Wecare At Murrysville Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Murrysville, Pennsylvania.
- Location
- 3300 Logan Ferry Road, Murrysville, Pennsylvania 15668
- CMS Provider Number
- 395295
- Inspections on file
- 53
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Wecare At Murrysville Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with depression, COPD, and heart failure, who was cognitively intact, alleged that a nurse aide forcefully grabbed her arm while redirecting her to the dining room, causing soreness. Although the incident was reported and an assessment was performed, the facility's investigation did not address the specific allegation, as most witness statements omitted details about the event in the hallway. Facility leadership confirmed the investigation was incomplete.
Eight resident rooms were found with issues such as stained and grimy bathroom tiles, chipped and stained plaster, missing vent covers, incomplete patchwork, and one bathroom without a toilet. These deficiencies were confirmed by the NHA and Regional Maintenance Director, indicating the facility did not provide a clean, safe, and homelike environment as required by policy.
A resident with multiple diagnoses, including dementia and dysphagia, was admitted to hospice services, but the facility did not complete the required significant change MDS assessment to reflect this change in care. This omission was confirmed by the RN Assessment Coordinator.
A resident with multiple diagnoses, including dementia and dysphagia, was admitted under hospice care, but the facility's care plan did not include the hospice agency's contact information or instructions for accessing the 24-hour on-call system. The DON confirmed the lack of coordination between hospice and facility services.
A resident with multiple medical conditions was not initially assessed as at risk for elopement, yet had physician orders for a Wander Guard and related monitoring. Despite these orders and an incident where the resident was found outside the facility, there was no comprehensive care plan developed to address wandering or elopement risk, nor were individualized interventions or measurable objectives documented. Facility leadership confirmed the lack of a care plan for this issue.
A resident with severe cognitive impairment and multiple medical conditions was able to exit the facility unsupervised due to inadequate supervision and a failure to identify elopement risk, despite having a Wander Guard in place. The resident was found outside by staff, and it was discovered that one exit door was not secure.
The facility failed to provide adequate nursing staff to meet resident needs, particularly on weekends, as revealed by survey findings. Staff interviews highlighted issues such as delayed call bell responses, inconsistent medication administration, and insufficient care due to time constraints. The Nursing Home Administrator confirmed the staffing inadequacies, noting limited use of agency staff.
The facility failed to label and date food in the Rose Dining Room pantry, creating a potential for foodborne illness. Items found unlabeled included cucumber salad, Chinese food, pumpkin pie, spaghetti and meatballs with mold, and rice. This was confirmed by an RN Supervisor.
The facility failed to maintain an adequate emergency water supply, storing only 125 gallons instead of the required 255 gallons for 85 residents. Additionally, the stored water was expired, and the hot water tanks were deemed unsafe for drinking. The NHA confirmed the lack of a safe emergency water supply.
The facility failed to implement written policies and procedures for thorough investigations of abuse and neglect allegations. A resident with cerebral palsy reported neglect when an aide refused to change his brief. Another resident with depression and diabetes reported abuse when a NA yelled and threw a brief at her. A resident with repeated falls had a dressing not changed as ordered, and another with heart failure was left in bed without assistance. The DON confirmed the lack of proper investigation in each case.
The facility failed to report allegations of neglect and abuse in a timely manner for four residents. A resident reported an aide's refusal to change a brief, another experienced yelling and inappropriate behavior from an NA, a third had a dressing not changed as ordered, and a fourth was left in bed without assistance. These incidents were not reported as required by facility policy and state regulations.
The facility failed to investigate allegations of abuse and neglect for four residents. A resident reported an aide's refusal to change a brief, another reported being yelled at and having a brief thrown at her, a third had a dressing not changed as ordered, and a fourth was not assisted out of bed. The DON confirmed these as neglect or abuse, but thorough investigations were not conducted.
The facility failed to complete comprehensive MDS assessments within the required time frame for three residents. The RAI User's Manual mandates that an admission MDS assessment be completed within 14 days of admission, and an annual MDS assessment within 14 days of the ARD. One resident's MDS was completed 17 days late, another's four days late, and a third's 18 days late. The RNAC confirmed that the facility was behind on assessments due to staffing issues.
The facility did not complete quarterly MDS assessments within the required timeframe for four residents. The assessments were delayed due to the departure of the RNAC, resulting in completion dates ranging from 9 to 23 days past the due date. This was confirmed by an RNAC during an interview.
The facility failed to ensure a safe environment by not using leg rests on wheelchairs during resident transport in four care areas. Multiple staff members were observed pushing residents without leg rests, leading to potential safety risks. Interviews confirmed the absence of leg rests and acknowledged the associated hazards.
The facility failed to ensure monthly medication regimen reviews by a licensed pharmacist for several residents, as required by policy. Residents with various medical conditions, including Alzheimer's, heart failure, and depression, lacked documented reviews for multiple months. The DON confirmed these deficiencies during interviews.
The facility failed to provide therapeutic meal selections for diabetic residents, as required by their policies. A resident reported increased blood glucose levels after consuming white bread, but the facility did not offer wheat bread or a variety of sugar-free beverages. The Registered Dietitian confirmed that these items were removed from the menu due to budget constraints after new ownership took over, leading to inadequate dietary options for diabetic residents.
The facility failed to prevent potential infection spread by not adhering to its infection control policies. Two residents under isolation precautions were not properly managed, as an LPN did not wear a gown during colostomy care, and another LPN entered a contact isolation room without a gown. Additionally, a resident with an indwelling catheter had their urine collection bag on the floor without a privacy cover, breaching catheter care policy.
The facility failed to maintain essential PTAC units in seven rooms on the east and west wings, rendering them uninhabitable. During a tour with the NHA, it was observed that the PTAC units were not in working order, violating the facility's policy to provide a safe and comfortable environment.
The facility failed to maintain an effective call system in four rooms on the East and [NAME] wing, as observed during a tour with the NHA. The call lights in rooms [ROOM NUMBER], 147, 148, and 158 were not functioning, which was confirmed by the NHA. This deficiency violates the facility's policy and Pennsylvania Code requirements for resident safety.
The facility did not provide effective communication training to five direct care staff members, as required by their policy. The Human Resources Director confirmed the lack of training and noted the absence of records from the previous management after the facility's acquisition. This deficiency violates state codes.
The facility failed to provide training on Resident Rights for five staff members, as required by its policy. A review of 2024 education documents showed that Employees E3, E4, E5, E6, and E7 did not receive this training. The Human Resources Director confirmed the deficiency, noting the absence of records from the previous management after the facility's acquisition.
The facility failed to provide mandatory QAPI training to five staff members, as required by its policy. The Human Resources Director confirmed the lack of training and noted the absence of records from the previous management following the facility's acquisition. This deficiency was identified under specific state regulations.
