Providence Point Healthcare Residence
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 200 Adams Ave, Pittsburgh, Pennsylvania 15243
- CMS Provider Number
- 396124
- Inspections on file
- 23
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Providence Point Healthcare Residence during CMS and state inspections, most recent first.
The facility did not provide the opportunity to formulate or periodically review advance directives for several residents with varying medical and cognitive conditions. Clinical records lacked documentation of these required actions, and the NHA confirmed the deficiency during an interview.
The facility did not ensure that comprehensive MDS assessments were accurate and fully completed for several residents. In multiple cases, a resident's ability to be understood was inconsistently documented across different MDS sections, resulting in required cognitive and mood interviews not being conducted. The DON confirmed these assessment inaccuracies and omissions.
A resident admitted for post-surgical care with a cold therapy device did not have all assigned staff adequately trained on its use. Only a portion of the staff received education on the device, and posted instructions in the resident's room did not address its operation or care. The facility confirmed that an effective training program for non-common procedures, such as the use of cold therapy machines, was not developed or maintained.
A resident with severe upper and lower extremity contractures and total care needs was unable to reach the call light or hand bell due to physical limitations. Despite policy and care plan instructions to keep the call light in reach, observations and interviews confirmed the devices were inaccessible, and the care plan did not address the resident's decreased range of motion or need for alternative alert systems.
A resident with a history of high blood pressure, osteoporosis, and post-joint replacement aftercare had her hospital discharge information, including personal and medical details, posted on her wall without her knowledge or consent. This information included her name, medical record number, medications, and follow-up appointments. The facility administrator confirmed that confidentiality requirements were not met.
A resident with dementia, COPD, and diabetes was administered quetiapine, an antipsychotic, without a documented indication or evidence of behavioral symptoms. Physician orders lacked an associated diagnosis, and behavior monitoring showed no behaviors to justify the medication. The facility's failure to ensure drug regimens were free from unnecessary psychotropic drugs was confirmed by the administrator.
A resident admitted for aftercare following joint replacement surgery, with intact cognition and multiple diagnoses, was using a cold therapy device that was not addressed in the comprehensive care plan developed at admission. The omission was confirmed by the Nursing Home Administrator after the resident reported issues with the device and uncertainty about staff knowledge regarding its use.
Two residents did not have care plans that reflected their current needs and provider orders. One resident with hand contractures and limited mobility was unable to use the call light or hand bell, yet the care plan only stated to keep the call light in reach. Another resident with Alzheimer's and dysphagia had a provider order to be out of bed for all meals, but this was not included in the care plan. The DON confirmed the care plans were not updated to provide person-centered care.
A resident admitted for post-operative care following joint replacement did not receive appropriate treatment and services due to the facility's failure to provide timely physician orders, develop a care plan, educate all staff on the use of a cold therapy device, and monitor the resident's skin condition. The resident reported concerns about staff knowledge and device operation, and observations confirmed a lack of clear instructions and staff competency.
The facility did not consistently obtain or document weights for two residents with complex medical conditions, nor did staff act upon significant weight changes as required by care plans and physician orders. Missed weight recordings were attributed to staff being too busy, equipment issues, and lack of follow-through on orders, resulting in inadequate monitoring of nutrition status.
Surveyors identified multiple expired and improperly stored medical supplies, including IV sets, catheters, and dressing change kits, in a medication room. Some supplies were found outside of their packaging, and non-sterile gloves were opened where sterile gloves were required. These issues were confirmed by nursing staff and facility administration, indicating a failure to follow proper storage and disposal protocols.
The facility failed to meet the required staffing levels for nurse aides during the night shift on multiple occasions, with staffing shortages noted on 9 out of 21 days. Despite the regulation requiring one nurse aide per 15 residents overnight, the facility consistently provided fewer aides than needed, as confirmed by the Nursing Home Administrator.
The facility failed to meet the required LPN staffing levels, with shortages during both day and night shifts over a 21-day period. On specific days, the facility did not provide the minimum LPNs needed per resident census, as confirmed by the Nursing Home Administrator.
A resident with multiple health conditions did not receive scheduled medications, including those for blood pressure and heart rate regulation, as documented by an RN. The medications were found in the cart later, and neither the physician nor the resident's representative was notified. The facility failed to document vital signs or assess for ill-effects.
A resident with dementia and multiple medical conditions sustained a skin tear during care due to neglect. The incident occurred when a nurse aide turned the resident, causing pressure and shearing on the resident's folded arms. The facility's Director of Nursing later acknowledged the failure to protect the resident from neglect.
