Transitions Healthcare North Huntingdon
Inspection history, citations, penalties and survey trends for this long-term care facility in North Huntingdon, Pennsylvania.
- Location
- 8850 Barnes Lake Road, North Huntingdon, Pennsylvania 15642
- CMS Provider Number
- 395585
- Inspections on file
- 34
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Transitions Healthcare North Huntingdon during CMS and state inspections, most recent first.
The facility failed to follow its call bell policy requiring immediate response to resident requests, resulting in multiple cognitively intact or moderately impaired residents who needed assistance with toileting and transfers waiting extended periods after activating call lights. Several residents with conditions such as diabetes, COPD, heart failure, traumatic brain injury, and end-stage renal disease reported routinely waiting 30 minutes or longer, sometimes over an hour, for help with toileting or incontinence care, with one resident documenting hours-long waits in a grievance and another reporting having called 911 when staff did not respond. Resident council minutes on two occasions recorded concerns that call bells were not answered timely, and facility leadership acknowledged that call lights were not consistently accessible or answered promptly, in violation of applicable Pennsylvania resident care, nursing services, and resident rights regulations.
The facility failed to maintain resident dignity and honor resident rights related to toileting and incontinence care. A resident with cognitive impairment and mobility needs was required to use a bedpan for bowel movements despite an active physician order and her stated preference for a bedside commode, which had been removed from her room and not returned. Another resident, fully dependent for toileting, reported going nearly an entire day without a brief change despite multiple calls for assistance and involvement of his daughter. A third resident, requiring substantial assistance, reported being left on a bedpan for an extended period while she slept. Leadership acknowledged that the facility did not ensure care was provided in a manner that maintained resident dignity.
The facility failed to follow physician-ordered blood pressure (BP) parameters and its own medication administration policy for two residents receiving antihypertensive medications. One resident with COPD and hypertension received metoprolol on multiple occasions despite documented systolic BP readings below the ordered hold parameter. Another resident with diabetes and hypertension had an order for lisinopril with a specified systolic BP hold parameter, but there was no documented BP monitoring for an extended period to support safe administration. The NHA and DON acknowledged that these issues resulted in significant medication errors for two of five residents reviewed.
A resident with chronic kidney disease and heart failure, previously without documented tremors or seizure-like activity, developed new Parkinson’s-like tremors, flopping and jerking movements, yelling out in pain, back arching suggestive of seizure activity, and decreased oxygen saturation along with an abnormal temperature. Nursing notes showed that provider and responsible party notification fields were marked as not applicable, and the clinical record lacked evidence that the medical provider was notified of these significant changes before the resident was sent to the hospital and later admitted to the ICU. This failure occurred despite a facility policy requiring notification of residents, providers, and representatives when a change in condition occurs.
A medication cart was left unattended in a hallway with an open laptop displaying resident-identifiable information, allowing any passerby to view confidential medical data. Staff and leadership confirmed the incident, which was not in accordance with facility policy on safeguarding PHI.
Multiple residents reported prolonged call light response times, with some waiting up to an hour and a half for assistance. Several residents described staff turning off call lights without providing help, feeling rushed during care, and not receiving timely assistance, particularly during night shifts. Facility leadership confirmed insufficient staffing to meet resident needs, and documentation showed ongoing concerns about delayed responses and unmet care needs.
A resident with severe cognitive impairment and multiple medical conditions experienced several changes to prescribed medications, including Ativan and Haldol, without the facility notifying the resident's representative in advance or discussing the risks, benefits, or alternatives. Review of records and staff interviews confirmed that required communication and documentation did not occur, in violation of resident rights and care policies.
A resident with heart disease, dementia, and asthma had a physician's order for continuous oxygen via nasal cannula, but the MAR lacked documentation of oxygen administration on several dates. The facility did not ensure complete and accurate clinical records for this resident.
The facility failed to properly design, approve, and follow its Winter five-week cycle menu, leading to potential inaccuracies in portion sizes and food consistencies for therapeutic diets. Documents lacked RD approval, and menu modifications were not pre-planned or reviewed, creating potential for inappropriate servings.
