Rehabilitation Center At Jefferson Hills, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson Hills, Pennsylvania.
- Location
- 540 Coal Valley Road, Jefferson Hills, Pennsylvania 15025
- CMS Provider Number
- 395948
- Inspections on file
- 22
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Rehabilitation Center At Jefferson Hills, The during CMS and state inspections, most recent first.
Surveyors found that multiple residents lived in rooms with dusty taped ceiling vents, baseboard molding pulled away from walls along their full length, and an in-use electrical outlet junction box with a visible hole near the floor by a bed. The affected resident and family reported these conditions had existed since admission. Additional issues included a cracked, partially patched, and unpainted ceiling area in a hallway, unpainted patched spots on hallway handrails, and a large dust-covered vent in the PT department. The NHA confirmed these environmental problems and that the facility did not provide a safe, clean, comfortable, and homelike environment as required by policy and state regulations.
The facility failed to ensure residents could anonymously file grievances by maintaining grievance boxes in three locations (lobby, north unit, south unit) at heights above ADA-recommended ranges and in positions visible to staff and sometimes blocked by furniture or equipment. Residents reported they could not reach some boxes, that they were not suitable for wheelchair users, and that staff visibility and the need to ask for assistance discouraged anonymous written complaints, leading them to instead ask staff to file grievances verbally. The Nursing Home Administrator confirmed that the grievance boxes were not accessible to residents, constituting a failure to honor resident rights.
Surveyors found that the facility did not maintain an ongoing activity program to meet residents' physical, mental, and psychosocial needs. Activity calendars over several months showed only one daily group activity at 1 p.m. on weekdays, limited rotating activities on Saturdays, and no group activities on Sundays, with only a cart of independent items offered. During interviews, residents reported wanting more activities and social interaction, stating there was little to do on weekends. The Activities Director confirmed there was no weekend activity coverage since an activity assistant left months earlier and acknowledged that only one weekday group activity was provided, and the NHA confirmed the failure on one of five units.
Surveyors found that the facility’s activities program was being directed by an individual who lacked required qualifications, including prior activities experience, therapeutic services education, social work or OT training, or a recreational services background. The Activities Director confirmed this lack of relevant education and experience. The facility’s OT reported having no oversight or involvement with the activities program, and the COTA/rehab director stated her role was limited to completing the mobility portion of the activities assessment without further involvement in activities programming or supervision. The NHA acknowledged that the facility did not have a qualified professional overseeing the activities department.
Surveyors found that the facility did not follow ordered pressure ulcer prevention and treatment interventions for three residents with existing pressure ulcers or identified risk. One resident with hemiplegia and a Stage III ulcer was repeatedly observed in bed without heel offloading or the ordered palm guard, despite care plan and physician orders, and an LPN confirmed these devices were not in place. Another resident with Parkinson’s disease and a Stage IV ulcer, assessed as high risk and needing assistance to roll, was observed multiple times lying on her back without the ordered wedge cushion in use, while the wedge sat unused in a nearby chair, and the resident indicated staff did not assist with wedge positioning. A third resident with hemiplegia, aphasia, and moderate risk for pressure ulcers was observed on several occasions without the ordered positioning wedge, and an LPN confirmed the resident did not have one, while leadership acknowledged the failure to provide the prescribed pressure ulcer care and prevention services.
Surveyors found that medications and medical supplies were not stored and managed according to policy. In one medication room, numerous expired items were present, including blood collection tubes, vacutainers, IV start kits, IV extension sets, syringes, antibiotic ointment, cleansing towelettes, and oral fluid collection devices, along with a partially used, undated vial of tuberculin solution in the refrigerator. On a medication cart, open multi-dose ophthalmic medications (Timolol, Dorzolamide/Timolol, and Latanoprost) were found without open dates on the bottles or storage containers. An LPN and the DON confirmed the presence of expired supplies and unlabeled, open medications.