The facility failed to investigate possible neglect and abuse for two residents. One resident with dementia suffered a skin tear during care, which was not classified as neglect by the DON. Another resident with Alzheimer's was transferred without the required assistance, as reported by the family. The facility did not investigate these incidents as potential neglect.
A resident with heart failure and dementia, requiring substantial assistance for daily activities, sustained a leg fracture after sliding off the bed during incontinence care. The CNA providing care was alone and rolled the resident away from herself, contrary to usual practice, leading to the fall. The facility failed to provide appropriate assistance, resulting in actual harm.
Failure to Provide and Review Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to provide residents with the opportunity to formulate an advance directive or to conduct periodic reviews of existing advance directives as part of the comprehensive care planning process. This deficiency was identified for four out of eight residents reviewed. For each of these residents, a review of their clinical records did not show evidence that the facility had offered the chance to create an advance directive or had periodically reviewed the residents' care instructions and whether the residents or their designated surrogates wished to change or continue these instructions. The affected residents had various medical conditions, including heart failure, depression, anxiety, cerebrovascular disease, hypothyroidism, aphasia, skin cancer, osteoarthritis, and Alzheimer's disease. Cognitive assessments such as the Brief Interview for Mental Status (BIMS) indicated varying levels of cognitive impairment among these residents, with some being moderately to severely impaired. Despite these conditions, there was no documentation in the clinical records to show that the facility had addressed advance directives in accordance with its policy and regulatory requirements. The Nursing Home Administrator confirmed this failure during an interview.
Inaccurate and Incomplete MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for six out of fifteen residents. According to the Resident Assessment Instrument (RAI) User's Manual, specific sections of the MDS, such as Section C (Cognitive Patterns) and Section D (Mood), require completion of the Brief Interview for Mental Status (BIMS) and Resident Mood Interview if the resident is at least sometimes understood. However, for the identified residents, there were inconsistencies between their ability to be understood as documented in Section B (Hearing, Speech, and Vision) and the coding in Sections C and D, resulting in the required assessments not being completed. For example, several residents were documented as being 'usually' or 'sometimes' understood in Section B, but were coded as 'rarely understood' in Sections C and D, leading to the omission of the BIMS and Mood Interview assessments. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not ensure the accuracy and completeness of the MDS assessments for these residents.
Failure to Provide Comprehensive Staff Training on Cold Therapy Device
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for staff regarding the use of a cold therapy device, specifically the Breg Polar Care Cube, for a resident who was admitted after a right shoulder replacement. The manufacturer's instructions for the device require specific procedures for safe use, including regular skin inspections and ensuring the device is not run without water. However, the only information posted in the resident's room pertained to general post-operative care and did not include instructions on the use or care of the cold therapy machine. Interviews and documentation revealed that the use of cold therapy machines was not common in the facility, and education on the device was inconsistently provided. While some nurse aides and therapy staff received instruction on the device, this education was not extended to all staff assigned to the resident's care, particularly those on afternoon and evening shifts. Staff members confirmed that not all personnel were trained, and some had never previously cared for a patient using such a device. The deficiency was further substantiated by the resident's own report that staff seemed unaware of how to use the cold therapy machine, and by the facility's own admission that an effective training program, including additional topics based on the resident population and non-common procedures, was not in place. Facility records showed that only a subset of staff received education on the device, despite multiple staff being assigned to the resident's unit during the relevant period.
Failure to Ensure Call Light Accessibility for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with significant upper and lower extremity range of motion impairment and contractures had access to a call light or alert device within reach, as required by facility policy. The resident, who had diagnoses including stroke, diabetes, and heart disease, was documented as needing total care and assistance with activities of daily living and feeding, and was non-ambulatory. Despite care plan instructions to keep the call light in reach at all times, observations and interviews revealed that the resident was unable to reach the call light tube placed on their lap or a hand bell located on a table, due to their physical limitations. Review of the resident's clinical record and therapy notes indicated ongoing issues with contractures and the use of bilateral palm guards, but the care plan did not address the progression of the resident's hand contractures or decreased range of motion that affected their ability to access the call light system or other alert devices. Staff interviews and direct observation confirmed that the resident could not activate the call light or reach the hand bell, and the care plan lacked specific interventions to accommodate these needs.
Failure to Maintain Resident Medical Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information, as required by both facility policy and state regulations. During an interview, a resident indicated that information about her cold therapy device was posted on her wall. Upon review, it was found that a copy of her hospital discharge information was taped to the wall, which included her name, gender, medical record number, birth date, hospital name, medications with dosages and reasons for use, diet order, and follow-up appointment information. The resident confirmed she was unaware of all the information posted and had not given permission for it to be displayed. The resident involved had a history of high blood pressure, osteoporosis, and was receiving aftercare following joint replacement surgery. A recent BIMS assessment indicated she was cognitively intact. The Nursing Home Administrator acknowledged that the facility did not maintain the confidentiality of the resident's medical information, as required by facility policy and state regulations.
