Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Thornwald Home during CMS and state inspections, most recent first.
Surveyors found that sprinkler heads in the Main Kitchen were covered with debris, particularly around vents, and this was confirmed by facility leadership during interviews. The deficiency affected one of nine smoke zones.
Surveyors found that three residents' assessments did not accurately reflect their clinical status. One resident with Parkinson's and another with hemiplegia were both using enabler bars for mobility, but their MDS assessments were incorrectly coded as restraint use. Another resident with a trauma history and adjustment disorder had PTSD omitted from her MDS despite relevant documentation and care planning. These errors were confirmed by facility leadership.
The facility did not verify the professional licensure status of a CNA and an LPN before hiring them, as required by policy. License and certification checks were completed only after the employees began working, and documentation of timely verification could not be found during review of personnel files and staff interviews.
A resident with multiple pressure ulcers did not receive timely or properly monitored use of a recommended air mattress, as there was a delay in implementation, lack of physician order, and inadequate monitoring of the equipment's function and settings, resulting in failure to provide necessary treatment consistent with professional standards.
A resident with hemiplegia had an enabler bar removed and later reinstalled on their bed, but the facility did not perform or document the required safety measurements at the time of reinstallation. Facility leadership confirmed that these checks should have been completed, resulting in noncompliance with regulations for regular inspection and compatibility of bed rails.
A resident with dementia and Down syndrome, who exhibited behavioral symptoms requiring a dignity suit as a physical restraint, did not receive the required 30-day ongoing evaluations for restraint use. Although initial and some follow-up assessments were completed, the facility failed to ensure monthly interdisciplinary reviews as per policy.
A resident with a history of stroke and hypertension, who required two-person assist with a stand aid for transfers, was transferred by a nurse aide alone using a stand pivot. This failure to follow the care plan and facility policy resulted in a severe leg laceration requiring 15 sutures.
Thornwald Home failed to provide required annual abuse training to a contracted Physician Assistant, as revealed by a review of training records. The facility's policy mandates annual education on abuse prevention and reporting for all staff, including contractors, but documentation for this training was missing for Employee 2. This deficiency was confirmed during an interview with the NHA and the Assistant Director of Nursing.
A resident with chronic kidney disease, heart failure, and anxiety disorder reported being assaulted in her genitalia, but the facility failed to report the allegation in a timely manner. Despite the resident's report to a physician, no physical assessment was conducted, and the allegation was not communicated to the administration. The oversight was discovered during a clinical meeting, leading to a delayed investigation.
A facility failed to thoroughly investigate abuse allegations made by a resident with chronic conditions, who reported being assaulted by staff. Despite the resident providing a description and stating she could identify the perpetrators, the facility did not obtain witness statements or ask the resident to identify the alleged perpetrators. The facility's investigation was insufficient, and no staff were suspended during the investigation, compromising the resident's safety.
The facility failed to document catheter care for two residents, leading to UTIs. One resident with urinary retention and a Foley catheter had multiple undocumented shifts of catheter care and was diagnosed with a UTI. Another resident with benign prostatic hyperplasia and chronic kidney disease also lacked documentation of catheter care and was treated for UTIs. The DON confirmed that catheter care should be documented every shift.
A facility failed to provide appropriate mobility support for a resident with Parkinson's Disease and muscle weakness. The resident's care plan required the use of an AFO and specific positioning in a Broda chair, but observations showed inconsistencies in their use. The resident was also on a walking RNP despite being non-ambulatory, with gaps in documentation and provision of care. Interviews with the NHA and DON revealed confusion about the resident's ambulation status and lack of documentation for the AFO.
The facility failed to monitor nutritional status and notify the physician of significant weight changes for two residents. One resident with malnutrition and other conditions lost 20.8 pounds over three weeks without timely re-weighing or physician notification. Another resident did not have a required weekly weight measure recorded. These lapses indicate non-compliance with facility policies on weight monitoring and physician communication.
The facility did not maintain sprinkler head assemblies per manufacturer specifications, affecting one smoke compartment. Observations revealed missing escutcheons on sprinkler heads in the Laundry and Kitchen Dish Room. The Director of Environmental Services confirmed the deficiency.