Transitions Healthcare North Huntingdon was found non-compliant with maintaining a homelike environment. Observations revealed peeling paint, gashes in walls, and splintering wood in resident rooms, hallways, and the dining room. The Nursing Home Administrator and Maintenance Director confirmed these deficiencies.
The facility failed to ensure privacy for resident group meetings, as staff repeatedly interrupted a meeting in the dining room despite posted signage. The Nursing Home Administrator confirmed that staff could use an alternative route, acknowledging the failure to provide a private space for the group.
The facility failed to provide four residents with the opportunity to formulate advance directives, as required by their policy. Despite having significant health conditions, these residents' clinical records lacked documentation of being informed about or given the chance to create an advance directive, confirmed by a social worker.
The facility failed to complete MDS assessments within the required time frame for several residents. The RAI User's Manual mandates that admission MDS assessments be completed within 14 days and annual assessments by the ARD. However, assessments for some residents were overdue, as confirmed by the RNAC and Nursing Home Administrator. The issue arose after the previous RNAC left without notice, resulting in multiple overdue assessments.
The facility failed to properly store and dispose of medications and supplies in the Orchards medication room. Expired items, including vacutainers, IV start kits, swabsticks, scalpels, glucometer testing solutions, and an undated vial of insulin, were found. The DON and Nursing Home Administrator confirmed these deficiencies.
The facility failed to maintain call light equipment, affecting five of seven residents. Observations showed that room lights were illuminated, but the nurses' station monitoring panel did not reflect this. Nurse Aides confirmed the panel's unreliability, and the Director of Nursing acknowledged the issue.
A resident with diabetes and coronary artery disease, assessed as at risk for elopement, exited the facility through an alarmed door that was reset by staff who assumed the alarm was triggered by an ambulance crew. The resident was later found near a gas station, expressing a desire not to return and making threats of self-harm, leading to a hospital transport for mental health evaluation.
Failure to Ensure Timely Response to Call Lights for Residents Requiring Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were accessible and answered in a timely manner for multiple residents who required staff assistance, particularly with toileting and transfers. Facility policy on call bells dated 4/1/25 required staff to respond to resident requests and needs when using the call bell system and, when answering from the nurse’s station, to ensure staff respond to resident requests immediately. Despite this policy, resident interviews, clinical record reviews, and resident council minutes documented repeated delays in call light responses and concerns about accessibility and timeliness. Resident R1, admitted 6/8/25 with diagnoses including adjustment disorder, diabetes mellitus, and hypertension and a BIMS score of 12, required supervision or touching assistance for toileting hygiene and substantial/maximal assistance for toilet transfers. R1 reported using the call light for help and stated it took a half hour or more, sometimes more than an hour, to receive assistance. Resident R2, admitted 7/22/24 with hypertensive chronic kidney disease, adjustment disorder, and hypertension and a BIMS of 15, required partial/moderate assistance with toileting hygiene and was unable to perform toilet transfers due to medical condition; R2 stated it took a half hour and sometimes much longer to get help after using the call light. Resident R3, with osteomyelitis of the vertebra, bipolar disorder, and hypertension and a BIMS of 15, required partial/moderate assistance with toileting hygiene and toilet transfers and reported that call light responses took at least thirty minutes, citing one instance of waiting from 11:45 a.m. to 1:15 p.m. Resident R4, admitted 5/4/21 with COPD, diabetes mellitus, and depression and a BIMS of 15, required partial/moderate assistance with toileting hygiene and supervision or touching assistance for toilet transfers and stated that after using the call light, there was always a wait, sometimes thirty minutes and other times much longer. Resident R5, admitted 4/3/25 with traumatic brain injury, end-stage renal disease, and diabetes mellitus and a BIMS of 15, was dependent for toileting hygiene and toilet transfers and had filed a grievance on 12/31/25 documenting hours of waiting for a brief change after calling for assistance. Resident R6, admitted 2/15/26 with hypertension, heart failure, COPD, and a BIMS of 11, required substantial/maximal assistance with toileting hygiene and toilet transfers and reported always having to wait for help and having called 911 on occasion when the wait was too long. Resident council minutes from two separate meetings documented that call bells were not being answered in a timely fashion, and in an interview, the Nursing Home Director and DON confirmed the facility failed to ensure call lights were accessible and answered promptly, in violation of 28 Pa. Code 211.10(c)(d), 211.12(d)(1)(2)(3)(5), and 201.29(i)(o).
