Quality Life Services - Westmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnstown, Pennsylvania.
- Location
- 787 Goucher Street, Johnstown, Pennsylvania 15905
- CMS Provider Number
- 396132
- Inspections on file
- 25
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Quality Life Services - Westmont during CMS and state inspections, most recent first.
The facility failed to adhere to physician's orders for medication administration for two residents, leading to inappropriate administration of Metoprolol, Amlodipine, Atenolol, and Hydralazine despite contraindicated blood pressure readings. Additionally, a resident received health shakes and fortified foods without a physician's order following hospital readmission. These actions were confirmed by facility staff.
A resident with diabetes did not have their insulin held as ordered by the physician when their blood sugar levels were below the specified threshold. The facility's failure to adhere to the physician's orders resulted in significant medication errors, as confirmed by the Nursing Home Administrator.
The facility failed to maintain sanitary conditions in the main kitchen, with surveyors observing dust and food debris under and behind the ice machine and stove. Items such as a clear drinking glass, a small red bowl, and a [NAME] Cup were also found misplaced. The Dietary Manager confirmed these findings.
The facility's QAPI committee failed to address repeated deficiencies, including inaccurate MDS assessments, inadequate care plans, and issues with medication accountability and food sanitation. Despite previous corrective plans, the same issues were cited again, indicating ineffective implementation.
A resident with a history of psychotic disorder and schizophrenia was verbally abused by a nurse aide, who made inappropriate comments about the resident's behavior. The incident was overheard by a registered nurse supervisor, who failed to report it immediately. The resident could not recall the incident, and other residents reported hearing a loud voice but could not confirm the content.
The facility failed to ensure timely reporting of verbal abuse allegations involving two residents. A resident with schizophrenia was allegedly verbally abused by a nurse aide, but the incident was not immediately reported by the RN supervisor. Another resident with COPD experienced a similar incident, which was delayed in reporting by a nurse aide. Both incidents violated the facility's abuse policy.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect documentation of medication administration. A resident receiving gabapentin for rheumatoid arthritis was not recorded as receiving anticonvulsant medication, while another on Seroquel was not noted as receiving antipsychotic medication. A third resident's gabapentin administration for polyneuropathy was also inaccurately documented. These discrepancies were confirmed by the Nursing Home Administrator.
A facility failed to create a care plan for a resident on Enhanced Barrier Precautions (EBP) due to a surgically implanted drain. Despite physician's orders and EBP signage, there was no documented care plan addressing the resident's specific needs. Staff interviews confirmed the requirement for gown use, but the Nursing Home Administrator acknowledged the lack of a care plan.
A facility failed to monitor a resident's weight as recommended by the dietitian, leading to a deficiency. The resident, who was moderately cognitively impaired, experienced significant weight fluctuations without timely re-weighing as per facility policy. The Director of Nursing and Nursing Home Administrator confirmed the oversight.
A facility failed to maintain accurate records for a resident's controlled medication, Clonazepam, used for anxiety. Although doses were signed out in the drug logs, there was no documentation in the MARs or nursing notes confirming administration on several occasions. The Nursing Home Administrator confirmed the absence of documentation.
A resident with an anxiety disorder was frequently administered Clonazepam without documented attempts of non-pharmacological interventions as required by their care plan. The facility failed to ensure these interventions were tried before medication, as confirmed by the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to discrepancies between the care plans and the residents' current conditions. One resident's care plan inaccurately indicated the use of oxygen and fall mat placement, another's care plan did not reflect the resolution of a pressure ulcer, and a third's care plan did not account for the removal of a PEG tube.
The facility failed to follow physician's orders for medications for three residents. One resident did not have their blood pressure monitored as required, another continued to receive a nutritional supplement after their wound had healed, and a third did not have their blood pressure and heart rate monitored as ordered. These deficiencies were confirmed by the Director of Nursing.
The facility failed to maintain accountability for controlled medications for three residents, as multiple doses of Tramadol, Lorazepam, and Oxycodone were signed out but not documented as administered in the MAR or nursing notes. This deficiency was confirmed by the Director of Nursing.