Sprinkler Heads Not Maintained Free of Debris in Main Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sprinkler heads in the Main Kitchen area, as they were found to be covered with debris throughout, particularly by all vents and sprinkler heads. This deficiency was identified during an inspection and was confirmed through interviews with the Administrator and Director of Environmental Services, who acknowledged the presence of debris on the sprinkler heads. The issue affected one of nine smoke zones within the component and was documented based on direct observation and staff confirmation. No information regarding residents' medical history or condition at the time of the deficiency was provided in the report.
Plan Of Correction
The facilities maintenance department audited the entire facility for other dirty/debris covered sprinkler heads. The affected sprinkler heads will be cleaned. Checking for dirty/debris on the sprinkler heads will be added to the monthly safety committee checklist. Checklists will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Inaccurate Resident Assessments and MDS Coding
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for three residents. For one resident with Parkinson's disease and weakness, clinical record review and observation revealed the use of a right-sided enabler bar, which the resident used for mobility in bed. However, the resident's quarterly MDS assessments were incorrectly coded as restraint use related to enabler bars, contrary to the actual use and physician orders for the device as an enabler. Another resident with a diagnosis of adjustment disorder and a history of trauma related to witnessing a choking incident had a care plan that included trauma-informed care and counseling services. Despite documentation in psychology consults indicating significant focus on grief and loss, the resident's quarterly MDS assessment failed to document PTSD, which was relevant to her care needs and supported by her clinical history and care plan. A third resident with hemiplegia was observed with a right-side enabler bar in the room, and physician orders supported its use for bed mobility and independence. However, the resident's quarterly MDS was also incorrectly coded for restraint use related to enabler bars, not reflecting the actual purpose and physician orders for the device. These inaccuracies in the MDS assessments were confirmed by the Nursing Home Administrator, who acknowledged the errors in coding and the need for modification.
Plan Of Correction
1. R 4 and R 14's Minimum Data Set (MDS) were modified on 12/9/25 to accurately reflect that a restraint was not in use. R 12's medical record was reviewed, and no PTSD diagnosis has been identified by the provider. R 12 does have a trauma history which has been care planned, and the CMS 802 roster was updated to reflect the history of trauma on 12/9/25. The provider will be notified to evaluate if a post-traumatic stress disorder (PTSD) diagnosis is warranted. 2. An audit was completed on 12/9/25 for current residents coded as restraints on Section 0 of the MDS, and modifications were completed as necessary. An audit was completed on 12/9/25 to identify residents with a history of trauma and/or PTSD diagnosis. The 802 was manually updated to indicate the history of trauma for identified residents, but no PTSD diagnoses were identified in any resident. No modifications to MDS accuracy were identified. The physician/provider will be notified to review identified residents to evaluate if a PTSD diagnosis is warranted. 3. The RNACs will be re-educated by the Executive Director on proper coding and accuracy of the MDS in its entirety with a focus on proper coding of restraints at Section O. In addition, education will be provided by the Executive Director to the RNACs that PTSD requires a physician diagnosis to be coded in Section I of the MDS and that the 802 rosters should be checked for PTSD diagnosis or identified history of trauma. The 802 roster will be submitted to DON weekly for review of accuracy of triggered items. The Interdisciplinary team completing sections of the MDS will be re-educated on accuracy of coding the MDS by the Executive Director. 4. The Director of Nursing or designee will conduct weekly audits of at least 5 residents per week for 12 weeks to validate accurate coding of Section 0 for restraints and Section I for PTSD. Audits will include at least 1 MDS per week for 12 weeks reviewed in its entirety for accuracy. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Verify Staff Licensure Prior to Hire
Penalty
Summary
The facility failed to ensure that residents were protected from the potential for abuse by not verifying the professional licensure status of two employees prior to their hire. Specifically, the personnel file for a Certified Nursing Assistant (CNA) showed that certification verification was completed after the employee's hire date. Similarly, the personnel file for a Licensed Practical Nurse (LPN) indicated that license verification with the state licensing board was also completed after the employee's hire date. These actions were not in accordance with the facility's own policy, which requires verification of active licensure or certification prior to employment. During interviews, it was revealed that Human Resources is responsible for completing a checklist to ensure all required items, including license verification, are completed and then forwarding this information to the hiring manager. However, the hiring manager discards information not entered into the employee's file, and the facility was unable to locate evidence that licensure verification was completed before the employees began working. This failure to verify licensure prior to hire was identified through review of facility policy, personnel files, and staff interviews.
