Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Twin Lakes Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to obtain RN assessment after coffee spill burn: A resident who was cognitively intact and independent in eating spilled hot coffee on himself after staff served it in a large Styrofoam cup. A nurse aide reported the spill to the nurse, and a later note identified the skin area as a burn, but there was no documented RN assessment of the injury; the DON stated an RN should have assessed the resident.
A resident with several wounds and intact cognition had a physician order for left leg wound care that included cleansing, triamcinolone 0.1%, Hydrofera blue, and a dry dressing. During observed wound care, an RN cleansed the wound and applied Hydrofera blue and gauze, but did not apply the triamcinolone as ordered. The RN acknowledged the omission, and the DON confirmed the cream should have been applied.
Unsafe Serving of Hot Liquids: A resident who was cognitively intact and independent in eating was served hot coffee in a large Styrofoam cup instead of the adaptive cup specified in his care plan. While staff assisted another resident, he spilled the coffee on himself while wearing only a brief, and the DON stated he should have been served hot liquids in the equipment required by his care plan.
Failure to provide ordered adaptive drinking equipment: A resident who was cognitively intact and independent in eating had a care plan requiring a one-handled cup with a straw lid for beverages, but staff served hot coffee in a large Styrofoam cup instead. The resident spilled the coffee on himself, and an aide stated she was not aware of the resident’s adaptive cup requirement; the DON confirmed the resident should have been served hot liquids in the appropriate equipment.
Improper infection control during wound care. An RN provided wound care for a resident with several wounds and did not follow the ordered treatment for a left leg wound. During the procedure, she removed the old dressing and then continued care without changing gloves or performing hand hygiene before applying the new dressing, and she also omitted the ordered triamcinolone cream. The DON confirmed the glove change and hand sanitization should have occurred between dressing removal and application of the new dressing.
A resident who was cognitively intact and required assistance with ADLs was admitted with a full set of dentures documented on the inventory sheet. Later, the resident’s dentures went missing and a grievance was filed reporting the loss, with the facility indicating it would reimburse the family for replacement. The resident’s son followed up with social services and provided the dentist’s contact information, and an invoice for replacement dentures was emailed to the main office. Despite this, the facility did not complete payment or otherwise resolve the grievance within the time frame required by its grievance policy, leaving the issue unresolved for an extended period.
The facility failed to keep the main kitchen stove/oven in working order, resulting in altered meal preparation for residents over an extended period. During a lunchtime observation, the stove/oven was found nonfunctional and staff were serving cold ham and cheese sandwiches instead of hot meals. The cook stated the stove/oven had been out of service for over 2 months and that the menu had been changed for more than a month, causing resident dissatisfaction. The Dietary Manager and the Nursing Home Administrator both confirmed that the stove/oven had been down for over a month and described unsuccessful attempts to replace it due to incompatible gas and electrical hookups.
The facility failed to follow and document ordered pressure ulcer treatments for two residents with buttock pressure injuries. One resident with a stage 4 ulcer and a history of stroke had physician orders for daily wound cleansing, iodoform packing, silicone border dressing, and later zinc oxide to the peri-wound, but the TAR lacked evidence that treatments were completed on multiple days. Another resident with dementia and bilateral buttock ulcers had wound care recommendations for cleansing, zinc oxide application, and dry or bordered gauze dressings with daily and PRN changes; instead, documentation showed the wounds left open to air on several days and later recorded treatments three times daily, inconsistent with the ordered frequency. The DON and ADON confirmed the absence of documentation that ordered or recommended wound treatments were carried out as specified.
Emergency exit doors on two units were found secured shut with zip ties and rolled gauze, preventing egress. Staff, including nurses, aides, and maintenance, were unaware of the obstructions, which were likely put in place to stop frequent alarms caused by high winds. The facility's policy required exits to remain unobstructed, but the deficiency was only discovered during a survey, placing residents in immediate jeopardy.
Facility administration and the DON failed to ensure emergency exit doors were accessible, as doors were secured with zip ties and rolled gauze, preventing resident egress during emergencies. This resulted in Immediate Jeopardy and was cited under F689 and state regulations.
A resident with a feeding tube, tracheostomy, and swallowing difficulty had physician orders for several medications written as by mouth, while staff administered medications through the feeding tube. The record showed no documentation that the route orders were clarified, and the resident, an LPN, and the DON all confirmed the resident did not take medications by mouth and that the orders should have been clarified.
Food was not served in a palatable condition after residents reported that meat and potatoes were repeatedly overcooked, dry, and tough to chew. During a kitchen observation, a test tray of Salisbury steak was found to be hard and crispy around the edges and tough to cut, and the Dietary Manager confirmed the oven heated unevenly, causing the edges to cook before the middle.
Food was not served under sanitary conditions because the facility did not document required sanitizer temperature or chemical checks for each meal. The kitchen observation showed the 3-compartment sink in use with utensils and pans drying on the counter, while the sanitizer log had no evidence of checks for multiple meals. The Dietary Manager confirmed the missing documentation.
A resident with seizures, stroke, incontinence, and impaired mobility was observed lying in bed requesting pain medication, but her call bell was placed on top of the bed and out of reach. The resident said she did not know where it was, and the RN supervisor and DON confirmed it should have been within reach.
The facility failed to complete comprehensive admission MDS assessments within the required timeframe for five residents. Review of clinical records showed that several admission MDSs were completed at or beyond the 14-day limit, including one completed 22 days after admission, and the DON confirmed the assessments were not completed on time.
Failure to develop a dental care plan for a resident with oral care needs. The MDS showed the resident needed help with ADLs, including oral care, and a physician order noted planned dental extractions with required pre-testing. Record review found no care plan for the resident’s dental problems, and the resident reported missing teeth, dental caries, and misaligned front teeth. The DON confirmed no care plan was in place.
A resident with cognitive impairment, dementia, anxiety, and psychosis had quetiapine discontinued, but the care plan was not revised to reflect the change. The existing care plan still identified the resident as being at risk for adverse effects related to antipsychotic medication, and the DON confirmed the update was missed.
A resident with DM and onychomycosis did not receive timely podiatry care after being placed on the podiatry list for routine follow-up. When observed later, all toenails were mycotic and overgrown, and both great toes were wrapped with dry dressings. The DON confirmed the resident should have been seen when the podiatrist visited but was not.
A resident who used a walker or wheelchair and required assistance from two staff members fell forward out of a wheelchair during transport when her footrests/leg rests were not in place. The resident, who had a hx of Covid pneumonia, bilateral stasis dermatitis, and TIA, sustained bleeding from her nose and upper lip. The aide reported the resident asked to use the bathroom and was pushed back to her room, and the DON confirmed the resident should have been transported with leg rests in place.
A resident with a feeding tube, tracheostomy, and opioid pain orders had fentanyl patches removed and replaced by an LPN, but the old patches were discarded in the resident’s waste basket instead of being destroyed per policy. MAR and controlled drug count records showed repeated patch changes with no documented evidence that two staff witnessed and signed the destruction of the removed patches, and the RN supervisor and DON confirmed the required disposal process was not followed.
A resident with atrial fibrillation and an anticoagulant care plan received Coumadin in excess of the physician’s order on two consecutive nights, with the MAR showing 5 mg plus an additional 2.5 mg each night. The resident was later noted to be bleeding, an INR was elevated at 3.2, and the ADON confirmed the incorrect dose and medication error.
QAPI Committee Failed to Address Repeated Care Planning and Order Clarification Deficiencies. The facility’s QAPI committee did not successfully implement prior plans of correction tied to repeated deficiencies involving accommodation of a resident’s needs, individualized care plans, care plan revisions, and clarification of questionable physician orders. Current survey findings showed the same issues recurred despite prior audits and QAPI review.
