Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Windber Woods Senior Living & Rehabilitation Ctr during CMS and state inspections, most recent first.
Unnecessary PRN Psychotropic Medication Use: The facility failed to document non-pharmacological interventions before repeated PRN doses of psychotropic medications for four residents with cognitive impairment and diagnoses including dementia, depression, anxiety, and behavioral symptoms. The records showed PRN Trazodone, Xanax, and Ativan were administered multiple times for anxiety, agitation, or behaviors, and the DON confirmed the lack of documentation. One resident’s PRN order also lacked a duration and had no documented prescriber rationale for extending use beyond 14 days.
Food storage practices did not follow facility policy or professional standards. Surveyors observed bakery items left open to air in the walk-in cooler, an employee fountain drink in the kitchen prep refrigerator, and employee food and drinks stored in the medication room refrigerator. The Dietary Director stated food should be stored closed to air and employee items should not be kept in the prep refrigerator, and the ADON confirmed no food should be stored in the medication refrigerator because a separate refrigerator was available.
Failure to Document Informed Consent for Psychotropic Medications: The facility did not document that the resident and/or resident representative was informed in advance of the risks, benefits, and treatment alternatives before psychotropic meds were started or increased for two residents. One resident was cognitively intact and had Sertraline increased for depression, while another resident was cognitively impaired and had Ativan ordered PRN for anxiety and behaviors; the NHA confirmed the lack of documentation.
Failure to investigate a resident’s bruise for possible abuse: A cognitively intact resident with ESRD on dialysis was noted by a nurse aide to have a bruise on the right knee after a shower. The bruise was not documented as being reported through risk management, and there was no incident report or investigation found to identify the cause or rule out abuse.
Care plans were not revised to match current resident status for several residents. One resident’s plan still listed pneumonia after the diagnosis was no longer active, another still showed an indwelling catheter after it had been discontinued, and a third continued to include mediport flushes and blood draws even though the port was de-accessed and not being used at the facility. Additional plans still listed Ativan after it was discontinued and active necrotizing fasciitis/surgical wounds despite no current treatment being documented.
Failure to document RN assessment of changes in condition for two residents. One resident with ESRD on dialysis had a bruise noted on the knee during a shower, but no documented RN assessment was completed. Another resident with dementia had an open area on the shin after a blood blister opened, but there was no documented follow-up assessment of the skin change.
The facility failed to follow and clarify physician orders for several residents. One resident with dementia continued receiving vitamins that had been discontinued per pharmacy/MD review, another resident had a Foley-related order left active even though no catheter was present, a resident received carvedilol despite pulse parameters requiring it to be held, and a resident on Eliquis had an anticoagulant-hold order that was not clarified after returning from the hospital, leading to a rescheduled biopsy.
A resident with moderate cognitive impairment, stroke, hemiplegia, and dementia was ordered to have B Prevalon boots on at all times while in bed, with skin checks at application and removal. Staff observed the resident in bed without the boots in place on multiple occasions, and an aide reported no boots were available in the room. The NHA stated the boots were not added to the task list and there was no documented evidence they were being applied as ordered.
A resident identified as a fall risk and cognitively impaired did not have a reacher tool available in the room as called for in the care plan. Staff observed the resident in a wheelchair reaching for items without the device present, and an aide confirmed it was missing. The NHA and Director of Therapy confirmed the reacher should have been available.
A resident with respiratory failure, CHF, and pneumonia was ordered oxygen via nasal cannula to keep pulse ox above 90%. Staff observed the resident receiving O2 at 3 LPM, but the clinical record had no documented evidence of oxygen use or pulse ox checks to confirm the appropriate liter flow. The ADON confirmed the lack of documentation.
Failure to document dialysis orders and monitor a resident’s fistula. A cognitively intact resident with ESRD was receiving hemodialysis, and the care plan directed staff to monitor the fistula for infection and assess bruit and thrill. However, the clinical record had no documented dialysis treatment orders showing when and where dialysis was scheduled, and there was no documented evidence that staff monitored the fistula site as required.
Controlled medication accountability was not maintained for a resident with Parkinson's disease who had orders for fentanyl transdermal patches for pain management. The MAR and controlled drug record did not show the required two signatures for patch removal and disposal on multiple occasions, and a later fentanyl patch was signed out without any MAR documentation that it was administered. The DON and NHA confirmed the documentation gaps.
Medication administration errors resulted in a 7.89% error rate, exceeding the required threshold. An LPN gave a resident Trelegy Ellipta and then provided iced tea instead of having the resident rinse and spit as directed by the manufacturer. In a separate event, an LPN crushed Ferrous Sulfate and Xtandi for another resident and gave only one 40 mg Xtandi tablet instead of the ordered 160 mg dose.
A resident with a UTI diagnosis had a urine specimen collected by straight cath for UA C&S after an order to obtain urine was in place, but there was no documented physician order for the invasive catheterization itself. The NHA confirmed the order for the cath should have been obtained.
The facility's QAPI committee failed to correct repeated deficiencies and did not maintain compliance with multiple cited areas, including care plan revision, quality of care, pressure ulcer prevention/healing, accident hazard prevention, lab services, controlled medication accounting, and infection control. Prior plans of correction relied on audits and QAPI review, but the current survey found those issues remained unresolved.
Failure to use contact isolation for a resident with C. difficile. A resident with cognitive impairment, bowel incontinence, and diagnoses including HTN and stroke tested positive for C. difficile, but contact isolation signs were not posted on the door. An LPN and the NHA both confirmed the signs were missing and should have been in place.
A resident with diabetes experienced a significant medication error when an LPN administered Insulin Lispro over an hour before the meal, contrary to the manufacturer's instructions. This led to critically low blood sugar levels, requiring emergency intervention. The resident's condition improved after receiving Glucagon and being fed by staff.
The facility failed to follow physician's orders and document medication administration for several residents. A resident did not have their blood pressure and heart rate checked before receiving Metoprolol, and another resident's blood pressure was not checked before administering Verapamil. A diabetic resident missed accu checks, and two residents did not receive bowel protocol treatments as ordered. Additionally, there was a lack of documentation for the administration of Oxycodone-Acetaminophen to a resident.
The facility failed to document the flushing of PICC lines with normal saline before and after medication administration for three residents, despite physician's orders and facility policy. This deficiency was confirmed by the Nursing Home Administrator, indicating a systemic issue in maintaining IV catheter care.
A facility failed to create a comprehensive care plan for a cognitively impaired resident with high blood pressure and diabetes, who was observed using smokeless tobacco without a documented care plan addressing this behavior. This deficiency was confirmed by the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to inaccuracies in their documented care needs. A resident's care plan lacked contact isolation precautions for ESBL, another resident's care plan incorrectly stated that her glasses were lost, and a third resident's care plan inaccurately indicated the use of Bumex. These deficiencies were confirmed by facility staff.
