Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Scenery Hills Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Improper food storage was identified in the main kitchen freezer when several opened food items, including egg patties, dinner rolls, chicken patties, and waffles, were found without opened dates and left open to the air. The Dietary Manager confirmed that kitchen food items should be labeled, dated, and kept closed.
A grievance/complaint box was mounted too high on the wall near the entrance, and the blank forms were also out of reach for residents seated in wheelchairs. The Social Worker confirmed there was only one box in the facility and that wheelchair users would need staff help to get a form and submit it, which would prevent anonymous filing.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not document notification to the state ombudsman for six residents who were transferred to the hospital. The affected residents had conditions including HF, encephalopathy, UTI, and a diabetic foot ulcer, and several required extensive assistance with daily care or had cognitive impairment. Nursing notes showed hospital admissions or ER transfers, but no evidence of ombudsman notification was found.
Inaccurate MDS coding was found for three residents when assessments did not match the medical record and MAR. One resident was coded as having a tube feed while a resident even though no tube feed was documented, another resident's MDS failed to indicate daily Furosemide use for edema, and a third resident's MDS failed to show ordered and administered Lispro for diabetes. The RN Assessment Coordinator confirmed the coding errors.
Failure to invite a resident’s representative to care plan meetings. A resident with severe cognitive impairment and encephalopathy had no documented evidence that the resident or representative was invited to attend or informed of care plan meetings. The spouse stated he had never been invited or given the results of any meetings, and the DON confirmed there was no documentation of invitation or participation.
A resident with cognitive impairment and low BP had a physician order for midodrine 10 mg BID with instructions to hold the dose if SBP was above 120 mm/Hg and DBP above 80 mm/Hg. MAR review showed multiple doses were given despite SBP readings above the ordered hold limit, and the DON confirmed the medication was administered when it should have been held.
A resident with cognitive impairment, an indwelling urinary catheter, and obstructive uropathy was observed in bed with the catheter drainage bag lying on the floor. An LPN and the DON confirmed the bag should not have been touching the floor, which was inconsistent with the facility’s catheter care policy.
Hand hygiene was not performed as required during wound care for a resident with a stage III sacral pressure ulcer. An LPN removed and replaced gloves multiple times while cleansing the wound and applying collagen, calcium alginate, and a silicone border dressing, but did not clean hands after each glove removal as required by policy; both the LPN and ADON confirmed this during interview.
The facility failed to designate a qualified infection preventionist to oversee the infection control program. The infection preventionist policy required the role to be filled by someone qualified through education, training, experience, and/or certification, but the ADON/Infection Preventionist stated she had not completed the required nursing home infection preventionist training course, and facility records confirmed the course was not completed. The NHA confirmed the facility had not designated a qualified individual responsible for infection prevention and control.
The facility failed to maintain safe hot water temperatures in resident rooms and bathing areas, despite a policy limiting water heater settings to 110°F and requiring routine monitoring and documentation by maintenance staff. A resident reported receiving “scalding hot” water for bedside bathing, and a surveyor confirmed that the sink water was painfully hot to the touch. Subsequent measurements in multiple rooms on both halls and in a shower room showed hot water temperatures ranging from just above 110°F up to over 120°F. The Maintenance Director and the NHA acknowledged that these temperatures were too high, and surveyors determined that this failure in three resident areas created immediate jeopardy due to unsafe water temperatures.
Administration and nursing leadership failed to maintain safe hot water temperatures in all three resident areas (North Hall, South Hall, and corridor rooms). The NHA did not effectively carry out defined duties to ensure a safe, properly maintained environment and regulatory compliance, and the DON did not ensure nursing staff followed facility policies on safe water temperatures. As a result, residents were exposed to unsafe water temperatures in their rooms, creating Immediate Jeopardy under F689 (Accidents) and violating applicable state management and nursing services regulations.
A resident with PTSD, depression, and anxiety did not have their specific trauma triggers identified or addressed by staff, despite facility policy requiring trauma-informed care. The DON confirmed that no measures were in place to prevent or minimize re-traumatization for this resident.
A multi-dose vial of Tubersol Tuberculin injection used for TB skin testing was found in the medication room without an opening date, contrary to manufacturer instructions requiring disposal 30 days after opening. The DON confirmed the vial was not dated as required, resulting in noncompliance with pharmacy and nursing service regulations.
