Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wecare At Murrysville Rehab And Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure accurate MDS assessments for five residents. One resident’s anticonvulsant use was not captured, another resident’s Stage 3 sacral ulcer and pressure injury risk were not documented, and a third resident’s antidepressant use was omitted. In addition, hospice services were not recorded for one resident and insulin use was not fully documented for another, despite physician orders, MAR/TAR entries, wound records, and staff confirmation showing the services and medications were in place.
A facility failed to include person-centered instructions in care plans for three residents. One resident with Parkinson's disease, depression, seizure disorder, and a vagal nerve stimulator had no care plan guidance for the device; another resident receiving trazodone for insomnia had no care plan instructions for the medication or sleep issue; and a third resident with DM2, dementia, and heart failure had no care plan guidance for antidepressant, anticoagulant, diuretic, or insulin therapy. The RNAC confirmed the omissions.
Failure to complete annual nurse aide evaluations. Review of personnel files showed that four of five sampled NA records did not have current annual performance reviews on file. The Assistant DON confirmed the facility failed to complete the required annual evaluations for the NAs.
Expired and undated drugs and supplies were found in the West Side Medication Room and in the 115 Hall, 136 Hall, and East Zone Two medication carts. Surveyors observed opened tuberculin vials, urine culture tubes past expiration, and multiple opened meds including Ipratropium bromide, Budesonide, Humalog insulin, Lispro Quick Pen, Albuterol solution, Fluticasone nasal spray, Trelegy inhaler, and Timolol eye drops; LPNs confirmed the items were not dated as required, and the DON confirmed the issue.
Unclean Resident Rooms and Wheelchair: The facility failed to maintain a clean, safe, comfortable, and homelike environment when three resident rooms had sticky, grimy, stained floors and soiled fall mats, and one resident’s wheelchair was covered in dried food, crumbs, black grime, and stickiness. An LPN and a nurse aide confirmed the conditions, and the NHA acknowledged the failure.
Failure to address ongoing resident council concerns: Residents repeatedly reported call bells not being answered in a timely manner, staff using phones while working, and snacks not being offered or passed. The same issues were documented across multiple council meetings, with residents stating the concerns continued without resolution and the NHA confirming the facility failed to address them over three months.
SNF-ABN Forms Missing Estimated Charges: The facility failed to provide two residents with SNF-ABNs that included the estimated amount for nursing services that could be charged. One resident had COPD, aphasia, and hyperlipidemia, and the other had COPD, HTN, and DM. The BOM confirmed the missing estimated charge information during interview.
A resident with atrial fibrillation, recurrent major depressive disorder, and anxiety disorders received PRN Hydroxyzine and then PRN Lorazepam over multiple days. The MAR and progress notes did not document the behaviors prompting the meds or any non-pharmacological interventions tried first, and the DON confirmed the facility failed to provide non-pharmacological interventions before giving the anti-anxiety medications.
Nutritional assessments and care plans were not accurately updated for two residents with significant nutrition-related needs. One resident with Parkinson’s disease, dementia, and schizoaffective disorder had documented weight loss, discontinued supplements that remained on the care plan, and no documented reason for stopping the supplements. Another resident with aphasia, HTN, and schizoaffective disorder had a mechanically altered diet and large-portion dinner order, but the care plan did not address those needs, the nutrition assessment did not explain the large portions, and a meal tray was missing items listed on the tray ticket.
Failure to provide trauma informed care for a resident with PTSD and TBI. The care plan noted a traumatic event but did not identify PTSD-related triggers, and the DON confirmed the facility failed to eliminate or mitigate triggers that could cause re-traumatization.
Improper hand hygiene during wound dressing change: An LPN failed to wash hands after removing gloves during a resident’s sacral wound dressing change, despite facility policy stating that gloves do not replace hand hygiene and that hands should be washed before and after handling dressings and contaminated items. The LPN removed and reapplied gloves multiple times without handwashing while completing the wound care, and the DON confirmed the failure to use proper hand washing to prevent cross contamination.
The facility failed to ensure one shower chair was in safe operating condition for a resident with dementia, Parkinson’s disease, and bipolar disorder. A NA was observed pulling the resident backward in the chair and stated the wheels were damaged and the chair would drive out of control if pushed forward, which led staff to pull it backward instead. The DON confirmed the equipment was not safe for use.
A resident with SBO, a mesenteric desmoid tumor, and heart failure received TPN by IV pump with a rate discrepancy. The order specified a staged infusion rate, but the pump was set at 174 ml/hr instead of the ordered 147 ml/hr for the main infusion period. The RN discovered the issue when the pump was beeping and complete, and the provider was notified; the DON confirmed the error.
