Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Scottdale Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to ensure PRN Ativan use was free from unnecessary psychotropic medication for two residents. One resident with dementia, cancer, and moderate cognitive impairment received multiple PRN doses for restlessness/agitation, and another resident with dementia and hospice services received PRN Ativan for restlessness/anxiety; in both cases, the MAR lacked documentation that non-pharmacological interventions were attempted before the medication was administered. The DON confirmed the missing documentation.
A resident with cancer and IV access received daily IV ertapenem through an implanted venous port, but the MAR had no documentation that the port was flushed before and after use as required by policy. Another resident admitted with a PICC line received IV vancomycin and Zosyn for cellulitis, but there was no documented evidence that the PICC was flushed before and after medication administration. The DON confirmed the missing documentation.
Controlled medication accountability was not maintained for two residents. One resident with COPD and HTN had ordered morphine for pain and SOB, and another resident with cognitive impairment had ordered tramadol PRN for pain; in both cases, the controlled drug records showed the meds were signed out, but the MARs had no documentation that the doses were actually administered. The DON and NHA confirmed the missing documentation.
A resident admitted for hospice respite care had a call bell that was not within reach after an aide adjusted the bed and set up the lunch tray. The call bell was found on the floor beside the bed, and both the aide and DON confirmed it should have been within the resident's reach.
A resident on hospice with COPD and assistance needs had a quarterly MDS showing cognitive intactness and active hospice status, but the facility did not complete a significant change MDS after hospice enrollment. The RN Assessment Coordinator confirmed the omission, despite RAI guidance requiring a comprehensive assessment when a terminally ill resident enrolls in hospice or has a significant change in condition.
A facility failed to accurately code MDS medication items for three residents. One resident received Tramadol but the opioid item was left unchecked, another resident had a topical treatment containing Silvadene applied but the antibiotic item was not checked, and a third resident received aspirin and apixaban but the anticoagulant and antiplatelet items were not coded while the opioid item was incorrectly marked. The RNAC confirmed the MDSs were coded inaccurately.
A resident receiving hospice services and diagnosed with dementia had PRN Ativan ordered for restlessness/anxiety and Erythromycin ointment ordered for a red eye, but the care plan did not address either need. The RNAC and DON confirmed the care plan lacked documentation for the resident’s anxiety/restlessness and antibiotic use.
Care plans for three residents were not updated to reflect current care needs. One resident’s plan still listed oxygen therapy even though MAR/TAR review showed no oxygen services, another still listed anticoagulant use despite no MAR or nurse note evidence of the medication, and a third still listed antidepressant therapy even though the MAR showed none. The RN Assessment Coordinator confirmed each plan should have been revised to match the resident’s current status.
Failure to Provide Ordered Pressure Ulcer Care: A resident who was cognitively intact, needed staff help with daily care, and had a Stage 4 coccyx pressure ulcer did not have ordered wound treatments documented as completed on multiple dates. The TAR lacked evidence that the prescribed cleansing, packing, and topical treatments were provided, and the DON confirmed the missing documentation.
A resident with dementia, cognitive impairment, and a history of falls did not have ordered bilateral fall mats in place while lying in bed. The care plan and MD orders required fall mats on both sides of the bed and staff checks each shift, but an observation found no mats present, and both a nurse aide and the DON confirmed they should have been in place.
Medication Administration Error Rate Exceeded 5 Percent: Surveyors observed two med admin errors during 26 opportunities, resulting in a 7.69% error rate. An LPN gave a resident 1000 mg sodium chloride instead of the ordered 500 mg dose and provided saline spray, then documented that he had given 500 mg sodium chloride and fluticasone propionate. The LPN confirmed the dosing error and stated he believed he had administered the ordered fluticasone even though it was not in his med cart; the DON confirmed meds are to be given as ordered.
QAPI committee failed to correct repeated deficiencies involving inaccurate MDS assessments, individualized care plans, care plan timing and revision, and controlled medication accountability. Prior plans of correction relied on audits and QAPI review, but the current survey found the same deficient practices remained, leading to citations under F641, F656, F657, and F755.
The facility failed to report allegations of abuse involving three residents in a timely manner, as required by state law and facility policy. Incidents included a nurse aide's refusal to assist a resident, rude behavior, and aggressive handling of a resident. These were not reported to authorities until six days later, resulting in a deficiency finding.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers and reasons for hospitalization for seven residents. This deficiency was identified through clinical record reviews and staff interviews, revealing a lack of documented evidence of written notices for transfers due to various medical conditions, including osteomyelitis, chest pain, altered mental status, fractures, cellulitis, and gastrointestinal issues.
