Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and physical debility, requiring assistance of two staff for transfers, was transferred by a single nurse aide who relied on incorrect information from a census sheet rather than the care plan. This failure to follow the resident's plan of care resulted in an ankle fracture, with the incident substantiated as neglect after facility investigation.
Unqualified Food Service Director. The facility failed to employ a qualified FSD to manage the daily operations of the dietary department. Record review showed an educational degree for the Dietary Manager, but interviews confirmed the RD worked across two facilities, did not take an active role in daily dietary operations, and the Dietary Manager was not a Certified Dietary Manager.
Food Labeling, Dish Sanitation, and Kitchen Cleanliness: Surveyors found soiled disposable cup lids, expired milk cartons, uncovered slicer and mixer equipment, and a soiled dish handling process in the Main Kitchen without hand hygiene or other contamination control. They also observed standing water and black sediment in an inoperable sink area used for food prep, and multiple unlabeled or undated food items in a Ground Floor nutrition room, including a jug of red liquid, sandwiches, fruit, and open snack packages.
Incomplete Legionella Water Management Program: The facility failed to maintain a comprehensive water management program to monitor the potential development and spread of Legionella and failed to implement control measures within the facility. The program lacked point-of-use disinfectant logs for hot and cold water chlorine concentration, did not identify control limits for chlorine levels, and did not include logs for monthly flushing of hot water and storage tanks or minimum water temperature testing. The NHA confirmed the deficiencies during interview.
Inoperable Kitchen Sink and Garbage Disposal: The Main Kitchen’s two-compartment sink had standing water and black sediment in the drain, and the Dietary Manager confirmed the garbage disposal was not operable. Staff were using a baking sheet over the inoperable sink area for food prep. The NHA and Maintenance Director were aware of the issue, and an electronic communication documented the sink and disposal as items needing repair or replacement.
Failure to Review Advance Directives: The facility failed to provide the opportunity for two residents to formulate an advance directive and failed to document annual review of existing advance directive instructions. One resident had Parkinson's disease, bipolar disorder, and anxiety with a BIMS of 13, and another had cerebrovascular disease, thyroid disorder, and depression with a BIMS of 15. The NHA confirmed the missing advance directive reviews.
Worn and holed bed linen was observed for multiple residents, and residents reported that linen changes were infrequent unless they asked for clean sheets or had an accident. Staff confirmed the facility was short on bed linen and that some available linen had holes. A closet on one nursing unit also contained mixed items such as an employee lunch bag, medical supplies, clothing, and a toolbox, and the NHA and DON confirmed the environment failed to meet homelike standards.
Residents reported fearing reprisal if they filed grievances, saying they could be blackballed or placed on a hitlist. One resident was upset after an employee confronted her about a confidential complaint, and the NHA and DON confirmed the interaction. The facility also did not display required grievance procedure and grievance official contact information in key areas of the building.
The facility failed to ensure written notice of the bed-hold policy was provided at the time of transfer for two residents. One resident had severe cognitive impairment, cirrhosis, muscle wasting, and a court-appointed guardian, while the other had schizophrenia, a hx of stroke, and a daughter documented as POA. Transfer forms for both residents were incomplete, with blank sections for resident or representative notification, bed-hold decisions, and required signatures.
MDS assessments did not accurately reflect resident status for five of twelve residents. One resident was coded as using a limb restraint without supporting orders or documentation, another was marked as receiving an anticoagulant despite no MAR evidence, and three residents had inaccurate or incomplete BIMS and mood interview coding even though they were at least sometimes understood. The NHA and DON confirmed the assessment errors.
Failure to Provide Needed ADL Assistance: The facility failed to ensure needed ADL care was provided to four residents with significant medical and cognitive needs. One resident was found with urine-soaked linens and a wound dressing saturated with urine, two residents repeatedly requested shaving but remained unshaven, and an RN told another resident to use her diaper instead of assisting her to the bathroom; the DON and NHA confirmed the failure.
Failure to follow ordered treatments and compression therapy. A resident with a lower-extremity wound had very soiled dressings left in place, another resident’s abdominal wound dressing was saturated with urine, and two residents with orders for ACE wraps or compression stockings were observed without them or with them applied incorrectly. One resident’s TAR documented stockings as held without a corresponding order, and another resident’s care plan did not include the ordered stockings.
Unsafe Access to Hazardous Areas and Equipment: The facility failed to keep multiple areas secured, including soiled utility rooms and maintenance rooms with sharps, biohazard waste, refuse, linen, and circuit breaker boxes accessible to residents. An outdoor smoking area also had a propane grill with an attached propane tank present, and the Maintenance Director confirmed the tank was accessible to residents and posed a danger near possible sparks or flames. The NHA confirmed the facility failed to provide a safe environment on two nursing units.
The facility failed to maintain enough nursing staff to meet resident needs, and multiple residents reported long call light waits, missed showers, and delayed personal care. A resident with cirrhosis and muscle wasting was observed in bed with urine-soaked linens and a urine-soiled abdominal wound dressing, while call lights were sounding at the nurse's station and aides were not responding. Staff interviews and grievances also reflected ongoing concerns about inadequate CNA coverage and delayed incontinence care.
Improper Storage of Medical Supplies and Unsecured Medication Cart: The facility failed to properly store and dispose of medical supplies in two nursing units and left one medication cart unlocked and unattended. Observations found supplies in soiled utility rooms, including blood-collecting items and expired urine collection kits, swab systems, and blood culture bottles. An LPN confirmed the findings, and an RN acknowledged leaving the medication cart unsecured.
Failure to Notify Physician of Elevated CBG Levels: The facility did not notify the physician of multiple elevated CBG readings for a resident with DM and HTN, despite an order to call the doctor when blood glucose was 400-999 mg/dl. Record review showed several CBG values over 400 mg/dl, and the NHA and DON confirmed the missed notifications.
Failure to Develop Person-Centered Care Plans: The facility did not include measurable goals and interventions in care plans for three residents. One resident with opioid abuse and an order for Suboxone had no care plan focus for opioid use disorder, another resident who used e-cigarettes had no care plan guidance for vape use, and a third resident with an order for compression stockings had no care plan focus for [NAME] hose use. Observations also showed a vape at one bedside and a resident twice without compression stockings, with swelling noted and the TAR reflecting an undocumented hold.
Medication timing errors involved two residents with levothyroxine orders that were scheduled at the same time as pantoprazole. An LPN questioned the timing because levothyroxine should be given before meals and not with other meds, and the ADON confirmed one order was incorrect and another resident also had levothyroxine ordered incorrectly. The package insert stated levothyroxine should be given on an empty stomach and separated from PPIs that can interfere with absorption.
Failure to Post Required State Agency and APS Contact Information: The facility did not post the required State Agency and APS contact information, including names, addresses, email, and phone numbers, or the statement that residents may file a complaint with the State Agency in the main lobby, G wing, and 1 wing. Surveyors observed the missing information, and the NHA confirmed the deficiency.
Failure to display required Medicare and Medicaid information. The facility did not post written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits or how to receive refunds for previous payments covered by those benefits. Observations in the main lobby and on the G and 1 wings showed the required information was missing, and the NHA confirmed the omission.
