Southwestern Veterans Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 7060 Highland Drive, Pittsburgh, Pennsylvania 15206
- CMS Provider Number
- 39A438
- Inspections on file
- 27
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Southwestern Veterans Center during CMS and state inspections, most recent first.
A nurse aide manually transferred a resident who required a full mechanical lift with two-person assistance, contrary to care plan and physician orders. This action resulted in the resident sustaining a comminuted and angulated fracture of the distal femur, as confirmed by clinical records and staff interviews. The incident was a direct result of not following established transfer protocols for a resident with significant medical needs.
A nurse aide manually transferred a resident with multiple medical conditions, despite physician orders and care plan requiring a full mechanical lift with two staff. This improper transfer led to the resident sustaining a comminuted fracture of the distal femur. Facility records and staff interviews confirmed the required transfer method was not followed.
Anonymous grievance boxes were not accessible on any nursing floor, and the only available box in the lobby was blocked by wheelchairs. Staff were unaware of grievance box locations, and several residents did not know how to file grievances anonymously, contrary to facility policy.
Three residents requiring respiratory support did not have their oxygen or BiPAP/CPAP equipment properly stored in labeled plastic bags as required by facility policy, with items left on nightstands or the floor. Nursing staff confirmed the improper storage, and one resident's care plan lacked interventions for oxygen and CPAP therapy.
The facility did not maintain complete and accurate documentation for multiple residents, including missing monthly weights and vital signs in the EMR and MAR, despite physician orders and facility policy. Staff interviews confirmed the lack of required documentation, and progress notes for some residents with complex care needs were also found to be incomplete or inaccurate.
A resident with hemiplegia, anxiety, and constipation was found to have their call bell on the floor under the bed, making it inaccessible. An LPN confirmed the call bell was not available for use, indicating the facility did not accommodate the resident's call bell needs.
Surveyors found that two residents' MDS assessments were not accurately coded to reflect the care provided. One resident received intermittent oxygen and CPAP therapy, but these were not documented on the MDS. Another resident was incorrectly marked as receiving hospice care, despite no evidence of hospice services in the clinical record. The errors were confirmed by the RN Assessment Coordinator.
The facility did not ensure that care plans addressed all identified needs for two residents. One resident's care plan lacked goals and interventions for prescribed antidepressant and sedative/hypnotic medications, while another resident's care plan did not include the use of TED hose for peripheral vascular disease, despite physician orders. These omissions were confirmed by facility staff.
The facility did not update care plans for three residents to reflect changes in their clinical status, including new antibiotic therapy for bacteremia, delayed addition of a wander guard intervention, and outdated tube feeding instructions. Staff confirmed that care plans were not revised as required.
Two residents with complex medical needs repeatedly requested staff assistance through call bells and direct requests, with staff documenting ongoing, frequent demands for attention and care. Despite staff addressing immediate needs, the residents continued to seek assistance, and the DON confirmed that professional standards of nursing practice were not followed.
The facility failed to ensure that two residents with pressure ulcers received and had documented wound care as ordered, and did not provide necessary preventive measures for another resident at high risk for pressure injury. Nursing staff confirmed that required treatments and preventive interventions, such as the use of Prevalon boots, were not consistently implemented or documented.
The facility did not consistently complete and maintain required dialysis communication forms for two residents receiving regular dialysis treatments. Despite facility policy mandating thorough documentation before and after each dialysis session, multiple treatment dates lacked complete records, as confirmed by nursing staff. This resulted in incomplete medical records for residents with significant renal and related health conditions.
The facility did not provide trauma-informed care for two residents with PTSD by failing to complete timely assessments and develop care plans that identified and addressed triggers for re-traumatization. One resident with PTSD from an accident and assault did not have a care plan or assessment completed within the required timeframe, while another resident with combat-related PTSD had no triggers identified or documented in the care plan.
A nurse aide's personnel record lacked documentation of an annual performance evaluation as required by federal regulations. Review of records and staff interview confirmed that the evaluation was not completed within the mandated timeframe.
