South Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethel Park, Pennsylvania.
- Location
- 60 Highland Road, Bethel Park, Pennsylvania 15102
- CMS Provider Number
- 395731
- Inspections on file
- 25
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at South Hills Post Acute during CMS and state inspections, most recent first.
Two dietary aides were observed working in the kitchen without required beard restraints, contrary to facility policy that mandates hair restraints for food service staff with facial hair. The Dietary Manager confirmed that beard restraints should have been used.
Multiple residents reported that staff frequently left soiled linen hampers open in hallways, causing strong odors to fill the area and enter resident rooms. Residents often had to close the hampers themselves and move them away from their rooms. These issues were documented in facility records and discussed with the DON, but staff compliance was inconsistent. Observations confirmed strong urine odors and the presence of soiled linen carts near resident beds. The facility administrator acknowledged the failure to maintain a clean and homelike environment.
The facility did not provide required written bed-hold policy notifications to residents or their representatives at the time of hospital transfer for several individuals with complex medical conditions, as confirmed by record review and staff interviews. Documentation of these notifications was missing in multiple cases involving transfers for acute medical issues.
Direct care staff were not made aware of physician-ordered fluid restrictions for three residents with complex medical needs, resulting in multiple instances where fluid intake exceeded prescribed limits. Staff interviews and documentation reviews revealed a lack of communication and monitoring, with the DON and administrator confirming the failure to ensure staff awareness of these critical orders.
Two residents with cardiac conditions received Coreg despite vital signs that did not meet physician-ordered parameters, including low blood pressure and low heart rate. Facility policy and care plans required medications to be administered according to prescriber orders, but these were not followed on multiple occasions, as confirmed by the facility's administration.
The facility did not post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program on any of its nursing units, omitting required address and email details and failing to make this information accessible and understandable to residents or their representatives.
Postings indicating the location of the Department of Health's most recent survey results were not accessible to residents and visitors on all nursing units. This was confirmed by the Nursing Home Administrator, who acknowledged the absence of these required postings.
Required written information on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs was not displayed on any of the facility's nursing units. This was confirmed by observation and staff interview.
South Hills Post Acute failed to provide prompt assistance to residents, compromising their dignity and quality of life. Multiple residents reported extended waits for care, with staff turning off call lights and delaying assistance. The facility's policy on resident rights was not followed, as confirmed by the Nursing Home Administrator and DON.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with toileting hygiene for several residents. Residents reported waiting from half an hour to several hours for help, often being left in soiled conditions. Interviews with the Nursing Home Administrator and DON confirmed the staffing inadequacies impacting resident care.
The facility failed to provide adequate supervision for a resident with a history of opioid dependence and alcohol use, leading to an overdose. Despite being alert and oriented, the resident was not care planned for his dependencies. The resident was found slumped over in a taxi, with heroin in his possession, and was administered Narcan with minimal outcome before being transported to the hospital.
The facility failed to establish baseline care plans within 48 hours for three residents admitted with various medical conditions, including diabetes, high blood pressure, colon cancer, obstructive and reflux uropathy, and panlobular emphysema. The Director of Nursing confirmed the oversight.
The facility failed to provide prescribed treatment and services for pressure ulcers for three residents. One resident with coronary artery disease and hemiplegia was not repositioned as required, leading to worsening ulcers. Another resident with dementia developed a Stage 4 ulcer that was not documented until it worsened, and wound care was inconsistently documented. A third resident with COPD and diabetes did not receive prescribed offloading boots, resulting in a new pressure ulcer. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to ensure that pneumococcal immunizations were offered to two residents as required by their policy and CDC guidelines. One resident with chronic osteomyelitis, high blood pressure, and chronic kidney disease, and another with coronary artery disease, hemiplegia, and a history of stroke, were not offered the vaccine, and there was no documentation of education provided about the vaccination.
The facility failed to ensure proper storage and disposal of medications in one medication room and two medication carts. Expired medications and improperly dated insulin vials were found, and a medication cart was left unlocked and unattended. Staff confirmed these deficiencies during interviews.