The facility did not ensure residents had reasonable access to mail services by failing to provide Saturday mail delivery. Facility policy required mail to be delivered to residents and outgoing mail sent within 24 hours of postal service delivery or availability, but activity calendars for several months showed mail delivery only Monday through Friday. During a group interview, residents reported that mail and mail services were not provided on Saturdays. The Activities Director stated she does not deliver mail on weekends because she is not present and is the only staff member in the activity department, and the Business Office Manager reported there is no Saturday postal delivery to the facility. The NHA and DON confirmed that residents were not provided mail delivery on Saturdays, contrary to policy and resident rights requirements.
Surveyors found that the facility failed to maintain a safe environment when the biohazardous waste room was repeatedly left unlocked with multiple sharps containers and biohazard bags accessible, and the beauty shop was left unlocked with an environmental services cart containing cleaning supplies and a large putty knife. The staff restroom door was not fully closed and lacked an emergency call light or call cord, yet remained unlocked and accessible to residents. An LPN confirmed these conditions during interview, and the administrator acknowledged the failure to provide a safe environment on one nursing unit.
Surveyors found that the facility did not display required written information in common posting areas, such as the lobby and hallways near nursing units, explaining how residents and their representatives can apply for and use Medicare and Medicaid benefits and obtain refunds for previous payments covered by those programs. During an interview, the NHA confirmed that this information was not posted anywhere in the building, resulting in noncompliance with state requirements for licensee responsibility and management.
The facility failed to follow its own staff development policy requiring ongoing education on resident needs and rights. Review of training records showed that multiple nurse aides, LPNs, an RN, and therapy staff did not receive resident rights education at hire or during required annual in-service periods. In total, nine of thirteen reviewed direct care staff members lacked documented training on resident rights, a deficiency confirmed by the Nursing Home Administrator during surveyor interview.
Surveyors found that the facility did not provide required Quality Assurance and Performance Improvement (QAPI) education to most of the sampled staff. Review of the staff development policy showed an expectation for ongoing coordinated education, but records revealed that multiple nurse aides, LPNs, an RN, therapy staff, a dietary worker, and an environmental services worker lacked documented QAPI training either at hire or during required annual in-service periods. The administrator confirmed that eleven of fifteen reviewed employees had not received the mandated QAPI training.
A resident with cognitive impairment and a history of wandering exited the facility unsupervised after staff failed to monitor the front entrance and did not implement elopement prevention interventions in the care plan. The resident was later found by police in a nearby neighborhood and taken to the ED. The incident exposed lapses in supervision, documentation, and adherence to elopement protocols.
The facility did not maintain emergency lighting as required, as observed when the battery back-up light in the generator room failed to illuminate during a test. This was confirmed by interviews with the facility's Owner, Administrator, and Maintenance Director.
The facility was found to be non-compliant with building construction requirements as it is a two-story, Type III (200), unprotected ordinary structure with a basement and attic, which is fully sprinklered. This type of construction is not permitted to exceed one story in height. An interview with the facility's Owner, Administrator, and Maintenance Director confirmed the non-compliance.
A resident with specific hygiene preferences and medical conditions did not receive the required number of showers or baths, as per facility policy. Despite expressing the importance of choosing their bathing method, the resident received mostly bed baths, with many months lacking any showers. The DON confirmed this inconsistency in care.
The facility failed to assess, document, and notify physicians of abnormal blood glucose levels for two residents, leading to a deficiency in care. One resident had critically low CBG levels, while another had a high CBG level, yet the facility did not follow care plans or notify physicians. Interviews revealed inconsistencies in staff actions, and the DON confirmed the failures.
A facility failed to ensure accurate documentation of a resident's cognitive assessment. The resident's MDS assessments showed a decline in BIMS scores, indicating cognitive impairment, but progress notes consistently recorded a higher score. The DON confirmed the documentation was inaccurate and incomplete, and the facility lacked a specific policy for clinical record documentation.