Failure to Maintain Resident Dignity in Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that maintained resident dignity and honored resident rights related to toileting and incontinence care. One resident with adjustment disorder, diabetes mellitus, hypertension, and a BIMS score of 12 reported that staff made her use a bedpan for bowel movements despite an active physician order for use of a bedside commode at the bedside with assistance of two for transfers. She stated that the bedside commode had been removed from her room and not returned, and that when she requested it, staff told her to use the bedpan instead. Review of her clinical record confirmed the ongoing physician order for bedside commode use, indicating that staff were not following the order and were not honoring her expressed preference for the commode. Another resident with traumatic brain injury, end stage renal disease, diabetes mellitus, and a BIMS score of 15, who was dependent for toileting hygiene and toilet transfers, filed a grievance stating that he went from 9:30 a.m. to 8:30 p.m. without having his brief changed. He reported calling for a nurse multiple times, speaking with a nurse aide around 4:30 p.m. who said she would return but did not, and that after his daughter called the facility in the evening, a nurse came but it then took an additional 30–40 minutes to find an aide to change him. A third resident with similar diagnoses and a BIMS score of 15, requiring substantial/maximal assistance for toileting hygiene, filed a grievance stating she was placed on a bedpan at 10:15 p.m., fell asleep, and awoke at 11:43 p.m. still on the bedpan, after which she called staff to have it removed. In an interview, the Nursing Home Director and Director of Nursing confirmed the facility failed to ensure care was provided in a manner that maintained resident dignity, in violation of resident rights requirements.
Failure to Follow BP Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not following physician orders and facility policy for safe medication administration and required monitoring. Facility policy dated 04/01/25 required that medications be administered in a safe and effective manner and that vital signs or other monitoring parameters ordered or deemed necessary be obtained and recorded prior to administration. For one resident with COPD and high blood pressure, a physician order dated 3/20/25 directed that 12.5 mg of metoprolol be given once daily and held if the systolic blood pressure was less than 100 mm Hg. Review of the January 2026 MAR showed that this medication was administered on multiple dates when the documented systolic blood pressures were below 100 mm Hg, including readings of 98/61, 98/61, 98/63, 87/56, and 97/54. For another resident with diabetes and high blood pressure, a physician order dated 12/27/25 directed that 5 mg of lisinopril be given once daily and held if the systolic blood pressure was less than 120 mm Hg. Review of this resident’s record failed to show any documentation of a blood pressure measurement after 12/29/25, despite the order requiring blood pressure monitoring to determine whether the medication should be administered or held. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents were free of significant medication errors for two of five residents reviewed.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the medical provider of a resident’s change in condition as required by facility policy. The facility’s “Change in Condition” policy dated 4/1/25 states that residents, medical providers, and resident representatives are to be informed of changes in the resident’s condition. The resident involved had diagnoses including chronic kidney disease and heart failure and was documented on the MDS as having no cognitive impairment. Review of the clinical record from admission through mid-November showed no prior documentation of tremors, convulsions, seizures, Parkinson’s disease, Parkinsonism, or yelling out. The resident’s care plan identified risk for complications related to high blood pressure, with interventions to observe for signs and symptoms of elevated blood pressure. On a mid-November date, nursing documentation indicated that information was passed from the night nurse that the resident was having Parkinson’s-like tremors with no prior history. The nurse and CNA repeatedly adjusted the resident in bed due to flopping and rapidly flapping legs, and the resident only briefly opened her eyes. The resident was yelling out in pain and received PRN pain medication but could not verbalize the pain location. While in a wheelchair, she arched her back as if having a seizure and snored loudly, taking only a few bites of food before snoring again. A skilled nursing note from that day documented yelling out in pain and marked provider and responsible party notification fields as “not applicable.” Later that day, the resident was transported to the hospital for severe back pain, with documentation of eyes closed, posturing of head, hands, and arms, and leg spasms and jerking, and inability to feed herself due to rigid hands. Vital signs showed oxygen saturation at 92% and 91% on room air, lower than any prior readings since admission, and a temperature flagged as abnormal by the electronic charting system. The clinical record did not show that the medical provider was notified of these changes when they occurred. The Nursing Home Administrator and DON confirmed that the facility failed to notify the medical provider of the change in condition for this resident.
