Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Whitehall Borough Post Acute during CMS and state inspections, most recent first.
Failure to Notify Providers and Recheck Out-of-Range Blood Glucose Values Multiple residents with diabetes had repeated CBG readings outside ordered parameters without documented provider notification, hypoglycemia protocol follow-up, or timely rechecks. Records showed both low and high glucose values, including readings below 70 mg/dL and above ordered call thresholds, with notes often limited to snacks given or insulin held. Staff interviews confirmed that nursing staff were expected to notify the MD, follow hypoglycemia protocol, and document interventions and rechecks when values were out of range.
Unsafe and Unkempt Resident Room Conditions: The facility failed to maintain a safe, clean, comfortable, and homelike environment on two nursing units. Observations found peeling wallpaper in multiple resident rooms, a large ceiling stain, a hole in a wall, and deep scratches with black marks and chipped drywall in two other rooms. The NHA and DON confirmed the room conditions.
Failure to Apply ACE Wraps per Physician Orders: Nursing staff did not consistently apply ACE wraps as ordered for multiple residents with conditions such as lymphedema, edema, HF, HTN, COPD, and kidney disease. Observations showed wraps missing, loosely applied, started at the ankle instead of the toes, or applied in an incorrect pattern; in one case, a resident reported the wraps had been left on since the prior morning and removal revealed a tourniquet effect with a deep ankle indentation and painful, swollen feet. The ADON confirmed the orders were not followed and the wraps were not applied appropriately.
The NHA and DON failed to effectively manage the facility to ensure provider notification of resident changes in condition. Review of clinical records and staff interviews found that physicians or other APPs were not notified when capillary blood glucose levels were outside ordered parameters for seven residents. The report states this administrative failure resulted in immediate jeopardy.
Incomplete and inaccurate clinical records were found for three residents. One resident had podiatry follow-up and another used oxygen frequently, but neither had the related physician order documented in the EHR. A third resident had a sacral wound with Therahoney and Border gauze noted, but there was no physician order or treatment record documentation showing the care was completed; the DON and wound care nurse confirmed the record gaps.
QAPI failed to show an effective response to repeated blood sugar notification deficiencies for seven residents with DM. Multiple episodes of high or low blood glucose were documented for several residents without evidence that the medical provider was notified. Although the facility had a QAPI monitoring plan, surveyors were not provided audit results or documentation showing the plan was re-evaluated for effectiveness, and the NHA and DON confirmed the committee did not make a good faith attempt to correct the deficiency.
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 Notify Providers and Recheck Out-of-Range Blood Glucose Values
Penalty
Summary
The facility failed to notify physicians of elevated and decreased capillary blood glucose (CBG) values and failed to assess residents for hyperglycemia and hypoglycemia for 7 of 36 residents. The deficiency was identified through review of facility policies, manufacturer instructions, clinical records, and staff interviews, and was cited as Immediate Jeopardy under 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. Resident R3 had diagnoses of diabetes and dementia and had physician orders for Humalog with sliding scale coverage and instructions to follow the hypoglycemic protocol if blood glucose was below 70 mg/dL and to call the MD if over 380 mg/dL. The resident’s blood sugar record showed multiple low and high readings without documentation of notification, follow-up, or recheck, including values such as 56, 41, 64, 49, 57, 50, 434, 58, 60, 67, 385, 68, 402, 401, 411, 47, 58, 51, and 464 mg/dL. Several entries noted that snacks were given or insulin was held, but there was no documented recheck or provider notification. Resident R17 had diagnoses of diabetes and COPD and orders directing staff to follow the hypoglycemic protocol for blood glucose below 70 mg/dL and to notify the provider if over 450 mg/dL. The blood sugar record showed repeated low readings, including 69, 68, 67, 64, 61, 57, 55, 48, and 64 mg/dL, as well as no documentation of notification or recheck. Resident R64 had diabetes and heart failure and orders to treat hypoglycemia and notify the MD if blood glucose was below 70 mg/dL, and to notify the MD if above 341 mg/dL or above 400 mg/dL after a later order change. The record showed high readings of 412, 402, and 437 mg/dL and low readings of 64 and 66 mg/dL without documented notification or follow-up, except one note about refusal of insulin. Resident R84 had diabetes and multiple sclerosis and orders to follow the hypoglycemic protocol if below 70 mg/dL and notify the provider if over 380 mg/dL. The record showed a 64 mg/dL reading with a note that the resident was asymptomatic and to recheck 2.5 hours later, and a 60 mg/dL reading with no documented notification or recheck. Resident R116 had diabetes and heart failure and orders to follow the hypoglycemic protocol if below 70 mg/dL and notify the provider if over 340 mg/dL; the record showed 67 mg/dL readings with no documented notification or recheck. Resident R145 had diabetes and osteomyelitis and orders to notify the provider if blood sugar was below 70 or over 380 mg/dL; the record showed multiple low readings, including 69, 64, 61, and 62 mg/dL, with no documented notification or recheck except one entry stating the provider was notified. Resident R148 had diabetes and hemiplegia and orders with sliding scale insulin and unclear directions for hypoglycemia protocol and MD notification; the record showed high readings of 404, 358, 427, 381, and 377 mg/dL without documented notification or recheck.