A facility failed to notify a resident's family of a change in condition in a timely manner. The resident, admitted with dementia and a fractured leg, developed a possible pressure ulcer. Despite facility policy requiring notification of skin integrity changes, there was no evidence the family was informed. The DON confirmed this oversight.
A facility failed to maintain accurate medical records for a resident admitted with dementia and a leg fracture. A physician's order for wound care on the resident's feet was incorrectly documented, as confirmed by LPNs and the DON. The resident's TAR showed treatment was applied, but weekly skin checks indicated no wounds. The error was due to documentation being entered on the wrong chart.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
The facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment on one of two nursing units (North Nursing Unit). Surveyors observed that two residents had tape surrounding their ceiling air vents, with dust collected on both the vents and the tape. Four residents had rubber baseboard molding pulled away from the wall for the entire length of the wall in their rooms. One of these residents also had an approximately 30.61-millimeter hole in the wall at an outlet junction box that was in use, located near the floor between the head of the bed and the outside wall. The resident and his parents confirmed that the room conditions had been present since admission. Additional environmental deficiencies were identified in common areas. In the hallway outside a resident room, the ceiling had a cracked, partially patched, and unpainted area. Handrails in the North Hallway had unpainted patched spots on both sides of the hall. In the Physical Therapy Department, a large vent in the middle of the room had dust woven throughout the vent. During rounds and interview, the Nursing Home Administrator confirmed these findings and acknowledged that the facility failed to provide a safe, clean, comfortable, and homelike environment, in violation of facility policy and applicable state regulations (28 Pa. Code 207.2(a) and 201.29(k)).
Inaccessible and Non-Private Grievance Boxes Limit Anonymous Resident Complaints
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal by not providing accessible grievance boxes in three locations: the main lobby, and the north and south nursing units. Facility policy on grievances/complaints, reviewed on 1/16/25, allows grievances to be submitted orally or in writing and filed anonymously. During a resident group interview, residents reported they did not feel they could anonymously file grievances in the grievance boxes. They stated that some boxes were too high to reach, not designed for people in wheelchairs, and that the boxes were in view of staff, requiring them to ask staff for help, leading them to instead verbally ask staff to file grievances for them. On observation and measurement conducted with the Nursing Home Administrator, the grievance box in the lobby was found to be mounted at 54 inches from the floor, the north nursing unit box at 53 inches, and the south nursing unit box at 57 inches, all above the ADA-recommended operable part height range of 15 to 48 inches. The lobby box was in view of the reception desk and partially blocked by a chair, the north nursing unit box was in view of the nursing station, and the south nursing unit box was blocked by a cart with a cooler and also in view of the nursing station. During an interview, the Nursing Home Administrator confirmed that the facility failed to make the grievance boxes accessible to residents, in violation of 28 PA Code: 201.18(e)(4) Management and 28 PA Code: 201.29(a)(b)(c) Resident rights.
Failure to Provide Ongoing, Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents. Review of activity calendars from September 2025 through February 2026 showed that there were no group activities scheduled on Sundays and that, on weekdays, only one group activity was scheduled at 1:00 p.m. following lunch. The calendars indicated daily 9:30 a.m. one-on-one visits consisting of distributing a written Daily Chronicle for residents to read, 11:30 a.m. lunch, and a single 1:00 p.m. group activity Monday through Friday. On Saturdays, the 1:00 p.m. activity rotated among puzzles, coloring, and games, and on Sundays the only listed offering was a 1:00 p.m. "residents' choice" cart with books, magazines, and items for residents to use independently in their rooms. During a group interview, residents reported that they would like additional activities and stated there was only one activity during the week at 1:00 p.m. They expressed that they wanted to participate in activities rather than just having a cart brought around for independent use in their rooms, and they specifically noted that they enjoyed the socialization of group activities and that there was not much to do on weekends. The Activities Director stated there was no activity department coverage on weekends since the activity assistant left approximately six months earlier and confirmed there was only one group activity during the week at 1:00 p.m. The Activities Director also reported not being in the building to confirm weekend activities. The Nursing Home Administrator confirmed that the facility failed to provide an ongoing program of activities to meet residents' interests and support their physical, mental, and psychosocial well-being on one of five nursing units, in violation of 28 Pa. Code 201.18(b)(3) and 207.2(a).