A resident with pressure ulcers did not receive wound care as ordered, as an LPN applied dressings without cleansing the wounds, contrary to physician's orders and facility policy. The LPN assumed the resident had been cleaned during morning care, which was confirmed by the Nursing Home Administrator.
A cognitively impaired resident who was ambulatory with assistance was found in the basement of the facility on two occasions, indicating a failure to maintain a safe environment. Despite the resident's known tendency to wander, no interventions were documented to prevent further incidents. The facility staff did not recognize these incidents as elopements, revealing a deficiency in management and resident care policies.
A facility failed to maintain accurate records for controlled medications for a resident. The policy required documentation of medication administration, but for a cognitively intact resident receiving opioids, there was no evidence in the MAR that the medication was administered, despite being signed out. The DON confirmed the lack of documentation.
The facility failed to properly store and label medications, including insulin and inhalers, according to manufacturer's instructions and facility policy. Two residents had undated insulin pens, and another resident had an undated Trelegy Ellipta inhaler. An undated bottle of Aplisol was also found. Staff confirmed these deficiencies, indicating a lapse in adherence to medication protocols.
The facility failed to obtain ordered laboratory tests for a resident on anticoagulant therapy and did not secure physician orders for straight catheterization to collect urine specimens for two residents with renal insufficiency. These deficiencies were confirmed by facility administrators.
The facility's QAPI committee failed to address recurring deficiencies in care plans, accident hazards, and pharmacy procedures, despite developing plans of correction. The deficiencies were repeatedly cited in surveys, indicating a systemic issue in the facility's quality assurance processes.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure sores, as required by updated CMS guidelines. One resident with a Stage 3 pressure ulcer and another with an unstageable pressure ulcer and diabetic foot ulcer did not have EBP in place, and there was no signage or PPE supplies outside their rooms. Additionally, an LPN did not wear a gown while performing wound care, as confirmed by the Nursing Home Administrator.
A facility failed to notify a physician in a timely manner about a resident's change in condition, which included increased confusion and abnormal behavior. Despite staff observations of these changes and the resident's daughter expressing concerns, the physician was not informed until approximately twenty hours later, delaying necessary medical intervention.
A resident with severe cognitive impairment and multiple diagnoses exhibited increased confusion and abnormal urine characteristics, but there was no documented RN assessment following these changes. The facility's policy and state regulations require such assessments, which were confirmed as missing by the Nursing Home Administrator.
A resident, who was cognitively impaired and required assistance, was injured after being improperly transported in a wheelchair without leg rests, leading to a fall and head injury. The incident occurred while the resident was asleep, and the facility's policy on wheelchair safety was not followed, resulting in a deficiency citation.
A resident, who was cognitively impaired and required assistance, fell from a wheelchair and sustained a head injury due to a nurse aide's failure to use leg rests during transportation, contrary to facility policy.
A cognitively impaired resident with Alzheimer's and anxiety fell when a housekeeper failed to secure the mattress to the bed with straps after cleaning the room, resulting in the mattress being completely off the bed.
The facility failed to ensure that food stored in the kitchen was labeled, dated, and secured. Observations revealed unlabeled and unsecured chicken tenders, dated but unsecured chicken patties, and dated but open sausage patties. Interviews with the Dietary Manager and Nursing Home Administrator confirmed the deficiency.
The facility failed to maintain a clean and homelike environment for a resident who required extensive assistance and had significant medical needs. Observations revealed that a fan blowing directly on the resident had visible dirt and debris, and staff confirmed it should have been clean but was not.
The facility failed to update a resident's care plan to reflect a change in the size of an indwelling foley catheter as ordered by the physician. The resident's care plan indicated a 16 French, 10 cc balloon catheter, while the physician's order specified an 18 French, 10 cc balloon catheter. This discrepancy was confirmed by the Nursing Home Administrator.
The facility failed to ensure a resident was transported safely in a wheelchair with leg rests and did not conduct thorough investigations for a cognitively impaired resident with a history of falls. Witness statements were photocopied and signed without individual accounts.
A facility failed to display a no smoking/oxygen-in-use sign for a resident receiving oxygen therapy, despite policy requirements. The resident, who was cognitively impaired and had diagnoses including pulmonary embolism and anemia, was observed receiving oxygen without the required signage. Staff confirmed the oversight.
The facility failed to maintain accountability for controlled medications for a resident. The policy required double signatures for discarding narcotic patches, but there was no documented evidence of this for multiple dates. The Nursing Home Administrator confirmed the deficiency.
The facility's QAPI committee failed to correct recurring deficiencies related to accident hazards, respiratory care, pharmacy services, and food procurement/storage/prepare/serve-sanitary. Despite previous plans of correction, the current survey revealed ongoing non-compliance in these areas.
The facility failed to maintain an effective pest control program, as evidenced by the presence of ants and gnats in the kitchen area. Observations revealed a large number of ants around the handwashing sink and several gnats in the same area. Staff interviews confirmed that the pests should not be present, and the facility's pest control measures were insufficient to prevent this issue.
A resident's privacy was breached when a cognitively impaired individual with dementia was photographed by a nurse aide while on the toilet. The picture, which exposed a small portion of the resident's upper leg, was taken in violation of the facility's cell phone policy and subsequently posted on social media. The incident was confirmed by the Nursing Home Administrator and involved two nurse aides.
A nurse aide violated facility policy by taking a photo of a cognitively impaired resident on the toilet and posting it on social media, leading to a failure to protect the resident from mental abuse. The incident was confirmed by staff interviews and acknowledged by the Nursing Home Administrator.
A facility failed to ensure accurate documentation and performance of wound treatment for a resident. An LPN documented that a treatment was completed, but an investigation revealed the treatment had not been performed as the dressing was found intact and dated two days prior. This discrepancy was confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for two residents. One resident did not receive the prescribed Triamcinolone cream for a rash, and another resident did not have their wound dressing changed as ordered. These deficiencies were confirmed through staff interviews and record reviews.
A resident at risk for falls fell because therapy staff did not place the required chair alarm on his wheelchair after a transfer. The resident was found on the floor with no injuries, and the Nursing Home Administrator confirmed the oversight.
The facility failed to ensure complete and accurate documentation of a resident's clinical records. A physician's order for wound care was not performed as required, and the LPN inaccurately documented the treatment as completed. This discrepancy was discovered through an investigation, revealing the treatment had not been performed as documented.
