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 Spring Hill Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Food products were found unlabeled and undated in the walk-in cooler, freezer, and dry storage area, while kitchen equipment in the Main Kitchen had visible dust, grime, and debris, and a condenser was dripping water onto food stored below. An aerosol can of insect repellant was stored next to pasta, some items were stored on the freezer floor, and a Dietary Aide was observed with a beard net not covering his beard and hair hanging below his cap.
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other auditable data for one quarter. Review of PBJ staffing data reports showed no submission for the quarter, and the NHA confirmed the facility did not submit the required direct care staffing information in the PBJ system.
Failure to Document COVID-19 Vaccine Offerings: The facility did not provide accurate and timely documentation showing that the COVID-19 vaccine was offered, administered, or declined for five residents. Records for a discharged resident and four other residents with diagnoses including HTN, DM, CAD, COPD, PVD, anemia, anxiety, and [NAME] syndrome showed COVID-19 vaccination was not up to date, and the IP RN stated the vaccine was not offered.
Expired Ambu Bags Found on Two Crash Carts: The facility failed to ensure two crash carts were in safe operating condition when an Ambu bag on the First Floor Crash Cart and an Ambu bag on the Second Floor Crash Cart were both found expired. RN staff confirmed the expired equipment and acknowledged the carts were not maintained as required by the facility's crash cart management process.
Failure to support voting rights and maintain dignity: Two residents had no documentation showing assistance with voter registration or voting during election cycles, despite a facility policy stating residents would be supported in exercising that right. In addition, a resident with an indwelling urinary catheter was observed with the drainage bag uncovered beside the bed, and a nurse aide confirmed the privacy cover was not in place.
The facility failed to obtain written authorization to open a resident trust account for one resident and failed to ensure another resident could access her funds. One resident with lumbar fracture, HTN, and alcohol dependence was discharged, but the chart lacked the required authorization even though the trust account showed a balance. Another resident with DM, CKD, and HTN reported not receiving her Social Security money for two months and not knowing who to contact, while staff said authorizations should be in the chart and residents access money through the Administrator or Admissions staff.
Failure to provide quarterly trust fund statements to two residents was identified. Staff stated residents should receive statements quarterly, but the NHA could not find documentation that the statements were mailed or handed out, and the two residents said they had never seen their statements.
Failure to Return Resident Trust Funds After Discharge: A resident was discharged with personal belongings and medications reviewed, but the record did not show that his trust funds were returned at discharge. The trust account still showed a remaining balance of $35.04 after discharge, and the NHA confirmed the facility did not convey the resident's funds and close the account within the required 30 days.
The facility failed to ensure its surety bond named only the residents as the obligee. Review of the prior bond showed the obligee was listed as the residents of Spring Hill Rehabilitation Center or unto the Commonwealth of Pennsylvania, and the NHA confirmed the bond was not limited to residents only.
Failure to Provide SNF-ABN for Medicare Non-Coverage: The facility did not provide SNF-ABN forms to two residents when Medicare Part-A coverage ended. One resident had hypothyroidism, MDD, dysphagia, and hyperlipidemia and remained in the facility for LTC after a NOMNC was issued; another resident had muscle weakness, arthritis, and anxiety disorder and also received a NOMNC, but the record did not show review or issuance of an SNF-ABN. The NHA confirmed the omission.
Failure to Provide Timely Incontinence Care: Two residents were found saturated at the start of the day shift and stated they had not been changed overnight. One resident was dependent for toileting hygiene and the other required partial/moderate assistance. Staff statements showed the night assignment was not revised after call-offs, leaving only two aides for about 50 residents, and the DON confirmed the residents were not changed throughout the night.
Care plan not updated for a resident with significant weight loss. A resident with adult failure to thrive, MDD, HTN, and dementia had a documented 16.5% weight decrease in one month, but the care plan only stated that she would maintain adequate nutritional status with supplements and ordered diet. The plan did not reflect the weight loss, include nutritional interventions, or add more frequent monitoring/reweighs. An LPN stated care plans should be updated when weight loss occurs, and the DON was informed of the issue.
The facility failed to maintain communication ADLs for two residents with hearing and speech deficits. One resident had cognitive communication deficit and bilateral hearing loss, but no care plan or assistive devices were available during survey interviews. Another resident had bilateral sensorineural hearing loss, unclear speech, and communicated by lip reading and sign language, yet the care plan lacked communication interventions and no communication board or interpreter was present. An LPN stated staff just talked loud and mouthed words, and the NHA confirmed the care plans were not individualized.
Failure to provide ADL assistance for a resident’s hair care needs was identified. The resident’s record and ADL documentation did not show a haircut, staff were unsure when the hairdresser last visited, and all residents in a council interview said they had not received hair services. The resident was observed with long gray hair and stated her last haircut was about a month ago and that she wanted one.
Pressure ulcer prevention and wound care order not followed. A resident with hemiplegia and diabetes did not consistently have ordered heel boots applied, and the care plan did not include the boots. Another resident at risk for skin breakdown had a care plan that did not reflect wound consultant recommendations to limit OOB time and use turning/repositioning precautions, while staff continued to keep the resident in a wheelchair for much of the day. A third resident’s wound dressing was applied contrary to the MD order when an RN omitted the ABD pad and placed Medi-honey directly on the calcium alginate.
Failure to supervise meals for dysphagia monitoring: Two residents with care plans requiring monitoring for signs of dysphagia were observed eating unsupervised. One resident with intellectual disabilities, esophageal varices, and GERD had meals left in the room and was seen eating at a fast pace without supervision, while another resident with heart failure, respiratory failure, and cardiac arrest was observed eating unsupervised in the common lounge. Staff, including an NA, an LPN, the RN supervisor, DON, and speech therapist, confirmed the residents were not being monitored as ordered.
Feeding tube care and treatment were not provided as ordered for two residents. One resident’s water flush bag was unlabeled and the enteral feeding pole was soiled with dried formula, while another resident’s tube feeding supplies were undated and the resident was observed disconnected from the feed with 600 ml still remaining in the bag. RN, LPN, DON, and NHA interviews confirmed the issues.
A resident with heart failure, respiratory failure, and cardiac arrest had an order for continuous oxygen at 5 to 7 L to keep O2 saturation above 90%. The care plan did not include oxygen settings, and staff observed the resident with an empty oxygen tank, a ripped tank sleeve, and an oxygen concentrator turned off. An LPN confirmed the resident was not receiving oxygen as ordered and the resident’s O2 saturation was 86% on room air.
The facility failed to provide trauma-informed care for two residents with PTSD by not identifying specific triggers in their care plans. One resident had PTSD related to sexual abuse, depression, and dysphagia, and the care plan did not identify triggers even though a psychiatry note referenced a trigger involving a resident who looked like the assailant. Another resident had PTSD related to past trauma, anxiety, COPD, alcohol use, and HTN, but his care plan also lacked specific PTSD triggers; staff interviews showed limited knowledge of the residents’ triggers.
The facility failed to complete required annual performance evaluations for two NA staff members. Facility policy required yearly written reviews, but the personnel files for two employees did not contain evaluations covering their first annual review periods. An HR employee confirmed the missing evaluations during interview.
A resident with dementia, HTN, and chronic pain did not have an individualized person-centered care plan addressing dementia or cognitive loss. Record review showed the care plan lacked dementia-specific interventions, and the DON confirmed the deficiency during interview.
A resident with adult failure to thrive, muscle wasting, and glaucoma had severe vision impairment and told staff he felt uncomfortable, that the facility was not equipped for a blind person, and that he wanted his own place. Although social services noted his interest in assisted living, the clinical record did not include a discharge care plan, and the NHA confirmed the failure to provide medically related social services.
A resident with chronic pain and other diagnoses did not receive ordered MS Contin on multiple occasions because the pharmacy did not provide the medication timely. The resident stated she had not received morphine in the past week, and the MAR and nursing notes documented repeated missed doses while the DON confirmed delays occurred when the facility changed pharmacies and new prescriptions had to be completed.
A resident with Alzheimer's disease, schizoaffective disorder, and major depressive disorder remained on Seroquel 100 mg TID while the consultant pharmacist twice recommended periodic AIMS testing. The record lacked evidence that the MRRs were completed and reviewed by the attending MD, and the chart also failed to show that the recommended AIMS test was performed.
Failure to Prime Insulin Pen Before Administration: An LPN failed to prime a resident’s Lantus insulin pen before administration, despite facility policy requiring priming before each use. The resident had DM, HTN, and hyperlipidemia and was ordered 38 units of Lantus daily. During med pass observation, the LPN prepared the insulin pen without priming the needle and later confirmed the omission.
