Whitehall Borough Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pittsburgh, Pennsylvania.
- Location
- 505 Weyman Road, Pittsburgh, Pennsylvania 15236
- CMS Provider Number
- 396066
- Inspections on file
- 35
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Whitehall Borough Post Acute during CMS and state inspections, most recent first.
A resident with a history of COPD, muscle weakness, and recent joint replacement surgery, who required supervision for eating, was served hot soup without adequate supervision despite showing confusion and tremors. The resident spilled the soup and sustained a burn to the thigh. Staff and clinical records confirmed the lack of increased supervision during meals despite the resident's declining condition.
The facility did not provide required written bed-hold policy notifications to residents or their representatives at the time of hospital transfer for four individuals with significant medical needs, and failed to notify the State Ombudsman Office of resident transfers and discharges over a two-year period, as confirmed by record review and staff interviews.
Two residents had inaccurate MDS assessments: one was incorrectly coded with a psychotic disorder diagnosis, and another's assessment failed to reflect ongoing hospice services, despite medical records and staff confirmation of these errors.
Surveyors identified that medications and medical supplies, including vials of Aplisol, cyanocobalamin, gabapentin, vacutainers, IV start kits, and nourishment shakes, were found expired, undated, or improperly stored in two medication rooms and two medication carts. Staff confirmed that facility policies for labeling, storage, and timely disposal were not followed, and facility leadership acknowledged the deficiencies.
A resident with severe cognitive impairment was transferred to the hospital without timely notification to her designated representatives, as required by facility policy. Documentation was incomplete or inaccurate, and staff confirmed that the appropriate emergency contacts were not informed of the change in condition or transfer.
A resident with severe cognitive impairment and high ADL needs did not receive appropriate skin assessments as required by care plans and physician orders. Staff failed to complete daily and weekly skin checks, resulting in wounds going unnoticed until a family member reported them. Facility leadership confirmed that these wounds should have been identified by staff during routine care.
A medication cart on the second floor for rooms 220-231 was found unlocked and unattended, contrary to the facility's policy requiring medication storage to be secured when not in use. The unsecured cart was confirmed by an LPN and an RN, and the issue was acknowledged by the Nursing Home Administrator and the DON.
The facility failed to meet the required staffing levels for nurse aides on multiple occasions, with insufficient coverage during daylight, evening, and night shifts. This was confirmed through staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing.
The facility failed to secure medications properly, with an unlocked refrigerator containing influenza vaccines accessible to visitors and an unattended medication cart with an open computer screen. Staff confirmed these security lapses, indicating a breach in the facility's medication storage policy.
The facility failed to assess the clinical appropriateness of medication self-administration for two residents. One resident with COPD had a Trelegy inhaler without proper documentation, while another resident, legally blind in one eye, had eye medications on her nightstand without a self-administration assessment. An LPN confirmed the medications were left at the bedside, and the DON acknowledged the oversight.
A resident with a history of high blood pressure, shoulder dislocation, and diabetes fell while being assisted in the bathroom, resulting in head and shoulder injuries. The facility did not complete witness statements or fully investigate the incident to rule out abuse or neglect, as confirmed by the DON, violating facility policies.
The facility failed to properly store and dispose of medications in three medication carts, with observations revealing opened, partially used, and undated medications, including eye drops and insulin pens. Interviews with RNs showed a lack of knowledge regarding disposal times for insulin, and the Nursing Home Administrator and DON confirmed the facility's failure to comply with state regulations.
The facility was found to have insufficient nursing staff, affecting the care of several residents. Observations and interviews revealed delayed responses to call lights and inadequate assistance with ADLs, such as hygiene care. Residents reported staffing shortages, and the facility's administration confirmed the deficiency, failing to meet the required standards for resident well-being.
Two residents were involuntarily secluded in a locked dining room without supervision, violating their rights. One resident, with severe cognitive impairment, was confined in a wheelchair under a table, while the other, with moderate impairment, was similarly restricted. Staff interviews revealed a lack of understanding of the residents' needs and facility policies, leading to their isolation due to perceived fall risks and disruptive behavior.
Two residents in a memory care unit were found restrained by being pushed against a table with a wheelchair blocking their exit, preventing movement. Both residents had cognitive impairments and were at risk for falls. Staff interviews revealed a lack of awareness regarding the use of restraints, with the DON not recognizing the setup as a restraint.
