Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southmont Of Presbyterian Seniorcare during CMS and state inspections, most recent first.
Failure to maintain and label oxygen equipment: Three residents receiving O2 at 2 L/min had tubing connected to their concentrators that was not labeled or dated. Facility policy required masks and nasal cannula tubing to be changed weekly and/or PRN, and the residents had physician orders for routine oxygen equipment, tubing, and humidifier changes. The RN observed the issue and the NHA confirmed the deficiency.
Significant Medication Administration Errors: Surveyors found multiple medication administration errors involving levothyroxine and diuretics. An LPN gave levothyroxine to a resident while she was eating breakfast, and other residents received levothyroxine with omeprazole or diuretics at the same time despite orders and package insert guidance indicating specific timing. The NHA and DON confirmed the medication errors.
A resident with HF, HTN, depression, and a BIMS of 14 reported that staff did not consistently honor her requests to be taken outside to smoke. She said there was no set smoking schedule, staff often told her to wait or gave reasons such as weather or darkness, and she frequently had to rely on her daughter to take her out. The NHA confirmed the facility failed to provide care in a manner that maintained resident rights.
A resident who required two-person assistance for transfers, as documented in their care plan and on the white board, was transferred by a single CNA, resulting in a left distal fibula fracture. The resident, with multiple diagnoses including osteoporosis, reported pain after the transfer, and the CNA admitted to not following the required protocol. This incident was identified as neglect, as it involved failure to provide necessary services to prevent physical harm.
A resident who required assistance from two staff members for transfers was moved by a single nurse aide, contrary to the care plan and physician orders. This improper transfer resulted in the resident sustaining a leg fracture. Staff interviews and documentation confirmed that the aide had received training on safe transfer methods, but failed to follow established protocols, leading to the injury.
Grievance boxes on three nursing units and in the main lobby were either blocked by equipment or mounted too high, making them inaccessible to residents, particularly those using wheelchairs. Staff confirmed the issue, and the Nursing Home Administrator acknowledged the failure to provide accessible grievance submission options.
Facility staff did not consistently complete required dialysis communication forms for a resident with end-stage renal disease who received dialysis three times weekly. Review showed that 17 out of 47 forms were incomplete, either by the dialysis center or by staff after the resident's return, despite facility policy and care plan requirements for monitoring and documentation.
The facility did not post the required Adult Protective Services (APS) contact information, including agency name, address, email, and phone number, in areas accessible to residents and their representatives. This omission was confirmed by staff and administration during interviews.
A resident with dementia and diabetes eloped from the facility due to inadequate supervision. Initially assessed as not at risk for elopement, the resident left unsupervised after returning from therapy. Staff found the resident at a nearby building on campus, attempting to catch a bus. The incident highlighted a failure in the facility's supervision and risk assessment processes.
A resident with cognitive impairment and Parkinson's disease suffered a second-degree burn when hot soup, served at 184°F, was placed within reach, leading to a spill. The resident's care plan required safety measures like mugs with lids, which were not followed, resulting in the injury.
The facility failed to maintain sanitary conditions and proper labeling in the main kitchen and two kitchenettes, leading to potential cross-contamination risks. Observations revealed undated food items, suspected mold, and unsanitary conditions such as gnats and sticky surfaces. These issues were confirmed by the Director of Dietary and the Nursing Home Administrator.
The facility failed to investigate incidents of possible neglect involving two residents. One resident with multiple diagnoses suffered a worsening skin tear after being bumped during transport, while another resident, requiring a two-person assist, was injured during a transfer with only one staff member. The facility did not conduct investigations into these incidents.
A resident with multiple diagnoses, including dementia and difficulty walking, was injured during a transfer due to the facility's failure to follow physician orders for a two-person assist. The nurse aide involved used an outdated care sheet, as the facility did not update it to reflect the current order. The incident resulted in a skin tear on the resident's forearm, and the facility did not fully investigate or provide accurate information on the report.
The facility failed to properly store and dispose of expired medical supplies on the third floor nursing unit. Expired items found in the emergency cart included suction tubing kits, intravenous catheter start kits, luer lock kits, nasal cannula oxygen tubing kit, and saline bottles. A RN Supervisor confirmed the oversight.