Unsecured treatment carts and improperly stored medications were observed in multiple areas. A treatment cart on each floor was left unlocked and unattended near the elevator, and several medication storage areas contained opened or unlabeled meds, co-mingled rectal and oral meds, and items without required dates or identification, which staff confirmed during interview.
Failure to Follow Posted Menus for Lunch Meals: The facility did not serve two observed lunch meals as posted. One resident received an egg salad sandwich on a hamburger bun instead of the listed croissant, and another resident on a Mechanical Soft diet received a chopped salad instead of the listed green beans. The Dietary Manager confirmed the planned menu was not followed.
A resident who was supposed to receive double portions at lunch was served only a single portion. An NA later confirmed that the facility did not provide the double portions per the resident’s preference.
The facility failed to coordinate hospice services with facility services for a resident admitted under hospice care. The resident had HTN, COPD, and muscle spasm, but the comprehensive care plan did not include the hospice agency’s contact information or how to access the hospice’s 24-hour on-call system. The DON confirmed the missing hospice coordination details in the care plan.
Failure to hold required QAA meetings. Review of QAA attendance records showed only one committee meeting in one quarter and one meeting in a later quarter, and the NHA confirmed the facility did not conduct QAA meetings at least quarterly with all required committee members.
An RN failed to wear a mask while administering meds to a resident on reverse isolation precautions, despite a posted sign and care plan requiring masking in close proximity. In separate observations, an RN completed a wound dressing change without cleansing the over-the-bed table afterward, and another RN handled all of a resident’s oral meds with the same gloved hand before placing them in a med cup. Surveyors also observed infection control concerns in a laundry room, including a full sharps container not mounted to the wall and a centrifuge stored there.
A facility failed to maintain a fully functioning resident call bell system on the second floor nursing unit. Staff observed the call bell sounding repeatedly while resident room call bell lights were not lit, and nurse aides said the system had been sounding for a while and they had to keep checking the call light board or hallways. The Maintenance Director said the system was ringing consistently but the cause had not been identified, and the NHA confirmed the system did not function correctly.
Loose Handrail in First Floor Corridor: A handrail on the front side of the nursing station was observed to be loose to touch during an inspection of the 1st floor nursing unit. A housekeeper confirmed it was not secured properly and said he had known about it since Thursday but was unsure whether maintenance had been notified. An RN supervisor confirmed that handrails should be securely affixed to the walls.
The facility failed to provide annual Effective Communication training for two nurse aides. Personnel file review showed the required in-service training was missing for both staff members, and HR confirmed the lapse during interview. Facility policy identified Effective Communication as mandatory training for direct care staff.
Failure to provide required abuse, neglect, and exploitation training was identified for an NA. Facility policy required annual training covering abuse, neglect, exploitation, misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention. The NA's personnel file did not show the required annual in-service training, and HR confirmed the training had not been provided.
Failure to provide required QAPI training for a nurse aide. Facility policy required mandatory QAPI training for staff, but the aide’s personnel file did not show annual in-service training in the required period. HR confirmed the facility did not provide QAPI training for one of three staff members reviewed.
Failure to provide mandatory Infection Control training for one NA was identified. Facility policy required compliance with training standards and mandatory infection control in-service education, but the NA’s personnel file did not show annual Infection Control training for the required period. HR confirmed the training was not provided.
Failure to provide required Compliance and Ethics training for an NA. Facility policy required annual training, but the NA’s personnel file did not show the required in-service training during the review period. HR confirmed the training was not provided.
The facility failed to ensure that two of three sampled nurse aides received the required minimum of 12 hours of annual in-service education. Review of policy and personnel files showed the aides did not have documentation of the required training in their records, and HR confirmed the deficiency.
Failure to Provide Behavioral Health Training: Behavioral Health training was not provided for two NAs as required by facility policy and the facility assessment. Personnel records did not show the required annual training for either NA, and HR confirmed the missing training during interview.
Surveyors found that the facility did not follow its own policies for one resident transferred to the hospital when it failed to document that required clinical and care-plan information, including diagnoses, status, medications, and special instructions, was communicated to the receiving provider. In addition, for two residents sent to the hospital, the clinical records lacked evidence that the residents or their representatives received the required written notice of the facility’s bed-hold policy at the time of transfer or within the specified timeframe, and the Assistant DON confirmed these failures.
Surveyors found that medications on three medication carts were not stored and labeled according to facility policy and professional standards. On two first-floor carts, multiple Lispro and Basaglar insulin pens were not kept in required bags, and a Stioloto Respimat inhaler lacked a date opened. On a second-floor cart, a Novolog insulin pen was not bagged, was labeled as house stock, and did not include a resident name. These issues were confirmed by involved LPNs and the DON.
A resident with chronic pain and multiple comorbidities, including DM, heart failure, and depression, had a PRN order for Oxycodone 5 mg PO every eight hours. Over three consecutive days, the resident reported requesting this medication for breakthrough pain but did not receive it, leading to increased pain, poor sleep, and reduced ability to perform usual ADLs. Review of the MAR showed no documentation of Oxycodone administration on those days, and the controlled substance record for the medication was missing. Nursing and clinical staff confirmed the absence of documentation and records, and that effective pain management was not provided, resulting in harm.
The facility failed to protect residents from misappropriation of property when multiple discrepancies were found in the controlled substance records for narcotic pain medications. Several residents with conditions such as heart failure, COPD, osteoarthritis, neuropathy, depression, and spina bifida had orders for MS Contin and Oxycodone, but pill counts did not reconcile with documented administrations, and in one case there was no controlled substance record for a dispensed PRN narcotic. Nursing staff reported that an agency RN on an overnight shift appeared shaky and could not account for missing Oxycodone tablets, and later review showed documentation inconsistencies, including records of narcotics given to a resident who reportedly slept all night. The NHA and DON confirmed that an agency RN allegedly took multiple residents’ narcotics and that the facility failed to ensure residents were free from misappropriation of their medications.
The facility failed to report and investigate allegations of misappropriation of resident property involving controlled medications for multiple residents. Despite policies requiring protection against exploitation and strict recordkeeping for controlled substances, staff identified repeated discrepancies between narcotic counts and documented administrations for several residents receiving MS Contin and Oxycodone for chronic pain and other conditions. An agency RN who worked the relevant overnight shifts appeared shaky and emotional, could not fully explain missing tablets, and staff discovered incorrect counts and documentation after shift change. The DON later confirmed that no formal investigation was completed and that the incident involving missing narcotics and suspected diversion was not reported to the Department of Health.
The facility failed to investigate multiple discrepancies in controlled substance counts and documentation involving five residents receiving MS Contin and Oxycodone for chronic pain and other conditions. Despite policies requiring protection against misappropriation of resident property and special recordkeeping for controlled drugs, narcotic records showed unexplained reductions in tablet counts, missing controlled substance records for a PRN medication, and documentation of doses that conflicted with resident status reports. Staff reported that an agency RN on an overnight shift appeared shaky and emotional, gave inconsistent explanations for missing tablets, and left after writing a statement. The DON and NHA acknowledged awareness of missing narcotics and alleged diversion but confirmed that no thorough investigation was conducted and the missing narcotics were not reported to the state health department.
The DON failed to timely and effectively manage and investigate five allegations of misappropriation of resident belongings, including narcotic diversion, affecting multiple residents. Although the DON’s job description required oversight of nursing operations, monitoring for potential abuse or neglect, and participation in investigations, no investigations were completed for these incidents. In interviews, the DON first indicated an investigation existed but later admitted there was none, and the NHA confirmed the DON’s failure to manage these allegations. These failures were cited under applicable Pennsylvania regulatory codes.
A resident with diabetes, heart failure, and depression had a physician order for a low air loss mattress with functioning checks every shift, but the motor controlling the foot portion of the bed broke and the resident was unable to raise or lower their legs in bed. Observation confirmed the bed made a loud noise and the lower portion did not move when the control was used. The Maintenance Director acknowledged being notified that the bed was broken and needing a new motor, had taken specifications to order the part, but did not know if it had been ordered, and the DON confirmed the facility failed to maintain the resident’s rights to a safe and comfortable environment by not ensuring the bed was in working order.
The facility failed to follow its own abuse prevention and credentialing policies by allowing an agency RN to work two shifts before verifying the nurse’s license status. Facility policies required pre-employment screening for abuse, neglect, exploitation, and misappropriation, as well as license verification for all licensed nurses upon employment, with documentation maintained. However, the RN’s license verification was completed and documented several days after the nurse had already worked, as confirmed by the DON and HR staff.