Plan Of Correction
F 0606 1. No individual resident has been identified. Employee 3 and Employee 4 license verification were completed on 12/9/25. 2. An audit of current employee files of those with Licenses or Certifications was completed on 12/16/2025 to validate employee licenses or certifications are in good standing, and employees are fit for service. 3. Re-education to HR Payroll Benefit Coordinator, Receptionist, and Nursing Leadership on the facility policy "Admin Freedom from Abuse Policy" will be provided by the Executive Director. The HR Payroll Benefit Coordinator or designee will verify licensure/certification and will print the verification prior to offering any position. This will be maintained in the HR office in the employee file. 4. The Executive Director, or designee will conduct weekly audits x 12 weeks of potential new hires to validate license/certification verification has occurred and is in employee file. Findings of audits will be analyzed to identify/track trends or patterns and will be reported monthly to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Provide Timely and Monitored Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive necessary treatment and services consistent with professional standards of practice to promote healing. The resident had a history of pressure ulcers on the right heel, right buttock, and left heel, as well as diagnoses of type II diabetes mellitus and peripheral vascular disease. Despite weekly wound consults recommending an air mattress for additional pressure relief, there was a three-week delay in applying the recommended air mattress to the resident's bed. There was no documentation to explain this delay, and no evidence of interdisciplinary team discussions regarding the delay was provided. When the air overlay mattress was eventually placed, there was no physician's order for its use, nor was there documentation that staff were monitoring the function or settings of the mattress. Observations revealed that the air overlay mattress pump was repeatedly found turned off, the air hose was disconnected and found on the floor, and the pump was set for an incorrect weight. Additionally, the securing clip for the hose was broken, and the pump was not consistently operational until maintenance intervened. The resident's actual weight was significantly lower than the pump setting, and there was no evidence that staff were ensuring the equipment was functioning as intended. Facility policies required that residents with wounds receive care to promote healing and prevent infection, and that interventions be revised based on their effectiveness. However, the lack of timely implementation of the recommended air mattress, absence of monitoring, and failure to ensure the equipment was functioning properly led to the resident not receiving the necessary treatment and services to promote healing of pressure ulcers. The deficiency was identified through clinical record review, staff interviews, and direct observation.
Plan Of Correction
1. R 10's air mattress connector hoses were immediately replaced on 12/11/25 and set to the proper weight setting. A physician order was obtained to check the mattress for each shift for proper functioning and weight setting. 2. A facility-wide audit was conducted on 12/11/25 to identify any resident with an air mattress. Physician orders will be obtained to check functioning and settings each shift. Most recent wound consultative reports will be reviewed by the Director of Nursing for any air mattress recommendations to validate follow-through. 3. Licensed nurses will be re-educated by the Director of Nursing on checking proper functioning/settings of air mattresses and follow-through of wound consult recommendations to promote healing of pressure ulcers. Licensed Nurses will sign each shift on the treatment record validating proper functioning and settings are in place for air mattresses. Wound consult reports will be reviewed weekly during the daily interdisciplinary team meeting to validate that recommendations have supportive documentation for being addressed. 4. DON or designee will conduct weekly random direct observations of air mattresses across all 3 shifts for proper functioning, settings, and documentation for a minimum of 12 observations per week x 12 weeks. DON or Designee will conduct weekly audits of 5 residents/week x 12 weeks receiving wound consultation for supportive documentation of follow-through of recommendations. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Inspect Bed Rails After Reinstallation
Penalty
Summary
The facility failed to conduct regular inspections of bed rails/enabler bars as part of its maintenance program to identify possible areas of entrapment for a resident with hemiplegia. The resident had a physician order for a right-side enabler bar to assist with bed mobility and independence, and the enabler bar assessment and consent were completed when the device was initially placed. However, the maintenance record for safety measurements was last documented several months prior to the most recent placement of the enabler bar. When the enabler bar was removed at the resident's request and later reinstalled, the facility did not perform or document the required safety measurements at the time of reinstallation. Interviews with facility leadership confirmed that safety measurements should have been completed when the enabler bar was placed back on the bed, but this was not done, resulting in noncompliance with regulatory requirements for regular inspection and compatibility checks of bed rails and related equipment.