Governing body failed to respond to equipment repair requests. In the Main Kitchen, the two-compartment sink had standing water with black sediment in the garbage disposal drain, and the Dietary Manager confirmed the garbage disposal was not operable and that maintenance knew about it. The NHA said she was aware of the issue after a walk-through with the Maintenance Director and corporate staff, and an email listed the sink and garbage disposal as items needing repair or replacement, but the NHA could not explain corporate management’s response.
A review of staffing records and staff interviews revealed that the facility did not provide the minimum required number of nurse aides on several day, evening, and night shifts, resulting in staffing levels below regulatory requirements for the census on those days. The Nursing Home Administrator confirmed the deficiency.
A resident with diabetes, obesity, and hypertension reported that an LPN performed a blood glucose finger stick while she was sleeping on two occasions. The DON and administrator confirmed that the facility did not conduct a full investigation into the alleged abuse, failing to interview the accused employee, witnesses, or other staff, as required by policy.
A medication cart on the first floor was observed left unlocked and unattended in the hallway near the nurse's station, contrary to facility policy requiring all medications and biologicals to be securely stored. Both a nurse and the DON confirmed the cart should have been secured when not in use.
Multiple residents did not receive their selected menu items, including desserts, beverages, supplements, and preferred salad dressings, as documented on their meal tickets. Additionally, artificial sweetener was unavailable for residents with diabetes or those preferring non-sugar options, and staff confirmed the facility could not meet these dietary needs due to supply shortages.
The facility did not consistently offer evening snacks to residents as required by its policy, with several residents reporting that snacks were rarely or never provided and sometimes consumed by staff instead. This failure was confirmed by the administrator and affected the majority of residents interviewed.
Multiple residents reported seeing ants and spiders in their rooms, and observations confirmed the presence of ants in several rooms and common areas. During PTAC unit replacement, no measures were taken to prevent insect entry, and the facility's pest control program was not effectively implemented, as confirmed by the administrator.
The facility failed to provide the required number of nurse aides (NAs) per resident on several shifts. Specifically, the facility did not meet the mandated staffing levels for NAs during the daylight, evening, and night shifts on multiple days. This deficiency was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on four days, with PPD hours recorded as 2.73, 2.78, 3.01, and 3.00. This was confirmed by the Nursing Home Administrator after reviewing staffing documents and schedules.
The facility did not meet the required staffing levels for nurse aides on multiple occasions. Specifically, the facility failed to provide the mandated number of NAs during the daylight, evening, and night shifts on various days, as confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 PPD hours of direct care on two days, providing only 3.16 and 2.94 PPD hours. This was confirmed by the Nursing Home Administrator.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and outdated care plans. The resident was found on a highway by a CNA and returned to the facility. The incident highlighted lapses in updating elopement risk assessments and care plans.
A facility failed to reassess a resident with cognitive decline for elopement risk, despite a significant drop in BIMS scores and incidents of confusion and anxiety. The resident, diagnosed with dementia, was found outside the facility on a highway, indicating a risk of elopement. The facility did not update the resident's care plan or complete a new elopement risk assessment, as confirmed by interviews with the DON and Regional DON.
The facility failed to maintain a homelike environment due to lukewarm water issues and structural problems on two floors. Residents and staff reported that water needed to run for extended periods to become warm, and there were holes in walls and unfinished plaster. A black substance with a musty odor was found on a shower room ceiling. The Maintenance Director confirmed the water system's limitations, affecting the entire building.
A facility failed to maintain infection control practices during a dressing change, as observed by surveyors. The RN did not wash or sanitize hands before donning clean gloves multiple times, did not use a clean barrier for items on the bedside table, and failed to label the dressing with date, time, and initials. Despite a bathroom being available, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the failure to prevent cross-contamination.
The facility did not provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, an RN, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code regulations on licensee responsibility, management, and staff development.
The facility failed to provide several residents with the opportunity to formulate an advance directive, as required by policy. Clinical records for residents with various medical conditions lacked documentation of advance directives or evidence that residents were given the chance to create one. This was confirmed by a social worker during an interview.
The facility failed to provide the required 12 hours of annual in-service education for five nurse aides, who each received only 4 hours of training within the specified timeframe. This deficiency was confirmed by the Nursing Home Administrator, acknowledging the shortfall in meeting the mandated training requirements.
A facility failed to conduct a required Level II PASARR evaluation for a resident diagnosed with Schizophrenia and bipolar disorder. Despite the facility's policy requiring a Level I screening and referral for Level II evaluation, the necessary referral and evaluation were not completed, as confirmed by a review of clinical records and an interview with a social services employee.
The facility failed to notify physicians and assess two residents for abnormal blood glucose levels. One resident had CBG levels of 53 and 477, while another had levels of 62 and 416, without proper notification or assessment. Care plan interventions were not followed, and interviews with LPNs revealed inconsistencies in handling abnormal CBG levels.
A resident with multiple health conditions required extensive assistance for bed mobility, but the facility failed to document this need adequately. The resident rolled out of bed during care, resulting in a head injury. The incident was witnessed, and the resident was taken to the hospital for evaluation. The Director of Nursing confirmed the lack of proper documentation contributed to the fall.
The facility failed to dispose of expired medical supplies in a medication room on the first floor. Observations revealed expired povidone iodine swabsticks, oil emulsion dressings, super absorbent dressings, strip paste coloplasts, and a small bore extension set. The Nursing Home Administrator confirmed the oversight, violating resident care policies and nursing services regulations.
The facility did not complete annual performance evaluations for five nurse aides, violating personnel policies. Employees hired between 1993 and 2020 lacked documented evaluations, confirmed by the Nursing Home Administrator. This deficiency breaches staff development regulations.
The facility failed to implement and maintain an effective training program for staff under contractual agreements, as required by their policy. The Director of Nursing and the Nursing Home Administrator confirmed that the previous HR Director did not maintain accurate and complete training files, leading to a deficiency in the facility's adherence to its training policy.
The facility failed to provide communication training to ten direct care staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates the facility's responsibility under relevant state codes.
The facility did not provide training on resident rights to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. This deficiency was confirmed by the Nursing Home Administrator and violates Pennsylvania Code sections on licensee responsibility and staff development.
The facility did not provide mandatory QAPI training to ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator and constitutes a violation of state regulations regarding staff development and licensee responsibility.
The facility did not provide compliance and ethics training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. This was confirmed by the Nursing Home Administrator.
A resident with anxiety and depression, who used jewelry making as a therapeutic activity, did not have her personal belongings returned for four weeks after returning from a psychiatric commitment. The facility delayed the return of her possessions to ensure she would remain in her new room, which was confirmed by the Social Worker and acknowledged by the Nursing Home Administrator.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
The facility failed to provide adequate supervision during transfers for one resident, resulting in an ankle fracture. The resident in question had a history of diabetes, arthritis, and physical debility, and was assessed as severely cognitively impaired with a BIMS score of 0. According to the resident's care plan and Kardex, the resident required assistance from two staff members for transfers. However, on the day of the incident, the resident was transferred by a single nurse aide, contrary to the documented care plan. The nurse aide relied on an outdated census sheet that incorrectly listed the transfer status and did not consult the electronic charting system for the most current information. Following the transfer, the resident was found to have swelling, warmth, and tenderness in the left foot and ankle, which was later confirmed by x-ray to be a fracture. The resident was unable to communicate what had occurred due to cognitive impairment. The facility's investigation substantiated neglect, as the nurse aide did not follow the resident's plan of care, leading to actual harm. Staff interviews and documentation confirmed that the plan of care was not followed during the transfer, resulting in the injury.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department. Document review provided to the survey team on 9/14/25 showed an educational degree for Dietary Manager Employee E4, and during an interview on 9/18/25 at 11:06 a.m., the RD Employee E5 confirmed that although she is employed full-time by the facility corporation, she works in two separate facilities. RD Employee E2 further confirmed that she does not take an active role in the daily operations of the dietary department. During interviews on 9/18/25, the Nursing Home Administrator confirmed that Dietary Manager Employee E4 is not a Certified Dietary Manager and that the facility failed to employ a qualified Food Service Director to manage the daily operations of the Dietary Department.