The facility did not provide required Behavioral Health training to five direct care staff members, as per their policy and facility assessment. The Human Resources Director confirmed the lack of training and noted the absence of records from the previous management after the facility's acquisition. This deficiency violates state codes on licensee responsibility and staff development.
The facility failed to maintain the privacy and dignity of two residents with indwelling urinary catheters. A resident with a suprapubic catheter had a visible urine collection bag without a privacy cover, confirmed by an LPN. Another resident's catheter bag was on the floor without a dignity cover, also confirmed by an LPN. Both instances violated the facility's resident rights policy.
The facility did not post complete contact information for the State Long-Term Care Ombudsman program. The posted information in the front lobby only included the county and phone number, missing the Ombudsman's name, address, and email address. This was confirmed by the Nursing Home Administrator.
A resident reported a missing phone, but the facility failed to resolve the grievance in a timely manner, leaving the corrective action section blank and not replacing the phone. The facility also did not have an updated grievance policy posted with the current grievance officer's name, and grievance forms were unavailable in the lobby. Staff confirmed these deficiencies, and the NHA acknowledged the issues.
A resident with a skin tear on the right elbow did not receive the required daily dressing change as per physician's orders. The dressing was observed to be two days old, and staff interviews confirmed the oversight. The facility failed to ensure the resident was free from neglect, as the necessary care was not provided.
A facility failed to identify and assess a bolster as a potential restraint for a resident with PTSD, high blood pressure, and stroke. The resident was observed with bolsters on both sides of the bed, but there were no assessments, orders, or evaluations documented. The DON confirmed the lack of assessment and physician's order for the bolster use.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately documented the proportion of calories received through tube feeding, while another resident's MDS failed to capture significant weight loss and tube feeding details. These discrepancies were confirmed by RNAC Employee E12.
A facility failed to provide appropriate treatment and care for a resident with high blood pressure, hyperlipidemia, and neurogenic bladder. An open irrigation syringe was found on the resident's dresser, indicating improper handling. Additionally, the resident's elevated blood glucose levels were not communicated to the physician as required, leading to a failure in medication management. The DON confirmed the lack of documentation and communication, highlighting deficiencies in care.
The facility failed to address the nutritional needs and significant weight loss of two residents. One resident experienced a significant weight loss due to a reduction in tube feeding without proper documentation or evaluation by the RD. Another resident's tube feeding was discontinued without support, and significant weight loss was not addressed. The RD did not complete required assessments, leading to violations of management and nursing service regulations.
A facility failed to provide trauma-informed care for a resident with PTSD by not identifying specific triggers or strategies to avoid them, as required by their policy. The resident's care plan lacked details on PTSD triggers, which was confirmed by a social worker during an interview.
A facility failed to conduct ongoing assessments for the use of bedrails for a resident with high blood pressure, anxiety, and chronic pain. Despite the presence of enabler bars on the resident's bed, no ongoing assessment was documented. The DON confirmed the lack of necessary assessments to ensure appropriate use and risk evaluation of the bedrails.
A resident with specific dietary orders for a regular texture diet with thin liquid consistency was incorrectly served a meal with ground-up meat. The resident expressed dissatisfaction, and staff confirmed the error, highlighting a failure to meet the resident's dietary needs.
The facility failed to meet required staffing levels for nurse aides on multiple shifts over six days. Specifically, it did not provide the mandated one NA per 10 residents during the day shift on three days, one NA per 11 residents during the evening shift on all six days, and one NA per 15 residents during the night shift on all six days. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels on certain evening and night shifts. Specifically, there was a shortage of LPNs on two evening shifts and one night shift, as confirmed by a review of nursing time schedules and census data. The Nursing Home Administrator acknowledged the staffing deficiencies.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on five out of six days. The PPD hours recorded were below the state requirement, with values ranging from 2.50 to 2.96. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required nurse aide staffing levels over a two-week period, failing to provide the mandated number of NAs during day, evening, and night shifts. This was confirmed through staffing documents and an interview with the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels, failing to provide the minimum number of LPNs per residents during day, evening, and night shifts on multiple occasions within a 14-day period. This was confirmed through a review of nursing schedules 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 over a 14-day period. Staffing documents showed PPD hours ranged from 2.37 to 3.06, which was confirmed by the Nursing Home Administrator.
WeCare at Murrysville Rehabilitation and Nursing Center failed to conduct state criminal background checks for two newly hired nurses before their employment start dates, violating federal and state regulations. The facility's policy requires such checks to ensure resident and staff safety, but personnel records for an LPN and an RN lacked evidence of completed checks. Interviews confirmed the oversight, with the Regional HR Employee and Nursing Home Administrator acknowledging the failure to comply with the facility's policies.
A facility failed to meet professional standards by allowing an RN to work with an expired license. The RN, Employee E4, was hired and continued to perform duties as a med cart nurse and RN supervisor despite his license being expired and on probation. The DON confirmed the facility's failure to adhere to accepted standards of practice.
The facility failed to ensure that an RN had a valid license, as RN Employee E4 worked with an expired license, performing duties requiring active licensure. This was confirmed by the DON and Nursing Home Administrator during personnel file reviews.
A facility failed to ensure an RN held an active license, allowing him to work 48 shifts without verification. The RN's license expired before his employment, and the issue was discovered during an audit. The facility's HR employee did not update the license status, leading to non-compliance with state laws.
The facility failed to implement an effective QAPI program for new hire employee files. A review revealed that professional licenses were not verified, physicals and Tuberculin tests were not completed, job descriptions were missing, and background checks were incomplete. An RN was allowed to work with an expired license. The Director of Nursing confirmed the failure to implement an effective QAPI plan.
The facility failed to include job descriptions in the personnel files of an LPN and three RNs. This was confirmed during a review of employee records and staff interviews, where the Regional HR Employee could not provide the required documentation.
The facility did not verify professional licenses for an LPN and three RNs before their employment, violating their policy. Staff interviews confirmed the oversight, with the Regional HR Employee and DON acknowledging the lapse in pre-employment screening procedures.
The facility did not ensure that personnel records included attestations of employees' ability to perform job duties before employment. A review of five personnel files revealed that required physical exams were either completed after hire dates or not completed at all, contrary to the facility's policy. Interviews confirmed this failure.