Plan Of Correction
1. R 14's bed was inspected by maintenance, and no area of entrapment was identified. 2. An audit was conducted throughout the skilled unit on 12/11/25 to identify current residents that have beds with rails. A Maintenance Bed evaluation and inspection was completed on the identified beds on 12/11/25 with no concerns noted. 3. Environmental Services will be re-educated by the Executive Director on the facility preventative maintenance program to include regular inspection of bed rails/enabler bars, and completion of the Bed Evaluation Tool. Education will include any device being added to the bed or frame requires inspection and completion of the Bed Evaluation Tool immediately upon adding to the bed or frame by maintenance. 4. Weekly audits x 12 weeks of residents with bedrails will be completed by the Director of Nursing or designee to validate current bed rail inspection is documented at least annually at the time of placing rails or enablers on bed if newly added, and when a significant change of condition occurs. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Complete Required 30-Day Restraint Evaluations
Penalty
Summary
The facility failed to complete an evaluation every 30 days for the ongoing use of a restraint for one resident. According to the facility's policy, the interdisciplinary team is required to review and reevaluate the use of all restraints ordered by a physician or their designee at least every 30 days. For the resident in question, who had diagnoses including dementia and Down syndrome, there were physician orders and care plan interventions for the use of a one-piece dignity suit at night to address behavioral symptoms such as smearing and ingesting feces. The initial equipment assessment and consent for the dignity suit were completed, and follow-up assessments were documented on two occasions several months apart. However, the clinical record review revealed that the required 30-day ongoing evaluations for the restraint were not consistently completed. The Nursing Home Administrator confirmed that although an ancillary order for monthly evaluations was entered, it did not populate in a way that ensured completion. As a result, the facility did not meet its own policy or regulatory requirements for regular restraint evaluation for this resident.
Plan Of Correction
1. R 27's dignity jumpsuit was evaluated on 12/9/25. A physician treatment order was obtained 12/9/25 to complete an evaluation every 30 days. 2. A review of current residents reveals that no other residents have been identified as utilizing restraints. 3. Licensed staff will be re-educated on restraints, proper documentation, and evaluations every 30 days for ongoing use of restraints. 4. The Director of Nursing or designee will audit residents with restraints weekly for 12 weeks to validate that evaluations of the restraint are completed every 30 days. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.
Failure to Provide Adequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance to prevent accidents, resulting in actual harm. A resident with a history of stroke and hypertension had a care plan and physical therapy discharge summary indicating the need for transfer with a stand aid and assistance from two staff members. Despite this, a nurse aide transferred the resident from a wheelchair to bed alone, using a stand pivot technique, rather than the required stand aid with two-person assist. This action was not in accordance with the resident's care plan or the facility's 'No Lift Program' policy, which prohibits transfers without the required equipment and staff. As a result of the improper transfer, the resident sustained a significant laceration to the right lower leg, measuring 10 cm x 8 cm x 1 cm, with exposure of the fatty layer, and required 15 sutures at the hospital. The nurse aide involved stated she was unaware of the need for two-person assist with a stand aid for transfers, having only seen the one-assist requirement for toileting in the care guide and not scrolling further to see the transfer instructions. The facility's investigation confirmed that the staff member did not follow the resident's care plan, leading to the injury.
Failure to Provide Annual Abuse Training to Contracted Staff
Penalty
Summary
Thornwald Home was found to be non-compliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. The facility failed to ensure that all staff, including contracted personnel, received the required annual training on abuse prevention and reporting. Specifically, a review of the training records revealed that a contracted Physician Assistant, referred to as Employee 2, did not receive the mandatory annual abuse training in 2024. This omission was confirmed during an interview with the Nursing Home Administrator and the Assistant Director of Nursing. The facility's policy, titled "Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property," mandates that all employees, including consultants and volunteers, receive education on abuse prevention and reporting upon hire and annually thereafter. The policy also requires an annual acknowledgment from vendors and contractors. However, the facility could not provide documentation of such training or acknowledgment for Employee 2, indicating a failure to adhere to their own policy and regulatory requirements.