The facility failed to ensure adequate supervision and assistance for a resident, resulting in a fall and injury. The resident, who required a one-person assist with ADLs, fell out of bed and sustained a laceration due to improper handling by a CNA. Interviews confirmed the failure to follow proper procedure.
Failure to Ensure Proper Use of Beard Restraints in Kitchen
Penalty
Summary
The facility failed to ensure that food service staff properly restrained facial hair while working in the Main Kitchen. During an observation, a dietary aide and a volunteer dietary aide were seen in the kitchen without beard restraints, despite the facility's policy requiring hair restraints to prevent hair from contacting food. The Dietary Manager confirmed that staff with facial hair are required to wear beard restraints, but this was not followed during the observed period.
Failure to Maintain a Clean and Homelike Environment Due to Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six of fourteen residents on the second and third floors. Residents reported that staff rarely closed hampers containing soiled linen, resulting in strong odors of soiled linen and urine permeating the hallways and entering residents' rooms. Residents stated they often had to close the hampers themselves and move them away from their rooms. These concerns were documented in the facility's Concern Log and Resident Council Minutes, and residents indicated that the issue was discussed multiple times with the Director of Nursing, but staff compliance was only temporary before the problem recurred. Observations confirmed the presence of strong urine odors on the third-floor nursing unit and a soiled linen cart was found next to a resident's bed. The Nursing Home Administrator acknowledged the facility's failure to maintain a clean and homelike environment for the affected residents on two of the three nursing units. The deficiency was substantiated by resident interviews, facility records, and direct observation.
Failure to Provide Bed-Hold Policy Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and/or their representatives at the time of transfer to the hospital for five of six residents reviewed. Federal regulation S483.15(d) requires that residents receive written information about bed-hold policies both prior to and upon transfer, with documentation of attempts to notify representatives if direct notification is not possible. The facility's own policy also states that this information should be provided upon admission, transfer, or therapeutic leave, and if any changes occur to the policy. Clinical record reviews for multiple residents revealed that, despite being transferred to the hospital for various acute medical needs—including exacerbation of UTI symptoms, abnormal vital signs, fever, chest pain, and complications related to dialysis—there was no documentation that the required written bed-hold notification was given at the time of transfer. This deficiency was identified for residents with significant medical histories, such as coronary artery disease, diabetes, stroke, heart failure, seizure disorder, cardiomyopathy, chronic kidney disease, pneumonia, atrial fibrillation, hemiplegia, and malnutrition. During staff interviews, both the Nursing Home Administrator and the Director of Nursing confirmed that the facility did not ensure the provision of written bed-hold policy notices to residents or their representatives at the time of hospital transfer. This failure was observed across multiple instances and residents, as evidenced by the absence of documentation in the clinical records reviewed.
Failure to Communicate and Enforce Fluid Restrictions for Residents
Penalty
Summary
The facility failed to ensure that direct care staff were aware of and adhered to physician-ordered fluid restrictions for three residents with significant medical conditions, including cardiomyopathy, chronic kidney disease, cerebral palsy, hyponatremia, coronary artery disease, and schizophrenia. Despite clear physician orders and care plans specifying daily fluid restrictions for these residents, staff interviews revealed that nurse aides were not informed of these restrictions. Observations showed that residents had access to large cups of ice water at their bedsides, and care records indicated multiple instances where fluid intake exceeded the prescribed limits. In some cases, the Kardex and nurse aide census sheets did not include information about the fluid restrictions, further contributing to the lack of staff awareness. Additionally, documentation for at least one resident failed to show any monitoring of fluid intake, and staff interviews confirmed a general lack of knowledge regarding which residents were on fluid restrictions. The Director of Nursing and the Nursing Home Administrator acknowledged that fluid restriction orders should have been communicated to staff and confirmed the failure to do so. These lapses resulted in the facility not maintaining acceptable parameters of nutritional status for the affected residents, as required by facility policy and state regulations.