Unnecessary Use of Psychotropic Medication Without Adequate Indication
Penalty
Summary
The facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications, as required by policy and regulation. Specifically, a resident with diagnoses of COPD, diabetes, and dementia (without behavioral, psychotic, or mood disturbances) was administered quetiapine, an antipsychotic medication, without an adequate indication for use. The physician orders for quetiapine did not list an associated diagnosis, and the resident's care plan for the medication lacked specific goals or evidence of behavioral symptoms that would justify its use. Behavior monitoring documentation over a two-and-a-half-month period showed no documented behaviors that would warrant antipsychotic therapy. Further review of psychiatric progress notes indicated the resident was diagnosed with major depressive disorder, generalized anxiety disorder, dementia, and primary insomnia, but there was no documentation of psychotic symptoms. Additionally, a psychiatric assessment was unable to be completed due to the resident's excessive sleepiness. During an interview, the Nursing Home Administrator confirmed the failure to ensure that residents' drug regimens were free from unnecessary medications used without adequate indications.
Failure to Include Cold Therapy Device in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included all required elements for a newly admitted resident when using a comprehensive care plan in place of a baseline care plan. Specifically, the care plan did not address the resident's use of a cold therapy device, which was brought with the resident upon admission following a right shoulder replacement. The resident, who had diagnoses including high blood pressure, osteoporosis, and was receiving aftercare for joint replacement surgery, was assessed to have intact cognition. Documentation showed that the cold therapy device was in use, but the comprehensive care plan initiated at admission did not include information or instructions regarding its use. During interviews, the resident reported that the ice in the cold therapy device had been running out and expressed uncertainty about staff understanding of the device's operation, referencing a paper with information taped to her wall. The Nursing Home Administrator confirmed that the facility did not develop a comprehensive, person-centered care plan with all requirements for this resident, as required when a comprehensive care plan is used in place of a baseline care plan.
Failure to Develop and Update Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of cerebrovascular disease, hypothyroidism, and aphasia, clinical records and therapy notes indicated the presence of hand contractures and the need for bilateral palm guards with specific instructions. Despite these documented needs and the resident's inability to reach the call light or hand bell due to contractures, the care plan only included a generic instruction to keep the call light in reach, without addressing the resident's physical limitations or providing alternative alert methods. For another resident diagnosed with Alzheimer's disease, cerebrovascular disease, and dysphagia, a provider's order required the resident to be out of bed for all meals. This instruction was posted on the nursing unit communication board, but the resident's care plan did not include this requirement. The Director of Nursing confirmed that care plans for both residents lacked necessary instructions to provide individualized, person-centered care as indicated by their current conditions and provider orders.
Failure to Provide Appropriate Post-Operative Care and Staff Education for Cold Therapy Device
Penalty
Summary
The facility failed to provide appropriate treatment and services related to post-operative care for a resident who was admitted after a right shoulder joint replacement. The resident was prescribed the use of a cold therapy device (Breg Polar Care Cube) with specific instructions for application duration and the use of a barrier, but the physician's order did not include detailed directions on device operation or necessary safety precautions to prevent skin injury. The resident's comprehensive care plan did not address the use of the cold therapy device or the need for skin monitoring, and there was no timely development of a care plan or orders for monitoring skin health following admission. Staff interviews and documentation revealed that education on the use and care of the cold therapy device was inconsistent and incomplete. While some nurse aides received education from therapy staff, this training was not provided to all shifts, and there was no evidence that all relevant staff were competent in operating the device or monitoring for potential complications. The resident reported that the device frequently ran out of ice and expressed concerns that staff were not knowledgeable about its use. Observations confirmed that instructions posted in the resident's room did not include information on the cold therapy device. The facility's policy required staff to have appropriate competencies to ensure resident safety, but this was not met in the case of the cold therapy device. The Nursing Home Administrator confirmed that there was a delay in obtaining a physician's order for the device, a delay in care planning, a lack of staff education, and no established plan for monitoring the resident's skin condition. These failures resulted in the facility not providing appropriate treatment and services for the resident's post-operative care as required.