The facility failed to protect two residents from staff-initiated verbal abuse. One resident was disparaged by an RN when requesting extra food, while another received an offensive remark from an NA after reporting a dietary issue. Both incidents were confirmed by the Nursing Home Administrator and Director of Nursing.
The facility failed to provide scheduled showers for four residents due to understaffing. Residents reported missing multiple showers, and nursing assistants confirmed they were unable to complete their tasks because of insufficient staff. The Director of Nursing acknowledged the failure to adhere to the shower schedule.
The facility failed to provide sufficient nursing staff, resulting in inadequate care for several residents, including missed showers and delayed call light responses. Staff and residents confirmed the facility was consistently understaffed, impacting the quality of care provided.
The facility failed to complete comprehensive MDS assessments within the required time frame for 12 residents. The assessments were overdue, with some not completed by the survey's end. The RNAC and Nursing Home Administrator confirmed the delay was due to insufficient staffing.
The facility failed to establish baseline care plans within 48 hours for three residents with various medical conditions, including fractures, high blood pressure, dementia, and constipation. Despite assessments and ongoing medical needs, the care plans did not adequately address these issues in the required timeframe, as confirmed by the DON.
The facility failed to provide prescribed treatment and services for a resident at high risk for pressure ulcers. Despite the care plan indicating the need for a positioning wedge and offloading heels, these measures were not implemented, leading to the resident's deteriorating skin condition. The resident reported not being repositioned every two hours and experiencing soreness, which was not communicated to the wound care nurse practitioner.
The facility failed to transmit MDS assessments within the mandated time frame for a resident. The RAI User's Manual requires MDS assessments to be completed and transmitted within 14 days of the event date. A resident's Discharge/Return Anticipated MDS was due but completed six days late due to insufficient staff, as confirmed by the RNAC and Nursing Home Administrator.
The facility failed to provide mandatory QAPI training for four staff members, including three Nurse Aides and an LPN, as required by their policy. The training records showed that these employees did not receive the necessary QAPI education within the specified annual timeframe, which was confirmed by the Nursing Home Administrator.
The facility did not meet the requirement of providing 12 hours of in-service education within 12 months for two nurse aides. Despite the policy mandating annual completion of in-service training, Employees E2 and E3 only completed 9:05 hours each. This was confirmed by the Nursing Home Administrator.
The facility failed to comply with state-mandated staffing requirements, not providing the required number of nurse aides per resident during various shifts and failing to meet the minimum general nursing care hours per resident. This was confirmed by the Nursing Home Administrator and the DON.
Failure to Provide Adequate Supervision During Meals Resulting in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent injury for a resident who required assistance during meals. The resident, who had diagnoses including COPD, muscle weakness, and was recovering from joint replacement surgery, was assessed as needing supervision for eating. Clinical documentation indicated that the resident experienced confusion, lethargy, tremors, and was below her baseline prior to the incident. Despite these symptoms, the care plan did not specify the required assistance level during meals, and the resident was served a hot soup meal without additional supervision. As a result, the resident spilled hot soup onto her lap, causing a burn to her thigh. Staff interviews confirmed that the resident had been exhibiting symptoms such as confusion and tremors before the incident, but no increased supervision was provided at the time the hot soup was served. The deficiency was identified through review of clinical records, progress notes, and staff interviews, which documented the resident's condition and the lack of appropriate supervision during meals.
Failure to Provide Bed-Hold Policy Notification and Notify Ombudsman of Transfers
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and/or their representatives at the time of transfer for four out of six residents reviewed who were hospitalized. Federal regulations require that residents receive two notices regarding bed-hold policies: one at admission and another at the time of transfer, or within 24 hours in the case of emergency transfers. Documentation for Residents R6, R89, R123, and R138 did not include evidence that this written notification was given at the time of their respective transfers to the hospital, despite clinical records showing that these residents experienced significant medical events such as falls, cognitive impairment, and acute illness leading to hospitalization. Additionally, the facility failed to notify the State Ombudsman Office of resident transfers and discharges over a period spanning from November 2023 through April 2025. This omission was confirmed by both a review of facility documentation and information provided by the State Ombudsman Office, which indicated that no notifications had been received during this time frame. The facility's own policy, as well as federal and state regulations, require timely notification to the Ombudsman Office regarding such resident movements. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these failures, acknowledging that written bed-hold notifications were not provided to the affected residents or their representatives at the time of transfer, and that required notifications to the State Ombudsman Office were not made for an extended period. The deficiencies were identified through review of facility policies, clinical records, and staff interviews.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, the MDS assessment incorrectly listed a diagnosis of psychotic disorder, despite clinical records and a psychiatric evaluation indicating diagnoses of adjustment disorder and unspecified dementia with behavioral disturbances, but no psychotic disorder. The Assistant Director of Nursing confirmed that the MDS was coded inaccurately for this resident. For another resident, the MDS assessment failed to indicate that the resident was receiving hospice services, even though physician orders and medical records showed that hospice care was provided continuously during the assessment period. The Assistant Director of Nursing confirmed that the MDS assessment was completed inaccurately regarding hospice services. The Nursing Home Administrator acknowledged that the facility did not ensure the accuracy of MDS assessments for these two residents.