Failure to Maintain and Label Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for three sampled residents who were receiving oxygen therapy. The facility policy stated that all residents receiving oxygen therapy were to have masks and nasal cannula tubing changed weekly and/or as needed. Review of the clinical records showed that Resident R1 had diagnoses including respiratory failure, schizophrenia, and seizure disorder, and had a physician order for oxygen equipment, tubing, and humidifier to be changed once a day every Sunday while receiving oxygen at 2 liters per minute. Resident R74 had diagnoses including CAD, heart failure, and hypertension, and also had an order for oxygen equipment, tubing, and humidifier to be changed once a day every Sunday while receiving oxygen at 2 liters per minute. Resident R117 had diagnoses including COPD, heart failure, and hypertension, and had a physician order for oxygen equipment, tubing, and humidifier to be changed once a day every Saturday while receiving oxygen at 2 liters per minute. During observations and interview on 5/19/26, the RN confirmed that Residents R1, R74, and R117 were observed with oxygen tubing connected to their oxygen concentrators, and the tubing had not been labeled and dated. During interview, the Nursing Home Administrator confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
Significant Medication Administration Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for five of eleven residents reviewed. Surveyors reviewed medication package inserts, facility policy, clinical records, physician orders, medication administration audit reports, and observed medication administration. The report identified errors involving levothyroxine timing and administration, as well as concomitant administration of medications that interfere with levothyroxine absorption or have interaction concerns, including omeprazole, metolazone, bumetanide, and furosemide. For one resident with hypothyroidism and dementia, levothyroxine 50 mcg was ordered to be given in the morning before breakfast, but during observation an LPN administered the dose while the resident was actively eating breakfast. The medication administration audit report documented the dose as given at 8:24 a.m., and another staff member confirmed the order was for 7:00 a.m. For another resident with hypothyroidism, levothyroxine 75 mcg and omeprazole 40 mg were both ordered for 7:00 a.m., and the audit report showed both were administered at 10:03 a.m. despite the package insert noting that proton-pump inhibitors may reduce levothyroxine absorption. The report also identified two residents who received diuretic medications at the same time despite orders indicating specific timing. One resident with COPD and heart failure was ordered metolazone 5 mg on Monday, Wednesday, and Friday at 7:00 a.m. and bumetanide 2 mg at 7:00 a.m.; the audit report showed both were administered together at 8:12 a.m. Another resident with hypertension and heart failure was ordered metolazone 2.5 mg at 7:00 a.m., with instructions to give it 30 minutes before the morning Lasix dose, and furosemide 10 mg at 7:00 a.m.; the audit report showed both were administered together at 8:35 a.m. The Nursing Home Administrator and DON confirmed the facility failed to ensure residents were free of significant medication errors for five of eleven residents reviewed.
Failure to Maintain Resident Rights for Smoking Requests
Penalty
Summary
The facility failed to ensure that care was provided in a manner that maintained resident rights for one resident. The resident had diagnoses of heart failure, hypertension, and depression, and the MDS dated 5/2/26 indicated a BIMS score of 14, showing the resident was cognitively intact. The resident’s functional assessment showed dependence on staff for transfers and movement from one location to another. The resident’s care plan included instruction about the facility smoking policy, including locations, times, and safety concerns. During an interview, the resident stated that staff did not make arrangements for her to go outside to smoke when she requested it. She reported that there was no set smoking schedule and that on many days staff did not take her out even when she asked. During a later observation and interview with the resident and the NHA, the resident again stated that staff told her to wait until someone was available, or that it was raining or dark, and that she often had to wait until her daughter visited to take her outside to smoke. The resident could not recall the last time staff had taken her out to smoke and said that in the prior week she had asked staff to take her out but was not taken. The NHA confirmed that the facility failed to make certain that care was provided in a manner which maintained resident rights.
Resident Sustains Fracture Due to Improper Transfer by Single CNA
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and required the assistance of two staff members for toileting and transfers as documented in their care plan and on the white board used by nurse aide staff, was transferred by a single Certified Nurse Aide (CNA). The resident, who had diagnoses including arthritis, high blood pressure, depression, and osteoporosis, was alert, oriented, and able to communicate needs. The resident reported pain in the left lower leg/ankle after being transferred by the CNA, who admitted to transferring the resident alone and causing pain during the process. Clinical documentation and staff statements confirmed that the resident's care plan and functional assessment required two-person assistance for transfers due to self-care performance deficits related to arthritis. Despite this, the CNA attempted the transfer alone, contrary to the established plan of care and facility protocols. The resident subsequently sustained a fracture to the left distal fibula, as confirmed by x-ray, after complaining of pain and reporting that their leg had been bumped during the transfer. The incident was identified as neglect, defined by facility policy as the failure to provide goods and services necessary to avoid physical harm. The CNA involved had received training and competencies in safe transfer methods prior to the incident. The failure to follow the resident's care plan and transfer requirements directly resulted in actual harm to the resident, specifically a fractured left fibula.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members for transfers due to arthritis and other medical conditions, was transferred by a single nurse aide. The resident's care plan, physician orders, and Minimum Data Set assessment all specified the need for assistance from two staff members during transfers and toileting. Despite this, the nurse aide attempted to transfer the resident alone, contrary to established protocols and documented requirements. As a result of this improper transfer, the resident experienced pain in the left lower leg and ankle, which was later diagnosed as a fracture to the left distal fibula. The incident was documented in the resident's clinical record, progress notes, and an incident report. The nurse aide involved acknowledged in a written statement that the resident was in pain and that the transfer caused harm. Interviews with facility staff and review of personnel files confirmed that the nurse aide had received training and competency assessments related to safe transfer methods and adherence to care plans. However, the failure to follow the resident's prescribed transfer protocol led directly to the resident's injury. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during interviews.