The facility failed to ensure a clean and homelike environment for a resident who was moderately cognitively impaired and used a wheelchair. Observations revealed a dried, brown/tan, removable substance on the wheelchair, and interviews confirmed the lack of a routine cleaning schedule. The DON stated that wheelchairs were power washed twice a year, but the resident's wheelchair had a removable substance that should have been cleaned.
The facility failed to verify the professional licensure of an LPN with the Pennsylvania State Board of Nursing prior to hire, as required by their abuse policy. This was confirmed by the DON during an interview.
The facility failed to develop individualized care plans for two residents. One resident, who was frequently incontinent, did not have a care plan addressing bladder incontinence. Another resident, with multiple lung-related diagnoses, did not have a care plan for long-term antibiotic therapy. The DON confirmed the absence of these care plans.
A resident at risk for falls, who was cognitively impaired and required assistance for daily care, did not have a tether alarm attached as required by the care plan. This deficiency was confirmed through staff interviews and observations.
The facility failed to obtain physician's orders for oxygen therapy for two residents. One resident with heart failure, respiratory failure, and COPD was using oxygen at 3 L/min without an order, and another resident with pulmonary fibrosis, respiratory failure, and COPD was using oxygen at 7 L/min without an order. The Director of Nursing confirmed the lack of required physician's orders.
A resident with cognitive impairment and diabetes received Novolog insulin on multiple occasions despite blood sugar levels being below the threshold specified in the physician's orders. The Director of Nursing confirmed that the parameters were not followed on 14 occasions, leading to significant medication errors.
The facility failed to discard two expired multi-dose insulin vials and did not securely store medication in the medication cart on B Hall. An LPN left Januvia tablets unsupervised on top of the cart, and the cart was observed unlocked with no staff in view. Insulin vials were not properly labeled or discarded after expiration.
The facility failed to discard an opened, expired container of Miracle Whip salad dressing found in the small kitchen refrigerator, as confirmed by the Dietary Manager.
The facility's QAPI committee failed to correct and maintain compliance with quality deficiencies identified in previous surveys, leading to repeated deficiencies in areas such as comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food procurement-storing/preparing/serving food under sanitary conditions.
Failure to Follow Physician's Orders for Medication and Nutrition
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not adhering to physician's orders for medication administration for two residents. Resident 24, who was cognitively impaired and required maximum assistance, was administered Metoprolol on multiple occasions despite her blood pressure readings being below the hold parameters specified by the physician's orders. This oversight was confirmed by the Nursing Home Administrator. Resident 25, who had hypertension and was understood to be able to communicate, was also administered medications contrary to physician's orders. The resident received Amlodipine and Atenolol despite having blood pressure readings below the specified hold parameters. Additionally, there was no documented evidence that the resident's heart rate was checked before administering Atenolol and Hydralazine, as required by the physician's orders. These discrepancies were confirmed by the Nursing Home Administrator. Furthermore, Resident 14, who was moderately cognitively impaired and had experienced weight loss, continued to receive health shakes and fortified foods without a physician's order following a hospital readmission. The Dietitian and Dietary Manager confirmed that these supplements were provided based on previous orders, but a new physician's order was not obtained upon the resident's readmission. This lack of adherence to obtaining necessary physician's orders contributed to the facility's failure to meet professional standards of practice.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to administer medication as ordered by the physician, resulting in significant medication errors for one resident. The facility's policy required medications to be administered safely and in accordance with physician's orders. However, for Resident 32, who was alert, oriented, and diagnosed with diabetes, the facility did not adhere to the physician's orders regarding insulin administration. The physician had ordered that Insulin Lispro be held if the resident's blood sugar was less than 140 mg/dL. Despite this order, the Medication Administration Records (MARs) for December 2024 and January 2025 showed that Resident 32 received insulin on multiple occasions when their blood sugar levels were below the specified threshold. Specifically, insulin was not held on several dates when the resident's blood sugar ranged from 83 mg/dL to 133 mg/dL. This oversight was confirmed by the Nursing Home Administrator during an interview, acknowledging that the insulin was not held as ordered.
Unsanitary Food Service Conditions
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as observed during multiple inspections of the main kitchen. On three separate occasions, surveyors noted an accumulation of dust and food debris under and behind the ice machine and stove. Additionally, a clear drinking glass, a small red bowl, and a [NAME] Cup were found under and behind the ice machine. These observations were confirmed by an interview with the Dietary Manager, who acknowledged the presence of dust, food debris, and the misplaced items.
