooms and a medication cart. Observations revealed expired medications, such as a bottle of stool softener and niacin, were present in the medication storage cabinet. The medication refrigerator was found unlocked and operating above the recommended temperature range, and there were no temperature logs maintained for the refrigerator during specific months. Additionally, the medication room refrigerator on the third floor had missing temperature recordings for several days, and another medication refrigerator was noted to be operating below the recommended temperature range. Staff interviews confirmed these findings, including the lack of temperature monitoring and failure to secure medication storage areas. Further deficiencies were identified on a medication cart, where expired insulin pens and medications without documented open dates were found for several residents. Staff confirmed that these medications were not properly stored or labeled according to facility policy and professional standards. These actions and inactions demonstrate a failure to comply with regulations regarding the secure storage, labeling, and temperature control of medications and biologicals within the facility.
Failure to Prevent Cross Contamination and Maintain Infection Control Surveillance
Penalty
Summary
The facility failed to prevent potential cross contamination in one of three medication refrigerators by allowing an eight-ounce container of milk to be stored in the 2B Nurses Station medication refrigerator, as confirmed by an LPN. This action was not in accordance with the facility's policy, which prohibits food storage in areas designated for medications and biologicals. Additionally, the facility did not implement proper infection control practices during a dressing change for a resident with diagnoses including high blood pressure, COPD, and hypothyroidism. During the dressing change, the LPN did not cleanse the resident's bedside table before setting up the clean field, used gloves stored in her scrub pocket, failed to place a clean field between the resident's wound and bed linens, and did not perform hand hygiene or change gloves between critical steps of the procedure. The bedside table was also not cleansed after the procedure. Furthermore, the facility failed to maintain an infection control program that included consistent surveillance for communicable diseases or infections. Review of infection control documentation revealed that surveillance for tracking resident infections was not conducted for four months within an eleven-month period. The Infection Preventionist confirmed the absence of surveillance for these months, indicating a lapse in the facility's infection prevention and control program.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that required immunizations for influenza and pneumococcal disease were offered and documented for certain residents, as identified through policy review, clinical record review, and staff interview. Specifically, one resident with diagnoses including dementia, high blood pressure, and hyperlipidemia was not offered the influenza vaccine during the current vaccination season, with documentation indicating the vaccine was not offered and no record of administration or refusal. Additionally, two residents with medical histories including high blood pressure, depression, anxiety, hemiplegia, and a history of falls did not have documentation in their clinical records that the pneumococcal vaccine was offered, administered, or declined. The facility's vaccination policy required that influenza, pneumococcal, and COVID vaccines be administered per orders, with consents, refusals, or medical ineligibility documented in the electronic health record. However, review of the Minimum Data Set (MDS) and clinical records for the affected residents showed missing documentation regarding the offering and administration or refusal of these vaccines. The Infection Preventionist confirmed that the facility did not ensure the required immunizations were offered as mandated.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) provided wound care to a resident who had been admitted with diagnoses including high blood pressure, COPD, and hypothyroidism, and who had developed a pressure ulcer on the outer right ankle. During the wound care observation, the LPN wrote on the dressing after it had already been placed on the resident's ankle. This action was confirmed by the LPN during an interview and was determined to be a failure to maintain the resident's dignity, as required by facility policy and resident rights documentation. The report specifically notes that residents are entitled to privacy and to be treated with dignity and respect, and this standard was not upheld in this instance.
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What surveyors actually found near you
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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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Nursing homes near Beaver Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Rehab And Health | 3 mi | ★★★★★ | 54 | 1 |
| Rochester Residence And Care Center | 3.9 mi | — | 58 | 2 |
| Beaver Valley Rehabilitation And Healthcare Center | 6 mi | ★★★★★ | 27 | 0 |
| Concordia At Villa St Joseph | 8.9 mi | ★★★★★ | 17 | 0 |
| Passavant Retirement And Healt | 9.7 mi | ★★★★★ | 18 | 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 October 2026) and official state health department websites.