Willows Of Presbyterian Senior
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakmont, Pennsylvania.
- Location
- 1215 Hulton Road, Oakmont, Pennsylvania 15139
- CMS Provider Number
- 395713
- Inspections on file
- 29
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 37
Citation history
Health deficiencies cited at Willows Of Presbyterian Senior during CMS and state inspections, most recent first.
Several residents who required two-person or mechanical lift assistance for transfers were instead transferred by a single aide, resulting in injuries such as a head contusion and skin tears. In each case, staff were aware of the required transfer protocols but proceeded alone due to lack of available help or to expedite care. Additionally, an unexplained skin injury was not properly documented or investigated, with no physician notification or follow-up, as confirmed by staff and the DON.
Several residents who required two-person or mechanical lift transfers were transferred by a single CNA, despite clear physician orders and facility protocols. These actions resulted in actual harm, including a head contusion and skin tears, when staff proceeded with solo transfers due to lack of available help or urgency in resident needs. Staff interviews confirmed that transfer requirements were clearly communicated through daily planners and color-coded systems.
A resident with dementia and a history of wandering was able to exit the facility unsupervised despite being identified as an elopement risk and having an elopement protection device in place. The alarm system only sounded in the lobby, and staff did not hear it from the nursing unit, allowing the resident to leave through the front entrance, which was found ajar and off its hinges. The lack of adequate supervision and ineffective alarm coverage led to the resident being found outside in the parking lot by an LPN.
Eight residents with conditions such as dementia, depression, and Alzheimer's disease, all identified as high risk for wandering or elopement, were found to have nearly identical care plans that lacked person-centered interventions or goals. Despite documented risk factors and facility policy requiring individualized care plans, the interventions and objectives were generic and not tailored to each resident's specific needs or behaviors, resulting in a deficiency.
The facility did not report to the state agency an allegation that staff improperly destroyed medications no longer prescribed for a resident. Although the Nursing Home Administrator and DON were aware of the incident and began an internal investigation, they failed to notify the state agency as required by facility policy and regulations.
A resident with a history of falls, epilepsy, and muscle weakness suffered a patella fracture when her leg fell off a wheelchair footrest and became caught during transport from an appointment. Despite the resident expressing pain, the van driver did not notice or report the incident immediately, resulting in actual harm. Facility documentation and staff interviews confirmed inadequate supervision and assistance in preventing the accident.
The facility failed to provide a safe, clean, and homelike environment for several residents. Observations revealed gouges in walls, missing transition strips creating safety hazards, and wheelchairs covered in dust and grime. These issues were confirmed by staff interviews, indicating a lack of maintenance and cleanliness in the facility.
The facility failed to provide proper respiratory care for four residents, as observed by surveyors. A resident with dementia had undated nebulizer equipment not included in the care plan. Another resident had an oxygen concentrator without physician orders or a care plan, with equipment found on the floor. A third resident's care plan did not reflect physician orders for oxygen, and the equipment was undated. Lastly, a resident with COPD had improperly stored nebulizer tubing. The DON confirmed these deficiencies.
A facility failed to assess a resident's ability to self-administer medications, as required by policy. A resident with multiple health conditions was found with a cup of pills on the bedside table and mentioned dropping a pill without knowing its location. An RN confirmed there were no orders for self-administration, highlighting a lapse in medication management procedures.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The resident's admission MDS assessment was completed, but no subsequent assessments were done, resulting in a 62-day overdue quarterly assessment. This deficiency was confirmed by the RN Assessment Coordinator.
The facility failed to ensure accurate MDS assessments for two residents. One resident with aphasia and dysphagia had conflicting information in their assessment, while another resident with Parkinson's Disease had an incorrect discharge status recorded. Staff interviews confirmed these inaccuracies.
The facility failed to update a resident's care plan to reflect a physician's order for fluid restriction, instead instructing staff to encourage fluids. This discrepancy was confirmed by the DON, highlighting a failure to revise the care plan according to the resident's current medical needs.
The facility failed to support two residents in their daily living activities. One resident with aphasia and dysphagia lacked a communication care plan and device, while another resident with dysphagia and hemiplegia was not assisted out of bed for meals as ordered. Staff confirmed these deficiencies, acknowledging the lack of appropriate services.