A resident with diabetes, heart failure, and depression had a physician order for Singulair 10 mg, two tablets daily, but the pharmacy supplied and staff administered only one tablet per day. The resident reported receiving only one tablet, and review of the medication supply confirmed that the pharmacy was dispensing a single 10 mg tablet instead of the ordered two. The pharmacist acknowledged the pharmacy cycle order was incorrect, and facility staff confirmed that the pharmacy did not provide the medication in the correct dose as ordered.
Food Storage, Sanitation, and Hair Restraint Failures in Kitchen
Penalty
Summary
The facility failed to properly label and date food products, maintain kitchen equipment in a sanitary condition, properly store chemicals, and properly restrain hair in the Main Kitchen. During observation in the walk-in cooler, a metal pan of pasta salad, an opened package of lunch meat, a metal pan with cooked chicken, and an opened bag of lettuce were found without labels or dates. The cold air condenser fan covers had a build-up of dust, grime, and dark colored debris, and a metal pan of chicken stored directly beneath the condenser had water pooled on the plastic wrap because the condenser was dripping water onto the food products below. Additional observations in the walk-in freezer found a Drumstick ice cream novelty and two bags of ice stored on the freezer floor, along with two angel food cakes that were not labeled and dated. In the dry storage area, four cans of fruit cocktail were not dated with received date, an open bag of penne pasta and an opened bag of macaroni were not labeled and dated, and an aerosol can of Flying Insect Repellant was stored next to the pasta. In the dish room, a Dietary Aide was observed with a beard net under his chin and not covering his beard, and a ball cap with three to four inches of hair hanging below it and not restrained. A Dietary Manager confirmed the facility failed to properly restrain hair.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS based on payroll and other verifiable and auditable data for one of the last four quarters, identified as Quarter 1 2026. Review of the ACA Section 6106 requirements and the PBJ staffing data reports showed that the facility did not submit staffing data for Quarter 1, listed as October 1 through December 31, 2026. During an interview on 5/21/26 at 1:10 p.m., the Nursing Home Administrator confirmed that the facility failed to submit direct care staffing information in the Payroll-Based Journal system as required.
Failure to Document COVID-19 Vaccine Offerings
Penalty
Summary
The facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for five of five residents reviewed: discharged Resident R9 and Residents R12, R55, R56, and R57. Review of the facility policy indicated the facility would offer and administer COVID-19 vaccinations in accordance with state and federal guidelines, but the clinical records for each of these residents did not include documentation that the vaccine was offered, administered, or declined. For discharged Resident R9, the MDS dated 2/4/26 showed diagnoses of hypertension, diabetes, and hyperlipidemia, and Question O0350 was coded no for COVID-19 vaccination up to date. Resident R12's MDS showed COPD, CAD, and orthostatic hypotension, and Question O0350 was coded no for COVID-19 vaccination up to date. Resident R55's MDS showed CAD, hypertension, and diabetes; Resident R56's MDS showed hypertension, diabetes, and PVD; and Resident R57's MDS showed anemia, anxiety, and [NAME] syndrome. For each of these residents, Question O0350 was coded no for COVID-19 vaccination up to date, yet the record lacked documentation that the vaccine was offered, administered, or declined. During interview, the Infection Preventionist RN stated, "we did not offer it," and confirmed the facility failed to provide accurate and timely documentation related to offering the COVID-19 vaccination for the five residents.
Expired Ambu Bags Found on Two Crash Carts
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for two crash carts, identified as the First Floor Crash Cart and the Second Floor Crash Cart. Facility documentation titled Crash Cart Management stated that crash carts must be maintained fully stocked, operational, and secured, and that routine checks must verify medication expiration dates, supply integrity, oxygen pressure levels, suction functionality, cleanliness, full inventory, equipment testing, battery checks, restocking, and infection control review of manufacturer maintenance recommendations. During an observation, the First Floor Crash Cart was found to contain an Ambu bag with an expiration date of 10/18/24. In a separate observation, the Second Floor Crash Cart was also found to contain an Ambu bag with the same expiration date of 10/18/24. RN Employee E4 confirmed the expired Ambu bag on the First Floor Crash Cart and acknowledged the facility failed to make certain the equipment was in safe operating condition. RN Employee E8 similarly confirmed the expired Ambu bag on the Second Floor Crash Cart and acknowledged the same failure.
Failure to Support Voting Rights and Maintain Catheter Dignity
Penalty
Summary
The facility failed to uphold residents’ right to vote for two sampled residents. The resident rights policy stated the facility would support residents in exercising their right to vote and provide access to timely information about upcoming elections. Resident R27, who had diagnoses including bipolar disorder, muscle weakness, and epilepsy, had a social services note showing she met with a voting services group to update her registration on 7/15/25, but her clinical record, activity documents, and social services notes did not show that she was assisted with voting during the 2026 election cycle. Resident R37, who had diagnoses including diabetes, morbid obesity, and major depressive disorder, also had no documentation in the clinical record, activity documents, or social services notes showing he was assisted with voting during the 2025 and 2026 election cycles. The facility also failed to ensure resident dignity was maintained for one resident with an indwelling urinary catheter. Resident R46’s care plan identified the catheter related to neuromuscular dysfunction of the bladder, and the facility’s catheter care policy stated privacy bags would be available and drainage bags would be covered at all times while in use. During observation, R46’s catheter drainage bag was seen beside the bed without a privacy cover, and a nurse aide confirmed the bag did not have a privacy cover to ensure dignity.
Resident Trust Funds and Access to Money
Penalty
Summary
The facility failed to obtain an authorization to open a resident trust fund account for Closed resident record CR66. CR66 was admitted with diagnoses including lumbar fracture, hypertension, and alcohol dependence. His clinical nurse notes indicated he was discharged on 2/6/26 with all personal belongings taken with him, medications reviewed with him and the home nurse, and social services calling current prescriptions to the pharmacy. However, review of his record did not include an authorization to open a resident trust fund account, even though the facility trust fund account dated 5/20/26 showed a balance of $35.04 for CR66. The facility also failed to ensure Resident R18 had access to her funds. R18’s record showed diagnoses including diabetes, chronic kidney disease, and hypertension, and her clinical record and social services notes did not document concerns with accessing money from the business office. During a resident council interview, two of nine residents voiced concerns about accessing their money. R18 stated she had not received her Social Security money for the prior month and the current month, did not know who to talk to, and wanted to know what was happening with her check. The regional business office manager stated resident fund account authorizations should be in residents’ charts and that residents access money through the Administrator or, if unavailable, Admissions staff. The Nursing Home Administrator confirmed the facility failed to obtain the required authorization for CR66, and surveyors informed the NHA that the facility failed to ensure R18 had access to her funds.
Failure to Provide Quarterly Trust Fund Statements
Penalty
Summary
The facility failed to properly hold, secure, and manage residents’ personal money deposited with the nursing home by not providing quarterly banking statements to two of four sampled residents, R56 and R57. Facility staff stated that residents should receive trust fund statements quarterly, but the Nursing Home Administrator found no documentation in the former Business Office Manager’s office showing that the statements had been sent to residents or responsible parties. The administrator later provided one-quarter statements for residents with trust funds, but was unable to show that they had been mailed or handed out. During interviews, R56 and R57 stated they had not seen, and had never seen, their quarterly statements. The Nursing Home Administrator confirmed that the facility failed to provide the quarterly banking statements as required.
Failure to Return Resident Trust Funds After Discharge
Penalty
Summary
The facility failed to convey resident funds and close a resident trust account within 30 days after discharge for one closed resident record, CR66. The facility policy stated that upon discharge, eviction, or death of a resident with personal funds deposited with the facility, the resident's funds and a final account of those funds would be conveyed within 30 days. Review of CR66's record showed he was admitted to the facility and later discharged on 2/6/26, with clinical nurse notes indicating that all personal belongings were taken with him and that medications were reviewed with him and a home nurse. Review of CR66's record did not show evidence that his monies were provided at discharge. A review of the facility trust fund account dated 5/20/26 showed CR66 still had a remaining balance of $35.04. During interview, the Regional Business Office Manager stated that money from the resident trust fund is ideally provided in real time but may take up to 30 days to refund to a resident. The Nursing Home Administrator later confirmed that the facility failed to convey resident funds and close the account upon discharge within 30 days for CR66.
Surety Bond Listed Incorrect Obligee
Penalty
Summary
The facility failed to ensure that the surety bond listed the obligee as only the residents of the facility. Review of the facility’s previous surety bond showed that the obligee was listed as "the residents of Spring Hill Rehabilitation Center or unto the Commonwealth of Pennsylvania," rather than residents only. During an interview, the Nursing Home Administrator confirmed that the facility failed to list the obligee as only the residents of the facility.