A resident with a foley catheter for obstructive uropathy was observed with the catheter collection bag lying on the floor, contrary to facility policy requiring catheter bags and tubing to remain off the floor. This lapse in infection control was confirmed by an RN and involved a resident with multiple medical conditions, including hypertension, cancer, and diabetes.
The facility failed to obtain physician orders for wound care and safety equipment for several residents, and did not develop comprehensive care plans or complete bed safety risk assessments. Observations showed residents with fall mats and alarms without corresponding orders or care plans, confirmed by staff interviews.
The facility failed to provide access to medical records to a resident or their representative within the required time frame. A request for a copy of medical records by a resident's representative was received and never sent due to a misunderstanding of the regulation by a medical records employee.
A facility failed to update a resident's care plan after a dietary change. The resident, with chronic atrial fibrillation and other conditions, had their tube feeding discontinued per a physician's order. However, the care plan still listed tube feeding as active, which was confirmed by a registered dietitian.
The facility failed to provide necessary treatment to prevent a decrease in range of motion for two residents. One resident, with conditions including hemiplegia, was observed without a prescribed palm guard, while another resident with functional quadriplegia was not wearing bilateral palm guards as ordered. Staff interviews revealed a lack of communication and system to ensure compliance with care plans and physician orders.
A facility failed to provide adequate supervision, resulting in a resident with dementia eloping unnoticed and two residents sustaining cat bites while outside. The elopement occurred due to a lack of quarterly assessments and inattentiveness, while the cat bites happened as residents fed cats outside. The Director of Nursing confirmed these supervision failures.
The facility failed to ensure consistent and complete communication with the dialysis center for three residents, resulting in incomplete or missing dialysis communication sheets. Additionally, one resident's care plan and physician orders were inaccurate, lacking documentation for an AV fistula. These deficiencies were confirmed by nursing staff and the Director of Nursing.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a nurse aide manually transferred a resident who was dependent for transfers and required the use of a full mechanical lift with two staff assistance, as specified in the resident's care plan and physician orders. The nurse aide admitted to physically picking up the resident from bed and placing them into a wheelchair without using the required Hoyer lift or a second staff member. This action was in direct violation of the facility's transfer policy, which mandates the use of mechanical lifts for residents with total dependence to ensure safety and prevent injury. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was cognitively intact according to assessment. The resident's care plan and orders clearly indicated the need for a mechanical lift and two-person assistance for all transfers. Despite these documented requirements, the nurse aide failed to follow protocol, resulting in the resident experiencing severe pain and swelling in the left stump, which was later diagnosed as an acute comminuted and angulated fracture of the distal left femur. Facility documentation, staff interviews, and clinical records confirmed that the nurse aide did not use the mechanical lift as required and instead performed a manual transfer. This neglectful action directly led to actual harm to the resident, as evidenced by the fracture and subsequent hospitalization. The deficiency was substantiated through witness statements and interviews with facility leadership, who acknowledged the failure to protect the resident from neglect during care.
Failure to Use Mechanical Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a facility failed to provide adequate supervision and implement effective transfer interventions as ordered by a physician, resulting in a preventable accident and actual harm to a resident. The facility's policy required the use of mechanical lifts for residents who are totally dependent or require extensive assistance for transfers, and specifically prohibited manual lifting to minimize risk of injury. Despite these protocols, a nurse aide physically picked up a resident from bed and placed them into a wheelchair without using the required mechanical lift or a second staff member, as mandated by the resident's care plan and physician orders. The resident involved had significant medical conditions, including diabetes mellitus, end stage renal disease, and hepatitis C, and was assessed as being dependent for transfers, requiring a full mechanical lift with two staff members. The resident was cognitively intact according to the BIMS assessment. Following the improper manual transfer, the resident experienced severe pain and was subsequently diagnosed with an acute comminuted, impacted, and angulated fracture of the distal left femur. Staff interviews and facility documentation confirmed that the nurse aide did not follow the prescribed transfer method, and the resident's care plan and orders were accurate at the time of the incident. The failure to use the mechanical lift as ordered directly resulted in the resident sustaining a serious injury during the transfer process.