Food Labeling, Dish Sanitation, and Kitchen Cleanliness
Penalty
Summary
The facility failed to properly label and date food, clean and sanitize food service items and dishes, and maintain cleanliness in the Main Kitchen and one of two nursing unit nutrition rooms. The Dietary Services policy, Sanitation dated 1/22/25, stated that all kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects, and that utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and free from breaks, corrosions, open seams, cracks, and chipped areas. In the Main Kitchen, surveyors observed unused disposable cup lids that were visibly soiled, nine 4-ounce milk cartons with a best-by date of 9/12/25, and an uncovered slicer and mixer that were not in use. On a later observation, a staff member was seen scraping soiled dishes, loading them into the dishwasher, and then removing clean dishes and storing them for use without hand hygiene, an apron, or any other method to remove contamination after handling the soiled dishes. The slicer and mixer remained uncovered, and the two-compartment sink in the food preparation area had approximately 2-3 inches of standing water in the right compartment with black sediment collecting in the garbage disposal drain and floating in the water. The Dietary Manager confirmed the garbage disposal was not operable and stated staff place a large baking sheet over the inoperable sink area to use it as a food preparation area. In the Ground Floor nutrition room, surveyors observed an undated gallon jug of red liquid, a staff lunch bag, an unmarked peanut-butter and jelly sandwich, a prepackaged chicken wrap without a name, a container of sliced watermelon without a name or date, and a grocery bag containing open packages of pretzels, pistachios, tortillas, and a container with unknown food, all without proper labeling or dating.
Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to maintain a comprehensive water management program to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for eleven of twelve months, from October 2024 through August 2025. Review of the facility’s Legionella Water Management Program showed that the policy identified core elements such as establishing a team, describing the water system, conducting a risk assessment, monitoring control measures, taking corrective actions, and documenting and communicating findings. Review of the Water Management Program Control Measures showed that it did not contain a log for point-of-use disinfectant to measure and record hot and cold water chlorine concentration, and it did not note chlorine concentrations below 0.5 ppm or above 4.0 ppm as outside control limits. Review of the Preventive Maintenance section also showed that it did not contain logs for monthly flushing of all hot water and storage tanks or minimum water temperature testing in all tanks. During interview, the Nursing Home Administrator confirmed that the facility failed to maintain a comprehensive program for water management and failed to implement control measures for Legionella within the facility.
Inoperable Kitchen Sink and Garbage Disposal
Penalty
Summary
The facility failed to make certain that equipment was maintained in operating condition in the Main Kitchen. During an observation of the Main Kitchen, the two-compartment sink in the food preparation area had approximately 2-3 inches of standing water in the right compartment, with a large amount of black sediment collecting in the garbage disposal drain and floating in the standing water. The Dietary Manager confirmed that the garbage disposal was not operable and stated that staff placed a large baking sheet over the inoperable sink area to create a food preparation area. The Nursing Home Administrator stated she had been made aware of the inoperable garbage disposal during a walk-through completed with the Maintenance Director and corporate staff. An electronic communication dated 8/28/25 documented the walk-through and listed the two-compartment sink and garbage disposal among the items needing repair or replacement. The Maintenance Director confirmed he had been made aware of the need to repair or replace the garbage disposal but was unable to provide the initial maintenance request when asked. The Nursing Home Administrator later confirmed that the facility failed to make certain that equipment was maintained in operating condition in the Main Kitchen.
Failure to Review Advance Directives
Penalty
Summary
The facility failed to provide the opportunity for two residents to formulate an advance directive and failed to document periodic review of advance directive instructions as part of the comprehensive care planning process. Facility policy stated that each resident has the right to formulate an advance directive and that the interdisciplinary team will review advance directives annually during the assessment process and record those reviews in the medical record. Resident R13 was admitted to the facility and had an MDS dated 7/3/25 showing diagnoses of Parkinson's disease, bipolar disorder, and anxiety, with a BIMS score of 13. Resident R85 was admitted to the facility and had an MDS showing diagnoses of cerebrovascular disease, thyroid disorder, and depression, with a BIMS score of 15. Review of both clinical records failed to reveal evidence of periodic advance directive review, including whether the existing care instructions remained the resident's wishes or whether the resident or designated surrogate wished to change or continue those instructions. The NHA confirmed the failure during interview on 9/16/25 at 1:30 p.m.
Worn and Holed Bed Linen With Poor Linen Availability and Storage
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on both the ground floor G wing and first floor 1 wing. During observation, Resident R77’s bed linen was extremely worn, with areas thin enough to show the blue mattress beneath it. Other residents, including R2, R10, and R13, were observed with bed linen that had holes. R13 stated that sheets were not changed often, and the surveyor observed holes in the resident’s bed linen during two separate observations. A group of residents on the first floor reported frustration with the lack of linen and the frequency of bed linen changes, stating they could have the same bed linen for one to two weeks unless they asked for clean sheets or had an accident in bed. The report also documented poor linen availability and storage practices. Facility staff confirmed that the facility had been short of bed linen and that some of the available linen had holes. During observation of a closet on the ground floor nursing unit, an employee lunch bag, toilet seat raiser, powdered drink thickener, disposable cup lids, medical supplies, clothing, and a toolbox were stored together on the shelves. The NHA and DON confirmed the facility failed to provide a safe, clean, comfortable, and homelike environment for fourteen of twenty residents on the two nursing units.
Residents Feared Reprisal for Grievances and Required Postings Were Missing
Penalty
Summary
The facility failed to ensure that residents who voiced grievances could do so without fear of discrimination or reprisal for ten of seventeen residents, including R86, R500, R501, R502, R503, R504, R505, R506, R507, and R508. During a group interview, these residents stated they feared being blackballed or placed on a hitlist if they complained or filed a grievance. The facility also failed to display written information on the grievance procedure and grievance official contact information in the main lobby, ground floor G wing, and first floor 1 wing. During observation, R86 was verbally engaged with the NHA and DON and appeared upset after stating that an employee had made comments to her about a complaint she had made earlier that day in a confidential setting. In interviews, the NHA and DON confirmed that R86 had been confronted by an employee regarding the complaint. R86 later stated that this was the fear residents had in the facility, explaining that if they complained, staff found out and residents were treated differently, and that she felt she needed to watch what she said. The facility policy reviewed stated residents have the right to voice concerns and grievances without fear of retaliation and that grievance postings, including contact information for the grievance official, Ombudsman, and DOH hotline, shall be visible throughout the facility.