Failure to Provide SNF-ABN for Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) to inform residents when items and services were no longer eligible for Medicare Part-A coverage for two sampled residents. Resident R4 was admitted to the facility and had an MDS dated 3/2/26 showing diagnoses that included hypothyroidism, major depressive disorder, dysphagia, and hyperlipidemia. A clinical social services note dated 3/16/26 indicated that R4 was issued a NOMNC with a last covered day of 3/18/26, and the resident remained in the facility for long-term care, but the record did not include evidence that an SNF-ABN was provided. Resident R57 was admitted and later readmitted to the facility, and her MDS documented diagnoses including muscle weakness, arthritis, and anxiety disorder. Her clinical record showed that she was issued a NOMNC on 5/11/26, but clinical nurse notes and social services notes did not indicate a review of the NOMNC form provided to her. Facility documentation did not include evidence that SNF-ABN forms were provided to either resident, and during an interview on 5/20/26 at 10:28 a.m., the NHA confirmed that the facility failed to provide the SNF-ABN form as required.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to protect residents from neglect for two residents who were found saturated and reported that they had not been changed during the night shift. Facility policy stated neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and that each resident will be free from abuse. The deficiency involved Resident R4, who had diagnoses including cognitive communication deficit, dysphagia, and depression and was dependent for toileting hygiene, and Resident R8, who had diagnoses including morbid obesity, difficulty walking, and depression and required partial/moderate assistance for toileting hygiene. For Resident R4, the oncoming shift reported that the resident was saturated, had his call bell on at the start of the shift, and told staff he needed to be changed. The resident stated he was not changed on the night shift. In the investigation, staff statements indicated the nurse aides shared the assignment, and the facility could not determine an alleged perpetrator. One aide stated the resident said he had not been changed all night, and another aide stated that when she asked who was assigned to the resident, an aide responded, "oh we forgot to change him." Another staff statement indicated the aides worked together the prior night. For Resident R8, the oncoming shift also found the resident saturated, and the resident stated he was not changed on the night shift. The resident’s grievance stated he was found saturated at the start of the day shift and said no one changed him all night. Staff statements described the resident as soiled from head to toe, lying in urine, and uncomfortable and cold. During interview, an aide confirmed there were only two nurse aides for approximately 50 residents because two scheduled aides called off, and the assignment sheets were not revised. The DON confirmed the facility failed to protect the residents from neglect.
Care Plan Not Updated for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to update the care plan for a resident with documented weight loss. Resident R30 had diagnoses including adult failure to thrive, major depressive disorder, hypertension, and dementia. Her care plan dated 5/5/26 stated that she would maintain adequate nutritional status by maintaining weight and receiving supplements and diet as ordered, but it did not reflect the resident’s March 2026 weight loss, review nutritional interventions to address the loss, or include additional monitoring such as more frequent reweighing. The resident’s weight record showed 103.4 lbs on 2/25/26 and 86 lbs on 3/4/26, representing a 16.5 percent decrease in one month. A CRNP note dated 2/6/26 stated she continued supportive care and that family was aware of ongoing weight loss, and a RD note dated 2/25/26 documented a weight of 103 lbs and improvement from 2/3/26. During interview, an LPN stated that care plans should be updated when weight loss occurs and should include interventions and reweighs. The DON was informed that the care plan had not been updated after the resident experienced weight loss.
Failure to Support Communication Needs
Penalty
Summary
The facility failed to implement care and services to maintain residents’ activities of daily living related to communication for two residents with hearing and speech deficits. One resident had diagnoses including cognitive communication deficit, dysphagia, and depression, and an audiology assessment documented bilateral hearing loss and refusal of an amplifier. The resident was noted in a progress note to be very hard of hearing and difficult to understand, and during survey interviews the resident was non-interviewable because of inability to hear and had no assistive devices available for communication. The clinical record did not include evidence of a care plan for the resident’s hearing and communication deficits. A second resident had a care plan identifying a potential communication problem due to bilateral sensorineural hearing loss and speech/language delay related to hearing loss, but the care plan did not include interventions for how to communicate with the resident. The resident’s MDS indicated highly impaired hearing and unclear speech, and an audiology evaluation stated the resident had hearing loss, did not use amplification, and communicated through lip reading and sign language. During survey interviews, the resident stated he was deaf, and there was no communication board or interpreter present. Staff stated one resident knew sign language and could interpret, and an LPN confirmed both residents had no assistive devices for communication and that she just talked loud and mouthed words. The NHA confirmed the residents’ care plans were not individualized and that the facility failed to implement care and services to maintain communication abilities.
Failure to Provide Hair Care Assistance
Penalty
Summary
The facility failed to provide ADL assistance for Resident R28, specifically hair care services. The facility’s ADL policy dated 5/1/26 stated that resident abilities in ADLs would not deteriorate and that care and services would be provided for bathing, dressing, grooming, and oral care. Review of Resident R28’s admission and readmission records showed she was admitted and later readmitted to the facility, and her MDS dated 4/21/26 listed anemia, hypertension, and adult failure to thrive as diagnoses. Review of Resident R28’s clinical nurse notes and ADL documentation did not show that she received a haircut. During a resident council group interview, nine of nine residents stated they had not received hair services. An RN stated the hairdresser had not been in during the last week, and another RN/ICP stated she believed activities set up haircuts but was not sure. During observation, Resident R28 was seen wearing a hat with gray hair hanging out to her shoulders, and she stated her last haircut was about a month ago and that she would like a haircut.
Pressure ulcer prevention and wound care order not followed
Penalty
Summary
The facility failed to ensure necessary services were provided to prevent and treat pressure ulcers for two residents and failed to follow a physician order during a dressing change for a third resident. Facility policy stated that evidence-based interventions for prevention would be implemented for residents at risk for or with a pressure injury, including pressure redistribution such as repositioning and heel offloading, and that interventions would be documented in the care plan and communicated to staff. Another policy required verification of a physician order for dry, clean dressing procedures. Resident R3 had diagnoses including aphasia, hemiplegia, and diabetes, and had a physician order for heel protection boots at all times related to hemiplegia. The care plan did not include heel protection boots as an intervention. During observations, the resident’s heel protection boots were found sitting in a wheelchair while the resident rested in bed, the resident was later observed without the boots applied, and the resident was also transported in a wheelchair without the boots. A nurse confirmed the resident was ordered heel protection boots to prevent pressure ulcers and did not have them on as ordered, and the ADON confirmed the care plan failed to include the boots. Resident R11 had diagnoses including Alzheimer’s disease, schizoaffective disorder, and major depressive disorder, and was identified in the MDS as at risk for pressure ulcers. The care plan called for reminders to turn and reposition at least every 2 hours, but a wound consultant later recommended limiting out-of-bed time to no more than 4 hours at a time and using ongoing pressure reduction and turning/repositioning precautions, including heel and bony prominence pressure reduction. The record did not show these recommendations were implemented, toileting documentation was missing on multiple shifts, and the care plan was not updated. Staff observed the resident sitting in a wheelchair at the nurses’ station, and staff stated the resident spent much of the day in the wheelchair because staff wanted to keep an eye on her. The wound care nurse practitioner stated the resident was at high risk due to inability to reposition herself and bowel and bladder incontinence, and the DON confirmed the facility failed to provide appropriate care and treatment to prevent the pressure ulcer as recommended. Resident R56 had diagnoses including hypertension, diabetes, and peripheral vascular disease, and had a physician order for left plantar foot wound care with cleansing, Medi-honey, calcium alginate, an abdominal pad, and kerlix. During a wound care observation, the RN cleansed the wound and applied Medi-honey directly on the calcium alginate, but did not place the abdominal pad before wrapping the foot with kerlix. The RN confirmed the dressing was applied contrary to the physician order.
Failure to Supervise Residents During Meals for Dysphagia Monitoring
Penalty
Summary
The facility failed to provide supervision during meals for two residents who had care plans requiring monitoring for signs and symptoms of dysphagia. Resident R1 had diagnoses including intellectual disabilities, esophageal varices, and GERD, and a speech therapy discharge summary recommended swallow precautions such as small bites and sips, altered liquid/solid consistency, rate modification, upright posture during meals, and remaining upright for more than 30 minutes after meals. Despite these directions, R1’s meal was observed dropped off in the room and left unsupervised, and R1 was later observed eating at a fast pace without supervision on two separate occasions. Nurse aides confirmed R1 was not being supervised for pocketing or monitoring, and one aide stated she did not know the resident’s baseline to determine whether the resident was eating too fast. Resident R8 had diagnoses including heart failure, respiratory failure, and cardiac arrest, and the care plan also directed staff to monitor, document, and report signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, repeated swallowing attempts, refusing to eat, or appearing concerned during meals. R8 was observed eating unsupervised in the common lounge on two occasions. An LPN confirmed R8 was not being monitored during meals as the care plan indicated, and the RN supervisor later confirmed that both R1 and R8 were not supervised with meals and monitored for dysphagia signs. The DON, speech therapist, and NHA also confirmed the facility failed to ensure these two residents were supervised during meals.
