Terrace Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Uniontown, Pennsylvania.
- Location
- 410 Terrace Drive, Uniontown, Pennsylvania 15401
- CMS Provider Number
- 395977
- Inspections on file
- 33
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Terrace Health & Rehab Center during CMS and state inspections, most recent first.
The facility did not provide food that was palatable or attractive, as evidenced by resident complaints of tasteless meals, food trays containing hair, and frequent discrepancies between menu items and what was served. Observations showed pureed foods were plated in an unappetizing manner and many residents did not receive the correct dessert as indicated on their tray slips. These issues were confirmed by facility leadership.
Surveyors observed multiple instances of unsanitary practices in the kitchen, including staff not fully covering hair, handling food with contaminated gloves, and failing to wash hands between tasks. Food items were handled after contact with potentially contaminated surfaces, and meal deliveries were delayed beyond scheduled times. These actions resulted in a failure to maintain sanitary conditions and prevent cross-contamination or foodborne illness.
The facility did not consistently accommodate the needs and preferences of a resident, as required, based on observations and review of facility practices.
A resident with a history of stroke and heart failure reported ongoing hearing difficulties and requested hearing aids, but the facility did not arrange follow-up audiology services or provide assistive devices as previously recommended. Staff and record reviews confirmed the lack of action to address the resident's hearing needs.
The facility did not ensure consistent and complete communication with the dialysis center for two residents with end stage renal disease, as required by policy. Multiple dialysis communication forms were found to be incomplete, and this deficiency was confirmed by the DON.
The facility did not employ a qualified Food Service Director for most of the year, with the individual in the role lacking Certified Dietary Manager credentials and only holding Serv Safe certification. The RD was not full-time and visited three times weekly, and there was no documentation to show the FSD met required qualifications.
A resident with severe cognitive impairment and multiple medical conditions was left without a meal for about 35 minutes while others at the same table were served and began eating. An LPN confirmed that this delay failed to provide a dignified dining experience for the resident.
A resident with multiple health conditions and a care plan requiring supervision and cueing during meals was left without assistance while eating. The resident experienced difficulty and distress, and staff did not provide the necessary support as outlined in the care plan, resulting in a deficiency.
A resident with multiple health conditions, including dementia and muscle weakness, did not receive the necessary supervision or assistance with eating as required by her care plan. Staff failed to provide help during mealtime, resulting in the resident struggling to eat independently and experiencing significant weight loss.
A resident with limited arm mobility and a care plan specifying the use of a Kennedy cup for hot liquids was observed struggling to eat without the necessary adaptive equipment or staff assistance. The resident's food was not cut up, and she experienced visible difficulty and distress during the meal. The lack of required adaptive utensils and absence of assistance was confirmed by facility leadership.
The facility failed to properly store food in the Main Kitchen, risking foodborne illness. Staff lunch bags were in the cooler with resident food, ice buildup in the freezer dripped onto food boxes, and bread was stored on the refrigerator floor. These issues were confirmed by the Dietary Manager, violating FDA Food Code guidelines.
A resident with multiple health issues alleged verbal abuse by an RN, which was confirmed by a family member. Despite previous abuse prevention training, the RN's behavior caused emotional distress and left the resident in a precarious situation during a transfer. The facility failed to ensure the resident was free from abuse, as confirmed by the DON.
The facility did not meet the required in-service education hours for two nurse aides. One aide, hired in April 2024, completed only 4.25 hours, while another, hired in August 2021, completed 7.50 hours within their respective 12-month periods. This was confirmed by the Nursing Home Administrator.
The facility failed to provide mandatory QAPI training for two staff members, a Nurse Aide and a Therapy Employee, as required by Pennsylvania Code. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of training for these employees.
The facility failed to provide behavioral health training for three Nurse Aides, despite it being a required educational topic in the facility's assessment. Employees E1, E2, and E3 did not receive the necessary training within their specified timeframes, as confirmed by the Nursing Home Administrator.