Unqualified Individual Directing Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional. The Activities Director’s job description stated that the position’s primary purpose was to plan, organize, implement, evaluate, and direct activity programs in accordance with federal, state, and local standards, and as directed by the administrator, to meet residents’ emotional, recreational, and social needs on an individual basis. Review of the Activities Director’s (Employee E1) personnel record showed she was hired on 1/9/25, but there was no documentation of prior experience as an Activities Director, education in therapeutic services, education as a social worker or occupational therapist, or a background in recreational services. During interviews, the Activities Director (E1) confirmed she did not have education in therapeutic services, social work, occupational therapy, or recreational services. The facility’s Occupational Therapist (E3) confirmed she had no oversight or involvement with the activity program and that she was the only regularly scheduled OT for the facility. The Certified Occupational Therapy Assistant and Rehabilitation Services Director (E2) stated she only completed the mobility portion of the activities assessment in the clinical record and had no other involvement or oversight of the activities department programming or staff. The Nursing Home Administrator confirmed that the facility failed to ensure the Activities Department had a qualified director to oversee the activities program, in violation of 28 Pa Code 201.18(b)(3) and 201.189(e)(6).
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed treatments and services for pressure ulcer care and prevention for three residents identified as being at risk or already having pressure ulcers. Facility policy required residents to receive skin care, repositioning, and nutritional support to prevent avoidable pressure ulcers, and the Braden Scale was used to identify risk levels. For one resident with hemiplegia, diabetes, hypertension, and a documented Stage III pressure ulcer, the care plan and physician orders required offloading both heels while in bed, turning and repositioning every two hours, and wearing a palm guard on the left hand except during hygiene. The treatment administration record showed the palm guard was only documented as applied on two days, and multiple observations over several days found the resident lying on his back with heels not offloaded and without the palm guard in place. The resident reported that staff only sometimes assisted with heel elevation or palm guard application, and an LPN confirmed during interview that the resident’s heels were not offloaded and the palm guard was not in place. A second resident, with Parkinson’s disease, diabetes, muscle weakness, and a documented Stage IV pressure ulcer, was assessed as high risk for pressure ulcer development and required assistance to roll in bed. The care plan and physician orders directed that heel pillow boots be on when in bed, that the resident be turned and repositioned every two hours, and that a wedge cushion be used every four hours to offload the buttocks. During multiple observations on consecutive days, the resident was seen lying on her back without the wedge in place, while the wedge was observed in a chair next to the bed. When asked if staff assisted with positioning the wedge, the resident indicated negatively, and there was no indication in the report that the ordered offloading with the wedge was being implemented as prescribed. A third resident, with hemiplegia, aphasia, a history of stroke, and identified as at moderate risk for pressure ulcer development, required assistance to roll in bed. The care plan and physician orders required turning and repositioning every two hours and obtaining a wedge for offloading while in bed. Across several observations on different days, this resident was repeatedly observed in bed without a wedge in place. An LPN confirmed that the resident did not have a positioning wedge, despite the existing order. In a subsequent interview, the Nursing Home Administrator and the Director of Nursing acknowledged that the facility failed to provide the prescribed treatments and services related to pressure ulcer care and prevention for three of six residents reviewed, in violation of applicable state regulations regarding resident rights, resident care policies, and nursing services.