Feeding Tube Care and Treatment Not Provided as Ordered
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with enteral feeding tubes. The facility policy stated feeding tubes were to be used in accordance with current clinical standards of practice and physician orders, with interventions to prevent complications to the extent possible. Resident R3, who had diagnoses including aphasia, hemiplegia, and diabetes and had a feeding tube, had physician orders for enteral tubing changes and for a water flush via the feeding tube. During observation, R3’s water flush bag had no label, initials, date, or time, and the enteral feeding pole was soiled with dried enteral formula covering the surface of the pole and the legs above the casters. RN E5 confirmed the bag was unlabeled, and the DON confirmed the pole appeared soiled with dried tube feeding formula. Resident R4, who had diagnoses including cognitive communication deficit, dysphagia, and depression and also had a feeding tube, had care plan directions for tube feeding formula, hydration, and flushes per order. Physician orders directed tube feeding at 95 ml/hour for 17 hours daily with water flushes, and orders also required enteral tubing, feed bottles, and syringes to be changed and dated. During observation, R4 was resting in bed with the tube feed disconnected, 600 ml of tube feed remained in the bag, and the enteral tubing, bag of tube feed, and syringes were undated. The LPN confirmed the items were undated and confirmed R4 did not receive the tube feeding as ordered, with 600 ml remaining. The DON and NHA confirmed the facility failed to ensure appropriate treatment and services for R4.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for one resident who had diagnoses of heart failure, respiratory failure, and cardiac arrest. The resident had a physician order to receive oxygen continuously at 5 to 7 liters to maintain oxygen saturation above 90% every shift related to acute and chronic respiratory failure with hypercapnia. The resident’s care plan identified that the resident received oxygen therapy due to respiratory failure, but it did not include oxygen settings. The resident’s MDS indicated continuous oxygen therapy while a resident. During observation on 5/17/26, the resident was sitting in a wheelchair in the common area and the oxygen tank was in the red zone and empty. An LPN confirmed the tank was empty and replaced it. During a later observation on 5/18/26, the resident was again observed in the common area with an empty oxygen tank on the wheelchair, a ripped sleeve holding the tank, and an oxygen concentrator nearby that was turned off. The resident was not receiving oxygen as ordered, and an LPN confirmed this and noted the resident’s oxygen saturation was 86% on room air. The Nursing Home Administrator later confirmed the facility failed to provide appropriate respiratory care for the resident.
Failure to Provide Trauma-Informed Care by Not Identifying PTSD Triggers
Penalty
Summary
The facility failed to provide trauma informed care for two residents with PTSD by not identifying and documenting specific triggers in their care plans. Facility policy stated that residents with a history of trauma should have triggers identified and care plan interventions developed to minimize or eliminate the effect of those triggers. Resident R1’s record showed diagnoses of PTSD, depression, and dysphagia, and the care plan noted PTSD due to sexual abuse, but it did not identify triggers. A psychiatry note stated to continue to offer support and care plan for triggers when identified, and listed a trigger as a resident who looks like the person who assaulted him, but no description of the assailant was provided. Staff interviews confirmed that the facility had not identified or care planned R1’s PTSD triggers. Resident R33’s record showed diagnoses including COPD, alcohol use, hypertension, and PTSD. His psychiatric note stated he had no recent PTSD symptoms, and his care plan identified PTSD related to past trauma and anxiety, but did not list specific PTSD triggers. During staff interviews, one LPN stated there was nothing about PTSD beyond psychotropic medications, and the RNAC stated that R33 gets anxious when needs are not met. The DON and NHA were informed that the PTSD care plan was not specific to R33’s behavioral triggers as required.
Missing Annual Performance Evaluations for Nursing Staff
Penalty
Summary
The facility failed to complete annual performance evaluations for two of three nursing staff personnel records, identified as Nurse Aide Employees E2 and E3. Facility policy for Evaluations Process, last reviewed 5/1/26, stated that employee work performance is to be reviewed in writing yearly. Review of E2's personnel record showed a hire date of 3/12/24, but the file did not contain an annual performance evaluation for the period 3/12/25 through 3/12/26. Review of E3's personnel record showed a hire date of 4/5/24, but the file did not contain an annual performance evaluation for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 stated they had recently started in February 2026 and were beginning to use a new process, and confirmed that the facility failed to complete annual performance evaluations for E2 and E3.
Failure to Individualize Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans to address dementia for one resident, R42. Clinical record review showed that R42 was admitted to the facility and had an MDS dated 2/19/26 listing diagnoses of high blood pressure, chronic pain, and dementia, described as a group of symptoms that affects memory, thinking, and interferes with daily life. Review of the care plan showed no individualized person-centered care plan addressing R42’s dementia and cognitive loss. During interview, the DON confirmed that the facility failed to develop and implement individualized person-centered care plans to address dementia for one of three residents reviewed.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to Resident R29. The resident was admitted with diagnoses including adult failure to thrive, muscle wasting, and glaucoma, and the MDS indicated severe vision impairment. A social service progress note documented that the resident wanted to pursue assisted living and that social services would continue to follow, but the clinical record did not include a discharge care plan. During interview, the resident stated he felt uncomfortable at the facility, said it was not equipped for a blind person, reported he had only four lessons from the blind school, and expressed that he felt stuck and wanted his own place. The Nursing Home Administrator confirmed the facility failed to provide medically related social services to this resident.
Delayed Medication Delivery for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure that pharmacy services provided medications timely for Resident R46. Resident R46 was admitted with diagnoses including high blood pressure, chronic pain, and muscle weakness, and had a physician order for MS Contin 15 mg by mouth three times daily for chronic pain. During an interview, the resident stated she had not received morphine in the past week. The clinical record and MAR showed multiple missed doses of MS Contin on several dates and times, with documentation that the medication was not available on 5/3/26, 5/4/26, 5/5/26, 5/6/26, 5/15/26, 5/16/26, and 5/17/26. A nurse's progress note stated pharmacy had been contacted and said the medication would be sent, but it had not arrived. The DON confirmed the facility failed to ensure the pharmacy provided the medication on the listed dates and stated that when the facility was informed on 5/8/26 that a new pharmacy would begin services the next day, new prescriptions had to be filled out for Resident R46, which caused further delays in providing the medication.
Missing MRR Documentation and AIMS Testing
Penalty
Summary
The facility failed to provide documentation that medication regimen reviews (MRR) were completed and reviewed by the resident's attending physician for one resident. Resident R11 was admitted with diagnoses of Alzheimer's disease with late onset, schizoaffective disorder, and major depressive disorder. The resident's care plan directed staff to consult with pharmacy, the medical doctor, and psychiatry to consider dosage reduction when clinically appropriate. A physician order dated 2/17/25 directed Seroquel 100 mg by mouth three times daily. The consultant pharmacist's MRR dated 5/10/25 and 6/4/25 both recommended a movement test, such as AIMS, at least every six months while the resident continued on antipsychotic therapy, and the resident remained on Seroquel. The clinical record from 5/10/26 to 4/30/26 failed to include evidence that an AIMS test was performed as recommended. During interview, the Nursing Home Administrator confirmed the facility failed to provide documentation that MRRs were completed and reviewed by the resident's attending physician and failed to timely conduct an AIMS test for the resident.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Ensure that residents are free from significant medication errors was not met when an LPN failed to prime an insulin pen before administering Lantus to one resident. Facility policy required insulin pens to be primed prior to each use by dialing up 2 units and confirming that at least one drop of insulin appears on the needle tip. Resident R55 had diagnoses of hypertension, diabetes, and hyperlipidemia, and had a physician order for Lantus 38 units subcutaneously once daily for diabetes. During a medication pass observation, the LPN was preparing R55's Lantus insulin pen and did not prime the needle as required. In interview shortly afterward, the LPN confirmed that the insulin pen needle had not been primed.
Unsecured treatment carts and improperly stored medications
Penalty
Summary
The facility failed to properly secure two treatment carts while they were not in use. During observation, the First Floor Treatment Cart was parked next to the elevator, unlocked, and unattended, and RN E4 confirmed the cart had been left in that condition. Later the Second Floor Treatment Cart was also observed parked next to the elevator, unlocked, and unattended, and the Infection Preventionist RN E8 confirmed that it was left unsecured while not in use. The facility also failed to properly store medications in the First Floor Medication Room, the First Floor East Hall Medication Cart, and the Second Floor [NAME] Hall Medication Cart. In the First Floor East Hall Medication Cart, opened liquid amantadine, a fluticasone inhaler, Robitussin, a stioloto inhaler, and inhaler spacers were found without required dates or identification. In the First Floor Medication Room, a bag of medications brought in with a resident, a can of lite beer without a name, and two opened tubersol vials without dates were observed. In the Second Floor [NAME] Hall Medication Cart, rectal suppositories were co-mingled with oral medications, opened oxcarbazepine and Haldol bottles lacked dates, opened ipratropium bromide/albuterol silver packs lacked dates, and Voltaren gel was sitting on top of the cart without a name or open date. Staff members confirmed these observations during interview.
