Vincentian Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 111 Perrymont Road, Pittsburgh, Pennsylvania 15237
- CMS Provider Number
- 395034
- Inspections on file
- 26
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Vincentian Home during CMS and state inspections, most recent first.
A resident with significant mobility impairments, requiring two-person assistance for transfers and bed mobility, was injured when a nurse aide provided care alone, contrary to care plan and physician orders. The aide did not seek help as required, resulting in the resident falling from bed and sustaining a head laceration. Facility staff and leadership confirmed that established protocols were not followed, leading to neglect.
A resident who was dependent on staff for transfers and positioning was found on the floor after rolling out of bed during care, and was transferred to the hospital. The facility did not report this incident of suspected neglect to the State Agency within the required 24-hour timeframe, as confirmed by facility leadership.
A resident with significant mobility impairments and orders for two-person assistance during bed mobility was left unattended by a single nurse aide, resulting in the resident rolling out of bed and sustaining a head laceration. Staff interviews and documentation confirmed that facility protocols and care plans requiring two-person assistance were not followed at the time of the incident.
A resident with multiple medical conditions was found self-applying Aquaphor ointment for skin irritation without a physician's order, care plan, or interdisciplinary assessment for self-administration. The ointment, brought in by family and lacking a pharmacy label, was not documented in the clinical record, and staff confirmed the absence of required orders and assessments.
A resident with an indwelling Foley catheter did not have physician orders specifying the catheter size or balloon inflation amount, as required by facility policy. The clinical record included instructions for catheter changes, use of a dignity cover, and irrigation, but omitted these key specifications. This deficiency was confirmed by the ADON during review.
Two residents did not receive proper respiratory care according to facility policy and physician orders. One resident's CPAP mask was repeatedly left out and not stored in a bag, and their care plan lacked CPAP interventions. Another resident's oxygen tubing was not labeled with a date as required. Staff and leadership confirmed these deficiencies.
A resident with anemia, kidney stones, and Alzheimer's Disease did not receive nine ordered doses of TheraLith XR because the medication was unavailable from the pharmacy. Staff and leadership confirmed the medication was out of stock, resulting in the resident not receiving the prescribed treatment.
Surveyors found that drugs and biologicals were not stored securely or in an orderly manner, including a resident keeping medications at the bedside, comingling of suppositories with oral medications in medication carts, unlabeled COVID-19 testing solution, unlabeled ice packs in a medication refrigerator, and expired insulin syringes in storage. These deficiencies were confirmed by nursing staff and the administrator.
The facility did not track or monitor residents who tested negative for COVID-19 during an outbreak, as required by policy, and failed to follow infection control procedures during a dressing change for a resident with multiple medical conditions. A nurse did not establish a clean field, placed a soiled dressing on the bed, and did not perform proper hand hygiene, resulting in a failure to prevent cross-contamination.
The facility failed to communicate necessary resident information during transfers to the hospital for three residents, as required by policy. The deficiency was confirmed by the ADON, who stated that the facility did not document what information was sent with the residents. This affected residents with conditions such as multiple sclerosis, dementia, and Parkinson's Disease.
The facility failed to notify the LTC Ombudsman of hospital transfers for three residents, as required by federal regulations. The residents, who had conditions such as multiple sclerosis, dementia, and Parkinson's Disease, were transferred without documented notification. The DON confirmed the facility's usual practice of not sending such notifications.
The facility failed to obtain necessary hospice diagnoses and coordinate hospice services for three residents receiving end-of-life care. Physician orders lacked hospice-related diagnoses, and care plans did not include hospice contact information or access to a 24-hour on-call system, as confirmed by the DON.
A resident did not receive prescribed medication for COPD, and three residents did not have weekly skin assessments as ordered. Additionally, one resident did not have weekly labs conducted. These deficiencies were confirmed by the DON.
A resident with hypertension, osteoporosis, and anxiety was found with medication at her bedside without a physician's order or assessment for self-administration. The facility's policy prohibits leaving medication at the bedside, and the RN and DON confirmed the oversight, leading to a deficiency.