The facility did not complete pre-employment tuberculin skin testing for five employees, violating CDC guidelines and its own policy. Personnel records lacked documentation of TB tests for an LPN and four RNs, which was confirmed by the Nursing Home Administrator.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse involving a resident who was cognitively intact and had diagnoses including depression, COPD, and heart failure. The resident reported that a nurse aide forcefully grabbed her arm while attempting to take her to the dining room, causing soreness. The incident was reported by both the resident and her family, and an X-ray was ordered, but no unusual findings were noted on assessment. The resident provided a detailed statement describing the incident, including her attempt to return to her room, her holding onto a handrail, and the nurse aide lifting her arm to redirect her to the dining room. Facility documentation and witness statements collected as part of the investigation failed to address the specific allegation of the nurse aide forcefully moving the resident's hand from the handrail. Most witness statements focused only on care provided in the resident's room and did not mention the incident in the hallway. Interviews with staff, including the nurse aide involved and the Director of Nursing, confirmed that the investigation did not adequately address the resident's specific allegation. Facility leadership acknowledged that the investigation was incomplete and did not fully explore the reported abuse.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment for residents in eight out of fifteen rooms, as evidenced by observations made during a facility tour. Specific deficiencies included stained and grimy tiles around toilets and throughout bathrooms, chipped and stained plaster behind toilets, missing vent covers, incomplete patchwork below sinks, and one bathroom lacking a toilet. These conditions were directly observed in resident rooms 114, 116, 119, 122, 139, 140, 143, and 144. The facility's own Homelike Environment policy, dated 5/30/25, states that residents are to be provided with a safe, clean, comfortable, and homelike environment and are encouraged to use their personal belongings. During interviews, the Nursing Home Administrator and the Regional Maintenance Director confirmed the observed deficiencies and acknowledged that the facility did not meet the required standards for cleanliness and maintenance in the affected resident rooms.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a notable change in condition. Clinical record review showed that the resident, who had diagnoses including high blood pressure, dysphagia, and dementia, was admitted to hospice services as indicated by a physician order. Despite this significant change in care status, the facility did not complete the required comprehensive MDS assessment to reflect the initiation of hospice services. This deficiency was confirmed during staff interview, where the Registered Nurse Assessment Coordinator acknowledged the omission.
Failure to Coordinate Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for a resident requiring end-of-life care. Review of the clinical record showed that the resident, who had diagnoses including high blood pressure, dysphagia, and dementia, was admitted under hospice services per a physician order. However, the resident's comprehensive care plan did not include necessary information such as the hospice agency's contact details or instructions on accessing the hospice's 24-hour on-call system. This omission was confirmed during an interview with the Director of Nursing, who acknowledged the lack of coordination and missing information in the care plan.
Failure to Develop Comprehensive Care Plan for Wandering/Elopement Risk
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan to address the risk of wandering and elopement for a resident. Although the resident had diagnoses including unspecified intracranial injury, hepatitis C, and liver cirrhosis, and was not initially assessed as being at risk for elopement, physician orders were in place for the use of a Wander Guard and for monitoring its placement and functionality. Despite these orders, the clinical record did not document any assessment or evidence of wandering or elopement behaviors that would justify the use of the Wander Guard, nor did it include a care plan outlining specific interventions, problem areas, causes, or measurable objectives related to wandering or elopement prevention. An incident occurred in which the resident was found outside the facility and was immediately brought back inside, after which a head-to-toe assessment revealed no injuries. Review of the resident's care plan showed that from the time the Wander Guard was ordered until after the incident, there was no documented plan of care addressing the use of the Wander Guard or interventions for wandering or elopement. Facility leadership confirmed that a comprehensive care plan with individualized interventions for wandering/elopement was not developed for this resident.
Failure to Prevent Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified intracranial injury with loss of consciousness, hepatitis C, and liver cirrhosis, was assessed as having a BIMS score of 6, indicating severe cognitive impairment. Despite this, the resident was not identified as being at risk for elopement on the facility's risk evaluation. The clinical record did not document any wandering or elopement behaviors, yet a Wander Guard was ordered and in use for the resident. The care plan noted impaired cognitive function and interventions to cue, reorient, and supervise as needed. On the day of the incident, the resident was found outside the facility in front of the building by a staff member, and was immediately brought back inside. A subsequent check revealed that one exit door was not secure, while the remaining doors were locked. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not provide adequate supervision to prevent the resident's elopement.
Insufficient Staffing Leads to Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple findings during a survey. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and maintaining a dignified existence. However, the facility's assessment tool, which is supposed to guide staffing decisions, indicated that staffing levels were inadequate, particularly on weekends. The Payroll Based Journal (PBJ) data revealed excessively low weekend staffing for two consecutive quarters. During group interviews, residents and staff expressed concerns about delayed responses to call bells, inconsistent medication administration times due to limited nursing staff, and inadequate backup for staff call-offs. Interviews with staff members highlighted the challenges faced due to insufficient staffing. A Licensed Practical Nurse reported being overwhelmed with responsibilities, including managing medications and blood sugar checks for 35 residents, while only four nursing assistants were available over the weekend. Nursing assistants also reported being unable to provide full care, such as shaving and showering residents, due to time constraints. The Nursing Home Administrator acknowledged the staffing issues, noting that the facility rarely uses agency staff except during outbreaks, and confirmed the lack of sufficient nursing staff to ensure the highest practicable well-being of the residents.
Failure to Label and Date Food in Pantry
Penalty
Summary
The facility failed to properly label and date food products in one of its nursing unit pantries, specifically the Rose Dining Room, which created the potential for foodborne illness. During an observation in the resident refrigerator, several items were found without labels, names, or dates. These items included a glass bowl containing cucumber salad, a plastic container of Chinese food, a plastic container with pumpkin pie, a plastic container of spaghetti and meatballs with a fuzzy, green substance on top, and a cardboard container of rice. This observation was confirmed by a Registered Nurse Supervisor, indicating a lapse in the facility's adherence to professional standards for food storage and labeling.
Inadequate Emergency Water Supply
Penalty
Summary
The facility failed to maintain an adequate backup water supply for essential areas in the event of a loss of normal water supply. The facility's policy, as outlined in their Disaster Manual, requires storing one gallon of potable water per day for three days for each resident, plus an additional 50 gallons for staff and volunteers. However, during a facility tour, it was discovered that only 125 gallons of water were available, which is insufficient for the resident census of 85, requiring at least 255 gallons. Additionally, the expiration dates on the stored water containers were not confirmed, and some were found to be expired, raising concerns about the safety of the water for drinking purposes. The Nursing Home Administrator (NHA) mentioned the possibility of using water from the facility's hot water tanks in an emergency. However, a representative from the company that provided the hot water tanks indicated that this water could be contaminated and is not recommended for drinking. The representative highlighted potential risks of bacterial growth and contamination in the hot water tanks. Consequently, the facility was unable to ensure a safe and adequate emergency water supply for residents and staff, as confirmed by the NHA.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement written policies and procedures to ensure complete and thorough investigations of allegations of abuse and neglect for several residents. Resident R14, who has high blood pressure, depression, and cerebral palsy, reported that an aide refused to change his brief, which was confirmed as an allegation of neglect. Resident R44, diagnosed with depression, diabetes, and irritable bowel syndrome, reported that a nursing assistant yelled at her and threw a clean brief at her, which was confirmed as an allegation of abuse. Resident R46, with high blood pressure, depression, and repeated falls, had a dressing on a skin tear that was not changed as per physician orders, which was confirmed as neglect. Resident R286, who had heart failure, high blood pressure, and diabetes, reported being left in bed for an entire shift without assistance, which was confirmed as neglect. In each case, the Director of Nursing confirmed that the facility did not follow its policies and procedures to conduct thorough investigations into these allegations. The facility's failure to investigate these incidents properly indicates a lack of adherence to established protocols for handling abuse and neglect allegations, as required by the facility's policies and state regulations.