Failure to Provide Palatable and Attractive Food Service
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and at a safe and appetizing temperature. Over a three-month period, food council meeting minutes and resident group meeting information documented multiple complaints from residents, including reports that the food was tasteless, food trays sometimes contained hair, and concerns about whether kitchen staff used hair nets. Residents also reported that kitchen staff were rude to both residents and floor staff, and that meal orders frequently did not match the posted menu or tray slips, with items such as cereal being served without milk or vice versa. During an observation of tray line service, pureed foods were plated in an unappetizing manner, with items mixed together, and 18 residents did not receive the cherry cheesecake dessert listed on the menu, instead receiving plain pudding or an alternate dessert despite tray slips indicating the cherry dessert. These findings were confirmed in an interview with the Nursing Home Administrator and Corporate Dietary Manager.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed during a survey. A foam glass with liquid, belonging to a dietary aide, was found on a food preparation table near the cooler. Multiple dietary staff members were observed with their hair not fully covered by hairnets. One dietary aide was seen wiping down prep areas, taking a rag with gloves into the hall, returning, donning gloves, and handling bread and cheese without washing hands between tasks. The dietary manager dropped a scoop on the floor, took it to the sink, then returned to the tray line, donned gloves, and began serving meals without washing hands. Staff were also observed removing buns and bread from packaging and handling food with contaminated gloves, without appropriate handwashing or glove changes between tasks. Additionally, the timing of meal deliveries to various dining rooms did not adhere to the posted schedule, with several deliveries leaving the kitchen later than scheduled. These observations were confirmed by the corporate dietary manager and the nursing home administrator, who acknowledged the failure to maintain sanitary conditions necessary to prevent cross-contamination or foodborne illness in the main kitchen.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of each resident. This deficiency was identified based on observations and review of facility practices, which did not ensure that residents' individual needs and preferences were consistently met as required.
Failure to Provide Follow-Up Hearing Services and Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain hearing abilities. The resident, who had a history of stroke, heart failure, and fibrillation, expressed difficulty hearing and requested hearing aids during an interaction with therapy staff. The clinical record showed that the resident had previously been evaluated by audiology, which identified impacted cerumen in both ears and recommended follow-up in 6-9 months. Physician orders included an otic solution for ear wax and an as-needed audiology consult. However, there was no documentation of any follow-up audiology appointments or further interventions to address the resident's hearing needs after the initial consult. The resident continued to report hearing difficulties, and staff interviews confirmed that the facility did not arrange for the necessary follow-up or assistive devices. The Nursing Home Administrator acknowledged the failure to provide proper treatment and assistive devices to maintain the resident's hearing abilities.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents diagnosed with end stage renal disease and other comorbidities. According to the facility's policy, ongoing communication, coordination, and collaboration between the dialysis center and the facility are required, including telephonic communication, pre- and post-dialysis assessments, care plan updates, and sharing of medication administration records. However, review of the clinical records and dialysis communication forms for both residents revealed multiple instances where these forms were incomplete on several dialysis dates. Both residents had physician orders and care plans specifying their dialysis schedules, including chair times, pickup, and return times. Despite these documented requirements, the facility did not ensure that the necessary dialysis communication forms were fully completed for each session. This deficiency was confirmed by the Director of Nursing, who acknowledged the lack of consistent communication documentation for both residents.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) to manage the daily operations of the Dietary Department for 11 out of 12 months. Staff interviews revealed that the individual serving as FSD was not a Certified Dietary Manager, although they were Serv Safe certified. Additionally, the Registered Dietitian was not employed full-time and only came in three times a week. The Nursing Home Administrator confirmed that there was no documented evidence that the FSD met the required qualifications for the position, as required by state regulations.
Resident Served Meal Late, Dignity Not Maintained During Dining
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident who had severe cognitive impairment and required supervision and assistance with eating. During a lunch meal observation, four residents at a dining table were served their meals and began eating, while the resident in question was left without a meal for approximately 35 minutes, only receiving their tray after the others had already started eating. This delay was confirmed by an LPN, who acknowledged that the resident's right to a dignified dining experience was not upheld. The resident's medical history included epilepsy, intellectual disability, diabetes, and a need for assistance with personal care, as documented in the clinical record and Minimum Data Set assessment.
Failure to Implement Care Plan for Meal Assistance
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who required supervision and cueing during meals. According to the resident's care plan and Minimum Data Set (MDS), the resident had multiple diagnoses including diabetes, bilateral cataracts, lung disease, anxiety, cognitive deficit, dementia, and muscle weakness, and was assessed as needing supervision or touching assistance while eating. Despite this, during an observation, the resident was left alone while eating, experienced difficulty, and expressed distress, stating she was not okay and began shaking. Staff were not present to provide the required assistance or cueing during the meal. When the nurse aide removed the meal tray, only the oatmeal had been eaten, and the aide stated the resident told her she was done. The Assistant Director of Nursing initially stated the resident feeds herself, but upon reviewing the care plan, confirmed that the required assistance was not provided. This failure to follow the care plan and provide the necessary support during meals constituted a deficiency in meeting the resident's care needs as outlined in facility policy and regulatory requirements.