The facility failed to follow physician orders for two residents. A resident with heart failure received Midodrine despite blood pressure readings above the ordered threshold. Another resident with chronic kidney disease and congestive heart failure did not have weights obtained as ordered on multiple occasions. The DON confirmed these deficiencies.
The facility failed to document the administration of controlled medications for three residents, leading to a deficiency in pharmaceutical services. Doses of Lorazepam, Tramadol, Morphine, and Oxycodone were signed out without corresponding documentation in the residents' clinical records. This discrepancy was confirmed by the DON, indicating a failure in the facility's processes for documenting medication administration.
The facility failed to complete comprehensive admission MDS assessments within the required timeframe for four residents. The assessments were completed 15 to 16 days after admission, exceeding the 14-day requirement. This was confirmed by the RNAC through clinical records and staff interviews.
The facility failed to complete quarterly MDS assessments within the required time frame for four residents. Two residents had assessments conducted beyond the 92-day limit, while two others had assessments completed late beyond the 14-day completion period. These deficiencies were confirmed by the Regional RNAC.
The facility failed to accurately complete MDS assessments for three residents, leading to incorrect documentation of medication administration. One resident's assessment did not reflect the administration of hypoglycemic medication and incorrectly recorded an anticonvulsant. Another resident's assessment inaccurately documented an injection, and a third resident's assessment failed to record anticoagulant and opioid medications while incorrectly indicating an anticonvulsant. These errors were confirmed by the Regional RN Assessment Coordinator.
A facility failed to create a comprehensive care plan for a resident with frequent UTIs, despite multiple antibiotic treatments and concerns from the resident's daughter. The facility's policy requires individualized care plans, but none was documented for this resident, as confirmed by the DON.
A facility failed to update a resident's care plan to reflect the correct dialysis schedule. The resident, who was cognitively intact and required assistance with care needs, had a diagnosis of end-stage renal disease and attended dialysis on Mondays, Wednesdays, and Fridays. However, the care plan inaccurately stated the dialysis days as Tuesdays, Thursdays, and Saturdays. This discrepancy was confirmed by the DON during an interview.
A facility failed to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a diagnosis of urinary retention and neurogenic bladder, was observed with catheter tubing lying on the fall mat, contrary to facility policy. The Director of Nursing confirmed the tubing should not have been in contact with the mat.
A facility failed to have a physician's order for a resident requiring dialysis. The resident, diagnosed with end-stage renal disease, received dialysis thrice weekly, but their clinical record lacked an active physician's order for these services. This was confirmed by the DON.
A facility failed to attempt non-pharmacological interventions before administering Ativan to a resident on multiple occasions, despite policy requirements. The resident, who was cognitively intact and receiving hospice services, was given the medication without documented evidence of prior interventions. The DON confirmed the oversight.
A resident with atrial fibrillation did not receive the prescribed doses of warfarin on multiple occasions. The resident was supposed to receive 3 mg daily, but it was not administered on two separate days. Additionally, an incorrect dose of 9 mg was given instead of 6 mg on another day. The DON confirmed these medication errors.
The facility's QAPI committee failed to maintain compliance with nursing home regulations, resulting in repeated deficiencies. These included failures in developing comprehensive care plans, updating resident care plans, following physician's orders, accounting for controlled medications, and adhering to infection control practices. Despite previous plans of correction, the committee was ineffective in implementing these plans, leading to repeated citations.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with a history of ESBL infections. Observations revealed a lack of signage and PPE outside the residents' rooms, and interviews with the DON confirmed that EBP should have been in place. This deficiency highlights a lapse in following infection control guidelines from CMS and CDC.
The facility did not maintain an effective preventative maintenance program for the walk-in freezer, resulting in significant ice accumulation on the ceiling, walls, and floor. The Dietary Manager confirmed the issue, and the Director of Maintenance, who had been in the role for six months, did not recall any maintenance work on the freezer. A Maintenance Worker mentioned a past compressor replacement and lack of a manual, with a service technician suggesting possible causes for the ice buildup.
The facility did not provide effective communication training to its nursing and direct care staff, as required by its Facility Assessment. The review of four employee files showed no documented evidence of such training, which was confirmed by the DON. This deficiency violates specific sections of the Pennsylvania Code related to staff development and management.
