Westmoreland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 2480 South Grand Blvd, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395435
- Inspections on file
- 31
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Westmoreland Manor during CMS and state inspections, most recent first.
A resident with a history of aggressive behaviors pushed another cognitively impaired resident after being tapped on the shoulder, causing a fall and a hip fracture. The incident occurred despite care plan interventions requiring close monitoring and redirection for the aggressive resident, and the facility's investigation substantiated that abuse occurred.
A resident with a history of CVA and diabetes filed a grievance alleging that an LPN repeatedly engaged in upsetting and inappropriate behaviors, including preparing incorrect insulin and making distressing comments. The facility did not document a thorough investigation into these concerns or obtain a statement from the LPN, as required by policy.
A resident with left-side hemiplegia requested coffee without a lid, which was prepared by a nurse aide using a Keurig and delivered without checking the temperature. The resident spilled the hot coffee onto his thigh, resulting in blisters and redness. Staff interviews confirmed that temperature checks for hot liquids were not routinely performed by nursing staff, and the hot liquid safety policy was not applied to them.
Two residents did not receive care in accordance with physician orders when staff failed to hold prescribed blood pressure medications despite documented low systolic blood pressure readings, as required by the orders. Medication Administration Records showed that Hydralazine and metoprolol tartrate were administered without adherence to hold parameters, and this was confirmed by Clinical Compliance.
The facility did not accurately complete MDS assessments for four residents, including failures to document administration of anticonvulsant and antiplatelet medications, incorrect coding of a resident's fall and fracture history after hospital readmission, and an error in recording a resident's discharge location. These inaccuracies were confirmed by the Director of Case Management.
A resident with renal failure and peripheral vascular disease was prescribed 250 mg calcium citrate twice daily, but was administered 950 mg calcium citrate with 200 mg calcium after the pharmacy substituted the medication due to a backorder. The pharmacy did not notify the facility, and nursing staff did not clarify the change with the provider, resulting in the administration of a non-equivalent medication without proper order clarification.
The facility did not ensure that two residents with PICC lines received IV flushes with saline before and after administration of IV antibiotics, as ordered by physicians and required by facility policy. Medication administration records lacked documentation of these flushes, and staff confirmed the omission.
Two residents received incorrect medication dosages during observed administration, resulting in a medication error rate of 6.67%. An LPN administered a higher dose of calcium citrate than ordered to a resident with renal failure and peripheral vascular disease, and only one drop of artificial tears instead of two to a resident with multiple sclerosis. The DON confirmed the discrepancies between the administered medications and physician orders.
The facility failed to maintain electrical equipment as required by NFPA 70, with two electrical panels obstructed by wheelchairs in a storage room, affecting one smoke compartment. This was confirmed by the Facility Administrator and Maintenance Director.
The facility was found to have improperly used an electrical extension cord as a fixed power source for a pump in the Maintenance/Shop Storage room. This deficiency was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain a safe and homelike environment in the A1 dining room, where residents reported concerns about peeling and rough tables that could cause skin tears. Observations confirmed the poor condition of all eight tables, and both the Maintenance Director and DON acknowledged the issue.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not attempting non-pharmacological interventions before administering Lorazepam. Despite a policy requiring such interventions and a psychiatric evaluation recommending them, the resident received Lorazepam multiple times without documented attempts at non-pharmacological approaches. The DON confirmed this oversight, indicating non-compliance with the facility's policy.
A facility failed to properly label medications and date multi-dose insulin vials. A resident received a different insulin dosage than labeled, and several insulin vials were not dated upon opening, as confirmed by staff interviews.
A nurse aide in an LTC facility failed to follow sanitary food handling practices by using bare hands to prepare a resident's meal, violating the facility's policy requiring gloves or barriers. This was confirmed by both the aide and the CRNP.
The facility failed to obtain required hospice documentation for two residents receiving hospice services. One resident, with cognitive impairment and malnutrition, lacked updated hospice nurse aide charting since January. Another resident, with a cerebrovascular accident, lacked updated hospice RN and nurse aide charting since admission. These deficiencies were confirmed by the DON.