Failure to Provide Written Bed-Hold Notice at Transfer
Penalty
Summary
The facility failed to ensure that the resident and/or the resident representative received written notice of the facility bed-hold policy at the time of transfer for two residents reviewed for hospitalization. Facility policy stated that residents or representatives are to be provided written information about bed-hold policies well in advance of transfer and again at the time of transfer, or within 24 hours if the transfer is an emergency. For one resident, the clinical record showed severe cognitive impairment, cirrhosis of the liver, and muscle wasting, and court documents indicated the resident had been adjudged incapacitated with a legal guardian appointed. Transfer/Discharge/Bed Hold forms dated for two hospital transfers showed incomplete documentation, including blank signature areas and blank sections identifying who agreed to the bed hold or whether the resident was cognitively impaired. For the second resident, the record showed diagnoses of schizophrenia and a history of stroke, with the daughter documented as power of attorney. The transfer documentation for that hospitalization also had blank sections for notification of the resident representative, whether the bed was to be held or released, and the resident/responsible party signature. The Nursing Home Administrator and DON confirmed the facility failed to ensure written notice of the bed-hold policy at the time of transfer for these two residents.
MDS Assessments Did Not Match Resident Status
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ status for five of twelve residents. The RAI User’s Manual stated that Section C, C0100 should be coded 0 if a resident is rarely or never understood, and coded 1 with the BIMS completed if the resident is at least sometimes understood; Section D, D0100 had the same requirement for the resident mood interview. Despite these instructions, Resident R53’s MDS dated 7/24/25 showed the resident was sometimes understood in Section B, but Section C was coded as rarely understood and the BIMS was not completed. Resident R66’s MDS dated 7/3/25 showed the resident was sometimes understood in Section B, but Section C was coded as rarely understood and the BIMS was not completed, and Section D was also coded as rarely understood with the Resident Mood Interview not completed. Resident R82’s MDS dated 6/10/25 showed the resident was understood in Section B, Section C indicated the BIMS should be completed, but all further questions were documented as Not Assessed. Resident R2’s MDS dated 8/12/25 indicated use of a limb restraint less than daily when in a chair or out of bed, but the clinical record contained no provider order or other documentation supporting restraint use, and the resident stated during interview that there was no plan for restraint utilization in care. Resident R5’s MDS dated 6/18/25 indicated receipt of an anticoagulant within the prior seven days, but the MAR showed no anticoagulant administration from 6/11/25 through 6/18/25. During interview, the Nursing Home Administrator and DON confirmed the facility failed to ensure that MDS assessments accurately reflected the residents’ status for five of twelve residents.
Failure to Provide Needed ADL Assistance
Penalty
Summary
The facility failed to make certain that necessary care and services were provided for four residents who were unable to complete activities of daily living independently. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The cited deficiencies involved residents with varying care needs, including one resident with cirrhosis and muscle wasting, one with Parkinson’s disease, bipolar disorder, anxiety, and a BIMS of 13, one with hemiplegia and a seizure disorder with a BIMS of 14, and one with coronary artery disease and diabetes. Resident R5 was observed in bed with a urine-saturated brief and bed linen, and the abdominal wound dressing was also saturated with urine; the RN confirmed the dressing should have been changed as needed. Resident R13, who required setup or clean-up assistance for personal hygiene, was observed with unkept facial hair and stated he had asked several times to be shaved but was still waiting. Resident R71 was observed with an untrimmed beard and stated he wanted to be shaved and never got shaved. Resident R97 told an RN she needed to go to the bathroom, and the RN told her, "you can do it in your diaper"; facility investigation information confirmed the RN refused to provide ADL assistance. The DON and Nursing Home Administrator confirmed the facility failed to make certain that necessary care and services were provided for these four residents.
Failure to Follow Ordered Treatments and Compression Therapy
Penalty
Summary
The facility failed to follow physician’s orders for five residents, including failure to provide ordered wound care and compression therapy as documented in the clinical record and observed by surveyors. Resident R37 had diagnoses including anoxic brain injury and chronic hepatitis, and had a left lower extremity skin impairment with orders to cleanse the wounds with Dakins 0.25, apply calcium alginate to the wound beds, and cover with border dressings. On observation, two dressings on the left lower leg were very soiled with dried exudate that had dripped and dried on the resident’s leg, and both dressings were dated several days earlier. The resident’s TAR showed dressing changes documented on multiple days, but the clinical record did not show any documented refusals of care between those dates and the observation. Resident R5 had diagnoses including cirrhosis and muscle wasting and had an order to cleanse an abdominal wound with NSS, apply a collagen sheet, and cover with an island dressing daily and as needed for displacement or drainage. During observation, the resident was found in bed with a urine-saturated brief and bed linen, and the abdominal wound dressing was also saturated in urine. An RN confirmed that the dressing was soiled and should have been changed as needed. Resident R4 had diagnoses including Parkinson’s disease and heart failure and a care plan intervention for ACE wraps on both lower extremities. She was observed with the wraps applied incorrectly, later without the wraps on, and again without them on while her lower legs were visibly swollen and the elastic at the top of her socks left indentations. Resident R10 had diagnoses including dementia and hypertension and had an active order for compression stockings to both legs on in the morning and off in the evening. She was observed without the stockings on during two observations, and the TAR documented the stockings as held due to physician’s order, but the record did not contain an order to hold them. Resident R77 had diagnoses including a seizure disorder and history of stroke and had an active order for compression stockings on in the morning and off in the evening. Her care plan did not include goals or interventions related to the stockings, and she was observed without them on during two observations; on one occasion her lower leg swelling was visible and the elastic top of her socks was constricting her leg. The NHA and DON confirmed that the facility failed to follow physician’s orders for five of eight residents.
Unsafe Access to Hazardous Areas and Equipment
Penalty
Summary
The facility failed to provide a safe environment for residents on two nursing units, with multiple unsecured areas and hazards accessible to residents. On the Ground Floor, the Soiled Utility Room was observed unsecured with sharps containers and biohazardous waste containers accessible to residents, and the Soiled Utility/Trash Room was also unsecured with refuse and soiled linen accessible to residents. In addition, maintenance rooms on both the Ground Floor and First Floor were observed unsecured with circuit breaker boxes accessible to residents. The outdoor smoking area also contained a propane grill with an attached propane tank, and the tank had labels warning of danger and to prevent flames from being near it. The Maintenance Director confirmed the propane tank was accessible to residents in the smoking area and acknowledged the danger of having it near possible sparks or flames. The Nursing Home Administrator later confirmed the facility failed to provide a safe environment for residents on two of two nursing units.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and maintain the highest practicable physical, mental, and psychosocial well-being for nineteen of twenty-four residents. During interviews, multiple residents stated that staffing was inadequate, call lights were not answered promptly, and care was delayed. One resident said the facility did not maintain sufficient staff, and a group of residents agreed there were not enough aides in the building and that some days were worse than others. Several residents described long waits for assistance, including call light response times reported as 30 to 60 minutes, and one resident reported waiting up to an hour. Residents also reported missed or delayed personal care, including showers being skipped when the facility was short of nursing assistants. Two residents stated they had repeatedly requested shaving but were still waiting, and one resident said he had never been shaved. Staff interviews also reflected concerns that there were not enough nurse aides most days and that staffing shortages had existed for some time. Observations supported these concerns. One resident with cirrhosis and muscle wasting was observed in bed with a brief and bed linen saturated with urine, and the resident's abdominal wound dressing was also saturated with urine. A registered nurse confirmed the dressing should have been changed as needed. In another observation, call lights for two rooms were sounding at the nurse's station while two nurse aides were not responding, with one appearing to be on a personal phone and the other reclined in a chair. Grievances reviewed by surveyors also documented concerns about incontinence care and call light wait times, and the administrator and DON confirmed the facility failed to have sufficient nursing staff.