A resident experienced multiple episodes of respiratory distress and hypoxia without documented assessments by an RN, as required by the Pennsylvania Nursing Practice Act. Despite symptoms such as shortness of breath and low oxygen levels, no RN assessment was recorded, leading to the resident's transfer to the ER with pneumonia and sepsis. The DON confirmed the lack of RN assessments during these critical times.
Unnecessary PRN Ativan Given Without Documented Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure that the medication regimen was free from unnecessary psychotropic medication for two residents reviewed. The facility policy dated September 24, 2025 stated that non-pharmacological approaches would be used unless contraindicated to minimize the need for medications, permit the lowest possible dose, and allow discontinuation when possible. Resident 26 had moderate cognitive impairment, was dependent on staff for most daily care needs, and had diagnoses including cancer and dementia. A physician ordered Ativan 0.5 mg every six hours as needed for restlessness/agitation for 14 days, and the MAR showed multiple administrations in November 2025, including on November 17, 19, 20, 21, 22, 23, and 29. For those administrations, there was no documented evidence that non-pharmacological interventions were attempted before the PRN Ativan was given. A nursing note for another resident indicated admission to the facility, hospice services, and diagnoses including dementia. That resident had an order for Ativan concentrate 0.5 ml every two hours as needed for restlessness/anxiety for 14 days, and the MAR showed administrations on December 9, 11, 13, and 14, 2025. There was no documented evidence that non-pharmacological interventions were attempted before those doses were administered. The DON confirmed on December 17, 2025, that there was no documented evidence of non-pharmacological interventions before administering Ativan to the two residents on the listed dates and times and that there should have been.
Failure to Flush Implanted Port and PICC Line per Policy
Penalty
Summary
The facility failed to ensure that an implanted venous port was flushed according to policy for one resident who was cognitively intact, had a diagnosis of cancer, and had intravenous access. The resident had an order for 1 gram of ertapenem sodium solution intravenously every evening for a urinary tract infection for 10 days, and the MAR showed the medication was administered each evening during that period. However, there was no documented evidence that staff flushed the implanted venous port before and after the ertapenem administration as required by the facility policy, which called for flushing with preservative free 0.9 percent sodium chloride before and after infusion or medication administration and daily flushing when the port is used intermittently. The facility also failed to ensure that a PICC line was flushed according to policy for another resident who was admitted from the hospital with a PICC line in place. That resident had orders for daily IV vancomycin and IV Zosyn every eight hours for left foot cellulitis, and the MAR showed the antibiotics were administered. However, there was no documented evidence that the PICC line was flushed before and after medication administration as required by the facility policy, which directed that peripheral or midline IV catheters be flushed with 10 mL of normal saline before and after each use. The DON confirmed that the records did not show the required flushing for either resident.
Controlled Medication Administration Not Documented
Penalty
Summary
The facility failed to ensure accountability of controlled medications for two residents. Resident 6 was cognitively intact, required assistance with daily care needs, and had diagnoses including COPD and high blood pressure. Physician orders included morphine 0.5 mL orally every 4 hours as needed for moderate pain or shortness of breath and morphine 1 mL orally every 2 hours as needed for severe pain or shortness of breath. The controlled drug record showed staff signed out morphine on multiple occasions, but the MAR for October and November 2025 had no documented evidence that the morphine was administered on those dates. The DON confirmed there was no documented evidence that Resident 6 received the ordered morphine on the referenced dates. Resident 14 had moderate cognitive impairment, occasional pain, received pain medication routinely and as needed, and received an opioid. Physician orders included tramadol 50 mg every 6 hours as needed for moderate to severe pain. The controlled drug record showed staff signed out tramadol on multiple occasions in October and November 2025, but the MAR contained no documented evidence that the tramadol was administered on those dates. The NHA confirmed there was no evidence that the tramadol was administered to Resident 14.
