Wecare At Rolling Meadows Rehab And Nursing Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Waynesburg, Pennsylvania.
- Location
- 107 Curry Road, Waynesburg, Pennsylvania 15370
- CMS Provider Number
- 395624
- Inspections on file
- 33
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Wecare At Rolling Meadows Rehab And Nursing Ce during CMS and state inspections, most recent first.
Staff failed to follow abuse and restraint policies when they used a bed sheet as a physical restraint on a resident with dementia and fall risk. After the resident reportedly fell twice onto a fall mat, two CNAs looped and tied a sheet across the resident’s hips/abdomen and to the bedframe from side to side, with the resident’s hands underneath, limiting movement and making the knot difficult to remove. Subsequent assessment documented a linear purple discoloration on the resident’s lower abdomen/pelvis, and the administrator and DON later confirmed that staff had restrained the resident with a sheet, resulting in abdominal bruising.
The facility failed to develop and implement written policies and procedures that included substantive training for new and existing staff on abuse, neglect, misappropriation of resident property, and exploitation, as required by regulation. Although sign‑in sheets showed that several CNAs attended abuse‑prevention education, the underlying policy only stated that such topics would be covered and did not itself include the required content, and the education on those topics was not actually provided. As a result, staff did not recognize that using a bed sheet looped and tied to the bed frame across a resident’s hips to prevent falls constituted an unauthorized physical restraint and a form of physical abuse. A resident with dementia, heart failure, and a history of falls was found with the sheet tied to the bed and later assessed with a linear purple discoloration on the lower abdomen/pelvis and scattered bruising, which surveyors attributed to the improper restraint and to staff’s lack of required training.
The facility did not have a qualified dietary manager for two weeks while also lacking a full-time dietitian. A new dietary manager was hired but did not have a CDM credential or enrollment in a CDM program, though she held a ServSafe certification. Staff confirmed the absence of both a full-time dietitian and a qualified dietary manager during this period.
The facility did not provide enough dietary staff to safely and effectively carry out food and nutrition services, resulting in delayed meal delivery, incomplete trays, and staff from other departments having to assist in the kitchen. Residents were left waiting for meals, and staff reported issues such as missing silverware and the need to provide snacks to residents who had already received insulin due to late meal service.
The facility did not have a qualified individual onsite responsible for infection prevention and control, as the newly hired Infection Control Nurse was untrained and the DON was temporarily fulfilling the role due to her training.
Staff reported that wipes were removed and washcloths were often discarded after use, resulting in a shortage of clean linens for resident care. Laundry staff and the administrator confirmed ongoing difficulties maintaining adequate supplies. Observations revealed widespread environmental issues, including damaged flooring, broken cabinets, missing ceiling tiles, and tripping hazards, with residents experiencing discomfort and persistent odors. Facility leadership confirmed these deficiencies, which compromised the safety and comfort of the environment.
Residents did not consistently receive menu items they selected or requested, with reports of missing food items, lack of alternatives, and frequent substitutions. Staff confirmed that food carts were often late and trays were incomplete, and the administrator acknowledged the failure to meet resident dietary preferences.
A resident with multiple medical conditions and an unstageable pressure injury did not have Enhanced Barrier Precautions (EBP) implemented during wound care, as required by facility policy. During a dressing change, an LPN failed to wear a gown, and the DON confirmed that EBP was not in place for this resident.
The facility did not have a qualified Dietary Manager on staff, relying instead on a manager from another facility to order food remotely and occasional visits from a dietician. The NHA and Maintenance Director were assisting with meal preparation and food purchasing, and kitchen staff confirmed the absence of an on-site Dietary Manager. The facility did not meet the required qualifications for a Certified Dietary Manager.
The facility did not employ a qualified full-time social worker after the previous social worker was terminated, as confirmed by staffing records and the Nursing Home Administrator.
The facility failed to accurately complete MDS assessments for nine residents, as discrepancies were found between their recorded communication abilities and the completion of cognitive and mood assessments. Despite being sometimes or usually understood, these assessments were not completed, indicating a significant oversight in the facility's assessment process.
A resident with a history of stroke and hemiplegia, at risk for pressure ulcers, was not provided with prescribed care in an LTC facility. Despite orders to reposition the resident every two hours, observations showed the resident was left on their back without repositioning, and a positioning wedge was not used. The DON confirmed the failure to follow care plans and physician's orders, leading to inadequate pressure ulcer care.
The facility did not provide mandatory QAPI training to four staff members, including three Nurse Aides and a Central Supply employee, as required by their policy. The Director of Nursing confirmed the lack of documented training for these employees during a review.