Failure to Provide Accessible Anonymous Grievance Boxes
Penalty
Summary
The facility failed to ensure that anonymous grievance boxes were readily accessible for residents, resident representatives, or visitors on all three nursing floors. Observations revealed that no grievance boxes were present on the Second, Third, or Fourth Nursing Floors. The only anonymous grievance box observed was located in the lobby hallway, but it was blocked by six wheelchairs, making it inaccessible. Staff interviews confirmed the absence of grievance boxes on the nursing floors and the inaccessibility of the box in the lobby. The Social Worker and Grievance Officer were not aware of any grievance boxes on the nursing units, and residents reported not knowing where to find a grievance box or how to file a grievance anonymously. The facility's Resident Rights policy states that residents have the right to make complaints without fear of reprisal and that the facility must address grievances promptly. However, the lack of accessible grievance boxes and the staff's lack of awareness regarding their location prevented residents from exercising this right. During a group interview, several residents indicated they were unsure how to file grievances anonymously and typically gave their complaints directly to the social worker.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required supplemental oxygen or noninvasive ventilation therapies. Facility policy required that used cannulas, masks, and tubing be stored in a labeled plastic bag off the floor when not in use. For one resident with coronary artery disease, hypertension, and diabetes, the BiPAP mask was observed sitting on the nightstand and not stored in a plastic bag as required. A second resident with peripheral vascular disease, depression, and sleep apnea also had their BiPAP mask left out on the nightstand without a storage bag. In both cases, nursing staff confirmed the equipment was not properly stored according to policy. A third resident with high blood pressure, COPD, and PTSD had a nasal cannula observed lying on the floor and a CPAP mask left on top of the machine, rather than stored in a labeled plastic bag. The nasal cannula was later moved off the floor, but staff confirmed it had not been properly stored. Additionally, this resident's care plan did not include interventions or a plan of care for oxygen or CPAP therapy, as confirmed by the Registered Nurse Assessment Coordinator. These failures were identified through observations, staff interviews, and clinical record reviews.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate documentation for five of eight residents, as evidenced by missing or incomplete records in the electronic medical record (EMR) and medication administration records (MAR). For several residents, including those with diagnoses such as coronary artery disease, hypertension, diabetes, anemia, hyperlipidemia, constipation, hypocalcemia, Alzheimer's Disease, Parkinson's Disease, depression, and end-stage renal disease, required monthly weights and vital signs were not documented as ordered by physicians and per facility policy. In some cases, the MAR indicated that weights were 'already complete' when no documentation was present in the EMR. Staff interviews, including those with the Registered Dietitian and the Director of Nursing, confirmed that the required documentation was not completed or entered into the EMR for the affected residents. The facility's own policies and job descriptions require that registered nurses record daily care and maintain accurate medical records, but these requirements were not met for the residents identified in the report. Additionally, progress notes for some residents described ongoing behavioral and care needs, such as frequent requests for staff attention and assistance, but the documentation was noted as inaccurate or incomplete by the Director of Nursing. The deficiencies were identified through clinical record review and staff interviews, and were found to be in violation of state regulations regarding the maintenance of medical records and nursing services.
Failure to Ensure Call Bell Accessibility for Resident with Hemiplegia
Penalty
Summary
The facility failed to accommodate the call bell needs of Resident R88, who had diagnoses including hemiplegia, anxiety, and constipation. During an observation, the resident's call bell was found on the floor under the bed, making it inaccessible and unavailable for use. This was confirmed by an LPN, who acknowledged that the call bell was not accessible to the resident. The deficiency was identified through review of facility policy, clinical records, direct observation, and staff interview.