Call Bell Not Within Resident's Reach
Penalty
Summary
The facility failed to ensure that a resident's call bell was within reach. Resident 32 was admitted for hospice respite care, and the admission assessment documented that staff verbally reviewed the call bell system with the resident and that he was able to call for the nurse effectively after being shown how to use it. During an observation, a nurse aide assisted the resident by adjusting his bed and setting up his lunch tray, then left the room, and the resident's call bell was found on the floor on the left side of the bed in front of the bedside table. The nurse aide confirmed that the call bell was not within the resident's reach and stated it should have been clipped to the bed, and the DON also confirmed that the call bell should have been within the resident's reach.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
A significant change MDS assessment was not completed for one resident who had a quarterly MDS dated August 31, 2025 showing the resident was cognitively intact, required staff assistance with daily care needs, was on hospice services, and had active diagnoses including COPD. Physician orders dated August 15, 2025, included an order to admit the resident to hospice care with an admitting diagnosis of COPD. The RAI User's Manual required the facility to complete a comprehensive assessment within 14 days after determining, or when it should have determined, that there was a significant change in the resident's physical or mental condition. The manual also stated that a significant change MDS should be completed when a terminally ill resident enrolls in hospice or changes hospice providers and remains in the nursing home. Review of the resident's clinical record showed that a significant change MDS was not completed, and the RN Assessment Coordinator confirmed this during interview.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to complete accurate MDS assessments for three residents by incorrectly coding medication use in Section N0415. For one resident, physician orders included Tramadol 50 mg four times daily as needed for pain, and the December 2025 MAR showed the resident received Tramadol during the assessment period, but the admission MDS dated December 2, 2025 did not check the opioid item in Section N0415H1. For another resident, a nursing note documented burning and itching to the buttocks with excoriation and dermatitis, and a physician ordered Magic Mix containing Silvadene to be applied to the buttocks three times daily; the October 2025 TAR showed the treatment was applied, but the quarterly MDS dated October 30, 2025 did not check Section N0415F1 for antibiotic use. For the third resident, physician orders included aspirin 81 mg daily and apixaban 2.5 mg daily, and the November 2025 MAR showed the resident received both medications during the seven-day look-back period and did not receive any opioid medication. However, the quarterly MDS dated November 22, 2025 did not code the anticoagulant item in Section N0415E, did not code the antiplatelet item in Section N0415I, and incorrectly coded Section N0415H as indicating opioid use. The RNAC confirmed that the MDS assessments for the residents were coded inaccurately.
Failure to Include Anxiety and Antibiotic Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 40 related to anxiety/restlessness and the use of antibiotic medications. Resident 40 was admitted on December 8, 2025, was receiving hospice services, and had diagnoses that included dementia. Physician orders on December 9, 2025 included Ativan concentrate 0.5 ml every two hours as needed for restlessness/anxiety for 14 days. A nursing note on December 11, 2025 documented continued redness to the right eye and a new order for 0.5% Erythromycin ointment to the right eye four times daily for one week. The December 2025 MAR showed the resident received Ativan as needed and Erythromycin ointment from December 11 through December 17, 2025. Review of the current care plan found no documented evidence that the resident's care plan addressed restlessness/anxiety or the use of antibiotic medications, and the RNAC and DON confirmed that these needs were not included in the care plan.
Care plans not revised to match current resident treatments
Penalty
Summary
The facility failed to ensure that the care plans for three residents were updated and revised to reflect their current care needs. A facility policy for comprehensive care planning stated that care plans would be reviewed and revised as needed based on a resident’s changing condition and at least quarterly with completion of an MDS assessment. For Resident 4, a quarterly MDS dated November 12, 2025, showed moderate cognitive impairment, assistance needed with daily care, and diagnoses including diabetes and heart disease, but the care plan dated September 12, 2025, still indicated oxygen therapy even though the December 2025 MAR and TAR showed no documentation that oxygen services were being provided. For Resident 6, an annual MDS dated December 1, 2025, showed cognitive intactness, assistance with daily care, and diagnoses including COPD and high blood pressure, but the care plan dated October 28, 2024, still indicated anticoagulant medication even though the December 2025 MAR and nurses notes showed no evidence that the resident was receiving anticoagulant medication. For Resident 27, a quarterly MDS dated October 22, 2025, showed moderate cognitive impairment, assistance with daily care, and diagnoses including diabetes and dementia, but the care plan dated May 29, 2025, still indicated antidepressant medication even though the December 2025 MAR showed no antidepressant medication administration. The RN Assessment Coordinator confirmed for each resident that the care plan should have been revised to reflect the current treatment status, but it was not.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
Pressure ulcer care and prevention treatments were not provided as ordered for one resident who was cognitively intact, required staff assistance with daily care needs, was at risk for pressure ulcer development, and had one Stage 4 pressure ulcer present on admission. Physician orders directed staff to cleanse the coccyx wound, pat it dry, apply collagen powder and triad paste onto rolled gauze and gently pack the wound, then apply silver sulfadiazine, zinc, hydrocortisone, and nystatin 1% cream to the peri wound with bordered foam daily and as needed. Review of the resident’s September and November 2025 TAR showed no documented evidence that the ordered treatment was completed on September 23, 28, 29, and November 14, 2025. A later physician order changed the wound care to cleansing the coccyx wound, patting it dry, applying betadine soaked rolled gauze and gently packing the wound, along with silver sulfadiazine, zinc, hydrocortisone, and nystatin 1% cream to the peri wound and bordered foam daily and as needed. Review of the December 2025 TAR showed no documented evidence that the treatment was completed on December 10, 2025. The DON confirmed during interview that there was no documented evidence the wound treatments were completed as ordered on the identified dates.