Grievance Boxes Inaccessible to Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents in four locations, including three nursing units and the main lobby. During rounds, it was observed and confirmed by a social worker that the grievance boxes on the third, fourth, and fifth floor nursing units were blocked by equipment, making them inaccessible. Additionally, the grievance box on the third-floor nursing unit was mounted at approximately 59 inches above the floor, and the lobby box was at approximately 52 inches, both of which are out of reach for residents using wheelchairs. A review of the facility's grievance policy indicated that grievances could be submitted orally or in writing, including anonymously. However, the physical placement and obstruction of the boxes did not comply with accessibility standards, as confirmed by staff interviews and direct observation. The Nursing Home Administrator acknowledged that the facility failed to make the grievance boxes accessible in all four identified locations.
Failure to Maintain Ongoing Dialysis Communication
Penalty
Summary
Facility staff failed to maintain ongoing communication with the dialysis center for a resident with end-stage renal disease who was dependent on dialysis. According to facility policy, a dialysis communication binder was to be used for all residents receiving dialysis, with specific sections to be completed by nursing staff before transfer, by the dialysis center, and by nursing staff upon the resident's return. Review of the clinical record showed that the resident was readmitted with diagnoses including ESRD and diabetes, and had physician orders for dialysis three times a week. The care plan required monitoring of vital signs before and after dialysis, assessment of the access area, and daily checks for adequate blood flow. However, review of dialysis communication forms from January through April revealed that 17 out of 47 forms were not fully completed, either by the dialysis center or by facility staff after the resident's return. This incomplete documentation was confirmed by the Assistant Director of Nursing, who acknowledged that the required communication forms were not consistently completed pre- and post-treatment between the facility and the dialysis center.
Failure to Post Required APS Contact Information
Penalty
Summary
The facility failed to post the required contact information for Adult Protective Services (APS) in areas accessible to residents and their representatives. Observations conducted on multiple nursing units and the main lobby revealed that the APS agency name, address, email, and phone number were not posted or accessible. This was confirmed by both a social worker and the Nursing Home Administrator during staff interviews. The deficiency was cited under 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.18(e), which require the posting of such information for resident awareness and access.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia and diabetes. The resident was admitted to the facility with a referral from the hospital indicating these diagnoses. An elopement observation assessment conducted shortly after admission indicated that the resident was not at risk for elopement. However, the resident managed to leave the facility unsupervised and was found at a nearby building on the campus, attempting to catch a bus. The incident occurred when the resident was brought back from therapy to the nurses' station, and shortly after, the chair alarm sounded. Staff searched for the resident for about 10 minutes before being informed by the supportive housing apartments on campus that the resident had walked over to their building. The resident was found with her personal belongings and was unharmed upon assessment. The initial elopement risk assessment had scored the resident as not at risk, which contributed to the lack of preventive measures in place at the time of the incident.
Resident Burned by Hot Soup Due to Inadequate Safety Measures
Penalty
Summary
The facility failed to implement effective safety measures for a resident, resulting in actual harm. Resident R78, who had moderately impaired cognitive ability and required extensive assistance for eating, suffered a second-degree burn on the right upper thigh. This incident occurred when the resident, who had a history of Parkinson's disease, grabbed a bowl of hot soup placed in the middle of the table, causing it to spill onto their lap. The soup was served at a temperature of 184 degrees Fahrenheit, and the resident's care plan indicated the need for mugs with lids to prevent burns. The incident was documented in a nurse progress note and an incident report, which noted blistering on the resident's thigh. Witness statements from nursing assistants confirmed that the resident had knocked the food over, resulting in the burn. The facility's policy on investigating adverse events required measures to prevent serious injury, but these were not effectively implemented in this case, leading to the resident's injury.
Removal Plan
- In-service training provided to dietary staff, including Registered Nurses, Licensed Practical Nurses, and Nurse Aides, on following facility policy and procedures for abuse neglect and serving hot beverages.