The facility failed to store food under sanitary conditions, as standing water was found in the basement dry storage area, affecting the emergency food supply and other items. A broken downspout was identified as the cause of the water intrusion, exacerbated by recent rain and snow. The presence of a sewer smell was also noted.
The facility failed to pay essential service bills on time, leading to service disruptions that jeopardized resident safety. Outstanding balances were owed to various providers, including Citizens Ambulance and REA, resulting in termination notices and halted services. Interviews confirmed these issues, and the facility had to change suppliers due to nonpayment.
The facility failed to conduct safety assessments for air mattress use for three residents with pressure ulcers and other conditions. Despite facility policy, there was no documented evidence of safety assessments before placing air mattresses on their beds. The DON confirmed the lack of specific assessments for these residents.
The facility did not comply with food safety standards by failing to discard pizza sauce in a timely manner and not maintaining the dishwasher's wash cycle temperature at the required 120 degrees Fahrenheit. The Dietary Manager acknowledged the oversight regarding the sauce, and the Nursing Home Administrator confirmed the dishwasher's temperature requirement.
The facility did not verify the Nurse Aide Registry for a newly hired nurse aide, as required by their abuse policy. The verification, which should have been completed upon hire, was delayed until several weeks after the nurse aide's start date. This oversight was confirmed by the HR Director.
The facility failed to document the administration of controlled medications for three residents, as required by its policies. Doses of oxycodone and hydrocodone-acetaminophen were signed out but not recorded as administered in the residents' clinical records, including the MARs and nursing notes. This discrepancy was confirmed by the DON.
The facility failed to securely store medications, as an LPN left a medication cart unattended with medications on top, and a resident's medications were left at the bedside instead of being returned to the cart. The DON confirmed these actions were against policy.
The facility failed to maintain complete and accurate clinical records for three residents. A resident's oxycodone administration was inconsistently documented, another resident's oxygen use was not recorded on two occasions, and a third resident's Morphine Sulfate administration was not properly documented. The DON confirmed these documentation errors.
The facility's QAPI committee failed to maintain compliance with regulations, resulting in repeated deficiencies related to accident hazards, controlled medication accountability, and medical record documentation. Despite previous plans of correction involving audits and QAPI review, the same issues were identified again, indicating ineffective quality assurance processes.
A facility failed to notify a resident's representative in writing about the reasons for multiple hospitalizations. Despite the resident being transferred to the hospital several times, there was no documented evidence of written notification. Interviews with facility staff confirmed that only verbal notifications were made, violating regulatory requirements.
Improper Food Storage in Main Kitchen Freezer
Penalty
Summary
Food in the main kitchen walk-in freezer was not stored in accordance with professional food service standards. The facility policy dated February 6, 2026 stated that any food that has been opened must be labeled, dated, and secured so that the food item is not open to air. During observation of the freezer on May 27, 2026, surveyors found a bag of egg patties, a bag of dinner rolls, a bag of chicken patties, and a bag of waffles that were not dated with an opened date and were open to the air. The Dietary Manager later confirmed that all food items in the kitchen should be labeled, dated, and not open to the air.
Grievance Box Not Accessible to Residents in Wheelchairs
Penalty
Summary
The facility failed to make certain that a complaint or grievance could be filed anonymously by residents who were dependent on wheelchairs for mobility. During observation, only one grievance/complaint box was found in the facility, attached to the wall near the entrance at standing height. Blank grievance/complaint forms were placed in front of the box, and completed forms were to be inserted into a slot on top of the box. The box and forms were too high for residents seated in wheelchairs to reach. The Social Worker, who was responsible for investigating grievances/complaints, stated that the facility had only one grievance/complaint box and that it was located too high on the wall for residents in wheelchairs to reach, so residents would need staff assistance to obtain a form and place it in the box or on her desk, preventing anonymous filing.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the state ombudsman of hospital transfers for six residents reviewed. Resident 1 was cognitively intact, required staff assistance for all daily care needs, and had a diagnosis of heart failure; a nursing note documented admission to the local hospital, but there was no evidence that the ombudsman was notified. Resident 4 was also cognitively intact, required assistance with all daily care needs, and had heart failure; a nursing note documented transfer to the local hospital, with no documented ombudsman notification. Resident 6 had severe cognitive impairment, required assistance with daily care needs, and had encephalopathy; after a critical lab result, the physician was notified and the resident was transferred to the hospital emergency room, but no ombudsman notification was documented. Resident 7 was cognitively impaired, required assistance with all daily care needs, and had a urinary tract infection; a nursing note documented admission to the local hospital, with no evidence of ombudsman notification. Resident 9 had mild cognitive impairment, required assistance with daily care needs, and had a diabetic foot ulcer; after the left foot condition declined, the physician was notified and orders were obtained to transfer the resident to the hospital, but no notification to the ombudsman was documented. Resident 52 was admitted for rehabilitation following hospitalization for acute cholecystitis and was later admitted to the hospital with urinary tract infection and cholecystitis; there was no documented evidence that the ombudsman was notified of the transfer. The Nursing Home Administrator confirmed that there was no evidence the state ombudsman was notified for these hospital transfers.