Failure to Timely Report Allegations of Neglect and Abuse
Penalty
Summary
The facility failed to report allegations of abuse and neglect in the required timeframe for four residents. Resident R14 reported that an aide refused to change his brief, which was confirmed by the Director of Nursing (DON) as not being reported in the required timeframe. Resident R44 reported that a nursing assistant (NA) yelled and threw a clean brief at her, and this incident was also not reported timely. Resident R46 had a dressing on his right elbow that was not changed as per physician's orders, and the nurse admitted to forgetting to change it, which was not recognized as neglect and thus not reported. Resident R286 reported being left in bed for an entire daylight shift without assistance, which was confirmed by the DON as not being reported in the required timeframe. These incidents highlight a pattern of failure to report allegations of neglect and abuse promptly, as required by facility policy and state regulations. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid harm, pain, or distress, which was not adhered to in these cases.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct thorough investigations of allegations of abuse and neglect for four residents. Resident R14 reported that an aide refused to change his brief, which was confirmed as an allegation of neglect by the Director of Nursing (DON). Resident R44 reported that a nursing assistant (NA) yelled and threw a clean brief at her, which was confirmed as an allegation of abuse. Resident R46 had a physician's order for daily dressing changes on a skin tear, but the dressing was not changed as required, which the DON acknowledged as neglect. Resident R286 reported not being assisted out of bed by an NA, which was also confirmed as neglect by the DON. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid harm or distress. Despite this policy, the facility did not conduct thorough investigations into these allegations, as confirmed by the DON during interviews. The lack of investigation into these incidents indicates a failure to adhere to the facility's own protocols and state regulations, which require thorough investigation and documentation of such allegations.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for three residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 calendar days following admission, and an annual MDS assessment must be completed no later than the Assessment Reference Date (ARD) plus 14 calendar days. Resident R45's annual MDS was completed 17 days late, Resident R48's was completed four days late, and Resident R54's was completed 18 days late. During an interview, the Registered Nurse Assessment Coordinator (RNAC) Employee E12 confirmed that the facility was behind on completing assessments due to the RNAC walking out in August, leading to these delays.
Failure to Complete MDS Assessments on Time
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for four residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly MDS assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD). However, the assessments for Residents R2, R8, R23, and R41 were completed between 9 and 23 days past the due date. The delay was attributed to the departure of the Registered Nurse Assessment Coordinator (RNAC) in August, which led to a backlog in completing assessments. This was confirmed by RNAC Employee E12 during an interview, acknowledging the facility's failure to meet the required timelines for MDS assessments.
Failure to Use Wheelchair Leg Rests During Resident Transport
Penalty
Summary
The facility failed to maintain a resident environment free of potential accidental hazards by not utilizing leg rests on wheelchairs while being transported by staff. Observations were made in four out of six resident care areas, where multiple residents were seen being pushed in wheelchairs without leg rests. This included instances where residents' feet were resting on the floor or audibly dragging, posing a risk of lower body injury. Staff members, including nurse aides and housekeeping employees, were observed transporting residents without ensuring the leg rests were attached, despite the availability of these safety devices. Interviews with staff confirmed the absence of leg rests during transportation and acknowledged the associated safety risks. A physical therapist stated that all wheelchairs are issued with leg rests and emphasized the importance of their use to prevent injury. The Director of Nursing confirmed the facility's failure to provide a safe environment by not utilizing leg rests on wheelchairs during transport, which is a violation of the facility's resident care policies and state regulations.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly medication regimen reviews (MRR) for four out of six residents, as required by their policy. The policy mandates that the consultant pharmacist perform these reviews monthly and document any irregularities in a written report. However, the clinical records for Residents R6, R22, R45, and R76 lacked documentation of completed MRRs for various months, indicating non-compliance with the facility's policy. Resident R6, diagnosed with high blood pressure, Alzheimer's disease, and depression, did not have a documented MRR for December 2024. Resident R22, with heart failure, high blood pressure, and diabetes, missed MRR documentation for multiple months, including April, May, June, July, October, and December 2024, as well as January and February 2025. Resident R45, diagnosed with high blood pressure, dysphagia, and anemia, also lacked MRR documentation for December 2024. Lastly, Resident R76, with depression, irritable bowel syndrome, and hypothyroidism, did not have documented MRRs for January and February 2025. The Director of Nursing confirmed these deficiencies during interviews.
Failure to Provide Therapeutic Diets for Diabetic Residents
Penalty
Summary
The facility failed to provide therapeutic meal selections for residents with diabetes, as required by their own policies and the dietary needs of the residents. The facility's policy on therapeutic diets, dated 2/12/25, states that such diets should be prescribed by the attending physician to support the resident's treatment and plan of care, in accordance with their goals and preferences. However, the facility did not adhere to this policy for eight of twelve months, as they did not provide appropriate dietary options for residents with diabetes. The facility's Diet Manual offers a Low-Concentrated Sweets (LCS) diet, which involves replacing high-sugar foods with sugar-free or reduced-calorie products, but this was not effectively implemented. A resident, newly diagnosed with diabetes, reported that his blood glucose levels increased after consuming white bread, yet the facility did not provide wheat bread, which he preferred. Additionally, the facility only offered diet ginger ale as a sugar-free beverage, despite the resident's request for more variety. The Registered Dietitian confirmed that the facility's menu is developed at the corporate level and that the Consistent Carb diet was discontinued after new ownership took over in August 2024. The dietitian acknowledged that sugar-free beverages and wheat bread are standard in diabetes management, but these were cut from the menu due to budget constraints, leading to the failure in providing therapeutic menu selections for diabetic residents.
Infection Control Deficiencies in Isolation and Catheter Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies, resulting in potential infection spread among residents. Specifically, two residents under isolation precautions were not properly managed. One resident, diagnosed with high blood pressure and a colostomy, was observed receiving colostomy care from an LPN who did not wear the required gown, violating the facility's Enhanced Barrier Precautions policy. Another resident, with diagnoses including high blood pressure, anxiety, and chronic pain, was under contact isolation for ESBL and MRSA in the urine. An LPN entered this resident's room to administer medication without donning a disposable gown, contrary to the facility's contact isolation policy. Additionally, the facility did not maintain proper infection control practices for a resident with an indwelling urinary catheter. This resident, who had high blood pressure, a urinary tract infection, and cancer, was observed with their urine collection bag on the floor without a privacy cover, breaching the facility's catheter care policy. These lapses in infection control practices were confirmed by the involved LPNs during interviews, highlighting the facility's failure to prevent potential infection spread.