A resident did not have their heart rate checked prior to receiving Metoprolol Tartrate as ordered, and was given Insulin Aspart on multiple occasions when their blood glucose was below the physician-ordered threshold. These actions were not in accordance with the facility's medication administration policy and physician's orders, as confirmed by facility leadership.
A resident with respiratory failure and a tracheostomy experienced hypoxia, prompting an LPN and RN to intervene and obtain urgent physician orders for diagnostic tests. However, there was no documentation in the clinical record explaining the change in condition or the rationale for the orders, as confirmed by facility leadership.
The facility did not meet the required NA-to-resident staffing ratios on certain days. On one occasion, the evening shift had 129 residents requiring 11.73 NAs, but only 11.07 were available. Another day, the day shift had 128 residents needing 12.80 NAs, but only 10.73 were present, and the evening shift required 11.64 NAs, but only 9.47 were available. No additional staff were available to cover these deficiencies.
The facility did not meet the required 3.20 hours of direct resident care per resident on two days, providing only 2.99 and 2.83 hours on those days. This was confirmed through nursing schedules and an interview with the Nursing Home Administrator.
The facility failed to meet the required LPN-to-resident staffing ratios on several occasions, with insufficient LPNs available during day, evening, and night shifts. The deficiency was confirmed through a review of nursing schedules and staff interviews, with no additional higher-level staff available to compensate for the shortfall.
Twin Lakes Rehabilitation and Healthcare Center failed to communicate critical lab results for a resident diagnosed with C-diff to the admitting facility during a transfer. The resident, who required assistance for daily care and had debilitating cardiorespiratory conditions, was transferred without the necessary documentation of their positive C-diff test results. This deficiency was confirmed by the DON, highlighting a breach in ensuring a safe and effective transition of care.
A facility failed to notify a physician of abnormal lab results for a resident with debilitating cardiorespiratory conditions. Despite a positive C-difficile toxin result, there was no documentation that the physician was informed, violating the facility's policy and regulatory requirements.
The facility failed to follow physician's orders for two residents with feeding tubes by not documenting the residual volumes during tube placement checks. Despite verifying tube placement, staff did not record the residual amounts as required, which was confirmed by the DON. Both residents were cognitively impaired and needed assistance with daily care tasks.
The facility failed to flush IV catheters according to policy for three residents. A resident with an infection had no documented measurements of catheter length and arm circumference. Two residents receiving IV antibiotics lacked documentation of catheter flushing before and after medication administration. The DON confirmed these documentation lapses.
The facility failed to ensure timely physician visits for three residents, resulting in gaps of over 100 days between visits. A resident with dementia and COPD, another with an indwelling catheter and End-Stage Renal Disease, and a third with dementia and bipolar disorder were not seen by a physician or delegate within the required 60-day intervals. The DON confirmed the lack of documentation and noted the absence of a physician's assistant or nurse practitioner to assist the physician.
The facility failed to provide scheduled showers to two residents, both cognitively intact and requiring assistance with bathing. One resident, with rheumatoid arthritis, was supposed to receive showers twice a week but only received them sporadically, while the other, with a traumatic brain injury, was only given showers once a week despite preferring twice-weekly showers. These failures were confirmed by the DON.
The facility failed to provide appropriate care for residents with indwelling urinary catheters and a nephrostomy tube. One resident lacked documented catheter care on specific shifts, while another had their catheter bag in contact with the floor. Additionally, a resident with a nephrostomy tube had no physician's orders for its care. These deficiencies were confirmed by the nursing staff.
The facility failed to ensure that residents and/or their representatives were informed and assisted in developing advance directives. Four residents, including those with dementia, mental health disorders, and physical impairments, had no documented evidence of being informed about their rights to create advance directives. The Nursing Home Administrator confirmed the oversight and acknowledged the need for improvement in addressing advance directives during care conferences.
The facility did not complete a criminal background check for a newly hired nurse aide, contrary to its policy on abuse prevention. The policy requires background checks to prevent hiring individuals with histories of abuse or neglect. The Human Resource Director confirmed the oversight, as the nurse aide was hired without the necessary check.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers for four residents. These residents, with varying cognitive and medical conditions, were transferred due to acute health issues such as lethargy, emesis with blood, respiratory distress, and sepsis. The Nursing Home Administrator confirmed the lack of documented written notices for these transfers.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in documenting treatments and care needs. Errors included incorrect recording of anticoagulant and opioid administration, oxygen therapy, care rejection, and discharge status. These inaccuracies were confirmed through staff interviews.
The facility failed to develop care plans for two residents, one receiving an anticoagulant and another with complex medical needs including a nephrostomy. The lack of care plans was confirmed by the DON.
The facility failed to update care plans for two residents. One resident's care plan inaccurately reflected ongoing anticoagulation therapy despite a medication change from Eliquis to Aspirin. Another resident's care plan did not reflect the use of a Foley catheter, instead indicating urinary incontinence, despite observations confirming catheter use. These discrepancies were confirmed by the DON.
A resident in a long-term care facility was left without hearing aids due to a series of communication lapses and inactions by the staff. The resident's right hearing aid was smashed, and both were taken for repair, but no follow-up was conducted. The Social Worker and Business Office Manager were unaware of the resident's need for new hearing aids, and the Social Services Director forgot to follow up with the audiologist, resulting in the resident being unable to communicate effectively.
A facility failed to provide trauma-informed care for a resident with PTSD, anxiety, depression, and schizophrenia. The facility's policy required assessments to identify traumatic triggers, but no such assessment was completed for the resident. This deficiency was confirmed by the DON.
The facility did not complete annual performance evaluations for two nurse aides as required by their policy. The evaluations were due based on hire dates but were not conducted, which was confirmed by the DON.
A resident with dementia and bipolar disorder was on antipsychotic and antidepressant medications. Despite pharmacy recommendations for dose reductions in March and June, there was no evidence that these were addressed. The DON confirmed the lack of documentation.
The facility failed to properly store and label medications, including not having a permanently affixed compartment for controlled drugs, not discarding expired inhalers, and not labeling insulin vials. Additionally, medications were left unsupervised and unlabeled at the bedside of two residents, which was confirmed as inappropriate by the DON.
A facility failed to maintain complete and accurate clinical records for a resident with COPD and GERD. The resident's care plan required monitoring of food intake due to potential weight changes, but documentation was missing for several meals over three months. The DON confirmed the absence of records, violating professional standards.
The facility's QAPI committee failed to address recurring deficiencies effectively, with repeated issues in MDS accuracy, care plan creation and updates, quality of care, and tube feeding management. Despite developing plans of correction, the committee did not successfully implement these plans, leading to ongoing non-compliance with nursing home regulations.
The facility failed to maintain two of three laundry dryers in safe operating condition, as there was an accumulation of lint in the compartment above the dryer drum where the gas line entered the back of the dryer. This was confirmed by the Director of Environmental Services and the Director of Maintenance, who stated that the dryers were last cleaned a month prior.
A resident requested lab work, which was completed, but the results were not reviewed with her. The resident was alert and oriented, and the DON confirmed the oversight.
The facility failed to assess residents for their ability to self-administer medications safely. An LPN left medication unsupervised for a resident without observing its intake, and two other residents were found with unsupervised medication on their overbed tables. The Director of Nursing confirmed that no assessments were conducted to determine if these residents could safely self-administer their medications.