Inaccurate MDS Coding for Feeding Tube, Diuretic, and Insulin Use
Penalty
Summary
The facility failed to complete accurate MDS assessments for three residents by incorrectly coding items related to tube feeding, diuretic use, and hypoglycemic medication use. For one resident, a quarterly MDS dated April 28, 2026, indicated that the resident had a tube feed while a resident, but the medical record showed the resident did not have a tube feed at the facility. The RAI User's Manual stated that Section K0520B should be checked if the resident had a feeding tube on admission, while not a resident, while a resident, or at discharge. For another resident, physician orders included 20 mg of Furosemide daily for edema, and the MAR showed the medication was administered daily throughout April 2026, but the quarterly MDS dated April 8, 2026, did not check the diuretic item in Section N0415G1. For a third resident with severe cognitive impairment and type 2 diabetes mellitus, physician orders included 6 units of Lispro every afternoon, and the MAR showed the insulin was administered from March 26 through March 31, 2026, but the quarterly MDS dated April 1, 2026, did not indicate hypoglycemic medication use in Section N0415J1. The RN Assessment Coordinator confirmed on May 29, 2026, that the three residents' MDS assessments were coded inaccurately.
Failure to Invite Resident Representative to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that Resident 6 and/or the resident’s representative were encouraged to attend and participate in the resident’s assessment and in the development of the resident’s person-centered care plan. The facility policy for Resident Participation - Assessment/Care Plans stated that the resident or legal representative is to be encouraged to attend and participate in the assessment and care planning process, and that a seven-day advance notice of the care planning conference is to be provided by the Social Services Director or designee with documentation of the contact and any input or refusal. Resident 6’s quarterly MDS assessment dated May 20, 2026, showed the resident was admitted to the facility on [DATE], had severe cognitive impairment, required staff assistance with daily care needs, and had a diagnosis of encephalopathy. There was no documented evidence that the resident or the resident’s representative was invited to attend or informed of any care plan meetings. The resident’s spouse stated on May 27, 2026, that he did not know what a care plan was and had never been invited to participate in any care plan meetings or given the results of any meetings. The DON confirmed on May 28, 2026, that there was no documented evidence that the resident’s representative was invited to participate in any care plan meetings for Resident 6.
Failure to Follow Midodrine Hold Parameters
Penalty
Summary
The facility failed to follow physician's orders for medication administration for one resident with cognitive impairment and a diagnosis of low blood pressure. The resident's orders, dated December 11, 2025, directed staff to administer 10 mg of midodrine twice daily and to hold the medication if systolic blood pressure was greater than 120 mm/Hg and diastolic blood pressure was above 80 mm/Hg. The resident's quarterly MDS assessment, dated April 5, 2026, indicated the resident required assistance with daily care needs and had cognitive impairment. Review of the MAR from February through May 2026 showed multiple instances in which 10 mg of midodrine was given even though the resident's systolic blood pressure exceeded the ordered hold parameter. The medication was administered when SBP readings were 124, 135, 136, 129, 144, 122, 127, 135, and 124 mm/Hg on various dates during that period. The DON confirmed on May 29, 2026, that the resident received midodrine when it should have been held per the physician's order.