Failure to Properly Store, Label, and Remove Expired Medications and Supplies
Penalty
Summary
Surveyors identified that medications and related medical supplies were not stored and managed according to facility policy and regulatory requirements. Review of the facility’s “Storage of Medications” policy stated that medications must be stored in a safe, secure, and orderly manner in accordance with federal and state regulations. During an observation of the North Unit medication room, surveyors found multiple expired items, including blood collection tubes, vacutainers, IV start kits, IV extension sets, syringes, antibiotic ointment packets, cleansing towelettes, and oral fluid collection devices, all with past expiration dates. In addition, a partially used vial of tuberculin solution was found in the medication room refrigerator without any date indicating when it had been opened. A nurse (LPN) confirmed these observations at the time of the survey. Further observations of the South Unit medication cart revealed that several multi-dose ophthalmic medications were open and undated. Specifically, bottles of Timolol eye drops, Dorzolamide/Timolol, and Latanoprost were found open with no dates on either the bottles or their storage containers to indicate when they had been opened. The LPN using the cart acknowledged that these undated multi-dose medications were already present on the cart when medication administration began. In a subsequent interview, the DON confirmed that the facility failed to ensure that unlabeled medications were present on one of two medication carts and that out-of-date supplies were not properly stored or disposed of in one of two medication storage rooms.
Failure to Provide Residents with Saturday Mail Delivery and Access to Mail Services
Penalty
Summary
The facility failed to provide residents with reasonable access to mail services comparable to those available in the community by not delivering mail on Saturdays. The facility’s mail policy, last reviewed on 12/5/25, required delivery of incoming mail or other materials to residents within 24 hours of postal service delivery (or to the facility post office box) and delivery of outgoing mail to the postal service within 24 hours when there is no regularly scheduled postal delivery and pick-up service. During a resident group interview on 2/11/26, residents reported that mail was not delivered and mail services were not provided on Saturdays. Review of facility activity calendars for the six-month period from 9/25 through 2/26 showed that mail delivery was listed as occurring Monday through Friday only. The Activities Director stated she does not deliver mail on Saturdays because she is not in the building on weekends and is the only employee in the activity department. The Business Office Manager reported that the facility does not receive mail delivery from the postal service on Saturdays. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure mail was delivered to residents on Saturdays, in violation of resident rights and applicable state regulations.
Unlocked Hazardous Areas and Lack of Call System in Staff Restroom
Penalty
Summary
Surveyors identified that the facility failed to ensure certain areas were free from accident hazards and adequately supervised. On multiple observations over several days, the biohazardous waste room was found unlocked, with 13 sharps containers on a shelf and two large biohazardous waste bags containing multiple sharps containers on the floor. The beauty shop was also observed unlocked, with an environmental services cart containing cleaning supplies and a large putty knife on top. Additionally, the staff restroom door was observed not fully closed, and the room lacked an emergency call light or call cord for emergency use. Further observations confirmed that on subsequent days the biohazardous waste room and staff restroom remained unlocked and accessible to residents. During interviews, an LPN acknowledged that the biohazardous waste room was unlocked and then engaged the locking mechanism, and also confirmed that the staff restroom was unlocked, accessible to residents, and did not have a call light available. The Nursing Home Administrator confirmed that the facility failed to provide a safe environment for residents on one of two nursing units, in violation of applicable Pennsylvania regulations regarding management, staff development, and resident rights.
Failure to Post Required Medicare/Medicaid Information for Residents
Penalty
Summary
The facility failed to display required written information for residents and/or their responsible persons on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits. During observations on 2/11/26 at approximately 11:30 a.m., surveyors inspected the first-floor lobby and hallways in and around the nursing units, where postings are typically available, and found that information on applying for Medicare and Medicaid and obtaining refunds for prior payments covered by these programs was not posted. In a subsequent interview on 2/12/26 at 9:00 a.m., the Nursing Home Administrator confirmed that the facility had not displayed this required written information anywhere in the building. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.18(e) Management.