Failure to Maintain Essential PTAC Units
Penalty
Summary
The facility failed to maintain essential PTAC units, which are ductless self-contained air conditioning and heating units, in seven rooms located on the east and west wings. During a tour of the facility with the Nursing Home Administrator, it was observed that the PTAC units in these rooms were not in working order. The rooms affected were identified as room numbers 123, 127, 146, 147, 148, and 156. The Nursing Home Administrator confirmed that these rooms were uninhabitable due to the malfunctioning PTAC units, which is a violation of the facility's policy to provide a safe, clean, comfortable, and homelike environment with comfortable and safe temperatures.
Deficiency in Call System Maintenance
Penalty
Summary
The facility failed to maintain an effective call system in four rooms located on the East and [NAME] wing, specifically in rooms [ROOM NUMBER], 147, 148, and 158. During a tour conducted with the Nursing Home Administrator (NHA) on March 25, 2025, at 10:48 a.m., it was observed that the call lights in these rooms were not in working order. This deficiency was confirmed by the NHA during an interview on the same day at 11:07 a.m. The lack of a functioning call system in these rooms is a violation of the facility's policy and the Pennsylvania Code, which outlines the responsibility of the licensee and management to ensure effective communication systems are in place for resident safety.
Failure to Provide Communication Training to Staff
Penalty
Summary
The facility failed to provide effective communication training to five direct care staff members, as required by their policy. The policy, dated January 16, 2025, mandates that all staff participate in initial orientation and annual in-service training. However, upon review of the facility's education documents for the year 2024, it was found that Nurse Aides E3, E4, E5, E6, and E7 did not receive training on effective communication. During an interview, the Human Resources Director, Employee E8, confirmed the lack of training and mentioned that the facility was acquired on August 1, 2024, and no records were available from the previous human resources manager. This deficiency is in violation of 28 Pa. Code: 201.14(a) and 28 Pa. Code: 201.20(a).
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on Resident Rights for five staff members, identified as Employees E3, E4, E5, E6, and E7. The facility's policy on in-service training, dated 1/16/25, mandates that all staff must participate in initial orientation and annual in-service training. However, a review of the facility's education documents for the year 2024 revealed that none of these employees received training on resident rights. During an interview, the Human Resources Director, Employee E8, confirmed the lack of training and mentioned that the facility was acquired on 8/1/24, and no records were available from the previous human resources manager. This deficiency is in violation of 28 Pa Code: 201.14 (a) Responsibility of licensee, 28 Pa Code: 201.18 (b)(1) Management, and 28 Pa Code: 201.20 (a) Staff development.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for five staff members, identified as Employees E3, E4, E5, E6, and E7. The facility's policy, dated 1/16/25, mandates that all staff must participate in initial orientation and annual in-service training. However, upon review of the facility's education documents for the year 2024, it was found that none of the five staff members had received training on QAPI. During an interview, the Human Resources Director, Employee E8, confirmed the lack of training and mentioned that the facility was acquired on 8/1/24, and no records from the previous human resources manager were available. This deficiency was identified under the regulations 28 Pa Code: 201.14 (a), 201.18 (b)(1), and 201.20 (a).
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide Behavioral Health training to five direct care staff members, as required by their policy and facility assessment. The facility's policy, dated January 16, 2025, mandates that all staff participate in initial orientation and annual in-service training. However, upon review of the facility's education documents for the year 2024, it was found that Nurse Aides E3, E4, E5, E6, and E7 did not receive training on behavioral health. During an interview, the Human Resources Director, Employee E8, confirmed the lack of training and mentioned that the facility was acquired on August 1, 2024, and he had no records from the previous human resources manager. This deficiency is in violation of 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(a) Staff Development.
Failure to Maintain Privacy and Dignity for Residents with Catheters
Penalty
Summary
The facility failed to uphold the privacy and dignity of two residents who were utilizing indwelling urinary catheters. Resident R12, who had a suprapubic catheter due to neuromuscular dysfunction, was observed with her catheter collection bag hanging on her bed without a privacy cover, making the urine visible. This observation was confirmed by LPN Employee E1, who acknowledged the lack of a privacy cover and the failure to maintain the resident's dignity. Similarly, Resident R187, who had an indwelling catheter, was observed with the urine collection bag on the floor beside the bed without a dignity bag covering it, also making the urine visible. This was confirmed by LPN Employee E10, who admitted that the facility did not uphold the resident's privacy and dignity. Both instances were in violation of the facility's policy on resident rights, which emphasizes treating residents with kindness, respect, and dignity.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility failed to provide complete contact information for the State Long-Term Care Ombudsman program as required by regulations. During an observation in the front lobby area, it was noted that the posted Ombudsman contact information only included the county and phone number, omitting the Ombudsman's name, address, and email address. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the omission of the required details.
Failure to Resolve Grievance and Update Grievance Policy
Penalty
Summary
The facility failed to effectively resolve a grievance in a timely manner for a resident who reported a missing phone. The resident, who is alert and oriented, had documented concerns about the missing phone on a grievance form, but the corrective action section of the form was left blank. The resident expressed dissatisfaction with the facility's response, as they were informed that the phone would not be replaced. The facility was unable to provide evidence that the resident was educated on the policy regarding lost personal items upon admission, nor could they produce a copy of the resident's inventory sheet. Additionally, the facility did not have an updated grievance policy posted in an accessible location, as required. The posted policy did not include the current grievance officer's name, and grievance forms were not available at the front lobby as stipulated by the facility's policy. Interviews with staff confirmed these deficiencies, and the Nursing Home Administrator acknowledged the failure to resolve the grievance in a timely manner and the lack of updated grievance information accessible to residents.
Neglect in Dressing Change for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R46, was free from neglect. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Resident R46, who was admitted with diagnoses including high blood pressure, depression, and repeated falls, had a physician's order for the application of Triple Antibiotic Ointment to a skin tear on the right elbow every day shift for seven days. However, during an observation, it was noted that the dressing on the resident's elbow was dated two days prior, indicating that the dressing had not been changed as required. Interviews with staff confirmed the oversight. An LPN acknowledged that the dressing date was indeed from two days earlier, and the Director of Nursing confirmed that the nurse responsible admitted to forgetting to change the dressing on the specified date. This lapse in care resulted in the facility failing to meet the requirement of ensuring the resident was free from neglect, as the necessary care for the resident's skin integrity was not provided as ordered.