Improper Urinary Catheter Drainage Bag Placement
Penalty
Summary
The facility failed to ensure proper care for an indwelling urinary catheter for one resident. The facility policy dated February 6, 2026 stated that catheter tubing and the drainage bag are to be kept off the floor to help prevent catheter-associated urinary tract infections. A quarterly MDS assessment dated March 20, 2026 showed that the resident was cognitively impaired, had an indwelling urinary catheter, and had diagnoses including obstructive uropathy. The care plan dated April 1, 2024 indicated the resident required a urinary catheter because of obstructive uropathy. On May 27, 2026, the resident was observed in bed with the catheter drainage bag lying on the floor on the right side of the bed. An LPN confirmed that the drainage bag was on the floor and should not have been touching the floor, and the DON also confirmed that the drainage bag should not have touched the floor.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
The facility failed to maintain professional practices that support infection prevention and control for one resident with a stage III pressure ulcer to the sacral region. The facility’s hand hygiene policy, dated February 6, 2026, stated that team members are to use alcohol-based hand rub or soap at specified times, including before and after handling clean or soiled dressings and after removing gloves. A quarterly MDS assessment for the resident, dated April 27, 2026, identified the resident as cognitively impaired, needing assistance with daily care needs, and having a stage III pressure ulcer to the sacral area. Physician’s orders dated May 12, 2026, directed wound care to cleanse the buttocks with wound cleanser, pat dry, pack the wound with collagen particles, and cover with calcium alginate and a silicone border super absorbent dressing twice daily and as needed. During observation on May 29, 2026, an LPN brought wound care supplies into the resident’s room, donned a gown and gloves, removed the dressing after the resident had just showered, cleansed the wound, removed gloves and put on clean gloves, applied collagen particles, removed gloves again, applied new gloves, cleaned scissors and cut the calcium patch, then applied the calcium patch and silicone border dressing. The LPN confirmed in interview that hand hygiene should have been performed after each glove removal and that it was not done. The ADON also stated that the LPN should have performed hand hygiene each time gloves were removed.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to designate a qualified individual responsible for implementing and overseeing the infection control program. The facility’s infection preventionist policy, dated February 6, 2026, stated that the infection preventionist must be qualified by education, training, experience and/or certification and have sufficient knowledge to perform the role. During an interview on May 28, 2026, the Assistant DON/Infection Preventionist stated that she did not complete the required nursing home infection preventionist training course. Facility-provided certification records also showed that she had not completed the nursing home infection preventionist training course required to fulfill the role. The NHA later confirmed that the facility failed to designate a qualified individual responsible for implementing programs and activities to prevent and control infections.
Unsafe Hot Water Temperatures in Resident Care Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe hot water temperatures in resident care areas, contrary to its policy requiring water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas to be set at no more than 110°F or the maximum allowable temperature per state regulation. The policy also required maintenance staff to check thermostats and temperature controls, record these checks in a maintenance log, and conduct periodic tap water temperature checks documented in a safety log, with staff instructed to report water that felt excessively hot to the touch. Despite these requirements, surveyors found that hot water temperatures in multiple resident rooms and a shower room on the North and South Halls and in the corridor area exceeded the facility’s stated maximum temperature. During an interview, a resident on the South Hall reported that she did not prefer to shower and instead used two basins to wash at the bedside, stating that the water provided was “scalding hot” and questioning why such hot water was given. When the surveyor ran the water in this resident’s bathroom sink, it was hot enough to cause the surveyor to remove her hand after just seconds. Subsequent temperature measurements by the Maintenance Director and surveyors showed readings ranging from just above 110°F up to 123.6°F in multiple resident rooms and the South Hall shower room sink, including specific readings of 120°F, 117.5°F, 113.9°F, 119.3°F, 122.7°F, 114.4°F, 111.2°F, 110.1°F, 111°F, 111.9°F, 112.2°F, and 120.7°F. The Maintenance Director and the Nursing Home Administrator both acknowledged that these water temperatures should not be that high. Surveyors determined that this failure to maintain safe water temperatures in three of three resident areas placed residents in immediate jeopardy of the likelihood of serious bodily injury, harm, or death.