Failure to Provide Required Resident Rights Training to Direct Care Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide required training on resident rights as part of its staff development program. The facility’s policy, last reviewed on 12/5/25, states that there shall be an ongoing, coordinated education program for facility personnel, including training related to the needs and rights of residents. Review of facility documents and in-service training records showed that multiple staff members lacked documented education on the resident rights program, either at the time of hire or during the required annual in-service period. Specifically, a nurse aide hired on 10/24/25 and another nurse aide hired on 11/23/25 did not receive resident rights education upon hire or thereafter. Additional nurse aides, LPNs, an RN, and therapy staff did not have documented resident rights in-service education during the applicable annual periods following their hire dates. In total, nine of thirteen reviewed staff members, including nurse aides, LPNs, an RN, and therapy employees, were found without the required resident rights training. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide resident rights training for these nine staff members, in violation of 28 Pa Code: 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Provide QAPI Training to Majority of Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required Quality Assurance and Performance Improvement (QAPI) training to the majority of sampled staff. Review of the facility’s Staff Development Program policy, last reviewed on 12/5/25, showed that the facility was to maintain an ongoing, coordinated education program for personnel, including training related to residents’ problems, needs, rights, and technology. However, review of facility documents and personnel in-service training records revealed that eleven of fifteen staff members lacked documented QAPI education as required by this program. The missing QAPI training affected multiple disciplines and hire dates. Several nurse aides (employees E5, E6, and E7) did not receive QAPI education upon hire or within the specified annual in-service periods. Two LPNs (employees E9 and E10) and one RN (employee E11) similarly lacked QAPI in-service education during their respective annual review periods. Therapy staff (employees E12 and E13), a dietary employee (E14), and an environmental services employee (E15) also had no documented QAPI training either upon hire or within the designated annual timeframes. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for eleven of the fifteen reviewed staff members, in violation of 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c).
Failure to Prevent Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for wandering and exit-seeking behaviors. The resident had a history of cognitive impairment, poor decision-making skills, and demonstrated wandering and exit-seeking behaviors, as documented in an Elopement Risk Assessment. Despite these findings, the resident's care plan did not include any interventions to address elopement risk, and there were no physician orders for elopement prevention measures. On the day of the incident, the resident was last seen by staff in a recliner in the community room and later in another resident's room before being returned to his own room around 7:30 p.m. The resident was left unsupervised, and staff failed to monitor the front door, which allowed the resident to exit the facility without detection. The absence of supervision at the front desk was confirmed by video footage, contradicting an initial staff statement. The facility did not document the resident's wandering behaviors in the progress notes, and there was no immediate notification to local authorities by the facility when the resident was discovered missing. The resident was found by police in a nearby residential area without shoes and with no memory of how he arrived there. The police were alerted by a passer-by, not the facility, and the resident was subsequently taken to the emergency department for evaluation. The incident revealed gaps in supervision, documentation, and adherence to elopement prevention protocols, resulting in an immediate jeopardy situation for the resident.
Removal Plan
- Complete a root cause analysis to validate the cause of the resident elopement.
- Complete a head count to ensure all residents are accounted for.
- Reassess the resident upon return from the hospital and implement frequent checks.
- Audit all elopement books to ensure accuracy.
- Review and assess all residents for elopement risk, wandering, and update care plans and orders to include appropriate interventions.
- Assess all residents in house for elopement risk by the Director of Nursing or designee.
- Review and update care plans for residents identified with elopement risks with interventions to prevent elopement by the Director of Nursing or designee.
- Add all residents identified to be elopement risk to Elopement Binder per protocol.
- Conduct a house audit on all doors and exit points to ensure that facility is secure and alarms are functional by Maintenance.
- Conduct education to all facility staff regarding dementia/behavior in LTC residents, elopement risk and mitigation, and elopement policy and procedures to include keeping doors secure.
- Educate all staff on elopement interventions such as responding to alarms, reorienting wandering patients, encouraging activities, monitoring the front lobby and sign in sheet, code 10, and safety checks.
- Educate staff that all residents assessed as an elopement risk will have their picture and face sheet in the elopement book.
- Place elopement books with identified resident photos on all nurses' stations in addition to the current one at the receptionist's desk by the Administrator or designee.
- Screen newly admitted residents for elopement risk on admission, quarterly and as needed, and update care plans appropriately.