Plan Of Correction
1. No individual resident has been identified. E2 has received training and education on the facility's abuse policy which covers the seven components of abuse. 2. The Executive Director/designee will review training records to validate that contracted care providers including UPMC Post Acute Providers have evidence of Annual or New Hire Abuse training within the previous year. 3. UPMC Post Acute Providers will be re-educated by the Executive Director/designee on the facility's abuse policy. 4. Monthly audits will be conducted for 3 months by the Executive Director or designee on facility training records to validate contracted care providers and UPMC Post Acute providers have completed annual abuse training or new hire abuse training within the previous year. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or further recommendation.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The facility's policy requires that any incident of abuse be reported immediately to the Executive Director or designee and thoroughly investigated. However, the facility did not adhere to this policy when a resident reported being assaulted in her genitalia. The resident, who had diagnoses including chronic kidney disease, heart failure, and anxiety disorder, reported the alleged assault to a physician on January 9, 2025. Despite the report, there was no documentation of a physical assessment of the resident's genitalia, and the allegation was not reported to the facility's administration. The physician's progress notes from January 9 and January 14, 2025, documented the resident's allegations of being assaulted and having delusional thoughts. However, the facility staff, including a Licensed Practical Nurse, did not recall any specific comments regarding the alleged assault. The physician believed the resident's thought content was delusional, and no physical examination was conducted to investigate the claims. The lack of immediate reporting and investigation of the resident's allegations was a significant oversight. The Assistant Director of Nursing discovered the documentation of the alleged assault during a clinical meeting on January 22, 2025. It was only then that an investigation was initiated. The Nursing Home Administrator confirmed that neither she nor any other administrative staff were made aware of the resident's allegations on January 9 or January 14, 2025. This failure to report and investigate the allegations promptly was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
R1's initial allegation documented on 1/9/25 was identified by the facility on 1/14/25, and reporting requirements to the Department of Health, Area of Aging, Local Police, and the PA Department of Aging occurred immediately. 2. The Executive Director spoke with E2 and the Medical Director about reporting immediately any allegations of abuse/neglect. An audit was conducted of Physician progress notes dated 12/9/24-1/30/24. No other documented allegations of abuse were identified. 3. UPMC Post Acute Providers and facility staff will be re-educated by the Executive Director on immediate abuse reporting requirements. Physician Progress notes will be reviewed during daily clinical meetings for three months to ensure that there are no entries of risk, including allegations of abuse that have been unreported to the facility. 4. Weekly random audits of physician progress notes conducted by the Executive Director or designee of at least 5 residents will occur x 3 months to validate any documented allegations have been immediately reported to the Executive Director. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident 1, who had chronic kidney disease, chronic heart failure, and an anxiety disorder. The resident reported being hit on the head and dragged by two staff members, whom she described as 'two black girls,' and stated she could identify one if seen again. Despite this, the facility did not take adequate steps to identify the alleged perpetrators or obtain witness statements from nursing staff. The facility's investigation documentation was insufficient, lacking any evidence of attempts to verify the resident's claims or protect her during the investigation. The facility's policy required immediate and thorough investigations of abuse allegations, including obtaining signed statements from the resident, witnesses, and the accused. However, the facility did not follow these procedures. The Assistant Director of Nursing confirmed that no investigation or witness statements were obtained, and the resident was not asked to identify the alleged perpetrators, despite providing a description. The facility's failure to suspend any staff members during the investigation further compromised the resident's safety. The Nursing Home Administrator acknowledged that the facility did not thoroughly investigate the allegations and confirmed that the resident was not asked to identify the alleged perpetrators. The facility's electronic health record system was unable to retrieve past 24-hour reports, hindering the investigation process. The lack of a comprehensive investigation and failure to protect the resident during the investigation period resulted in a deficiency in meeting the regulatory requirements for investigating and preventing abuse.
