Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint Anne Home during CMS and state inspections, most recent first.
Food was served at improper temperatures and was unpalatable during a lunch meal service. A resident said the food was garbage, the vegetables were mush, and the meat was tough, and the Culinary Director confirmed the tomato bisque was cold and the beef tips were cold and difficult to chew. A test tray showed the beef tips and tomato bisque were below appropriate serving temperature.
Food storage and prep practices were not sanitary. Surveyors observed opened food items and beverages that were undated, improperly covered, or past use-by dates in kitchen storage areas and resident kitchenette areas. In the main kitchen, multiple dietary staff were observed preparing or plating food without proper beard guards or hairnets, and the Culinary Director confirmed that food should be labeled and dated properly, expired items should be discarded, and hair restraints should be worn properly.
A facility failed to maintain a clean, home-like environment in a common area and in a resident room. Surveyors observed dust, dirt, crumbs, debris, a plastic spoon, and food on the floor and under furniture, and Housekeeping staff confirmed the areas were dirty and that staffing shortages were affecting cleaning. The M/H Supervisor also acknowledged that the facility was not clean.
A facility failed to report an allegation of abuse involving a cognitively impaired resident with dementia who was slapped by another resident in the dining area and became weepy. The record showed no documentation that the incident was reported to the supervisor, DON, administrator, or corporate compliance officer, and the DON stated he was not aware of the event and that staff should have reported it so an investigation could be conducted.
Failure to Notify Residents, Representatives, and Ombudsman of Hospital Transfers: The facility did not provide written notice to residents or their representatives explaining the reason for hospital transfer, and it did not notify the ombudsman of the transfers. Affected residents included cognitively intact and cognitively impaired residents transferred for altered mental status, hematuria, lethargy, falls, change in condition, dysphagia, dyspnea, choking, and bleeding, and the DON confirmed the missing notifications.
Failure to provide scheduled showers for a resident with hemiplegia and ADL dependence. The resident’s care plan identified a shower preference, but bathing records showed repeated bed baths and a sponge bath instead of the scheduled shower, with some entries marked N/A and no documentation that the resident was offered, refused, or rescheduled for a shower. The resident said staff do not get him out of bed, and the DON confirmed there was no documented evidence of showers being offered or refused as scheduled.
Failure to follow physician orders affected two residents. One resident with diabetes had bedtime blood glucose checks completed early on multiple occasions instead of between 8:00 p.m. and 9:00 p.m. as ordered for sliding-scale NovoLog, and the DON confirmed the checks were not done per the order. Another resident with CHF had an order for daily chair-scale weights, but several required weights were not documented, and the DON confirmed they should have been obtained.
A resident with limited mobility, heart failure, and low back pain had a care plan for active ROM twice daily and ambulation with a front wheeled walker and CGA, but chart review showed no documented evidence that these services were provided over several months. The resident said walking depended on staff availability, and the OT and DON stated the facility did not currently have a restorative nursing program in place, so no active ROM or ambulation orders were implemented.
Failure to maintain safe resident environments: one resident with a history of falls and wheelchair use was found on the floor after the ordered bedside wheelchair intervention was documented, another resident did not have dycem placed as ordered on the wheelchair seat cushion, and a third resident had an air mattress placed without a documented safety-hazard assessment. The DON confirmed the missing assessment, and staff confirmed the wheelchair order was not fully followed.
Failure to obtain physician orders for IV therapy and flush orders affected two residents. One resident had a midline IV for osteomyelitis and was receiving Meropenem, but there was no documented flush order or evidence the line was flushed before and after med administration. Another resident had an IV heparin lock in the forearm, but the MAR showed no physician order for IV therapy and no flush orders; the DON confirmed the orders should have been obtained.
A resident with PTSD was not assessed for specific trauma triggers or given documented trauma-informed interventions to prevent or minimize re-traumatization. The care plan noted the PTSD was related to laying on the floor for days, and the DON stated the trigger assessment should have been completed when the resident received a new PTSD diagnosis from the facility psychiatrist.
Failure to Address Pharmacy Medication Review Recommendations: The facility did not respond to pharmacy MRR recommendations for two residents. One resident had a pharmacist note to clarify an ergocalciferol order, but there was no documentation that the order was clarified. Another resident, who was on a pureed/mechanical soft diet and had multiple chronic conditions including HTN, HF, kidney failure, and diabetes, had several meds that required a "do not crush" order, but the chart did not reflect this and an LPN said the meds were being crushed because no such order existed. The same resident also had an AIMS recommendation that was not documented as completed until later, and the DON confirmed the recommendations were not appropriately addressed.
Improper medication labeling and storage were found in a medication cart when an opened bottle of latanoprost eye drops lacked the date opened and loose pills were found scattered in the drawers. An LPN and the DON confirmed the cart should not have contained loose pills, and the DON confirmed the eye drops should have been dated when opened.
Inaccurate clinical documentation was found for a resident with cognitive intactness and left-sided hemiplegia after a stroke. The resident had an order to be out of bed every other day for 2 hours, but the TAR documented multiple out-of-bed episodes that the DON confirmed did not occur. The resident stated staff were not offering to get him out of bed and that he had not been out of bed in over a month.
The facility’s QAPI committee failed to resolve repeated deficiencies involving medication storage and labeling, food served at improper temperatures and not palatable, and staff not wearing hair coverings in the kitchen. Prior POCs called for audits and reporting to QAPI, but surveyors again cited the same issues under F761, F804, and F812 on the current survey.
A facility failed to ensure one resident received a pneumococcal vaccine after consent was obtained, with no documentation that it was administered or contraindicated. The facility also failed to document that another resident was offered the influenza vaccine and refused it, despite the MDS indicating the vaccine was not received in the facility. The DON confirmed the missing documentation for both residents.
The facility failed to ensure that three nurse aides completed the required annual education. Review of employee education files showed no documented evidence that Nurse Aides 10, 11, and 12 completed the required 12 hours of annual training, and the DON confirmed the missing documentation during interview.
A cognitively impaired resident with dementia, who required staff assistance for daily care, was transported in a wheelchair without leg rests in violation of the facility’s wheelchair transport policy requiring footrests during transport. A nurse aide pushed the resident in the wheelchair without leg rests, the resident leaned forward, fell out of the wheelchair, and sustained abrasions and a bruise to the forehead and eyebrow. The administrator later confirmed that leg rests should have been in place during the transport, demonstrating noncompliance with established resident care and nursing service policies.
Three residents with varying cognitive and physical needs had care plans that did not include their specific bed placement preferences, such as having the bed against the wall, despite these preferences being observed and confirmed by the DON. This omission was identified through MDS assessments, room observations, and staff interviews.
The facility did not ensure that food was served at safe and appetizing temperatures, with two residents reporting that meals were not warm and tasted poor. A test tray revealed that hot foods were served below the required temperature, and the main entrée lacked seasoning, which was confirmed by the Chef Manager.
An LPN misappropriated controlled pain medications by signing out doses for nine residents without administering them, as shown by discrepancies between controlled substance logs and MARs. Both cognitively impaired and intact residents with orders for opioid pain medications were affected, with no documentation or resident reports confirming receipt of the medications. The facility's investigation confirmed a pattern of diversion by the LPN.
The facility did not consistently update care plans to reflect changes in resident status or physician orders, such as discontinuation of transmission-based precautions, new medication orders, changes in oxygen therapy, and transfer assistance requirements. These discrepancies were confirmed through record reviews and staff interviews, resulting in care plans that did not accurately represent the current needs of several residents.
A resident with an indwelling urinary catheter and obstructive uropathy did not have urinary output measured and recorded as required by their care plan on multiple shifts and dates. Review of clinical records and staff interviews confirmed the absence of documentation for these periods.