The facility failed to document vital signs parameters on the MAR for two residents as per physician orders, and did not discontinue incisional care for a resident once healed. One resident with high blood pressure did not have bedtime blood pressure documented, and another resident's blood pressure was not recorded as required. Additionally, a resident's wound care continued despite the incision being healed. Staff confirmed these deficiencies.
A resident admitted with a stage 3 pressure ulcer on the coccyx did not receive proper assessment and treatment. The facility failed to document the ulcer's details and omitted necessary cleansing instructions in physician orders. Additionally, there was no comprehensive care plan for the ulcer, as confirmed by facility staff.
A facility failed to provide physician-ordered contracture management for a resident with hemiplegia, as the resident did not receive her palm guard on shower days. The resident reported that staff did not apply the palm guard, and an LPN confirmed the oversight. The DON and Nursing Home Administrator acknowledged the failure to follow the care plan.
A nurse aide trainee, Employee E12, worked beyond the four-month certification period without obtaining certification, as required by federal regulations. Despite completing the training program, E12 failed the written exam and continued to provide direct care to residents. The facility's administration confirmed this oversight, which affected one of five employees reviewed.
A facility failed to develop and implement a person-centered care plan for a resident with dementia, as required. The resident was admitted with a diagnosis of dementia, and assessments indicated moderate cognitive impairment. However, from mid-April to late September, there was no documentation of a care plan addressing the resident's dementia and cognitive loss. This deficiency was confirmed by the RN Assessment Coordinator.
The facility failed to provide food items consistent with prescribed diet orders for two residents. One resident was given thin fluids instead of nectar/mildly thick consistency, and another was served thin iced tea instead of nectar thick liquids. Both discrepancies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to provide adaptive feeding devices for a resident with dementia, orthostatic hypotension, and acute kidney failure. The resident's care plan required a Kennedy cup with meals, but during an observation, the resident did not have the cup at lunch. This was confirmed by both an RN and the DON.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, affecting three residents with various medical conditions. This lack of documentation was confirmed by a medical records employee.
A resident with multiple health conditions, including unsteadiness on feet and a right artificial knee, was injured during a transfer when a nurse aide failed to follow the physician's order for a two-person transfer. The nurse aide, unaware of the resident's transfer status, attempted the transfer alone, resulting in a skin tear on the resident's leg. The facility's policy required two-person assistance for mechanical lifts, which was not adhered to in this instance.
The facility failed to meet the nutritional and special dietary needs of a resident with dementia, COPD, and CHF, due to an unstructured meal delivery system and inadequate substitutions for prescribed supplements. Observations and staff interviews revealed disorganized meal service and supply issues with the prescribed Boost Plus supplement.
The facility failed to maintain accurate clinical records for a resident with dementia, COPD, and CHF. The resident was given Ensure instead of the prescribed Boost Plus without updating the physician's orders, and a required low air loss mattress was not in place as per the physician's order.
Failure to Ensure Adequate Supervision and Assistance During Resident Transfers Resulting in Harm
Penalty
Summary
The facility failed to ensure residents were free from neglect by not providing adequate supervision and assistance during transfers, resulting in actual harm to multiple residents. In several documented incidents, residents who required two-person assistance or mechanical lifts for transfers were instead transferred by a single nursing aide, contrary to physician orders and facility policy. This led to injuries including a head contusion for one resident and skin tears for two others. In each case, the aides involved acknowledged they were aware of the required transfer status but proceeded alone due to the unavailability of additional staff or in an attempt to expedite care. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a head contusion after a CNA transferred her independently instead of using the required mechanical lift with two staff. Another resident with high blood pressure, hyperlipidemia, and diabetes suffered a skin tear to her lower extremity during a solo transfer by a CNA, despite being ordered for a two-person mechanical lift assist. A third resident, with high blood pressure, heart failure, osteoporosis, and moderate cognitive impairment, also sustained a significant skin tear when transferred by a single aide, who admitted knowing the resident's two-person assist status but was unable to find help at the time. Additionally, the facility failed to document, assess, and investigate an unexplained skin injury for one resident, as required by policy. There was no record of physician notification, assessment, or follow-up for a skin condition that required a dressing, and staff interviews confirmed that the appropriate procedures were not followed. The DON and other staff confirmed these failures to ensure adequate supervision, adherence to transfer protocols, and proper incident documentation, resulting in neglect and actual harm to the residents involved.