Failure to Maintain Confidentiality of Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information when a medication cart on the orchards unit was left unattended in the hallway with an open laptop displaying resident-identifiable information. This allowed any passerby to view personal and confidential resident data. The facility's policy on safeguarding posted protected health information (PHI) requires that resident PHI be protected from intentional or unintentional view in public areas. During observation, staff confirmed that the medication cart was left unattended with the laptop open, and both the LPN responsible and facility leadership acknowledged the incident.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of nine out of thirteen residents, as evidenced by multiple resident interviews, observations, and review of facility documents. Several residents reported long call light response times, with some waiting up to an hour and a half for assistance. Specific instances were documented, including a resident who kept a notepad of delayed response times, ranging from 20 to 55 minutes. Residents also described situations where staff would turn off call lights without providing the requested assistance, and some reported feeling rushed during personal care, such as bathing, or not receiving help at all, especially during night shifts staffed by agency personnel. One resident was observed to have facial hair, suggesting a lack of attention to personal grooming needs. Resident Council minutes from two separate meetings indicated ongoing concerns about long call light response times, and a grievance documented a resident not being changed during the night shift, resulting in the resident and their bed being soaked. During interviews, both the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to ensure sufficient staffing to meet resident needs. These findings were cited as violations of state regulations regarding the responsibility of the licensee and nursing services.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to inform a resident's representative in advance about proposed care, specifically regarding changes in prescribed medications, including the risks and benefits associated with those medications. Review of the clinical record for a resident with severe cognitive impairment and multiple diagnoses, including traumatic subarachnoid hemorrhage, dysphagia, diabetes, and seizures, showed that there were several changes to the resident's medication orders, such as adjustments to Ativan and Haldol dosages. Despite facility policy requiring notification and documentation of such changes, there was no evidence that the resident's representative was notified or that discussions occurred regarding the advantages, disadvantages, or alternative options for the medication changes. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not inform the resident's representative as required. The deficiency was identified through review of nurse progress notes and psychiatry recommendations, which lacked documentation of any communication with the resident's representative about the medication changes. This failure was found to be noncompliant with state regulations regarding resident rights and care policies.
Incomplete Documentation of Oxygen Administration in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a review of the clinical record for a resident with heart disease, dementia, and asthma revealed a physician's order for continuous oxygen administration via nasal cannula at 4 liters per minute every shift. However, the medication administration record (MAR) for May did not include documentation that the resident received oxygen as ordered on multiple specified dates. The Nursing Home Administrator confirmed these findings, indicating that the facility did not maintain complete and accurate clinical records for this resident.
Deficiency in Menu Planning and Approval
Penalty
Summary
The facility failed to properly design, approve, and follow its Winter five-week cycle menu and modifications, as evidenced by a review of facility policies, documents, observations, and staff interviews. The facility's 'Menu Planning' policy required that menus be completed at least two weeks in advance and approved by the registered dietitian (RD). However, the Winter cycle menu extension sheets did not provide guidance for regular and therapeutic diets as outlined in the facility's template, and they lacked portion sizes and food consistency guidance for Mechanical soft and Puree diets. This created the potential for dietary staff to serve inaccurate portion sizes and food consistencies. The facility's documents, such as the 'SLP Mech Soft Recommendations' and 'Puree Serving Guidelines,' lacked documented evidence of review and approval by the facility's RD. These documents provided conflicting recommendations for portion sizes, which could lead to inappropriate servings for residents on puree diets. Additionally, the 'Small, Regular and Large Portion Sizes' document also lacked RD approval. The Mechanical Soft/Puree menu extension sheets included items like rice pilaf and pineapple, which were not permitted for these diets according to the SLP's recommendations. Interviews with staff, including the Food Service Director (FSD) and a cook, confirmed the discrepancies in the menu extension sheets and the lack of RD approval. The facility also failed to pre-plan menu modifications, such as substituting chef salad for residents on a renal diet, without RD review and approval. These failures in menu planning and approval created the potential for conflicting guidance, which may result in residents receiving inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diets.