The facility did not ensure proper cleaning of the kitchen area, as evidenced by a build-up of black residue on the wall behind the dishwasher and dust on the dishwasher vents, and failed to consistently document dishwasher wash and rinse temperatures as required by policy. The Dietary Manager confirmed these lapses in cleaning and record-keeping.
The facility did not accurately complete MDS assessments for three residents, including failures to document administration of anticonvulsants, antibiotics, antiplatelet medications, and IV access, as well as incorrect coding of cognitive status that led to a required BIMS interview not being conducted. These errors were confirmed by review of clinical records and staff interviews.
A resident with orders for Tramadol did not have documented evidence of receiving several signed-out doses of the controlled medication, as required by facility policy. The MAR and clinical record lacked documentation for these administrations, which was confirmed by the facility's QA nurse.
Two medication administration errors were observed, resulting in an error rate above five percent. One involved an LPN crushing Metoprolol ER tablets for a resident, contrary to manufacturer instructions, and another involved an LPN applying Voltaren gel without measuring the prescribed dose. Both errors were confirmed by the staff involved and the facility's quality assurance nurse.
Surveyors found that multi-dose insulin containers were not labeled with the date opened and an expired Aplisol testing solution was not discarded as required. An LPN and the QAPI RN confirmed these lapses, which were identified through policy review, manufacturer instructions, observation, and staff interviews.
The QAPI committee failed to correct recurring deficiencies, including breaches of resident health information confidentiality, inaccurate MDS assessments, improper care plan timing, inadequate urinary output monitoring, medication errors above 5%, improper medication storage, and serving unpalatable food at incorrect temperatures. Despite audit and review processes, these issues persisted across multiple surveys.
Surveyors observed that the reach-in refrigerator in the Main Kitchen had a loose and hanging rubber gasket at the bottom of the door, making it difficult to close. The Chef Manager confirmed the issue and stated it should have been repaired.
A nurse failed to administer medication according to a resident's stated preference and clinical record, giving all pills at once instead of one at a time. This led to the resident experiencing coughing, watery eyes, and emotional distress, with the nurse refusing to assess the resident after the incident. The event resulted in a change to the resident's diet and a referral to speech therapy.
The facility failed to ensure hot liquids were served at safe temperatures, resulting in burns to two residents. The policy required temperatures not to exceed 155°F, but this was not followed, leading to incidents where residents were served beverages at higher temperatures. Interviews confirmed lapses in policy adherence, placing residents at risk of injury.
The facility failed to serve food at appetizing temperatures, as residents reported cold meals on certain days. Observations confirmed that food items were not maintained at required temperatures, with onion rings at 92°F, soup at 132.8°F, and milk at 55.5°F, contrary to the facility's policy.
The NHA and DON failed to manage the facility effectively, leading to a deficiency related to serving hot liquids at inappropriate temperatures, jeopardizing the health and safety of two residents. The deficiency was cited under federal and state regulations, highlighting the failure to maintain an environment free of accident hazards.
A resident with Alzheimer's and osteoporosis was improperly transferred by an agency nurse aide without using the required mechanical lift, resulting in a fracture. The incident was not reported immediately, violating the facility's abuse and neglect policies.
A resident with Alzheimer's and osteoporosis fell due to improper transfer by a nurse aide who was unaware of the need for a mechanical lift. The fall was not reported immediately, leading to a delay in medical assessment and treatment for a fracture.
The facility failed to update care plans for several residents, leading to discrepancies in medication management, fall prevention, dietary needs, and wound care. These oversights were confirmed by the DON and Corporate Compliance Officer.
The facility failed to adhere to physician's orders for several residents, including not reporting a bruise for a resident on Eliquis, administering midodrine against blood pressure parameters, and missing documentation for pulse oximetry and intake/output measurements. These deficiencies were confirmed by the DON.
A facility failed to maintain a medication error rate below five percent, with eight errors occurring during a medication pass. An LPN did not prepare Klonopin for a resident and held all medications due to perceived excessive gastric residual without a physician's order. The medications were later wasted, and the Director of Nursing confirmed the error, initiating a report.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. The resident, who was cognitively intact but needed extensive assistance, had no documented evaluation or physician's order for self-administration. An LPN left the resident with a medication cup without observing the medication intake, which was confirmed by the DON.
The facility failed to inform and assist residents with advance directives, affecting three residents with cognitive impairments and various diagnoses. An interview with the Social Service Director revealed the absence of an official process to address advance directives, leading to the deficiency.
A facility failed to provide a resident with the required notice following the end of their Medicare coverage. Although the resident signed a SNF Beneficiary Protection Notification Review form, there was no documented evidence of receiving a SNF Beneficiary Protection Notification form or an ABN. The Social Worker confirmed the oversight in issuing ABN notices.
A facility failed to maintain the confidentiality of a resident's health information during medication administration. An LPN left a computer screen displaying personal health information visible to the hallway while assisting a resident, violating the facility's privacy policy. Both the LPN and the DON confirmed the breach of protocol.
A resident's grievance about food temperatures was not properly addressed, as evidenced by observations of meal service where food was served on an open cart, resulting in cool temperatures. The Dietary Director acknowledged the need for more insulated carts to maintain proper food temperatures.
A cognitively impaired resident, known to be afraid of showers, was inappropriately handled by a nurse aide who picked her up and carried her down the hallway despite her cries of pain. The incident, witnessed by an LPN and the resident's daughter-in-law, highlighted a failure to adhere to the facility's abuse policy, resulting in the resident's distress and potential harm.
A resident's medication was misappropriated when an agency LPN failed to perform a narcotic count, leading to the discovery of tampered medication packaging. The facility's investigation confirmed the misappropriation, and the incident was reported to the PA State Board of Nursing.
The facility failed to notify the Ombudsman in writing about the reasons for hospital transfers for five residents, as required by policy. These residents were transferred for various medical reasons, including agitation, falls, and pressure ulcers. Interviews confirmed the lack of notifications.
A facility failed to develop a comprehensive care plan for a resident with dementia and depression, who was receiving antipsychotic medications. Despite facility policy requiring care plans to address specific needs, the resident's care plan lacked documentation for their antipsychotic medication needs. This deficiency was confirmed by the DON during an interview.
A cognitively impaired resident requiring maximum assistance was transported in a broda chair without leg/footrests, contrary to the facility's policy. A nursing assistant, aware of the requirement, pushed the resident without the necessary footrests. The DON confirmed that all staff should adhere to this policy.
A facility failed to follow physician's orders for monitoring the urinary output of a cognitively impaired resident with an indwelling catheter. Despite a policy requiring output monitoring for residents with Foley catheters, records showed no documentation of monitoring across multiple months. The DON confirmed the lack of documentation, highlighting a deficiency in adhering to care protocols.
Food Served at Improper Temperatures and Unpalatable
Penalty
Summary
Food and drink were not served at palatable, attractive, and safe appetizing temperatures during the lunch meal service in the Courtyard unit. The facility policy dated May 29, 2026 stated that hot foods were to be cooked, held, and served at appropriate internal temperatures. During observation of the lunch meal service on July 29, 2026, the meal included a turkey cutlet or beef tips, a baked sweet potato, and tomato bisque, and the last resident was served at 12:22 p.m. A test tray checked at 12:33 p.m. showed the turkey cutlet at 124.5 degrees F, beef tips at 124.6 degrees F, baked sweet potato at 142.0 degrees F, and tomato bisque at 123.5 degrees F. The tomato bisque and beef tips were not served at the appropriate temperature, and the beef tips were described as tough to chew and unpalatable. A resident also stated that the food was garbage, the vegetables were mush, and the meat was tough, and the Culinary Director confirmed that the tomato bisque was cold and the beef tips were cold and difficult to chew.