Failure to Provide Adequate Supervision and Assistance During Resident Transfers
Penalty
Summary
Multiple residents who required two-person assist or mechanical lift transfers were transferred by a single nurse aide, contrary to physician orders and facility policy. In each case, the assigned aide was aware of the resident's transfer status, as indicated by daily planners, color-coded stickers, and shift reports, but proceeded to transfer the resident alone due to the unavailability of additional staff or in an attempt to expedite care. These actions resulted in actual harm to the residents, including a head contusion and skin tears. One resident with diagnoses including high blood pressure, glaucoma, and anemia sustained a contusion to the left side of her head after a CNA, acting alone, attempted to transfer her from the toilet without using the required Sara lift and second staff member. The CNA admitted to transferring the resident independently to hurry the process, which led to both the resident and the aide bumping heads. The resident developed a raised, bruised area on her head as a result. Two other residents, both with significant medical histories such as high blood pressure, diabetes, heart failure, and osteoporosis, suffered skin tears during transfers. In both cases, the CNAs assigned to them acknowledged that they were aware of the two-person assist requirement but proceeded to transfer the residents alone because they could not find available help and the residents urgently needed assistance. These transfers resulted in actively bleeding skin tears that required immediate first aid. Interviews with other staff confirmed that transfer statuses are clearly communicated and that staff are educated not to transfer residents alone when two-person assistance is required.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as high risk for wandering, resulting in an elopement event. Upon admission, the resident was assessed as not at risk for elopement, but subsequent documentation showed wandering, exit-seeking behaviors, and impaired safety awareness. Despite these behaviors, the resident was able to exit the facility unsupervised through the front entrance, which was found ajar and off its hinges, with the elopement protection device (EPD) alarm sounding only in the lobby area. Staff did not hear the alarm from the nursing unit, and the resident was last seen in her room before being found outside in the parking lot by an LPN. The resident had a history of dementia, atrial fibrillation, and previous falls, and was noted in progress notes to wander aimlessly, enter other residents' rooms, and exhibit delusions. The care plan and physician orders indicated the use of an EPD and daily checks, but these interventions did not prevent the resident from leaving the building. Staff interviews and documentation revealed that the resident was able to force open the front doors, which, while equipped with an EPD system, could be pushed open due to their fire door function. The alarm system was not audible throughout the facility, limiting staff's ability to respond promptly. The deficiency was confirmed by the Nursing Home Administrator and DON, who acknowledged that the lack of adequate supervision and ineffective alarm coverage led to the resident's elopement. The incident was classified as immediate jeopardy due to the failure to ensure the safety of a resident at high risk for wandering, as required by facility policy and state regulations.
Failure to Individualize Care Plans for High-Risk Wandering Residents
Penalty
Summary
The facility failed to ensure that residents identified as high risk for wandering or elopement had person-centered care plans individualized to their specific needs. Eight residents with diagnoses such as dementia, depression, heart failure, and Alzheimer's disease were identified as having behaviors or histories that placed them at risk for wandering or elopement. Each of these residents had completed elopement evaluations indicating risk factors such as aimless wandering, history of elopement attempts, and verbal expressions of wanting to leave the facility. Despite these individualized risk factors, a review of the care plans for all eight residents revealed that the plans were nearly identical, lacking specific interventions or goals tailored to each resident's unique needs and behaviors. The care plans included generic goals such as maintaining resident safety, ensuring happiness with daily routines, and preventing residents from leaving the facility unattended. Interventions listed were also generic, including assessing for fall risk, providing diversions, monitoring for fatigue, and offering structured activities, without any customization based on the resident's personal history or preferences. The facility's own policies required comprehensive, person-centered care plans with measurable objectives and timetables, as well as ongoing assessment and revision as resident conditions changed. However, interviews and documentation confirmed that the facility did not meet these requirements for the eight residents at high risk for wandering or elopement, resulting in a deficiency under state regulations for admissions policy and nursing services.