Missing Fall Mats for Resident With History of Falls
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible by not ensuring that fall/injury prevention interventions were in place for one resident with a history of falls. The resident’s quarterly MDS dated October 1, 2025, showed cognitive impairment, dependence on staff for most daily care needs, and a diagnosis of dementia. The care plan dated April 7, 2025, identified a history of falling and included an intervention dated May 1, 2025, for bilateral fall mats to be in place. Physician’s orders dated April 30, 2025, directed staff to place fall mats on both sides of the bed and check their placement every shift. During an observation on December 16, 2025, the resident was lying in bed with no fall mats on either side, and a nurse aide confirmed the mats should have been in place but were not. The DON also confirmed that the resident should have had bilateral fall mats in place while in bed.
Medication Administration Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent. Review of the facility’s medication administration policy dated September 24, 2025, showed that the person administering medications is to check the label three times to verify the right resident, right medication, right dosage, right time, and right method before giving the medication, and is to initial the MAR after giving each medication and before administering the next one. During observations of medication administration on December 15 and 16, 2025, surveyors identified two medication administration errors during 26 opportunities for error, resulting in a 7.69 percent error rate. For one resident, physician orders included fluticasone propionate nasal spray, sodium chloride 500 mg daily, and saline spray nasal solution as needed for dryness, with permission for the saline spray to be self-administered. During the December 16, 2025 medication pass, an LPN administered a 1000 mg sodium chloride tablet instead of the ordered 500 mg dose and provided saline spray for the resident to self-administer, but later documented that he had administered 500 mg sodium chloride and one spray to each nostril of fluticasone propionate. In interview, the LPN confirmed he gave 1000 mg sodium chloride when he should have cut it in half to give 500 mg, and said he believed he had administered the ordered fluticasone propionate even though he also stated it was not in his medication cart. The DON confirmed that medications are to be administered as ordered.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to maintain compliance with nursing home regulations and did not effectively address recurring deficiencies identified in prior and current surveys. The report states that the facility had previously developed plans of correction after a State Survey and Certification survey ending November 19, 2024, which included quality assurance systems and audits to be reviewed by the QAPI committee. Despite those plans, the current survey ending December 17, 2025 found repeated deficiencies involving inaccurate MDS assessments, individualized care plans, care plan timing and revision, and accountability of controlled medications. The current survey cited the facility under F641, F656, F657, and F755 for these repeated problems. The report states that the QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments, the development of individualized care plans, ongoing compliance with care plan timing and revision requirements, and controlled medication accountability. The report also notes that the facility’s prior plans of correction for these issues relied on audits and reporting results to the QAPI committee for review, but the current survey found that these measures did not successfully correct the deficient practices.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report timely allegations of abuse to the State Survey Agency and other state agencies as required by the Older Adults Protective Services Act. The facility's policy mandates immediate reporting of suspected abuse, neglect, exploitation, or misappropriation to the administrator and relevant authorities. However, the facility did not report the allegations involving three residents until several days after the incidents occurred. Resident 131, who required assistance due to a hip fracture, reported feeling scared of a nurse aide who refused to assist her and was argumentative. Resident 132, with a fractured tibia, experienced rude behavior from the same nurse aide, who knocked over a drink and did not clean it up. Resident 133's wife reported aggressive behavior by the nurse aide, who snatched a urinal from her hand and handled the resident roughly in bed. These incidents were not reported to the appropriate authorities until six days later. Interviews with staff confirmed the delay in reporting. The Director of Nursing acknowledged that the allegations were not reported in a timely manner, attributing the oversight to her absence on vacation. The lack of immediate reporting violated both state law and the facility's own policies, resulting in a deficiency finding by the surveyors.