Food Storage and Staff Hair Restraint Deficiencies
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions. In the kitchen dry storage, surveyors observed a quarter bottle of olive oil that was opened and undated with no lid and covered only by an unsecured piece of plastic wrap, a half full gallon of Worcestershire sauce that was opened and undated, and a 3/4 full gallon of cooking [NAME] that was opened and undated. In the kitchenette on [NAME] Garden, surveyors observed a half full half gallon of almond milk that was opened and undated, along with a bag of unidentifiable leftover food in to-go containers with an expiration date of July 9, 2026. In the kitchenette on [NAME] Courtyard, surveyors observed six peanut butter and jelly sandwiches and two tuna fish sandwiches with a use by date of July 22, 2026, two containers of applesauce with a use by date of July 22, 2026, a yogurt with a use by date of July 25, 2026, a quart of skim milk 3/4 full opened and undated, and a quart of 2% milk half full opened and undated. In the main kitchen, Kitchen Staff 5, Kitchen Staff 6, and Kitchen Staff 8 were observed with fully exposed beards and no beard guards, Kitchen Staff 7 was observed preparing food without a hair guard and with a fully exposed moustache, and Kitchen Staff 9 was observed with a hairnet that only covered her ponytail, leaving approximately four inches of bangs exposed. The Culinary Director confirmed that food items should be labeled and dated properly, expired items should be thrown out, and staff should be wearing beard guards and hairnets properly.
Failure to Maintain Clean Common Areas and Resident Room
Penalty
Summary
The facility failed to provide a clean and home-like environment in the [NAME] courtyard common area and in Resident 163’s room. The facility’s cleaning policy, dated May 29, 2026, stated that resident rooms, floors, and common areas including the dining area are to be swept daily. However, observations on July 27 and July 28, 2026, showed a moderate to large amount of dust, dirt, crumbs, and debris along the perimeter floor and wall of the common area and outside room C108, along with a plastic spoon under a chair in the common area. Observations in the dining area also showed approximately three quarter-sized pieces of yellow eggs under the dining table. Resident 163’s room was observed on July 27 and July 28, 2026, with potato chip crumbs and a piece of chocolate on the floor on both occasions while the resident was seated in a wheelchair. Housekeeper 1 confirmed the debris in the common area, the spoon under the chair, the eggs under the table, and the dirty floor in Resident 163’s room. She stated that staffing was short, that her priority was resident rooms, and that she was missing things because she could not keep up with the workload. The Maintenance/Housekeeping Supervisor also confirmed that the facility should be clean and it was not, and stated that staff currently had two units each to clean and that one staff member had left two weeks earlier.
Failure to Report Resident-on-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident. The resident’s significant change MDS dated May 2, 2026, showed that the resident was cognitively impaired, was sometimes understood and could sometimes understand others, was dependent on staff for daily care needs, and had a diagnosis that included dementia. A nursing note dated May 23, 2026 at 1:00 p.m. documented that the resident was slapped by another resident while sitting in the dining area and became weepy. The clinical record contained no documented evidence that the incident was reported to the resident’s immediate supervisor, the DON, the administrator, or the corporate compliance officer. During interview on July 29, 2026, the DON stated he was not made aware of the incident and that staff should have reported it per policy so an investigation could have been conducted. The report cited 28 Pa Code: 201.14(a)(c) Responsibility of management and 28 Pa Code: 201.18(b)(1) Management.
Failure to Notify Residents, Representatives, and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives explaining the reason for transfer to the hospital, and it also failed to notify the ombudsman of those transfers. Review of policies showed a facility policy dated May 29, 2026, stating that the ombudsman would be notified monthly of any emergent facility-initiated discharge or transfer, but no policy was provided for giving written notice to the resident and resident representative upon transfer to the hospital. The deficiency was identified for seven of 38 residents reviewed: Residents 1, 4, 7, 12, 76, 100, and 144. Clinical records showed multiple hospital transfers without documented written notice or ombudsman notification. Resident 1, who was cognitively intact and had bladder cancer, was transferred after altered mental status and blood in the urine. Resident 4, who was cognitively intact and had dementia, was sent to the ER after becoming nonverbal and lethargic. Resident 7 was sent to the hospital after an unwitnessed fall. Resident 12 was transferred after a change in condition. Resident 76 was transferred twice for difficulty swallowing. Resident 100, who was cognitively impaired and dependent on staff for daily care, was transferred for difficulty breathing and later for a choking episode. Resident 144 was sent to the ER after a large amount of blood was found in her brief. The DON confirmed that for these residents there was no written notification provided to the resident or representative and the ombudsman was not notified as required.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required assistance with daily care needs was provided showers as scheduled. Resident 19 was cognitively intact, had no behaviors, and had diagnoses including left-sided hemiplegia following a stroke. The resident’s care plan identified a bathing preference for showers, and the facility’s bathing policy stated that residents should be safely showered and that if a resident was unable to shower, refused, or requested another time, the unit supervisor should be notified and documentation entered into the medical record for the reason the bath or shower was not given or for any alternate arrangement. Review of the bathing documentation showed that Resident 19 was scheduled to receive a shower every Saturday, but instead received multiple bed baths and one sponge bath during the reviewed months. On several documented dates, the shower was marked as not applicable, and there was no evidence that the resident was offered a shower, refused a shower, or was provided an alternate shower time. The resident stated that he could not remember when he was last offered a shower because staff do not get him out of bed, though he would reluctantly agree if offered. The DON confirmed there was no documented evidence that the resident was offered or refused showers according to the care schedule or at alternative times.
Failure to Follow Physician Orders for Blood Glucose Checks and Daily Weights
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. One resident had a significant change MDS assessment showing cognitive impairment, dependence on staff for all daily care needs, and a diagnosis of diabetes. The care plan stated that diabetes medication was to be administered per physician's orders. A physician's note stated that the resident's blood sugar check was to be completed later between 8:00 p.m. and 9:00 p.m. because the blood sugars were believed to be inaccurate when obtained earlier and were thought to reflect a post-meal reading rather than a true bedtime blood sugar. Physician's orders directed that NovoLog insulin be given by sliding scale before meals and at bedtime, with bedtime blood glucose monitoring to be completed between 8:00 p.m. and 9:00 p.m. Review of the clinical record showed that blood glucose monitoring was completed early on multiple dates in June and July 2026, at times ranging from 7:06 p.m. to 7:57 p.m. The DON confirmed that the blood glucose monitoring was completed early and not per physician's orders. A second resident had a quarterly MDS assessment showing cognitive intactness, dependence on staff for daily care needs, and a diagnosis of CHF. Physician's orders required daily weights by chair scale, but the clinical record showed no documented evidence that weights were obtained on several dates in June 2026. The DON confirmed that the resident's weights were to be obtained per physician's orders on those dates and should have been.
Failure to Provide Restorative Nursing Services for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. Resident 6 was cognitively intact, had diagnoses including heart failure and low back pain, and the care plan identified a potential for decline in ROM. The care plan directed active ROM to all extremities twice daily, six to seven days a week for at least 15 minutes, and ambulation up to 100 feet with a front wheeled walker and contact guard assist. The resident’s MDS also indicated the need for supervision or touching assistance with transfers and ambulation. Review of nurse aide documentation and Treatment Administration Records for April through July 2026 showed no documented evidence that the resident received active ROM or assistance with ambulation. The resident stated that she sometimes walked in the hall with her walker, depending on what staff were available to help her. The OT stated that the facility previously had an active restorative nursing program but did not currently have one in place, and that no active ROM or ambulation orders were put into place for Resident 6 because there was no restorative nursing program. The DON confirmed that the facility did not currently have a restorative nursing program in place, although one should have been in place.