Failure to Obtain RN Assessment After Coffee Spill Burn
Penalty
Summary
The facility failed to ensure that a professional assessment was completed by a registered nurse after a resident spilled hot coffee on himself and developed a new skin area identified as a burn. Resident 1’s quarterly MDS dated April 23, 2026 described the resident as cognitively intact, always understood and always understood others, and independent in eating. The resident’s care plan dated September 24, 2025 noted that he required a one-handled cup with a straw lid for beverages. A nurse’s note dated May 7, 2026 stated that a nurse was asked to assess a new skin area on Resident 1, and the nurse identified the wound as a burn related to a coffee spill on May 6, 2026. A nurse aide stated that she made coffee for Resident 1 and his roommate, poured it into large Styrofoam cups, and helped Resident 1 add sugar and cream before turning to assist the roommate; she then heard Resident 1 react and saw that he had spilled coffee over the front of his legs while wearing only a brief. She reported the spill to the nurse. The record contained no documented evidence that Resident 1 was assessed for burns related to the coffee spill, and the DON stated that a registered nurse should have assessed him after the spill.
Failure to Follow Ordered Wound Treatment
Penalty
Summary
The facility failed to ensure that physician-ordered wound care was followed for one resident with several wounds. The resident’s quarterly MDS dated April 23, 2026, indicated the resident was cognitively intact, always understood and was always understood by others, and had several wounds. The care plan dated March 16, 2026, stated that treatments should be applied per physician’s orders. A physician’s order dated May 6, 2026, directed staff to cleanse the left leg wound with wound cleanser, pat dry, apply triamcinolone 0.1%, then Hydrofera blue, and secure with a dry dressing. During observed wound care on May 14, 2026, an RN cleansed the wound, applied Hydrofera blue, and covered it with secured gauze, but did not apply the triamcinolone cream as ordered. The RN acknowledged she did not apply the cream, and the DON stated the RN should have applied it as ordered.
Unsafe Serving of Hot Liquids
Penalty
Summary
The facility failed to ensure a safe environment for one resident when hot coffee was served in a large Styrofoam cup instead of the one-handled cup with a straw lid identified in the resident’s care plan. The resident’s quarterly MDS dated April 23, 2026 showed that he was always understood, always understood others, cognitively intact, and independent in eating. His care plan dated September 24, 2025 specified that he required a one-handled cup with a straw lid for beverages. An investigation dated May 7, 2026 found that the resident spilled a cup of coffee on himself after being served coffee in a large Styrofoam cup. A nurse aide stated that she made coffee for the resident and his roommate, poured both into large Styrofoam cups, and served them. She helped the resident add sugar and cream, then turned to assist the roommate and heard the resident exclaim before noticing coffee spilled over the front of his legs while he was wearing only a brief. The DON stated that the resident should have been served hot liquids in the adaptive equipment required by his care plan.
Failure to Provide Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure that staff provided assistive drinking equipment in accordance with a resident’s care plan for one resident reviewed. The resident’s quarterly MDS assessment dated April 23, 2026, indicated that he was cognitively intact, always understood and was always understood by others, and was independent in eating. His care plan, dated September 24, 2025, specified that he required a one-handled cup with a straw lid for beverages. An investigation into a coffee spill found that on May 6, 2026, the resident was served coffee in a large Styrofoam cup instead of the adaptive cup identified in his care plan. After being served the coffee, he spilled it on himself. A nurse aide stated that she poured coffee into large Styrofoam cups for the resident and his roommate, helped add sugar and cream, and was not aware that the resident required a one-handled cup with a straw lid. The DON confirmed that the resident should have been served hot liquids in the adaptive equipment required by his care plan.
Improper infection control during wound care
Penalty
Summary
The facility failed to use proper infection control practices during wound care for one of four residents reviewed. The resident had several wounds, was cognitively intact, and was always understood and always understood others. Physician orders for the left leg wound directed staff to cleanse the wound with wound cleanser, pat dry, apply triamcinolone 0.1%, then Hydrofera blue, and secure with a dry dressing. During observed wound care, the RN washed her hands, donned gloves, removed the old dressing, cleansed the wound, applied Hydrofera blue, and covered the wound with gauze, but did not apply the triamcinolone cream. The RN also did not change her gloves or perform hand sanitization after removing the dirty dressing and before applying the new wound dressing, which she later acknowledged should have been done. The DON confirmed that the RN should have changed gloves and performed hand sanitization between removing the dirty dressing and applying the new dressing.
Failure to Timely Resolve Grievance Regarding Missing Dentures
Penalty
Summary
The facility failed to honor a resident’s right to have grievances promptly resolved when it did not complete resolution of a grievance regarding missing dentures within the time frame specified in its own policy. The facility’s grievance policy, dated April 8, 2026, stated that residents and family members may file a grievance and that grievances will be resolved within five working days. Resident 2’s comprehensive MDS assessment dated December 17, 2025 showed the resident was cognitively intact, required assistance with daily care needs, and had a full set of dentures, and the resident’s inventory sheet dated December 11, 2025 documented that a full set of dentures was present at admission. A grievance filed on December 29, 2025 reported that the resident’s dentures had been missing since that morning, and the grievance findings indicated the facility would reimburse the family for the missing dentures. A social services note dated January 9, 2026 documented that the resident’s son inquired about the status of the missing dentures and provided the name and phone number of the dentist. The Nursing Home Administrator later stated that the main office was emailed the invoice with the amount and address for payment to replace the dentures on February 20, 2026, but as of April 17, 2026 the invoice had not been paid and the grievance remained unresolved. This deficiency was cited under 28 Pa. Code 201.29(i) Resident rights and 28 Pa. Code 211.12(d)(5) Nursing services.
Failure to Maintain Functional Kitchen Stove/Oven for Resident Meal Service
Penalty
Summary
The facility failed to maintain essential kitchen equipment in working condition when the main stove/oven in the kitchen was not operational for over a month. During a kitchen observation at lunchtime, surveyors noted that the main stove/oven was not working and that lunch being prepared consisted of a cold ham and cheese sandwich instead of a hot meal. The cook reported that the stove/oven had been nonfunctional for over 2 months and that the residents’ menu had been altered for over a month due to the lack of a working stove/oven, resulting in resident dissatisfaction with the meals. The Dietary Manager confirmed that the stove/oven had been down for over a month and explained that a replacement stove with a gas hookup had been ordered but could not be used because the facility was not set up for gas, and that a subsequent replacement with an electric hookup did not match the required wattage. The Nursing Home Administrator also confirmed that the stove/oven was not working and had not been working for over a month. No specific individual residents, their medical histories, or clinical conditions at the time of the deficiency are described in the report, other than the general statement that residents were unhappy with the altered menu.