Inaccurate MDS Assessments for Oxygen, CPAP, and Hospice Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the care and services provided to two residents. For one resident with diagnoses including COPD and PTSD, clinical records showed the use of intermittent oxygen therapy and CPAP during the assessment period. However, the resident's quarterly MDS did not indicate that oxygen therapy or non-invasive mechanical ventilator therapy had been provided, despite documentation in the clinical record and confirmation from the Registered Nurse Assessment Coordinator that these treatments were administered. For another resident with diagnoses of high blood pressure, dementia, and bipolar disorder, the MDS indicated that the resident was receiving hospice care. A review of the clinical record, however, did not reveal any orders or documentation supporting that hospice services were provided. The Registered Nurse Assessment Coordinator confirmed that this resident had never received hospice care and that the MDS was marked incorrectly. These findings demonstrate that the facility did not follow its policy or the RAI User's Manual guidelines for accurate MDS coding.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified care needs for two residents. For one resident with diagnoses including anemia, hypertension, and Parkinson's Disease, the clinical record showed active physician orders for antidepressant and sedative/hypnotic medications. However, the resident's care plan did not include goals or interventions related to the use of these medications. This omission was confirmed by the Director of Nursing during an interview. For another resident with difficulty swallowing, vitamin deficiency, and Alzheimer's disease, the clinical record included a physician order for daily application of bilateral lower knee TED hose due to peripheral vascular disease. The care plan for this resident did not reflect the use of TED hose as ordered. This was confirmed by the Registered Nurse Assessment Coordinator. These findings demonstrate that the facility did not ensure care plans were comprehensive and addressed all current physician orders and resident needs as required by facility policy and state regulations.
Failure to Revise Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for three residents to reflect their current clinical needs as required by policy. For one resident with end stage renal disease, hypertension, and diabetes, the care plan did not include interventions, goals, or management strategies for a newly prescribed long-term antibiotic for bacteremia. Another resident with dementia, atrial fibrillation, and pain had a physician order for a wander guard, but the care plan was not updated to include this intervention in a timely manner, with a delay of several months before the intervention was added. A third resident with hemiplegia, anxiety, and constipation had a change in tube feeding orders, but the care plan continued to reflect an outdated feeding rate and did not match the current physician order. Staff interviews confirmed that the care plans for these residents were not revised to reflect their current status as required by facility policy and regulatory standards.
Failure to Meet Professional Standards in Nursing Services
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality for two residents. For one resident with diagnoses including constipation, hypocalcemia, and Vitamin D deficiency, progress notes documented repeated requests for staff assistance, with the resident frequently using the call bell, calling the nurses' station, and flagging down staff in the hallway. Staff described the resident as anxious and continuously making small, individual requests, often immediately after previous needs were addressed. Documentation indicated that staff repeatedly asked the resident to make all needs known at once, but the resident continued to request assistance one task at a time. For another resident with high blood pressure, hyperlipidemia, and end-stage renal disease, progress notes indicated excessive use of the call bell, with the resident requesting assistance multiple times in a short period. Staff documented that the resident was clean, dry, fed, and repositioned, and had received PRN analgesics, but continued to ring the call bell soon after staff left the room. The Director of Nursing confirmed that the facility did not follow standards of professional practice for these residents.
Failure to Provide and Document Pressure Ulcer Treatment and Prevention
Penalty
Summary
The facility failed to ensure that residents received proper treatment for existing pressure ulcers and necessary services to prevent new ulcers from developing. For two residents with pressure ulcers, required wound care treatments were not documented as completed according to physician orders. Specifically, one resident with a sacral wound had missing documentation for wound care on two occasions, with no evidence in the clinical record that the treatment was performed as required. Another resident with a sacral wound also had missing documentation for daily wound care on two separate shifts, and the clinical record did not confirm that the treatments were completed. Additionally, the facility did not provide necessary preventive measures for a resident identified as high risk for pressure injury. This resident had physician orders and a care plan specifying the use of bilateral Prevalon boots while in bed to prevent pressure ulcers due to impaired mobility. However, during two separate observations, the resident was found lying in bed without the prescribed boots on, and staff confirmed that the resident was not receiving the required preventive intervention as ordered. Interviews with nursing staff, including the Director of Nursing, confirmed that the facility did not ensure proper treatment for pressure ulcers and failed to implement necessary preventive services for residents at risk. These deficiencies were identified through review of facility policies, clinical records, direct observations, and staff interviews.