The facility failed to prevent accidents and ensure proper neurological assessments for residents after falls. A resident slid off the bed during care, resulting in a head injury, while two other residents did not receive complete neurological checks as required by facility policy. Staff interviews confirmed these deficiencies.
The facility failed to ensure proper physician orders and care for residents with urinary catheters. A resident lacked a physician's order specifying catheter details and a valid medical diagnosis. Additionally, two residents did not have dignity bag covers for their catheters, as confirmed by staff. The Director of Nursing acknowledged these deficiencies.
The facility failed to monitor and address significant weight changes in residents, including severe weight loss in a resident and missed daily weights for two residents. Additionally, a resident's weight gain was not reported to the physician as required.
A medication cart on the second floor of Building One was found unlocked and unattended, with the top drawer open, violating the facility's policy on secure medication storage. This was confirmed by a registered nurse and the Nursing Home Administrator.
Failure to Follow Two-Person Assist Protocol Resulting in Resident Fall
Penalty
Summary
The facility failed to protect a resident from neglect when a nurse aide provided care without following the required two-person assist protocol for a resident with significant mobility impairments. The resident, who had diagnoses of muscle wasting, muscle weakness, and abnormal gait, was care planned and had physician orders for a full body mechanical lift and two-person assistance for all transfers, hygiene, and bed repositioning. Despite these documented requirements, the nurse aide attempted to provide care alone, resulting in the resident rolling out of bed and sustaining a head laceration. The incident was reported by the nurse aide, who admitted to not seeking help as typically required, and was corroborated by the resident's statement and facility documentation. Facility policies reviewed emphasized the necessity of using appropriate transfer techniques and ensuring two-person assistance for residents with such needs. Staff interviews confirmed that aides are expected to reference the Kardex and report sheets for transfer status and to wait for assistance when required. The incident was acknowledged by facility leadership as a failure to protect the resident from neglect, as the established protocols and care plan directives were not followed, directly leading to the resident's fall and injury.
Failure to Timely Report Suspected Neglect to State Agency
Penalty
Summary
The facility failed to report an incident of neglect involving a resident within 24 hours to the local state field office, as required by both facility policy and regulatory standards. The incident involved a resident with diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, who required a full body mechanical lift and two-person assistance for all transfers, hygiene, and repositioning. According to the care plan and physician orders, the resident was dependent on staff for bed positioning and movement. On the day of the incident, a nurse aide reported that the resident rolled out of bed while care was being provided, resulting in the resident being found on the floor and subsequently transferred to the hospital for further evaluation. Despite the facility's policies mandating immediate or within 24-hour reporting of suspected neglect to the State Agency, the incident was not included in the information submitted to the State Agency on the days following the event. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the required report of neglect was not made within the specified timeframe for this resident.
Failure to Provide Required Two-Person Assistance for Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses of muscle wasting, muscle weakness, and mobility abnormalities, was not provided with the required assistance for bed mobility. The resident's care plan, physician orders, and Minimum Data Set all indicated a need for a full body mechanical lift and assistance from two staff members for transfers, hygiene, and repositioning in bed. Despite these documented requirements, a nurse aide attempted to provide care and reposition the resident alone. During this process, the aide lost balance, and the resident rolled out of bed, sustaining a partial head laceration and a headache, which required hospital evaluation. Facility policies required staff to use appropriate transfer techniques and to assess and provide the necessary assistance for each resident. Staff interviews confirmed that aides are expected to follow the care plan and obtain help when two-person assistance is required. The nurse aide involved admitted to typically seeking help but failed to do so on this occasion. The incident was confirmed by the resident, staff, and facility leadership, who acknowledged that the appropriate assistance was not provided, resulting in the resident's fall.