Failure to Assess Bolster as Restraint for Resident
Penalty
Summary
The facility failed to properly identify and assess the use of a bolster as a potential physical restraint for a resident, referred to as Resident R70. The facility's policy on the use of restraints requires that any restraint be used only for the safety and well-being of the resident, and only after other alternatives have been tried unsuccessfully. Additionally, the policy mandates a pre-restraining assessment and a physician's order before implementing any restraint. However, the facility did not conduct an assessment to determine if the bolster was a restraint, nor did they obtain a physician's order for its use. Resident R70, who has diagnoses of PTSD, high blood pressure, and stroke, was observed lying in bed with bolsters on both sides of his body. The clinical record for Resident R70 lacked any documentation of assessments, orders, or ongoing evaluations regarding the use of bolsters. The Director of Nursing confirmed these deficiencies during an interview, acknowledging the failure to assess the resident for a restraint, the absence of ongoing evaluations, and the lack of a physician's order for the bolster use.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status for two residents. Resident R39, who was admitted with diagnoses including high blood pressure, stroke, and dysphagia, had a physician's order for enteral feeding and mechanical soft pleasure feeds. However, the MDS inaccurately documented the proportion of total calories received through parenteral or tube feeding as 25% or less, despite the resident receiving enteral tube feeding as ordered. This discrepancy was confirmed during an interview with RNAC Employee E12. Resident R45, admitted with high blood pressure, dysphagia, and anemia, also had inaccuracies in their MDS. The resident's annual MDS failed to document the proportion of total calories and average fluid intake through tube feeding, despite receiving enteral feeding and water flushes as ordered. Additionally, the resident experienced a significant weight loss of 17.2% over six months, which was not captured in the MDS. RNAC Employee E12 confirmed these inaccuracies during an interview, acknowledging that the MDS should have reflected the resident's significant weight loss.
Failure in Medication Management and Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident R12, as evidenced by several deficiencies in medication administration and catheter care. Resident R12, who has a history of high blood pressure, hyperlipidemia, and neurogenic bladder, was found to have an open irrigation syringe on their dresser with a date of 11/7/24, indicating improper handling and potential contamination. Additionally, the facility's policy on administering medications was not followed, as the resident's blood glucose levels were not properly managed according to the physician's sliding scale order. The resident's blood glucose levels were recorded as significantly elevated on multiple occasions, yet there was no documentation that the physician was notified of these increased levels, as required by the physician's order. The Director of Nursing confirmed that the facility failed to document the notification of the physician regarding the resident's increased blood glucose levels. This lack of documentation and communication with the physician represents a failure to ensure that Resident R12 received appropriate treatment and care. The facility's oversight in both medication management and catheter care highlights a significant deficiency in adhering to prescribed medical orders and maintaining proper hygiene practices, which are critical for the resident's health and well-being.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to address specific nutritional interventions for two residents, R39 and R45, as evidenced by a lack of comprehensive nutritional assessments and timely responses to significant weight loss. Resident R39, who was admitted with conditions including high blood pressure, stroke, and dysphagia, experienced an 8.4% weight loss over three months and a 10.3% weight loss over six months. Despite a physician's order to reduce the resident's tube feeding formula, resulting in a 630-calorie deficit per day, there was no documentation from the Registered Dietitian (RD) to support or evaluate this change. Furthermore, the RD did not conduct a quarterly assessment for the Minimum Data Set (MDS) dated 10/15/24. Resident R45, admitted with high blood pressure, dysphagia, and anemia, experienced an 11.65% weight loss in one month. The resident's tube feeding was discontinued without documented support or evaluation from the RD. Additionally, the RD failed to complete both an annual and a quarterly assessment for the MDS dated 8/10/24 and 11/2/24, respectively. The clinical record lacked documentation regarding the significant weight loss and any nutritional recommendations. Interviews with RD Employee E11 confirmed the deficiencies, including the lack of documentation and assessments for both residents. The RD acknowledged the failure to address the significant weight loss and the absence of documentation to support changes in tube feeding orders. These deficiencies were identified as violations of specific Pennsylvania Code regulations related to management and nursing services.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident identified as a trauma survivor, specifically Resident R70, who has a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility's policy on Behavioral Assessment, Intervention, and Monitoring requires that residents receive behavioral health services to maintain their highest practicable well-being, which includes identifying behavioral symptoms through approved screening tools and comprehensive assessments. However, the care plan for Resident R70, who also has high blood pressure and a history of stroke, did not identify specific PTSD triggers or strategies to avoid them. This oversight was confirmed during an interview with Social Worker Employee E13, who acknowledged the facility's failure to identify and mitigate potential triggers for re-traumatization in Resident R70.
Failure to Conduct Ongoing Bedrail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments for the use of bedrails for a resident, identified as Resident R40. The clinical record review indicated that Resident R40 was admitted with diagnoses of high blood pressure, anxiety, and chronic pain. An observation revealed that two top enabler bars were present on the resident's bed. However, there was no ongoing assessment documented for the use of these enabler bars. The Director of Nursing confirmed that the facility did not perform the necessary assessments to ensure that the bedrails were used appropriately to meet the resident's needs and to evaluate the risks associated with their usage.
Failure to Provide Correct Food Consistency for Resident
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of Resident R44. According to the clinical record, Resident R44 was admitted with diagnoses including depression, irritable bowel syndrome, and diabetes. The resident's physician orders specified a regular texture diet with thin liquid consistency. However, during a lunch observation, it was noted that the resident received a meal with ground-up meat, which was inconsistent with the prescribed diet. Resident R44 expressed dissatisfaction, stating that they were supposed to be on a regular diet but continued to receive the wrong food. The deficiency was confirmed through staff interviews and observations. A Licensed Practical Nurse (LPN) acknowledged that the resident was not provided the correct food consistency. Additionally, the Director of Nursing confirmed the facility's failure to meet the dietary needs of Resident R44. This incident was documented as a violation of the facility's policies and Pennsylvania Code regulations regarding management and resident care policies.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over a period of six days. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on three out of six days, one NA per 11 residents during the evening shift on all six days, and one NA per 15 residents during the night shift on all six days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified dates and shifts.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff meets PA Regulation. The RDO re-educated NHA/DON on ensuring sufficient nursing staff and a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x daily for x4 weeks; then Weekly x2 Months and then Monthly X 2 months; to ensure required PPD and ratios are met. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
LPN Staffing Deficiency on Evening and Night Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on specific shifts, as mandated by the regulation effective July 1, 2023. On two occasions during the evening shift, the facility did not provide the minimum of one LPN per 30 residents, specifically on 2/27/25 and 3/1/25. Additionally, on the night shift of 2/28/25, the facility did not meet the requirement of one LPN per 40 residents. The review of nursing time schedules and facility census data from 2/25/25 through 3/2/25 confirmed these staffing shortages. The Nursing Home Administrator acknowledged the failure to meet the staffing requirements during an interview conducted on 3/4/25.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required LPN ratios and implement a contingency plan if needed by calling in off duty LPN staff, calling sister facilities or utilizing agency as needed to ensure sufficient Cart nurse staff meets PA Regulation. The RDO re-educated NHA/DON on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x per week for x4 weeks; then Weekly x2 Months and then Monthly x 2 months; to ensure LPN ratios are met. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
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 five out of six days, specifically on 2/25/25, 2/27/25, 2/28/25, 3/1/25, and 3/2/25. The nursing time schedules and staffing documents reviewed indicated that the PPD hours were 2.56, 2.96, 2.90, 2.82, and 2.50, respectively, on these dates. This deficiency was confirmed during an interview with the Nursing Home Administrator on 3/5/25, who acknowledged the failure to provide the required minimum PPD hours of direct care on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff meets PA Regulation. The RDO re-educated NHA/DON on ensuring sufficient nursing staff and a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x per week for x4 weeks; then Weekly x2 Months and then Monthly X 2 months; to ensure required PPD and ratios are met. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) across multiple shifts over a two-week period from January 7, 2025, to January 20, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on all 14 days, one NA per 11 residents during the evening shift on six days, and one NA per 15 residents during the night shift on nine days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in NA staffing on the specified shifts.