Unsafe and Unkempt Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two of four nursing units, including TCU 1st floor and ARU1. Review of the facility policy on Homelike Environment, dated 1/6/26, stated that staff and management are to maximize, to the extent possible, characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment. Observations on 5/4/26 and 5/7/25 found multiple resident rooms with peeling wallpaper, including rooms 122, 125, 129, 133, 137, and 141; a large stain on the ceiling in room 126; and a hole in the wall in room 145. Additional observations on 5/7/26 found deep scratches in the walls near the window and bathroom wall, along with black scratches and chipped drywall, in rooms 404B and 405B. The Nursing Home Administrator and the DON both confirmed the conditions of the resident rooms during interviews.
Failure to Apply ACE Wraps per Physician Orders
Penalty
Summary
Nursing staff failed to ensure that ACE wraps were applied and used according to physician orders for 11 of 14 residents identified in the report. The deficiency involved residents with diagnoses including lymphedema, edema, heart failure, hypertension, COPD, Parkinson’s disease, kidney failure, pulmonary fibrosis, cancer, and coronary artery disease. The report states that the facility failed to ensure nursing staff possessed the specific competencies and skill sets related to the use of ACE wraps. For Resident R16, the physician ordered ACE wraps to the left ankle in the morning and off in the evening, but observations showed the wraps were not on at times they should have been applied, and on one occasion they were wrapped on the foot and calf with no coverage at the ankle and visible swelling between the wrapped areas. For Resident R32, the order was for ACE wraps to both lower extremities every morning, but repeated observations showed the wraps were not on, and the resident stated, “I don't think they have thought about it. It is hit or miss.” For Resident R50, the order was for an ACE wrap to the left foot in the morning and off in the evening, but observations showed the wraps were not on on multiple occasions, and when present they were not wrapped correctly; the resident’s feet were also described as grossly swollen. For Resident R62, the order directed bilateral ACE wraps from distal to proximal, starting from the bottom of the toes and wrapping to above the knee, but observations showed the wraps were loosely applied or not on, with visibly swollen legs when absent. For Resident R74, the order was for bilateral wraps from the base of the toes upward to the knee, but the wraps were not on at one observation and were applied in an up-then-down pattern at another. For Resident R97, the order was for ACE wraps to both lower extremities on in the morning and off at bedtime, but observations showed the wraps were not on, were loosely applied, and were later found wrapped from the ankle; the resident stated the wraps had remained on since the previous morning, and when removed by the Assistant Director of Nursing, they caused a tourniquet effect with a deep indentation at the ankle and the feet were grossly swollen and painful to touch. For Resident R117, the order required bilateral ACE wraps every morning and off every evening, but the wraps were not on during several observations, and when applied they started at the ankle with visibly swollen feet. For Resident R123, the order required ACE wraps to both lower extremities every evening and night shift for lymphedema, but the wraps were not on during observation. For Resident R130, the order required bilateral ACE wraps on in the morning and off at night, but the wraps were not on during several observations and were later observed wrapped from the ankle with the feet grossly swollen and painful to touch. For Resident R147, the order required ACE wraps to both lower extremities for edema on in the morning and off at night, but the wraps were not on during observations. For Resident R174, the order required ACE wraps to both lower extremities on in the morning and off at bedtime, but the wraps were not on during observations. The Assistant Director of Nursing confirmed that the facility failed to follow physician orders and/or failed to apply ACE wraps appropriately for these residents.