The facility failed to provide sufficient staffing to meet the needs of ten residents, as evidenced by interviews and observations. Residents reported insufficient staff, inadequate personal care, and long call light response times. Observations showed staff not responding to call lights, and residents had unkempt appearances. The deficiency was confirmed by the Nursing Home Administrator and DON, with Resident Council minutes also highlighting concerns about call light response times.
Resident Restrained to Bed With Sheet Resulting in Abdominal Bruising
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints, as required by facility policy and regulatory standards. Facility policies defined a physical restraint as any manual method or material attached or adjacent to the resident’s body that the resident cannot easily remove and that restricts freedom of movement, including tightly tucked sheets that prevent a resident from getting out of bed. The facility’s abuse and restraint policies also stated that even unintentional use of restraints must be recognized and reported by staff. The resident involved, identified as R1, had diagnoses including heart failure, anxiety, depression, and dementia, with a BIMS score of 9 indicating moderate cognitive impairment. R1 had a care plan for fall risk related to gait and balance problems, with staff directed to follow the facility’s fall protocol. A weekly skin evaluation completed prior to the incident did not show new skin issues, and nurse aide skin observations from the beginning of the month through the date of discovery consistently documented no discoloration or other skin concerns. On the morning of the incident, a head-to-toe assessment documented scattered fading discolorations on the resident’s extremities and a 0.5 x 4 cm linear purple discoloration on the left lower abdomen/pelvis. That same day, the DON documented that it had been reported that R1 was found in bed with a sheet over her, tied to the bed to hold her down at the beginning of the 6 a.m.–2 p.m. shift. Multiple staff statements described the sheet as rolled or placed across the resident’s abdomen/hips, with the ends looped or tied to the bedframe from one side of the bed to the other, and the resident’s hands underneath the sheet so she could not move them. Staff reported difficulty in untying the knot and indicated that the configuration of the sheet restricted the resident’s movement. Several nurse aides provided statements acknowledging their involvement or knowledge of the sheet being used in this manner. One nurse aide stated that after the resident reportedly fell twice onto a fall mat during the night, she and another aide placed a bed sheet across the resident’s hips and “lightly looped” it through the bed so the resident could not fall, and that they did not realize this could be considered a restraint. Another aide confirmed helping to get the resident off the floor and then looping a sheet around the bed to keep the resident safe, also stating she did not realize this was a restraint. A different aide reported discovering the sheet tied to the bedframe at two points and showing it to the oncoming day-shift aide, who told her to leave it in place. Other staff, including an RN and LPN on duty, stated they were unaware of any fall or did not observe the sheet in place when they were in the room. During a later interview, the Nursing Home Administrator and DON confirmed that the facility failed to ensure residents were free from physical restraints, and that staff had restrained the resident to the bed with a bed sheet, which caused abdominal bruising.
Failure to Provide Adequate Abuse-Prevention Training Led to Unauthorized Restraint and Injury
Penalty
Summary
The deficiency involves the facility’s failure to develop written policies and procedures that include substantive training for new and existing staff on abuse, neglect, misappropriation of resident property, and exploitation, as required by 42 CFR §483.95. The facility’s abuse prevention policy stated that staff orientation and training programs would include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior, but the policy itself did not contain this information, and the corresponding education on these topics was not provided. During interview, the Nursing Home Administrator and DON confirmed that the facility lacked written policies and procedures that actually included the required training content, despite having sign‑in sheets showing that certain nurse aides had attended an abuse and neglect prevention education session. The resident involved, identified as R1, had diagnoses including heart failure, anxiety, depression, and dementia, with a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. R1 had a care plan for risk of falls related to gait and balance problems, with instructions for staff to follow the facility fall protocol. On a head‑to‑toe assessment, staff documented scattered fading discolorations to the bilateral upper extremities, scabbed areas, and a 0.5 x 4 cm linear purple discoloration on the left lower abdomen/pelvis, along with scattered bruising and scabbed areas on the bilateral lower extremities. On one night shift, R1 reportedly fell out of bed twice onto a fall mat. According to written statements, two nurse aides placed a bed sheet across the resident’s hips and looped it through the bed frame to prevent further falls, stating they did not intend harm and did not realize this could be considered a restraint. A third nurse aide reported discovering the sheet tied to the bed frame on both sides and, after discussing it with a day‑shift CNA, initially left it in place. The facility’s own policy on involuntary seclusion and unauthorized restraint defined physical restraints and specifically listed tightly tucking a sheet or fastening fabric so that a resident cannot get out of bed as examples of restraints. Staff statements and the facility’s investigation report indicated that the aides did not recognize the sheet as a restraint, and the surveyors concluded that this lack of understanding, linked to the absence of adequate written training policies and procedures, resulted in the resident being restrained with a sheet, causing abdominal bruising and constituting actual harm.