Failure to Follow and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that ordered pressure ulcer treatments were provided and documented for two residents with pressure injuries. For one resident, an admission change MDS dated December 30, 2026, showed the resident was cognitively intact, had a stage 4 pressure ulcer on admission, required staff assistance for daily care, and had a medical history including stroke. Physician orders dated January 6, 2026, directed that the left buttock wound be cleansed with wound cleanser, patted dry, packed with iodoform packing strip, and covered with a silicone border every dayshift. Review of the January 2026 Treatment Administration Record (TAR) showed no documented evidence that these treatments were completed as ordered on January 12 and January 18, 2026. Subsequent physician orders for the same resident dated January 19, 2026, added application of zinc oxide paste to the peri-wound area while continuing cleansing, packing with iodoform, and covering with a silicone border every dayshift. Review of the January 2026 TAR again revealed no documented evidence that these updated treatments were completed as ordered on January 24 and January 25, 2026. The Director of Nursing confirmed on February 4, 2026, that there was no documented evidence that the resident’s wound treatments were completed on the identified dates. For another resident, a quarterly MDS dated December 20, 2025, indicated the resident was cognitively intact, required staff assistance for daily care, had pressure ulcers, and had dementia. Skin and wound notes dated December 22, 2025, January 2, 2026, and January 9, 2026, documented wound care recommendations for right and left buttocks pressure ulcers: cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with a dry dressing, and change daily and as needed. However, the January 2026 TAR showed that from January 1 through January 12, the wounds were documented as being left open to air with no dry dressing. A skin and wound note dated January 26, 2026, revised recommendations to cleanse with wound cleanser or normal saline, apply zinc oxide paste to the wound base, secure with bordered gauze, and change daily and as needed, but the January 2026 TAR documented the treatment as being completed three times a day from January 26 through February 3, 2026, rather than as ordered. The Assistant Director of Nursing confirmed there was no documented evidence that the wound care consultant’s recommendations were followed as ordered.
Emergency Exit Doors Obstructed with Zip Ties and Gauze
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.
Removal Plan
- Removed the zip ties and rolled gauze that secured the emergency exit doors shut
- Inspected all doors to ensure proper functioning
- Educated all staff on emergency doors and route of egress and the facility's policy that all emergency exit doors should be unobstructed
- Maintenance checks all exit doors for proper functioning
Failure to Maintain Accessible Emergency Exits Creates Immediate Jeopardy
Penalty
Summary
Facility administration, including the Nursing Home Administrator and Director of Nursing (DON), failed to ensure that emergency exit doors were accessible to residents, thereby not allowing egress to the outside during an emergency situation. This was determined through a review of policies, employee job descriptions, observations, and staff interviews. The job description for the Administrator included responsibilities such as maintaining a safe environment and implementing an effective accident prevention program, while the DON was responsible for ensuring compliance with safety regulations and maintaining safe resident care areas. Despite these outlined duties, emergency exit doors were found to be secured shut with zip ties and rolled gauze, preventing their use in emergencies. This failure to maintain accessible emergency exits was observed on specific units and resulted in Immediate Jeopardy to the health and safety of residents. The deficiency was cited under federal and state regulations, specifically referencing F689 (Accidents) and relevant Pennsylvania codes. The report does not mention any specific residents or their medical conditions, but it clearly documents a systemic lapse in administrative oversight and resource allocation necessary to ensure resident safety during emergencies.
Unclear Medication Route Orders Not Clarified
Penalty
Summary
The facility failed to clarify questionable physician’s orders for one resident who was cognitively intact, had a feeding tube, received tube feedings, was on a mechanically altered diet, had a tracheostomy, and had diagnoses including chronic respiratory failure, malignant neoplasm of the oropharynx, and acquired absence of the larynx. The resident’s quarterly MDS also noted scheduled routine pain medications, complaints of difficulty or pain when swallowing, and use of opioid medications. Physician’s orders included Trazadone 100 mg by mouth at bedtime, Oxycodone 5 mg by mouth every 24 hours as needed for breakthrough pain, Gabapentin 600 mg by mouth three times daily for pain, and Cephalexin 500 mg by mouth twice daily for five days. During observation, an LPN administered the resident’s morning medications through the feeding tube. The clinical record contained no documented evidence that the facility attempted to clarify whether the listed medications were to be given by mouth or through the feeding tube. The DON stated that the resident took some medications by mouth and some via feeding tube per his preference, while the resident stated that he did not take any medications by mouth and that all medications were crushed and administered through the feeding tube because he could not swallow. An LPN confirmed that the resident did not take any medications by mouth and that all medications were crushed and given through the feeding tube, and the DON later confirmed the orders should have been clarified but were not.
Food Not Served Palatably
Penalty
Summary
Food and drink were not served in a palatable condition because residents reported that meat and potatoes were repeatedly overcooked, dry, and tough to chew. One resident stated that the meat and potatoes were always overcooked and tough, and another resident reported that the meat was very tough, dry, and at times could not be eaten because it was too tough to cut or chew. During a kitchen observation, a lunch meal of Salisbury steak, scalloped potatoes, mixed vegetables, and gelatin was placed on a test tray and tasted for palatability; the Salisbury steak was covered with gravy but was hard and crispy around the edges and tough to cut. The Dietary Manager confirmed that the Salisbury steak was harder and crispy on the edges and stated that the oven did not heat evenly, with one side hotter than the other, causing the edges of the food to get done before the middle.
Sanitation Checks Not Documented for Food Service
Penalty
Summary
Food was not served under sanitary conditions because the facility failed to ensure required sanitizer temperature or chemical checks were documented for each meal. The facility policy dated July 28, 2025 required equipment, food contact surfaces, and utensils to be washed, rinsed, and sanitized using a three-step process with hot water and detergent, followed by rinsing and sanitizing with hot water or a chemical sanitizing solution. During an observation in the kitchen on November 17, 2025, at 9:08 a.m., the three-compartment sink was in use and utensils and pans were drying on the counter, but the sanitizer log for November 2025 showed no documented evidence that temperature or chemical checks had been completed for each meal from November 11, 2025 through breakfast on November 17, 2025. The Dietary Manager confirmed at the time of the observation that there was no documented evidence of those checks during that period.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to ensure that the call bell was within reach for one resident. The resident’s admission MDS indicated that she could make herself understood and understand others, required staff assistance for care needs, was incontinent of bowel and bladder, and had diagnoses including seizures and stroke. Her care plan identified her as at risk for falls due to impaired mobility and stated that the call bell was to be in reach. During observation, the resident was lying in bed requesting pain medication, but her call bell was positioned on top of the bed above her and out of reach, and she stated that she did not know where it was. A RN supervisor confirmed that the tap call bell should have been over her lap so she could reach it, and the DON also confirmed that the resident’s call bell should have been within reach.
Late Completion of Admission MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive admission MDS assessments were completed within the required time frame for five of 48 residents reviewed. The RAI User's Manual dated October 2024 stated that an admission MDS assessment must be completed no later than 14 days after admission. Review of the clinical records showed that Resident 46's admission MDS was completed 14 days after admission, Resident 68's was completed 22 days after admission, Resident 71's was completed 14 days after admission, Resident 83's was completed 14 days after admission, and Resident 122's was completed 15 days after admission. The report also states that the DON was interviewed on November 20, 2025, at 1:48 p.m., and confirmed that the comprehensive MDS assessments were not completed within the required time frames. The deficiency was cited under 28 Pa. Code 211.5(f), Clinical records.
Failure to Develop Dental Care Plan
Penalty
Summary
The facility failed to implement an individualized care plan for the dental needs of Resident 89. A quarterly MDS assessment dated September 16, 2025, indicated that the resident was alert and oriented and required assistance with daily care, including oral care. A physician’s order dated November 2025 showed that the resident was scheduled for dental extractions in January 2026 and required pre-testing in December 2025. Clinical record review found no documented evidence that a care plan was developed to address the resident’s dental problems. During an interview on November 17, 2025, the resident stated she had multiple missing teeth, obvious dental caries, and misaligned front teeth, and said she needed dental care to have several teeth pulled. The DON later confirmed on November 19, 2025, that there was no care plan in place for the resident’s dental needs and that there should have been.