Failure to Follow Posted Menus for Lunch Meals
Penalty
Summary
The facility failed to follow the displayed menu for two observed lunch meals. On 5/17/26, the posted lunch menu listed an egg salad sandwich on a croissant, but during an observation in the First Floor Lounge at 12:50 p.m., Resident R21 was served lunch and identified the bread as a plain hamburger bun instead of a croissant. During an interview at 12:57 p.m., the Dietary Manager, Employee E14, stated the facility did not have croissants and confirmed the planned menu was not served. On 5/18/26, the lunch menu for the Mechanical Soft diet listed green beans, but during an observation at 12:25 p.m., Resident R1 was served a Mechanical Soft meal that included a chopped salad instead of green beans. During an interview at 1:00 p.m., Employee E14 confirmed that green beans were not served according to the planned menu for the Mechanical Soft diet.
Failure to Provide Ordered Double Portions
Penalty
Summary
The facility failed to provide food products based on resident preferences for one of five residents, Resident R1. During an observation on 5/18/26 at 12:25 p.m., Resident R1's lunch ticket indicated that he was to receive double portions, but only a single portion of food was served. During an interview on 5/18/26 at 12:29 p.m., Nurse Aide Employee E23 confirmed that the facility failed to provide double portions per resident preference.
Failure to Coordinate Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the needs of one resident receiving hospice care. Resident R25 was admitted to the facility and had diagnoses including high blood pressure, COPD, and muscle spasm. The resident’s MDS dated 2/3/26 indicated these conditions, and a physician order dated 10/29/25 showed the resident was admitted under hospice services. Review of the resident’s current comprehensive care plan showed it did not include a plan of care documenting coordination of hospice services, including the hospice agency’s contact information or how to access the hospice’s 24-hour on-call system. During interview, the DON confirmed the care plan did not include this information and that the facility failed to ensure coordination of hospice services with facility services for Resident R25.
Failure to Hold Required QAA Meetings
Penalty
Summary
The facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to include all required committee members. Review of QAA Committee meeting sign-in sheets showed only one meeting in August 2025 and one meeting in April 2026. During an interview on 5/21/26 at 1:09 p.m., the Nursing Home Administrator confirmed that the facility did not conduct QAA meetings at least quarterly with all required committee members as required.
Infection Control Failures During PPE Use, Wound Care, and Medication Administration
Penalty
Summary
The facility failed to utilize appropriate PPE for a resident on reverse isolation precautions. Resident R57 had diagnoses including anemia, anxiety, and [NAME] syndrome, and physician orders included reverse isolation precautions every shift related to [NAME] syndrome. The care plan stated that staff and family were to wear a mask while in close proximity to the resident. During observation, a sign on the resident’s door indicated reverse isolation precautions and instructed staff to wear a mask when in close proximity and to use meticulous cleaning and disinfecting. During a medication pass, an RN entered the room to administer medications without wearing a mask, and later confirmed she did not wear one and did not see the sign. The facility also failed to prevent cross contamination during a dressing change for Resident R56. Resident R56 had diagnoses including hypertension, diabetes, and peripheral vascular disease. Physician orders directed wound care to the left plantar foot with cleansing, application of Medi-honey and calcium alginate, and coverage with an abdominal pad and kerlix. During the wound care observation, the RN completed the dressing change, removed items and the barrier from the bedside stand, and exited the room without cleansing the over-the-bed table. The RN confirmed she did not cleanse the table after completing the dressing change. The facility further failed to prevent cross contamination during medication administration for Resident R18. Resident R18 had diagnoses including anemia, diabetes, and hypertension. During a medication administration observation, an RN applied gloves and prepared all of the resident’s oral medications by removing them from the blister pack or bottle and placing them into her gloved hands before placing them into the medication cup. The RN confirmed she touched all of the resident’s oral medications using the same gloved hand. In addition, surveyors observed the first-floor personal laundry room with a full sharps container unattached to the wall and a centrifuge sitting on top of the dryer, and the RN supervisor confirmed those observations.
Failed to Maintain Functioning Call Bell System on Second Floor
Penalty
Summary
The facility failed to maintain a fully functioning resident call bell system on the second floor nursing unit, including the resident bathroom and bathing area call system. During observations on 5/17/26, 5/18/26, and 5/19/26, the second floor call bell was heard ringing, but the resident room call bell lights were not lit. Nurse aides on the unit stated that the call bell system had been sounding for a while, that there was no light for any room, and that staff had to keep checking the call light board or looking down the hallways. The Maintenance Director stated that the system was ringing consistently and that all call bells worked for light and sound, but the cause of the repeated sounding had not been identified. The Nursing Home Administrator later confirmed that the second floor nursing unit call bell system did not function correctly and that the facility failed to maintain a fully functioning resident call system for that unit.
Loose Handrail in First Floor Corridor
Penalty
Summary
The facility failed to ensure that its corridors were equipped with firmly secured handrails on one of two nursing floors, specifically the 1st floor. During an observation of the first floor nursing unit, the handrail affixed to the front side of the nursing station was found to be loose to touch. The housekeeper confirmed that the handrail was not secured properly and stated he had been aware of the issue since Thursday but was unsure whether maintenance had been notified. The Registered Nurse Supervisor also confirmed that handrails should be securely affixed to the walls.
Missing Annual Effective Communication Training for Nurse Aides
Penalty
Summary
The facility failed to provide annual training on Effective Communication for two of three nurse aide staff members, Employees E2 and E3. Facility policy stated that compliance with the facility’s standards, policies, procedures, and training program was a condition of employment, and the Training Requirements- Communication Training policy identified effective communication as mandatory training for direct care staff. Review of Employee E2’s personnel record showed a hire date of 3/12/24, but the file did not contain annual in-service training on Effective Communication for the period 3/12/25 through 3/12/26. Review of Employee E3’s personnel record showed a hire date of 4/15/24, but the file did not contain annual in-service training on Effective Communication for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide annual training on Effective Communication for these two staff members.
Failure to Provide Required Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide annual in-service training on Abuse, Neglect, and Exploitation for one of three staff members, Nurse Aid (NA) Employee E3. Review of the facility's policy on Continuing Education showed that compliance with facility standards, policies, procedures, and the training program is a condition of employment. Review of the Training Requirements- Abuse, Neglect and Exploitation Training policy showed the facility will include activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, along with procedures for reporting incidents of abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention. Review of NA Employee E3's personnel record showed a hire date of 4/5/24, and the file did not contain annual in-service training on Abuse, Neglect, and Exploitation for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed the facility failed to provide this training for NA Employee E3.
Failure to Provide Required QAPI Training
Penalty
Summary
Conduct mandatory training for all staff on the facility’s Quality Assurance and Performance Improvement (QAPI) Program. Review of facility policy showed that compliance with the facility’s standards, policies, procedures, and training program is a condition of employment, and that the facility will include mandatory training as part of its QAPI program to outline and inform staff of the elements and goals of the QAPI program. Review of the personnel record for Nurse Aide Employee E3 showed a hire date of 4/5/24, and the current file did not contain annual in-service training on QAPI for the period 4/5/25 through 4/5/26. During an interview, Human Resource Employee E9 confirmed that the facility failed to provide QAPI training for one of three staff members, Nurse Aide Employee E3.
Failure to Provide Required Infection Control Training
Penalty
Summary
The facility failed to provide mandatory Infection Control training for one of three staff members, Nurse Aide (NA) Employee E3. Facility policy for Continuing Education stated that compliance with the facility’s standards, policies, and procedures is a condition of employment, and the Training Requirements-Infection Control Training policy stated that the facility will include mandatory in-service training as part of its infection control program. Review of NA Employee E3’s personnel record showed a hire date of 4/5/24, and the current file did not contain annual Infection Control in-service training for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide Infection Control training for NA Employee E3.
Failure to Provide Required Compliance and Ethics Training
Penalty
Summary
The facility failed to provide annual Compliance and Ethics training for one of three staff members, a Nurse Aide (NA) identified as Employee E3. Facility policy on Continuing Education stated that compliance with the facility’s standards, policies, and procedures is a condition of employment, including compliance with the training program, and the policy on Training Requirements-Compliance and Ethics Committee Training stated that the facility must include annual training of the compliance and ethics program. Review of Employee E3’s personnel record showed a hire date of 4/5/24, and the current personnel file did not contain annual in-service training on Compliance and Ethics for the period from 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide Compliance and Ethics training for Employee E3.