Failure to Assess and Document Resident's Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and authorized to self-administer medications. According to facility policy, residents must be evaluated for competency to self-administer medications, and the results must be documented in the resident's record and care plan. Additionally, a specific order for self-administration must be present in the medical record. In this case, a resident with diagnoses including irritable bowel syndrome, overactive bladder, and dysphagia was observed to be self-applying Aquaphor ointment and desitin cream for skin irritation and incontinence-related issues. The ointment was found in the resident's bathroom without a pharmacy label, and staff confirmed it was brought in by the family. Review of the resident's clinical record revealed there were no physician orders for the Aquaphor ointment, no orders or care plan for self-administration of medications, and no interdisciplinary assessment to determine the resident's competency for self-administration. The Director of Nursing confirmed that the required documentation and assessment were not present for this resident. These findings indicate the facility did not follow its own policies or regulatory requirements regarding self-administration of medications for one of five residents reviewed.
Lack of Physician Order Specifications for Foley Catheter
Penalty
Summary
The facility failed to obtain and document physician order specifications for the size of the indwelling Foley catheter and the balloon inflation amount for one resident. According to the facility's Foley Catheter Care policy, physician orders for catheter use must include the bulb and catheter size, frequency of catheter changes, and catheter care instructions. However, a review of the clinical record for a resident admitted with diagnoses including dysphagia, chronic kidney disease, and urinary retention revealed that the physician orders only specified the frequency of catheter changes, use of a dignity cover, and irrigation instructions, but did not include the required catheter size or balloon inflation amount. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the clinical record lacked the necessary specifications for the indwelling catheter. The deficiency was identified for one of three residents reviewed for catheter care, indicating noncompliance with both facility policy and regulatory requirements regarding proper documentation and physician orders for catheter use.
Failure to Provide Appropriate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents as required by facility policy and physician orders. For one resident with diagnoses including anemia, heart failure, and dysphagia, the physician order specified nightly use of a CPAP machine, with instructions for cleaning and storage. However, the order did not include the CPAP settings or a diagnosis, and the resident's baseline care plan lacked interventions related to CPAP use. Observations over several days showed the resident's CPAP mask was repeatedly left out on the bed or dresser, not stored in a bag as required by policy. Staff interviews confirmed the improper storage and the absence of a baseline care plan for CPAP care. For another resident with pneumonia, congestive heart failure, and emphysema, the oxygen tubing in use was not labeled with a date, contrary to facility policy that requires dating and weekly changing of such equipment. This was confirmed by staff during interviews. Facility leadership acknowledged the failure to provide appropriate respiratory care for both residents.
Failure to Provide Ordered Medication Due to Pharmacy Out-of-Stock
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate provision of medications for one resident. According to the facility's policy, pharmacy services are to be provided routinely and in a timely manner. However, a review of the clinical record for a resident admitted with diagnoses including anemia, kidney stones, and Alzheimer's Disease revealed that a physician's order for TheraLith XR, to be administered twice daily, was not followed. The resident did not receive nine doses of the medication between 4/24/25 and 4/28/25, as documented in the Medication Administration Record. Progress notes and staff interviews confirmed that the medication was unavailable from the pharmacy during this period. On 4/29/25, during a medication pass, the medication was still not in stock, and both a registered nurse and the Director of Nursing verified that the pharmacy was out of TheraLith, resulting in the resident not receiving the medication as ordered. The Nursing Home Administrator also confirmed the failure to implement pharmaceutical services to ensure accurate medication provision for the resident.
Failure to Properly Store and Label Medications and Biologicals
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in a safe, secure, and orderly manner across multiple nursing units and medication storage areas. On one unit, a resident was observed to have several medications, including eye drops and an inhaler, stored on their bedside table inside a tissue box on two separate occasions. This improper storage was confirmed by both a registered nurse and the nursing home administrator. Additionally, during reviews of medication carts, suppositories were found comingled with oral medications, and a vial of COVID-19 testing solution was not labeled with an open date. These issues were confirmed by nursing staff during interviews. Further deficiencies were identified in medication storage rooms, where two unlabeled cold brick ice packs were found in a medication refrigerator, and a box of insulin safety syringes with an expired use-by date was discovered in a cupboard. These findings were also confirmed by nursing staff. The facility's policies require that medications and biologicals be stored securely and according to manufacturer recommendations, and that only authorized personnel have access, but these procedures were not followed in the instances cited.