Plan Of Correction
The RD reviewed the current menu cycle for the remainder of this season. Menus, extensions, and diet consistencies were updated and signed by the RD and reviewed with the CDM. Extension sheets include portion sizes for all diets and combined guidance for Mechanical soft and Puree diets consistencies. For subsequent seasons, the RD will review and sign the menu, extensions, and consistencies. RD provided education to the CDM on menus, extensions, and diet consistency. The CDM will provide education to the dietary line staff on how to follow the menu, recipe, extensions, and portion size for each meal respectively. The RD/designee will complete audits of three meals a week for four weeks to ensure that the meal is prepared and served per the menu and with appropriate portion control. Audits will be taken to QAPI for review and discussion.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
Transitions Healthcare North Huntingdon was found to be non-compliant with the requirements for maintaining a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During an observation conducted on February 5, 2025, several deficiencies were noted throughout the facility. In resident rooms 123 W, 126 W, 119 W, and 203 D and W, there were issues such as peeling and scuffed paint, deep gashes in the walls, and peeling wallpaper. Additionally, the doors to the dietary department and the hallway wall underneath the dining room bulletin boards exhibited scuff marks, peeling paint, and broken plaster. Further observations revealed that the dining room had peeling paint on the walls, and the door jam leading to the outside courtyard had peeling plaster and lacked proper baseboard covering. The wooden handrails throughout the facility, particularly outside the dietary department and conference room, were found to have gashes with splintering wood and unfinished surfaces. These findings were confirmed during an interview with the Nursing Home Administrator and Maintenance Director, who acknowledged the facility's failure to maintain a homelike environment.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Areas identified during the survey have been repaired by placing InPro wall protection behind the headboards, painting and plastering as indicated, and sanding and staining as indicated. Areas repaired are as follows: - Resident room 123 W (window) the area behind the resident's bed headboard contained peeling and scuffed paint. - Resident room 126 W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint. - Resident room 119 W the area behind the resident's bed headboard contained peeling paint. - Resident room 203 D (door) and W the area behind the resident's bed headboard contained peeling wall paper. - The doors to the dietary department contained scuff marks and peeling paint. - The hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster. - The wall in the dining room contained peeling paint. - The door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering. - The wooden handrails contained gashes that contained splintering wood and non-smooth unfinished surfaces, located in the following hallways: outside the dietary department and outside the conference room. A schedule has been implemented to resurface and paint the remaining handrails in the facility. Project will be completed by July 31, 2025. A schedule has been implemented to place InPro wall protection behind an additional 33 beds. Project will be completed by July 31, 2025. The Maintenance Director will complete a facility walk thru audit. Any other areas identified will be repaired. The Administrator/designee will complete staff training on utilizing the TELS electronic maintenance system when environmental concerns are identified so the work can be completed in a timely manner. Environmental audits will be conducted by the NHA or designee weekly x 2, then monthly thereafter prior to the safety committee meetings. The Administrator will complete weekly audits of the progress of handrail resurfacing project and InPro wall protection project to ensure completion as scheduled. The Administrator/designee will complete a comparison audit of work needing completed against work completed to maintain a clean, comfortable and home-like environment. Audit will be completed weekly for two weeks. Results will be taken to the QAPI committee for review of findings and further interventions if indicated.