Failure to Report Misappropriation of Resident Property to State Agency
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency as required by policy and regulation. Specifically, staff members were alleged to have improperly destroyed medications that were no longer prescribed for residents. The Nursing Home Administrator and Director of Nursing were aware of these allegations and initiated an internal investigation, but did not notify the state agency of either the allegation or the ongoing investigation. Facility policy defines abuse to include misappropriation of resident property and requires reporting such allegations to the appropriate agencies. This omission was confirmed during staff interviews and through a review of facility documents submitted to the state agency.
Failure to Prevent Accident During Resident Transport Resulting in Knee Fracture
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in actual harm to a resident who sustained a patella (knee) fracture. The resident, who had diagnoses including epilepsy, a history of falls, and muscle weakness, was cognitively intact according to the most recent assessment. During transport back to the facility from an appointment, the resident's left leg fell off the wheelchair footrest and became caught under the wheelchair. Despite the resident expressing pain and asking the driver to stop, the driver continued pushing the wheelchair, unaware of the injury until alerted by the resident's reaction and bystanders. Documentation and staff interviews confirmed that the van driver did not notice the resident's leg had fallen off the footrest and did not immediately report the incident. The resident continued to experience pain, and subsequent imaging revealed a mid-patella fracture. The facility's own policy required thorough investigation and timely response to incidents, but the lack of adequate supervision and failure to promptly recognize and address the resident's distress directly led to the injury.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for eight residents. Observations revealed gouges in the walls behind the beds of two residents, indicating a lack of maintenance in their living spaces. Additionally, two residents' rooms had missing transition strips at the entrance to the bathrooms, creating uneven surfaces that posed safety hazards. These deficiencies were confirmed during a tour and interview with the Unit Manager. Furthermore, several residents were observed in wheelchairs that were covered with dust, dried debris, and grime. The wheelchairs of four residents were noted to have frames, undercarriages, and wheels that were not clean, with one resident's wheelchair having a right lateral support and brakes grossly corroded with dried grime and debris. These observations were confirmed by interviews with nursing aides and an environmental aide, highlighting the facility's failure to maintain a sanitary and orderly environment as required by federal regulations.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide specialized respiratory care in accordance with professional standards for four residents. Resident R12, diagnosed with Non-Alzheimer's Dementia, anxiety, and depression, had a physician order for Ipratropium-Albuterol Inhalation Solution via nebulizer, but the care plan did not include this treatment. The nebulizer equipment was found undated and improperly stored on the dresser. Resident R24, with high blood pressure, Non-Alzheimer's Dementia, and depression, had an oxygen concentrator in the room without physician orders or a care plan for oxygen administration. The equipment was undated, and the nasal cannula was found on the floor. Resident R44, diagnosed with asthma, anxiety, and depression, had physician orders for oxygen administration, but the care plan did not reflect this. The oxygen equipment in the room was undated. Resident R60, with dysphagia, COPD, and hemiplegia, had a physician order for Ipratropium-Albuterol Solution, but the nebulizer tubing was improperly stored. The Director of Nursing confirmed the facility's failure to provide respiratory care according to professional standards for all four residents.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, which is a requirement for ensuring safe medication management. Resident R46, who was admitted with diagnoses including morbid obesity, congestive heart failure, and diabetes mellitus, was observed with a cup containing four pills on the bedside table. The resident mentioned having dropped a pill and was unaware of its location. During an interview, a Registered Nurse confirmed that there were no orders for the resident to self-administer medication, indicating a lapse in following the facility's policy that requires written orders for medication administration.
Failure to Timely Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for Resident 144 within the required timeframe. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, quarterly assessments must be completed no more than 92 days after the Assessment Reference Date (ARD) of the most recent assessment, with a completion date no later than 14 days after the ARD. Resident 144 had an admission MDS assessment completed on June 6, 2024, but there was no evidence of any subsequent MDS assessment, including a quarterly assessment, being completed after that date. A review of the resident's clinical record on November 21, 2024, indicated that the quarterly MDS assessment was due by September 20, 2024, making it 62 days overdue. This deficiency was confirmed by the Registered Nurse Assessment Coordinator during an interview on November 21, 2024.