Improper Storage of Medical Supplies and Unsecured Medication Cart
Penalty
Summary
The facility failed to make certain that medical supplies were properly stored and/or disposed of in two nursing units and one medication cart. Review of the facility policy dated 1/22/25 stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner and that unlocked medication carts are not left unattended. During an observation of the Ground Floor Soiled Utility Room, a large box of vacutainer one-use holders was found. During an observation of the First Floor Soiled Utility Room, clean items were observed including blood-collecting sets, more than 100 vacutainers, gauze, alcohol wipes, bandages, and urine collection kits, along with expired items such as an aerobic blood culture bottle, an anaerobic blood culture bottle, urine collection kits, eswabs, and Covid swabsticks. During an observation of the First Floor high end medication cart, the cart was noted to be unlocked with no staff present in the vicinity. An LPN confirmed the observations in the soiled utility room, and an RN confirmed that she had left her medication cart unsecured. The NHA and DON later confirmed that the facility failed to make certain that medical supplies were properly stored and/or disposed of in two of two nursing units and one of four medication carts.
Failure to Notify Physician of Elevated Blood Glucose
Penalty
Summary
The facility failed to notify the physician of increased capillary blood glucose levels for Resident R42. The resident was admitted and later readmitted to the facility, and the MDS dated 8/8/25 listed diagnoses of high blood pressure and diabetes. A physician order dated 12/18/24 and reordered 7/15/25 directed staff to administer Humalog insulin per sliding scale and to call the doctor if blood glucose was 400-999 mg/dl. Review of the clinical record, progress notes, July and September MARs, 24-hour reports, and hard-copy provider notification books did not show physician notification for multiple elevated CBG readings for R42, including 401 mg/dl on 7/03/25, 420 mg/dl on 7/18/25, 453 mg/dl on 7/19/25, 497 mg/dl on 7/20/25, 425 mg/dl on 7/25/25, and 428 mg/dl on 7/26/25. During interview on 9/18/25, the Nursing Home Administrator and DON confirmed the facility failed to notify physicians of the increased blood glucose levels for one of three residents.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans with measurable objectives and timetables for three residents. Facility policy stated that a comprehensive, person-centered care plan should be developed and implemented for each resident, and that instruction specific to e-cigarette safety should be documented in the resident care plan for residents who use e-cigarettes. Review of Resident R14’s record showed diagnoses including neuropathy, hypertension, chronic pain, and opioid abuse, along with a physician order for Suboxone twice daily for opioid use disorder, but the care plan initiated 6/16/23 and updated 8/4/25 did not include goals or interventions related to opioid abuse. Resident R62’s record showed diagnoses of heart failure and asthma, but the care plan initiated 8/22/25 did not include goals or interventions related to the use of electronic cigarettes. Resident R77’s record showed diagnoses of a seizure disorder and history of stroke, and an active physician order dated 2/9/24 for compression stockings on in the morning and off in the evening for edema. Her care plan updated 8/7/25 did not include goals or interventions related to the use of [NAME] hose. During observations, Resident R62 was seen with a vape on her bedside table. Resident R77 was observed without her [NAME] hose on at 11:45 a.m. on 9/15/25, and the TAR indicated the hose was held due to physician’s order, but the clinical record did not reveal an order to hold it. On 9/18/25, Resident R77 was again observed without her [NAME] hose, with visible swelling and the elastic top of the socks constricting her lower leg; later that day the TAR indicated the [NAME] hose was applied by an LPN. The NHA and DON confirmed the facility failed to develop person-centered care plans for three of eight residents.
Medication Timing Errors With Levothyroxine and Pantoprazole
Penalty
Summary
The facility failed to ensure that two residents were free of significant medication errors involving levothyroxine administration. One resident was admitted with discharge orders for levothyroxine 100 mcg every morning and also had pantoprazole 40 mg every morning ordered by the physician. The Medication Admin Audit Report showed both medications scheduled for 9:00 a.m., and during a medication administration observation, an LPN stated she needed to verify the levothyroxine time because it should be given before eating and not with other medications. The Assistant DON later confirmed that the levothyroxine timing for this resident was incorrect and had been adjusted that morning, and she also confirmed one additional resident had levothyroxine ordered incorrectly. The second resident had diagnoses including dementia and a thyroid disorder and had physician orders for levothyroxine 150 mcg each morning and pantoprazole 20 mg each morning. The Medication Admin Audit Report again showed both medications scheduled for 9:00 a.m. Review of the levothyroxine package insert indicated it should be administered on an empty stomach, preferably one-half to one hour before breakfast, and at least 4 hours before or after drugs that interfere with absorption, including proton-pump inhibitors. The facility also had a medication and treatment orders policy requiring refills to be reordered at least three days before the last dose is given. The NHA and DON later confirmed the facility failed to ensure residents were free of significant medication errors for two of five residents reviewed.
Failure to Post Required State Agency and APS Contact Information
Penalty
Summary
The facility failed to post information for the State Agency, Adult Protective Services (APS), and a statement that residents may file a complaint with the State Agency as required. Based on observations, the required information was not posted or otherwise accessible to residents or resident representatives in the main lobby, the ground floor G wing, and the first floor 1 wing. During observations on the ground floor G wing and first floor 1 wing nursing units, and in the main lobby, surveyors found that the facility did not have any elements of the State Agency or APS contact information, including the agency name, address, email, and phone number, and did not have the required statement that residents may file a complaint with the State Agency. During an interview, the NHA confirmed that the facility failed to post the State Agency information, APS information, and the complaint statement in the building.
Failure to Display Required Medicare and Medicaid Information
Penalty
Summary
The facility failed to display written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits. During observations on the ground floor G wing, first floor 1 wing, and in the main lobby, the required information was not included in the posted materials. During a follow-up observation and interview with the Nursing Home Administrator, the administrator confirmed that the facility did not display the required written information in the main lobby, ground floor G wing, or first floor 1 wing.