Failure to Monitor and Document Resident Weights and Nutrition Status
Penalty
Summary
The facility failed to properly monitor the weight and nutritional status of two residents by not obtaining weights as ordered and not acting upon significant weight changes. For one resident with diagnoses including COPD, diabetes, and dementia, the care plan did not include goals or interventions related to nutrition. Despite physician orders to obtain monthly weights, there were missed weight recordings on multiple occasions, with nursing notes indicating the task was not done or staff were too busy. Additionally, a dietitian's order for special weight monitoring was not carried out, and a subsequent physician order to obtain and document weight was also not completed. For another resident with lymphedema, morbid obesity, and hypertension, the care plan required weight monitoring and notification of the physician for significant weight changes. However, weight documentation was inconsistent, with several missed entries due to resident refusal, equipment issues, or lack of documentation. The facility's failure to consistently obtain and document weights, as well as to act upon notable weight changes, was confirmed by the Nursing Home Administrator during an interview.
Expired and Improperly Stored Medical Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and disposed of on one of its nursing units. During an observation of the Second-Floor Nursing Unit medication room, multiple expired medical supplies were found, including IV administration sets, central line dressing change kits, Sterilux AMD gauze, winged IV catheters, IV catheters, Luer Lok access devices, and syringe tip caps. Additionally, some Sterilux AMD gauze was found outside of its packaging, and a package of non-sterile gloves was opened when sterile gloves were required. These findings were confirmed by a registered nurse during the observation. The facility's policy requires that medications and biologicals be stored safely, securely, and according to manufacturer or supplier recommendations. However, the presence of expired and improperly stored supplies in the medication room indicated non-compliance with this policy. The Nursing Home Administrator confirmed that the facility did not ensure proper storage and disposal of medical supplies on the affected nursing unit.
Night Shift Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides during the night shift on 9 out of 21 days between November 22, 2024, and December 12, 2024. The regulation mandates a minimum of one nurse aide per 15 residents overnight, but the facility did not comply with this requirement on several occasions. For instance, on November 23, 2024, with a census of 42 residents, the facility required 2.80 nurse aides but only provided 2.28. Similarly, on November 24, 2024, with a census of 41, the facility required 2.73 nurse aides but only provided 2.16. These staffing shortages were consistent across multiple dates, with no additional higher-level staff available to compensate for the deficiencies. The Nursing Home Administrator confirmed the staffing shortfalls during an interview on December 12, 2024. The facility's failure to provide the mandated number of nurse aides was evident in the review of nursing time schedules and deployment sheets. The report highlights specific dates and census numbers, illustrating the consistent inability to meet the required staffing levels, which directly led to the deficiency noted by the surveyors.
Plan Of Correction
The facility will correct the deficiency: the administrator educated the director of Nursing and the Staffing Coordinator on PA Code 211.12 as it relates to Staff to resident Ratios and Direct Nursing Care Hours for certified nurse aides for the following dates: 11/23, 11/24, 11/26, 11/27, 11/28, 11/29, 12/03, 12/08, and 12/12/2024. To prevent reoccurrence, the staffing coordinator will ensure that the correct number of NA's are scheduled for each shift (day, evening and night) utilizing the staffing ratio/PPD worksheet and review with the DON daily. The facility will utilize the on-call nursing staff to maintain nursing hours should the facility fall below nursing rations on the overnight shift with an RN within a 30-minute drive from the facility. The facility will continue weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external candidates, and offer referral bonuses to attract and retain staff. The facility will conduct audits by the DON/Designee/Scheduling Coordinator, who will review the worksheet daily for compliance for two weeks, then weekly for two weeks, and continue with weekly review and report quarterly thru QAPI.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as per the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on two occasions and one LPN per 40 residents during the night shift on three occasions within a 21-day period. On November 30, 2024, with a census of 32 residents, the facility required 1.28 LPNs during the day shift but only provided 1.00 LPN. Similarly, on December 1, 2024, with a census of 33 residents, 1.32 LPNs were needed, but only 1.03 LPNs were available. No additional higher-level staff were available to compensate for these deficiencies. During the night shifts on November 22, 23, and 24, 2024, the facility also failed to meet the required LPN staffing levels. With a census of 42 residents on November 22 and 23, 1.05 LPNs were needed, but only 1.00 LPN was provided. On November 24, with a census of 41 residents, 1.03 LPNs were required, yet only 1.00 LPN was available. The Nursing Home Administrator confirmed these staffing shortages during an interview on December 12, 2024, acknowledging the facility's failure to meet the minimum LPN staffing requirements on these specific days.