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, leading to a deficiency. For Resident R36, who was admitted with diagnoses of aphasia and dysphagia, the MDS assessment contained conflicting information. Section B indicated that the resident was understood, while Section C stated that the resident was rarely or never understood, and the Brief Interview for Mental Status (BIMS) was not completed. Interviews with staff confirmed that Resident R36 could not be understood, highlighting the inaccuracy in the MDS assessment. For Resident R158, who was admitted with Parkinson's Disease, high blood pressure, and anxiety, the MDS assessment inaccurately recorded the discharge status. Despite a progress note indicating a hospital transfer due to altered mental status and other health issues, the MDS stated the resident was discharged to home/community. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the inaccuracies in the MDS assessments for both residents, demonstrating a failure to accurately capture the residents' conditions.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R316 to accurately reflect the resident's current medical status. Resident R316 was admitted with diagnoses including congestive heart failure, asthma, and atrial fibrillation. The Minimum Data Set assessment confirmed these diagnoses were current. Despite a physician's order for a fluid restriction of 1800 ml, the Resident Care Plan Summary Report instructed staff to encourage fluids. This discrepancy was confirmed by the Director of Nursing during an interview, indicating a failure to revise the care plan in accordance with the resident's needs.
Failure to Support Residents' Daily Living Activities
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ability of two residents to carry out activities of daily living. Resident R36, who was admitted with diagnoses of aphasia and dysphagia, did not have a care plan addressing her communication needs. Despite having expressive aphasia and being rarely understood, the resident was not provided with a communication device. This was confirmed by both a Licensed Practical Nurse and the Director of Nursing, who acknowledged the lack of appropriate services to support the resident's communication abilities. Resident R60, admitted with dysphagia, depression, and hemiplegia, had physician orders to be out of bed for meals to aid in lung function and swallowing. However, during an observation, the resident was found eating lunch in bed, contrary to the physician's orders. The resident reported that staff did not assist her out of bed on shower days, which was confirmed by an LPN. The Director of Nursing and Nursing Home Administrator acknowledged the failure to provide the necessary treatment and services to support the resident's dining and eating needs.
Failure to Document Vital Signs and Discontinue Healed Incisional Care
Penalty
Summary
The facility failed to document vital signs parameters on the medication administration record (MAR) as per physician orders for two residents. Resident R24, diagnosed with high blood pressure, dementia, and depression, was prescribed losartan to be administered at bedtime with a condition to hold the medication if blood pressure was less than 110. However, the MAR from November 5 to November 19 did not document the blood pressure at bedtime, and the blood pressure log showed recordings on nine occasions, none of which were at bedtime. Similarly, Resident R70, diagnosed with high blood pressure, dementia, and anxiety, was prescribed amlodipine besylate with a condition to hold if systolic blood pressure was less than 100. The MAR from November 12 to November 19 did not document the blood pressure, and the blood pressure log recorded only once before the medication started. RN Employee E8 confirmed the lack of documentation for both residents. Additionally, the facility failed to discontinue incisional care for Resident R151 once the incision was healed. Resident R151, with a diagnosis of dementia, thyroid disorder, and hip fracture, had an order for daily wound care on an upper back incision. The treatment administration record indicated the treatment was administered from November 1 to November 17. However, an observation on November 19 revealed the incision was healed, and no dressing was in place as ordered. Unit Manager Employee E2 acknowledged forgetting to discontinue the order, and the Director of Nursing confirmed the facility's failure in both documenting vital signs parameters and discontinuing incisional care once healed.
Failure to Properly Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure proper assessment and treatment of a pressure ulcer for a resident, identified as R72, who was admitted with a stage 3 pressure ulcer on the coccyx. Upon admission, the clinical assessment did not document any pressure injuries, but a subsequent skin check revealed a 5 x 5 cm open area on the coccyx, lacking detailed description and staging. The facility's physician orders from 10/11/24 to 10/15/24 included applying a butterfly dressing but omitted necessary cleansing instructions for the stage 3 pressure ulcer, which is inconsistent with professional standards of practice. The facility's documentation and care planning were inadequate, as evidenced by the absence of a comprehensive pressure ulcer care plan for Resident R72. Interviews with the Director of Nursing, Resident Nurse Assessment Coordinator, and Wound Care Nurse confirmed the lack of appropriate physician orders and care planning. The facility's failure to document and implement a care plan for the pressure ulcer was acknowledged by the Nursing Home Administrator, highlighting a deficiency in meeting the resident's medical and nursing needs as per regulatory requirements.