Governing Body Failed to Respond to Equipment Repair Requests
Penalty
Summary
The governing body failed to implement policies regarding the management of the facility’s operation by not responding to requests for equipment repairs. During an observation of the Main Kitchen food preparation area, the two-compartment sink had approximately 2-3 inches of standing water in the right compartment, with a large amount of black sediment collecting in the garbage disposal drain and floating in the standing water. The Dietary Manager confirmed that the garbage disposal was not operable and that the maintenance department was aware of the issue. The Nursing Home Administrator confirmed that she had been made aware of the non-operable garbage disposal during a walk-through completed with the Maintenance Director and corporate staff. An electronic communication dated 8/28/25 documented the walk-through and listed the two-compartment sink and garbage disposal among items needing repair or replacement. When asked about the corporate management response to the needed repair or replacement, the NHA was unable to provide an answer. During a later interview, the NHA confirmed that the governing body failed to implement policies regarding management of the facility by failing to respond to facility requests for equipment repairs.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet required nurse aide (NA) staffing ratios on multiple shifts over a six-day period, as evidenced by a review of staffing documents and staff interviews. Specifically, the facility did not provide at least one NA per 10 residents during the day shift on two days, one NA per 11 residents during the evening shift on three days, and one NA per 15 residents during the night shift on two days. Staffing records showed that the actual NA hours provided were below the required hours for the census on these dates. The Nursing Home Administrator confirmed during an interview that the facility did not meet the required NA staffing levels on the identified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shift's staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, phone calls and text messages are sent to staff. The facility is utilizing agency to assist with open shifts. The facility attendance policy is followed for staff and disciplines occur per policy. Attendance is tracked on a calendar and reviewed weekly. The facility holds a monthly retention committee meeting and ads are posted on Indeed for open positions. Interviews are conducted immediately. We have a dedicated recruiter to assisting us with recruiting and hiring new nursing staff. The Administrator or designee will educate the Nursing Admin, the scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios with the NHA, DON, and scheduler. Daily recruiting calls occur to update the status of new applicants and interviews. The 3-week DOH Staffing Calculator Tool will be updated daily to monitor hours. The audits will be taken to QAPI for review.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate incidents of possible abuse and neglect involving one resident. According to facility policy, staff are required to assess, document, and investigate all alleged abuse and neglect, including interviewing witnesses and other relevant individuals. In this case, a resident reported that a nurse entered her room and performed a blood glucose finger stick while she was sleeping on two occasions. The Director of Nursing confirmed that the incident occurred, but the facility did not conduct a full investigation as required by policy. Specifically, the facility did not interview the accused employee, any possible witnesses, other staff members present, or other residents who may have received care from the same employee. The resident involved had diagnoses including diabetes, obesity, and high blood pressure, and was re-admitted to the facility prior to the incident. The failure to follow investigative procedures was confirmed by both the Director of Nursing and the Nursing Home Administrator.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to properly secure a medication cart, as observed during a survey. On the first floor, Team #1's medication cart was found unlocked and unattended in the hallway near the nurse's station. Facility policy requires that medications and biologicals be stored safely and securely in locked compartments, with access limited to authorized personnel. During interviews, both a registered nurse and the Director of Nursing confirmed that the cart was left unattended and unlocked, which was not in accordance with facility policy.
Failure to Provide Resident-Selected Menu Items and Dietary Preferences
Penalty
Summary
The facility failed to provide resident-selected menu items for 14 out of 20 residents, as evidenced by meal observations and review of meal tickets. Specific deficiencies included residents not receiving requested items such as ginger ale, puddings, cookies, ice cream, house supplements, cranberry juice, nutritional supplements, and preferred salad dressings. In one instance, a resident received Italian dressing instead of the requested ranch, which the resident stated caused heartburn. Additionally, several residents consistently received fewer cookies than requested on their meal tickets. During staff interviews and cart inspections, it was revealed that the facility did not have any artificial sweetener available for residents with diabetes or those who preferred non-sugar sweeteners. The Dietary Manager confirmed the absence of artificial sweetener and indicated that the next food delivery was not expected for several days. The Nursing Home Administrator also confirmed the failure to provide selected food items to the affected residents. These findings are in violation of the facility's policy and state dietary service regulations.
Failure to Consistently Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to consistently provide evening snacks to residents as required by its own policy and in accordance with residents' needs and preferences. The facility's policy, dated 9/9/24, states that evening snacks will be routinely offered to all residents. However, interviews with six out of eight residents revealed that snacks were either not provided, only occasionally provided, or not available when requested. Several residents reported that they rarely or never received evening snacks, with some stating that staff consumed the snacks instead of offering them to residents. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged that the facility did not consistently provide snacks as desired by the majority of residents interviewed. The findings indicate a failure to adhere to established policy and to meet the nutritional and personal preferences of residents regarding snack availability outside of scheduled meal times.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the Ground Floor nursing unit, as required by its own pest control policy. Multiple residents reported seeing ants and spiders in their rooms, with one resident specifically noting that her room was not treated during a recent exterminator visit. Observations confirmed the presence of ants in several resident rooms, including under and inside PTAC units, as well as in the lounge area where both live ants and dead bugs were found. An empty room with a removed PTAC unit had visible ants in the remaining metal case, which had grates allowing air flow and potential pest entry. Interviews with the Maintenance Director revealed that no measures had been taken to prevent insects from entering the building during PTAC unit replacement. The Nursing Home Administrator confirmed the failure to maintain an effective pest control program for the affected nursing unit. These findings were based on direct observations and resident and staff interviews, and were cited under 28 Pa. Code: 207.2 (a) regarding the administrator's responsibility.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on five out of eight days, one NA per 11 residents during the evening shift on four out of eight days, and one NA per 15 residents during the night shift on one out of eight days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the failure to meet the staffing requirements on the specified shifts.
Plan Of Correction
The Facility submits this Plan of Correction under the procedures established by the Department of Health in order to comply with the Departments directive to change conditions which the department alleges is deficient under state and/or Federal Long Term Care regulations. This Plan of Correction should not be construed as either a waiver or the facility right to appeal or challenge the accuracy of severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. The CNA schedule is created to ensure staffing ratios reflect the current census per shift. Each shifts staffing is adjusted based on census. When additional staff is needed to meet ratios, shifts are posted on our staffing portal, bonuses are offered, text messages are sent to staff. The Administrator or designee will educate the Nursing Admin, the scheduler and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review ratios and audited for 3 weeks. The Audits will be taken to QAPI for review.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on four specific days. A review of staffing documents and nursing staff schedules from January 21, 2025, through January 28, 2025, revealed that the facility did not provide the required PPD on January 24, 26, 27, and 28, 2025. Specifically, the PPD hours were 2.73, 2.78, 3.01, and 3.00, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 29, 2025, who acknowledged the failure to meet the required staffing levels on the specified days.
Plan Of Correction
The Nursing schedule is created to ensure staffing ratios reflect the current census per shift to meet PPD. When additional staff is needed to meet PPD, shifts are posted on our staffing portal, bonuses are offered, and text messages are sent to staff. The Administrator or designee will educate Nursing Admin, the Scheduler, and RN Supervisors on the staffing ratio grid and how to adjust. A staffing meeting will occur daily to review PPD and audited for 3 weeks. The Audits will be taken to QAPI for review.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on several occasions between December 10, 2024, and December 15, 2024. Specifically, on December 13, 2024, the facility did not provide the mandated one NA per 10 residents during the daylight shift. Additionally, on December 12 and December 15, 2024, the evening shift was understaffed, with the facility failing to provide one NA per 11 residents. Furthermore, on the night shift of December 15, 2024, the facility did not meet the requirement of one NA per 15 residents. These deficiencies were confirmed by the Nursing Home Administrator during an interview on December 16, 2024.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. P5520 1. The facility cannot correct that the nurse aide staffing ratio was not met on 12/12/24, 12/13/24, and 12/15/24. There were no adverse effects to residents on the identified dates. 2. The scheduler will be re-educated regarding the state ratios by the Nursing Home Administrator/designee. 3. Nursing Administration will be re-educated on staffing ratios by the Nursing Home Administrator/designee. Twice a day staffing meetings will be held to review the schedule with ratios. Nursing supervisors will monitor on weekends. If the facility is projected to not meet staffing ratios, the scheduler/or designee will call off duty facility staff and will utilize external staffing support resources. The facility has started regular job fairs to increase staffing. 4. Nursing Home Administrator/designee will audit staffing daily for three weeks and monthly for three months to ensure staffing ratios are being met. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on two specific days. A review of staffing documents and nursing schedules from December 10, 2024, through December 15, 2024, revealed that the facility did not meet the required PPD hours on December 12, 2024, and December 15, 2024. On December 12, 2024, the facility provided 3.16 PPD hours, and on December 15, 2024, it provided only 2.94 PPD hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 16, 2024, who acknowledged the failure to meet the required direct care hours on the specified dates.