Repeated Deficiencies in QAPI Committee's Effectiveness
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included inaccuracies in Minimum Data Set (MDS) assessments, inadequate development of comprehensive person-centered care plans, and issues related to the quality of care. Additionally, the facility struggled with accountability for controlled medications, preventing significant medication errors, and ensuring food was procured, stored, prepared, and served under sanitary conditions. The facility had previously developed plans of correction for these issues, which included conducting audits and reporting results to the QAPI committee. However, the current survey revealed that these plans were ineffective, as the same deficiencies were cited again. The QAPI committee's inability to implement successful corrective actions resulted in ongoing non-compliance with regulations, as indicated by the repeated citations under F641, F656, F684, F755, F760, and F812.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically involving Resident 19. Resident 19, who had a history of a psychotic disorder and schizophrenia, was involved in an incident where Nurse Aide 1 verbally abused the resident. The incident was reported by Registered Nurse Supervisor 2, who overheard Nurse Aide 1 making inappropriate comments to Resident 19, including a statement about the resident's genitalia and urination on the floor. Despite hearing this, Registered Nurse Supervisor 2 did not immediately report the incident to the Nursing Home Administrator or Director of Nursing, citing that Nurse Aide 1 does not listen. The investigation revealed that Nurse Aide 1 admitted to making a comment about the resident's behavior but denied using swear words. Resident 19 was unable to recall the incident, and other residents in the area reported hearing a loud voice but could not confirm the content of the conversation. The facility's abuse policy mandates that all residents be treated with kindness and respect, free from any form of abuse. The failure to immediately address and report the verbal abuse incident led to the deficiency being cited as past non-compliance.
Failure to Timely Report Allegations of Verbal Abuse
Penalty
Summary
The facility failed to ensure timely reporting of allegations of verbal abuse involving two residents. Resident 19, who has a history of a psychotic disorder and schizophrenia, was allegedly verbally abused by Nurse Aide 1. The incident was overheard by Registered Nurse Supervisor 2, who did not immediately report it to the Nursing Home Administrator or Director of Nursing as required by the facility's abuse policy. The verbal abuse involved inappropriate language directed at the resident, but the resident could not recall the incident when interviewed. Another incident involved Resident 136, who has a history of a hip fracture and chronic obstructive pulmonary disease. Nurse Aide 1 was again accused of verbal abuse, this time for using inappropriate language after the resident spilled water on herself. Nurse Aide 3 overheard the incident but did not report it until several hours later, after consulting with a union representative. The resident did not recall the incident when interviewed, and other staff members did not witness the exchange. The facility's policy requires immediate notification of the Nursing Home Administrator or Director of Nursing in cases of suspected abuse. However, both Registered Nurse Supervisor 2 and Nurse Aide 3 failed to adhere to this protocol, resulting in a delay in addressing the allegations. The incidents were eventually reported, but the delay in reporting violated the facility's abuse policy and procedures.
Inaccurate MDS Assessments for Medication Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of medication administration. For Resident 14, physician's orders indicated the administration of gabapentin, an anticonvulsant medication, twice daily and at bedtime for rheumatoid arthritis. However, the MDS assessment inaccurately recorded that the resident did not receive any anticonvulsant medication during the seven-day assessment period. Similarly, Resident 24 was prescribed Seroquel, an antipsychotic medication, to be taken daily, but the MDS assessment incorrectly noted that no antipsychotic medication was administered. Resident 32 was ordered to receive gabapentin three times a day for polyneuropathy, and the Medication Administration Records (MARs) confirmed this administration. Despite this, the MDS assessment for Resident 32 also inaccurately indicated that no anticonvulsant medication was given during the assessment period. These inaccuracies were confirmed during an interview with the Nursing Home Administrator, highlighting a failure in the facility's assessment process as per the guidelines in the Resident Assessment Instrument User's Manual.