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. The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDO educated NHA/DON/on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance the NHA/DON/scheduler will complete staffing meetings 5x weekly x4 weekly then monthly x2 to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
LPN Staffing Shortages Identified
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) as mandated by the regulation effective July 1, 2023. Specifically, the facility did not provide the minimum of one LPN per 25 residents during the day shift on one occasion, one LPN per 30 residents during the evening shift on six occasions, and one LPN per 40 residents during the night shift on six occasions within a 14-day period. This deficiency was identified through a review of nursing time schedules and confirmed by the Nursing Home Administrator during an interview. The census data and actual hours worked by LPNs were consistently below the required hours, leading to the staffing shortages on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDO educated NHA/DON on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly x4 weekly then monthly x2 to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
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) over a 14-day period from January 7, 2025, to January 20, 2025. A review of staffing documents and nursing staff schedules revealed that the facility consistently provided less than the required PPD hours on each of these days, with PPD hours ranging from 2.37 to 3.06. This deficiency was confirmed during an interview with the Nursing Home Administrator on January 24, 2025, who acknowledged the facility's failure to meet the mandated staffing levels on the specified dates.
Plan Of Correction
The facility cannot retroactively correct cited deficiencies. The facility will continue to maintain the required ratios and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDO educated NHA/DON on ensuring sufficient nursing staff and ensuring a minimum of 3.20 PPD. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 5x weekly for 4 weeks, then monthly for 2 months to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
WeCare at Murrysville Rehabilitation and Nursing Center was found to be non-compliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. Specifically, the facility failed to conduct state criminal background checks for two newly hired employees, a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), prior to their employment start dates. The facility's policy, dated January 11, 2024, mandates that background checks, including criminal history checks, must be completed to ensure the safety and well-being of residents and staff. However, the personnel records for the LPN hired on November 14, 2024, and the RN hired on November 4, 2024, lacked evidence of completed state criminal background checks before their hiring. Interviews conducted during the survey revealed that the Regional Human Resource Employee acknowledged the oversight, stating that background checks should have been completed before the employees' start dates. The Nursing Home Administrator confirmed the facility's failure to adhere to its own policies and regulatory requirements by not completing the necessary background checks for the two employees. This deficiency was identified during an abbreviated survey conducted in response to complaints and an infection control survey, highlighting a lapse in the facility's personnel policies and procedures.
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. 1. A criminal background check was completed for Licensed Practical Nurse Employee El by 1/17/25. Registered Nurse Employee E4 no longer works at the facility. 2. The Human Resource Director/design will audit new hires from the past 3 months to ensure criminal background checks were completed prior to their start date. 3. The Human Resource Director will be reeducated on completing state criminal background checks on new hires prior to their start date by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure criminal background checks were completed prior to employee start date. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Expired RN License Leads to Deficiency
Penalty
Summary
The facility failed to meet professional standards of care by allowing a Registered Nurse (RN), identified as Employee E4, to work with an expired license. Employee E4 was hired on November 4, 2024, and a review of his license verification on December 17, 2024, revealed that his license had expired on October 31, 2024, and was on probation. Despite this, Employee E4 continued to perform duties as a med cart nurse and RN supervisor, providing medications and completing documentation in residents' medical records, which was outside his legal scope of practice due to the expired license. The Director of Nursing (DON) confirmed during an interview that the facility did not provide care and services in accordance with accepted standards of practice. The facility's RN job description requires licensed personnel to practice nursing only with a valid registration certificate, which was not adhered to in this case. This oversight indicates a failure in the facility's responsibility to ensure that all nursing staff maintain current and valid licenses to practice, as required by professional and legal standards.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. The Human Resource Director/designee will audit current licensed staff to ensure licenses are active and in good standing. 3. The Human Resource Director will be re-educated on facility policies by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure licensed staff licenses are in good standing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Expired RN License Leads to Deficiency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs, as evidenced by the case of RN Employee E4. The personnel records review revealed that RN Employee E4 was hired on November 4, 2024, but their RN license had expired on October 31, 2024. Despite this, RN Employee E4 continued to work as a licensed professional RN, performing duties such as passing medications, documenting in medical records, and sometimes acting as an RN supervisor. These responsibilities require a current and active RN license, which RN Employee E4 did not possess at the time. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the facility did not ensure that RN Employee E4 had the necessary valid license to perform their duties. This oversight was identified during a review of personnel files, facility documentation, and policy review, highlighting a failure in the facility's processes to verify and maintain up-to-date licensure for their nursing staff. The deficiency was noted for one out of five personnel files reviewed, indicating a lapse in compliance with the regulatory requirements for nursing services.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. The Human Resource Director/designee will audit current licensed staff to ensure licenses are active and in good standing. 3. The Human Resource Director will be re-educated on facility policies by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure licensed staff licenses are in good standing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Verify RN License Status
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN), identified as Employee E4, held an active license in accordance with state laws. The RN was hired on November 4, 2024, but the facility did not verify his RN license until December 17, 2024, at which point it was discovered that his license had expired on October 31, 2024, and he was on probation. Despite this, RN Employee E4 worked 48 shifts from November 4, 2024, through January 5, 2025, as a medication passing nurse and RN supervisor. The facility's Human Resource employee, who was terminated on December 31, 2024, failed to ensure the RN's license was updated and active before his start date. The Regional Human Resource Employee E2 discovered the expired license during an audit on January 6, 2025, and informed the Nursing Home Administrator. The Director of Nursing confirmed that RN Employee E4 worked in his capacity without a valid license, and the Nursing Home Administrator acknowledged the facility's failure to comply with state licensing requirements.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. The Human Resource Director/designee will audit current licensed staff to ensure licenses are active and in good standing. 3. The Human Resource Director will be re-educated on facility policies for Background checks and RN job description by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure licensed staff licenses are in good standing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Deficiency in QAPI Program for New Hire Employee Files