Failure to Employ Qualified Dietary Manager in Absence of Full-Time Dietitian
Penalty
Summary
The facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian. Review of job descriptions indicated that the Registered Dietician (RD) was responsible for planning, organizing, coordinating, and evaluating the nutritional components of dietary services, as well as overseeing the duties of the Dietary Manager and other staff. The Food Service Director's role was to direct the overall operation of the Food Services department. Staff interviews confirmed that there was no Dietary Manager present in the facility for two weeks, and a new Dietary Manager had just started orientation. The new Dietary Manager did not possess a Certified Dietary Manager (CDM) credential and was not enrolled in a CDM program, though she did have a ServSafe certification. The Nursing Home Administrator confirmed that there was not a full-time dietitian employed and that the facility did not have a qualified dietary manager during the absence of a full-time dietitian.
Insufficient Dietary Staffing Resulting in Delayed and Incomplete Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to perform essential kitchen duties, as evidenced by observations and staff interviews. On multiple occasions, only two or three staff members were present in the kitchen to serve 110 residents, and staff from housekeeping or environmental services were required to assist with meal service. Scheduled meal times were not met, with lunch tray lines starting late and trays being delivered up to 45 minutes past the scheduled time. Observations showed that residents were left waiting in the dining room for their meals, and staff reported that food carts were often late and that residents did not always receive all required items on their trays. Staff interviews confirmed that the delays and incomplete meal service were due to low staffing in the kitchen. An LPN reported having to provide cookies to residents who had already received insulin because of the late meal delivery, and noted that there was sometimes not enough silverware for residents at breakfast. The Nursing Home Administrator acknowledged that meal delays were a result of insufficient dietary staffing. These findings were in violation of the facility's own staffing policy and relevant state regulations.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual onsite to be responsible for implementing infection prevention and control programs and activities. During an interview, the DON stated that although an Infection Control Nurse was recently hired, this individual was not yet trained, and the DON was currently acting in this role due to having the necessary training. The DON confirmed that there was no qualified, designated individual onsite responsible for infection prevention and control at the time of the survey.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on both A and B nursing units, as evidenced by multiple observations and staff interviews. Staff reported that the facility removed wipes previously used for resident care, requiring the use of washcloths, which were often discarded after use on residents' private areas. This practice led to a shortage of clean washcloths available on linen carts, with only three to five washcloths observed at a time. Laundry staff confirmed difficulties maintaining adequate supplies due to staff discarding washcloths, and the Nursing Home Administrator acknowledged awareness of the issue. The Corporate Regional Clinical Director also noted the need for wipes. These actions resulted in insufficient linen supplies for resident care. Additionally, numerous environmental deficiencies were observed throughout both nursing units. These included lifted or damaged floor trim, broken or sharp cabinet edges, missing ceiling tiles, dented heaters with sharp edges, uneven septic drains creating tripping hazards, water-damaged and moldy bathroom flooring, and walls with gouges or unpainted plaster. Residents reported persistent odors and discomfort due to these conditions. The Maintenance Director and Nursing Home Administrator confirmed the presence of these issues, which collectively contributed to the failure to maintain a safe, clean, and homelike environment for residents.
Failure to Provide Resident-Selected Menu Items and Accommodate Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated resident allergies, intolerances, and preferences, as well as appealing options, for all 12 residents reviewed. According to facility policy, individual food preferences are to be assessed upon admission and communicated to the interdisciplinary team, with modifications made only with resident or representative consent. However, interviews with multiple residents revealed that the dietary department did not serve all items listed on meal tickets and did not provide requested alternates. Residents reported receiving repetitive food items, such as rice and eggs, and being unable to obtain alternatives when requested. During a resident council meeting, it was noted that menu items were substituted without notice, and meal trays were often missing several items. Observations confirmed that specific items, such as milk, diet cola, Ms. Dash, and diet ginger ale, were not provided as ordered. Staff interviews indicated that food carts were frequently late and residents did not consistently receive all items on their trays. The Nursing Home Administrator confirmed the failure to provide resident-selected menu items for all 12 residents reviewed.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for one resident with a pressure injury, as required by facility policy and infection prevention protocols. The policy specified that EBP, including the use of gown and gloves, must be used during high-contact care activities such as wound care for residents with certain types of wounds. The resident in question had a diagnosis of high blood pressure, heart failure, and atrial fibrillation, and was documented to have an unstageable pressure injury on the sacrum that required daily dressing changes with Dakins solution and gauze. On direct observation, there was no evidence that EBP was in place for this resident, despite the presence of a pressure ulcer. During a wound care procedure, an LPN failed to don a gown as required by EBP guidelines. The Director of Nursing confirmed that EBP had not been implemented for this resident. These findings were based on a review of facility policies, clinical records, direct observation, and staff interviews.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the daily functions of the food and nutrition services department. The Nursing Home Administrator (NHA) confirmed that there was no current Dietary Manager, and that a Dietary Manager from another facility was remotely ordering food and only visited occasionally. The NHA also stated that the remote Dietician was only present weekly, and that the Regional Dietician had only visited once since the previous Dietary Manager was terminated. In the absence of qualified dietary staff, the NHA and Maintenance Director were assisting with meal preparation and food procurement, including the NHA personally purchasing food items as needed. Kitchen staff confirmed the lack of an on-site Dietary Manager and reliance on a whiteboard list for food orders. Facility staffing records indicated the previous Dietary Manager was terminated, and the NHA acknowledged the facility did not meet the qualifications for a Certified Dietary Manager as required.