Failure to Maintain Safe Resident Environments
Penalty
Summary
The facility failed to ensure a safe environment for three residents by not consistently following ordered fall-prevention and safety interventions. One resident was cognitively intact, used a manual wheelchair, required partial assistance to transfer, and had a care plan directing that the wheelchair be placed at the bedside facing the bed with brakes locked when in bed. After a fall, nursing documentation again identified that intervention, but the resident was later found lying on the floor beside the bed with a bruise to the right cheek, followed by complaints of bilateral knee pain, right leg pain, and later transfer to the hospital with a diagnosis of fall, altered mental status, and fractured pelvis. The ADON and DON stated the care plan should not have been updated to reflect that intervention after the fall, but there was no documented evidence that it was in error or that another fall intervention had been put in place. A second resident with severe cognitive impairment, cerebral palsy, and profound intellectual disorders had a care plan and physician order for dycem above and below the wheelchair seat cushion, but observations showed dycem was present only above the cushion and not below it as ordered. A third resident, who was cognitively impaired and dependent for daily care with a history of decreased mobility and pressure injury risk, had a physician order for an air mattress on the bed. The clinical record contained no documented evidence that the air mattress was assessed for potential safety hazards before it was placed on the resident's bed, and the DON confirmed that no such assessment had been completed.
Failure to Obtain IV Therapy and Flush Orders
Penalty
Summary
Failure to provide for the safe, appropriate administration of IV fluids occurred when physician orders were not obtained before IV therapy was started for two residents, and flush orders were not documented for either resident. One resident had a midline IV catheter for treatment of osteomyelitis and was ordered to receive Meropenem 2 grams twice daily through July 28, 2026, but the MAR for July 2026 showed no documented order to flush the midline and no evidence that staff flushed the catheter before and after medication administration. A second resident had an IV heparin lock inserted into the right forearm, and a nursing note documented the insertion of a 22-gauge IV catheter. Review of the resident’s July 2026 MAR showed no documented evidence that a physician order was obtained for IV therapy and no flush orders were obtained. The DON confirmed that physician orders should have been obtained for both residents before starting IV therapy and that flush orders should have been obtained.
Failure to Assess PTSD Triggers and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of PTSD was assessed and received trauma-informed care to eliminate or mitigate triggers. Review of the resident’s quarterly MDS showed the resident was cognitively intact, dependent on staff for daily care needs, and had PTSD. The care plan documented that the PTSD was related to laying on the floor for days, but there was no documented evidence that the facility identified the resident’s specific triggers that could re-traumatize the resident or implemented measures for staff to prevent or minimize those triggers. The DON stated in interview that the resident had been seen by a psychiatrist at the facility and had a new PTSD diagnosis, and that the assessment for triggers should have been completed at that time.
Failure to Address Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to respond to pharmacy medication regimen review recommendations for two residents. For one resident, who was cognitively impaired, required maximum assistance, received insulin, and had diagnoses of hypertension, heart failure, kidney failure, and diabetes, a pharmacy review noted that the physician order for ergocalciferol 200 micrograms/milliliter to give 2 drops by mouth at bedtime needed clarification to reflect 2 dropperfuls = 2 milliliters = 400 micrograms. There was no documented evidence in the clinical record that the order was clarified. For another resident, who was cognitively impaired, had diagnoses of high blood pressure, heart failure, kidney failure, and diabetes, received antipsychotic medications, and was on a pureed or mechanical soft diet with pills crushed in applesauce, a pharmacy review stated that "do not crush" should be added to orders for divalproex DR 125 mg, Protonix 20 mg, metoprolol ER 50 mg, and tamsulosin. There was no documented evidence that these orders were updated, and an LPN stated that all medication for this resident was being crushed because there was no do not crush order in place. A separate pharmacy review also indicated the resident needed an AIMS assessment, and there was no documented evidence that it was completed until about one month later. The DON confirmed that the recommendation was not appropriately addressed for the residents.
Improper Medication Labeling and Storage in Medication Cart
Penalty
Summary
The facility failed to properly label and date an opened bottle of Latanoprost Ophthalmic Solution 0.005 percent eye drops in the [NAME] courtyard medication cart. The facility policy dated May 29, 2026 stated that multi-dose medications that have been opened or accessed are to be labeled with the date they were opened, considering manufacturer specifications, and that medications and biologicals are to be stored properly to maintain their integrity and support safe effective drug administration. Observations of the [NAME] courtyard medication cart on July 28, 2026, found 12 loose pills scattered throughout the bottom of the first medication drawer. On July 29, 2026, observations of the same cart found one opened bottle of Latanoprost eye drops without an open date label and 8 loose pills scattered throughout the first and second medication drawers. An LPN confirmed the loose pills should not have been in the drawer, and the DON confirmed both that the eye drops should have been labeled with the date opened and that the loose pills should not have been in the drawers.
Inaccurate Documentation of Resident Out-of-Bed Care
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for one resident. Facility policy required medical record documentation to be an accurate, factual, objective, and timely representation of the resident’s actual experiences, assessments, observations, and services provided. The resident’s quarterly MDS dated May 8, 2026, identified the resident as cognitively intact, needing staff assistance with daily care needs, having no behaviors, and having diagnoses that included left-sided hemiplegia following a stroke. Physician orders dated July 17, 2026, directed that the resident be out of bed every other day for two hours per day. The TAR for July 2026 documented that the resident was out of bed for two hours on July 17, 19, 21, 23, 25, and 27. However, nurse aide documentation for the same period showed the resident’s chair/bed-to-chair transfer ability was recorded as not applicable on some days and resident refused on others. The resident stated that staff do not offer to get him out of bed and that he did not believe he had been out of bed in over a month. The DON confirmed that the resident had not been getting out of bed because he refused and that the TAR documentation showing he was out of bed on those dates was inaccurate.
QAPI Failed to Resolve Repeated Medication, Food Service, and Kitchen Compliance Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior surveys and did not ensure that plans of correction effectively addressed repeated problems in the delivery of care and services. The report states that a prior State Survey and Certification survey ending June 26, 2026, had cited deficiencies involving medication storage and labeling, food being served at improper temperatures and not being palatable, food items not being dated as required, and staff not wearing hair coverings in the kitchen, with plans of correction that included audits and reporting results to the QAPI committee. On the current survey ending July 30, 2026, surveyors again found repeated deficiencies related to medication storage and labeling under F761, food not being palatable and not at appropriate temperatures under F804, and failure to wear hair coverings in the kitchen under F812. The report states that the facility’s QAPI committee failed to successfully implement the prior plans to ensure ongoing compliance with medication labeling/storage, food temperature and palatability, and the wearing of appropriate hair coverings in the kitchen.
Failure to Document and Provide Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were administered for one resident and failed to ensure that influenza vaccination documentation was complete for another resident. The facility’s pneumococcal vaccine policy, dated May 29, 2026, stated that all residents would receive immunizations and/or vaccinations to help prevent infectious disease unless medically contraindicated or refused. A quarterly MDS assessment for Resident 83 dated June 18, 2026, showed the resident was cognitively intact, needed staff assistance with daily care needs, and that the pneumococcal vaccination was not up to date and had not been offered. A Pneumococcal Pneumonia Immunization Consent Form dated March 20, 2026, showed education was provided and authorization to administer the vaccine was obtained, but there was no documented evidence that the vaccine was given or that it was contraindicated. An annual MDS assessment for Resident 6 dated February 13, 2026, showed the resident was cognitively intact, needed staff assistance with daily care needs, and did not receive the influenza vaccine in the facility for that flu season because it was offered and refused. However, there was no documented evidence that the resident was offered the influenza vaccine during the 2025-2026 flu season or that she refused it. The DON confirmed that Resident 83 had signed consent for the pneumococcal vaccine but there was still no documentation that it had been administered, and also confirmed there was no documented evidence that Resident 6 was offered the influenza vaccine and refused it.
Failure to Document Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual education for three of three nurse aides reviewed, identified as Nurse Aides 10, 11, and 12. Review of the facility's policy on continuing education, dated May 29, 2026, showed that compliance with the facility's standards, policies, and procedures was a condition of employment, including compliance with the facility's training program policies and procedures. Review of the employee education files for Nurse Aides 10, 11, and 12 showed no documented evidence that each had completed the required 12 hours of education between 2025 and 2026. The Director of Nursing confirmed during interview on July 29, 2026, at 10:34 a.m. that there was no documented evidence that these three nurse aides completed the required annual training.