The QAPI committee at the facility failed to address recurring deficiencies related to assessment accuracy, tube feeding management, drug labeling/storage, and infection control. Despite previous plans of correction, the committee was ineffective in maintaining compliance, leading to repeated citations.
A facility failed to prevent the misappropriation of medication for a resident with chronic pain. Despite documentation of five narcotic cards being received, only four were delivered to the nursing unit. An investigation confirmed that a nurse was the last person in possession of the missing card, leading to the conclusion of misappropriation.
A facility failed to update a resident's care plan to reflect her new preference for receiving medications early due to a change in her dialysis schedule. The resident's care plan was outdated, and the DON confirmed it should have been revised.
A facility failed to provide a resident with weekly showers as per their policy. The resident, who was alert and oriented, had a care plan specifying morning showers. However, during April, the resident did not receive showers on two occasions, instead receiving bed baths due to testing positive for COVID-19. This was confirmed by the DON.
A facility failed to follow its policy for feeding tube management for a resident with cognitive impairment and a feeding tube due to stroke and dementia. The policy requires that feeding tube bags be labeled with the date and time they are started, but an observation revealed that the bag in use was not labeled as required. This was confirmed by a nurse and the DON.
A facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers, as two nurses did not wash their hands between glove changes. Additionally, a nurse aide improperly handled soiled linens by throwing them on the floor during a bed bath for another resident. These actions were confirmed by staff interviews and did not comply with the facility's infection control policies.
The facility failed to provide written notification of emergency hospital transfers to responsible parties and the State Ombudsman for three residents. One resident with end-stage renal disease was transferred after a dialysis catheter incident, another with dementia after a fall, and a third with Huntington's disease due to hypoxemia. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident with a history of aggressive behaviors. According to the facility's abuse policy, staff were required to monitor, assess, and implement care planning interventions for residents with behaviors that could lead to conflict or harm. Resident 2, who had diagnoses including dementia, anxiety, and depression, exhibited multiple behavioral issues such as agitation, paranoia, and hostility, and was to be closely monitored and redirected as needed. Despite these interventions being outlined in the care plan, Resident 2 was able to push another resident, resulting in harm. On the day of the incident, Resident 3, who was also cognitively impaired and had a history of behavioral issues, approached Resident 2 and tapped him on the shoulder. Resident 2 responded by forcefully pushing Resident 3, causing her to fall and sustain a right hip fracture. The facility's investigation, supported by video evidence and staff interviews, substantiated that abuse occurred, as Resident 3 suffered significant injury as a result of the altercation.
Failure to Investigate Resident Grievance Regarding Staff Conduct
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's grievance regarding the actions and behaviors of a specific LPN. The resident, who had a history of cerebral vascular accident with right side hemiplegia and diabetes, submitted a grievance form detailing multiple incidents over the course of a year. These included the LPN preparing the wrong insulin, making upsetting comments, and engaging in behaviors perceived as passive-aggressive or intended to distress the resident. The resident also reported that the LPN made statements about her hallucinating and expressed a desire not to have this LPN involved in her care. Upon review, it was found that the facility's investigation did not include documentation addressing the resident's specific concerns about the LPN's conduct, nor was there evidence that a statement was obtained from the LPN in question. The facility's grievance policy required a thorough investigation with supporting documentation, but these steps were not completed or recorded in this case. The DON confirmed the absence of documented evidence addressing the resident's concerns or obtaining a statement from the LPN.