Plan Of Correction
1. The facility cannot correct that the state required PPD (per patient daily) minimum hours of 3.20 was not met on 12/12/24 and 12/15/24. 2. The facility scheduler will continue to be educated regarding the state ratios and daily PPD by the NHA/designee. 3. The NHA, DON and scheduler will meet twice a day to review PPD and projected PPD. Nursing supervisors will monitor it on weekends. If the facility is projected to not meet daily PPD, the scheduler or designee will call off duty facility staff and utilize external staffing support resources. 4. NHA/designee will audit staffing daily for three weeks and monthly for three months to ensure daily PPD is being met. Outcomes will be reported to the QA&A committee for review and recommendations.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of Resident R1, who was identified as having a severe cognitive impairment with a BIMS score of 5. Despite having a care plan initiated for the risk of wandering and elopement, the plan was not updated until after the incident occurred. The facility's elopement evaluations previously documented Resident R1 as not being at risk for elopement, and a significant change assessment that included an elopement risk evaluation was not completed. This lack of updated assessments and care plan adjustments contributed to the resident's ability to leave the facility unsupervised. On the day of the incident, Resident R1 was found outside the facility on a highway by a CNA, who brought the resident back. The resident was reportedly attempting to get a cigarette. The incident was confirmed by the Director of Nursing and the Regional Director of Nursing, who acknowledged the failure in supervision. The facility's policies and procedures, as well as the resident's rights, were not adhered to, resulting in the resident's unsupervised exit from the facility.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. F689 1. Resident R1 was safely returned to the facility by nurse aide. Resident R1 was assessed for injuries upon return and no injuries noted. Resident R1 was dressed appropriately for the weather. A new elopement assessment was completed 11/15/24 and wander guard placed on Resident R1. 2. The facility will provide adequate supervision to prevent elopements. Residents are evaluated for elopement risk on admission, readmission and as needed. 3. Facility staff will be re-educated on the wandering and elopement policy by the Director of Nursing/designee. 4. The Interdisciplinary Team (IDT) will meet weekly for four weeks and then monthly for three months to discuss any potential elopement risks with each department including status changes of current residents and new admissions. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Reassess Elopement Risk for Resident with Cognitive Decline
Penalty
Summary
The facility failed to reassess a resident with cognitive decline for elopement risk, leading to a deficiency. Resident R1, who was diagnosed with dementia and mood disturbance, exhibited a significant decline in cognitive function over several months, as evidenced by a decrease in BIMS scores from 14 and 15 to 5. Despite this decline, the resident's care plan did not include goals or interventions for dementia or cognitive decline, and the facility did not complete a new elopement risk assessment after the resident's cognitive status changed. The resident's clinical records and staff notes indicated ongoing memory problems, confusion, and episodes of anxiety, such as worrying about his truck and attempting to leave the facility to check on it. On one occasion, the resident was found outside the facility on the highway, indicating a clear risk of elopement. Despite these incidents, the facility's elopement evaluations had previously documented the resident as not being at risk for elopement, and a significant change assessment initiated in September was not completed. Interviews with the Director of Nursing and the Regional Director of Nursing confirmed that the facility did not reassess residents with cognitive decline for elopement risk as required. The facility's failure to complete the necessary assessments and update the resident's care plan contributed to the resident's ability to leave the facility unsupervised, posing a potential risk to the resident's safety.
Plan Of Correction
F744 1. The facility cannot correct that Resident R1 was not reassessed for elopement with a cognitive decline until 11/15/24. 2. The Social Service Director/designee will review current residents BIMS to ensure if there was a cognitive decline they were reassessed for elopement. 3. The nursing staff and social service will be re-educated on the policy dementia -clinical protocol by the Director of Nursing/designee. Social Service will notify the interdisciplinary team when there is a change in resident BIMS to ensure resident is reassessed for elopement risk. 4. The Social Service will audit 5 residents BIMS weekly for four weeks and then monthly for three months to ensure if there was cognitive decline the resident was reassessed for elopement. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Facility Fails to Maintain Homelike Environment Due to Water and Structural Issues
Penalty
Summary
The facility failed to maintain a clean and homelike environment on both the ground and first floors, as observed during a survey. Several issues were identified, including lukewarm water in resident bathrooms that required running for extended periods to reach a warmer temperature. This was confirmed by residents and staff, who noted that the water system's inefficiency affected the entire building. Additionally, there were structural issues such as holes in the walls, unfinished plaster, and an HVAC unit improperly installed, which compromised the homelike environment. Further observations revealed a black substance with a musty odor on the ceiling of a shower room, indicating potential mold presence. The Maintenance Director acknowledged the water system's limitations, citing a single water holding tank for the entire building, which led to inconsistent water temperatures. These deficiencies were noted under the Pennsylvania Code sections related to the responsibility of the licensee, management, and resident rights.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change, as observed during a survey. The facility's policy on Dry/Clean Dressings required cleaning the bedside stand before and after the dressing change, placing clean equipment on a clean field, and washing and drying hands thoroughly. However, during an observation, several lapses were noted. A red biohazard bag was improperly placed in the resident's regular garbage can, and the registered nurse (RN) did not wash or sanitize hands before donning clean gloves multiple times throughout the procedure. The bedside table was wiped but not cleared of resident belongings, and a clean barrier was not used for the items placed on it. Personal scissors were cleansed, but the same scissors were used to cut a dirty dressing without being cleansed afterward. The RN also failed to label the dressing with the date, time, and initials as required by the facility policy. Despite the presence of a bathroom with running water and soap in the resident's room, the RN claimed there was nowhere to wash hands. The Director of Nursing confirmed the facility's failure to prevent cross-contamination during the dressing change. These actions and inactions led to a deficiency in infection control practices, as outlined by the relevant Pennsylvania Code sections.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide behavioral health training for ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The deficiency was identified through a review of facility documents and staff interviews, which revealed that none of the ten employees had received the required training on behavioral health. This lack of training was confirmed by the Nursing Home Administrator during an interview. The deficiency is in violation of several Pennsylvania Code regulations related to the responsibility of the licensee, management, and staff development.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide six out of nine residents reviewed with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The facility's policy on advance directives, dated 12/29/23 and 4/9/24, states that residents have the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The clinical records of residents with various diagnoses, including diabetes, depression, anxiety, high blood pressure, Huntington's Disease, cancer, congestive heart failure, obesity, and chronic pain, were reviewed. For each of these residents, the records did not contain an advance directive or documentation indicating that they were given the opportunity to formulate one. This was confirmed during an interview with Social Worker Employee E6, who acknowledged the absence of such documentation for the residents in question.