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.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to make certain that resident assessments were accurate for five of eight residents reviewed. The RAI User’s Manual required accurate completion of MDS items related to high-risk drug classes, pressure ulcer/injury risk, hospice care, and insulin use. Review of records and staff interviews showed that the RNAC confirmed multiple MDS entries were incorrect and did not reflect each resident’s current needs. For one resident with Parkinson’s disease, depression, and a seizure disorder, the MDS did not include anticonvulsant use in Section N0415K even though physician orders and the MAR showed daily Depakote Sprinkles administration. For another resident with atrial fibrillation, heart failure, and hypertension, the MDS did not mark pressure ulcer/injury risk in Section M0100, marked no unhealed pressure ulcers/injuries in M0210, and did not identify a Stage Three ulcer in M0300-C, despite the wound list, physician orders, TAR, and staff interview confirming a sacral wound treated daily and classified as a Stage Three ulcer. Additional inaccuracies were found for a resident with diabetes, dementia, and heart failure whose MDS did not indicate antidepressant use in Section N0415C even though Venlafaxine was ordered and administered daily. A resident with Alzheimer’s disease, failure to thrive, and heart failure had an MDS that did not indicate hospice care in Section O0110K1 despite hospice orders and a care plan showing hospice services. Another resident with diabetes, heart disease, and hypertension had an MDS that did not record the number of days insulin was received in Section N0350 even though orders and the MAR showed daily insulin injections. The DON confirmed the facility failed to make certain that resident assessments were accurate for these five residents.
Care plans lacked person-centered instructions for multiple residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans that included measurable objectives, timetables, and instructions for care and management for three of eight residents reviewed. Facility policy required each resident to have a comprehensive person-centered care plan addressing physical, psychosocial, and functional needs. For Resident R4, the clinical record showed diagnoses of Parkinson's disease, depression, and a seizure disorder, along with evidence of a vagal nerve stimulator, but the current physician orders and care plan did not include instructions for care and management of the vagal nerve stimulator. For Resident R29, the record showed diagnoses of heart failure, high blood pressure, and weakness, and a physician order for trazodone every night at bedtime for sleeplessness; the MAR showed the medication was administered as ordered, but the care plan did not include instructions for trazodone or insomnia. For Resident R33, the record showed diagnoses of diabetes mellitus, dementia, and heart failure, with physician orders for venlafaxine, apixaban, furosemide, insulin degludec, and multiple daily doses of Novolog; the MAR showed these medications were given as ordered, but the care plan did not include instructions for management of the antidepressant, anticoagulant, diuretic, or insulin therapy. The RNAC confirmed these omissions during interview.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to complete annual nurse aide employee evaluations for four of five sampled records, including Nurse Aide Employees E1, E2, E3, and E4. Review of personnel files on 3/18/26 at 9:00 a.m. showed that E1 was hired on 1/5/23 and had a last annual performance review on 2/23/25, E2 was hired on 9/5/22 and had a last annual performance review on 2/23/25, E3 was hired on 12/16/06 and had a last annual performance review on 1/6/25, and E4 was hired on 1/8/18 and had a last annual performance review on 1/3/25. During an interview on 3/18/26 at 9:30 a.m., the Assistant DON confirmed that the facility failed to complete annual nurse aide employee evaluations as required.
Expired and Undated Medications Found in Medication Room and Carts
Penalty
Summary
The facility failed to discard expired medical supplies and failed to ensure drugs and biologicals were stored under proper temperature controls in one of two medication rooms and three medication carts. During an observation of the West Side Medication Room, surveyors found two opened tuberculin vials that were not dated and multiple bags of urine culture tubes with expiration dates of [DATE]. An LPN confirmed that the tuberculin vials were not dated and that the supplies were expired. Additional observations found expired or opened and undated medications in the 136 Hall Medication Cart, East Zone Two Medication Cart, and 115 Hall Medication Cart. These included Ipratropium bromide, Budesonide, Humalog insulin vial, Lispro Quick Pen, Albuterol inhalation solution, Fluticasone nasal spray, Trelegy inhaler, and Timolol eye drops, all noted as opened and not labeled with a date as required. LPNs confirmed the medications were opened and not labeled as required, and the DON later confirmed the facility failed to discard expired medical supplies and ensure proper storage conditions for the identified carts and medication room.
Unclean Resident Rooms and Wheelchair
Penalty
Summary
The facility failed to provide a clean, safe, comfortable, and homelike environment by not maintaining clean resident rooms and a clean wheelchair. Review of the facility policy stated the environment would be safe, clean, comfortable, and homelike. During observation, Resident R22 was lying in bed while the floor in the room was sticky, stained with darkened areas, and covered in grime. A licensed practical nurse confirmed the condition of the floor. Resident R50 was sitting on the side of the bed when the room floor was observed to be sticky, stained with darkened areas, and covered in grime, and the fall mat was sticky, had spots of dried liquids, and covered in grime; an LPN confirmed these conditions. Resident R61 was observed sitting in a wheelchair in the hallway, and the wheelchair seat and right arm were completely covered in dried foods, crumbs, black grime, and were sticky; a nurse aide confirmed the condition of the wheelchair. Resident R65 was not in the room at the time of observation, but the room floor was sticky, stained with darkened areas, and covered in grime, and the fall mat was sticky, had spots of dried liquids, and covered in grime; an LPN confirmed these conditions. The Nursing Home Administrator confirmed the facility failed to provide a clean environment for three resident rooms and one resident wheelchair.