Failure to Provide Required ADL Assistance During Mealtime
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including diabetes, bilateral cataracts, lung disease, anxiety, cognitive deficit, dementia, and muscle weakness, did not receive the required assistance with activities of daily living (ADLs), specifically during mealtime. Observation revealed that the resident was having difficulty eating independently, as she was unable to properly scoop food and did not have her assistive Kennedy cup available. No staff were present to assist her, and her food was not prepared in a way that accommodated her needs. When asked, the resident expressed she was not okay and exhibited physical difficulty while attempting to eat. Further review of the resident's clinical record and care plan indicated she required supervision or touching assistance while eating, as documented in her Minimum Data Set (MDS) and care plan. Despite this, staff assumed she could feed herself and did not provide the necessary support. The resident's weight records showed a significant weight loss of approximately two pounds per week. The Assistant Director of Nursing confirmed that the facility failed to provide the required ADL assistance as outlined in the resident's care plan and facility policy.
Failure to Provide Adaptive Eating Equipment and Assistance
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils to a resident with documented needs. According to the facility's policy, assistive eating devices are to be provided to residents with limited arm mobility or grasp as recommended by nursing or therapy. During an observation, a resident was seen having difficulty eating in her room; she did not have her prescribed Kennedy cup for hot liquids, and her food was not cut up to facilitate easier consumption. No staff were present to assist, and the resident was observed struggling to get food into her mouth, shaking when attempting to scoop food, and verbally expressing distress. The resident's care plan specified the need for a Kennedy cup, but this was not provided at the time of observation. The Assistant Director of Nursing confirmed the failure to provide the required adaptive equipment and utensils.
Improper Food Storage in Main Kitchen
Penalty
Summary
The facility failed to properly store food products in the Main Kitchen, which created the potential for foodborne illness. During an initial observation of the dietary department, it was identified that three staff lunch bags were stored in the cooler alongside resident food items. Additionally, the deep freezer had ice buildup on vent pipes, with food stored directly under the ice, causing it to drip onto boxes. Bread was also found stored on a shelf on the floor of the refrigerator. These observations were confirmed by the Dietary Manager, indicating non-compliance with the facility's policy on food storage, which requires all food items to be stored 6 inches above the floor and 18 inches below the sprinkler units, in accordance with FDA Food Code guidelines.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, neglect, or misappropriation of property. Resident R69, who was admitted with multiple diagnoses including kidney disease, cognitive communication deficit, and respiratory failure, alleged verbal abuse by RN Employee E6. The resident, who was cognitively intact, reported that the RN was rude and verbally abusive, causing emotional distress. This was corroborated by a family member who witnessed the event. Further investigation revealed that the RN had previously received abuse prevention training. However, during the annual survey, Resident R69 reiterated that the RN had been mean and expressed a desire not to have her in his room. The resident also reported an incident where the RN chased away a trusted Nurse Aide, leaving the resident in a precarious situation while transferring into a chair. The Director of Nursing confirmed the facility's failure to protect the resident from abuse.
Deficiency in Nurse Aide In-Service Education
Penalty
Summary
The facility failed to provide the required in-service education for nurse aides, as mandated by regulations. Specifically, two of the five nurse aides reviewed did not receive at least 12 hours of in-service education within 12 months of their hire date anniversary. Nurse Aide Employee E2, hired on April 1, 2024, only completed 4.25 hours of in-service education between April 1, 2023, and April 1, 2024. Similarly, Nurse Aide Employee E3, hired on August 9, 2021, completed only 7.50 hours of in-service education between August 9, 2023, and August 9, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator on September 13, 2024.
Failure to Provide QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for two staff members, Nurse Aide Employee E2 and Therapy Employee E5. Employee E2, hired on April 1, 2014, did not receive QAPI in-service education between April 1, 2023, and April 1, 2024. Similarly, Employee E5, hired on August 15, 2022, did not receive effective communication in-service education between August 15, 2023, and August 15, 2024. This deficiency was confirmed during an interview with the Nursing Home Administrator on September 13, 2024, who acknowledged the lack of training for these employees. The deficiency is supported by the review of facility documents and training records, which revealed the absence of documented training for the specified staff members. The failure to provide this training is a violation of the Pennsylvania Code, specifically sections 201.14 (a), 201.18 (b)(1), and 201.20 (a)(c), which pertain to the responsibility of the licensee, management, and staff development.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training for three out of ten staff members, specifically Nurse Aides (NAs) identified as Employees E1, E2, and E3. According to the facility's assessment, training on caring for persons with Alzheimer's or other dementia was included as a necessary educational topic. However, a review of the facility's documents and training records revealed that Employee E1, hired on 7/5/21, did not receive behavioral health in-service education between 7/5/23 and 7/5/24. Similarly, Employee E2, hired on 4/1/14, lacked this training between 4/1/23 and 4/1/24, and Employee E3, hired on 8/9/21, did not receive the training between 8/9/23 and 8/9/24. This deficiency was confirmed by the Nursing Home Administrator during an interview on 9/13/24.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
