Woodhaven Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroeville, Pennsylvania.
- Location
- 2400 Mcginley Road, Monroeville, Pennsylvania 15146
- CMS Provider Number
- 395653
- Inspections on file
- 35
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Woodhaven Health & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to provide needed ADL assistance and timely call light response for multiple residents. One resident was observed near the nurses’ station inadequately dressed, with unkempt hair and crusting around the mouth. In another room, two residents were heard yelling for staff while their call light alarmed on the monitor for over 17 minutes, despite nurse aides and an LPN being present on the unit. During mealtime, a nurse aide was on a personal phone call while feeding a resident, and another resident, unable to manage meal packets independently, had to ask the surveyor to open and apply salt, ketchup, and salad dressing because staff had not set up the lunch tray. Staff and the administrator confirmed that these residents required assistance and that such assistance had not been provided.
Surveyors found that the facility did not follow its own Covid-19 transmission-based precautions and state guidance for many residents with active infections. Documentation showed a large number of residents on one unit were Covid-positive, yet observations revealed open room doors where doors were required to be closed, missing or incorrect isolation signage, and PPE caddies without N95 or other masks. Some rooms with infected residents had only Enhanced Barrier Precautions signage or no signage at all, while one room displayed Covid-19 precautions despite no documentation of infection for the current or former occupant. These failures in room restriction, signage, and PPE availability affected a substantial portion of the unit’s residents.
A resident with diabetes, hypertension with heart failure, and chronic kidney disease, who required max assist x2 for transfers and assistance of two for bed mobility, fell from bed during a full bed bath when the NA turned away to obtain supplies after positioning the resident on their side. The resident rolled out of bed, struck a nearby chair, and then the floor, sustaining facial lacerations and subconjunctival bleeding while reporting double vision and eye pain. Review of records and staff interviews confirmed the facility failed to provide adequate supervision during bed mobility, resulting in this incident being cited as past noncompliance.
Two residents did not receive appropriate care and services for activities of daily living and behavioral management. One resident, fully dependent for bed mobility, fell during a dressing change when only one staff member was present, contrary to care plan requirements. Another resident with dementia and a subdural hemorrhage exhibited new behavioral disturbances, but there was no documentation that a physician was notified or that care plans were updated, and the resident later sustained injuries from a fall.
A resident with a history of atrial fibrillation, COPD, and diabetes experienced significant weight gain and symptoms of heart failure, but staff failed to document, address, or update the care plan for heart failure. Orders for weights and Lasix were present, but the resident's changing condition was not adequately monitored or communicated to the physician, resulting in a lack of appropriate intervention.
A resident with intellectual disabilities and complex medical needs was repeatedly sent to medical appointments without a required caregiver, resulting in missed treatments, appointment cancellations, and distress for the resident. Despite multiple communications from providers and acknowledgment by facility staff, the facility failed to ensure appropriate support and services were provided.
A resident with advanced cancer, end stage renal disease, and severe cognitive impairment missed multiple medically necessary appointments, including Faslodex injections and diagnostic procedures, due to the facility's failure to schedule appointments and provide required transportation or an escort. Staff and provider documentation confirmed repeated cancellations and missed visits, with the DON and administrator acknowledging the ongoing issue.
The facility failed to notify physicians and assess for hyperglycemia and hypoglycemia in multiple residents with diabetes, despite repeated blood glucose readings outside of ordered parameters. This lack of timely intervention and documentation led to immediate jeopardy, with some residents requiring hospital transfer for severe hypo- or hyperglycemic events.
Surveyors identified that several MDS assessments were inaccurate or incomplete, including incorrect coding of cognitive and mood status, omission of active diagnoses such as bipolar disorder and dementia, and failure to document special treatments like hospice care and oxygen therapy. In one instance, an outdated weight was used for a resident's nutritional assessment. These deficiencies were confirmed by facility leadership.
The facility did not develop or implement complete care plans for several residents, omitting necessary goals and interventions for conditions such as dementia, bipolar disorder, PTSD, depression, hospice care, and oxygen therapy. Some residents' care plans failed to address all active diagnoses or personal preferences, and observations showed that residents' needs for social interaction and specific treatments were not consistently met.
The facility did not ensure that the activities component of the comprehensive assessment was accurately completed for residents with severe cognitive impairment. Staff consistently documented that all activity preference questions were answered as 'Very Important' by the resident, even when residents were unable to communicate due to cognitive status, and did not seek input from family or staff as required.
The facility did not provide documentation that monthly medication regimen reviews by a licensed pharmacist were completed for two residents, as required. This deficiency was confirmed through record review and staff interviews, which showed that the necessary reviews and documentation were not performed over a six-month period.
Two residents experienced a lack of dignity during care: one was left exposed during a nursing assessment without privacy measures in place, and another was told to wait or use a brief instead of being assisted to the bathroom, despite his and his spouse's requests. These actions were confirmed by facility leadership as not maintaining resident dignity.
The facility did not display required written information about applying for Medicare and Medicaid benefits or obtaining refunds for previous payments covered by these programs on both nursing floors, as confirmed by observations and the NHA.
The facility did not consistently obtain or act upon residents' weights as required, resulting in unaddressed significant weight changes for several residents with complex medical conditions such as diabetes, dementia, and recent fractures. Despite physician orders and facility policy, weights were missed or not followed up by the physician or RD, and staff interviews confirmed the lack of monitoring and intervention.