Care plan not revised after antipsychotic discontinuation
Penalty
Summary
The facility failed to ensure that Resident 7’s care plan was updated to reflect a change in care needs when quetiapine was discontinued. Resident 7’s quarterly MDS assessment dated October 31, 2025, showed that the resident was cognitively impaired, dependent on staff for daily care needs, and had diagnoses including anxiety, dementia, and psychosis. Physician’s orders dated April 25, 2025, directed discontinuation of quetiapine, an antipsychotic medication. However, the care plan dated June 12, 2025, still indicated that the resident was at risk for adverse effects related to antipsychotic medication. The DON confirmed on November 19, 2025, that the care plan should have been revised when quetiapine was discontinued and that it was not.
Delayed Podiatry Care
Penalty
Summary
The facility failed to ensure timely foot care for one resident with diabetes and onychomycosis. The resident’s annual MDS indicated he was alert and oriented, dependent on staff for daily care needs, and had diabetes. A podiatry note documented that he was seen for routine podiatry care and that his chief complaint was onychomycosis, with a recommendation for routine podiatry follow-up in 12 weeks and placement on the podiatry list for a visit on September 12, 2025. However, observation on November 17, 2025, showed all toenails were mycotic and approximately one-quarter inch over the ends of his toes, and both great toes were wrapped with a dry dressing. There was no documented evidence that the resident received podiatry care on the scheduled date, and the DON confirmed that the resident should have been seen when the podiatrist visited the facility and was not.
Wheelchair Transport Without Leg Rests Led to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was free from an accident that resulted in injury when Resident 46 was transported in a wheelchair without the leg rests in place. The facility’s Assistive Devices and Equipment policy stated that residents who did not self-propel should have leg rests on their wheelchair when being transported. Resident 46 was admitted with diagnoses including Covid pneumonia, stasis dermatitis of both lower extremities, and a history of TIA, and she used a walker or wheelchair for mobility. She was alert and oriented and required assistance from two staff members for care. During transport back to her room by an activity aide, Resident 46 dropped her feet to the floor while the wheelchair was in motion and fell forward out of the wheelchair onto the floor. The resident sustained bleeding from her nose and upper lip. The aide stated that the resident asked to go to the bathroom and was pushed back to her room, where she put her feet on the floor and fell out of the wheelchair. The resident later stated that the footrests were not in place at the time of the fall, and the DON confirmed that she did not have her leg rests on the wheelchair during transport and should have been transported with them in place.
Failure to Document and Witness Fentanyl Patch Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident who was cognitively intact, had a feeding tube, a mechanically altered diet, chronic respiratory failure, malignant neoplasm of the oropharynx, and an acquired absence of the larynx. The resident had physician orders for fentanyl transdermal patches for pain, first at 25 mcg every 72 hours and later at 50 mcg every 72 hours, with removal per schedule. Facility policy required removed fentanyl patches to be folded adhesive-to-adhesive, placed in inert material, and destroyed in the presence of two licensed personnel with documentation of disposal. During observation, an LPN removed the resident’s fentanyl patch from the chest, rolled it up in her glove, and discarded it in the resident’s waste basket before applying a new patch. Review of the MAR and controlled drug count record showed fentanyl patches were applied repeatedly in October and November 2025, but there was no documented evidence that two staff members witnessed and signed that the old patch was destroyed after removal on those dates. The LPN confirmed she should not have discarded the patch in the waste basket, and the RN supervisor and DON confirmed the patch should have been disposed of in the drug buster with two nurses witnessing and signing the destruction.
Medication Administration Error with Coumadin
Penalty
Summary
The facility failed to provide medications as ordered by the physician, resulting in a significant medication error for one resident. The resident had diagnoses including atrial fibrillation, was cognitively intact, and had a care plan directing anticoagulant administration per physician orders. The physician ordered Coumadin 5 mg daily, but the Medication Administration Record showed the resident received 5 mg plus an additional 2.5 mg Coumadin on two consecutive nights, for a total of 7.5 mg each night. After the resident was noted to be bleeding, an INR was obtained and was elevated at 3.2, and the physician ordered Coumadin held for two nights. The Assistant Director of Nursing confirmed that the resident received the incorrect Coumadin dose on both nights and that a medication error occurred.
QAPI Committee Failed to Address Repeated Care Planning and Order Clarification Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct recurring quality deficiencies identified in prior surveys and in the current survey. Review of the facility’s plans of correction for an annual survey ending October 9, 2024, and a complaint survey ending May 14, 2025, showed that the facility had developed plans of correction with quality assurance systems intended to maintain compliance with cited nursing home regulations, but the current survey ending November 20, 2025, found repeated deficiencies involving failure to accommodate a resident’s needs, failure to develop individualized care plans, failure to revise care plans, and failure to clarify questionable physician’s orders. For the deficiency related to accommodations of need, the prior plan of correction stated that audits would be completed and results reported to the QAPI committee, but the current survey under F558 found that the QAPI committee failed to successfully implement that plan to ensure the resident’s needs were accommodated. Similar repeat findings were identified under F656, F657, and F658, where the prior plans of correction also relied on audits and QAPI review, yet the current survey found that the facility failed to ensure care plans were developed for individual needs, revised as needed, and that questionable physician’s orders were clarified.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders regarding medication administration for one resident. According to the facility's medication administration policy, staff are required to verify specific information, such as medication allergies and vital signs, prior to administering medications. For a resident with diagnoses including diabetes and hypertension, physician's orders specified that Metoprolol Tartrate should be held if the resident's heart rate was less than 60, and that Insulin Aspart should be held if the resident's blood glucose was less than 120 mg/dL. Review of the resident's Medication Administration Record (MAR) showed that there was no documented evidence that the resident's heart rate was checked prior to administering Metoprolol Tartrate over a period of several weeks. Additionally, Insulin Aspart was administered multiple times when the resident's blood glucose was below the threshold specified in the physician's order. These findings were confirmed by the Assistant Director of Nursing during interviews.
Failure to Document Change in Condition and Physician Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, as required by accepted professional standards. A resident with a history of hemiplegia, COPD, respiratory failure, and a tracheostomy experienced a significant change in condition, including hypoxia with pulse oximetry readings between 78 and 80 percent, which did not improve above 90 percent despite interventions such as suctioning and increased oxygen. Staff, including an LPN and an RN, responded by notifying the physician and obtaining orders for a STAT chest x-ray, CBC, CMP, and sputum culture. Despite these actions, there was no documented evidence in the resident's clinical record explaining the reason for obtaining the physician's orders or describing the change in the resident's condition on the date in question. Both the LPN and RN stated in interviews that they had communicated and acted upon the resident's declining status, but a review of the clinical record confirmed the absence of required progress notes or documentation regarding the incident. The Nursing Home Administrator and Director of Nursing also confirmed the lack of documentation.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2023. Specifically, the facility did not provide the necessary number of NAs during the day and evening shifts on certain days. On April 4, 2025, the facility had a census of 129 residents during the evening shift, necessitating 11.73 NAs, but only 11.07 NAs were available. Similarly, on April 6, 2025, with a census of 128 residents, the day shift required 12.80 NAs, yet only 10.73 NAs were present, and the evening shift required 11.64 NAs, but only 9.47 NAs were available. There were no additional higher-level staff to compensate for these staffing deficiencies. The Nursing Home Administrator confirmed the shortfall in meeting the required staffing ratios.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Deficiency in Direct Resident Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.20 hours of direct resident care per resident for two out of five days reviewed. Specifically, on April 5, 2025, the facility provided only 2.99 hours of direct care per resident, and on April 6, 2025, it provided 2.83 hours. This deficiency was identified through a review of nursing schedules and confirmed during an interview with the Nursing Home Administrator on April 7, 2025.