Unnecessary PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medication regimen was free from unnecessary psychotropic medication for four residents who had cognitive impairment and diagnoses that included dementia, depression, anxiety, or related behavioral concerns. The cited medications included PRN Trazodone for anxiety and agitation for one resident, PRN Xanax for another resident, PRN Ativan for a third resident, and repeated PRN Ativan orders for a fourth resident. The facility policy stated that non-pharmacological approaches were to be used unless contraindicated to minimize the need for medications, permit the lowest possible dose, and allow discontinuation when possible. For Resident 10, the record showed a significant change MDS indicating cognitive impairment, dependence for daily care, and diagnoses of dementia and depression. A physician ordered Trazodone 50 mg every 8 hours as needed for anxiety and agitation, and the MAR showed multiple administrations in February 2026. The record contained no documented evidence that non-pharmacological interventions were attempted before those doses were given, and the Nursing Home Administrator confirmed this. The administrator also confirmed that the order did not include a duration and that there was no documented physician or prescriber rationale to extend the PRN Trazodone beyond 14 days. For Resident 13, Resident 14, and Resident 92, the records similarly showed cognitive impairment and diagnoses including dementia, depression, anxiety, or behavioral symptoms, with PRN orders for Xanax or Ativan for anxiety, agitation, or behaviors. The MARs documented repeated administrations over the cited periods, but there was no documented evidence that non-pharmacological interventions were attempted before the PRN doses were administered. The Nursing Home Administrator confirmed the lack of documentation for these residents as well. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.
Food Storage Not Kept in Accordance With Policy
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. A facility policy dated December 18, 2025 stated that food would be stored closed to open air and that no employee food or drinks would be stored in pantry refrigerators. During observation of the walk-in cooler on February 24, 2026, surveyors found a half box of dinner rolls and a full box of dough balls open to air. In the prep refrigerator in the kitchen, an employee fountain drink that was half full was observed. During observation of the refrigerator in the medication room on Spruce on February 27, 2026, surveyors found a cup of coffee, a sandwich, two containers of yogurt, and an Oikos yogurt drink belonging to an employee. The Dietary Director stated that food should be stored closed to air and employee food should never be stored in the prep refrigerator, and the ADON confirmed that no food should be stored in the medication refrigerator because there is a separate refrigerator.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medications and the treatment alternatives before administering them for two residents. Facility policy dated December 18, 2025 stated that residents and/or representatives have the right to decline psychotropic treatment and that staff and the physician will review the risks of not taking the medication and appropriate alternatives with the resident/representative. For one resident, a significant change MDS dated November 22, 2025 showed the resident was cognitively intact, received psychotropic medications, and had a diagnosis of depression. A nursing note dated November 20, 2025 documented a physician visit and an order to increase Sertraline to 100 mg daily, and physician orders dated November 21, 2025 included Sertraline 100 mg daily for depression. There was no documented evidence that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives before the increased dose was started. For another resident, a quarterly MDS dated May 27, 2026 showed the resident was cognitively impaired and received psychotropic medications, including antidepressants. Physician orders dated June 7, 2025 included Ativan 0.5 mg every 8 hours as needed for anxiety and behaviors. There was no documented evidence in the clinical record that the resident and/or resident representative were informed in advance of the risks and benefits and treatment alternatives prior to initiating the Ativan order. The Nursing Home Administrator confirmed on interview that there was no documented evidence that the resident's representative had been informed in advance for either resident.
Failure to Investigate Resident Bruise for Possible Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of a bruise to rule out neglect and/or abuse for one resident. The facility’s abuse prohibition policy stated that it would have procedures in place to identify suspicious bruising, occurrences, patterns, and trends that may constitute abuse, and its risk management reporting policy stated that all injuries and incidents, including bruises, were required to be reported through risk management in the electronic medical record, with the risk management report serving as the actual investigation into the cause of the injury or incident and to rule out abuse. The resident involved was cognitively intact, required assistance with daily care needs, had end stage renal disease, and was receiving dialysis. A nurse’s note documented that after a shower, a nurse aide noticed a bruise on the resident’s right knee. There was no documented evidence that an investigation was started to identify the cause of the bruise or to rule out abuse, and the Nursing Home Administrator confirmed that no incident report or investigation could be found for the bruise.
Care plans not updated to match residents’ current conditions
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect residents’ current care needs for five residents reviewed. Facility policy stated that an interdisciplinary plan of care must be established and updated as indicated for every resident, and that the care plan is to be reviewed ongoingly and revised based on the resident’s needs, wishes, or change in condition. For one resident, a significant change MDS showed cognitive intactness, oxygen therapy, and diagnoses including respiratory failure, CHF, and pneumonia, but the care plan still listed pneumonia even though there was no documented evidence of an active pneumonia diagnosis and the Assistant DON confirmed the resident was not being treated for it. For another resident, an admission MDS showed cognitive impairment and a diagnosis of cognitive communication deficit, but the care plan still reflected an indwelling catheter even though nursing documentation showed the catheter had been discontinued and the resident was incontinent of urine afterward; staff confirmed the resident did not have an indwelling catheter. For a third resident with cancer, the care plan continued to describe a mediport with routine heparin and saline flushes and blood draws through the port, although there was no documented order for port flushes and staff confirmed the port was de-accessed and not being used at the facility. For a fourth resident, the care plan stated the resident was receiving Ativan even though there was no documented evidence of an active Ativan order and the DON confirmed it had been discontinued. For a fifth resident, the care plan continued to identify necrotizing fasciitis and surgical back wounds, although there was no documented evidence of active treatment for those conditions and the NHA confirmed the care plan should have been resolved.
Failure to Document RN Assessment of Changes in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse assessed changes in condition for two residents. One resident, who was cognitively intact, required assistance with daily care needs, had end stage renal disease, and was receiving dialysis, was noted during a shower to have a bruise on the right knee. The nurse aide identified the bruise, but there was no documented evidence that a registered nurse completed an assessment of the bruise. The Nursing Home Administrator confirmed that no documented RN assessment was completed for the bruise identified on the right knee. Another resident, who had severe cognitive impairment, was dependent on staff for most daily care needs, and had a diagnosis including dementia, had an order for treatment of an open area on the left shin after an old bruise/blood collection opened. The nurse's note documented the change in skin condition on the left shin, but there was no documented evidence of any further assessments of that change in skin condition after it was identified. The Director of Nursing confirmed that the resident had a previous blood blister that opened on the left shin and that there was no documented evidence of assessments of the change in skin condition since it was identified.
Failure to Follow and Clarify Physician Orders
Penalty
Summary
The facility failed to follow and clarify physician orders for four residents. One resident with dementia and cognitive impairment had a pharmacist recommendation, later agreed to by the physician, to change a multivitamin to multivitamin-M and discontinue vitamin B12, vitamin D, magnesium oxide, and folic acid, but the medication administration record showed the multivitamin was not changed and the discontinued vitamins were still administered. Another resident with cognitive impairment and a cognitive communication deficit had an order to change a Foley catheter as needed for leakage or blockage, even though staff confirmed the resident did not have an indwelling catheter and the order should have been discontinued. A cognitively intact resident with hypertension had an order for carvedilol 25 mg to be held if pulse was below 60 bpm or systolic blood pressure was below 100, but the medication was administered on multiple occasions when the pulse was documented below 60. A fourth resident with cancer and anticoagulant use had an order to hold Eliquis three days before a breast biopsy; after the resident returned from the hospital, there was no documented evidence the order was clarified, and the Eliquis was given when the facility later received a call from the Breast Care Center about holding it, resulting in the biopsy being rescheduled.