Failure to Use Wheelchair Footrests During Transport Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to follow its wheelchair transport policy requiring the use of footrests during transport, resulting in a resident fall and injuries. The written policy dated January 8, 2026, specified that footrests must be used when staff, family, volunteers, and healthcare partners transport residents in wheelchairs, Broda chairs, or other chairs with attachable footrests to prevent accidents and injuries. Resident 1’s annual MDS assessment dated February 13, 2026, documented that the resident was cognitively impaired, required staff assistance for daily care needs, and had dementia among other diagnoses. On December 20, 2025, at approximately 10:40 p.m., Nurse Aide 1 was pushing Resident 1 in a wheelchair without leg rests in place when the resident leaned forward and fell to the floor. The incident investigation and witness statement from Nurse Aide 1 confirmed that the resident did not have leg rests on the wheelchair at the time of transport and that the resident leaned forward and fell out of the wheelchair. As a result of the fall, Resident 1 sustained a 1.5 by 1.5-centimeter abrasion to the left side of the forehead, a 0.5 by 0.5-centimeter abrasion to the left eyebrow, and a 3 by 3-centimeter bruise to the left side of the forehead. In an interview, the Nursing Home Administrator confirmed that leg rests should have been in place when transporting this resident, indicating noncompliance with the facility’s resident care policies and nursing services requirements under 28 Pa. Code 211.10(c)(d) and 211.12(d)(5).
Failure to Individualize Care Plans for Bed Placement Preferences
Penalty
Summary
The facility failed to develop individualized care plans for three residents, as required by regulation. Clinical record reviews, observations, and interviews revealed that the care plans for these residents did not address specific needs and preferences related to bed placement. For one resident with confusion, a hip fracture, and dementia, the care plan did not mention that the bed was positioned against the wall, despite this being observed in the resident's room. Another resident, who was alert with some confusion and had dementia, also had a care plan that omitted her preference to keep her bed against the wall. A third resident, who was alert and oriented with a diagnosis of schizoaffective disorder, similarly had a care plan that did not include her preference for bed placement. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged that the care plans should have included information about the residents' beds being against the wall. The lack of individualized care planning for these residents was identified through comprehensive and quarterly MDS assessments, as well as direct observation and staff interviews.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and maintained at proper temperatures, as required by its dietary policy. Review of the policy indicated that food should be prepared to retain flavor, appearance, and nutrients, and held at safe temperatures—hot foods at 140°F or above and cold foods at 40°F or below. Interviews with two residents revealed complaints about food not being warm, poor taste, and inconsistent temperatures. Observation of a test tray during a lunch meal showed that oven roasted potatoes and brussel sprouts were served at 104.1°F and 106.2°F, respectively, which are below the required hot holding temperature. Additionally, the chicken was found to be bland and unseasoned. The Chef Manager confirmed the low temperatures and lack of seasoning in the food.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medications for nine residents, as evidenced by discrepancies between the controlled substance dispense logs and the medication administration records (MARs). The facility's policy strictly prohibits the misappropriation of resident property, including medications, but an audit revealed that an LPN signed out doses of Norco and Oxycodone for multiple residents without documentation that the medications were administered. In several cases, the residents' MARs and clinical records contained no evidence that the signed-out doses were given, and interviews with alert residents confirmed they did not receive the medications at the documented times. The residents affected included both cognitively impaired and cognitively intact individuals, many of whom had orders for as-needed or routine opioid pain medications due to frequent or constant pain. The controlled drug records showed that doses were removed from the blister cards and signed out for administration, but there was no corresponding documentation in the MARs or clinical records to indicate that the medications were actually provided to the residents. For residents who were not alert and oriented, records indicated they did not routinely request as-needed pain medications, further supporting the finding that the medications were not administered as documented. The facility's investigation identified a pattern of misappropriation by the LPN, who removed and signed out narcotics for the affected residents without administering them. This was confirmed through record reviews, resident interviews, and the facility's own investigation, which concluded that the LPN had diverted the medications for personal use or other unauthorized purposes. The deficiency was cited under state regulations related to the responsibility of license, management, and nursing services.
Failure to Update Care Plans Following Changes in Resident Status and Physician Orders
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the current care needs of five residents. According to the facility's policy, care plans must be evaluated at least every 90 days, annually, and whenever there is a significant change in a resident's condition, including after hospital stays or incidents. However, clinical record reviews and staff interviews revealed that care plans were not consistently updated following changes in physician orders or resident status. For example, one resident was initially placed on transmission-based precautions for VRE of the urine, but after the precautions were discontinued by physician order, the care plan was not revised to reflect this change. Similarly, another resident was placed on droplet precautions for influenza, but the care plan was not updated after the precautions were discontinued. In another case, a resident was prescribed an antipsychotic medication, but the care plan did not include this new medication. Additionally, a resident receiving oxygen therapy had a care plan that did not match the current physician orders regarding oxygen flow rate and target oxygen saturation. Finally, a resident's care plan continued to indicate a two-person assist for transfers, despite a physician order changing the requirement to a one-person assist. These deficiencies were confirmed through interviews with the Quality Assurance and Performance Improvement Registered Nurse, who acknowledged that the care plans had not been revised to reflect the most current orders or resident needs. The lack of timely updates to care plans resulted in discrepancies between the care being provided and the documented care plans for these residents.
Failure to Document Urinary Output for Catheterized Resident
Penalty
Summary
The facility failed to ensure that urinary output was measured and recorded as care planned for a resident with an indwelling urinary catheter. The resident, who had obstructive uropathy and required a catheter, had a care plan directing staff to accurately measure and document urinary output every shift. Clinical record review showed multiple instances across various shifts and dates where there was no documented evidence that the resident's urinary output was obtained. This lack of documentation was confirmed by the Quality Assurance and Performance Improvement Registered Nurse during an interview.
Failure to Maintain Sanitary Conditions and Incomplete Dishwasher Temperature Monitoring
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not adhering to its own cleaning and monitoring policies. Observations revealed a significant build-up of a black, removable substance on the lower wall behind the dishwasher and a thick accumulation of dust and debris on the dishwasher exhaust vents, indicating that required cleaning was not performed as specified in the facility's policy. Additionally, review of the dishwasher temperature log showed that staff did not consistently record the required wash and rinse temperatures before each meal, with multiple dates missing entries and staff initials. The Dietary Manager confirmed that both the cleaning and temperature logging procedures were not followed as required.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident, the quarterly MDS assessment did not indicate the administration of anticonvulsant medication, despite physician's orders and the Medication Administration Record (MAR) confirming that the resident received Divalproex during the seven-day look-back period. This discrepancy was confirmed by the Quality Assurance and Performance Improvement Registered Nurse. Another resident's significant change in status MDS assessment was inaccurately coded regarding cognitive status. Although the resident was sometimes understood, the assessment was marked as if the resident was rarely/never understood, resulting in the Brief Interview for Mental Status (BIMS) not being attempted, contrary to manual instructions. Additionally, a third resident's significant change MDS assessment failed to indicate the administration of antibiotics, antiplatelet medications, and the presence of IV access, despite physician's orders and the MAR confirming these treatments occurred during the assessment period. These inaccuracies were confirmed through staff interviews.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. According to facility policy, staff are required to initial the Medication Administration Record (MAR) after administering each medication. For a resident who was cognitively intact and required assistance with daily care, physician orders specified the administration of 50 mg of Tramadol every six hours for pain. Review of the resident's MAR for a specific month showed that several doses of Tramadol were signed out for administration on multiple dates. However, there was no documented evidence in the MAR or clinical record that these doses were actually administered to the resident on those dates. This lack of documentation was confirmed by the Quality Assurance and Performance Improvement Registered Nurse during an interview. The deficiency was cited under the relevant state pharmacy and nursing services regulations.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as required. During medication administration observations, two errors were identified out of 35 opportunities, resulting in an error rate of 5.71 percent. One error involved a nurse crushing Metoprolol Extended Release (ER) tablets for a resident, despite manufacturer instructions and physician orders specifying that the ER tablets should not be crushed, as this could alter the medication's effectiveness and safety. The nurse confirmed the error during an interview, as did the Quality Assurance and Performance Improvement Registered Nurse. A second error was observed when a nurse administered Voltaren 1 percent gel to a resident without measuring the prescribed two-gram dose as directed by the manufacturer and physician orders. Instead, the nurse applied the gel by squeezing it onto her gloved hand and then onto the resident's toes, without using the dosing card to ensure the correct amount. The nurse acknowledged during an interview that she routinely applied the gel in this manner and did not measure the dose. The Quality Assurance and Performance Improvement Registered Nurse also confirmed that the gel should have been measured according to the manufacturer's instructions.