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to ensure that hot water temperatures in resident care areas were maintained at safe levels. Review of the NHA’s job description showed responsibilities that included overseeing staff, explaining and assisting with facility policies and procedures, assuring the facility is properly maintained, clean and safe, maintaining necessary equipment and supplies, and ensuring adequate, properly trained personnel are on duty to meet resident needs and comply with regulations. Despite these defined duties, surveyors found that water temperatures in resident rooms on the North Hall, South Hall, and corridor rooms were not maintained at appropriate temperatures for resident safety, placing residents at risk for scalding injuries. The DON’s job description indicated responsibility for leading and managing the nursing department, overseeing clinical operations, supervising nursing staff, ensuring regulatory compliance, and collaborating with other department heads to promote quality outcomes in a resident-centered environment. However, the DON did not ensure that nursing staff followed facility policies related to safe water temperatures. As a result, residents in three of three resident areas (North Hall, South Hall, and corridor rooms) were exposed to unsafe water temperatures. Surveyors determined that this failure to maintain safe water temperatures and to ensure adherence to facility policies and regulatory requirements constituted Immediate Jeopardy under F689 (Accidents), as well as violations of specified Pennsylvania Code provisions related to licensee responsibility, management, and nursing services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD), along with depression and anxiety, was properly assessed and received trauma-informed care. The resident was cognitively intact and required staff assistance for daily care needs. Although the facility's policy required culturally competent and trauma-informed approaches that minimize triggers for trauma survivors, there was no documented evidence that the facility identified the resident's specific triggers or implemented measures to prevent or minimize re-traumatization. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that specific triggers for the resident had not been identified or addressed.
Failure to Label Multi-Dose Tuberculin Vial per Manufacturer Instructions
Penalty
Summary
Surveyors found that a multi-dose vial of Tubersol Tuberculin injection, used for Mantoux TB skin testing, was present in the medication room without a date indicating when it was opened. Manufacturer's instructions specify that such vials should be discarded 30 days after opening, making it necessary to label them with the date of first use. The Director of Nursing confirmed that the vial was not dated as required. This failure to properly label the multi-dose vial constitutes noncompliance with accepted professional principles and state regulations regarding pharmacy and nursing services. No information was provided about specific residents or their medical conditions in relation to this deficiency.
Food Storage and Preparation Deficiency Due to Water Intrusion
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety, as evidenced by observations in the basement dry storage area. On December 4, 2024, standing water was found covering a 12-foot by 12-foot area, with a stream extending to a floor drain next to several metal shelves containing the emergency food supply and other items. These items included cans of chicken and dumplings, pureed beef stew, cans of chicken puree, cans of tomato soup, cans of ravioli, boxes of thick and easy Hormel dairy beverage, four cases of bottled water, and cases of plastic spoons and forks. Additionally, there was a noticeable sewer smell in the basement area, and a dehumidifier was in use by the floor drain. Interviews with the Dietary Manager and the Nursing Home Administrator, along with the Maintenance Director, confirmed the presence of standing water and the sewer odor. The Dietary Manager was unsure of the water's cause but noted a crawl space behind the wall. The Maintenance Director, upon re-examination, determined that a broken downspout was causing the excess water in the basement, which had increased significantly since it was last cleaned up. The recent rain and snow were cited as contributing factors to the increased groundwater in the basement.
Plan Of Correction
The water on the floor in the storage basement was immediately cleaned and a ventilator fan placed in the area to keep it dry. The cause was determined to be a detached drain spout along the outside wall at that point; it was immediately repaired. The other outside roof drain spouts were checked to ensure they were all in good working order and none were found to be out of order. While the entire sewer drainage system was recently rebuilt, this was not seen as a possible cause; nonetheless, a Sewer Drain contracting company was brought in with a line camera which was used to scope both drain pipes and no issues were found from the farthest point on both lines up to and including the initial drainage tank in the on-site sewage treatment plant. To ensure any rainwater or melting snow accumulation would not run down the wall to possibly penetrate the basement walls, dirt and mulch was added at the base of the exterior wall to provide drainage away from the building for any water that is not handled by the down spouts. As a preventative measure, Scenery Hill contracted with the sewage contractors for jet spray line cleaning for both the North and South halls' sewage pipes on a bi-annual basis. The roof down spouts will be added to the monthly maintenance checklist so these are reviewed monthly. The Maintenance team will be educated on the new monthly checklist requirements by the Nursing Home Administrator. They will also be educated on the new sewer cleanout contract requirements. The Maintenance Director or designee will audit the dietary storage floor for water daily for one week and weekly for three weeks. The Maintenance Director or designee will also audit the down spouts daily for a week and weekly for three weeks to ensure proper function and drainage. The results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Pay Essential Service Bills Jeopardizes Resident Safety
Penalty
Summary
The facility failed to pay bills in a timely manner for services essential to the residents' health and safety, as evidenced by a review of the facility's accounts payable ledger and interviews with administrative staff. The outstanding balances included significant amounts owed to various service providers such as Citizens Ambulance, REA for electric service, Suburban Propane, US Foods, Liberty Healthcare, Medvan Transport, RCP O2, Twin Med, Supply Line, Penn Highlands Dubois, Hugill Sanitation, and ICMSA. These unpaid bills resulted in termination notices and service disruptions, which could jeopardize the residents' well-being. An email communication revealed that the facility had fallen behind in payments to Citizen's Ambulance Service, leading to a halt in non-emergent transportation services until the payment was settled. Additionally, a billing statement from REA indicated a significant arrears balance, and a termination notice from the Indiana County Municipal Authority highlighted an overdue water bill. Interviews with the Nursing Home Administrator and Business Office Manager confirmed the existence of these outstanding balances and the receipt of termination notices due to nonpayment. The facility had to change medical suppliers and transportation services when services were terminated for nonpayment.