Failure to Ensure Hot Liquid Safety Results in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident with a history of cerebral vascular accident resulting in left-side hemiplegia. The resident, who was alert, oriented, and able to communicate preferences, requested a cup of coffee using his own K-Cup and specified that he did not want a lid on the cup. The coffee was prepared by a nurse aide using a Keurig machine and delivered to the resident's bedside table without the temperature being checked, as was the usual practice at the time. Shortly after receiving the coffee, the resident attempted to drink from the open cup, which slipped from his hand and spilled onto his left thigh. The incident resulted in the formation of blisters and redness on the resident's thigh, as documented in the nursing note. The resident reported mild pain, and the affected area was treated by staff. There was no evidence that the temperature of the coffee was measured prior to serving, and the facility's hot liquid safety policy was not applied to nursing staff, only to kitchen staff. Interviews with staff confirmed that the temperature of hot liquids from the Keurig was not routinely checked before serving to residents. The nurse aide involved in the incident stated that she followed the resident's request for no lid and did not measure the temperature of the coffee. The DON confirmed the lack of documentation regarding temperature checks and clarified that the policy was not extended to nursing staff at the time of the incident.
Failure to Follow Physician Orders for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents, resulting in care and treatment not being provided in accordance with professional standards of practice. For one resident with a history of congestive heart failure and hypertension, physician's orders required Hydralazine to be held if the systolic blood pressure was less than 120 mmHg. However, review of the Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's systolic blood pressure was below the specified threshold, with no documentation that the medication was held as ordered. Similarly, another resident with hypertension and dementia had a physician's order for metoprolol tartrate to be held if the systolic blood pressure was less than 130 mmHg or if the heart rate was less than 60 beats per minute. The MAR indicated that the medication was not held on several occasions when the resident's systolic blood pressure was below the ordered threshold, and there was no documentation to show compliance with the physician's order. These findings were confirmed in an interview with Clinical Compliance staff.
Inaccurate Completion of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for four residents, as required by the Resident Assessment Instrument (RAI) User's Manual. For one resident with a seizure disorder and cerebral palsy, the MDS did not accurately reflect the administration of an anticonvulsant medication during the seven-day look-back period, despite physician orders and medication administration records confirming its use. Another resident with coronary artery disease and a history of heart attack was not accurately coded for receiving an antiplatelet medication, even though both physician orders and the medication administration record indicated the medication was given during the assessment period. These inaccuracies were confirmed by the Director of Case Management. Additionally, a resident who was readmitted to the facility after a hospital stay for a hip fracture was not properly coded in the MDS to indicate this was the first assessment since reentry, which prevented the documentation of a recent fall and fracture. Another resident's discharge status was incorrectly recorded in the discharge tracking MDS, with the record indicating a discharge to the hospital instead of a personal care home, as documented in the nursing notes. These errors were also confirmed by the Director of Case Management.
Failure to Clarify Provider Order After Pharmacy Medication Substitution
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not clarifying a provider's order for a resident. Specifically, a physician's order directed that a resident with renal failure and peripheral vascular disease receive 250 mg of calcium citrate twice daily for Vitamin D deficiency. However, during medication administration, the resident was given 950 mg of calcium citrate containing 200 mg of calcium, which did not match the original order. The pharmacy had substituted the medication due to a backorder but did not notify the facility or ensure the substitution was equivalent. Nursing staff, including an LPN, were unaware of the reason for the substitution and did not clarify the change with the physician. There was no documentation in the resident's clinical record indicating that the order was clarified, and the DON confirmed that the medication administered did not match the physician's order. The facility's policy required that such substitutions be communicated and orders updated, but this process was not followed, resulting in the administration of a non-equivalent medication without proper provider clarification.