Failure to Label Insulin and Discard Expired Testing Solution
Penalty
Summary
Surveyors identified that the facility failed to properly label multi-dose containers of insulin with the date they were opened on one of four medication carts reviewed. Specifically, a multidose vial of Lantus insulin for one resident and a prefilled pen of Insulin glargine for another resident were found opened and not labeled with the date of opening. Interviews with an LPN and the Quality Assurance and Performance Improvement RN confirmed that these insulin containers should have been labeled with the date they were opened, in accordance with facility policy and manufacturer instructions. Additionally, the facility failed to discard an expired bottle of Aplisol testing solution in one of four medication room refrigerators reviewed. The Aplisol multidose vial was observed to have been opened 34 days prior, exceeding the manufacturer's recommended 30-day use period. The LPN confirmed that the vial should have been discarded. These findings were based on review of facility policies, manufacturer directions, clinical records, direct observation, and staff interviews.
Repeated QAPI Failures Lead to Ongoing Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure that plans to improve the delivery of care and services were effective. Despite developing plans of correction for previously cited deficiencies, the facility continued to have repeated issues identified in multiple surveys. These deficiencies included failure to provide confidentiality of residents' personal health information, inaccurate Minimum Data Set (MDS) assessments, improper care plan timing and revision, inadequate monitoring of urinary output, failure to maintain a medication error rate below 5 percent, improper labeling and storage of medications, and not serving palatable food at appropriate temperatures. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but the same deficiencies were repeatedly cited in subsequent surveys, indicating that the committee's actions were ineffective. The report specifically notes that for each cited deficiency, the facility's plan of correction involved conducting audits and reporting the results to the QAPI committee. However, the current survey found that these measures did not result in sustained compliance, as the same issues persisted across multiple survey periods. The deficiencies were cited under specific federal tags (F583, F641, F657, F690, F759, F761, F804) and referenced state regulations, but there is no mention of individual residents' medical histories or conditions in the report.
Failure to Maintain Kitchen Refrigerator in Safe Working Condition
Penalty
Summary
The facility failed to maintain the reach-in refrigerator in the Main Kitchen in proper working condition. During an observation, the rubber gasket at the bottom of the refrigerator door was found to be loose and hanging down, which prevented the door from closing easily. The Chef Manager confirmed that the gasket was loose and acknowledged that it should have been repaired. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Follow Resident Medication Administration Preferences Resulting in Distress
Penalty
Summary
A deficiency occurred when a nurse failed to follow a resident's stated preference and clinical record instructions for medication administration. The resident, who was cognitively intact and diagnosed with Parkinson's Disease, informed the nurse that he takes his pills one at a time on a spoon. Despite this, the nurse placed all of the resident's pills in his mouth at once, leading to a coughing episode, watery eyes, and a runny nose. The nurse did not remain with the resident to assess his condition and dismissed concerns raised by a nurse aide, refusing to check on the resident after the incident. The resident continued to experience distress until another staff member intervened and a registered nurse assessed him. The incident resulted in a downgrade of the resident's diet and a referral to speech therapy. Interviews confirmed that the nurse's actions caused both physical and emotional distress to the resident and that the nurse failed to report the incident or seek appropriate assessment for the resident after the adverse event.
Failure to Monitor Hot Liquid Temperatures Leads to Resident Burns
Penalty
Summary
The facility failed to ensure that the environment was free of accident hazards by not adhering to its policy on serving hot liquids at safe temperatures. Specifically, the facility did not check the temperature of hot liquids before serving them to residents, which resulted in burns to two residents. The policy required that hot liquids should not exceed 155 degrees Fahrenheit when served, but this was not consistently followed, leading to incidents where residents were served beverages at higher temperatures. Resident 2, who was cognitively impaired and required assistance with daily care needs, spilled hot coffee on herself, resulting in redness on her left upper thigh. The coffee temperature was later found to be 149 degrees Fahrenheit, but there was no documented evidence that the temperature was checked before serving. Similarly, Resident 5, who also required assistance with daily activities, suffered burns after spilling hot tea on herself. The tea was found to be at 185.1 degrees Fahrenheit, and again, there was no documentation of the temperature being checked prior to serving. Interviews with facility staff, including the Assistant Nursing Home Administrator and the Dietary Manager, confirmed that there were lapses in following the policy for checking and documenting the temperature of hot liquids. The Dietary Manager noted that the coffee machine used was not the facility's and that no temperature logs were being completed. These oversights placed residents at risk of serious injury, as evidenced by the burns sustained by Residents 2 and 5.
Removal Plan
- The facility will review all daily temperature logs for the current dinner meal being served to ensure the temperature falls within current policy guidelines with all staff currently working.
- The facility will educate all Dining Service staff that the requirement of taking temperatures of hot beverages in the serving container prior to serving these beverages to the residents must be done prior to every meal and documented on the Daily Temperature Log.
- If the temperature of a hot beverage falls outside the range of 145 degrees Fahrenheit to 155 degrees Fahrenheit, do not serve the beverage until it cools down and is in these parameters.
- Daily monitoring of Daily Temperature Logs will be done by the Director of Dining Services or designee.
- The Director of Dining Services or designee will audit for any allegations of abuse or neglect emphasizing to all employees zero tolerance.
- Audits will include assessing whether the unit report sheets are up to date and that staff are utilizing these quick reference guides prior to initiating care.
- All findings will be reported to the Quality Assurance Performance Improvement Committee.
- If deficient practices are identified, additional corrective action will be taken.
Failure to Maintain Appetizing Food Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures, as evidenced by observations and staff interviews. The facility's policy on taste and temperature control requires that hot foods be held at temperatures of 140 degrees Fahrenheit or above, and cold foods at 40 degrees Fahrenheit or below. However, during a Resident Council meeting, residents from the Villa [NAME] Unit reported that their food was often cold on Thursdays and Fridays when the usual dietary aide was absent. This complaint was substantiated by observations made on November 21, 2024, when food items were not maintained at the required temperatures. During the observation, it was noted that the dietary worker placed prepared food items into the steam table and later removed cold beverages from the refrigerator, placing them on the counter without ice. The meals were prepared for residents in the dining room first, followed by those who eat in their rooms. By the time the last resident was served, the temperature of the onion rings was 92 degrees Fahrenheit, the Italian Wedding soup was 132.8 degrees Fahrenheit, and the white milk was 55.5 degrees Fahrenheit. These temperatures were confirmed to be unpalatable by the Chef Manager, indicating a failure to adhere to the facility's policy on maintaining appropriate food temperatures.