Plan Of Correction
The facility cannot retroactively correct. The residents' health and safety were / are not jeopardized due to this practice. The disposition of the listed invoices are: - Citizens Ambulance - invoice to be paid December 30. - REA Energy - $3872.83 was due within the past week and was paid in full. - Suburban Propane - Was paid on 12/4 and delivery received on 12/6. - US Foods - This vendor has always been on autopay and has never been late. - Liberty Healthcare - This is a consulting firm that ended service in August of 2022. They were assigned to review the buyout and not clinically related. - MedVan - Up to date, invoice payment made. - RCP 02 - paid up and regular deliveries every Friday prior to survey and since. - Twin Med - Invoice paid December 2. - Supply Line - invoice paid under payment agreement. - Penn Highlands Dubois - We don't know what this is for as they are not a vendor. - Hugill Sanitation - no service break, invoices up to date. - ICMSA - Invoice paid 12/3/24 with no break in service at any time. The accounts payable ledger was reviewed for any other outstanding invoices with shut-off notices and none were found. REA Energy, the provider that initiated this survey, was put on the auto-pay list so their invoices will be automatically paid upon receipt. The Nursing Home Administrator (NHA) or designee will educate the Operator (person responsible for approving payment to vendors) on timely bill payment for invoices incurred in the operation of the facility that for services without which the residents' health and safety would be jeopardized. The NHA or designee will audit the monthly payment arrangement to ensure payments are made to the vendor per the arrangement plan. These audits will be performed monthly for three months, and the results of these audits will be reviewed by the Quality Assurance Performance Improvement committee for adherence or further action. The plan of correction date of compliance will be January 7, 2025.
Failure to Conduct Safety Assessments for Air Mattress Use
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing safety assessments for the use of air mattresses for three residents. The facility's policy stated that air mattresses were reserved for residents with pressure ulcers, yet there was no documented evidence of safety assessments being conducted for these residents before the air mattresses were placed on their beds. This oversight was identified for three residents who were cognitively intact and had various medical conditions, including pressure ulcers and a history of stroke. Resident 20 had a Stage III pressure ulcer and was observed with an air mattress in place without a prior safety assessment. Similarly, Resident 44, who had multiple pressure ulcers and venous and arterial ulcers, was also observed using an air mattress without a documented safety assessment. Resident 47, who had a stroke and limited range of motion, was using an air mattress with bolsters, again without a safety assessment. The Director of Nursing confirmed that no specific assessments were completed to ensure the safety of air mattress use for these residents.
Food Safety and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not discarding food in a timely manner and not maintaining the appropriate washing cycle temperature for the dishwasher. During an observation in the kitchen, a plastic container of pizza sauce was found with a date indicating it should have been discarded after seven days, but it was still present nine days later. The Dietary Manager confirmed that the sauce should have been discarded. Additionally, the dishwasher's wash cycle was observed to reach only 100 degrees Fahrenheit, below the manufacturer's recommended operational temperature of 120 degrees Fahrenheit. The Dietary Manager did not express any concerns about the temperature that morning, and the Nursing Home Administrator confirmed the manufacturer's instructions regarding the required temperature.