Failure to Document PICC Line Flushing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICCs) were flushed as ordered by physicians for two residents. Facility policy required that intravenous catheters be flushed with 0.9% sodium chloride before and after medication administration. For one resident with cognitive impairment and multiple diagnoses, including heart failure and a urinary tract infection, physician orders specified administration of intravenous antibiotics. However, review of the medication administration records showed no documented evidence that the resident's PICC line was flushed after antibiotic administration, as required by policy. Another resident, who was cognitively intact and had diagnoses including peripheral vascular disease and diabetes, returned from the hospital with a PICC line and orders for daily intravenous Vancomycin, with instructions to flush the IV access site with saline before and after medication administration. The medication administration records indicated that the resident received the IV antibiotics, but there was no documentation that the PICC line was flushed with saline before and after each administration. Staff interviews confirmed the lack of documentation for both residents.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy and regulation. During medication administration observations, two errors were identified out of 30 opportunities, resulting in a 6.67 percent error rate. The facility's policy required staff to verify the electronic medical record against the prescription label and adhere to the six rights of medication administration. However, these procedures were not followed in the observed instances. One cognitively intact resident with renal failure and peripheral vascular disease was ordered to receive 250 mg of calcium citrate twice daily but was instead administered 950 mg. Another cognitively intact resident with multiple sclerosis was ordered to receive two drops of artificial tears in each eye three times daily but was only given one drop per eye. Both errors were confirmed by the LPN involved and the Director of Nursing, who acknowledged that the medications administered did not match the physician's orders.
Obstructed Electrical Panels in Storage Room
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 70, National Electric Code, as required by NFPA 101 (2012 Ed.). During an observation on April 30, 2025, at 9:20 a.m., it was noted that two electrical panels were obstructed by wheelchairs in the B-2 storage room on the second floor of the B wing. This deficiency affected one out of 27 smoke compartments in the facility. An interview with the Facility Administrator and Maintenance Director on May 1, 2025, at 11:00 a.m., confirmed the presence of the electrical equipment deficiency. The obstruction of the electrical panels by wheelchairs indicates a failure to ensure clear access to electrical equipment, which is necessary for safety and compliance with the relevant codes.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the wheelchairs in the second-floor b-wing storage room that were obstructing the electrical panels on 5/1/2025. The Director of Maintenance/designee will conduct random weekly audits throughout the facility two times per week for two weeks then weekly for two weeks to ensure there are no electrical panels obstructed by wheelchairs. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Improper Use of Extension Cord in Maintenance Room
Penalty
Summary
The facility failed to maintain electrical wiring systems and equipment, as evidenced by the use of an electrical extension cord as a fixed power source for a small electric or mechanical pump. This deficiency was observed in the Maintenance/Shop Storage room located in the basement of the facility. The observation was made on April 30, 2025, at 10:35 a.m. During an interview conducted on May 1, 2025, at 11:00 a.m., both the Facility Administrator and the Maintenance Director confirmed the deficiency related to the electrical wiring systems.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. Maintenance removed the electrical extension cord in the Maintenance/Shop Storage room in the basement on 5/2/2025. The Director of Maintenance/designee will conduct random weekly audits in the facility two times per week for two weeks, then weekly for two weeks to ensure there are no extension cords. The results of these audits will be brought to the Quality Assurance and Performance Improvement Committee for further analysis and corrective actions.
Unsafe Dining Room Environment
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment in the A1 dining room, as required by their policy dated February 4, 2024. During an interview with a group of residents, concerns were raised about the condition of the dining room tables, which were described as peeling and rough, posing a risk of skin tears. Observations confirmed that all eight tables in the A1 dining room were peeling and had sharp edges. The Maintenance Director and the Director of Nursing both confirmed the poor condition of the tables, acknowledging that the environment was neither safe nor comfortable for the residents.