Failure to Provide Ordered Heel Protection
Penalty
Summary
Pressure ulcer care and prevention treatments were not provided as ordered for one resident with moderate cognitive impairment, stroke, hemiplegia, and dementia. The resident’s quarterly MDS dated January 17, 2026, showed the resident required assistance with daily care needs, and the care plan dated August 5, 2025, identified the resident as having the potential for pressure ulcer development and requiring extensive-total assistance with bed mobility. Physician’s orders dated January 22, 2026, directed that B Prevalon boots be on at all times when the resident was in bed and that skin integrity be checked with application and removal. An intervention dated January 23, 2026, repeated this direction. However, observations on February 24, 2026, at 11:00 a.m. and February 26, 2026, at 10:15 a.m. found the resident lying in bed without the boots in place. A nurse aide stated the resident did not have the boots on and that no B Prevalon boots were available in the room to apply as ordered. The Nursing Home Administrator stated the boots were not added to the task list to alert nurse aides, they should have been available in the room, and there was no documented evidence they were being applied as ordered.
Missing Reacher for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for one of 33 residents reviewed, Resident 14. The facility policy on falls stated that residents identified as fall risks would have interventions in place to prevent further falls. Resident 14’s quarterly MDS assessment dated February 27, 2026, indicated that the resident was cognitively impaired and required assistance for daily care. The resident’s care plan identified a fall risk and included interventions such as keeping personal belongings within reach and having a reacher tool available. However, observations on February 24, 2026, and February 26, 2025, showed Resident 14 in a wheelchair in the room without the reacher available, including while reaching for items on a stand. A nurse aide confirmed that the reacher was not in the room and was missing, and the NHA and Director of Therapy confirmed that the reacher should have been available to the resident.
Failure to Document and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for one resident who required oxygen therapy. The resident was cognitively intact and had diagnoses including respiratory failure, congestive heart failure, and pneumonia. Physician orders directed oxygen at 1-5 LPM via nasal cannula to keep pulse oximetry above 90 percent, with titration as needed for readings below 90 percent and/or shortness of breath. During multiple observations, the resident was found lying in bed with oxygen being delivered via nasal cannula at 3 LPM. However, there was no documented evidence in the clinical record that the facility was documenting the resident's oxygen use or checking pulse oximetry to ensure the resident was receiving the appropriate liter flow. The Assistant DON confirmed that the record lacked documentation showing oxygen use and pulse oximetry monitoring.
Failure to Document Dialysis Orders and Monitor Fistula
Penalty
Summary
The facility failed to follow its dialysis policy for Resident 61, a cognitively intact resident with end stage renal disease who required hemodialysis. The policy stated that when a resident requires dialysis, an order should be written for the dialysis, the place of treatment, port checks every shift and as needed, medications to be held prior to dialysis, and any specific dialysis orders including dietary restrictions, fluid restrictions, intake and output, and laboratory studies. Resident 61’s MDS assessment showed the resident required assistance with daily care needs and was receiving dialysis. The care plan indicated the resident had end stage renal failure and required hemodialysis, with staff to monitor the fistula and watch for signs or symptoms of infection and monitor bruit and thrill as per orders. Review of the clinical record, including medication and treatment administration records, found no documented evidence of orders for dialysis treatments showing when and where dialysis was scheduled, and no documented evidence that staff were monitoring the resident’s dialysis fistula site. The Nursing Home Administrator confirmed there was no documented evidence that the resident’s record included dialysis treatment orders or that the fistula was being monitored per the care plan.
Controlled Medication Accountability Not Maintained for Fentanyl Patch
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident who was cognitively intact, required extensive assistance with daily care needs, and had Parkinson's disease. The resident had physician's orders for a 25 mcg/hour fentanyl transdermal patch to be applied every 72 hours for pain management and removed per schedule. The facility policy stated that removal of fentanyl patches required two signatures to ensure proper disposal, but the controlled drug record and MAR for December 2025 and January 2026 did not show two signatures for removal and disposal of the patch on December 26, 2025 and January 5, 8, 11, and 14, 2026. The DON confirmed this lack of two signatures during interview. The resident later had a current order for a 37.5 mcg/hour fentanyl transdermal patch applied every 72 hours and removed per schedule. The controlled drug record showed that a 37.5 mcg/hour fentanyl patch was signed out on February 23, 2026, but the MAR for February 2026 had no documented evidence that the patch was administered on that date. The NHA confirmed there was no documented evidence that the fentanyl patch signed out on February 23, 2026 was administered to the resident.
Medication Error Rate Exceeded Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent after surveyor observations on February 26 and February 27, 2026 identified three medication administration errors in 38 opportunities for error, resulting in a 7.89 percent error rate. One error involved a resident with COPD who was ordered Trelegy Ellipta 100-62.5-25 mcg/act, with manufacturer directions stating the resident should rinse the mouth with water without swallowing after inhalation; after the LPN administered one puff, she gave the resident iced tea instead, and later stated she was not sure whether mouth rinsing was required. A second resident had orders for Xtandi 160 mg daily for prostate cancer and Ferrous Sulfate 325 mg daily. During medication administration, an LPN crushed the resident’s Ferrous Sulfate tablet and crushed one 40 mg Xtandi tablet before giving the medications. The same observation also showed the LPN administered only one 40 mg Xtandi tablet even though the order required 160 mg daily, and the medication was supplied as 40 mg tablets. The LPN later confirmed the medications should not have been crushed and that four 40 mg Xtandi tablets were needed to equal the ordered dose; the NHA and DON also confirmed the incorrect dose was given.
Missing Order for Straight Catheterization to Obtain Urine Specimen
Penalty
Summary
The facility failed to obtain a physician's order before performing a straight catheterization to collect a urine specimen for a urinalysis and culture and sensitivity for one resident. The resident's quarterly MDS dated February 12, 2026, identified the resident as cognitively intact and noted a diagnosis of urinary tract infection. Physician's orders dated June 24, 2025 included an order to obtain a urine specimen to rule out a urinary tract infection, and a progress note from that same date documented that staff performed a straight catheterization to obtain the specimen. There was no documented evidence that staff obtained a physician's order for the catheterization itself, and the Nursing Home Administrator confirmed that such an order should have been obtained.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility's QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed recurring problems identified in prior surveys. The current survey, ending February 27, 2026, found repeated deficiencies related to care plan revision, quality of care, services to prevent or heal pressure ulcers, a safe environment free of accident hazards, laboratory services, complete and accurate accounting of controlled medications, and infection control. The facility's prior plans of correction for the survey ending March 27, 2025, stated that audits would be completed and the results reported to the QAPI committee for review. Despite those plans, the current survey found that the QAPI committee was ineffective or failed to maintain compliance with the cited regulations, including care plan revisions under F657, quality of care under F684, pressure ulcer services under F686, accident hazard prevention under F689, laboratory services under F773, controlled medication accounting under F755, and infection control under F880.