Failure to Develop EBP Care Plan for Resident with Drain
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for a resident who was on Enhanced Barrier Precautions (EBP) due to a surgically implanted percutaneous drain. The resident, who was cognitively intact and dependent on staff for daily care tasks, had physician's orders prohibiting showers and requiring daily vigorous flushing of the gallbladder drain. Despite these specific care needs, there was no documented evidence of a care plan addressing the resident's EBP requirements. Observations confirmed the presence of EBP signage and personal protective equipment outside the resident's room, and staff interviews acknowledged the need for gown use when providing care. However, the Nursing Home Administrator confirmed the absence of a care plan addressing the resident's EBP needs.
Failure to Monitor Resident's Weight as Recommended
Penalty
Summary
The facility failed to monitor a resident's weight as recommended by the dietitian, which led to a deficiency. The facility's policy required a re-weight to be obtained within 24 hours if a significant weight change was noted. Resident 14, who was moderately cognitively impaired, experienced a weight loss from 127.4 pounds to 117.8 pounds between December 13, 2024, and January 1, 2025. A dietitian noted the significant weight change on January 9, 2025, and requested a re-weight, but there was no documented evidence that this re-weight was obtained. Subsequently, on January 16, 2025, the resident's weight was recorded as 136.2 pounds, indicating a gain of 18.4 pounds. However, a re-weight was not documented until January 21, 2025, when the resident's weight was 116.4 pounds. An interview with the Director of Nursing and Nursing Home Administrator confirmed that the re-weights were not conducted according to the dietitian's recommendations or the facility's policy.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. A quarterly Minimum Data Set (MDS) assessment for the resident revealed that they were understood, could understand others, and had a diagnosis of anxiety. The care plan indicated the use of anti-anxiety medications as ordered by the physician. Physician's orders included a prescription for Clonazepam, a narcotic medication, to be administered every eight hours as needed. However, the controlled drug logs for January and February showed that staff signed out doses of Clonazepam for administration on several specific dates and times. Despite this, there was no documented evidence in the resident's clinical record, including the Medication Administration Records (MARs) and nursing notes, that the Clonazepam was actually administered on those dates and times. An interview with the Nursing Home Administrator confirmed the lack of documentation for the administration of the medication.
Failure to Attempt Non-Pharmacological Interventions Before Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering anti-anxiety medication to a resident. The resident, who was diagnosed with an anxiety disorder, had a care plan that required staff to try non-medication interventions such as massage, music, or quiet time before offering as-needed psychotropic medication. Despite this, the resident was frequently administered Clonazepam without documented evidence of attempting these non-pharmacological methods first. The resident's Medication Administration Records for January and February 2025 showed multiple instances where Clonazepam was given for anxiousness or restlessness, yet there was no documentation of non-medication interventions being tried beforehand. An interview with the Nursing Home Administrator confirmed the lack of documentation for these interventions, indicating a failure to adhere to the care plan and regulatory requirements.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were updated and revised to reflect their specific care needs. For Resident 1, the care plan indicated the use of oxygen for a respiratory illness, but observations revealed no oxygen in the room, and the resident did not have orders for oxygen use. Additionally, the care plan for fall prevention was inaccurate, as it specified a fall mat on the right side of the bed, while the mat was observed on the left side. The Director of Nursing confirmed these discrepancies and acknowledged that the care plan should have been updated accordingly. Resident 4's care plan included a focus on a Stage 2 pressure ulcer to the sacrum, which was resolved as per a nurse's note, but the care plan was not updated to reflect this resolution. Similarly, Resident 12's care plan indicated a risk for self-injury related to a PEG tube, which had been removed, but the care plan was not updated. The Director of Nursing confirmed that the care plans for both residents should have been updated to reflect their current conditions.