Facility Fails to Provide Private Space for Resident Group Meetings
Penalty
Summary
The facility failed to provide a private space for the resident group meetings, as evidenced by multiple interruptions during a Resident Group meeting held in the facility dining room. Despite signage indicating that a private meeting was in progress, facility staff entered the room 13 times to use it as a passageway, disrupting the meeting. When questioned by the surveyor, a staff member acknowledged the signage but stated she needed to access the front office. Additionally, a staff member was observed standing close to the dining room door, potentially overhearing the meeting, and had to be instructed to move further away. The issue of interruptions was corroborated by the Ombudsman, who confirmed that previous resident group meetings and training sessions had also been disrupted. The Nursing Home Administrator admitted that the facility layout included a connecting hallway, which staff could use instead of the dining room, acknowledging the failure to provide a private space for the resident group. This deficiency affected all ten residents involved in the group meeting.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated. This deficiency was identified for four out of five residents reviewed during the survey. The facility's policy, reviewed on multiple occasions, states that it is their intent to inform and provide residents with written information regarding their right to formulate advance directives. However, the clinical records for Residents R23, R65, R84, and R87 did not contain an advance directive or documentation indicating that these residents were given the opportunity to formulate one. Resident R23 was admitted with diagnoses including diabetes, depression, and high blood pressure, while Resident R65 had similar diagnoses. Resident R84 was admitted with pulmonary fibrosis, reduced mobility, and obesity, and Resident R87 was readmitted with scoliosis, difficulty speaking, and diabetes. Despite these varied and significant health conditions, there was no documentation in their clinical records to show that they were informed about or given the chance to create an advance directive. This was confirmed by Social Worker Employee E2 during an interview, who acknowledged the absence of such documentation in the clinical records of the mentioned residents.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for seven out of 20 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in late MDS assessments for several residents. Specific residents had MDS assessments completed past their due dates, with some assessments being overdue by several days. The deficiency was confirmed during interviews with the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator. The RNAC acknowledged the late assessments, attributing the issue to the previous RNAC leaving without notice, which led to multiple overdue assessments. The Nursing Home Administrator also confirmed the facility's failure to complete the MDS assessments on time for the affected residents. This deficiency was noted under the regulation 28 Pa. Code: 211.5(f) concerning clinical records.
Improper Storage and Disposal of Medications and Supplies
Penalty
Summary
The facility failed to ensure that medications and medication supplies were properly stored and disposed of in the Orchards medication room. During an observation, several expired items were found, including 57 vacutainers, multiple intravenous (IV) start kits, Povidone-iodine swabsticks, disposable scalpels, a bottle of glucometer testing solutions, and an opened, undated vial of insulin. The Director of Nursing confirmed the expiration of these items during an interview. Additionally, the Nursing Home Administrator acknowledged the facility's failure to properly store and dispose of these medications and supplies.
Failure to Maintain Call Light Equipment
Penalty
Summary
The facility failed to maintain call light equipment for five of seven residents. During observations, it was noted that the lights above the room doors for several residents were illuminated, but the nurses' station call light monitoring panel did not show these rooms as alarming. Interviews with Nurse Aides revealed that the monitoring panel was unreliable, with one stating, 'That doesn't work,' and another indicating it was 'hit or miss if it works.' The Director of Nursing confirmed the failure to maintain the call light equipment, which affected the residents' ability to signal for assistance effectively.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk for elopement. The resident, who had diagnoses of diabetes and coronary artery disease, was assessed as being at risk for elopement on 2/4/24. Despite this assessment, the resident was able to exit the building through an alarmed door, which was reset by a staff member who mistakenly assumed the alarm was triggered by an ambulance crew. The resident was later found by the Social Service Director near a gas station and expressed a desire not to return to the facility, exhibiting signs of mental distress and making threats of self-harm. The police were called, and the resident was transported to a hospital for a mental health evaluation. The incident revealed that the facility's procedures for monitoring and preventing elopement were not effectively implemented. The staff failed to properly respond to the door alarm, allowing the resident to leave the premises unnoticed. The facility's investigation confirmed that the resident exited through the ambulance entrance hallway and was not seen by the receptionist. This lapse in supervision and failure to follow elopement prevention protocols led to the resident's elopement and subsequent mental health crisis.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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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.
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