Failure to Use Contact Isolation for Resident with C. difficile
Penalty
Summary
The facility failed to follow CDC guidance to reduce the spread of infections and prevent cross-contamination related to Clostridioides difficile infection for one resident. The facility policy on isolation and transmission-based precautions stated that contact precautions are to be used for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact or indirect contact with environmental surfaces or resident-care items, and that residents with diarrhea and suspected clostridium difficile are to be placed on contact precautions while awaiting laboratory results. A quarterly MDS assessment for the resident showed cognitive impairment, bowel incontinence, need for staff assistance with daily care needs, and diagnoses including high blood pressure and stroke. A nursing note documented that the resident tested positive for clostridium difficile, and a laboratory test confirmed the positive result. During observation, the resident was lying in bed and did not have contact isolation signs on the door. An LPN confirmed that the resident did not have contact isolation signs on the door and should have had them, and the NHA also confirmed that the resident did not have contact isolation signs on the door and should have had them.
Failure to Follow Insulin Administration Guidelines
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions for administering Insulin Lispro, resulting in a significant medication error for one resident. The manufacturer's directions specified that Insulin Lispro should be administered within 15 minutes before or immediately after a meal. However, a Licensed Practical Nurse administered 22 units of Insulin Lispro to a resident more than an hour before the meal was delivered. This deviation from the prescribed timing led to the resident experiencing a critically low blood sugar level, requiring medical intervention. The resident, who had a diagnosis of diabetes, was found with a blood sugar level of 35 mg/dL, which is significantly below the normal range. The resident exhibited symptoms of lethargy and diaphoresis and was minimally responsive. Emergency treatment with Glucagon was administered, and the resident's condition gradually improved as their blood sugar levels increased. The Nursing Home Administrator confirmed that the insulin should have been administered closer to the meal time, as per the manufacturer's instructions.
Failure to Follow Physician's Orders and Document Medication Administration
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice. For Resident 19, staff did not document obtaining the resident's blood pressure and heart rate before administering Metoprolol, as required by the physician's orders. Similarly, for Resident 41, there was no documented evidence that staff obtained the resident's blood pressure before administering Verapamil, which was necessary to determine if the medication should have been held. Resident 60, who had diabetes, did not receive the required accu checks on specific dates as per physician's orders. Additionally, the facility did not follow the bowel protocol for Resident 52, who experienced extended periods without bowel movements. Staff failed to administer the necessary laxatives and enemas as ordered by the physician, leading to non-compliance with the prescribed bowel management plan. For Resident 102, there was a lack of documented evidence that doses of Oxycodone-Acetaminophen were signed out on the controlled medication record, despite being recorded as administered on the MAR. This discrepancy indicates that the medication may not have been administered as documented. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these deficiencies in following physician's orders and documentation practices.
Failure to Document IV Catheter Flushing
Penalty
Summary
The facility failed to ensure proper care and maintenance of intravenous catheters for three residents, as evidenced by the lack of documented flushing of PICC lines with normal saline before and after medication administration. The facility's policy required flushing before and after each infusion, but this was not adhered to for the residents in question. Resident 1, who was cognitively intact and receiving IV medications, had multiple physician's orders for Vancomycin administration, yet there was no documented evidence of PICC flushing on the specified dates. Similarly, Resident 45 had physician's orders for a normal saline flush every shift for IV patency and was receiving IV Ceftriaxone. However, the MARs indicated that the required saline flushes were not documented on several occasions, and there was no evidence of flushing before and after Ceftriaxone administration. This lack of documentation was confirmed by the Nursing Home Administrator. Resident 255, admitted with a right knee infection and a PICC line, was also affected by this deficiency. Despite orders for a normal saline flush every shift and IV Ceftriaxone administration, there was no documented evidence of PICC flushing before and after medication administration. The Nursing Home Administrator confirmed the absence of documentation for the required saline flushes, indicating a systemic issue in following physician's orders and facility policy for IV catheter care.
Failure to Develop Comprehensive Care Plan for Resident's Tobacco Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 60, who was cognitively impaired and required assistance for daily care needs. The resident had diagnoses including high blood pressure and diabetes. During an observation, it was noted that the resident possessed two containers of smokeless tobacco and an empty milk carton used as a spittoon. Despite these observations, there was no documented evidence of a care plan addressing the resident's use of smokeless tobacco. This deficiency was confirmed through an interview with the Nursing Home Administrator.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect specific care needs for three residents. For Resident 48, the care plan did not include contact isolation precautions for ESBL, despite physician's orders and posted signage indicating the need for such precautions. The Director of Nursing confirmed the omission in the care plan. Resident 90's care plan inaccurately stated that her glasses were lost, although observations confirmed she had them in her possession. The Nursing Home Administrator acknowledged that the care plan should have been updated to reflect the current status of the resident's glasses. Resident 94's care plan inaccurately indicated that the resident was on Bumex, a medication that increases urination, despite no documented evidence in the clinical record that the resident was currently receiving this medication. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current medication status. These deficiencies highlight the facility's failure to maintain accurate and up-to-date care plans for residents, as required by their policies and regulatory standards.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that pressure ulcer dressing changes were completed as ordered for a resident, leading to a deficiency in care. The resident, who was dependent on staff for turning, transfers, and lower body care, had an unstageable pressure ulcer on the left heel and a diabetic foot ulcer on the right plantar heel. Physician's orders required cleansing of the wounds with wound cleanser and application of specific dressings. However, during an observation, an LPN applied dressings without cleansing the wounds, assuming the resident had been cleaned during morning care. This was confirmed by the LPN and the Nursing Home Administrator. The facility's policy required a no-touch care approach, ensuring wounds and surrounding skin were cleaned and dried with gauze without contamination. Despite the availability of wound cleanser, the LPN did not follow the prescribed procedure, resulting in a failure to adhere to the physician's orders. This oversight was acknowledged by the Nursing Home Administrator, confirming the deficiency in executing the required wound care treatments for the resident.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who was cognitively impaired and ambulatory with assistance. The resident, who was known to wander and self-propel in a broda chair, was found in the basement of the facility on two separate occasions. Despite these incidents, there was no documented evidence in the resident's clinical record indicating that interventions were implemented to prevent further occurrences. Interviews with facility staff revealed a lack of recognition of the incidents as elopements, as the resident did not leave the building. The Director of Nursing did not consider the resident's movement from the second floor to the basement as an elopement, indicating a potential gap in understanding or policy regarding resident safety and supervision. The absence of documented interventions highlights a deficiency in the facility's management and resident care policies.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. The policy for medication administration required that medications be administered following the 5 Rights, with an additional requirement for the right documentation. This includes signing out the narcotic on the controlled drug record before administration and recording the signature in the resident's Medication Administration Record (MAR) after the medication is taken by the resident. For Resident 102, who was cognitively intact and receiving an opioid medication for pain, there was a discrepancy in the documentation. The controlled drug records indicated that Oxycodone-Acetaminophen was signed out on two occasions, but there was no documented evidence in the MAR that the medication was administered. The Director of Nursing confirmed the lack of documentation for these doses, indicating a failure to adhere to the facility's medication administration policy.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store and label multi-dose containers of insulin and other medications according to manufacturer's instructions and facility policy. Specifically, for two residents, the facility did not date the opened pen injectors of Lantus and Lispro insulin, which are required to be dated upon opening and discarded after 28 days. Additionally, an opened bottle of Aplisol solution was found undated in the medication refrigerator, contrary to the manufacturer's instructions that require it to be discarded after 30 days of use. Furthermore, a Trelegy Ellipta inhaler for another resident was found opened and undated on the medication cart, despite the manufacturer's instructions to date the inhaler upon opening and discard it six weeks later. Interviews with nursing staff confirmed these deficiencies, acknowledging that the medications should have been dated when opened. These findings indicate a failure to adhere to proper medication storage and labeling protocols, as outlined in the facility's policy and the manufacturer's guidelines.
