Transitions Healthcare Washington Pa
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Pennsylvania.
- Location
- 90 Humbert Lane, Washington, Pennsylvania 15301
- CMS Provider Number
- 395692
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Transitions Healthcare Washington Pa during CMS and state inspections, most recent first.
The facility failed to carry out its COVID-19 vaccination program as outlined in its infection control policy by not administering the vaccine to multiple residents after obtaining consent. Residents and/or their responsible parties were educated about the COVID-19 vaccine and signed consent forms, including newly admitted residents, but review of electronic MARs showed that the vaccine was not administered as consented. The DON confirmed that dozens of residents who had consented to vaccination had not received the COVID-19 vaccine.
A resident with significant mobility and medical needs, including a requirement for mechanical lift transfers with two staff, was transferred by a single nursing assistant without proper equipment. During the transfer, the resident sustained a 5 cm laceration to the shin after striking the wheelchair, requiring sutures. The nursing assistant was unaware of the resident's transfer requirements, leading to inadequate supervision and actual harm.
A resident with locked-in state was observed with bruising and pain on the right thumb, but nursing progress notes did not include documentation of an evaluation for these findings. The DON confirmed the lack of required documentation, resulting in incomplete clinical records.
A resident received medications publicly in the dining hall, contrary to the facility's policy for private administration. Additionally, two residents expressed fear of retaliation when voicing grievances, with one feeling discriminated against and another fearing neglect. The facility's administration confirmed these failures.
A facility failed to ensure a resident's drug regimen was free from unnecessary psychotropic medications without adequate indications for use. The resident received multiple antidepressants without a documented depression diagnosis in the MDS assessment. The Nursing Home Administrator and DON confirmed the oversight, indicating a failure to adhere to the facility's policy and relevant regulations.
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, affecting two smoke compartments. An observation revealed an excessive gap between the meeting edges of the doors leading to rooms 100-132, compromising their ability to resist smoke passage. This was confirmed by interviews with facility staff.
The facility was found to have mixed standard response and quick response sprinkler heads in the basement hallway, failing to meet automatic sprinkler system installation requirements. This was confirmed through observation and interviews with facility staff.
The facility failed to maintain the automatic sprinkler system, with deficiencies found in the Electrical Room/Maintenance Office and the laundry room. A large gap in the ceiling tile above an electrical panel and a missing escutcheon plate on a sprinkler head were observed. These issues were confirmed by the Facility Administrator, Maintenance Personnel, and the Plant Operations Director.
The facility failed to maintain corridor doors according to NFPA 101 standards, as four doors did not close and latch properly during an inspection. This deficiency was confirmed through interviews with facility staff.
The facility failed to maintain battery-operated carbon monoxide alarms according to the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. It was observed that the facility did not have an Evacuation and Alarm Protocols policy for the carbon monoxide detectors/alarms. This deficiency was confirmed in an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director, impacting the entire facility.
The facility did not ensure smoke dampers were inspected every four years as required by NFPA 105. Documentation review revealed the absence of inspection records, and interviews with facility staff confirmed the lack of available documentation.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for weekly inspections of battery electrolyte levels or voltage and monthly electrolyte specific gravity or conductance testing was missing. Interviews confirmed the lack of documentation, indicating non-compliance with NFPA standards.
Transitions Healthcare Washington PA failed to secure a medication cart, leaving it unlocked and unattended with various medications and medical supplies on top. The facility's policy requires that medication carts be locked when not attended by authorized personnel. Staff interviews confirmed the lapse in securing the cart and its contents, violating federal and state regulations.
A resident with severe cognitive impairment was physically abused by a nurse aide, who was witnessed striking the resident multiple times. The incident resulted in a visible injury, and the resident's care plan for managing agitation was not followed. The facility failed to protect the resident from abuse.