Failure to Follow Physician's Orders for Medications
Penalty
Summary
The facility failed to ensure that physician's orders for medications were followed for three residents. Resident 1, who was cognitively impaired and had diagnoses including heart failure, high blood pressure, and dementia, had physician's orders to monitor blood pressure before administering certain medications. However, there was no documented evidence that the blood pressure was being monitored as required. This was confirmed by the Director of Nursing during an interview. Resident 4, who was cognitively intact and had a Stage 2 pressure ulcer, had a physician's order to receive a nutritional supplement, Expedite, for 14 days or until the wound was healed. Despite the wound being resolved, the resident continued to receive the supplement for 22 days beyond the resolution. Resident 12, who was cognitively impaired and had diagnoses including heart failure, respiratory failure, and chronic obstructive pulmonary disease, had physician's orders to monitor blood pressure and heart rate before administering Metoprolol. There was no documented evidence that these vital signs were being monitored, which was also confirmed by the Director of Nursing.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents. For Resident 1, who was cognitively impaired and had diagnoses including heart failure and dementia, there were multiple instances where Tramadol was signed out but not documented as administered in the Medication Administration Record (MAR) or nursing notes. The Director of Nursing confirmed the lack of documentation for these doses during an interview. Similarly, Resident 30, who was cognitively intact and had diagnoses including pulmonary fibrosis and anxiety disorder, had several doses of Lorazepam signed out without corresponding documentation of administration in the MAR or nursing notes. This was also confirmed by the Director of Nursing during an interview. Lastly, Resident 31, who was cognitively intact and had undergone spinal fusion surgery, had multiple doses of Oxycodone signed out without documented evidence of administration in the MAR or nursing notes. The Director of Nursing confirmed this deficiency as well during an interview. The facility's policy on medication administration requires that all administered medications be documented on the MAR, including the initials and time of administration for as-needed medications. However, the review of clinical records and controlled drug records for the three residents revealed a failure to adhere to this policy. The lack of documentation for the administration of controlled medications such as Tramadol, Lorazepam, and Oxycodone indicates a significant lapse in maintaining accountability for these drugs, which have a high potential for abuse. This deficiency was confirmed through staff interviews and a review of the facility's policies and clinical records.
Failure to Maintain Clean Wheelchair
Penalty
Summary
The facility failed to ensure a clean and homelike environment for Resident 18, who was moderately cognitively impaired, required assistance for daily care needs, had impairment on one side of the upper and lower extremities, and used a wheelchair. Observations on two separate occasions revealed that Resident 18's wheelchair had a dried, brown/tan, removable substance on the metal bars. Interviews with nurse aides confirmed the presence of the substance and indicated that there was no routine cleaning schedule for wheelchairs. The Director of Nursing stated that wheelchairs were power washed twice a year, but Resident 18's wheelchair had a removable substance that should have been cleaned.
Failure to Verify Professional Licensure
Penalty
Summary
The facility failed to complete a professional licensure verification with the Pennsylvania State Board of Nursing prior to hiring a Licensed Practical Nurse (LPN). The facility's abuse policy, dated October 12, 2023, required that all staff meet regulatory standards for hire, including verification of nursing licenses. However, the personnel file for an LPN hired on January 4, 2024, showed that as of April 2, 2024, the licensure verification had not been completed. This was confirmed by the Director of Nursing during an interview on April 2, 2024, at 11:39 a.m. The failure to verify the LPN's professional licensure was a violation of the facility's own policies and state regulations.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized care plans that included resident-centered interventions for two residents. Resident 23, who was cognitively intact and frequently incontinent of bowel and bladder, did not have a care plan addressing his bladder incontinence. This was confirmed by the Director of Nursing during an interview, and it was noted that the care plan should have been developed based on the resident's needs and the facility's policy. Similarly, Resident 30, who was cognitively intact and had multiple diagnoses including pulmonary fibrosis, respiratory failure, and COPD, did not have a care plan addressing the need for long-term antibiotic therapy. Despite physician's orders for the resident to receive sulfamethoxazole-trimethoprim, there was no documented evidence of a care plan for this treatment. The Director of Nursing confirmed the absence of the care plan during an interview, acknowledging that it should have been in place.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place as care planned for a resident who was at risk for falls. The resident, who was cognitively impaired and required assistance for daily care needs, had a history of tripping over oxygen tubing due to poor balance. A care plan intervention required the use of a tether alarm to prevent falls. However, during an observation, it was found that the alarm was not attached to the resident as required by the care plan. The deficiency was confirmed through staff interviews and observations. The resident was observed lying in bed with the alarm on the enabler bar but not attached to her. An LPN confirmed that the alarm should have been attached to the resident. The Director of Nursing also confirmed that the alarm should have been in place, indicating a failure to follow the care plan designed to minimize fall risks for the resident.