Failure to Properly Store, Label, and Dispose of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored, labeled, and disposed of in accordance with professional standards and facility policy. During observations in two of three medication rooms and two of five medication carts, surveyors found multiple instances of expired or undated medications and medical supplies. Specifically, vials of Aplisol and cyanocobalamin were found open and undated, and a bottle of liquid gabapentin was also open and undated. Numerous vacutainers, IV start kits, IV catheters, and a Huber infusion set were found with expired dates. Staff interviews confirmed that these items were either expired or not properly labeled as required by policy. Additionally, on two medication carts, containers of MedPlus Vanilla nourishment shake were not handled according to policy. One container was unopened but not labeled with the date it was opened, while another was opened, partially used, and still present on the cart beyond the 24-hour usage window specified by facility policy. Staff interviews further confirmed that the required procedures for labeling and disposing of these items were not followed. The Nursing Home Administrator and Assistant Director of Nursing acknowledged that expired and undated medications and supplies were not properly stored or disposed of in the affected medication rooms and carts.
Failure to Notify Resident Representatives of Hospital Transfer
Penalty
Summary
The facility failed to notify the designated resident representatives of a significant change in condition and subsequent transfer to the hospital for one resident. According to facility policy, notification of a resident's family or representative is required as soon as possible, and no later than 24 hours after a significant change is identified. In this case, the clinical record for a resident with Alzheimer's disease and severe cognitive impairment (unable to complete the BIMS interview) showed that the resident required a proxy for decision-making. The resident's son, daughter-in-law, and another son were listed as emergency contacts and representatives. Documentation review revealed that the Change in Condition Evaluation form was left blank, and the Transfer to Hospital form incorrectly indicated that the resident herself was the representative notified. Progress notes only documented that the son was informed after the resident had already been admitted to the hospital, with no evidence that emergency contacts were notified at the time of the change in condition or transfer. The Nursing Home Administrator and DON confirmed that the required notifications were not made for this resident.
Failure to Observe and Report Resident Wounds During Routine Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with significant cognitive impairment and multiple diagnoses, including dementia, muscle weakness, and a seizure disorder. The resident was assessed as unable to complete the Brief Interview for Mental Status (BIMS) and required substantial to maximal assistance with activities of daily living (ADLs) such as bathing, dressing, and personal hygiene. The resident's care plan required daily skin observation during ADL care and reporting of any abnormalities, and weekly skin checks were ordered to be completed with showers. However, documentation revealed that the skin observation tool was not completed at all during March, and weekly skin checks were not properly documented. Progress notes did not indicate that wounds on the resident's ankles were identified or reported between 5/19/25 and 5/23/25. A wound was only discovered after the resident's daughter informed nursing staff of wounds on the resident's right outer ankle and left leg, which were found to be old, dry, and scabbed. The nurse agreed with the daughter that the wounds were not new. Later, a new skin tear was discovered by a nurse during scheduled wound care, with evidence suggesting it was caused by wheelchair foot pedals. The resident was unable to explain how the injury occurred. Facility leadership confirmed that the wounds should have been observed during routine care and that it was inappropriate for family members to be the first to notice the wounds.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medications were properly secured in one of its medication carts, specifically the second-floor cart for rooms 220-231. According to the facility's policy on Medication Storage, medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized personnel. However, during an observation, the medication cart was found unlocked and unattended. The surveyor was able to open the drawers and review the medication cards, confirming the lack of security. LPN Employee E2 and RN Employee E1 later confirmed the cart was unsecured. The Nursing Home Administrator and the Director of Nursing acknowledged the failure to secure the medications properly.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between January 8, 2025, and January 20, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the daylight shift on 10 out of 13 days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on nine days. This deficiency was confirmed through a review of staffing documents and an interview with the Nursing Home Administrator, who acknowledged the shortfall in staffing on the specified shifts. The report details the specific dates and the discrepancy between actual and required staffing hours, highlighting the facility's failure to comply with the staffing regulation effective July 1, 2024.