Failure to Administer COVID-19 Vaccine After Obtaining Resident Consent
Penalty
Summary
The facility failed to implement its COVID-19 vaccination program in a timely manner for multiple residents after obtaining consent for vaccination. Facility policy titled "Infection Control - Covid 19 Care and Management Policy, Section Vaccinations" dated 1/6/26 stated that residents are encouraged to remain up to date with all recommended COVID-19 vaccine doses and that newly admitted residents’ vaccination status is to be determined and a vaccine offered as recommended. Review of resident education and consent documents showed that residents and/or their responsible parties were educated about the COVID-19 vaccine and consent forms were completed on 9/29/25, 9/30/25, and upon admission during the period of 12/22/25 through 1/7/26. During this timeframe, 48 resident consent forms were completed for administration of the vaccine. However, review of the electronic medication administration records revealed that the facility did not administer the COVID-19 vaccine at the time the consent forms were completed, and the vaccinations were not provided as consented. This failure affected 30 of 105 residents on 9/29/25, five of 108 residents on 9/30/25, 10 residents admitted between 12/22/25 and 1/7/26, and three residents whose consent forms were undated. During an interview on 1/28/26 at 12:15 p.m., the DON confirmed that as of that date, the facility had failed to provide 48 residents the COVID-19 vaccine despite having obtained consent from the residents or their responsible parties, in violation of 28 Pa Code: 201.18(b)(1) Management.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and follow established transfer protocols, resulting in actual harm to a resident. The resident, who had diagnoses including anxiety, spinal stenosis, muscle weakness, and syncope, required substantial/maximal assistance for transfers and had a physician order and care plan specifying transfer with a mechanical lift and the assistance of two staff members. Despite these documented requirements, the resident was transferred from bed to wheelchair by a single nursing assistant without the use of a mechanical lift. During this transfer, the resident's left shin struck the wheelchair leg rest, causing a 5 cm laceration that required hospital treatment and sutures. The nursing assistant involved stated that the transfer was performed alone because the resident indicated that one person could assist her, and the assistant was unaware of the resident's need for a mechanical lift. Review of facility policies and the resident's care plan confirmed that the transfer should have been performed with two staff and a mechanical lift. The incident was identified as past non-compliance, and interviews with staff and facility leadership confirmed the failure to provide adequate supervision and adherence to transfer protocols, resulting in injury.
Incomplete Documentation of Resident Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a resident with a diagnosis of locked-in state was admitted with ongoing complex care needs. An incident report noted that the resident was observed with bruising and a complaint of pain on the right thumb. However, a review of the resident's nurse progress notes revealed there was no documentation of an evaluation for the bruising and pain. The Director of Nursing confirmed that the required documentation was missing, indicating that the facility did not maintain complete clinical records as required by policy and regulation.
Failure to Uphold Resident Privacy and Address Grievances
Penalty
Summary
The facility failed to uphold the privacy and dignity of a resident, identified as R77, during medication administration. Despite the facility's policy requiring medications to be administered in private, R77 was observed receiving both pills and liquid medications in the dining hall while awaiting a Resident Group meeting. This was confirmed by both a Licensed Practical Nurse and a Registered Nurse, who acknowledged that there was no order or care plan allowing for medication administration outside of the resident's room. Additionally, the facility did not ensure that residents could voice grievances without fear of retaliation. Three residents expressed concerns about potential retaliation when voicing complaints. One resident felt discriminated against and feared not receiving assistance or being able to arrange transportation for an event. Another resident was hesitant to be interviewed until assured of anonymity, fearing that speaking up would lead to neglect or mistreatment by staff. The Nursing Home Administrator and Director of Nursing confirmed these failures in upholding resident rights.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically psychotropic drugs, without adequate indications for use. The facility's policy on the Behavioral Health Program mandates that psychotropic medications should only be used when necessary to treat a specific diagnosed and documented condition. However, a review of Resident R50's records revealed that the resident was receiving multiple antidepressant medications, including Mirtazapine, Trazodone, and Duloxetine, without a documented diagnosis of depression in the Minimum Data Set (MDS) assessment. This indicates a lack of adherence to the facility's policy regarding the use of psychotropic medications. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the oversight in ensuring that the resident's drug regimen was free from unnecessary medications. The deficiency was identified for one of five residents reviewed, highlighting a failure in the facility's processes to adequately document and justify the use of psychotropic medications. The report cites specific Pennsylvania Code regulations related to the responsibility of the licensee, physician services, pharmacy services, and nursing services, which were not adhered to in this instance.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors in compliance with NFPA 101 standards, specifically affecting two of nine smoke compartments. During an observation on March 19, 2025, at 11:40 a.m., it was noted that the smoke barrier doors leading to rooms 100-132 (ICF-1) had an excessive gap between the meeting edges. This gap compromised the doors' ability to resist the passage of smoke, which is a critical safety requirement. An interview conducted with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director at 12:30 p.m. on the same day confirmed the presence of the excessive gap. This deficiency indicates a failure to ensure that the smoke barrier doors met the necessary standards to prevent smoke passage, as required by the 2012 NFPA 101 code for existing buildings.