Failure to Notify Residents and Representatives of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives in writing about transfers to the hospital and the reasons for hospitalization for seven residents. This deficiency was identified through clinical record reviews and staff interviews. For Resident 1, there was no documented evidence of a written notice provided to the resident's representative and state ombudsman when the resident was transferred to the hospital for osteomyelitis. Similarly, Resident 5 experienced a change in mental status and was transferred to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis. However, there was no documented evidence of a written notice provided to the resident's representative and state ombudsman. Resident 9 was transferred to the emergency room due to lethargy and low blood oxygen levels, but again, no written notice was documented for the resident's representative and state ombudsman. Additional cases included Resident 14, who was transferred due to chest pain, Resident 22, who was transferred after a fall resulting in fractures, Resident 23, who was transferred with cellulitis, and Resident 24, who was transferred with gastrointestinal pain and other symptoms. In all these cases, there was no documented evidence of written notices provided to the residents' representatives and state ombudsman regarding the transfers and reasons for hospitalization.
Failure to Administer Medications and Obtain Weights as Ordered
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents. Resident 5, who was moderately cognitively intact and diagnosed with heart failure, had a physician's order to receive 5 mg of Midodrine three times a day for hypotension, with instructions to hold the medication if the systolic blood pressure exceeded 130 mmHg. However, the Medication Administration Record (MAR) showed that staff administered the medication on multiple occasions when the resident's systolic blood pressure was above the specified threshold, including readings of 138/76 mmHg, 135/76 mmHg, and 140/90 mmHg, among others. The Director of Nursing confirmed that the medication was improperly administered on these dates. Additionally, the facility did not obtain weights as ordered for Resident 17, who was cognitively impaired and had diagnoses including chronic kidney disease Stage 3 and congestive heart failure. The physician's orders required weekly weights on Thursdays, but the MAR revealed that weights were not obtained on several specified dates across multiple months, with no documentation indicating attempts or refusals by the resident. The Director of Nursing confirmed the failure to obtain the required weights on the mentioned dates.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for three residents, leading to a deficiency in pharmaceutical services. For Resident 12, there were multiple instances where doses of Lorazepam and Tramadol were signed out but not documented as administered in the resident's clinical records, including the Medication Administration Record (MAR) and nursing notes. This lack of documentation occurred despite the resident having physician's orders for these medications and being on hospice care with a diagnosis of congestive heart failure. Resident 22, who was cognitively intact and required assistance with daily care, had physician's orders for Morphine Sulfate to be administered as needed for pain. However, several doses of Morphine were signed out without corresponding documentation in the resident's clinical records to confirm administration. This discrepancy was confirmed by the Director of Nursing during an interview. Similarly, Resident 26, who was also cognitively intact and receiving routine and as-needed pain medications, had doses of Oxycodone signed out without evidence of administration in the clinical records. The Director of Nursing confirmed the absence of documentation for these signed-out doses. These findings indicate a failure in the facility's processes for documenting the administration of controlled medications, as required by their policy and state regulations.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission. However, the assessments for Residents 181, 182, 183, and 184 were completed 15 to 16 days after their respective admissions, exceeding the mandated timeframe. The deficiency was confirmed through a review of clinical records and staff interviews, specifically with the Regional Registered Nurse Assessment Coordinator (RNAC). The RNAC acknowledged that the assessments for the four residents were not completed within the required timeframes, as outlined in the RAI User's Manual. This oversight indicates a failure to adhere to the regulatory guidelines for timely resident assessments.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the assessment reference date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment must be completed no later than 14 days after the ARD. However, the quarterly MDS assessments for Residents 10 and 29 were conducted 93 days after their previous assessments, exceeding the 92-day requirement. Additionally, the quarterly MDS assessments for Residents 11 and 18 were not completed within the required 14-day period following the ARD. Resident 11's assessment was completed two days late, and Resident 18's assessment was completed three days late. These deficiencies were confirmed during an interview with the Regional Registered Nurse Assessment Coordinator, who acknowledged that the assessments were not completed within the required time frames.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in the documentation of their medication administration. For one resident, the MDS assessment incorrectly indicated that the resident did not receive hypoglycemic medication, despite physician's orders and the Medication Administration Record (MAR) confirming the administration of Metformin. Additionally, the assessment inaccurately recorded the administration of an anticonvulsant medication, which the resident did not receive. This error was confirmed by the Regional Registered Nurse Assessment Coordinator. Another resident's admission MDS assessment inaccurately documented the receipt of an injection, which was not supported by the MAR. Similarly, a third resident's significant change MDS assessment failed to record the administration of anticoagulant and opioid medications, while incorrectly indicating the receipt of an anticonvulsant medication. These inaccuracies were also confirmed by the Regional Registered Nurse Assessment Coordinator, highlighting a pattern of errors in the facility's MDS assessments.