Failure to Maintain Consistent Dialysis Communication Documentation
Penalty
Summary
The facility failed to maintain consistent and complete dialysis communication for two residents who required regular dialysis treatments. According to facility policy, licensed staff are required to complete a Dialysis Communication Form prior to each transfer to the dialysis clinic and upon the resident's return, ensuring all relevant treatment information is documented and filed in the clinical record. For one resident with diagnoses including renal failure, stroke, and hemiplegia, the clinical record was missing complete communication forms for thirteen separate dialysis dates. This was confirmed by a registered nurse who acknowledged the absence of the required documentation on those dates. A second resident, diagnosed with high blood pressure, hyperlipidemia, and end-stage renal disease, also had incomplete dialysis communication forms for three treatment dates. The care plan for this resident specified that the entire first page of the communication form should be completed and passed to the next shift nurse, but this was not consistently done. A licensed practical nurse confirmed the missing documentation for the identified dates. These findings indicate that the facility did not ensure consistent communication and documentation for residents receiving dialysis, as required by facility policy and state regulations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to two residents diagnosed with Post Traumatic Stress Disorder (PTSD). For one resident with a history of hemiplegia and PTSD stemming from an automobile accident and an assault, the facility did not complete a PTSD assessment or develop a care plan within 30 days of admission as required. The resident's care plan eventually identified loud noises as a trigger, but this was not addressed in a timely manner. The Social Work Director confirmed that the assessment and care plan were not completed within the required timeframe, resulting in a lack of interventions to eliminate or mitigate triggers that could cause re-traumatization. For another resident with PTSD related to combat experiences during the Vietnam War, the care plan did not include any identified triggers or documentation indicating that the resident declined to identify triggers. The Social Work Director confirmed that the facility failed to provide trauma-informed care for this resident as well. The facility's policy requires assessment of trauma history and identification of triggers upon admission, annually, and with significant change, but these steps were not followed for the two residents involved.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of three nurse aide personnel records reviewed. Specifically, the personnel record for NA Employee E18, who was hired on a specified date, did not contain documentation of an annual performance evaluation as required by federal regulations. This deficiency was confirmed during an interview with the Human Resources employee, who acknowledged that the annual performance evaluation based on the date of hire was not completed for this nurse aide. The review referenced the requirement under CFR S483.35(d)(7), which mandates that every nurse aide must have a performance review at least once every 12 months, with regular in-service education provided based on the outcomes of these reviews. The absence of the required evaluation was identified through personnel record review and staff interview.
Failure to Maintain Infection Control for Indwelling Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices in the care of an indwelling urinary catheter for one resident. According to facility policy, catheter collection bags and tubing are never to touch the floor to promote a healthy urinary tract and prevent infection. During an observation, a resident with a foley catheter for obstructive uropathy was seen sitting in a wheelchair with the catheter collection bag lying directly on the floor beside him. This was confirmed by a registered nurse, who acknowledged that the facility did not follow its own infection control procedures in this instance. The resident involved had a history of high blood pressure, cancer, and diabetes, and was admitted with a physician's order for a foley catheter. The deficiency was identified through review of facility policies, the resident's clinical record, and direct observation. The failure to keep the catheter bag off the floor was a direct violation of the facility's infection control plan and urinary catheter procedures, as well as relevant state regulations.
Failure to Obtain Physician Orders and Develop Care Plans
Penalty
Summary
The facility failed to obtain physician's orders for five residents, specifically for wound care and safety equipment. For Resident R25, the facility did not include directions for cleansing a wound on the left buttock, despite having orders for applying Medi honey and foam dressing. Similarly, for Resident R94, the orders for a clean dry dressing on a left ankle deep tissue injury lacked instructions for wound cleansing. These omissions were confirmed by Employee E4 during interviews. Additionally, the facility did not develop comprehensive care plans for three residents, R88, R89, and R90, to meet their care needs. Observations revealed that these residents had thick blue fall mats placed on both sides of their beds, and in the case of Resident R89, a silent bed alarm was also noted. However, the physician orders for these residents did not include the use of these safety devices, and there were no current care plans addressing their use. Interviews with RN Employee E3 and RN Employee E14 confirmed the absence of orders and care plans for these safety measures. The facility also failed to complete bed safety risk assessments for Residents R88, R89, and R90, despite the use of thick fall mats. The Director of Nursing confirmed these deficiencies during interviews. The lack of physician orders, comprehensive care plans, and bed safety risk assessments for these residents indicates a failure to adhere to established facility policies and guidelines, as well as state regulations.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide access to medical records to a resident or their representative within the required time frame. Specifically, a request for a copy of medical records by a representative of Resident R202 was received on 11/21/23 and was never sent. During an interview on 5/8/24, Medical Records Employee E2 admitted to receiving the signed request but did not send the records, citing a misunderstanding of the regulation. This failure to comply with the regulation was identified during a review of facility documents and staff interviews.