Failure to Address Ongoing Resident Council Concerns
Penalty
Summary
The facility failed to address residents’ council ongoing concerns for three consecutive months, involving call bells not being answered in a timely manner, employees on phones while working, and snacks not being offered or passed to residents. Facility policy stated that residents and their representatives must be able to submit grievances orally or in writing and that concerns would be investigated and responded to promptly. Resident Council Minutes documented repeated complaints in January, February, and March 2026. In January, residents reported call bells not being answered and employees on phones while working. In February, residents again reported call bells not being answered within 30 minutes to 2 1/2 hours, employees on phones while working, and snacks not being offered or passed. In March, residents reported the same concerns continued, with call bell wait times of 2 to 2 1/2 hours, employees on phones while working, and snacks not being offered or passed. During a resident group interview, residents stated these concerns were ongoing and remained unresolved from meeting to meeting. The NHA confirmed that the residents’ council concerns had been ongoing and that the facility failed to address them for three of three months.
SNF-ABN Forms Missing Estimated Charges
Penalty
Summary
The facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that would be charged for two residents, R8 and R31. The facility policy on Advanced Beneficiary Notices stated that Medicare requires SNFs to issue the SNF-ABN to original Medicare beneficiaries before providing care that Medicare usually covers but may not pay for, so the beneficiary can decide whether to receive the care and assume financial responsibility. Resident R8 was admitted to the facility and had an MDS dated 1/5/26 that listed COPD, aphasia, and hyperlipidemia. Resident R8's SNF-ABN dated 10/23/25 stated that beginning on 10/25/25 the resident may have to pay out of pocket for care if insurance does not cover the costs, but the estimated amount for the nursing services was left as "$ Current PL per day/item or service." Resident R31 was admitted to the facility and had an MDS dated [DATE] that listed COPD, high blood pressure, and diabetes. Resident R31's SNF-ABN dated 11/26/25 stated that beginning on 11/29/25 the resident may have to pay out of pocket for care if insurance does not cover the costs, but the estimated amount was left as "$ At current rate per day/item or service." During an interview on 3/17/26 at 12:51 p.m., the Business Office Manager confirmed the facility failed to provide the SNF-ABN with the estimated amount of nursing services that would be charged for these two residents.
Unnecessary PRN psychotropic use without documented behaviors or non-pharmacological interventions
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from potentially unnecessary psychotropic medications. Resident R1 was admitted and later re-admitted to the facility, and the MDS dated 1/8/26 listed atrial fibrillation, major depressive disorder recurrent, and anxiety disorders on the admit sheet. The clinical record and MAR for February 2026 showed Hydroxyzine Pamoate 50 mg ordered every 8 hours as needed for anxiety for 14 days, followed by Lorazepam 1 mg every 8 hours as needed for anxiety for 14 days, and then Lorazepam continued as needed until 4/2/26. The February MAR showed Hydroxyzine was administered on 8 days in a row, and Lorazepam was administered on multiple days in February and repeatedly in March. The MAR did not include what behaviors Resident R1 was experiencing or other attempts to relieve the behaviors before the psychotropic medication was given. Progress notes for February and March 2026 also did not describe behaviors or non-pharmacological interventions prior to administration. During an interview on 3/20/26 at 9:15 a.m., the DON confirmed the facility failed to provide non-pharmacological interventions prior to giving anti-anxiety medications to Resident R1.
Nutritional assessments and care plans were not accurately updated for two residents
Penalty
Summary
The facility failed to accurately assess the nutritional status of two residents and failed to update individualized care plans to address their specific nutritional concerns. Facility policy required nutritional assessments to identify current nutritional status and risk factors for impaired nutrition, and required care plans to be revised when a resident’s condition changed, when desired outcomes were not met, and at least quarterly. The policy also required resident food preferences to be assessed and documented in the care plan. One resident had diagnoses including Parkinson’s disease, dementia, and schizoaffective disorder. The resident’s MDS indicated significant weight loss, and the record showed orders for a no added salt diet with mechanical soft textures and multiple nutritional supplements that were later discontinued. The current care plan still included interventions for supplements that had been discontinued, but it did not establish nutritional focus or goals related to the mechanically altered and therapeutic diet identified on the MDS. The nutritional progress notes did not document why the supplements were discontinued despite the history of significant weight loss, and the RD confirmed the care plan was not updated and the reason for discontinuation was not documented. A second resident had diagnoses including cerebral infarction with aphasia, hypertension, and schizoaffective disorder. The MDS indicated use of a mechanically altered diet, and the physician order included a regular diet with mechanical soft textures and large portions with dinner. During a meal observation, the resident’s lunch tray did not contain all items listed on the tray ticket, including cookies and portions of sweet and sour chicken. The care plan still referenced supplements that had been discontinued and did not include nutritional focus and goals related to the mechanically altered diet or the large-portion dinner order. The nutrition assessment also failed to identify the use and reason for large portions at dinner, and the RD confirmed the tray tickets were inaccurate and the nutritional assessment did not identify the rationale for the large portions.