Failure to Obtain Laboratory Tests and Physician Orders for Invasive Procedures
Penalty
Summary
The facility failed to obtain laboratory studies as ordered by the physician for one resident and did not secure a physician's order for an invasive procedure to collect a specimen for laboratory tests for two other residents. For the first resident, who was cognitively intact and diagnosed with atrial fibrillation, the physician ordered a PT/INR test to monitor the therapeutic levels of Coumadin, a blood-thinning medication. However, there was no documented evidence that the PT/INR tests were completed as ordered, which was confirmed by the Nursing Home Administrator. For the other two residents, both of whom had renal insufficiency, the facility failed to obtain a physician's order for straight catheterization to collect urine specimens for UA/C&S tests. In one case, the urine was collected via straight catheterization without a documented physician's order. In the other case, an attempt was made to collect the urine specimen via straight catheterization due to incontinence, but the resident refused further attempts after two unsuccessful tries. The lack of documented physician's orders for these procedures was confirmed by the Director of Nursing and the Nursing Home Administrator.
Recurring Deficiencies in Care Plans, Accident Hazards, and Pharmacy Procedures
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in multiple surveys. The deficiencies were related to the revision of care plans, accident hazards, and pharmacy procedures, services, and records. Despite developing plans of correction that included quality assurance systems and audits, the facility did not maintain compliance with nursing home regulations. The deficiencies were first cited in a State Survey and Certification survey ending April 18, 2024, and a complaint investigation survey ending October 23, 2024, and were found again in the current survey ending March 27, 2025. Specifically, the facility failed to update residents' care plans, address accident hazards, and maintain proper pharmacy procedures, services, and records. The QAPI committee was responsible for reviewing audit results and ensuring compliance, but they did not successfully implement their plans. The repeated deficiencies were cited under F657 for care plans, F689 for accident hazards, and F755 for pharmacy procedures, indicating a systemic issue in the facility's quality assurance processes.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Sores
Penalty
Summary
The facility failed to adhere to infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to prevent the spread of infections and cross-contamination. Specifically, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with pressure sores or indwelling medical devices, as required by updated CMS guidance. Resident 47, who was cognitively impaired and had a Stage 3 pressure ulcer on the sacrum, did not have EBP in place, and there was no signage or PPE supplies outside her room. This was confirmed during an interview with the Nursing Home Administrator. Similarly, Resident 106, who was also cognitively impaired and had an unstageable pressure ulcer on the left heel and a diabetic foot ulcer on the right plantar heel, did not have EBP in place. Observations revealed that there was no signage or PPE supplies outside her room, and a Licensed Practical Nurse (LPN) failed to wear a gown while performing wound care. The Nursing Home Administrator confirmed that EBP should have been in place for Resident 106 due to the presence of pressure sores, and staff should have worn a gown during wound care.
Failure to Timely Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a change in condition for a resident. According to the facility's policy dated December 14, 2023, nurses are required to notify the resident's physician when there is a change in the resident's condition. However, for one resident who was severely cognitively impaired with diagnoses including dementia, depression, and Alzheimer's disease, this protocol was not followed. On September 13, 2024, at 9:30 p.m., staff observed that the resident was more confused than usual, exhibited abnormal behavior such as swearing and yelling, and had dark-colored, foul-smelling urine. Despite these observations, there was no documented evidence that the physician was notified at that time. The physician was only informed the following day, on September 14, 2024, at 5:24 p.m., after the resident's daughter expressed concerns about her mother's condition, suspecting a urinary tract infection. This resulted in a delay of approximately twenty hours before the physician was notified and a urine culture was ordered. An interview with the Nursing Home Administrator confirmed that the physician should have been notified sooner about the resident's change in mental and physical condition, as per the facility's policy.
Failure to Conduct RN Assessment After Change in Condition
Penalty
Summary
The facility failed to ensure that a registered nurse conducted an assessment after a change in condition for one of the residents. According to the Pennsylvania Code and the facility's policy, a registered nurse is required to assess, document, and update the physician when a resident experiences a change in condition. However, for a resident with severe cognitive impairment and diagnoses including dementia, depression, and Alzheimer's disease, there was no documented evidence of an assessment by a registered nurse after the resident exhibited increased confusion, swearing, and yelling, along with dark-colored, foul-smelling urine. On a subsequent day, the resident's daughter noted her mother's increased confusion and suspected a urinary tract infection, prompting a physician to order a urine culture. An interview with the Nursing Home Administrator confirmed the absence of a registered nurse's assessment for the resident's change in condition, which was required by both state regulations and the facility's policy.
Resident Injury Due to Improper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that residents were free from abuse or neglect, as evidenced by an incident involving a resident who was improperly transported in a wheelchair without leg rests. This resulted in the resident falling forward and sustaining a head injury that required sutures. The resident, who was cognitively impaired and required assistance for daily care needs, was being transported by a nurse aide while asleep in the wheelchair. The absence of leg rests, contrary to the facility's policy on wheelchair safety, led to the resident falling and hitting her head on the floor. The incident was witnessed by another nurse aide, who confirmed that the resident was being pushed without leg rests, leading to the fall. The facility's abuse policy required staff to be educated on preventing abuse and neglect, but in this case, the staff member failed to adhere to the policy, resulting in harm to the resident. The nursing home administrator confirmed that the nurse aide should have used leg rests during the transport, highlighting a lapse in following established safety protocols.