Failure to Verify Nurse Aide Registry
Penalty
Summary
The facility failed to complete a Nurse Aide Registry verification for one of the five nurse aides reviewed upon hire. The facility's abuse policy, dated February 15, 2024, mandates that they will not employ individuals with findings of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property in the state Nurse Aide Registry. However, the personnel file for Nurse Aide 1, who was hired on May 10, 2024, lacked documented evidence of registry verification until May 28, 2024. This was confirmed during an interview with the Human Resources Director on May 30, 2024.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, as evidenced by discrepancies in the documentation of medication administration. The facility's policy requires that the nurse administering the medication record specific details, including the resident's name, medication details, time, method, remaining quantity, and the nurse's signature. However, for Resident 6, a dose of oxycodone was signed out but not documented as administered in the clinical record, including the Medication Administration Record (MAR) and nursing notes. This lack of documentation was confirmed by the Director of Nursing. Similarly, for Resident 28, a dose of hydrocodone-acetaminophen was signed out but not documented as administered in the clinical record. Additionally, Resident 47 had multiple instances where doses of oxycodone were signed out but not documented as administered. These discrepancies were also confirmed by the Director of Nursing. The failure to document the administration of these controlled substances is a violation of the facility's policies and state regulations regarding pharmacy and nursing services.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, as evidenced by an unattended medication cart in the hallway with a medication souffle cup containing medications in applesauce. This incident occurred when a Licensed Practical Nurse (LPN) left the cart unattended due to being called to an emergency. The LPN later confirmed that the medication should not have been left on top of the cart, and the Director of Nursing (DON) corroborated that medications should not be left unattended on the cart. Additionally, the facility did not securely store medications for Resident 28, who was cognitively intact and required assistance for daily care needs. Observations revealed that Resident 28 had a brown bottle of Flonase nasal spray and a Trelegy Ellipta inhaler on her overbed table, which the nurse forgot to take back after administration. The DON confirmed that these medications should have been returned to the medication cart and secured after administration, rather than being left at the resident's bedside.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for three residents. For Resident 6, there was a discrepancy in the documentation of oxycodone administration. The controlled drug record indicated a dose was signed out on May 9, 2024, but there was no evidence in the clinical record that it was administered. Conversely, the MAR showed a dose was administered on May 10, 2024, without corresponding documentation in the controlled drug record. The Director of Nursing confirmed the documentation errors, attributing them to a night shift nurse's oversight. Resident 20's records also lacked documentation of oxygen administration on two observed occasions, despite the resident being on oxygen as per physician's orders. The Director of Nursing confirmed the absence of documentation for these dates. Similarly, for Resident 28, the MAR indicated a dose of Morphine Sulfate was administered, but the controlled drug record did not reflect this. The Director of Nursing acknowledged the inaccuracies in Resident 28's MAR documentation.
Ineffective QAPI Committee Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations, as evidenced by repeated deficiencies identified in the current survey. These deficiencies included ensuring that the resident's environment was free of accident hazards, accountability of controlled medications, and complete and accurate clinical record documentation. The facility had previously developed plans of correction for these issues, which included quality assurance systems with audits to ensure compliance. However, the results of the current survey indicated that these plans were ineffective, as the same deficiencies were identified again. Specifically, the facility's plans of correction for deficiencies regarding accident hazards, controlled medications, and medical record documentation, cited during the survey ending on June 22, 2023, involved conducting audits and presenting the results to the QAPI committee for further monitoring. Despite these measures, the current survey revealed that the QAPI committee was ineffective in maintaining compliance with the regulations, as the same issues were cited again under F689, F755, and F842. This indicates a failure in the facility's quality assurance processes to address and rectify these recurring deficiencies.
Failure to Provide Written Notification of Hospitalization
Penalty
Summary
The facility failed to provide written notification to the resident's representative regarding the reasons for hospitalization for one of the residents reviewed. Specifically, Resident 29, who was cognitively intact and required assistance for daily care needs, was transferred to the hospital multiple times between December 2023 and May 2024. Despite these transfers, there was no documented evidence in the clinical record that the resident's representative was notified in writing about the purpose of these hospitalizations. Interviews with the Social Services Director and the Director of Nursing confirmed that the facility only provided verbal notifications and did not document written notifications to the resident's representative. This lack of documentation was acknowledged by the facility staff, indicating a failure to comply with the requirement to notify the resident's representative in writing, as mandated by the relevant regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 218 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indiana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Communities At Indian Haven, | 2.6 mi | ★★★★★ | 17 | 0 |
| Julia Pound Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Beacon Ridge | 4 mi | ★★★★★ | 25 | 0 |
| Kittanning Health & Rehab Center | 17.4 mi | ★★★★★ | 41 | 0 |
| Embassy Of Hillsdale Park | 19.2 mi | ★★★★★ | 17 | 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 July 2026) and official state health department websites.