Plan Of Correction
1. A thorough investigation has been completed for R1's allegations to include written witness statements of nursing staff. R1 was interviewed by the Executive Director on 2/3/25 and confirms feeling safe in the facility. 2. The Executive Director/designee will review 24-hour report and physician/other practitioner progress notes over last 7 days to ensure that there are no unreported allegations of abuse. In addition, an audit will be conducted on any allegations occurring over the last 7 days to ensure thorough investigations are in place. 3. Licensed staff will be re-educated by the Executive Director on the facility's abuse policy which includes recognizing documentation that constitutes initiation of the facility's abuse policy, and on the steps for an immediate, thorough investigation to include interviewing and obtaining signed statements from any witness or individual who has knowledge of the alleged incident. 4. Weekly audits of abuse investigations will be conducted by the Executive Director or Designee x 3 months to validate thorough investigations have been completed to include immediate measures implemented to protect resident safety, identification of perpetrator, if able and written statements are in place. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or recommendation.
Failure to Document Catheter Care Leads to UTIs
Penalty
Summary
The facility failed to ensure that residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections (UTIs). Specifically, for Resident 65, there was a lack of documentation indicating that catheter care was provided on multiple shifts from October through December 2024. This resident, diagnosed with urinary retention and using an indwelling Foley catheter, was found to have a UTI on October 25, 2024, with a urine culture indicating the presence of E. coli. The Nursing Home Administrator and Director of Nursing confirmed that catheter care should be provided and documented every shift. Similarly, Resident 72, who had diagnoses including benign prostatic hyperplasia and chronic kidney disease, also did not have documented catheter care on several shifts during the same period. This resident had physician orders for catheter checks every shift starting September 27, 2024. Despite this, there was no documentation of catheter care on numerous occasions, and the resident was treated with antibiotics for UTIs in October and December 2024. The Director of Nursing confirmed that catheter care should be completed and documented per facility protocol daily on every shift.
Plan Of Correction
1. R 65 has been evaluated and is currently experiencing no signs and symptoms of infection. R72 is currently being treated on antibiotic therapy and is showing no signs or symptoms of urinary tract infections. 2. Residents with indwelling catheters will be identified, and will be evaluated for signs and symptoms of urinary tract infections. In addition, documentation will be reviewed to validate catheter care has been completed. Physician will be notified for follow-up as needed. 3. Certified Nursing Assistants will be re-educated on completion of catheter care and proper documentation. Licensed Nurses will be re-educated on role and responsibility of oversight of completion of CNA documentation for each shift. 4. Director of Nursing or designee will conduct audits on at least 3 residents/per week with catheters to validate care documentation is complete. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Failure to Provide Appropriate Mobility Support for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. Resident 27, diagnosed with Parkinson's Disease and muscle weakness, had a care plan that included specific interventions such as the use of an Ankle Foot Orthotic (AFO) for transfers and proper positioning in a Broda chair. However, observations revealed inconsistencies in the use of the AFO and leg rests, with the AFO often found on the floor rather than in use. Additionally, the resident's care plan indicated they were non-ambulatory, yet they were on a walking Restorative Nursing Program (RNP), which was not consistently documented or provided. The Physical Therapy Discharge Summary recommended a Restorative Nursing Program for sit-to-stand transfers and therapeutic exercises, but there was no mention of the AFO. Documentation from November 22 to December 11 showed gaps in the provision of range of motion and ambulation programs. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed confusion regarding the resident's ambulation status and the lack of documentation for the AFO. The NHA confirmed that the care plan should have been followed, and range of motion exercises should have been documented, highlighting a deficiency in the facility's adherence to the resident's care plan.