Failure to Ensure Wheelchair Safety Leads to Resident Fall
Penalty
Summary
The facility failed to maintain a safe environment for a resident, resulting in a fall that required medical attention. The resident, who was cognitively impaired and required assistance for daily care needs, fell out of her wheelchair and hit her head on the floor in the solarium. This incident occurred while the resident was being transported by a nurse aide without the use of leg rests on the wheelchair, which was against the facility's policy on wheelchair safety. The resident sustained a 2-centimeter laceration on the left side of her head and a bruised right eye, necessitating four sutures. The incident report and witness statement confirmed that the resident was asleep in the wheelchair when the fall occurred, and the nurse aide failed to apply the leg rests as required. The Nursing Home Administrator acknowledged that the leg rests should have been used during transportation.
Failure to Secure Mattress Leads to Resident Fall
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for a resident who experienced a fall. The resident, who was cognitively impaired and required extensive assistance with personal hygiene, had diagnoses including Alzheimer's disease and anxiety. On June 19, 2024, the resident was found on the floor with the mattress completely off the bed. An interview with the Nursing Home Administrator revealed that the housekeeper did not secure the mattress to the bed with straps, as required, after cleaning the room.
Failure to Properly Label, Date, and Secure Food Items
Penalty
Summary
The facility failed to ensure that food stored in the kitchen was labeled, dated, and secured. Observations in the walk-in freezer revealed a bag containing six chicken tenders that was not labeled, dated, or secured, and a bag containing five chicken patties that was dated but unsecured. Additionally, observations in the cook's cooler revealed approximately eighteen sausage patties in a box that was dated, but the bag holding the sausage patties was open and unsecured. Interviews with the Dietary Manager and the Nursing Home Administrator confirmed that all food items in the kitchen should be labeled, dated, and secured, as per the facility's policy dated December 14, 2023.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one of the residents reviewed. The facility's policy on cleaning and disinfecting required housekeeping to remove visible debris from surfaces to ensure a healthy environment. However, observations revealed that a fan in Resident 7's room, which was blowing directly on the resident, had a moderate amount of visible dirt and debris accumulated on the blade cover. This was observed on two separate occasions, and staff interviews confirmed that the fan should have been clean but was not. Resident 7 was cognitively impaired, required extensive assistance for daily care needs, and had diagnoses including pulmonary embolism and anemia. The resident's care plan indicated a potential for altered respiratory status and required oxygen as needed. Despite these needs, the fan, which was essential for the resident's comfort, was not properly cleaned, potentially compromising the resident's environment and care. Interviews with housekeeping and nursing staff, as well as the Nursing Home Administrator, confirmed the deficiency in maintaining the cleanliness of the fan.
Failure to Update Care Plan for Catheter Change
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in care needs for one of 32 residents reviewed. An annual Minimum Data Set (MDS) assessment for Resident 51 revealed that the resident was cognitively intact, required assistance with daily care needs, and had diagnoses including obstructive and reflux uropathy. The care plan for Resident 51, revised on February 16, 2024, indicated that the resident had an indwelling foley catheter size 16 French, 10 cc balloon. However, physician's orders dated February 2, 2024, included an order to change the size of the indwelling foley catheter to an 18 French, 10 cc balloon. There was no documented evidence in Resident 51's clinical record to indicate that her care plan was revised when the size of the indwelling foley catheter was changed. An interview with the Nursing Home Administrator confirmed that Resident 51's care plan should have been revised when the size of the indwelling foley catheter was changed.
Failure to Ensure Accident-Free Environment and Conduct Thorough Investigations
Penalty
Summary
The facility failed to ensure that the residents' environment remained as free of accident hazards as possible. Specifically, a resident who was cognitively intact and required extensive assistance for all care was observed being transported in a wheelchair without leg rests. The leg rests were in a bag hanging off the back of the wheelchair, and the LPN pushing the resident was aware that leg rests should be used. The Director of Nursing confirmed that staff should use leg/footrests when transporting residents in wheelchairs. Additionally, the facility failed to conduct thorough investigations for a cognitively impaired resident with a history of falls. The resident had multiple unwitnessed falls, and the witness statements for these incidents were photocopied and signed by multiple witnesses without individual accounts. There was no evidence of thorough investigations being conducted for these falls. The Nursing Home Administrator confirmed that witnesses needed to write statements in their own words, not just sign a photocopy of someone else's statement.
Failure to Display Oxygen-In-Use Signage
Penalty
Summary
The facility failed to ensure that a no smoking/oxygen-in-use sign was in place for a resident who was receiving oxygen therapy. The facility's policy, dated December 14, 2023, required that a sign be in place indicating that oxygen was in use. However, during observations on April 15 and April 16, 2024, it was noted that there was no signage on the resident's door frame indicating that oxygen was in use, despite the resident receiving oxygen at a flow rate of 2 liters per minute via nasal cannula. The resident in question was cognitively impaired and required extensive assistance from staff for daily care needs. The resident had diagnoses including pulmonary embolism and anemia, and physician's orders dated September 27, 2023, included orders for oxygen therapy as needed. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed that the resident was receiving oxygen and that there was no signage in place, which was against the facility's policy.
Failure to Maintain Accountability for Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident. The policy required that all narcotic patches be placed immediately in a sharps container when discarding and require a double signature. However, for Resident 64, who was cognitively intact and received routine pain medication including an opioid, there was no documented evidence of two signatures when the old Fentanyl patches were removed and discarded on multiple dates in January, February, and March 2024. The deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the absence of the required two witness signatures for the destruction of Fentanyl patches on the specified dates. This failure to adhere to the facility's policy regarding the handling of narcotic patches was identified during a review of policies, clinical records, and staff interviews.
Recurring Quality Deficiencies Due to Ineffective QAPI Committee
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct recurring quality deficiencies and ensure effective plans to improve the delivery of care and services. The deficiencies identified in the current survey included issues related to accident hazards/supervision/devices, respiratory care, pharmacy services/procedures/records, and food procurement/storage/prepare/serve-sanitary. These deficiencies were previously cited in surveys ending March 16, 2023, and March 12, 2024, and were supposed to be monitored by the QAPI committee as part of the facility's plans of correction. However, the current survey ending April 18, 2024, revealed that the QAPI committee was ineffective in maintaining compliance with these regulations, leading to repeated deficiencies in the same areas. Specifically, the facility's plan of correction for accident hazards/supervision/devices, cited under F689, respiratory care cited under F695, pharmacy services/procedures/records cited under F755, and food procurement/storage/prepare/serve-sanitary cited under F812, were all found to be ineffective. The QAPI committee's failure to maintain compliance with these regulations indicates a systemic issue in addressing and rectifying the cited deficiencies. The repeated nature of these deficiencies suggests that the corrective actions taken were insufficient or improperly implemented, leading to ongoing non-compliance with state and federal regulations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of ants and gnats in the kitchen area. Observations on April 15, 2024, revealed a large number of ants around the handwashing sink and several gnats in the same area. The Dietary Manager was unaware of the ants but acknowledged the presence of gnats and confirmed that such pests should not be in the kitchen. The Maintenance Director indicated that the pest control company was last on-site on February 27, 2024, and was scheduled to return on April 24, 2024. He mentioned that the facility has a good working relationship with the pest control company and that they visit four times a year or as needed. Despite these measures, the presence of pests persisted, particularly due to recent rain pushing ants and spiders to the surface. He also confirmed that ants and gnats should not be around the handwashing sink in the kitchen. The Nursing Home Administrator confirmed that the presence of ants and gnats in the kitchen is unacceptable. The facility's policy on pest control, dated December 14, 2023, states that treatment will be rendered as required to control insects. However, the observations and staff interviews indicate that the facility did not effectively implement this policy, leading to the deficiency. The report cites specific regulations under 28 Pa. Code 207.2(a) and 28 Pa. Code 201.18(e)(2)(3) that were not adhered to, highlighting the administrator's responsibility and management's failure to maintain a pest-free environment in the kitchen area.