Failure to Obtain Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order was obtained to provide oxygen therapy for two residents. Resident 12, who was cognitively impaired and had diagnoses including heart failure, respiratory failure, and chronic obstructive pulmonary disease, was observed using supplemental oxygen at 3 liters per minute without a corresponding physician's order. The Director of Nursing confirmed that there was no physician's order for the oxygen therapy being administered to Resident 12, despite the care plan indicating the need for oxygen due to chronic obstructive pulmonary disease. Similarly, Resident 30, who was cognitively intact and had diagnoses including pulmonary fibrosis, respiratory failure, and chronic obstructive pulmonary disease, was observed using supplemental oxygen at 7 liters per minute without a physician's order. The Director of Nursing also confirmed that there was no physician's order for the oxygen therapy being administered to Resident 30, despite the care plan indicating the need for oxygen due to her medical conditions. These findings indicate a failure to adhere to the facility's policy for oxygen administration, which requires a physician's order for such therapy.
Failure to Adhere to Physician's Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one of the residents reviewed. Resident 12, who was cognitively impaired and required assistance for daily care needs, had a physician's order to receive 5 units of Novolog insulin before meals, with the instruction to hold the insulin if the Accucheck reading was 150 mg/dL or less. However, the review of the March 2024 Medication Administration Record (MAR) revealed that the resident received 5 units of Novolog insulin on multiple occasions despite having blood sugar levels below the specified threshold. Specifically, the insulin was administered at 8:00 a.m. on March 1, 2, 7, 13, 17, 18, 25, and 31, and at other times on March 2, 7, 12, 13, 21, and 31, even though the blood sugar readings were below 150 mg/dL on these dates. An interview with the Director of Nursing on April 2, 2024, confirmed that the parameters set by the physician's orders were not followed on 14 occasions, resulting in the administration of Novolog insulin to Resident 12 when it should have been withheld. This failure to adhere to the physician's orders constitutes a significant medication error, as the insulin was given despite the resident's blood sugar levels being below the threshold specified in the orders.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to discard two expired multi-dose insulin vials and did not securely store medication in the medication cart on B Hall. During a medication pass, an LPN left a card of Januvia tablets unsupervised on top of the medication cart while entering a resident's room. Additionally, the medication cart was observed to be left unlocked with no staff in view. The Director of Nursing confirmed that medications should not be left unsupervised and the cart should be locked when not in use or view. Further observations revealed that a multi-use vial of Lantus insulin for one resident was not labeled with the date it was opened, and another vial for a different resident was labeled with an expired date but not discarded. The LPN confirmed that the insulin should have been labeled when opened and discarded after expiration. The Director of Nursing also confirmed these findings, indicating that the facility's policies were not followed regarding medication labeling and storage.
Expired Food Item Not Discarded
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety by not discarding an opened, expired food item. The facility's policy required staff to date food items when opened and discard them by the stamped expiration date. During an observation in the small kitchen refrigerator, an opened container of Miracle Whip salad dressing with a resident's name on it was found without a use-by date and with a stamped expiration date that had passed. The Dietary Manager confirmed that the expired item should have been discarded but was not.
Repeated Deficiencies in Quality Assurance and Compliance
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and maintain compliance with quality deficiencies identified in previous surveys. The deficiencies were related to comprehensive care plans, care plan timing and revision, quality of care, safe environment/supervision, respiratory care, pharmacy services, labeling and storage of drugs/biologicals, and food procurement-storing/preparing/serving food under sanitary conditions. Despite developing plans of correction that included quality assurance systems and audits, the facility did not achieve ongoing compliance with these regulations as evidenced by repeated deficiencies in the current survey. The deficiencies were identified in multiple areas, including comprehensive care plans (F656), care plan timing and revision (F657), quality of care (F684), safe environment/supervision (F689), respiratory care (F695), pharmacy services (F755), labeling and storage of drugs/biologicals (F761), and food procurement-storing/preparing/serving food under sanitary conditions (F812). The facility's QAPI committee was responsible for reviewing audit results and ensuring compliance, but the current survey revealed that the committee failed to maintain ongoing compliance with these regulations, leading to repeated deficiencies.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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