Failure to Implement Infection Surveillance and Infection Control Practices
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program as evidenced by two main deficiencies. First, during a COVID-19 outbreak spanning six months, the facility did not include residents who tested negative for COVID-19 on its case line listing, contrary to the requirements outlined in the Respiratory Virus Outbreak Toolkit. The Infection Preventionist and Director of Nursing confirmed that there was no surveillance plan in place to track and monitor residents who tested negative during the outbreak period, based on a misunderstanding of current guidance. Second, during a wound care observation for a resident with diagnoses of anemia, hypertension, and heart failure, a registered nurse did not follow established infection control practices. The nurse failed to establish a clean field, placed a soiled dressing on the bed, did not perform hand hygiene at required steps, handled a washcloth without gloves, and did not complete hand hygiene after the procedure. These actions were confirmed by the nurse during an interview, indicating a failure to prevent cross-contamination during a dressing change.
Failure to Communicate Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for three residents. The facility's policy required a comprehensive transfer and referral record to be completed and sent with the resident, including details such as the reason for transfer, physical and psychosocial status, care summary, treatment, progress towards goals, and other pertinent information. However, the clinical records for the three residents transferred to the hospital did not contain documented evidence that this information was communicated, including care plan goals, advanced directive information, specific instructions for ongoing care, and resident representative information. The deficiency was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the facility did not typically document in the progress notes what information was sent with the resident to the hospital. This lack of documentation and communication was identified for three residents with various medical conditions, including multiple sclerosis, dementia, muscle weakness, and Parkinson's Disease, who were transferred to the hospital and later returned to the facility. The failure to communicate necessary information to the receiving health care provider was a violation of resident rights as per 28 Pa. Code 201.29.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Office of the Long-Term Care Ombudsman Division regarding the transfer of three residents to the hospital. This deficiency was identified through a review of clinical records and staff interviews. Specifically, the facility did not document evidence of written transportation notifications for residents who were transferred to the hospital. The residents involved had various medical conditions, including multiple sclerosis, high blood pressure, dementia, muscle weakness, and Parkinson's Disease. During an interview, the Director of Nursing confirmed that the facility did not usually send notifications to the Ombudsman when residents were sent to the hospital. This oversight affected three out of four residents reviewed, indicating a failure to comply with the requirements outlined in Title 42 Code of Federal Regulations S483.15(c)(5), which mandates that such notifications include specific details about the transfer or discharge, including the resident's appeal rights and contact information for the Ombudsman.
Failure to Coordinate Hospice Services for Residents
Penalty
Summary
The facility failed to obtain a diagnosis for hospice services and ensure the coordination of hospice services with facility services for three residents receiving end-of-life care. The facility's policy on hospice services, dated 4/17/24, mandates a collaborative effort between the hospice provider and the facility staff, including obtaining hospice staff contact information and access to a 24-hour on-call system. However, the clinical records for Residents R17, R53, and R62 revealed that physician orders to admit them to hospice services did not include a diagnosis related to the need for hospice services. Additionally, the comprehensive care plans for these residents did not display the coordination of hospice services, as they lacked contact information for the hospice agency and details on accessing the hospice's 24-hour on-call system. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the facility's failure to meet the needs of the residents for end-of-life care. The report cites violations of 28 Pa. Code 211.2(a) regarding physician services and 28 Pa. Code 211.11(d) concerning resident care plans.