Plan Of Correction
1. The smoke door on ICF 1 is being evaluated by the vendor for repair or replacement if indicated. 2. No other smoke doors were identified with gaps. 3. The Director of Plant operations or designee will audit smoke barrier doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Sprinkler System Installation Deficiency
Penalty
Summary
The facility failed to maintain automatic sprinkler system installation requirements as evidenced by the presence of mixed standard response and quick response sprinkler heads in the basement hallway. This deficiency was identified during an observation conducted on March 19, 2025, between 10:35 a.m. and 10:55 a.m. The issue was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day at 12:30 p.m.
Plan Of Correction
1. Sprinkler heads were converted so that all sprinkler heads were standardized to the quick response sprinkler head. 2. No other variant sprinkler heads were identified within the facility. 3. The Director of Plant operations or designee will audit sprinkler heads to ensure that they are all the quick response sprinkler heads monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in two instances during an inspection of over 30 rooms. The first deficiency was observed in the Electrical Room/Maintenance Office, where a large gap in the ceiling tile above an electrical panel was noted. This gap could potentially allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The second deficiency was identified in the laundry room, where a sprinkler head was missing an escutcheon plate near the washing machines. These deficiencies were confirmed during an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director.
Plan Of Correction
1. The ceiling tile in the electrical/maintenance office was replaced so no gap exists. The escutcheon plate was replaced in the laundry room. 2. No further ceiling tiles were identified that had a gap. No other escutcheon plates were identified as missing. 3. The Director of Plant operations or designee will audit ceiling tiles and escutcheon plates monthly x 3 months. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Failure to Maintain Corridor Doors
Penalty
Summary
The facility failed to maintain corridor doors in compliance with NFPA 101 standards, as evidenced by observations made during a survey. Specifically, four out of more than 40 corridor doors inspected did not close and latch properly. This deficiency was identified during an inspection on March 19, 2025, when surveyors observed that the doors to resident rooms 124, 125, and 134 did not close and latch when tested. The deficiency was confirmed through an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director on the same day. The report highlights that the corridor doors are required to resist the passage of smoke and have positive latching hardware, which was not met in these instances. The failure to maintain these doors could potentially compromise the safety standards set for the facility.
Plan Of Correction
1. The doors of room 124, 125 and 134 had the hinges tightened and the transitions trips have been exchanged to ensure an easy closure of the door. 2. No other doors were identified as not latching. 3. The Director of Plant operations or designee will audit the latching of doors monthly x 3 months. 4. Audits will be taken to the safety committee and submitted to the QAPI committee for review of findings and further interventions are warranted.
Failure to Implement Carbon Monoxide Alarm Protocols
Penalty
Summary
The facility was found deficient in maintaining battery-operated carbon monoxide alarms as per the 2016 Act 48-Care Facility Carbon Monoxide Alarms Standards Act. During an observation on March 19, 2025, it was noted that the facility had not developed or implemented an Evacuation and Alarm Protocols policy for the carbon monoxide detectors/alarms. This deficiency was confirmed in an interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director, indicating a failure to comply with the required safety standards, affecting the entire facility.
Plan Of Correction
1. The facility has a Carbon Monoxide Evacuation and alarm policy that has been effective since 6/1/2018. 2. The Director of Operations provided education to the Nursing Home Administrator and Director of Plant Operations as to the location of this policy. 3. The policy will be reviewed by the Safety committee and a carbon monoxide alarm drill will be conducted. 4. Additionally, the policy was taken to QAPI for review and placed in the emergency preparedness binder.