Failure to Provide Trauma Informed Care
Penalty
Summary
The facility failed to provide trauma informed care for Resident R9, who had a diagnosis of PTSD and TBI. Review of the facility policy indicated that trauma informed care should recognize the effects of trauma, identify triggers, and incorporate that knowledge into care plans to avoid re-traumatization. However, review of Resident R9’s care plan for PTSD showed that a traumatic event had occurred but did not identify any triggers related to the resident’s PTSD. During interview, the DON confirmed that the facility failed to provide trauma survivors with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization for Resident R9.
Improper hand hygiene during wound dressing change
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when proper hand washing was not used during a dressing change for Resident R11. Facility policy for Handwashing/Hand Hygiene dated 6/11/25 stated alcohol-based hand rub or soap and water should be used before handling clean or soiled dressings and after handling used dressings or contaminated equipment, and that gloves do not replace hand hygiene. The Wound Care policy dated 6/11/25 also directed staff to wash and dry hands thoroughly before and after dressing care steps. Resident R11 was admitted to the facility with diagnoses including atrial fibrillation, heart failure, and high blood pressure, and had a physician order dated 3/11/26 for sacral wound care with saline cleansing, Dakins-packed gauze, and a border dressing daily and as needed. During observation of the dressing change on 3/17/26 at 11:30 a.m., the LPN washed hands, applied new gloves, and removed the old soiled dressing. The nurse then removed the gloves, did not wash hands, and applied new gloves. After cleansing the wounds with saline, the nurse again removed the gloves, did not wash hands, and applied new gloves to complete the dressing change. When interviewed, the LPN stated washing hands after each glove change would be a big waste of products. The DON later confirmed the facility failed to use proper hand washing to prevent cross contamination during the dressing change for Resident R11.
Unsafe Shower Chair Condition
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for one of three shower chairs used by Resident R82. The facility policy dated 6/11/25 stated that device condition and equipment are maintained on schedule and according to manufacturer’s instructions, and that defective or worn devices are discarded or repaired. Resident R82’s record showed diagnoses of dementia, Parkinson’s Disease, and bipolar disorder. During observation on 3/16/26 at 10:35 a.m., a nurse aide was seen pulling Resident R82 backwards down the hall in a shower chair. When interviewed immediately afterward, the nurse aide stated awareness that residents should not be pulled backward, but said the wheels of the shower chair were “all messed up” and that if staff pushed forward as required, the chair would drive out of control, so it was easier to pull the chair backwards. The DON later confirmed that the facility failed to make certain the shower chair was in safe operating condition.
TPN Infusion Rate Set Incorrectly
Penalty
Summary
The facility failed to ensure Total Parenteral Nutrition (TPN) was administered consistent with professional standards of practice and in accordance with physician orders for one resident. The resident had diagnoses of persistent small bowel obstructions, small bowel mesenteric desmoid tumor, and heart failure. A physician order dated 1/8/26 directed that 2500 milliliters be infused over 18 hours, with the infusion running at 74 ml/hr for the first hour, 147 ml/hr for 16 hours, and 74 ml/hr for the last hour via infusion pump intravenously. A progress note dated 1/9/26 documented that the resident was on TPN for SBO and that the RN was alerted when the IV pump was beeping and complete; the TPN had been initiated at 8:00 p.m. on 1/8/26. The note stated the resident received the correct medication and concentration but with a rate discrepancy, and the provider was notified. The facility Medication Incident form indicated the ordered TPN rate of 147 ml/hr for 16 hours had been set at 174 ml/hr in error. The DON confirmed in interview that the facility failed to ensure TPN was administered consistent with professional standards of practice and physician orders for this resident.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,198 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Murrysville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodhaven Health & Rehab Center | 2.5 mi | ★★★★★ | 17 | 0 |
| Concordia At The Cedars | 2.6 mi | ★★★★★ | 2 | 0 |
| Harmony Physical Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Monroeville Post Acute | 3.1 mi | ★★★★★ | 18 | 0 |
| Wecare At Monroeville Rehabilitation And Nsg Ctr | 4.5 mi | ★★★★★ | 48 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.