Plan Of Correction
There were no adverse effects to the residents of our facility as a result of decreased nursing assistant staffing ratios for the days noted. Education will be provided by the Director of Nursing or designee to the scheduler and nursing supervisors on all shifts regarding the updated facility protocol and duties for filling call-offs and agency shift cancellations if nursing staff ratios drop below state minimum. The facility increased nurse aide hourly rates to recruit house staff, continues to focus on recruitment daily, and uses PRN agency staff to supplement open shifts. Staffing meetings will be held 5 days per week to review nursing assistant ratios for all shifts of the current and next day. Audits of nursing assistant ratios will be completed by the Nursing Home Administrator or designee weekly for 6 weeks to ensure the facility meets the state minimum staffing ratios. Results of the audits will be forwarded to our QAPI committee for review and recommendations.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to properly secure medications in two separate instances, leading to a deficiency. During an observation, an unlocked medication refrigerator was found in the Family Conference room, which was accessible to visitors, family, and residents. This refrigerator contained several vials and boxes of influenza vaccines, both opened and unopened. The Front Desk Employee confirmed that the room was never locked and accessible at all times, while the Nursing Home Administrator acknowledged that the medications should not have been stored there and was unable to locate the key to secure the refrigerator. Additionally, a medication cart was observed to be unsecured and unattended, with the computer screen open and accessible to residents, family, and visitors. A Registered Nurse confirmed that the cart was left in this state, and the Director of Nursing acknowledged the failure to properly secure medications in the cart. These observations and interviews indicate a breach in the facility's policy on medication labeling and storage, which requires all medications and biologicals to be stored in locked compartments when not in use.
Failure to Assess Medication Self-Administration
Penalty
Summary
The facility failed to assess the clinical appropriateness of medication self-administration for two residents, leading to a deficiency. Resident R1, who was admitted with diagnoses including high blood pressure, muscle weakness, and COPD, was observed with a Trelegy inhaler on her over-the-bed table. However, her clinical record lacked a physician's order for self-administration, a self-administration assessment, or care planning for self-administration of medications. Similarly, Resident R2, admitted with diagnoses including diabetes, muscle weakness, and high blood pressure, was found with Latanoprost eye drops and Muro 5% eye medication on her nightstand. Despite being legally blind in one eye and unable to correctly use the eye drops, her clinical record also lacked the necessary documentation for self-administration. During interviews, an LPN confirmed that medications were left at the bedside without proper assessment or documentation, and the Director of Nursing acknowledged the facility's failure to assess the clinical appropriateness of medication self-administration for these residents. This oversight was in violation of the facility's policy, which requires an interdisciplinary team to determine the safety and appropriateness of self-administration, with documentation in the medical record and care plan.
Failure to Investigate Resident Fall Incident
Penalty
Summary
The facility failed to fully investigate an incident involving a resident, identified as Resident R3, which led to a deficiency. Resident R3, who had diagnoses including high blood pressure, dislocation of the right shoulder joint, and diabetes, was admitted to the facility. On November 27, 2024, Resident R3 fell while being assisted by one staff member in the bathroom, resulting in a head and right shoulder injury. The resident was sent to the local emergency room for evaluation. However, the facility did not complete witness statements or conduct a full investigation to rule out abuse or neglect, as confirmed by the Director of Nursing during an interview on December 12, 2024. This lack of investigation was in violation of the facility's policies on abuse prohibition and accident/incident investigation and reporting.