Failure to Employ Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker after the previous social worker was terminated. Staffing records showed that the position has been vacant since the termination date. During an interview, the Nursing Home Administrator confirmed that the facility has not had a qualified social worker in the position since that time. This deficiency was identified through a review of facility files and an interview with the Nursing Home Administrator. No information about specific residents or their conditions was provided in the report.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were completed accurately for nine out of eleven residents. The deficiency was identified through a review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews. The manual specifies that resident interviews should be conducted for the Brief Interview for Mental Status (BIMS) and Resident Mood Interview if the resident is at least sometimes understood, and an interpreter is available if needed. However, for the residents in question, there were discrepancies between their ability to be understood as recorded in Section B: Hearing, Speech, and Vision, and the lack of completion of the BIMS and Mood assessments in Sections C and D. For each of the nine residents, the MDS assessments indicated that they were sometimes or usually understood, yet the cognitive and mood assessments were not completed, as they were marked as rarely understood. This inconsistency suggests that the facility did not accurately assess the residents' communication abilities, leading to incomplete assessments. The Registered Nurse Assessment Coordinator confirmed the failure to complete the MDS assessments accurately during an interview, highlighting a significant oversight in the facility's assessment process.
Failure to Provide Prescribed Pressure Ulcer Care
Penalty
Summary
The facility failed to provide prescribed treatment and services for pressure ulcer care for a resident, identified as Resident R82. The resident, who had a history of stroke, hemiplegia, and muscle weakness, required substantial assistance with personal care and was at risk for pressure ulcer development. The resident had an unhealed Stage II and Stage III pressure ulcer. Despite a physician's order to encourage and assist the resident to turn and reposition every two hours, observations over several days showed that the resident was left lying on their back without being repositioned, and a positioning wedge was not utilized as it was found on a chair in the room. The facility's policy indicated that the physician would help identify factors contributing to skin breakdown, and the resident's care plan and Kardex instructed staff to assist with turning and repositioning. However, these instructions were not followed, as confirmed by the Director of Nursing during an interview. The facility's failure to adhere to the prescribed care plan and physician's orders resulted in inadequate care for the resident's pressure ulcers, as noted in the survey findings.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training on the Quality Assurance and Performance Improvement (QAPI) program for four out of ten staff members, specifically Employees E2, E3, E4, and E5. According to the facility's policy dated March 28, 2023, all staff are required to participate in initial orientation and annual in-service training, which includes QAPI. However, a review of the training records revealed that these employees did not have documented QAPI training within the specified time frames. Employee E2, a Nurse Aide hired on June 14, 1999, did not receive QAPI training between June 14, 2023, and June 14, 2024. Employee E3, also a Nurse Aide hired on July 17, 2023, lacked QAPI training between July 17, 2023, and July 17, 2024. Employee E4, another Nurse Aide hired on August 2, 2023, did not have QAPI training between August 2, 2023, and August 2, 2024. Lastly, Employee E5, a Central Supply employee hired on September 8, 2021, failed to receive QAPI training between September 8, 2022, and September 8, 2023. The Director of Nursing confirmed this deficiency during an interview on September 5, 2024.
Staffing Deficiency in Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of ten out of twelve residents, as evidenced by resident interviews and observations. Residents reported insufficient staff, with one resident noting that staff worked too hard, and another stating they only received one bath in a week due to staff shortages. Call light response times were also a concern, with one resident waiting over an hour and another stating they had to press the button multiple times before receiving assistance. Observations revealed that staff did not respond to a call light alarm, and residents were noted to have unkempt appearances, indicating a lack of personal care. The deficiency was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged the facility's failure to provide adequate staffing. Resident Council minutes from May and June 2024 also highlighted concerns about call light response times. The facility's policy, dated January 16, 2024, stated that adequate staffing would be provided to meet resident needs, but this was not upheld, leading to the identified deficiencies.
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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