Penalty
Summary
The facility failed to maintain and implement an effective Quality Assurance and Performance Improvement (QAPI) program, specifically in the area of new hire employee files. The facility's policy, dated January 11, 2024, aimed to establish a framework for continuous improvement in the quality of care and services. However, during a review of the facility's documentation and interviews with staff, it was found that the facility did not follow a performance improvement project (PIP) for new hire employee files. A new process for new hire employees was initiated on December 13, 2024, but was not effectively implemented. During the review of five employee records, several deficiencies were identified: four out of five professional licenses were not verified for accuracy prior to employment, all five physicals were not completed before employment, all five Tuberculin tests were not conducted, four out of five employee job descriptions were missing, and two out of five background checks were not completed prior to employment. Additionally, a Registered Nurse (RN) was allowed to work despite having an expired and probationary license. The Director of Nursing confirmed that the facility failed to implement an effective QAPI plan for new employees, as the past HR director did not communicate the expired license issue.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. 2. A new process for new hires has been implemented and will be followed for new hires. An audit of new hires for the past 3 months will be completed to ensure all the required paperwork is completed. 3. The Human Resource Director will be reeducated on the new process by the Regional Human Resource Director/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for three weeks and monthly for three months to ensure all required paperwork is completed and the performance improvement plan is followed. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Missing Job Descriptions in Personnel Files
Penalty
Summary
The facility failed to ensure that personnel records included a copy of the employee's job description for four out of five personnel files reviewed. This deficiency was identified during a review of employee personnel records and staff interviews. Specifically, the personnel files of a Licensed Practical Nurse and three Registered Nurses did not contain documented evidence of their job descriptions. The Regional Human Resource Employee was unable to provide the job descriptions upon request. The Nursing Home Administrator confirmed the absence of job descriptions in the personnel records during an interview.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. Job descriptions will be added to Licensed Practical Nurse Employee 1, Registered Nurse Employee 5, and Registered Nurse E6's employee file. 2. The Human Resource Director/designee will audit new hire employee files from the past three months to ensure the employee's job description is in the file. 3. The Human Resource Director will be reeducated by the Nursing Home Administrator/designee on the ensuring a job description is in the employee file. 4. The Nursing Home Administrator/designee will audit new hires weekly for three weeks and monthly for three months to ensure files have an employee job description. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Verify Professional Licenses Before Employment
Penalty
Summary
The facility failed to verify professional licenses prior to employment for four out of five new hires, which is a violation of their own personnel policies and procedures. The policy, dated 1/11/24, mandates that background checks, including verification of professional licenses, be completed before employment to ensure the safety and well-being of residents and staff. However, the personnel records for an LPN and three RNs did not include completed license verification checks before their respective hire dates. Interviews with facility staff confirmed the oversight. The Regional Human Resource Employee acknowledged that the verification should have been completed before the start date, and the Director of Nursing confirmed the failure to verify licenses for the four employees. This deficiency was identified during a review of new hire files and staff interviews, highlighting a lapse in adherence to the facility's established procedures for pre-employment screening.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. Licensed Nurse Employee E1, Registered Nurse E3, Registered Nurse E5's licenses were verified by 1/17/25. 2. The Human Resource Director/designee will audit current licensed staff to ensure licenses are verified and in good standing. 3. The Human Resource Director will be re-educated on facility policies for Background checks by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure licensed staff licenses are verified and in good standing. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Ensure Employee Health Assessments
Penalty
Summary
The facility failed to ensure that personnel records included an attestation that employees could perform their job duties prior to employment. This deficiency was identified during a review of five personnel files, which included a Licensed Practical Nurse and four Registered Nurses. The facility's policy, dated January 11, 2024, required that employees be in good health and physically able to complete their assigned duties. However, the personnel files reviewed showed that the required physical examinations were either completed after the employees' hire dates or not completed at all. Specifically, the physicals for the employees were dated after their hire dates, and one employee did not have a physical on file. Interviews with the Regional Human Resource Employee and the Nursing Home Administrator confirmed the facility's failure to comply with its policy regarding employee health assessments.
Plan Of Correction
1. Registered Nurse Employee E4 no longer works at the facility. Facility cannot correct that Licensed Practical Nurse Employee E1, Registered Nurse Employee E3, Registered Nurse Employee E5 and Registered Nurse Employee E6's physicals were dated after hire. 2. The Human Resource Director will audit employee files from the past three months to ensure that a physical was completed prior to employment. 3. The Human Resource Director will be reeducated on the facility policy for Health Assessments for Employees by the Nursing Home Administrator/designee. 4. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure that physicals were completed prior to employment. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
Failure to Conduct Pre-Employment TB Testing
Penalty
Summary
The facility failed to adhere to the Centers for Disease Control and Prevention (CDC) guidelines for tuberculosis (TB) screening, testing, and surveillance, as evidenced by the lack of pre-employment tuberculin skin testing for five employees. The facility's policy, dated January 11, 2024, mandates that a two-step TB test be completed as part of the health assessment for new employees to ensure they are in good health and capable of performing their job duties. However, a review of personnel records revealed that there was no documentation of completed tuberculin skin tests for Licensed Practical Nurse Employee E1 and Registered Nurse Employees E3, E4, E5, and E6 prior to their employment. During an interview, the Nursing Home Administrator confirmed the facility's failure to conduct the required pre-employment TB testing for these five employees. This oversight indicates a lapse in the facility's compliance with its own health assessment policy and the CDC's recommendations for TB prevention and control. The deficiency was identified through a review of personnel files and interviews with staff, highlighting a systemic issue in the facility's hiring and health assessment processes.
Plan Of Correction
5. Registered Nurse Employee E4 no longer works at the facility. Licensed Practical Nurse Employee E1, Registered Nurse Employee E3, Registered Nurse Employee E5, and Registered Nurse Employee E6's will have tuberculin skin tests completed. 6. The Human Resource Director will audit employee files from the past three months to ensure that tuberculin skin tests were completed prior to employment. 7. The Human Resource Director will be reeducated on the facility policy for Health Assessments for Employees by the Nursing Home Administrator/designee. 8. The Nursing Home Administrator/designee will audit new hires weekly for four weeks and monthly for three months to ensure tuberculin skin tests were completed prior to employment. Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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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