Failure to Provide Contracture Management for a Resident
Penalty
Summary
The facility failed to provide physician-ordered contracture management interventions for Resident R60, who was admitted with diagnoses including dysphagia, depression, and hemiplegia. According to the care plan, Resident R60 was supposed to wear a palm guard daily from morning until dinner time. However, during an observation and interview, it was noted that the resident was not wearing the palm guard, and she reported that staff did not apply it on her shower days. An LPN confirmed that the resident was not taken out of bed on shower days, which likely led to the omission of the palm guard application. The Director of Nursing and Nursing Home Administrator acknowledged the failure to adhere to the care plan for Resident R60.
Non-Certified Nurse Aide Worked Beyond Allowed Period
Penalty
Summary
The facility failed to ensure that a nurse aide trainee, identified as Employee E12, who did not become certified within the required four-month period, was not working in the facility. According to Title 42 Code of Federal Regulations S483.35(d), a facility must not use any individual as a nurse aide for more than four months unless they have completed a training and competency evaluation program. Employee E12 completed the training program but was unable to pass the written exam, resulting in the individual providing direct care to residents without certification. The documentation reviewed indicated that Employee E12 continued to work as a nurse aide on multiple dates despite not having obtained certification within the 120-day requirement. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged the facility's failure to comply with the certification requirement for nurse aides. The deficiency was identified for one of five employees reviewed, highlighting a lapse in the facility's adherence to regulatory standards for nurse aide certification and employment.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia, leading to a deficiency. The resident, identified as Resident 67, was admitted with a diagnosis of dementia, which involves loss of memory, language, problem-solving, and other cognitive abilities that interfere with daily life. The Minimum Data Set Assessment dated 4/4/24 indicated that the resident's cognition was moderately impaired. However, a review of the clinical record from 4/17/24 through 9/22/24 showed no evidence that the facility had created or implemented a care plan to address the resident's dementia and cognitive loss. This was confirmed by an interview with the Registered Nurse Assessment Coordinator, who acknowledged the lack of documentation for a care plan prior to 9/23/24.
Failure to Provide Prescribed Diet Consistency
Penalty
Summary
The facility failed to provide food items consistent with the prescribed diet orders for two residents. Resident R60 had a physician's order for a regular diet with pureed texture and nectar/mildly thick consistency fluids. However, during an observation, Resident R60 was given a yellow, thin fluid instead of the prescribed nectar/mildly thick consistency. An LPN confirmed that Resident R60 had previously received regular apple juice instead of the required nectar/mildly thick apple juice. The Director of Nursing confirmed that Resident R60 should have received nectar thick liquids as ordered. Similarly, Resident R74 had a physician's order for a regular diet with mechanical soft ground meat texture and nectar/mildly thick consistency fluids. During dining observations, Resident R74 was served thin iced tea instead of the prescribed nectar thick liquids. A Registered Nurse confirmed these findings, and the Director of Nursing acknowledged that Resident R74 should have received nectar thick liquids as ordered.
Failure to Provide Adaptive Feeding Devices
Penalty
Summary
The facility failed to provide adaptive feeding devices as required for two of five residents, specifically for a resident with dementia, orthostatic hypotension, and acute kidney failure. According to the resident's care plan dated 8/19/24, a Kennedy cup was to be provided with meals. However, during an observation on 11/18/24, the resident did not have the Kennedy cup during lunch as care planned. This was confirmed by an interview with a Registered Nurse and the Director of Nursing, who acknowledged that the resident should have had the specified cup as per the care plan.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers, as required by regulations. This deficiency was identified for three residents who were transferred to the hospital and subsequently returned to the facility. Specifically, there was no documented evidence that Residents R131, R77, and R96 or their representatives were provided with written information about the facility's bed-hold policy at the time of their respective hospital transfers. Resident R131, with diagnoses including anxiety disorder, depression, and diabetes mellitus, was transferred to the hospital on March 23, 2024, without receiving the required notification. Similarly, Resident R77, who had heart failure, hyperlipidemia, and dysphagia, was transferred on two occasions, July 26, 2024, and October 23, 2024, without the necessary documentation. Resident R96, with a history of a right humerus fracture, repeated falls, and hyperlipidemia, was also transferred on November 9, 2024, without being informed of the bed-hold policy. This oversight was confirmed during an interview with Medical Records Employee E7.