- Reviewed like residents for non-compliance with hot beverages and meal service.
- Audited all residents' meals for accuracy.
- Adjusted employee workflow to allow for increased supervision of the dining area while meals are being served.
- Ordered protective aprons for residents in the dementia unit in case of spills of hot liquids.
- Implemented a plan of correction and achieved compliance to ensure residents are provided hot liquids in a manner that promotes safety.
Sanitation and Labeling Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and properly label and date food products, leading to potential unsafe conditions and cross-contamination risks. During an observation in the main kitchen, several issues were noted, including undated food items such as opened mayonnaise, water bottles, chocolate syrup, and a beverage dispenser with red liquid. Additionally, cooler #2 had fans with white splotches, suspected to be mold, and cooler #3 contained undated bags of chicken tenders and potatoes. These observations were confirmed by the Director of Dietary, who acknowledged the failure to adhere to required labeling and maintenance standards. Further observations in the 4th and 5th floor kitchenettes revealed unsanitary conditions, including gnats flying, sticky cabinet handles, and food debris in the cabinets. The lower freezers in both kitchenettes had ice build-up, indicating possible seal malfunctions. Moldy bread and buns were found in the cabinets, along with undated condiments such as ketchup, mustard, relish, and chocolate syrup. The Nursing Home Administrator confirmed these findings, acknowledging the facility's failure to maintain the kitchenettes in a sanitary manner, which could lead to cross-contamination.
Failure to Investigate Incidents of Possible Neglect
Penalty
Summary
The facility failed to identify and investigate incidents of possible neglect and abuse for two residents, as required by their policy. Resident R27, who has diagnoses including heart failure, kidney failure, and stroke with right-sided hemiplegia, suffered a skin tear when staff bumped their elbow on a doorframe during transport. The initial treatment was a Tegaderm dressing, but the wound worsened over time, requiring a Xeroform dressing. Despite the worsening condition, the facility did not conduct an investigation into the incident. Resident R35, diagnosed with dementia, difficulty walking, restless leg syndrome, anxiety, and diabetes, was involved in an incident where they were transferred with the assistance of one staff member, contrary to the physician's order for a two-person assist. This resulted in a skin tear and bruise on the resident's left forearm. The facility did not identify, investigate, or report this potential neglect. The Director of Nursing confirmed the facility's failure to address these incidents appropriately.
Failure to Follow Physician Orders Results in Resident Injury
Penalty
Summary
The facility failed to provide person-centered care consistent with professional standards of practice by not following physician orders for the proper transfer of a resident, resulting in an injury. Resident R35, who has diagnoses including dementia, difficulty walking, restless leg syndrome, anxiety, and diabetes, was supposed to be transferred with the assistance of two staff members as per the physician's order. However, during a transfer with only one staff member, the resident sustained a skin tear on her left forearm after hitting a walker. The incident report noted that a skin flap needed to be placed before treatment was applied, and the injury was documented as a bruise measuring 7.5 cm x 2.5 cm. Interviews revealed that the nurse aide involved followed the Southmont 5th Floor Need to Know Care Sheet, which had not been updated to reflect the physician's order for a two-person assist transfer. The Nursing Home Administrator confirmed that nurse aides do not have access to the kardex, and the care sheet was not updated due to a lapse in communication when the night nurse did not update the sheet after taking the order. The Director of Nursing acknowledged that the facility failed to fully investigate and review the incident, and the information on the report was inaccurate, leading to the failure to provide the correct transfer order to the nurse aide.
Expired Medical Supplies in Emergency Cart
Penalty
Summary
The facility failed to ensure that medical supplies were properly stored and disposed of on the third floor nursing unit. During an observation, surveyors identified expired items in the emergency cart, including five suction tubing kits, three intravenous catheter start kits, two intravenous luer lock kits, one nasal cannula oxygen tubing kit, and two 100 cc saline bottles for oxygen use. These items were past their expiration dates, indicating a lapse in the facility's management of medical supplies. A Registered Nurse Supervisor confirmed the failure to properly dispose of these expired emergency cart biologicals.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Transitions Healthcare Washington Pa | 1.9 mi | ★★★★★ | 13 | 0 |
| Kadima Rehabilitation & Nursing At Washington | 3.1 mi | ★★★★★ | 29 | 0 |
| Premier Washington Rehabilitation And Nursing Ctr | 3.7 mi | ★★★★★ | 17 | 0 |
| Greenery Center For Rehab And Nursing | 6.1 mi | ★★★★★ | 45 | 1 |
| Townview Health And Rehabilitation Center | 6.9 mi | ★★★★★ | 4 | 0 |
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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.