- Place new admissions and any resident assessed as an elopement risk in the elopement book that includes photograph and face sheets. Book is available for staff to review and monitor at all times.
- Investigate all incidents, perform root cause analysis and follow up with appropriate interventions by the DON or designee.
- Review elopement interventions and update as required by the QAPI team.
- Ensure the front door is monitored 24 hours 7 days a week by the RN supervisor until the wander guard system is installed.
- Review the lobby monitoring sign in sheet regularly.
- Audit door alarms daily by maintenance.
- Conduct elopement drills monthly on all shifts.
- Monitor the plan of correction by QAPI including all door audits, elopement book, elopement drills and all new admissions will be audited for elopement risk.
- Monitor the plan of correction at the Quality Assurance and Process Improvement meeting until consistent substantial compliance has been met.
Failure to Maintain Emergency Lighting
Penalty
Summary
The facility failed to maintain emergency lighting as required. During an observation on March 17, 2025, at 10:00 a.m., it was noted that the battery back-up light in the generator room did not illuminate when tested. This deficiency was confirmed through an interview with the Owner of the facility, the Facility Administrator, and the Maintenance Director on the same day at 1:00 p.m.
Plan Of Correction
I. The back-up battery light in the generator was turned back on at the time of the surveyors observation. II. No other emergency lights failed to illuminate when tested. III. Nursing Home Administrator will re-educate Director of Maintenance on the requirement to maintain emergency lighting. IV. Director of Maintenance will conduct 5 audits weekly for 8 weeks to ensure the back-up battery light in the generator illuminates when tested. Audit results will be taken through Quality Assurance Committee Meeting for tracking and trending purposes.
Non-compliance with Building Construction Requirements
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as it is a two-story, Type III (200), unprotected ordinary structure with a basement and attic, which is fully sprinklered. According to the NFPA 101 standards, this type of construction is not permitted to exceed one story in height. This deficiency was identified during an observation on March 17, 2025, at 8:45 a.m. An interview with the facility's Owner, Administrator, and Maintenance Director later confirmed that the building construction type did not meet the necessary requirements for an existing health care building.
Plan Of Correction
I. New owner will have an architect review the blueprint and construction plan of the building in order to determine a solution to correct the deficiency for building construction. II. After architectural review, the facility will be able to determine a date for correction of deficiency. III. Director of Maintenance/Designee will monitor progress of correcting the deficiency for building construction. IV. Progress will be reported to the Quality Assurance Committee monthly for tracking and trending purposes. V. Facility will be submitting a request for a one time waiver.
Failure to Provide Adequate Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living, received the necessary services to maintain personal hygiene. Specifically, the facility did not consistently provide showers or baths for a resident identified as R37. The facility's policy required residents to have two baths or showers per week unless otherwise stated by the resident. However, documentation revealed that Resident R37 received significantly fewer showers than required, with many months showing no showers at all and only bed baths documented. Resident R37, admitted with diagnoses including repeated falls, diabetes, and low blood pressure, expressed that choosing between a tub bath, shower, bed bath, or sponge bath was somewhat important. Despite this preference, the resident reported being unable to recall the last time they had a shower. The Director of Nursing confirmed the facility's failure to consistently provide the necessary showers or baths for Resident R37, which was a violation of the resident's rights and the facility's care policies.
Plan Of Correction
I. Resident R37 received a shower on 3/17/2025. Moving forward, all residents will be offered a shower twice a week. II. Director of Nursing/Designee will conduct a full facility sweep to ensure all residents have been offered and received a shower if requested. III. Director of Nursing/Designee will re-educate all licensed nursing and CNA on the policy that care will be provided to residents, as needed 24-hours a day to attain and maintain the highest level of functioning; to include residents are to have two bath/showers/week unless the resident states otherwise. IV. Director of Nursing/Designee will conduct a random audit of 10 showers weekly for 8 weeks to ensure residents are being offered and receiving a shower if requested. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Failure to Manage Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for two residents, leading to a deficiency in quality of care. Resident R20, who was re-admitted with diagnoses including diabetes, dementia, and high blood pressure, had instances where glucagon was administered, and CBG levels were recorded as low as 50 and 52. Despite these critical readings, the facility did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by the care plan. Similarly, Resident R24, admitted with diabetes, high blood pressure, and depression, had a CBG level recorded at 438. The facility failed to assess for hyperglycemia, did not recheck the blood sugar, and did not notify the physician of this abnormal result, contrary to the care plan's interventions. The facility's policies on diabetic care and physician notification were not followed, contributing to the deficiency. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, with some staff indicating they would notify the doctor and recheck blood glucose, while others did not follow through with these steps. The Director of Nursing confirmed the facility's failure to notify the doctor, document assessments, and follow physician orders for the residents involved.