Plan Of Correction
1. The hours of direct care staffing noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of direct care staffing will be completed and reviewed daily for accuracy by the scheduler or designee. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding direct care staffing regulations. 3. Facility scheduler, Director of Nursing, Human Resources and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Direct care staffing will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions during the review period from December 8, 2024, to January 11, 2025. Specifically, the facility did not provide the minimum number of LPNs needed for the day shift on three days, the evening shift on one day, and the night shift on four days. For instance, on December 11, 2024, the facility's census required 5.20 LPNs during the day shift, but only 5.03 LPNs were available. Similarly, on December 25, 2024, the day shift required 5.08 LPNs, but only 4.88 LPNs were present. These discrepancies were confirmed through a review of nursing schedules, staffing information, and staff interviews. The deficiency was further highlighted by the lack of additional higher-level staff to compensate for the shortfall in LPNs. On December 9, 2024, the night shift required 3.10 LPNs, but only 2.22 LPNs were available. On December 23, 2024, the night shift required 3.15 LPNs, but only 2.56 LPNs were present. The Nursing Home Administrator confirmed on January 17, 2025, that the facility did not meet the required staffing ratios on the specified days, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
1. The ratios noted in the survey findings cannot be corrected as this is a past event. 2. Calculation of shift ratios will be completed and reviewed daily for accuracy by the scheduler or designee. 3. The facility has developed internal incentives to retain and attract staff and meet shift ratio requirements. Administrator will re-educate Director of Nursing and Scheduler regarding staffing ratios regulations. Facility scheduler, Director of Nursing, Human Resources, and Administrator have a daily staffing meeting (5 days per week) to review schedules including compliance with ratios. For staff call offs, every effort will be made to replace the call off using resources available including communicating with staff to replace the vacancy. Staffing patterns are projected at least one week in advance to enable ongoing efforts to fill any vacant shifts. The facility will take admissions when staffing is appropriate. 4. Ratios will be monitored daily by Scheduler and/or Director of Nursing or designee. Audits of ratios will be completed by Director of Nursing or designee daily for 4 weeks then 3 days per week x 2 months or until substantial compliance is achieved. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Failure to Communicate Critical Lab Results During Resident Transfer
Penalty
Summary
Twin Lakes Rehabilitation and Healthcare Center was found to be non-compliant with federal and state regulations regarding the transfer and discharge of residents. Specifically, the facility failed to update the admitting facility with critical laboratory information for a resident who was transferred. The resident, who was cognitively intact and required assistance for daily care, had been diagnosed with debilitating cardiorespiratory conditions and was experiencing recurrent watery stools. A physician ordered a test for Clostridioides difficile (C-diff), which returned positive results. However, there was no documented evidence that this information was communicated to the receiving facility upon the resident's discharge. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the communication of the resident's laboratory results to the admitting facility. This oversight violated the requirements for ensuring a safe and effective transition of care, as outlined in the federal regulations and the Pennsylvania Long Term Care Licensure Regulations. The failure to provide this critical information could potentially impact the ongoing care and safety of the resident at the new facility.
Plan Of Correction
F0622 Transfer and Discharge Requirements 1. Resident 2 no longer resides in the admitting facility that she was discharged to. 2. A 30 day look back audit was completed of discharged residents to ensure that abnormal laboratory results were communicated to the admitting facility. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that abnormal results received proximal to date of discharge were communicated to the admitting facility. The Director of Nursing will educate the Intradisciplinary team and Registered Nurse Supervisors to notify the admitting facility of a discharged resident of abnormal laboratory results received proximal to the date of discharge. 4. The Director of Nursing or designee will complete audits to ensure abnormal laboratory results are received for discharged residents are communicated to the receiving facility. This audit will be completed weekly times 4 weeks. The results of the audit will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for a resident, leading to a deficiency in compliance with regulatory requirements. The facility's policy, dated July 26, 2024, mandates that laboratory results must be reported in writing to the resident's attending physician or the facility, with the Director of Nursing Services or charge nurse responsible for notifying the physician of such results. However, in the case of a resident with debilitating cardiorespiratory conditions, the facility did not adhere to this policy. The resident, who was cognitively intact and required assistance for daily care, had physician orders dated September 4, 2024, for a Clostridioides difficile (C-diff) toxin stool test due to frequent watery stools. The laboratory results, dated September 5, 2024, confirmed the presence of the C-difficile toxin, with the sample collected on September 4, 2024. Despite the positive result, there was no documented evidence in the resident's clinical record that the physician was notified or reviewed the abnormal laboratory results. An interview with the Director of Nursing on December 3, 2024, confirmed the lack of documentation regarding the notification of the physician about the abnormal results. This oversight indicates a failure to comply with the facility's policy and regulatory requirements for notifying physicians of laboratory results that fall outside of clinical reference ranges.
Plan Of Correction
F0773 Lab Services Physician Order/Notify of Results 1. Resident 2 no longer resides at the facility. 2. A 30 day look back audit was completed of laboratory study orders to ensure that laboratory studies were obtained, results were received and reviewed with the physician. 3. The Director of Nursing or designee will review the Order Entry Report and the laboratory results during clinical meeting to ensure that laboratory studies were obtained, results were received and reviewed by the physician. The Director of Nursing or designee will complete education with Registered Nurse Supervisors to ensure laboratory studies that are ordered are obtained, results are received and then reviewed with the physician. 4. The Director of Nursing or designee will complete audits to ensure that laboratory studies that are ordered are obtained, results are received and then reviewed by the physician. This audit will be completed weekly times 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.
Failure to Document Residual Volumes for Residents with Feeding Tubes
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents with feeding tubes. For Resident 88, the physician's orders required the staff to check the placement of the feeding tube by assessing the residual volume once a day. If the residual was 150 mL or less, the staff were to reinsert the volume into the stomach and continue the feeding; if greater than 150 mL, they were to hold the feeding and notify the physician. However, the Medication Administration Records (MARs) for August, September, and October 2024 showed that while staff verified the placement of the feeding tube, they did not document the amount of residual present during these checks. This lack of documentation was confirmed by the Director of Nursing. Similarly, for Resident 109, the physician's orders also required the staff to check the residual volume once a day with the same instructions regarding the residual volume. The MARs for the same period indicated that staff verified the tube placement but failed to document the residual volume. This omission was also confirmed by the Director of Nursing. Both residents were cognitively impaired and required assistance with daily care tasks, highlighting the importance of adhering to physician's orders to ensure their safety and well-being.