Failure to Update Care Plan After Dietary Change
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as Resident R119, after a change in dietary needs. According to the facility's policy, care plans should be updated within 30 days following an annual assessment or any changes in the resident's needs. Resident R119, who was admitted with diagnoses including chronic atrial fibrillation, malaise, and dry eye syndrome, had a physician's order dated April 9, 2024, to discontinue tube feeding. However, the care plan still listed tube feeding as active. This discrepancy was confirmed during an interview with a registered dietitian on May 9, 2024, indicating a failure to update the care plan to reflect the resident's current dietary status.
Failure to Provide ROM Treatment for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for two residents, R2 and R25. Resident R2, who has diagnoses including diabetes, peripheral vascular disease, and hemiplegia, was observed without the prescribed left palm guard on multiple occasions, despite physician orders specifying its use from 6:00 a.m. to 8:00 p.m. The care plan for Resident R2 indicated the need for the palm guard to maintain range of motion and prevent skin breakdown, yet observations confirmed the device was not in place as required. Similarly, Resident R25, diagnosed with functional quadriplegia, muscle contractures, and dementia, was observed without bilateral palm guards while out of bed, contrary to physician orders for their use up to four hours per shift. Staff interviews revealed a lack of clarity and communication regarding the schedule for wearing the palm guards, with the Director of Nursing acknowledging the absence of a system to ensure compliance with the prescribed wear schedule. This lack of adherence to care plans and physician orders resulted in the facility's failure to provide necessary services to prevent further decline in residents' range of motion.
Inadequate Supervision Leads to Elopement and Cat Bites
Penalty
Summary
The facility failed to ensure adequate supervision and safety for its residents, resulting in an elopement incident and two cases of cat bites. Resident R140, who was diagnosed with Non-Alzheimer's Dementia, depression, and hyperlipidemia, was not assessed for elopement risk quarterly as required. On one occasion, the resident exited the facility unnoticed by security, as the security guard had left the desk unattended and the resident was not wearing a wander guard device. Staff inattentiveness was also noted as a contributing factor to the elopement. Additionally, two residents, R14 and R119, sustained cat bites while outside feeding cats. Resident R14, with diagnoses including diabetes mellitus and osteoarthritis, was bitten on the right index finger, while Resident R119, diagnosed with chronic atrial fibrillation and depression, was bitten on the left wrist. Both incidents required medical attention, with Resident R119 receiving a rabies series as a precaution. The Director of Nursing confirmed the facility's failure to provide adequate supervision, which led to these incidents. The facility's policies on incidents, accidents, and elopement prevention were not adequately followed, contributing to the deficiencies observed during the survey.
Inadequate Dialysis Communication and Documentation
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for three residents, identified as R35, R81, and R106. For Resident R35, the facility's policy required a Dialysis Communication Form to be completed and returned with each dialysis session. However, between March 25, 2024, and May 8, 2024, nine communication sheets were found incomplete, and two additional sheets were undated. Similarly, for Resident R81, five communication sheets were missing between April 1, 2024, and May 7, 2024. Interviews with registered nurses confirmed the incompleteness of these records. Additionally, the facility failed to maintain accurate physician orders and care plans for Resident R106. The resident was supposed to have a dialysis port in the right upper chest, but it was discovered that the resident had an AV fistula instead, which was not documented in the physician orders or care plan. The care plan also failed to include management instructions for the AV fistula. This lack of documentation and communication was confirmed by interviews with nursing staff and the Director of Nursing.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