Failure to Prevent Significant Medication Errors Related to Coreg Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of Coreg (carvedilol) to two residents despite vital signs that did not meet the parameters set by physician orders. Facility policy required medications to be administered in accordance with prescriber orders, which for these residents included holding Coreg if systolic blood pressure (SBP) was less than 110 mmHg or if heart rate was less than 60 beats per minute. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, the physician order specified to hold Coreg for SBP less than 110 or heart rate less than 60. However, review of the medication administration records showed that Coreg was administered multiple times when the resident's SBP was below 110, with readings as low as 89. The resident's care plan also indicated that medications should be administered per physician order, but this was not followed on several occasions. Another resident with coronary artery disease, diabetes, and hypertension had a physician order to hold Coreg for heart rates less than 60. Despite this, the medication was administered repeatedly when the resident's heart rate was below 60, with documented rates as low as 48 beats per minute. The care plan for this resident also required medication administration per physician order, but this was not adhered to. The Nursing Home Administrator and DON confirmed these findings during an interview.
Incomplete Posting of State Agency and Ombudsman Contact Information
Penalty
Summary
The facility failed to post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program on all three nursing units, as required by regulation. Observations conducted on the First Floor, Second Floor, and Third Floor nursing units revealed that the posted information was missing the address and email contact details for both agencies. This information was not made available in a form and manner that was accessible and understandable to residents or their representatives. The Nursing Home Administrator confirmed during an interview that the required contact information was not fully posted on any of the nursing units.
Survey Results Location Not Posted
Penalty
Summary
The facility failed to ensure that postings identifying the location of the Department of Health's most recent survey results were readily accessible to residents and visitors on all three nursing units. During an observation, no such postings were found in the facility. This was confirmed by the Nursing Home Administrator, who acknowledged that the required postings were not present in any of the three nursing unit locations.
Failure to Display Medicare and Medicaid Information on Nursing Units
Penalty
Summary
The facility failed to display written information regarding the application process for Medicare and Medicaid benefits, as well as information on receiving refunds for previous payments covered by these programs, on all three nursing units (First Floor, Second Floor, and Third Floor). This deficiency was identified during observations conducted on each unit, where the required information was not present. The Nursing Home Administrator confirmed during an interview that the facility did not have the mandated written information displayed on any of the nursing units, as required by state regulations.
Failure to Provide Prompt Assistance and Maintain Resident Dignity
Penalty
Summary
South Hills Post Acute was found to be non-compliant with federal and state regulations regarding resident rights and dignity. The facility failed to provide prompt assistance to meet the care needs of five residents, as evidenced by resident interviews and clinical record reviews. The facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity, was not adhered to, resulting in residents experiencing delays in receiving necessary care. Resident R1 reported being left in soiled conditions for several hours despite using the call bell multiple times. Staff reportedly turned off the call light and dismissed the resident's requests for assistance. Similarly, Resident R2 experienced delays in receiving care, with staff turning off the call light and leaving the resident waiting for extended periods. Resident R3, who was dependent on assistance due to a broken hip, also reported long waits for care, with staff citing breaks as a reason for the delay. Residents R4 and R5 shared similar experiences of waiting for assistance, with staff turning off call lights and delaying care. These incidents were confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to provide an environment that promotes dignity and quality of life for the residents involved.