Plan Of Correction
The facility will correct the deficiency. The administrator educated the Director of Nursing and the Staffing Coordinator on PA Code 211.12 as it relates to Staff to Resident Ratios and Direct Nursing Care Hours for LPN's for the following dates: 11/22, 11/23, 11/24, 11/30, and 12/01/2024. To prevent reoccurrence, the Staffing Coordinator will ensure that the correct number of LPN's are scheduled for each shift (day, evening, and night) utilizing the staffing ratio/PPD worksheet and review with the DON daily. The facility will utilize the on-call nursing staff to maintain nursing hours should the facility fall below nursing ratios on the overnight shift with an RN within a 30-minute drive from the facility. The facility will continue with weekly recruitment and retention meetings to review open positions, post open positions weekly for internal and external candidates, and offer referral bonuses to attract and retain staff. The facility will conduct audits by the DON/Designee/Scheduling Coordinator, who will review the worksheet daily for compliance for two weeks, then weekly for two weeks, and continue with weekly review and report quarterly through QAPI.
Failure to Administer Scheduled Medications and Notify Physician
Penalty
Summary
The facility failed to provide scheduled medication to a resident, identified as Resident R1, who was readmitted with diagnoses including malnutrition, orthostatic hypotension, high blood pressure, and paroxysmal atrial fibrillation. On a specific date, the Medication Administration Record (MAR) indicated that several medications were documented as administered by RN Employee E1, but a subsequent check revealed that the medications were still in the medication cart and had not been given. The medications included Eliquis, Immodium, Klor-Con, Midodrine, and Sotalol, which are critical for managing the resident's conditions. The facility's Medication Error Report and Safety Events documentation showed that the physician and the resident's representative were not notified of the medication omission. Additionally, there was no documentation of vital signs being assessed for potential ill-effects after the missed medications. The Nursing Home Administrator confirmed the lack of documentation and notification, acknowledging the failure to provide care as per the resident's needs and the facility's policies.
Neglect Resulting in Resident Skin Tear
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in a skin tear that required treatment. The incident involved a resident with a medical history of dementia with behavioral disturbances, atrial fibrillation, a pacemaker, difficulty walking, artificial heart valve, artificial knees, left hip, and malnutrition. The resident required assistance from two staff members for care while in bed. During a routine round, a nurse aide turned the resident, causing a skin tear on the left forearm due to the resident's arms being folded, which likely led to pressure and shearing. The incident was reported by the nurse aide to a licensed practical nurse, who observed the skin tear and notified the physician for treatment. The Director of Nursing initially did not identify the incident as neglect but later acknowledged the failure to protect the resident from neglect. The facility's policies on preventing resident abuse and incident reporting were reviewed, indicating that the facility did not adequately protect the resident from neglect, as required by federal regulations.
Failure to Investigate Possible Neglect and Abuse
Penalty
Summary
The facility failed to identify and investigate incidents of possible neglect and abuse for two residents. Resident R7, who has a history of dementia, atrial fibrillation, and other conditions, experienced a skin tear on her left forearm. This occurred when a nurse aide turned her during rounds, and it was reported to an LPN. The Director of Nursing (DON) acknowledged looking into the incident but did not classify it as neglect, despite the skin tear requiring treatment. Resident R28, diagnosed with Alzheimer's disease, dementia, and other conditions, was to be transferred with the assistance of two staff members for safety. However, a grievance was filed by the resident's family, indicating that staff transferred him without a second person, contrary to the physician's order. The Nursing Home Administrator and DON confirmed that the facility did not identify and investigate the potential neglect in this case.
Failure to Provide Appropriate Assistance Resulting in Resident Injury
Penalty
Summary
The facility failed to provide appropriate assistance to prevent falls, resulting in actual harm to a resident who sustained a leg fracture. The resident, who had diagnoses of heart failure and dementia, required substantial to maximal assistance for activities of daily living, including rolling in bed. Despite this, the resident's care documentation showed inconsistencies in the level of assistance provided, with the resident being documented as totally dependent 66% of the time, requiring extensive assistance 28% of the time, and limited assistance 6% of the time over a one-month period. On the night of the incident, two CNAs transferred the resident to bed using a Hoyer lift. One CNA left to attend to other residents, leaving the remaining CNA to provide incontinence care alone. The CNA rolled the resident to her left side, away from herself, which is not the usual practice. The resident began to slide off the bed, and the CNA was unable to prevent the fall due to the resident's size and lymphedema. The resident landed on her knee and buttocks, resulting in a fracture of the distal femoral diaphysis. Interviews with the involved CNA and another staff member confirmed that residents should be rolled towards the person providing care to prevent such incidents. The Nursing Home Administrator in training acknowledged that the facility failed to provide appropriate assistance, leading to the resident's fall and subsequent injury.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