Failure to Ensure Safe Serving of Hot Liquids
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to manage the facility effectively, resulting in a deficiency related to the serving of hot liquids at inappropriate temperatures. This failure jeopardized the health and safety of two residents, identified as Resident R2 and Resident R5, during the survey. The job descriptions for both the NHA and DON emphasize their responsibility to direct the functions of the Nursing Department and ensure compliance with professional standards and regulations. However, the survey findings indicate that they did not fulfill these essential duties, leading to an environment that was not free of accident hazards. The deficiency was cited under the Code of Federal Regulatory Groups for Long-Term Care, specifically 483.25(b)(1)(2) Free of Accident Hazards/Supervision/Devices (F689). Additionally, the report references state regulations, including 28 Pa. Code 201.14(a) Responsibility of Licensee, 28 Pa. Code 201.18(e)(1) Management, and 28 Pa. Code 211.12(d)(1)(5) Nursing Services. These citations highlight the failure of the NHA and DON to ensure that the facility operated in compliance with state regulations and codes, particularly concerning the safe serving of hot liquids to residents.
Resident Injury Due to Improper Transfer
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, as evidenced by an incident involving a resident who was transferred incorrectly, resulting in a fracture. The resident, who was cognitively impaired and required assistance with transfers due to Alzheimer's disease and osteoporosis, was supposed to be transferred using a mechanical lift. However, an agency nurse aide attempted to transfer the resident without the lift, leading to the resident falling and sustaining a minimally impacted supracondylar fracture of the distal left femur. The incident occurred when the agency nurse aide, unaware of the resident's care plan requirements, attempted to help the resident stand and pivot without the necessary equipment. The resident fumbled to the floor during this process. Another nurse aide entered the room and assisted in lifting the resident into a wheelchair without reporting the incident to the licensed practical nurse or registered nurse on duty. The resident was later assessed and found to have a swollen left leg and was in severe pain, leading to the discovery of the fracture. The facility's investigation revealed that the agency nurse aide had received abuse and neglect training earlier in the year but failed to follow the care plan for the resident. The incident was not reported immediately, and the failure to notify the appropriate nursing staff was verified. The facility's policies clearly stated that residents must not be subjected to abuse or neglect by anyone, and the actions of the nurse aides were in direct violation of these policies.
Failure to Report Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that staff immediately reported a fall with injury involving a resident who was cognitively impaired and required assistance with care needs. The resident, who had Alzheimer's disease and osteoporosis, was dependent on a mechanical lift for transfers. On August 5, 2024, Nurse Aide 1 discovered the resident on the floor in her room with Nurse Aide 2 present. Despite the incident, neither nurse aide reported the fall to the licensed practical nurse or registered nurse on duty. The resident was assessed the following day, complaining of severe pain in her left leg, which was swollen. An x-ray revealed a minimally impacted supracondylar fracture of the distal left femur, and the resident was subsequently sent to the hospital. Investigation documents revealed that Nurse Aide 2 had attempted to transfer the resident without the required mechanical lift, leading to the fall. Nurse Aide 2 claimed she was unaware of the resident's need for a mechanical lift and did not see the hoyer sling in the room. The incident was reported to the Area Agency on Aging after the fact, and it was confirmed that the licensed practical nurse assigned to the resident was not informed of the fall. The failure to follow the resident's care plan for transfers and the delay in reporting the incident were verified. Nurse Aide 2 had previously received abuse and neglect training, yet the incident was not reported promptly, resulting in a deficiency finding against the facility.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the specific care needs of several residents. For Resident 3, the care plan did not include the need for antianxiety and antipsychotic medications, despite physician orders for Olanzapine and Lorazepam. The Director of Nursing confirmed that the care plan should have been revised to include these medications. Similarly, Resident 7's care plan was not updated to address the need for a reacher to aid in fall prevention, nor did it include the resident's need for re-education on using the reacher after a fall incident. Resident 26's care plan failed to reflect the use of plastic utensils, which were necessary for the resident's safety as part of a feeding program. The Director of Nursing acknowledged that the care plan should have been updated to include this information. For Resident 30, the care plan did not reflect the current physician's order for feeding tube flushes, which had been changed from 175 ml to 250 ml of water every four hours. This discrepancy was confirmed by the Director of Nursing. Additional deficiencies were noted for Resident 64, whose care plan was not revised to reflect the discontinuation of a urinary catheter. Resident 66's care plan did not reflect the current anticoagulant medication, Eliquis, and instead contained outdated information about Xarelto. Lastly, Resident 73's care plan was not updated to reflect current treatment orders for pressure ulcers and did not indicate that certain wounds had resolved. The Corporate Compliance Officer confirmed these oversights in the care plans.
Failure to Follow Physician's Orders for Multiple Residents
Penalty
Summary
The facility failed to follow physician's orders for four residents, leading to deficiencies in care. For one resident, who was cognitively impaired and on Eliquis, a bruise was observed but not reported to the physician as required. Another resident, who was cognitively intact and had atrial fibrillation, received midodrine despite blood pressure readings that should have prompted the medication to be held according to physician's orders. Additionally, a resident with hypoxia did not have pulse oximetry readings documented for several days, contrary to the physician's orders for every shift monitoring. Lastly, a resident with chronic kidney disease did not have intake and output measurements documented for multiple days, as was ordered by the physician. These failures were confirmed through interviews with the Director of Nursing.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, as evidenced by observations during a medication administration session. During this session, eight medication errors were made out of 28 opportunities, resulting in an error rate of 28.57 percent. The errors involved a resident with multiple medical conditions, including a seizure disorder and profound mental retardation with agitation, who was prescribed several medications to be administered via a gastric tube. However, the Licensed Practical Nurse (LPN) responsible for administering these medications did not prepare one of the prescribed medications, Klonopin, and subsequently held all medications due to perceived excessive gastric residual without a physician's order to do so. The LPN, upon checking the gastric residual, found approximately 60 ml and decided not to administer the prepared medications, contacting her supervisor instead. Despite not having an order to hold the medications based on residual amount, the LPN and a Registered Nurse Supervisor later wasted the prepared medications. Interviews with the nursing staff and the Director of Nursing confirmed that the medications should have been administered, as the residual content was not over 100 ml. This incident was documented in the Medication Administration Record, and a medication error report was initiated by the Director of Nursing.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine if a resident was safe to self-administer medications, as required by their policy. The policy stated that a physician's order was necessary for a resident to self-administer medications, and the nurse must remain with the resident until the medication is taken. However, for one resident, there was no documented evidence of an evaluation or a physician's order for self-administration of medications. The resident was cognitively intact but required extensive assistance from staff, and had multiple medications prescribed, including Colace, Eliquis, Renvela, Benadryl, and aspirin. During an observation of medication administration, the resident was found lying in bed with a medication cup containing their morning doses, and the LPN was not present in the room. The LPN confirmed that she left the room after administering the medication and did not observe the resident taking it. The Director of Nursing also confirmed that no assessment was completed to determine the resident's capability to self-administer medications and that the LPN should not have left the medications with the resident.
Failure to Inform and Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of their rights to develop advance directives and were not provided with the opportunity or assistance to formulate one. This deficiency was identified for three residents during a review of clinical records and staff interviews. Resident 3, who was cognitively impaired and diagnosed with dementia, had no evidence in their clinical record indicating that they or their representative were informed about advance directives. Similarly, Resident 7, who was cognitively impaired with diagnoses including hemiplegia and stroke, also lacked documentation of being informed or assisted with advance directives. Resident 55, with cognitive impairment and a diagnosis of dementia, was found in the same situation. An interview with the Social Service Director confirmed that there was no official process in place to address advance directives with residents or their representatives upon admission or during their stay. The Social Service Director acknowledged that if residents did not have an advance directive, they were not offered assistance in formulating one. This lack of a formal process contributed to the facility's failure to uphold residents' rights to request, refuse, or discontinue treatment, and to formulate an advance directive, as required by regulations.