Plan Of Correction
Social services met with resident R1, R2, R3, R4, and R5 to ensure the care provided to these residents since initial discovery was completed with respect, kindness, and dignity. A complete floor audit was completed by DON and/or designee to ensure there was no skin breakdown, emotional distress, and no further issues identified since initial discovery indicating lack of respect, kindness, and dignity. All staff was given Resident rights education by the staff educator to ensure understanding of resident rights covering prompt care, incontinence needs, and call bell response. The administrative team and/or designee will complete guardian angel rounds on the unit 2x a week for 2 weeks to ensure all residents are treated with respect, kindness, and dignity. Guardian Rounds audits will be reviewed by Administrator and/or designee at the monthly QAPI meeting to ensure citation has been cleared. Date of Corrective action: 4/24/2025
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the care needs of five residents, as evidenced by multiple instances of delayed response to call lights and inadequate assistance with toileting hygiene. The facility's policy on answering call lights, which requires staff to promptly respond to residents' requests and provide necessary assistance, was not adhered to. This resulted in residents being left in soiled conditions for extended periods, ranging from half an hour to several hours. Resident R1 reported being left in a soiled brief from 6 p.m. to 2 a.m. over a weekend, despite using the call bell multiple times. Staff reportedly turned off the call light without providing assistance, indicating they would return later. Similarly, Resident R2 experienced delays in receiving help for toileting hygiene, with waits ranging from half an hour to two hours. Resident R3, who has a broken hip and is dependent on staff for toileting, reported waiting up to three and a half hours for assistance, with staff citing breaks as a reason for the delay. Resident R4, who requires substantial assistance for toileting, also experienced delays, having to wait over an hour on occasion. Resident R5 reported similar issues, with waits exceeding half an hour. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to provide sufficient staffing to meet the residents' needs, impacting the quality of care for these individuals.
Plan Of Correction
F 0725 Sufficient Nursing Staff The facility failed to ensure sufficient staffing to meet residents' care needs for five of fifteen residents who require care (Residents R1, R2, R3, R4 and R5). What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Social Services met with residents R1, R2, R3, R4 and R5 to discuss the identified situation and ensure all care needs were met in a timely manner. Daily staffing meetings will be held with scheduler, DON and Admin and/or designee to ensure sufficient staffing is provided for all 3 shifts and meeting the staffing ratio and PPD. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The staff educator provided education to all staff on prompt response for "Answering call Lights." Daily Huddles will occur with administrative staff and/or designee with all floor staff to communicate necessary needs expressed by residents during guardian rounds. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? Daily Huddles will be initiated to ensure all staff is informed of residents' needs and staffing will be reviewed as well as assignments given to ensure all residents receive timely care. The DON and/or designee will complete an audit 2x a week with 5 residents for two weeks to ensure all residents have received prompt care and in a timely manner, as well as complete staffing tool to ensure facility is meeting ratio and PPD. How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established? All audit findings will be reviewed by DON and/or designee at the monthly Quality Assurance Meeting to determine if deficient practice has been corrected or will need to continue by DON and/or designee. Dates of when the corrective action will be completed: April 24th, 2025.
Failure to Provide Adequate Supervision Resulting in Resident Overdose
Penalty
Summary
The facility failed to provide adequate supervision for Resident R1, who had a history of opioid dependence and alcohol use. Despite being alert and oriented, and able to make his own decisions, Resident R1 was not care planned for his opioid and alcohol dependence. On the evening of 5/9/24, a taxi service brought Resident R1 back to the facility, finding him slumped over in the back seat and appearing to be under the influence. Emergency services were called, and the police found a bag of heroin on Resident R1. Medics administered Narcan with minimal outcome, and Resident R1 was transported to the hospital. Interviews with the Director of Nursing (DON), Nurse E1, and the Nursing Home Administrator (NHA) confirmed the incident and acknowledged the facility's failure to provide adequate supervision. The facility's policy on Opioid Use Disorder, which mandates assessing patients for the risk of opioid use disorder and implementing appropriate interventions, was not followed for Resident R1. This lack of supervision and failure to implement the necessary care plan led to Resident R1's overdose.
Failure to Establish Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to establish a baseline care plan within 48 hours of admission or readmission for three residents. Resident R301, who was admitted with diagnoses including diabetes, high blood pressure, and colon cancer, did not have a baseline care plan for his colostomy. Resident R307, admitted with high blood pressure, obstructive and reflux uropathy, and a fracture of the right lower leg, did not have a baseline care plan for catheter care. Resident R312, admitted with high blood pressure, diabetes, and panlobular emphysema, did not have a baseline care plan for supplemental oxygen via nasal cannula. The Director of Nursing confirmed that the baseline care plans for these residents were not initiated within the required 48-hour timeframe. The facility's policy mandates the development and implementation of a baseline person-centered care plan within 48 hours of admission or readmission, but this was not adhered to for the three residents mentioned. The lack of timely baseline care plans was identified through clinical record reviews and staff interviews.