Improper Storage and Disposal of Medications
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications in three medication carts, specifically on Medbridge B-hall, Medbridge A-hall, and TCU-1. Observations revealed multiple instances of opened, partially used, and undated medications, including eye drops and insulin injection pens. These medications were not stored separately from other medications as required by the facility's policy on Storage and Expiration Dating of Medications, Biologicals. The policy mandates that expired or improperly stored medications should be separated until they are destroyed or returned to the pharmacy. Interviews with registered nurses (RNs) confirmed a lack of knowledge regarding the appropriate disposal times for insulin after opening, with one RN incorrectly stating a two-week period and another admitting to not knowing the correct timeframe. The Nursing Home Administrator and the Director of Nursing acknowledged the facility's failure to dispose of out-of-date medications in the medication carts, as required by state regulations. This deficiency was identified through a review of facility policy, observations, and staff interviews.
Insufficient Nursing Staff Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by observations, interviews, and grievance reviews. Seven out of twelve residents reported or were observed to experience inadequate care due to staffing shortages. Residents expressed concerns about delayed responses to call lights and insufficient assistance with activities of daily living (ADLs), such as hygiene care. Specific observations included a resident with untrimmed facial hair and another with unkempt hair, indicating a lack of timely personal care. Interviews with residents revealed a consistent perception of inadequate staffing, with some residents explicitly stating that the facility needed more aides. The Nursing Home Administrator and the Director of Nursing confirmed the deficiency, acknowledging the facility's failure to provide sufficient nursing and related services to ensure the highest practicable physical, mental, and psychosocial well-being of the affected residents. The report cites specific Pennsylvania Code regulations related to the responsibility of the licensee, management, staff development, and nursing services, underscoring the facility's non-compliance with these standards.
Failure to Prevent Involuntary Seclusion of Residents
Penalty
Summary
The facility failed to prevent involuntary seclusion for two residents, identified as R1 and R2, as revealed through clinical record reviews, observations, and interviews. The facility's policy prohibits involuntary seclusion, which is defined as the separation of a resident from others or confinement to their room against their will. On the day of observation, both residents were found in the locked Memory Care Unit's dining room, isolated from other residents and without staff supervision. Resident R1 was confined in her wheelchair, pushed under a table, and unable to move, while Resident R2 was similarly restricted, backed against a locked exit door with a table pushed against her. Resident R1, who has diagnoses including dementia, anxiety, and depression, was admitted to the facility with a BIMS score indicating severe cognitive impairment. Her care plan emphasized socialization and participation in group activities, yet she was found isolated and unable to move freely. Resident R2, with diagnoses of high blood pressure, cognitive communication deficit, and depression, had a BIMS score indicating moderate cognitive impairment. Her care plan highlighted the need for frequent repositioning and assistance with toileting, yet she was similarly isolated and restricted in movement. Interviews with staff revealed a lack of awareness and understanding of the residents' needs and the facility's policies. A registered nurse unfamiliar with the unit speculated that the residents were isolated to prevent falls, while a unit manager and a nurse aide indicated that the residents were placed in the dining room due to their disruptive behavior and fall risk. This lack of appropriate supervision and understanding of resident rights led to the involuntary seclusion of Residents R1 and R2, violating their rights to a dignified existence and freedom from involuntary seclusion.
Failure to Prevent Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident R1 and Resident R2, were free from physical restraints. During an observation, both residents were found in the locked Memory Care Unit sitting in their wheelchairs at a table in the dining room. The table was positioned in such a way that it prevented the residents from moving freely, with a wheelchair blocking the side exit and the table pushed against the wall. This setup restricted the residents' freedom of movement, effectively acting as a physical restraint. Resident R1, who has diagnoses including dementia, anxiety, and depression, was observed facing a locked door with her wheelchair pushed under the table, preventing her from moving. Her care plan indicated a need for socialization and frequent repositioning to ensure comfort, as well as a risk for falls. Resident R2, with diagnoses including high blood pressure and cognitive communication deficit, was observed backed up against the locked exit door with the table pushed against her, also preventing movement. Her care plan similarly noted a risk for falls and the need for assistance with repositioning and toileting. Interviews with facility staff revealed a lack of awareness and understanding regarding the use of physical restraints. A registered nurse and a unit manager were unsure why the residents were in the dining room alone, while a nurse aide mentioned that the residents were placed there to prevent disturbances and potential falls. The Director of Nursing acknowledged seeing the wheelchair blocking the residents but did not recognize it as a restraint. This indicates a failure in staff training and awareness regarding the facility's policies on physical restraints and resident rights.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from staff-initiated verbal abuse for two of nine residents. Resident R74, who was readmitted with diagnoses including Acute Kidney Injury, gastroesophageal reflux disease, small b-cell lymphoma, and high blood pressure, reported that a Registered Nurse (RN) made a disparaging comment when she asked for a second sandwich. The resident did not report the incident due to fear of retribution or being denied extra food in the future. The facility's policy on abuse prohibition clearly defines verbal abuse and prohibits such behavior, but this policy was not adhered to in this instance. Resident R156, admitted with diagnoses including embolism of the left lower leg, muscle weakness, and depression, experienced verbal abuse from a Nursing Assistant (NA) when she reported receiving pork on her breakfast tray despite her dietary restrictions. The NA responded with an inappropriate and offensive remark before eventually ordering a new tray. Both incidents were confirmed during a group interview with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to ensure residents were free from verbal abuse and neglect.