Failure to Inspect Smoke Dampers Within Required Period
Penalty
Summary
The facility failed to ensure that smoke dampers were inspected within the required four-year period, as mandated by NFPA 105, Standard for the Installation of Smoke Door Assemblies and Other Opening Protectives. During a documentation review on March 19, 2025, it was discovered that the facility lacked the necessary documentation to confirm that these inspections had been conducted. An interview with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director further confirmed that the smoke damper inspection documentation was not available at the time of the survey.
Plan Of Correction
1. The damper inspection was completed on 2/27/2025 and a copy of the inspection was obtained from the vendor and is maintained at the facility. 3 motors were installed 3/10/24 and all dampers had passed inspection. 2. Education was completed by the NHA to the Director of Plant Operations on keeping documents in an orderly binder. 3. The document was placed in the life safety binder. 4. TELS was updated to reflect the next 4-year scheduled inspection due date.
Failure to Maintain Emergency Generator Documentation
Penalty
Summary
The facility failed to maintain and inspect the emergency generator as required, which affected the entire facility. During a document review on March 19, 2025, it was found that the facility could not provide documentation for weekly inspections of battery electrolyte levels or battery voltage. Additionally, there was no documentation for monthly electrolyte specific gravity or conductance testing. Interviews with the Facility Administrator, Maintenance Personnel, and the Plant Operations Director confirmed the absence of the necessary documentation at the time of the survey. This lack of documentation indicates a failure to adhere to the maintenance and testing protocols outlined in NFPA 101 and related standards, which are critical for ensuring the reliability of the emergency power system.
Plan Of Correction
1. The facility generator runs on a maintenance free battery. A battery voltage testing device has been obtained. The maintenance director or designee will conduct weekly battery voltage testing and monthly conductive testing and document the findings. 2. No other generator documentation was identified as missing. 3. Education was provided to the Maintenance Director on K918 and the weekly and monthly testing has been added to the TELS system. 4. The Director of Plant operations or designee will battery voltage and conductive testing monthly x 3 months.
Medication Cart Security Lapse
Penalty
Summary
Transitions Healthcare Washington PA was found to be non-compliant with federal and state regulations regarding the labeling and storage of drugs and biologicals. During an abbreviated survey conducted in response to a complaint, it was observed that a medication cart, referred to as 'A' cart, was left unlocked and unattended. The computer screen on the cart was open to the electronic medication administration record, which should have been secured. On top of the cart, there were various medications and medical supplies, including a pair of scissors, a bottle of Miralax, 13 bottles of over-the-counter medications, six bottles of liquid prescription medication, an intravenous antibiotic solution bag, and four medication blister packs. Interviews with staff revealed a lack of adherence to the facility's policy on medication storage. A Licensed Practical Nurse (LPN) acknowledged that the bottles on the cart were over-the-counter medications, while the Assistant Director of Nursing confirmed that medication carts should be secured when unattended, and medications should be stored inside the cart. The failure to secure the medication cart and its contents was a direct violation of the facility's policy and federal regulations, which require that drugs and biologicals be stored in locked compartments and only accessible to authorized personnel.
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. Immediately upon identification, all biologicals identified were secured including the scissors. The cart was locked, and the computer screen closed. The four other medication carts were checked and no other concern identified. Employee 1 was immediately provided education on the storage of biologicals policy and procedure. Education on the storage of biologicals policy and procedure has been completed with the licensed staff. On March 4, 2025, the Director of Nursing initiated visual cart inspections five days a week for four weeks. Results of audits will be taken to the next QAPI meeting on March 14, 2025, for review/discussion.
Resident Abuse Incident in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a nurse aide (NA) who was witnessed striking a resident multiple times. The resident, who had severe cognitive impairment due to dementia, was unable to defend herself or report the abuse effectively. The incident was observed by another NA, who reported that the abusive NA restrained the resident by holding her arms down and then slapped her in the face several times. This resulted in a visible abrasion on the resident's nose. The resident's care plan included strategies for managing agitation, such as allowing the resident to de-escalate and guiding her away from sources of distress. However, there were no documented behavioral symptoms in the days leading up to the incident, suggesting that the resident was not exhibiting combative behavior at the time. The facility's failure to ensure the resident's safety and adherence to the care plan contributed to the occurrence of the abuse.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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