Failure to Develop Individualized Care Plan for Frequent UTIs
Penalty
Summary
The facility failed to develop comprehensive care plans with specific and individualized interventions for a resident's care needs. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident. However, for one resident, who was moderately cognitively impaired and frequently experienced urinary tract infections (UTIs), there was no documented evidence of a care plan addressing these specific needs. The resident had multiple physician's orders for antibiotics to treat UTIs over several months, and a nursing note indicated that the resident's daughter was concerned about the frequent UTIs. Despite these ongoing issues, the facility did not create an individualized care plan to address the resident's frequent UTIs. This deficiency was confirmed by the Director of Nursing during an interview.
Failure to Update Resident's Care Plan for Dialysis Schedule
Penalty
Summary
The facility failed to update and revise a resident's care plan to accurately reflect the resident's specific care needs. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, with revisions made as the resident's condition changes. However, for one resident, the care plan was not updated to reflect the correct days the resident attended dialysis, which were Mondays, Wednesdays, and Fridays. Instead, the care plan inaccurately stated that the resident attended dialysis on Tuesdays, Thursdays, and Saturdays. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to reflect the correct dialysis schedule. The resident in question was cognitively intact, required assistance with care needs, and had a diagnosis of end-stage renal disease, necessitating regular dialysis treatments. The failure to update the care plan was identified during a review of the resident's clinical record and dialysis communication records.
Failure to Prevent Urinary Tract Infections in Resident with Catheter
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy, dated December 7, 2023, stated that indwelling urinary catheters should be used sparingly and monitored for complications such as symptomatic infections. However, during an observation on November 12, 2024, it was noted that the resident's catheter tubing was lying on the fall mat, which is not in accordance with the facility's policy. This observation was confirmed by the Director of Nursing, who acknowledged that the catheter tubing should not have been in contact with the fall mat. The resident in question was cognitively intact and had a diagnosis of urinary retention, necessitating the use of an indwelling urinary catheter due to neurogenic bladder. Physician's orders required the catheter to be changed every 30 days or as needed for dislodgement or blockage, and the care plan specified that the catheter should be secured with a securement device. Despite these directives, staff failed to reposition the catheter tubing after entering the resident's room to administer a flu shot, leaving it improperly placed and potentially increasing the risk of infection.
Lack of Physician's Order for Dialysis Services
Penalty
Summary
The facility failed to ensure there was a physician's order for a resident who required dialysis services. Resident 16, who was cognitively intact and diagnosed with end-stage renal disease, received dialysis treatment every Monday, Wednesday, and Friday. Despite the care plan indicating that the resident received dialysis services, there was no documented evidence of an active physician's order for the resident to attend dialysis in the clinical record. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Implement Non-Pharmacological Interventions Before Antianxiety Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications by not attempting non-pharmacological behavioral interventions before administering as-needed antianxiety medications. Specifically, for one resident, non-pharmacological approaches were not documented as being attempted prior to the administration of Ativan, an antianxiety medication, on multiple occasions. The facility's policy, dated December 7, 2023, mandates the use of non-pharmacological approaches to minimize medication use unless contraindicated. The resident in question was cognitively intact, required assistance with care needs, and was receiving antianxiety and opioid medications, along with oxygen therapy and hospice services. Despite these conditions, the Medication Administration Record showed repeated administration of Ativan without documented evidence of prior non-pharmacological interventions. The Director of Nursing confirmed that such interventions should have been attempted before administering the medication.
Failure to Administer Warfarin as Prescribed
Penalty
Summary
The facility failed to ensure that physician's orders were followed, resulting in significant medication errors for a resident. The resident, who was cognitively intact and had a diagnosis of atrial fibrillation, was prescribed warfarin, a blood-thinning medication. On October 25, 2024, the resident was supposed to receive 3 mg of warfarin daily, but the medication was not administered as ordered. Additionally, on October 28, 2024, the resident was given 9 mg of warfarin instead of the prescribed 6 mg. Further discrepancies were noted on October 29, 2024, when a PT/INR test was ordered to monitor the resident's clotting time, and the results indicated a therapeutic INR level of 2.3. Despite this, there was no documented physician's order to administer 3 mg of warfarin on October 30, 2024, and the medication was not given. The Director of Nursing confirmed these errors during an interview, acknowledging that the staff failed to administer the correct doses of warfarin on the specified dates.