Failure to Notify Providers of Blood Glucose Changes
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure provider notification of resident changes in condition. Based on review of job descriptions, clinical records, and staff interviews, the facility did not ensure that physicians or other advanced practice providers were notified when capillary blood glucose levels were beyond the parameters set in the physicians' orders. This failure involved seven of 36 residents identified in the report: R3, R17, R64, R84, R116, R145, and R148. The NHA job description stated the administrator is responsible for directing the day-to-day functions of the skilled nursing facility in accordance with federal, state, and local requirements to assure a high degree of quality of care, and the DON job description stated the DON is responsible for overall management of the nursing department, staffing levels, nursing policies and procedures, compliance, and resident safety. During interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to ensure provider notification of resident changes in condition, and the report states this resulted in immediate jeopardy.
Incomplete and inaccurate clinical records for resident care orders and treatments
Penalty
Summary
The facility failed to maintain clinical records that were complete and accurate for three residents. For one resident with diagnoses including CAD, HF, and HTN, staff observed thick, discolored, fungus-like toenails during rounds, but the physician order record did not contain an order for podiatry services. The DON confirmed there was no podiatry order in the EHR even though the resident was currently followed by podiatry, and consultation reports dated 1/6/26, 3/17/26, and 5/5/26 were provided later but were not present in the resident’s EHR. For another resident with diagnoses including atrial fibrillation, pneumonia, and HTN, the care plan indicated oxygen therapy as ordered for shortness of breath when lying flat, and documentation showed oxygen use on 26 of 30 days, but the physician order record did not include an oxygen order. The DON confirmed there was no oxygen order in the EHR. For a third resident with Parkinson’s disease and diabetes, a skin note documented a sacral wound with Therahoney and Border gauze to be applied, but the clinical record did not include a physician order or documentation that the treatment was completed in the treatment record. The wound care nurse and the DON confirmed the records were not complete and accurate.
QAPI Plan Not Effectively Implemented for Blood Sugar Notification Deficiencies
Penalty
Summary
The facility's QAPI committee failed to implement a good faith attempt to correct quality deficiencies and ensure that plans to improve the delivery of care and services were effective for seven residents with diabetes mellitus. Review of the clinical records showed multiple instances of high or low blood sugar levels for Resident R3, R17, R64, R84, R116, R145, and R148 without documentation that the medical provider was notified. The findings included 20 such instances for R3, 15 for R17, five for R64, two for R84, two for R116, six for R145, and five for R148. The facility had identified non-notification of low blood sugar levels in February 2026 and documented a QAPI monitoring plan for residents with diabetes mellitus. That plan included education for licensed nursing staff on the hypoglycemic policy, documentation, timely monitoring, and signs and symptoms of hypoglycemia, along with random audits by the DON. However, during the survey, the facility did not provide audit information or documentation showing that the performance improvement plan was re-evaluated to determine whether it was effective. The NHA and DON confirmed that the QAPI committee failed to implement a good faith attempt to correct the quality deficiencies for the seven residents.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,252 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pittsburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose Meadows Health & Rehab Center | 2 mi | ★★★★★ | 11 | 0 |
| South Hills Post Acute | 2.6 mi | ★★★★★ | 3 | 0 |
| Wecare At Mt Lebanon Rehabilitation And Nrsg Ctr | 3.2 mi | ★★★★★ | 21 | 0 |
| Asbury Health Center | 3.3 mi | ★★★★★ | 1 | 0 |
| Concordia Of The South Hills | 3.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.