Failure to Implement Non-Pharmacological Interventions Before Administering Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the lack of documented non-pharmacological interventions prior to administering Lorazepam. The facility's policy, dated February 4, 2024, mandates the use of non-pharmacological interventions when clinically indicated to reduce the need for psychotropic medication. However, for one resident, there was no evidence that such interventions were attempted before administering Lorazepam on multiple occasions in January and February 2024. The resident in question had cognitive impairment and required assistance with transfers, with diagnoses including dementia and anxiety. Despite a psychiatric evaluation recommending the continuation of positive psychosocial and non-pharmacological approaches, the Medication Administration Records showed repeated administration of Lorazepam without prior attempts at non-pharmacological interventions. The Director of Nursing confirmed the absence of these interventions during an interview, highlighting a failure to adhere to the facility's policy and regulatory requirements.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of medications for a resident and did not label multi-dose containers of insulin with the date they were opened. Specifically, for one resident, the label on their Lantus insulin did not reflect the correct dosage and timing as per the physician's orders. The label indicated 25 units at bedtime, while the resident was administered 20 units in the morning. This discrepancy was confirmed by an LPN during an interview, who acknowledged that a 'Change in Direction' label should have been applied. Additionally, the facility did not adhere to its policy of dating multi-dose vials upon opening. During an inspection of a medication cart, it was observed that insulin vials for several residents were opened but not dated, contrary to the manufacturer's instructions which require vials to be discarded after a specific period. This was confirmed by another LPN and the Director of Nursing, who acknowledged that the vials should have been labeled with the opening and discard dates.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was served under sanitary conditions, as evidenced by a violation of their policy on feeding with dignity. During a lunch meal observation in the A3 unit dining room, a nurse aide was seen handling a resident's food without using gloves or a barrier. Specifically, the nurse aide used his bare hand to place a mechanical soft prepared hamburger onto a bun for a resident, who then consumed the food. This action was in direct violation of the facility's policy, which mandates that staff cleanse hands between residents, avoid touching food with bare hands, and use gloves or barriers when handling food. The nurse aide confirmed the breach of protocol during an interview, and the Corporate Compliance/Certified Registered Nurse Practitioner corroborated the requirement for using gloves or barriers when touching residents' food items.
Failure to Obtain Required Hospice Documentation
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two residents receiving hospice services. Resident 97, who was cognitively impaired and diagnosed with malnutrition, had a care plan indicating hospice services due to a terminal illness. However, as of May 9, 2023, there was no documented evidence of updated hospice nurse aide charting in the resident's clinical record or the hospice provider's clinical record since January 2024. This was confirmed by an interview with the Director of Nursing. Similarly, Resident 228, who was cognitively intact and diagnosed with a cerebrovascular accident, had a care plan for hospice services due to terminal cerebrovascular disease. As of May 9, 2023, there was no documented evidence of updated hospice registered nurse or nurse aide charting in the resident's clinical record or the hospice provider's clinical record since the admission notes dated April 27, 2024. This deficiency was also confirmed by the Director of Nursing.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to effectively address recurring deficiencies identified in multiple surveys. These deficiencies included issues with the accuracy of assessments, tube feeding management, labeling and storage of drugs and biologicals, and infection prevention and control. Despite having developed plans of correction in response to previous surveys, the QAPI committee was unable to maintain compliance with the relevant regulations, as evidenced by the repeated citations in the current survey. The deficiencies were initially identified in surveys conducted on June 13, 2023, August 15, 2023, and August 29, 2023. The facility's plans of correction included monitoring by the QAPI committee to ensure compliance. However, the current survey, ending May 9, 2024, revealed that the QAPI committee was ineffective in addressing these issues, leading to repeated citations under F641, F693, F761, and F880. The facility's inability to correct these deficiencies indicates a failure in the QAPI committee's role in maintaining regulatory compliance.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medication for one resident, identified as Resident 34. The resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain. The physician's orders included Norco for pain management. On a specific date, narcotics were delivered to the B3 nursing unit, and Registered Nurse Supervisor 1 documented the receipt of five narcotic cards. However, during a shift change, it was discovered that only four cards were delivered to the unit, despite five being documented on the accountability form. An investigation revealed that Registered Nurse 2 was the last person in possession of the narcotics card, as confirmed by video footage. The footage showed Registered Nurse 2 entering the medication room alone, and there was no evidence that all five narcotic cards were delivered to the B3 unit. The investigation concluded that misappropriation of Resident 34's medication occurred, as only four cards were documented and delivered, leading to the determination that one card was missing.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan of Resident 66 to reflect changes in her care needs. The resident's Medication Administration Record for May 2024 showed that she was receiving medications at 6:00 a.m., despite her care plan from January 21, 2020, indicating a preference for no medications or care before 7:00 a.m. An interview with Resident 66 on May 6, 2024, revealed that she had switched to early dialysis and did not mind receiving medications early, but her care plan was not updated to reflect this change. The Director of Nursing confirmed on May 9, 2024, that the care plan was outdated and should have been revised to accommodate the resident's new preferences.