Failure to Provide Two-Person Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing a two-person transfer as per the physician's order. The incident involved a resident who had been admitted with diagnoses including hyperlipidemia, hypertension, unsteadiness on feet, a right artificial knee, and chronic kidney disease. The resident's care plan and physician's order specified that transfers should be conducted with a mechanical lift and assistance from two persons. However, on the evening of the incident, a nurse aide attempted to transfer the resident alone, resulting in a skin tear on the resident's right lower leg. The nurse aide involved in the incident reported that she was unaware of the resident's transfer status because the information was not available on the report paper she had. She relied on the resident's statement that she could transfer regularly. The nurse aide admitted to transferring the resident alone, which led to the resident's leg being injured, possibly by the wheelchair or bed. The facility's policy required that mechanical lifts be operated by two nursing or therapy personnel, and the nurse aide's actions were contrary to this policy. Interviews with staff revealed that the facility had a color-coded system to indicate transfer status, and the nurse aide had been oriented to this system. However, the nurse aide did not have the necessary information at the time of the incident. The facility's investigation confirmed that the nurse aide did not follow the protocol for a two-person transfer, as required by the resident's care plan and physician's order. This failure resulted in the resident sustaining a skin tear during the transfer.
Failure to Meet Nutritional and Dietary Needs
Penalty
Summary
The facility failed to meet the daily nutritional and special dietary needs for one resident (Resident R1) and lacked a structured meal delivery system to ensure accurate and timely meal service. Resident R1, who has diagnoses of dementia, chronic obstructive pulmonary disease, and congestive heart failure, was observed not receiving a lunch tray on one occasion and not receiving the prescribed Boost Plus supplement on multiple occasions. The care plan for Resident R1 included specific dietary requirements, such as a regular diet with mechanical soft, ground meat texture, and Boost Plus twice a day, which were not consistently met. Observations and interviews revealed that the meal delivery system was disorganized, leading to missed or incorrect meal deliveries, and the facility had ongoing supply issues with the prescribed nutritional supplement, resulting in inadequate substitutions that did not meet the resident's nutritional needs. During meal service observations, staff were seen struggling to locate meal tickets and delivering incorrect trays. Interviews with staff confirmed that the facility had not had Chocolate Boost Plus for some time and was substituting it with chocolate milk, which did not provide equivalent nutritional value. The Registered Dietitian acknowledged the supply issues and confirmed that the substitutions were not nutritionally adequate. The Nursing Home Administrator and Director of Nursing confirmed the deficiencies, highlighting the facility's failure to provide accurate and timely meals and supplements as per the residents' dietary needs.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for one of six residents reviewed. Resident R1 was admitted with diagnoses of dementia, chronic obstructive pulmonary disease, and congestive heart failure. The physician orders dated 3/20/24 indicated that Resident R1 was to receive Boost Plus twice a day. However, the Medication Administration Record showed that Boost Plus was administered from 3/1/24 through 3/19/24, despite the facility not having Boost Plus in stock. Instead, Ensure was being given, but the physician's orders were not updated to reflect this change. The Director of Nursing confirmed that the nurses were documenting the administration of Boost Plus inaccurately and that the physician's orders should have been updated accordingly. Additionally, Resident R1 had a physician order from 2/13/24 for a low air loss mattress to be checked by a nurse every shift. However, an observation on 3/20/24 revealed that Resident R1 had a perimeter mattress instead. The Director of Nursing confirmed that the low air loss mattress was not in place and that the physician order needed to be updated. This failure to ensure complete and accurate clinical records was confirmed by the Director of Nursing during the interview.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