Repeated Deficiencies in Care Plan Development and Compliance
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 the failure to develop comprehensive care plans, update resident care plans, follow physician's orders, account for controlled medications, and adhere to proper infection control practices. Despite having developed plans of correction in response to a previous survey, the facility's QAPI committee was ineffective in implementing these plans to ensure ongoing compliance. The deficiencies were initially identified in a survey ending December 20, 2023, and the facility had developed plans of correction that involved completing audits and reporting the results to the QAPI committee. However, the current survey, ending November 14, 2024, revealed that the QAPI committee did not successfully implement these plans, resulting in repeated citations under F656, F657, F684, F755, and F880. The facility's inability to address these recurring issues indicates a failure in the QAPI committee's role in maintaining regulatory compliance.
Failure to Implement Enhanced Barrier Precautions for Residents with ESBL
Penalty
Summary
The facility failed to adhere to infection control guidelines from CMS and CDC, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for two residents with a history of Extended Spectrum Beta Lactamase (ESBL) infections. Resident 9, who was cognitively intact and required assistance with care needs, had a documented history of ESBL as indicated by a physician's progress note. However, during a facility tour, it was observed that there was no signage or personal protective equipment (PPE) available outside the resident's room, indicating a lack of EBP implementation. Similarly, Resident 14, who was also cognitively intact and required staff assistance for daily care, had a confirmed diagnosis of ESBL. Despite this, observations revealed that there was no signage or PPE present at the resident's room to indicate EBP precautions. Interviews with the Director of Nursing confirmed that both residents should have had EBP in place due to their ESBL history, but these precautions were not implemented, leading to a deficiency in infection control practices.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to maintain an effective preventative maintenance program for the walk-in freezer, as observed on two separate occasions. There was a significant accumulation of ice on the ceiling, extending from the condenser to the opposite side of the freezer, as well as on the four side walls and multiple areas on the floor. The Dietary Manager confirmed the presence of ice accumulation during an interview. The Director of Maintenance, who had been in the position for six months, did not recall any maintenance work being performed on the walk-in freezer. Additionally, a Maintenance Worker reported not having a manual for the freezer and mentioned that a compressor had been replaced last summer by a contracted vendor. The worker also noted that the service technician suggested the ice buildup could be due to a bad door seal or improper door closure by staff.
Failure to Provide Effective Communication Training
Penalty
Summary
The facility failed to provide training on effective communication to its nursing and other direct care staff, as evidenced by the review of four employee files. The facility's Facility Assessment, dated July 17, 2024, indicated that the training program should include effective communication as part of the orientation and ongoing training for all staff. However, there was no documented evidence that Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, and Registered Nurse 8 received this training within their respective employment periods. The Director of Nursing confirmed during an interview that there was no documentation to support that these staff members had received the required education on effective communication. This lack of training was identified as a deficiency under the Pennsylvania Code, specifically sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Failure to Conduct RN Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse conducted an assessment for a change in condition for a resident, as required by the Pennsylvania Nursing Practice Act. The resident, who was cognitively intact and required assistance for daily care needs, experienced respiratory distress on multiple occasions. On April 26, 2024, the resident was noted to be short of breath, breathing heavily, with a dusky skin color and blue nail beds and lips. Despite these symptoms, there was no documented evidence of an assessment by a registered nurse during or after this episode. Further incidents occurred on April 29, 2024, when the resident's oxygen level dropped to 72 percent, and again, there was no documented assessment by a registered nurse. On May 1, 2024, the resident experienced shortness of breath and low oxygen levels, leading to a transfer to the emergency room where they were admitted with pneumonia and sepsis. An interview with the Director of Nursing confirmed the lack of documented assessments by a registered nurse during these critical episodes, which was a violation of the required nursing services standards.
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.
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What surveyors actually found near you
We read the 456 citations issued within 25 miles in the last 12 months — including the 6 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 Scottdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmon House Health & Rehab Center | 2.4 mi | ★★★★★ | 8 | 0 |
| Hempfield Manor | 12.2 mi | ★★★★★ | 20 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 12.3 mi | ★★★★★ | 11 | 0 |
| Westmoreland Manor | 12.9 mi | ★★★★★ | 9 | 0 |
| Twin Lakes Rehabilitation And Healthcare Center | 13.2 mi | ★★★★★ | 29 | 1 |
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.