Deficiency in Nurse Aide In-Service Training
Penalty
Summary
The facility failed to provide the required 12 hours of annual in-service education for nurse aides within 12 months of their hire date anniversary, as mandated by regulations. This deficiency was identified for five nurse aides, Employees E1, E2, E3, E4, and E5, who each received only 4 hours of in-service training within the specified timeframe. The facility's policy on in-service training, dated 4/9/24 and 12/29/23, requires all staff to demonstrate competency in training topics to enhance residents' quality of life and care. A review of the facility's assessment indicated that staff training should align with their roles and include updates to policies and procedures as needed. However, the education records for the nurse aides showed a shortfall in the required training hours. During an interview, the Nursing Home Administrator confirmed the deficiency, acknowledging that the facility did not meet the 12-hour annual in-service education requirement for the five nurse aides.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to complete a Level II evaluation for a resident, as required by the Preadmission Screening and Resident Review (PASARR) process. The facility's policy mandates that all residents undergo a Level I screening and, if necessary, a referral for a Level II evaluation in compliance with state and federal regulations. Resident R15, who has been diagnosed with Schizophrenia and bipolar disorder, was identified as needing a Level II evaluation. However, a review of the clinical records and an interview with Social Services Employee E6 confirmed that the referral and completion of the Level II evaluation by a state PASARR representative were not conducted for this resident.
Failure to Notify Physicians and Assess Residents for Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R39, who was readmitted with diagnoses including diabetes, had a CBG of 53 and 477 on separate occasions, but the physician was not notified, and the resident was not assessed for hyper-/hypoglycemia. The care plan interventions, such as monitoring for signs and symptoms of hypoglycemia and providing insulin coverage, were not followed. Similarly, Resident R78, admitted with diagnoses including diabetes, had a CBG of 62 and 416 on different dates. The facility failed to assess the resident for hyper-/hypoglycemia, did not recheck blood sugar levels, and did not notify the physician of these abnormal results. The care plan interventions, which included monitoring for signs and symptoms of hypo and hyperglycemia, were not adhered to. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, such as notifying the doctor and documenting in the medical records. The Director of Nursing confirmed the facility's failure to notify the doctor of changes in condition related to blood glucose for the affected residents.
Inadequate Supervision and Documentation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and documentation for the bed mobility needs of a resident, resulting in the resident rolling out of bed. The resident, who had diagnoses of diabetes, end-stage renal failure, and intellectual disabilities, required extensive assistance from two or more staff members for bed mobility. However, there was no documented assistance level for bed mobility in the resident's care plan until several months after admission. A progress note indicated that the resident was found lying on the floor with a hematoma on the right side of the head after a CNA attempted to turn the resident for care. The CNA reported that the resident became stiff and rolled out of bed, hitting the head on the nightstand. The incident was witnessed, and the resident was subsequently taken to the hospital for evaluation. A CT scan showed no acute central nervous system findings or fractures, but a small right frontal hematoma was noted. The Director of Nursing confirmed the lack of adequate documentation for the resident's bed mobility needs, which contributed to the incident.
Expired Medical Supplies Not Disposed Properly
Penalty
Summary
The facility failed to properly dispose of expired and/or opened medical supplies in one of the two medication rooms located on the first floor. During an observation, it was noted that the medication room contained 19 Medline triple pack povidone iodine swabsticks, 16 Curad oil emulsion dressings, 16 Dynarex DynaSorb super absorbent dressings, 25 Brava strip paste coloplasts, and one I Medical Devices IM41000 small bore extension set, all of which were past their expiration dates. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the failure to dispose of these expired supplies appropriately. The deficiency was identified as a violation of 28 Pa. Code: 211.10(c) regarding resident care policies and 28 Pa. Code: 211.12(d)(1)(2)(5) concerning nursing services. The presence of expired medical supplies in the medication room indicates a lapse in the facility's adherence to proper storage and disposal protocols, as required by the regulations.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for five nurse aides. The employees involved were hired on various dates ranging from 1993 to 2020. Upon review, there was no documented evidence that the facility conducted these evaluations annually as required. An interview with the Nursing Home Administrator confirmed that the performance evaluations were not completed for the five employees in question. This deficiency is a violation of the facility's personnel policies and procedures as outlined in 28 Pa. Code 201.19 (2) and 28 Pa Code: 201.20 (a)(b)(c)(d) regarding staff development.
Deficiency in Staff Training Program Implementation
Penalty
Summary
The facility failed to implement and maintain an effective training program for individuals providing services under contractual agreements, as required by their policy. The policy, dated April 9, 2024, mandates the development, implementation, and maintenance of a training program for all new and existing staff, including those under contractual arrangements, consistent with their expected roles. However, during interviews, both the Director of Nursing and the Nursing Home Administrator confirmed that the previous Human Resource Director did not maintain accurate and complete training files. This deficiency was identified during a review of the facility's policy and staff interviews, indicating a lapse in the facility's adherence to its own training policy.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility was found to have failed in providing necessary communication training to all ten direct care staff members reviewed. This deficiency was identified through a review of facility education documents and staff interviews, which revealed that the facility did not offer communication education to its direct care staff. The staff members affected included nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. Each of these employees' records lacked documentation of training on effective communication. During an interview, the Nursing Home Administrator confirmed the absence of communication training for the direct care staff. This lack of training is a violation of the facility's responsibility under the 28 Pa. Code: 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively. The failure to provide this essential training could potentially impact the quality of care and communication within the facility.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on resident rights to its staff members, as revealed by a review of facility documents and staff interviews. This deficiency affected ten staff members, including nurse aides, an activities aide, a dietary aide, a housekeeper, a registered nurse, and an occupational therapy employee. The facility's education documents did not include any training on resident rights for these employees. During an interview, the Nursing Home Administrator confirmed the lack of Resident Rights training for direct care staff. This failure is a violation of the Pennsylvania Code, specifically sections 201.14(a) and 201.20(c), which pertain to the responsibility of the licensee and staff development, respectively.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program to all staff members reviewed. This deficiency was identified through a review of facility documents and staff interviews, which revealed that ten employees, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee, did not receive QAPI training. The Nursing Home Administrator confirmed the lack of training for these employees during an interview. This failure is a violation of the 28 Pa. Code: 201.20(a) Responsibility of Licensee and 28 PA. Code: 201.20(c) Staff Development.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on compliance and ethics for all ten staff members reviewed, including nurse aides, an activities aide, a dietary aide, a housekeeping employee, a registered nurse, and an occupational therapy employee. The review of facility-provided information for each of these employees revealed the absence of training on compliance and ethics. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of such training for the staff members in question.
Failure to Return Personal Possessions in a Timely Manner
Penalty
Summary
The facility failed to ensure the right of a resident to retain personal possessions, as required by their policy. The resident, who had been diagnosed with anxiety and depression, used jewelry making as a therapeutic activity. After being transported to the hospital for an involuntary psychiatric commitment due to suicidal plans and increased behaviors, the resident returned to the facility. However, her personal belongings, which included jewelry making supplies, were not returned to her for four weeks. The delay in returning the resident's belongings was confirmed by the Social Worker, who stated that the facility wanted to ensure the resident would remain in her new room before returning her possessions. The Nursing Home Administrator acknowledged the failure to uphold the resident's rights. The facility's policy allows residents to retain personal possessions unless it infringes on the rights or safety of others, but the delay in returning the resident's belongings was not justified by these criteria.
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.
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What surveyors actually found near you
We read the 1,199 citations issued within 25 miles in the last 12 months — including the 21 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Hills Post Acute | 1.1 mi | ★★★★★ | 3 | 0 |
| Concordia Of The South Hills | 1.1 mi | ★★★★★ | 0 | 0 |
| John J Kane Regional Center-sc | 1.5 mi | ★★★★★ | 4 | 0 |
| Asbury Health Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Providence Point Healthcare Residence | 1.8 mi | ★★★★★ | 0 | 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.