Failure to Flush IV Catheters as per Policy
Penalty
Summary
The facility failed to ensure that long-term intravenous catheters were flushed according to their policy for three residents. The policy, dated July 19, 2024, required that peripheral or midline catheters be flushed with 10 cc's of normal saline before and after each use. For Resident 101, who was cognitively intact and had an infection in his left shoulder, there was no documented evidence that the external catheter length and circumference of the upper arm were measured as ordered on specific dates in September and October 2024. This was confirmed by the Director of Nursing during an interview. Resident 104, who was cognitively impaired and had a stroke, was receiving IV Meropenem for sepsis. The MAR for October 2024 showed no documented evidence that the IV catheter was flushed before and after medication administration as per facility policy. Similarly, Resident 136, who was cognitively intact and had a PICC line for administering IV antibiotics for osteomyelitis, also lacked documentation of catheter flushing before and after medication administration from late September to early October 2024. The Director of Nursing confirmed the absence of documentation for both Residents 104 and 136.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for three residents. Resident 8, who was cognitively impaired and had diagnoses including dementia with behaviors and COPD, was not seen by a physician or physician delegate for 155 days between February 26, 2024, and July 29, 2024. Resident 13, who was cognitively intact and had an indwelling catheter, received dialysis, and had diagnoses including neurogenic dysfunction of the bladder and End-Stage Renal Disease, was not seen by a physician or physician delegate for 116 days between October 26, 2023, and February 29, 2024, and for 155 days between February 29, 2024, and July 29, 2024. Resident 61, who was cognitively intact and had diagnoses including dementia, Wernicke's encephalopathy, bipolar disorder, and depression, was not seen by a physician or physician delegate for 144 days between October 6, 2023, and February 28, 2024, and for 148 days between February 28, 2024, and July 24, 2024. The Director of Nursing confirmed the lack of documented evidence for these visits and noted that the physician responsible for these residents does not have a physician's assistant or certified registered nurse practitioner to assist in overseeing their care.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths to two residents, leading to a deficiency in care. Resident 36, who is cognitively intact and dependent on staff for bathing due to rheumatoid arthritis, was supposed to receive showers twice a week. However, records show that the resident was only given bed baths on different days and only received showers on three specific dates over a two-month period. The resident expressed dissatisfaction, stating that showers were not offered as preferred, and staff provided excuses such as the unavailability of hot water. This was confirmed by the Director of Nursing. Similarly, Resident 68, who is also cognitively intact and requires assistance with bathing due to a traumatic brain injury, was scheduled to receive showers twice a week. However, documentation revealed that the resident was only given showers once a week. The resident expressed a preference for twice-weekly showers, which was not met. This discrepancy was also confirmed by the Director of Nursing, indicating a failure to adhere to the residents' bathing schedules and preferences.
Failure to Provide Appropriate Catheter and Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for three residents with indwelling urinary catheters. For one resident, there was no documented evidence of catheter care being provided during specific shifts in August and October, despite the requirement for catheter care every shift. The Director of Nursing confirmed the lack of documentation for these dates. Another resident was observed with their catheter collection bag in direct contact with the floor, which was against facility policy. The Assistant Director of Nursing confirmed this observation, and there was also a lack of documented catheter care for this resident on several dates across August, September, and October. Additionally, a third resident with a nephrostomy tube had no documented physician's orders for the care and treatment of the nephrostomy, despite having a history of urinary tract infection and obstructive uropathy. The Director of Nursing confirmed the absence of orders for the nephrostomy care. These deficiencies indicate a failure to adhere to facility policies and ensure proper catheter and nephrostomy care, potentially increasing the risk of urinary tract infections for the affected residents.
Failure to Ensure Residents' Rights to Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop advance directives, as required by regulations. This deficiency was identified during a review of clinical records and staff interviews, which revealed that four residents did not have advance directives documented in their records. Specifically, there was no evidence that these residents or their representatives were informed of their rights to create advance directives, nor was there any documentation showing that they were provided assistance in formulating such directives. Additionally, the facility did not address advance directives with the residents or their representatives periodically throughout their stay. The residents involved in this deficiency included individuals with varying cognitive and physical conditions. One resident had a diagnosis of dementia, another was cognitively intact but had mental health diagnoses such as schizophrenia and bipolar disorder, a third resident had glaucoma and hemiplegia following a cerebral vascular accident, and the fourth resident was cognitively intact. Despite these conditions, there was no documented evidence that the facility engaged with these residents or their representatives regarding advance directives. The Nursing Home Administrator confirmed the lack of documentation and acknowledged that the facility had not been addressing advance directives regularly at care conferences, which was a requirement they needed to improve upon.
Failure to Conduct Background Check for Nurse Aide
Penalty
Summary
The facility failed to adhere to its policy on abuse, neglect, exploitation, and misappropriation prevention by not completing a criminal background check for a newly hired nurse aide. The policy, dated July 19, 2024, mandates that employee background checks be conducted to ensure no individual with a history of abuse, neglect, exploitation, or misappropriation is employed. However, upon review of the personnel file for Nurse Aide 3, it was found that he was hired on June 6, 2024, without a completed criminal background check as of October 8, 2024. This was confirmed during an interview with the Human Resource Director, who acknowledged the absence of documented evidence of a background check for the nurse aide prior to his hiring.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding transfers to the hospital for four residents. Resident 13, who was cognitively intact and required assistance for care needs, was transferred to the hospital after experiencing increased lethargy during dialysis. There was no documented evidence that a written notice of this transfer was provided to the resident's representative. Resident 88, who was cognitively impaired and had a feeding tube, was transferred to the hospital after a large emesis with blood-like appearance was noted. Similarly, Resident 109, who was cognitively impaired and had multiple medical conditions including aphasia and Parkinson's disease, was transferred multiple times to the hospital for various acute conditions such as hyponatremia, respiratory distress, and sepsis. In each instance, there was no documented evidence of written notification to the resident's representative regarding the reasons for these transfers. Resident 131, who was cognitively intact and required oxygen, was transferred to the hospital due to increased work of breathing and cyanosis. Again, there was no documented evidence that a written notice of this transfer was provided to the resident's representative. The Nursing Home Administrator confirmed that the facility did not provide the required written notices for these transfers.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for seven residents, leading to discrepancies in the documentation of their care needs and treatments. For Resident 6, the MDS assessment did not reflect the administration of Pradaxa, an anticoagulant, despite physician orders and medication administration records indicating its use during the assessment period. Similarly, Resident 13's MDS inaccurately recorded the administration of intravenous Vancomycin, which was not given during the seven-day period as it was intended for dialysis administration. Resident 51's MDS assessment incorrectly indicated the receipt of oxygen therapy, which was not administered according to the medication administration records. Resident 78's assessment failed to document multiple instances of care rejection, such as refusing dressing, getting out of bed, and meals, which were noted in nurse aide documentation. Additionally, Residents 80 and 88's assessments did not accurately reflect the administration of Tramadol, an opioid, despite records showing its use during the assessment period. Lastly, Resident 128's discharge status was incorrectly recorded in the MDS as a discharge to the hospital, while nursing notes confirmed the resident was discharged home. These inaccuracies were confirmed through interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing, highlighting a pattern of errors in the facility's MDS assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which is a requirement according to their policy dated July 19, 2024. For one resident, who was cognitively intact and receiving an anticoagulant, there was no documented care plan addressing the use of the blood thinner Xarelto, despite a physician's order for its daily administration. This oversight was confirmed by the Director of Nursing during an interview. Another resident, who had moderate cognitive impairment and was dependent on staff for daily hygiene, had multiple medical conditions including an indwelling catheter, an ostomy, and a nephrostomy. Despite these complex needs, there was no care plan developed to address the care and treatment required for the nephrostomy. This deficiency was also confirmed by the Director of Nursing during an interview.