Breach of Resident Privacy Due to Unauthorized Photograph
Penalty
Summary
The facility failed to maintain the personal privacy of a resident, identified as Resident 2, who was cognitively impaired and had a diagnosis of dementia. The incident involved a violation of the facility's cell phone usage policy, which prohibits staff from using cell phones in resident care units and from taking photographs of residents. Despite these policies, Nurse Aide 1 took a picture of Resident 2 while he was sitting on the toilet, with his pants pulled up almost entirely, exposing a small portion of his upper leg. The picture, which did not include the resident's face, was then posted on social media. The investigation confirmed that Nurse Aide 1 took the picture and posted it online, as corroborated by statements from both Nurse Aide 1 and Nurse Aide 2, who saw the picture on social media. The Nursing Home Administrator confirmed the incident and reiterated that employees were not allowed to take pictures of residents on their cell phones. This breach of privacy was identified as a deficiency in the facility's adherence to resident rights and privacy regulations.
Resident Mental Abuse Due to Unauthorized Photograph
Penalty
Summary
The facility failed to protect a resident from mental abuse, as evidenced by an incident involving a nurse aide. The facility's abuse policy, dated December 14, 2023, outlined procedures for preventing and addressing abuse, including prohibiting the use of cell phones in resident care areas and forbidding the photographing of residents. Despite these policies, Nurse Aide 1 took a picture of a cognitively impaired resident, who was sitting on the toilet, and posted it on social media. The resident, identified as having dementia and being frequently incontinent, was photographed from the waist down, with a small portion of the upper leg exposed. The incident was confirmed through investigative interviews with both Nurse Aide 1 and Nurse Aide 2, who saw the picture on social media. The Nursing Home Administrator also confirmed the incident, acknowledging that employees were not allowed to take pictures of residents. This breach of policy resulted in a failure to ensure the resident's right to be free from mental abuse, as outlined in the facility's policies and state regulations.
Failure to Accurately Document and Perform Wound Treatment
Penalty
Summary
The facility failed to ensure that a nurse documented treatments accurately for one of the residents reviewed. Specifically, a Licensed Practical Nurse (LPN) documented that a treatment to cleanse and dress a resident's left shin wound was completed on a certain date. However, an investigation revealed that the treatment had not been performed as the dressing was found to be intact and dated two days prior. This discrepancy was confirmed by the Nursing Home Administrator during an interview. The resident's clinical records and the LPN's personnel file were reviewed, revealing that the LPN had falsely documented the completion of the treatment. The physician's order required the treatment to be performed every other day, but the LPN failed to follow this order and inaccurately recorded the treatment as completed. This failure to document and perform the treatment as ordered led to the citation of the deficiency.
Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by not following physician's orders for two residents. For Resident 4, a physician's progress note recommended the application of 0.025 percent Triamcinolone cream to a rash on the resident's back twice a day. However, there was no physician's order entered into the electronic medical record, and the Treatment Administration Record for January and February 2024 showed no evidence that the cream was applied. This was confirmed by an interview with Registered Nurse 2, who admitted to missing the physician's order, and the Nursing Home Administrator, who confirmed the resident did not receive the recommended treatment. For Resident 6, the care plan indicated a potential for pressure ulcer development, and physician's orders required the application of Xeroform gauze and border foam dressing to an abrasion on the resident's left shin every other day. However, a disciplinary action revealed that the treatment was not performed as ordered on January 14, 2024, as the dressing was found intact with a date of January 12, 2024. This failure was confirmed by the Nursing Home Administrator, who acknowledged that the Licensed Practical Nurse did not complete the treatment as ordered.
Failure to Ensure Chair Alarm Placement Leads to Resident Fall
Penalty
Summary
The facility failed to provide an environment free of accident hazards for Resident 6, who was at risk for falls due to weakness, balance problems, and poor safety awareness. Despite physician's orders requiring bed and chair alarms to be checked every shift, the resident fell on November 22, 2023, because the chair alarm was not placed on his wheelchair after being transferred by therapy staff. The resident was found on the floor beside his wheelchair with no injuries, and it was confirmed that the chair alarm was missing at the time of the fall. The fall investigation revealed that therapy staff did not place the chair alarm on the resident's wheelchair after transferring him from his recliner. This oversight was confirmed by the Nursing Home Administrator, who acknowledged that therapy staff should have ensured the alarm was in place. The deficiency was cited as past non-compliance, and the facility took corrective actions to address the issue, including re-educating therapy staff and conducting a whole-house assessment of alarm placements.
Incomplete and Inaccurate Documentation of Resident's Clinical Records
Penalty
Summary
The facility failed to ensure that residents' clinical records were complete and accurately documented for one of the residents reviewed. Specifically, a physician's order for a resident required staff to cleanse the resident's left shin with wound cleanser, apply Xeroform gauze, and secure it with a border foam dressing every other day. However, the treatment was not performed as ordered on one of the specified days. The resident's Treatment Administration Record (TAR) indicated that the treatment had been completed, but an investigation revealed that the dressing was still intact from a previous date, indicating the treatment had not been performed as documented. The deficiency was confirmed through a review of the resident's clinical records, personnel files, and staff interviews. The Licensed Practical Nurse (LPN) responsible for the treatment documented that the treatment was completed, but an intact dressing from a previous date indicated otherwise. This discrepancy was discovered by the wound nurse, leading to a disciplinary action against the LPN and confirmation from the Nursing Home Administrator that the treatment was not performed as ordered and was inaccurately documented in the resident's TAR.
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 201 citations issued within 25 miles in the last 12 months — including the 2 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.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Windber
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richland Nursing And Rehab | 2.5 mi | ★★★★★ | 12 | 0 |
| Laurel View Village | 3.2 mi | ★★★★★ | 7 | 0 |
| Concordia At Arbutus Park | 3.3 mi | ★★★★★ | 14 | 0 |
| Quality Life Services - Westmont | 6.8 mi | ★★★★★ | 4 | 0 |
| Heritage Ridge Senior Living At Johnstown | 6.9 mi | ★★★★★ | 21 | 1 |
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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.