Failure to Provide Weekly Showers Due to COVID-19
Penalty
Summary
The facility failed to ensure that a resident was provided with weekly showers, as required by their policy. The policy, dated February 4, 2024, stated that residents should be offered a shower at least once a week. An annual Minimum Data Set (MDS) assessment for the resident, dated April 26, 2024, indicated that the resident was alert and oriented, and it was important for them to choose their preferred method of bathing. The resident's care plan, dated July 7, 2023, specified that they were to receive a shower in the morning. However, the resident's bathing records for April 2024 showed that they did not receive a weekly shower on April 5 and 12, instead receiving a bed bath. This was confirmed by the Director of Nursing, who stated that the resident was not showered on those dates due to testing positive for COVID-19.
Failure to Follow Feeding Tube Labeling Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the management of feeding tubes for one resident, identified as Resident 159. The policy, dated February 4, 2024, mandates that the formula and tubing used for feeding tubes must be labeled with the date and time they were started and should not be used for more than 24 hours. However, during an observation on May 8, 2024, it was noted that the bag of Isosource 1.5 formula being used for Resident 159 did not have the required date and time label. This was confirmed by a Registered Nurse at the time of observation. Resident 159, who is cognitively impaired and requires staff assistance, has a feeding tube for nutrition due to diagnoses including stroke and dementia. The resident's care plan and physician's orders specify the administration of Isosource 1.5 at a rate of 38 mL/hr for 21 hours. Despite these orders being followed as per the Medication Administration Record for May 2024, the lack of proper labeling on the feeding bag represents a failure to comply with the facility's established procedures. The Director of Nursing confirmed that staff are responsible for ensuring that feeding tube labels contain the necessary information.
Infection Control Deficiencies in Hand Hygiene and Linen Handling
Penalty
Summary
The facility failed to ensure proper hand hygiene during wound care for a resident with multiple ulcers and infections. During an observation, two nurses were seen performing wound care on a resident with a Stage 3 and Stage 4 pressure ulcer on the right great toe and a venous ulcer on the right lower leg. Despite the facility's policy requiring hand washing and glove changes at specific intervals during wound care, the nurses did not wash their hands after removing soiled gloves and before applying clean ones. This lapse occurred multiple times during the treatment process, including between handling soiled and clean dressings and between treating different wound sites. Additionally, the facility did not adhere to proper infection control practices while handling soiled linens. A nurse aide was observed throwing a soiled towel and washcloth on the floor during a bed bath for another resident who required extensive assistance with daily care. The facility's protocol dictates that soiled linens should be placed in bags and taken to the dirty utility room, which was not followed in this instance. Interviews with the involved staff and the Director of Nursing confirmed the failure to follow hand hygiene protocols during wound care. Similarly, the Clinical Coordinator confirmed that the handling of soiled linens did not comply with the facility's infection control practices. These deficiencies highlight lapses in adherence to established infection prevention and control measures, as outlined in the facility's policies.
Failure to Notify Responsible Parties and Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to provide written notification of emergency hospital transfers to the responsible parties and the State Ombudsman for three residents. Resident 63, who had end-stage renal disease and required hemodialysis, was transferred to the hospital after a traumatic removal of her dialysis catheter led to uncontrollable bleeding. There was no documented evidence that a written notice of this transfer was provided to the resident's responsible party or the State Ombudsman. Similarly, Resident 82, who had cognitive impairment and dementia, was transferred to the hospital following a fall that resulted in shoulder pain. Additionally, Resident 118, who was nonverbal and had Huntington's disease, was transferred due to hypoxemia and a possible ileus. In both cases, there was no documented evidence of written notification to the responsible parties or the State Ombudsman. The Nursing Home Administrator confirmed the lack of notification and was unaware of the requirement for written notices in such situations.
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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