Failure to Provide Scheduled Showers Due to Understaffing
Penalty
Summary
The facility failed to consistently provide showers for four residents, as required by their care plans. Resident R74, who has kidney failure, neurocognitive disorder, diabetes, and obesity, reported receiving only one shower a week or sometimes none at all, despite being scheduled for showers every Wednesday and Saturday. Documentation showed that Resident R74 missed multiple scheduled showers in April and May without any recorded reasons. Similarly, Resident R85, who has Alzheimer's disease and is totally dependent on two staff members for bathing, did not receive any showers in April, and the clinical record did not indicate reasons for these missed opportunities. Resident R124, with a left lower leg fracture and diabetes, also missed several scheduled showers in April and May, and Resident R328, with multiple rib fractures and muscle weakness, only received bed baths instead of the scheduled showers. Interviews with the residents, their family members, and nursing assistants revealed that the primary reason for the missed showers was a lack of sufficient staff. Nursing assistants consistently reported being unable to complete their assigned showers due to understaffing. The Director of Nursing confirmed that the facility failed to provide the scheduled showers for the affected residents. The facility's failure to adhere to its shower schedule and provide necessary hygiene care as outlined in the residents' care plans constitutes a deficiency in nursing services and resident care planning.
Inadequate Staffing Leads to Missed Showers and Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care for nine of 32 residents and four of nine group residents. The deficiency was identified through a review of facility policies, resident observations, interviews with residents and staff, and resident care records. Specific issues included missed showers, delayed call light responses, and insufficient assistance with activities of daily living (ADLs). For example, Resident R74 did not receive scheduled showers on multiple occasions, and Resident R128 was left in a soiled brief for an entire day due to a lack of staff to assist with repositioning and hygiene care. Interviews with staff members, including registered nurses and nursing assistants, confirmed that the facility was consistently understaffed, leading to missed showers and delayed responses to call lights. Residents and their family members also reported similar concerns, with some residents stating they had to wait up to three hours for call lights to be answered. The facility's shower schedule and Point of Care-Bathing documentation further corroborated these findings, showing multiple missed opportunities for scheduled showers without documented reasons. The facility's Medical Director and Director of Nursing acknowledged the staffing issues and their impact on resident care. The Medical Director confirmed that call light response times were a concern, and the Director of Nursing admitted that the facility failed to consistently provide showers for several residents. Additionally, the Registered Nurse Assessment Coordinator noted that approximately 20 Minimum Data Set assessments were overdue due to insufficient staffing. These findings indicate a systemic issue with staffing levels, directly affecting the quality of care provided to residents.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for 12 out of 16 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not meet these requirements for several residents, with some assessments being overdue by several days as of the end of the survey. The deficiency was confirmed during interviews with the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator, who acknowledged that the assessments were not completed on time due to insufficient staffing. This failure to adhere to the required assessment schedule was documented for residents with specific due dates that were missed, highlighting a systemic issue in the facility's ability to manage timely assessments as mandated by the regulations.
Failure to Establish Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to establish a baseline care plan within 48 hours of admission or readmission for three residents, as required by their policy. Resident R61 was admitted with multiple diagnoses, including a fracture of the left femur, high blood pressure, repeated falls, dementia, and chronic kidney disease. Despite these conditions, the care plan did not include a baseline plan for incontinence within the required timeframe. Similarly, Resident R72, admitted with high blood pressure, a fracture of the right humerus, and constipation, did not have a baseline care plan for constipation care established within 48 hours. The resident was on multiple medications for chronic constipation, yet the care plan failed to address this need promptly. Resident R324 was admitted with high blood pressure, a fracture of the left tibia, and seizures. Although the resident was assessed daily for various medical diagnoses, including pain, movement, dysphagia, anticoagulants, constipation, seizures, and falls, an adequate baseline care plan for these issues was not developed within the 48-hour timeframe. The Director of Nursing confirmed that baseline care plans reflecting the residents' current statuses were not initiated within the required period for these residents.