Medication and Assessment Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications as prescribed by the physician for one resident and did not perform weekly skin assessments as ordered for three residents. Specifically, Resident R174 did not receive the prescribed Trelegy Ellipta medication during their stay from April 18, 2024, to April 24, 2024, despite having orders from the hospital to administer it once daily. This oversight was confirmed by the Director of Nursing during an interview. Additionally, the facility did not conduct weekly skin assessments for Residents R50, R382, and R385 as per physician orders. Resident R50, who had diagnoses including anemia, dementia, and heart failure, was also supposed to have weekly lab work done, which was not completed. The failure to perform these assessments and obtain labs was confirmed by the Director of Nursing, highlighting a lapse in following physician orders and facility policy.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to determine the ability of a resident to self-administer medications, which is a requirement for allowing residents to self-administer drugs if clinically appropriate. The facility's policy on medication administration specifies that medications should only be administered upon a physician's order and should not be left at the resident's bedside. However, during an observation, a medication cup with two pills was found on the overbed table of a resident, who stated she was not taking the pills. This indicates a lapse in following the facility's medication administration policy. The resident in question, who was admitted with diagnoses of hypertension, osteoporosis, and anxiety, did not have a physician's order for self-administration of medications, nor was there a self-administration assessment included in her clinical record. Additionally, her care plan did not address self-administration of medication management. The RN confirmed the presence of the pills at the bedside, and the Director of Nursing acknowledged the facility's failure to assess the resident's ability to self-administer medications, which contributed to the deficiency.
Failure to Prevent Accidents and Complete Neurological Assessments
Penalty
Summary
The facility failed to prevent accidents and ensure proper neurological assessments following incidents involving falls for residents. Resident R13, who had a history of high blood pressure, muscle weakness, and dementia, was at risk of falls. During care, she slid off the bed and hit her head against the wall, resulting in a traumatic hematoma, head injury, and nasal laceration. The incident report indicated that the nurse aide was unable to prevent the fall due to the resident's weight. Additionally, the facility's policy required neurological checks after such incidents, but these were not completed as required for Resident R54 and Resident R81. Resident R54, diagnosed with osteoporosis, muscle weakness, and dementia, reported falling and bumping her head and arm. However, the neurological checklist for her did not include the required documentation of vital signs at specified intervals. Similarly, Resident R81, who had muscle weakness, overactive bladder, and dementia, was found on the floor in the bathroom. Although she denied hitting her head, only 15 out of the required 21 neurological checks were completed. Interviews with staff confirmed the failure to complete neurological assessments as per facility policy.
Deficiency in Urinary Catheter Care and Physician Orders
Penalty
Summary
The facility failed to ensure proper physician orders and appropriate care for residents with urinary catheters. Resident R385 did not have a physician's order specifying the size of the catheter, when to change it, or a valid medical diagnosis for its use. Additionally, the facility did not implement the use of a dignity bag cover for Resident R385's foley catheter, as observed during a survey. Registered Nurse Employee E7 confirmed the absence of necessary foley orders and the lack of a privacy bag. Resident R49, who was diagnosed with Parkinson's disease, obstructive uropathy, and muscle weakness, was observed with a urinary drainage bag hanging on the bed without a privacy cover. Registered Nurse Employee E8 confirmed the failure to use a privacy bag for Resident R49. The Director of Nursing acknowledged the facility's failure to ensure a physician order for a urinary catheter for Resident R385 and to provide appropriate treatments and services for the use of urinary catheters for both Resident R49 and R385.
Failure to Monitor and Address Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes in several residents, leading to deficiencies in care. Resident R78 experienced severe weight loss of 9.9% in one month and 10.4% over two months, yet there was no documentation from the dietary department addressing this issue. The Dietary Technician was aware of the weight loss but did not document any actions taken to address it. The Nursing Home Administrator confirmed that the facility did not identify and address the weight loss in a timely manner. Additionally, the facility failed to obtain daily weights for Residents R114 and R382 as per physician orders. Resident R114 also experienced a weight gain of 4.8 pounds in one day, but the facility did not notify the physician as required. The Director of Nursing confirmed these failures, indicating a lack of adherence to the facility's policies and physician orders regarding weight monitoring and management.
Medication Cart Security Breach
Penalty
Summary
The facility failed to properly secure one of the four medication carts reviewed, specifically the Building One Second Floor Low Side Med Cart. According to the facility's policy on Drug Acquisition, Storage, Inspection, and Dispensing, medications should be stored securely, and lockable medication carts must be used to store unit-of-use medications in the resident medication dose system. These carts are required to be locked when not attended. However, during an observation, the medication cart was found unlocked and unattended with the top drawer pulled open. This was confirmed by Registered Nurse Employee E2 and later by the Nursing Home Administrator, indicating a breach in the facility's protocol for securing medications.
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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