Plan Of Correction
I. R 20 and R24 were assessed with no negative outcomes found. II. A facility sweep of all residents on CBG's will be reviewed to ensure proper hypoglycemic protocol is in place. III. Director of Nursing/Designee will re-educate all licensed nursing staff on notification of change and hypoglycemic protocol policies and procedures. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure proper hypoglycemic protocols and notifications are in place and documented. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Inaccurate Documentation of Cognitive Assessment
Penalty
Summary
The facility failed to ensure that the clinical records for a resident, identified as R37, were complete and accurately documented. The resident was admitted with diagnoses including repeated falls, diabetes, and low blood pressure. The Minimum Data Set (MDS) assessments, which are mandated to evaluate a resident's abilities and care needs, showed discrepancies in the Brief Interview of Mental Status (BIMS) scores over time. Initially, the BIMS score was recorded as 15, indicating the resident was cognitively intact. However, subsequent MDS assessments showed a decline in the BIMS score to 12 and then to 10, suggesting moderate cognitive impairment. Despite these changes in the MDS assessments, the clinical record progress notes consistently documented a BIMS score of 15, indicating no cognitive impairment. This inconsistency was confirmed by the Director of Nursing (DON) during an interview, who acknowledged the failure to ensure accurate and complete documentation for the resident. The facility did not have a specific policy for documentation in clinical records, contributing to the deficiency.
Plan Of Correction
I. R37 BIMS score was updated by the Nurse Practitioner under the Palliative Care Note. II. Facility Nurse Practitioner(s) will conduct a full facility sweep to ensure all residents BIMS scores are updated and correctly documented. Moving forward, facility nurse practitioner(s) will ensure their documentation is current and updated in the resident charts. III. Director of Nursing/Director will re-educate the facility Nurse Practitioner(s) on clinical records are complete and accurate. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure nurse practitioner(s) are documenting the correct BIMS score on residents. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family of a change in condition for one of four residents in a timely manner. The facility's policy, dated 5/1/24, requires that the responsible party or guardian be notified of any break in the resident's skin integrity. Resident R1, who was admitted with dementia and a fractured left leg, had a skin alteration to the coccyx noted upon admission. On 7/8/24, a nurse progress note indicated a possible pressure ulcer to the coccyx, measuring 6.5 cm by 7 cm, with a dressing applied and a CRNP involved in the treatment plan. However, there was no evidence in the clinical record that the resident's family was informed of this change in condition. The Director of Nursing confirmed this failure during an interview on 8/22/24.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as evidenced by the case of a resident who was admitted with diagnoses including dementia and a left leg fracture. A physician's order was documented for wound care on both feet, which was incorrectly recorded in the resident's Treatment Administration Record (TAR) for July. The TAR indicated that the treatment was applied on two specific dates, but the resident was discharged shortly thereafter. Weekly skin check documentation prior to these dates showed no open areas on the resident's feet. Interviews with facility staff, including two Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed that the documentation was incorrect. The LPNs revealed that the resident did not have wounds on the feet during their stay, and the DON confirmed that the physician order and TAR documentation were mistakenly entered on the wrong resident's chart. This error led to the facility's failure to maintain complete and accurate medical records for the resident, violating specific state code requirements for clinical records.
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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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