Failure to Provide Prescribed Pressure Ulcer Care
Penalty
Summary
The facility failed to provide prescribed treatment and services related to the care of pressure ulcers for Resident R128. The resident, who was admitted with a history of stroke, hemiplegia, and required substantial assistance with personal care, was identified as being at high risk for pressure ulcer development. Despite the care plan and wound nurse practitioner's report indicating the need for interventions such as the use of a positioning wedge and offloading heels, these measures were not implemented. Observations over several days revealed that the resident was consistently lying flat on her back without the positioning wedge in place and her heels not elevated, leading to reddened and overly soft heels, and bruising on the right heel. The resident also reported not being repositioned every two hours as required and experiencing soreness in her heels and toes, which was not communicated to the wound care nurse practitioner by the nursing staff. The clinical record review and staff interviews confirmed that the facility's failure to follow prescribed treatments and services contributed to the resident's deteriorating skin condition. The facility's policy on skin integrity and wound management was not adhered to, as evidenced by the lack of physician orders for necessary interventions and the absence of these directives in the nurse aide staff's Kardex. The Nursing Home Administrator acknowledged the deficiency, confirming that the facility did not provide the required care for the resident's pressure ulcers.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments to the required electronic system within the mandated time frame for one of the 16 residents reviewed. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, MDS assessments, including Entry, Death, and Facility and Discharge tracking, must be completed and transmitted within 14 days of the event date. Resident R20, who had a discharge date, was required to have a Discharge/Return Anticipated MDS completed by 5/1/24, but it was not completed until 5/7/24, six days late. During interviews, the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator confirmed the delay, attributing it to a lack of sufficient staff.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on Quality Assurance and Performance Improvement (QAPI) for four out of ten staff members, specifically Employees E2, E3, E4, and E5. According to the facility's policy on in-service training, all mandatory training, including QAPI, must be completed annually as a condition of continued employment. However, a review of the training records revealed that these employees did not have documented QAPI training within the required timeframe. Employee E2, a Nurse Aide, was hired on 2/26/07 and did not receive QAPI training between 2/26/23 and 2/26/24. Similarly, Employee E3, another Nurse Aide hired on 3/23/09, Employee E4, a Nurse Aide hired on 1/3/18, and Employee E5, a Licensed Practical Nurse hired on 2/24/19, also lacked QAPI training within their respective annual periods. The Nursing Home Administrator confirmed this deficiency during an interview.
Deficiency in In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to provide the required 12 hours of in-service education within 12 months of the hire date anniversary for two nurse aides, Employees E2 and E3. According to the facility's policy on in-service training, all mandatory in-service requirements must be completed annually as a condition of continued employment, ensuring continuing competence for no less than 12 hours per year for nurse aides. However, a review of the education records revealed that NA Employee E2, hired on 2/26/07, completed only 9:05 hours of in-service education between 2/26/23 and 2/26/24. Similarly, NA Employee E3, hired on 3/23/09, also completed only 9:05 hours of in-service education between 3/23/23 and 3/23/24. This deficiency was confirmed during an interview with the Nursing Home Administrator.
Non-Compliance with Staffing Requirements
Penalty
Summary
The facility was found to be non-compliant with state laws regarding mandated minimum staffing requirements for nursing staff. Specifically, the facility failed to provide the required minimum number of nurse aides per resident during various shifts. The regulations stipulate that there should be at least one nurse aide per twelve residents during the day and evening, and one nurse aide per twenty residents overnight. However, multiple surveys conducted between July 2023 and April 2024 revealed consistent failures to meet these staffing ratios on numerous days across different months. Additionally, the facility did not meet the required minimum number of general nursing care hours per resident in a 24-hour period. The regulations require a minimum of 2.87 hours of direct resident care per resident per day. Surveys indicated that the facility failed to provide these minimum hours on several occasions. During an interview on April 8, 2024, the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to ensure sufficient nursing staff to comply with the mandated staffing requirements.
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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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