Failure to Provide Prescribed Pressure Ulcer Care
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of pressure ulcers for three residents. Resident R22, who had a history of coronary artery disease, hemiplegia, and stroke, was at high risk for pressure ulcer development. Despite physician orders and care plans indicating the need for turning and repositioning every two hours, observations revealed that Resident R22 was consistently positioned on their back, leading to the deterioration of existing pressure ulcers and the development of new ones. The Nursing Home Administrator confirmed that Resident R22 was not turned and repositioned appropriately during the observations. Resident R76, diagnosed with dementia and traumatic brain injury, also experienced a failure in pressure ulcer care. The resident developed a new Stage 4 pressure ulcer on the left ankle, which was not documented until it had significantly worsened. Observations showed that Resident R76 was not turned and repositioned as required, and there were multiple days where wound care was not documented as completed. The Nursing Home Administrator confirmed the development of a facility-acquired pressure ulcer and the lack of appropriate repositioning and wound care documentation. Resident R85, with diagnoses of COPD and diabetes, was admitted with existing pressure ulcers and was at high risk for developing new ones. Despite care plans and orders for offloading boots, observations indicated that Resident R85's heels were not offloaded, and the resident was not wearing the prescribed offloading boots. The Nursing Home Administrator confirmed that Resident R85 developed a facility-acquired pressure ulcer and was not turned and repositioned appropriately during the observations. The facility failed to provide the necessary treatment and services for pressure ulcer care for these residents.
Failure to Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered to two of five residents, as required by their policy and CDC guidelines. Resident R101, who was admitted on [DATE], had diagnoses including chronic osteomyelitis, high blood pressure, and chronic kidney disease. The Minimum Data Set (MDS) dated 3/28/24 indicated that Resident R101 was not offered the pneumonia vaccine, and there was no documentation of education provided to the resident or their representative about the risks and benefits of the vaccination. Similarly, Resident R119, admitted on [DATE], had diagnoses of coronary artery disease, hemiplegia, and a history of stroke. The MDS dated [DATE] also indicated that Resident R119 was not offered the pneumonia vaccine, and there was no documentation in the clinical record of the resident being offered the vaccination. During an interview, the Nursing Home Administrator confirmed the facility's failure to offer the pneumococcal immunization to these residents.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure that medications and medication supplies were properly stored and/or disposed of in one of three medication rooms and two of seven medication carts. Specifically, in the Second-floor medication room, a bottle of prescription barrier lotion for a resident was found with an expired use-by date, and multiple vacutainers were found to be expired. Additionally, a medication cart on the second floor was observed to be unlocked and unattended, and several insulin vials and injectable pens were found to be improperly dated or undated. During interviews, staff confirmed the presence of expired and improperly stored medications. The Nursing Home Administrator acknowledged that the facility did not comply with its policy on the storage and expiration dating of medications and biologicals. The deficiencies were observed during a survey, and the facility's failure to adhere to proper medication storage and disposal protocols was confirmed by multiple staff members.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for Resident R1. Resident R1, who was admitted with diagnoses including pneumonia, bladder dysfunction, and seizure disorder, required a one-person assist with all activities of daily living (ADLs). During care, CNA Employee E1 rolled Resident R1 away from them, resulting in the resident falling out of bed and sustaining a three-centimeter laceration to the left forehead. The CNA had received training on resident turning and positioning, body alignment, and moving in bed but failed to follow proper procedure during the incident. Interviews with the CNA, Resident R1, the Director of Nursing (DON), and the Nursing Home Administrator confirmed the failure to follow proper procedure. The CNA was confused about the details of the incident and could not recall how it happened. The DON and the Nursing Home Administrator acknowledged that the facility did not provide adequate supervision and assistance to prevent the accident, leading to Resident R1's fall and injury.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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