Failure to Provide Required Annual Nurse Aide In-Service Training
Penalty
Summary
The facility failed to ensure that two of three sampled Nurse Aides received a minimum of 12 hours of yearly in-service education. Review of the facility's Continuing Education policy and Training Requirements-Required In-service Training for Nurse Aides policy showed that compliance with training requirements was a condition of employment and that nurse aide in-service training was to be sufficient to ensure continuing competence and no less than 12 hours per year. Review of the personnel records for NA Employee E2 and NA Employee E3 showed hire dates of 3/12/24 and 4/5/24, respectively, and their files did not contain documentation showing they had received the required minimum 12 hours of in-service training during their respective yearly periods. During an interview, Human Resource Employee E9 confirmed that the facility failed to ensure these two nurse aides received the required yearly in-service education.
Failure to Provide Behavioral Health Training
Penalty
Summary
Behavioral Health training was not provided for two of three staff members, Nurse Aide Employee E2 and Nurse Aide Employee E3, as required by facility policy and the facility assessment. Review of the facility's Continuing Education policy indicated that compliance with the facility's standards, policies, and procedures is a condition of employment, including compliance with the training program. Review of the Training Requirements-Behavioral Health Training policy indicated that the facility will provide Behavioral Health training. Employee E2's personnel record showed a hire date of 3/12/24, but the current file did not show Behavioral Health training for the period 3/12/25 through 3/12/26. Employee E3's personnel record showed a hire date of 4/5/24, but the current file did not show Behavioral Health training for the period 4/5/25 through 4/5/26. During an interview, Human Resource Employee E9 confirmed that the facility failed to provide Behavioral Health training for these two staff members.
Failure to Communicate Transfer Information and Provide Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to a receiving health care provider during a facility-initiated transfer and failed to provide required written bed-hold policy notices during hospital transfers. Facility policy on transfers required that contact information for the responsible practitioner, resident representative information, advance directives, resident status (including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs), diagnoses, allergies, medications with last administration times, recent labs and diagnostics, immunizations, and special instructions or precautions be provided to the receiving provider. For one resident with diabetes, hyperlipidemia, and aphasia whose G-tube became dislodged and who was transferred to a local hospital ED for G-tube replacement, the clinical record did not contain documented evidence that this specific information, including care plan goals and all information necessary to meet the resident’s specific needs, was communicated to the receiving provider. The facility’s bed-hold policy required that written information regarding bed-hold practices be provided to the resident and/or representative both in advance and at the time of transfer for hospitalization or therapeutic leave, or within 24 hours in the event of an emergency transfer, with documentation of multiple attempts if the representative could not be reached. For the resident transferred for G-tube replacement and another resident with high blood pressure, hyperlipidemia, and diabetes who was transferred to the hospital via EMS for low sodium level, the clinical records contained no documented evidence that the residents or their representatives were provided written information about the facility’s bed-hold policy at the time of transfer. During interview, the Assistant DON confirmed that the facility failed to ensure necessary information was communicated to the receiving provider for one resident and failed to notify two residents or their representatives of the facility bed-hold policy during hospital transfers.
Improper Storage and Labeling of Insulin Pens and Inhaler on Multiple Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices, specifically related to labeling and storage of insulin pens and an inhaler on three of four medication carts. Review of the facility’s “Medication Storage” policy, last reviewed on 3/26/26, showed that all medications were to be stored according to manufacturer recommendations with appropriate sanitation, temperature, light, ventilation, moisture control, segregation, and security. However, during an observation of the first-floor [NAME] medication cart on 4/1/26 at 11:30 a.m., two Lispro insulin pens were found not stored in a bag as required. An LPN (Employee E7) confirmed at 11:35 a.m. that these two Lispro insulin pens were not stored in a bag as required. Further observations on 4/1/26 revealed additional issues on other carts. At 11:42 a.m., the first-floor East medication cart contained two Basaglar insulin pens that were not stored in a bag as required, and a Stioloto Respimat inhaler that was not labeled with a date opened as required; an LPN (Employee E8) confirmed these findings. At 12:08 p.m., the second-floor [NAME] medication cart contained one Novolog insulin pen that was not stored in a bag, was labeled as “house stock,” and did not have a resident name as required; an LPN (Employee E4) confirmed at 12:11 p.m. that the Novolog pen was not bagged and lacked a name, stating it must have been pulled prior to receiving the one sent by the pharmacy. At 3:05 p.m., the Director of Nursing confirmed that the facility failed to properly store medications on three of the four medication carts reviewed, in violation of state code requirements for pharmacy and nursing services.
Failure to Administer PRN Oxycodone and Maintain Controlled Substance Records
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain, resulting in excessive pain, poor sleep, and decreased ability to perform activities of daily living. The resident had diagnoses including diabetes, heart failure, and depression, and was care planned for chronic pain with an intervention to administer medications per physician orders. A physician order dated 12/23/25 directed staff to administer Oxycodone 5 mg by mouth every eight hours as needed. The resident reported requesting Oxycodone for breakthrough pain and not receiving it on three consecutive days, stating that this caused significantly increased pain, poor sleep, reduced time out of bed, and inability to complete usual activities such as doing laundry. Review of the resident’s Medication Administration Record for the relevant days showed blank entries for the as-needed Oxycodone, indicating it was not administered. Additionally, when the resident’s chart was reviewed, the controlled substance record for Oxycodone was missing, preventing verification of whether any doses had been given. A registered nurse confirmed that the controlled substance record could not be located and that they were unable to identify if the resident had received Oxycodone as requested. The clinical consultant later confirmed that the MAR entries for the three days in question were blank and acknowledged that the facility failed to provide effective pain management, causing harm to the resident, in violation of 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Misappropriation and Poor Control of Residents’ Narcotic Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of property by not ensuring accurate control, documentation, and safeguarding of multiple residents' controlled medications. Facility policies on Abuse, Neglect & Exploitation and on Medication Ordering and Receiving from Pharmacy required protection of resident property and special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, controlled substance records for several residents showed discrepancies between documented administration and remaining pill counts, and in one case, the absence of any controlled substance record for a prescribed PRN narcotic. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed for pain. Review of the controlled substance record for MS Contin 15 mg showed that on a specific date the resident was documented as receiving two tablets, with a starting count of 25 and an ending count of 21, which did not reconcile. For MS Contin 30 mg twice daily, the record showed that on two dates the resident was documented as receiving three tablets, with a starting count of 18 and an ending count of 11, again not reconciling. Additionally, there was no controlled substance record for the resident’s Oxycodone 5 mg PRN from the date of order initiation through the date of review, even though the pharmacy confirmed dispensing 18 tablets. Another resident with coronary artery disease, COPD, and osteoarthritis had an order for Oxycodone 7.5 mg every eight hours as needed; the controlled substance record showed that on two dates the resident was documented as receiving one tablet, with a starting count of 40 and an ending count of 36, which did not match the documented usage. A third resident with high blood pressure, depression, and spina bifida had an order for MS Contin 15 mg three times daily. The controlled substance record indicated that on two dates the resident was documented as receiving two tablets, with a starting count of 38 and an ending count of 32, reflecting a discrepancy. A fourth resident with high blood pressure, depression, and neuropathy had an order for Oxycodone 5 mg every 12 hours as needed; the record showed that on one date the resident was documented as receiving one tablet, with a starting count of 12 and an ending count of 9, which did not reconcile. A fifth resident with heart failure, COPD, and muscle spasms had an order for Oxycodone 10 mg three times daily; the controlled substance record showed that on two dates the resident was documented as receiving four tablets, with a starting count of six and an ending count of two, while the resident was reported to have slept all night. Staff interviews further described events surrounding these discrepancies. A RN supervisor reported working a double shift while an agency RN worked the overnight shift; the oncoming RN identified that one resident’s Oxycodone count was four tablets short. The agency RN stated she might have given a double dose and could not account for the remaining tablets. The RN supervisor notified the DON and adjusted the narcotic count so the oncoming nurse could begin medication administration. Another RN later noted that while her narcotic counts were correct at shift change, the controlled substance records contained documentation discrepancies, including inconsistent count changes for one resident’s MS Contin and documentation of Oxycodone administration to another resident who had reportedly slept all night. The Nursing Home Administrator and DON acknowledged that an agency RN allegedly took multiple residents’ narcotics and confirmed that the facility failed to ensure residents were free from misappropriation of property. The facility did not provide documentation showing that the missing narcotics were reported to the Department of Health.