Plan Of Correction
1. R27's Restorative Nursing Program and nurse aide task documentation has been reviewed and revised to reflect discontinuation of ambulation and to continue with Transfers and ROM programming. Certified Nursing Assistants providing care on December 9, 2024, and December 10, 2024 have been re-educated on R 27's Care plan, and responsibility to provide equipment, devices and services in accordance with the resident care plan. 2. Residents receiving Restorative Nursing have been identified to validate current programs and nurse aide task documentation is reflective of current program needs and resident status. 3. The Registered Nurse Assessment Coordinators will be re-educated on role and responsibility of the Restorative Nursing Program to include revision of the resident care plan and validating proper documentation of devices and programming is in place. Nursing Staff will be re-educated on providing equipment, devices, and services in accordance with the resident care plan and on completing accurate documentation of care provided. Therapy staff will be educated in including functional devices and equipment in discharge summaries. A Weekly Restorative Committee has been established to review current programs, resident status, and documentation. 4. Weekly audits of at least 5 residents receiving Restorative Nursing per week will be conducted by the Director of Nursing or designee to validate current programming and task documentation is accurate and reflective of status. In addition, Director of Nursing or designee will conduct random observations of at least 5 residents per week to validate equipment and devices are in place per the resident care plan. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Failure to Monitor Nutritional Status and Notify Physician
Penalty
Summary
The facility failed to ensure proper monitoring of nutritional status and did not notify the physician of significant weight changes for two residents. Resident 38, who had diagnoses including moderate protein-calorie malnutrition, dementia, and congestive heart failure, experienced a significant weight loss of 20.8 pounds over a period of three weeks. Despite the facility's policy requiring re-weighs and physician notification for significant weight changes, Resident 38 was not re-weighed until a week later, and the physician was not notified of the weight loss until December 10, 2024, several weeks after the initial weight loss was recorded. The dietitian's note on November 26, 2024, acknowledged the weight loss but did not document any communication with the physician. Resident 79, who had diagnoses including hypertension, hyperlipidemia, and osteoporosis, did not have a weekly weight measure recorded for the week of September 15 through 21, 2024, as required by physician orders and facility policy. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the absence of the weight measure and acknowledged the expectation for weekly weights to be obtained. These deficiencies highlight lapses in the facility's adherence to its own policies regarding weight monitoring and physician notification, potentially impacting the residents' health management.
Plan Of Correction
1. R 38's provider was notified of weight loss identified from 11/3-11/26/24 on 12/10/24. R 79 no longer resides in the facility. 2. Residents with orders for weekly weights will be audited that weights were completed as orders, reweighs obtained as necessary, and follow-up with physician and dietitian notification has occurred as appropriate. The facility has reviewed and revised its current procedure for weights for obtaining weights/reweights and to include notification of the physician and dietitian as appropriate. 3. The facility will re-educate Nursing Staff and the Dietician on the revised weight procedure to include weekly weights, reweights, and to include physician and dietitian notification of identified weight changes. A weekly weight committee has been established to include a review of weekly and monthly weights to validate reweighs and notification to physician and dietitian has occurred. 4. The Director of Nursing or designee will perform audits of at least 5 residents/week and documented weights to validate weight procedure has been followed to include re-weighs and proper notifications as necessary. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.
Sprinkler System Deficiency Due to Missing Escutcheons
Penalty
Summary
The facility failed to maintain sprinkler head assemblies according to manufacturer specifications, affecting one of nine smoke compartments. During an observation on December 10, 2024, between 10:33 AM and 10:55 AM, it was noted that sprinkler heads in specific locations were missing an escutcheon. These locations included the Laundry area by the dryers and the Kitchen Dish Room. An interview with the Director of Environmental Services confirmed that the sprinkler head assembly did not meet the required specifications.
Plan Of Correction
The escutcheons in the laundry dryer room and the kitchen dish room were replaced. The facilities maintenance department audited the entire facility for any other missing escutcheons. Checking for missing sprinkler escutcheons has been added to the safety committee's safety checklist and performed monthly. Findings will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) Committee for review and recommendation.
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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 Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Park Nursing And Rehabilitation | 0.1 mi | ★★★★★ | 9 | 0 |
| Carlisle Skilled Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 3 | 0 |
| Chapel Pointe At Carlisle | 0.6 mi | ★★★★★ | 0 | 0 |
| Sarah A Todd Memorial Home | 0.7 mi | ★★★★★ | 2 | 0 |
| Cumberland Crossings Retirement Community | 1 mi | ★★★★★ | 0 | 0 |
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