Failure to Update Care Plans for Anticoagulation and Catheter Use
Penalty
Summary
The facility failed to update and revise care plans to reflect the specific care needs of two residents. For one resident, the care plan for anticoagulation therapy was not updated after the resident's anticoagulant medication, Eliquis, was discontinued and replaced with Aspirin. Despite the physician's note indicating the change in medication, the care plan continued to reflect that the resident was taking an anticoagulant. This discrepancy was confirmed by the Director of Nursing during an interview. For another resident, the care plan was not revised to accurately reflect the resident's current condition. The resident, who had moderate cognitive impairment and an indwelling catheter due to obstructive uropathy, had an active care plan indicating urinary incontinence. However, observations confirmed the presence of a urinary drainage bag, and the Director of Nursing acknowledged that the care plan should have been updated to reflect the use of a Foley catheter instead of urinary incontinence.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure that a resident had proper assistive devices to maintain adequate hearing. Resident 14, who was understood and able to understand others, required assistance with daily care needs and used hearing aids. A social services note indicated that the resident's right hearing aid was smashed, and both hearing aids were taken by audiology for repair. However, during an interview, Resident 14 expressed that she needed a new pair of hearing aids and had not received any updates. Observations confirmed that the resident did not have any hearing aids, making communication difficult due to her hearing impairment. Interviews with facility staff revealed a lack of follow-up and communication regarding the resident's hearing aids. The Social Worker was aware of the situation but had not confirmed payment options for repairs. The Business Office Manager was unaware of the resident's need for new hearing aids and expressed uncertainty about the feasibility of obtaining them due to the resident's limited funds and lack of family support. The Social Services Director admitted to forgetting to follow up with the audiologist and only learned that the hearing aids could not be repaired after speaking with them. This series of inactions and communication lapses led to the resident being without necessary hearing aids, impacting her ability to communicate effectively.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident diagnosed with Post Traumatic Stress Disorder (PTSD) received trauma-informed care to mitigate potential triggers. The facility's policy, dated July 19, 2024, required universal screenings and assessments to identify possible traumatic exposures and triggers. However, for one resident, there was no documented evidence that the facility identified specific triggers or implemented measures to prevent or minimize these triggers. The resident in question was cognitively intact and required assistance for daily care needs, with diagnoses including anxiety, depression, PTSD, and schizophrenia. Despite these conditions, the facility did not complete a trauma-informed care assessment for the resident. This was confirmed during an interview with the Director of Nursing, who acknowledged the lack of assessment.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations for nurse aides were completed as required. Specifically, for two of the three nurse aides reviewed, Nurse Aides 8 and 9, there was no documented evidence of performance evaluations being conducted. According to the facility's policy dated July 19, 2024, these evaluations were to be completed annually based on the hire dates. The evaluations for these nurse aides were due between April 8 and July 1, 2024, but were not completed. This was confirmed during an interview with the Director of Nursing on October 8, 2024.
Failure to Address Pharmacy Recommendations for Medication Dose Reduction
Penalty
Summary
The facility failed to ensure timely physician response to pharmacy recommendations for a resident. The resident, who was cognitively intact and required minimal assistance, was taking antipsychotic and antidepressant medications for conditions including dementia, Wernicke's encephalopathy, bipolar disorder, and depression. The pharmacy conducted monthly medication regimen reviews and recommended gradual dose reductions for Risperidone and Sertraline in March and June 2024. However, there was no documented evidence that these recommendations were addressed or that any dose reduction was attempted. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation regarding the pharmacy's recommendations for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication storage and labeling protocols, as evidenced by several deficiencies observed during a survey. In one of the medication rooms, the refrigerator used for storing controlled drugs did not have a permanently affixed, separately locked compartment, which is a requirement for controlled substances. This unsecured compartment contained both opened and unopened bottles of Ativan, a medication that is tightly controlled due to its potential for abuse. Additionally, the facility did not properly manage the expiration and labeling of medications. An expired multi-dose inhaler was found on a medication cart, which should have been discarded according to the manufacturer's instructions. Furthermore, a multi-dose vial of Lantus insulin was not labeled with the date it was opened, contrary to the manufacturer's guidelines that require such labeling to ensure timely disposal. The survey also revealed that medications were left unsupervised and unlabeled at the bedside of two residents. One resident, who was cognitively intact, was found with an unsupervised medicine cup containing two unlabeled pills, which he was unaware of. Another resident, who had bipolar disorder and surgical wounds, had nine unlabeled pills left on her overbed table. In both cases, the LPNs involved did not ensure the residents took their medications, leaving them unsupervised, which was confirmed by the Director of Nursing as inappropriate practice.
Incomplete Documentation of Resident's Meal Consumption
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and accurately documented. Specifically, the deficiency involved Resident 130, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease (GERD). The resident's care plan indicated a potential for weight loss or gain, requiring staff to provide diet and supplements as ordered. However, there was a lack of documented evidence regarding the amount of food consumed by the resident during specific meals in June, July, and August 2024. The absence of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record for Resident 130 did not include the necessary information about meal consumption on the specified dates. This failure to document the resident's food intake contravenes accepted professional standards for maintaining complete and accurate clinical records, as required by 28 Pa. Code 211.5(f).
Repeated Deficiencies in Quality Assurance and Care Management
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as evidenced by repeated issues identified in multiple surveys. The deficiencies included inaccuracies in Minimum Data Sets (MDS), inadequate creation and implementation of care plans, failure to update care plans, poor quality of care, and improper tube feeding management. These issues were identified in surveys conducted on November 9, 2023, March 5, 2024, and May 30, 2024, with the most recent survey ending on October 9, 2024, highlighting the facility's inability to maintain compliance with nursing home regulations. The facility had previously developed plans of correction for these deficiencies, which included conducting audits and reporting the results to the QAPI committee for review. However, the current survey findings revealed that the QAPI committee did not successfully implement these plans to ensure ongoing compliance. Specific deficiencies were cited under F641 for assessment accuracy, F656 for comprehensive care plan development, F657 for updating care plans, F684 for quality care, and F693 for tube feeding management, indicating a systemic failure in the facility's quality assurance processes.
Failure to Maintain Laundry Dryers in Safe Condition
Penalty
Summary
The facility failed to maintain two of three laundry dryers in safe operating condition. According to the manufacturer's directions for use, the area around the exhaust opening and adjacent surrounding area should be kept free from the accumulation of lint, dust, and dirt. Additionally, the interior of the tumble dryer and exhaust duct should be cleaned periodically by qualified service personnel. During an observation in the laundry department, it was noted that there was an accumulation of lint in the compartment above the dryer drum where the gas line entered the back of the dryer. This was confirmed by the Director of Environmental Services and the Director of Maintenance, who stated that the dryers were last cleaned on September 9, 2024.
Failure to Inform Resident of Lab Results
Penalty
Summary
The facility failed to honor a resident's right to make informed choices and participate in their treatment. Resident 84, who was alert, oriented, and able to understand and be understood, requested lab work to be done. The lab work was completed, but there was no documented evidence in the clinical record that the results were reviewed with the resident. An interview with Resident 84 confirmed that she was not informed of her lab results. The Director of Nursing acknowledged the lack of documentation and confirmed that the results should have been reviewed with the resident.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to self-administer medications safely. For Resident 19, a Licensed Practical Nurse (LPN) left a cup containing polyethylene glycol on the resident's overbed table without observing the resident take the medication. The Director of Nursing confirmed that there was no assessment to determine if Resident 19 was safe to self-administer medications. Similarly, Resident 78, who was cognitively intact but dependent on staff for daily care needs, was found with a medicine cup containing pills on his overbed table. The resident was unaware of the pills, and the LPN admitted to leaving them there without supervision. Resident 108, who required assistance for daily care needs and had a diagnosis of bipolar disorder, was found with a medicine cup containing nine pills on her overbed table. The LPN believed the resident had taken the medication, but the pills were left unsupervised, and the resident had not taken them. The Director of Nursing confirmed that there were no assessments conducted to determine if Residents 78 or 108 could safely self-administer their medications. These actions were in violation of the facility's policy, which requires an interdisciplinary team assessment to determine if self-administration is clinically appropriate and safe.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 405 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Hill Rehabilitation & Healthcare Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Greene Health & Rehab Center | 3 mi | ★★★★★ | 44 | 0 |
| Loyalhanna Care Center | 4.2 mi | ★★★★★ | 19 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 4.5 mi | ★★★★★ | 11 | 0 |
| Saint Anne Home | 4.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.