Failure to Report and Investigate Alleged Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures prohibiting misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, review of clinical records and controlled substance records on multiple residents revealed discrepancies in narcotic counts and missing documentation, and the facility did not report these issues to the Department of Health as required. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed. Review of the controlled substance records showed that on specific dates, the documented doses and the beginning and ending counts for MS Contin 15 mg and 30 mg did not reconcile. Additionally, there was no controlled substance record for the ordered Oxycodone 5 mg as needed over more than a month, even though the pharmacy confirmed dispensing 18 tablets. Similar discrepancies were identified for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg as needed count decreased from 40 to 36 tablets over two days while documentation indicated only two tablets were administered. Further review showed that a resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily with count discrepancies over two days, and another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg as needed with a count that dropped from 12 to 9 tablets while only one tablet was documented as given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily, with records indicating four tablets given over two days while the count decreased from six to two tablets, and this resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and could not adequately account for missing tablets. The RN supervisor and oncoming RN identified incorrect counts and documentation, notified the DON, and obtained a statement from the agency RN. However, the DON later acknowledged that no investigation of the alleged narcotic diversion was completed and that the incident was not reported to the Department of Health, confirming the facility’s failure to report allegations of misappropriation of resident belongings for the five affected residents.
Failure to Investigate Alleged Misappropriation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into allegations of misappropriation of resident property, specifically missing controlled substances, for five residents. Facility policy on Abuse, Neglect, & Exploitation required written procedures to prohibit misappropriation of resident property, and the Medication Ordering and Receiving from Pharmacy policy required special ordering, receipt, and recordkeeping for controlled substances. Despite these policies, multiple discrepancies were identified in narcotic counts and documentation for several residents’ controlled medications, and the facility did not complete an investigation into these discrepancies or the alleged diversion by an agency RN. For one resident with heart failure, diabetes, and depression, physician orders included MS Contin 15 mg at bedtime, MS Contin 30 mg twice daily, and Oxycodone 5 mg every eight hours as needed. Review of the controlled substance records showed that for MS Contin 15 mg, the record documented two tablets given with a starting count of 25 and an ending count of 21, and for MS Contin 30 mg, three tablets were documented as given over two days with a starting count of 18 and an ending count of 11. No controlled substance record was found for the resident’s Oxycodone 5 mg PRN from 1/18/26 through 2/25/26, although the pharmacy confirmed that 18 tablets had been dispensed. Similar discrepancies were found for another resident with coronary artery disease, COPD, and osteoarthritis, whose Oxycodone 7.5 mg PRN count decreased from 40 to 36 while documentation indicated only two tablets were given. Additional residents were affected. One resident with high blood pressure, depression, and spina bifida had MS Contin 15 mg three times daily ordered; the controlled substance record showed the count going from 38 to 32 while documentation indicated only two tablets were given over two days. Another resident with high blood pressure, depression, and neuropathy had Oxycodone 5 mg every 12 hours PRN ordered; the count went from 12 to 9 while documentation indicated one tablet given. A fifth resident with heart failure, COPD, and muscle spasms had Oxycodone 10 mg three times daily ordered; the record showed four tablets documented as given over two days, with the count going from six to two, while the resident was reported to have slept all night. Staff interviews described that an agency RN worked the overnight shift when the discrepancies occurred, appeared shaky and emotional, and gave inconsistent explanations for missing tablets. The DON and NHA acknowledged that missing narcotics from those dates were known, that police were present, and that the DON had not conducted or produced an investigation into the alleged narcotic diversion or misappropriation, and the missing narcotics were not reported to the Department of Health.
Failure of DON to Investigate Multiple Allegations of Misappropriation and Narcotic Diversion
Penalty
Summary
The deficiency involves the DON’s failure to timely and effectively manage and investigate five allegations of misappropriation of resident belongings, including narcotic diversion, involving five residents (R1, R2, R3, R4, and R5). The DON’s job description dated 12/9/24 required him to plan, organize, develop, and direct the overall operations of the nursing services department, establish facility policies and procedures, ensure appropriate care and services, perform rounds to observe residents, and monitor for allegations of potential abuse or neglect while participating in the investigative process. Despite these defined responsibilities, the facility did not have investigations completed for the reported misappropriation incidents that included diversion of narcotic medications. During an interview on 2/25/26 at 3:15 p.m., the DON initially stated that he had the investigation of the incident in his office and would provide a copy to the state agency. Later that same day at 4:45 p.m., when asked directly if he had an investigation concerning the narcotic diversion, the DON replied that he did not and confirmed he had failed to have an investigation for the misappropriation of resident belongings that included narcotic diversion for all five residents. On 2/26/26 at 3:00 p.m., the NHA confirmed that the DON failed to timely and effectively manage these five allegations of misappropriation of resident belongings, which included narcotic diversion. These failures were cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).
Failure to Maintain Resident Bed in Safe Working Condition
Penalty
Summary
The facility failed to maintain a resident’s right to a safe, comfortable, and homelike environment by not ensuring that a bed was in proper working order. The facility’s Resident Rights policy dated 9/22/25 stated that residents have the right to a safe, clean, comfortable environment and to receive treatment and support for daily living safely. One resident, admitted on the documented admission date, had an MDS dated 1/10/26 reflecting diagnoses of diabetes, heart failure, and depression, and a physician order dated 9/29/25 for a low air loss mattress with instructions to check placement and functioning every shift. During an interview on 2/25/26 at 1:50 p.m., the resident reported that on 2/22/26 the motor for the foot portion of the bed broke, and since then they had been unable to raise or lower their legs while in bed. An observation on 2/25/26 at 1:55 p.m. showed that when the resident used the bed control to move the leg area, the bed made a loud noise and the bottom portion did not move. In a 2/25/26 interview at 2:07 p.m., the Maintenance Director stated that his department had been notified that the bed was broken and needed a new motor, that he had taken the specifications from the bed to place an order, but he did not know if the motor had actually been ordered. At 3:15 p.m. on the same day, the DON confirmed that the facility failed to maintain resident rights by not having the bed in working condition for this resident.
Failure to Verify RN License Prior to First Shift
Penalty
Summary
The facility failed to follow its own policies for preventing abuse, neglect, exploitation, and misappropriation of resident property by not completing required pre-employment screening and license verification for a registered nurse before the nurse began working. The facility’s Abuse, Neglect, and Exploitation policy required that potential employees be screened for a history of abuse, neglect, exploitation, and misappropriation of resident property, with documentation maintained as proof of screening. The Licensed Nurse Credentialing and License Verification policy required that all licensed nurses have their credentials and license verified upon employment. An agency RN (Employee E1) worked in the facility on two consecutive days, but review of the personnel file showed that the nurse’s license verification was not conducted until three days after those shifts. In interviews, the DON confirmed the RN’s work dates, and the HR staff member confirmed there was no documented evidence of license verification prior to the RN’s first working shift.
Failure to Ensure Pharmacy Supplied Correct Singulair Dose per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its contracted pharmacy provided medications in accordance with the physician’s order for one resident. Facility policy on “Medication Ordering and Receiving from Pharmacy” dated 9/22/25 states that medications are to be administered in an organized and safe manner, including pouring the correct number of tablets or capsules into the medication cup and administering them to the resident. Resident R1’s admission record showed admission on an unspecified date, and the MDS dated 1/10/26 documented diagnoses including diabetes, heart failure, and depression. A physician’s order dated 1/25/26 directed that Singulair 10 mg be given as two tablets every day. During an interview on 2/25/26 at 11:45 a.m., the resident reported that he should be receiving two Singulair 10 mg tablets daily but had only been receiving one tablet. On 2/26/26 at 11:20 a.m., observation of the resident’s medication with Clinical Consultant Employee E9 showed that the pharmacy was supplying Singulair 10 mg in a quantity of one tablet to be administered. In a phone interview at 11:41 a.m. the same day, Pharmacist Employee E10 confirmed that the resident had been receiving only one 10 mg tablet and acknowledged that the pharmacy cycle order was incorrect. Later that day at 3:00 p.m., Clinical Consultant Employee E9 confirmed that the facility failed to ensure the pharmacy provided medications timely and correctly for this resident, resulting in noncompliance with 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.
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What surveyors actually found near you
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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 Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Reformed Presbyterian Home | 0.8 mi | ★★★★★ | 7 | 0 |
| Canterbury Place | 1.9 mi | ★★★★★ | 19 | 1 |
| Little Sisters Of The Poor | 2.6 mi | ★★★★★ | 15 | 0 |
| Upmc Magee-womens Hospital Tcu | 2.7 mi | ★★★★★ | 5 | 0 |
| Ivy Park Post Acute | 3.5 mi | ★★★★★ | 10 | 1 |
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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.