Failure to Provide Required Medicare Coverage Notice
Penalty
Summary
The facility failed to provide the required notice to a resident or the resident's representative following the end of their Medicare coverage. Specifically, for one resident, Medicare coverage began on April 21, 2024, and ended on May 8, 2024. Although the resident signed a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form on May 6, 2024, there was no documented evidence that the resident received a SNF Beneficiary Protection Notification form or an Advanced Beneficiary Notice (ABN) as required. An interview with the Social Worker confirmed that the ABN was not completed in a timely manner, as she forgot to issue any ABN notices for any residents.
Breach of Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal health information during medication administration. On July 25, 2024, at 8:27 a.m., a Licensed Practical Nurse (LPN) left the medication cart unattended while assisting a resident, leaving the computer screen displaying the resident's personal health information visible to the hallway. This action was in violation of the facility's privacy policy dated October 13, 2023, which mandates that residents' health information must remain private. The LPN confirmed during an interview that she should have secured the computer screen to cover the resident's personal information when leaving the medication cart. The Director of Nursing also confirmed that the computer screen should have been covered when unattended, ensuring the confidentiality of the resident's health information.
Failure to Address Dietary Grievance and Maintain Food Temperatures
Penalty
Summary
The facility failed to adequately address a grievance related to dietary complaints from a resident. The resident expressed concerns about the temperature of hot meals during a resident council meeting, suggesting that meals would be better if served from a hot meal cart. Despite this, the facility's grievance logs did not reflect any grievances related to food. A memo from the Director of Resident and Community Engagement indicated that the Dietary Director was informed of the food temperature concerns and had instructed dietary staff to ensure proper temperature checks. However, observations during a lunch meal service revealed that food was served on a metal, open cart without insulation, resulting in food temperatures that were below acceptable levels. The French fries and hamburger were notably cool to taste, with temperatures recorded at 108°F and 116°F, respectively. The Dietary Aide suggested reheating the food in a microwave if necessary. Interviews with the Dietary Director confirmed that there was only one insulated cart available, and she acknowledged the need for additional insulated carts to maintain food temperatures during transport.
Inappropriate Handling of Resident During Shower Refusal
Penalty
Summary
The facility failed to protect Resident 63 from abuse and neglect, as evidenced by an incident involving inappropriate handling by a staff member. Resident 63, who was cognitively impaired with diagnoses including dementia and Alzheimer's disease, was known to be afraid of showers and became agitated during certain times of the day. On the morning of January 29, 2024, Nurse Aide 3 and an LPN attempted to give Resident 63 a shower, which she refused. During this interaction, Nurse Aide 3 picked up Resident 63 by the waist and carried her down the hallway, despite the resident's repeated cries of 'ouch' and complaints of pain. The incident was witnessed by the resident's daughter-in-law, who is also an employee, and the LPN. Both witnesses reported that Resident 63 was visibly distressed and stated that she was hurt, rubbing her right hip after being put down. The daughter-in-law attempted to calm the resident and suggested that an evening bath might be more suitable, given the resident's usual mood patterns. Despite the resident's agitation and refusal, Nurse Aide 3 continued to insist on the shower, demonstrating a lack of sensitivity to the resident's needs and preferences. The facility's investigation revealed that Nurse Aide 3 had previously used similar methods to coax Resident 63 into the shower, believing it to be a calming technique. However, this approach was deemed inappropriate and contrary to the facility's abuse policy, which emphasizes the residents' right to be free from any form of abuse or mistreatment. The incident highlighted a failure in adhering to the policy, resulting in the resident experiencing unnecessary distress and potential harm.
Medication Misappropriation Incident
Penalty
Summary
The facility failed to prevent the misappropriation of medication for one resident, identified as Resident 111. The resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. Physician's orders indicated that the resident was to receive Carisoprodol, a muscle relaxant, four times a day. During a routine narcotic count, it was discovered that the count for Resident 111's medication was incorrect, with one extra pill noted. Further inspection revealed that the blister pack containing the medication had been tampered with, and the pills in the opened slots did not match the remaining ones. The alleged perpetrator was an agency nurse, identified as Licensed Practical Nurse 9, who left the facility without performing the required medication count at the end of her shift. The facility attempted to contact her for a statement, but she did not respond, leading to the involvement of the local police to identify the pills. The investigation concluded that misappropriation of the resident's medication had occurred, and the incident was reported to the PA State Board of Nursing.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman in writing regarding the reasons for transfers or discharges to the hospital for five residents. The facility's policy, dated October 13, 2023, requires reporting of emergent facility discharges/transfers to the Ombudsman on a monthly basis. However, there was no documented evidence of such notifications for Residents 11, 47, 67, 73, and 108, who were transferred to the hospital for various medical reasons. Resident 11, who was cognitively impaired and receiving antipsychotic medications, was transferred to the hospital due to agitation and a potential septic condition. Resident 47, with Parkinson's disease, was sent to the hospital after a fall resulting in a hip fracture. Resident 67, who had heart failure, was transferred for evaluation. Resident 73, with a Stage 4 pressure ulcer, was sent for surgical debridement. Resident 108, who had a stroke, was transferred following a fall. Interviews with the Director of Nursing confirmed the lack of written notifications to the Ombudsman for these transfers.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed for a resident to reflect their specific care needs. The deficiency was identified during a review of facility policy, clinical records, and staff interviews. The facility's policy, dated October 13, 2023, mandates that care plans should address resident concerns and unique characteristics, including diagnosis, activity level, diet, medication, treatments, and specific therapeutic interventions. However, for one resident, identified as Resident 84, the care plan did not include the necessary details regarding the resident's need for antipsychotic medications, despite the resident being cognitively impaired and diagnosed with depression and dementia. The quarterly Minimum Data Set (MDS) assessment for Resident 84, dated June 8, 2024, indicated that the resident required assistance with care needs and was receiving antipsychotic medications. A physician's order dated April 2, 2024, prescribed 25 mg of Quetiapine twice a day for depression and behaviors. Despite these documented needs, there was no evidence in the clinical records that a care plan was created to address the resident's requirement for antipsychotic medications in conjunction with their dementia diagnosis. This oversight was confirmed during an interview with the Director of Nursing on July 25, 2024.
Failure to Use Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure a safe environment for residents by not adhering to its transportation policy, which mandates the use of footrests when transporting residents in wheelchairs. This deficiency was identified during a review of policy, clinical records, observations, and staff interviews. Specifically, a cognitively impaired resident, who required maximum assistance for all care and used a broda chair, was observed being transported without leg/footrests. The incident occurred when a nursing assistant pushed the resident from her room to the dining room without the necessary leg/footrests, despite being aware of the policy requirement. The Director of Nursing confirmed that all staff, including agency and hospice staff, should use leg/footrests when transporting residents in wheelchairs.
Failure to Monitor Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to adhere to physician's orders for monitoring the urinary output of a resident with an indwelling urinary catheter. According to the facility's policy dated October 13, 2023, output monitoring is required for residents with specific conditions, including those with a Foley catheter. The resident in question, who was cognitively impaired and required assistance for daily care, had a physician's order dated February 9, 2024, mandating intake and output monitoring every shift. However, a review of the Treatment Administration Records (TARs) for April, May, June, and July 2024 revealed a lack of documented evidence that the resident's catheter output was monitored as ordered. Specifically, there was no documentation of output monitoring on all three shifts for the entire months of April, June, and July, with only a few exceptions in May and July. The Director of Nursing confirmed the absence of documentation for the specified dates and shifts, indicating a failure to comply with the physician's orders.
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What surveyors actually found near you
We read the 780 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rehab & Nursing Ctr Greater Pittsburgh | 1.2 mi | ★★★★★ | 11 | 0 |
| Westmoreland Manor | 1.4 mi | ★★★★★ | 9 | 0 |
| Redstone Highlands Health Care | 1.7 mi | ★★★★★ | 14 | 0 |
| Oak Hill Rehabilitation & Healthcare Center | 2 mi | ★★★★★ | 9 | 0 |
| Greene Health & Rehab Center | 2 mi | ★★★★★ | 38 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.