A resident with multiple diagnoses, including COPD, was observed receiving oxygen therapy without a provider's order, proper care planning, or documentation of oxygen needs in the MDS. Facility leadership confirmed that clinician competence, provider orders, and care planning requirements for oxygen administration were not met.
The facility did not consistently complete or maintain required dialysis communication forms for two residents dependent on hemodialysis, resulting in multiple instances of missing or incomplete documentation as required by facility policy and physician orders. The DON confirmed the lack of consistent communication between the facility and the dialysis provider.
A resident with dementia, anemia, and a history of stroke experienced significant weight loss, but the physician did not verify or address this change in the clinical record. Progress notes and physician documentation failed to show that the weight loss was evaluated or managed, and the medical director relied on nursing staff to communicate such changes. The facility confirmed the physician did not review the resident's total program of care as required.
A resident with a history of depression and ongoing behavioral symptoms, including verbal aggression, threats, and physical altercations, did not receive necessary behavioral health care or services. Despite repeated incidents and documentation of disruptive behaviors, the facility did not provide or arrange for behavioral health interventions, nor did it update the care plan to address these needs, as confirmed by facility leadership.
A resident with a diagnosis of depression and a history of behavioral disturbances, including verbal aggression, threats of self-harm, and physical aggression, did not receive appropriate behavioral health services as required by facility policy. Despite multiple documented incidents and ongoing behavioral symptoms, the care plan did not address behavioral health needs, and there was no evidence of referral or provision of behavioral health interventions. Facility leadership confirmed this failure during interviews.
A resident with depression, morbid obesity, diabetes, and a history of behavioral issues—including aggression, threats of self-harm, and verbal abuse—did not receive timely or adequate social services. Despite repeated incidents and physician orders for social services consultation, documentation showed only routine assessments and no evidence of behavioral health interventions or referrals. Facility leadership confirmed the lack of sufficient social services to address the resident's needs.
Surveyors found multiple expired medications and biologicals stored alongside current stock in a medication room. An LPN confirmed the expired status of these items, and both the administrator and DON acknowledged the failure to properly store and separate expired drugs and biologicals as required by facility policy.
The facility failed to assess and care plan for the self-administration of medications for three residents. Observations showed a resident with a medicine cup on its side with pills, another with a cup containing a pill, and a pill on the floor in a third resident's room. Clinical records lacked assessments or care plans for self-administration, confirmed by the Nursing Home Administrator.
The facility failed to provide sufficient nursing staff, affecting 16 residents. Observations and interviews revealed delayed call light responses, inadequate personal care, and missed meals. Residents reported long wait times for assistance, with some call lights unanswered for up to two hours. Grievances highlighted issues like missed showers and insufficient staff presence, confirmed by the Nursing Home Administrator.
A resident with type 2 diabetes received her morning dose of insulin aspart significantly later than the scheduled time, contrary to the facility's medication administration policy. The LPN confirmed the late administration, and the Nursing Home Administrator acknowledged the error, noting that insulin administrations are not subject to the facility's flexible medication policy.
Woodhaven Health and Rehab Center failed to notify a resident's family about a significant decline in the resident's health status, specifically regarding a worsening pressure ulcer. Despite the facility's policy, there was no evidence that the family was informed of the condition change, which was confirmed by the Nursing Home Administrator and the DON.
The facility failed to ensure the Activities Department was directed by a qualified professional. The Life Enrichment Director was hired without the necessary qualifications and performed duties unsupervised, as confirmed by the DON and the director herself.
The facility failed to provide two residents with the opportunity to formulate an advance directive, as required by their policy. Despite having significant medical conditions, the clinical records for these residents did not include documentation of being offered the chance to create an advance directive. This was confirmed by the DON and a social worker during an interview.
Failure to Provide Timely ADL Assistance and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide needed assistance with activities of daily living (ADLs) and to respond promptly to call lights for multiple residents. Facility policy dated 6/27/24 required staff to respond to call lights promptly. During observation, one resident was seated in a wheelchair near the nurses’ station wearing only a gown tied at the neck but pulled forward off the shoulders, with unkempt hair and crusting around the mouth, indicating a lack of grooming and dressing assistance. On the same day, another room’s residents were heard yelling for staff from behind a closed door while staff, including nurse aides and an LPN, were present on the unit. The call light monitor at the nurses’ station showed that this room’s call light had been alarming for at least 17 minutes and was still alarming at 21 minutes when the surveyor left the floor. Additional observations showed failures to assist with ADLs during mealtime. One nurse aide was observed engaged in a personal phone conversation while feeding a resident, indicating inattention during feeding assistance. Another resident called out to the surveyor for help with opening and applying multiple meal-related items, including a salt packet for french fries, a ketchup packet, and a salad dressing packet for a salad. A nurse aide later confirmed that this resident was unable to perform these tasks independently and that staff had not set up the lunch tray for the resident. The Nursing Home Administrator confirmed that the facility failed to provide ADL assistance for five of eleven residents reviewed, in violation of 28 PA Code 201.18(b)(2) Management and 201.29(a) Resident’s Rights.
Failure to Implement Covid-19 Transmission-Based Precautions and PPE Practices
Penalty
Summary
Surveyors identified that the facility failed to implement its infection prevention and control program and transmission-based precautions for residents with active Covid-19 infections on one nursing unit. Facility policy required that when airborne precautions are needed and an AIIR is not available, residents be placed in private rooms with doors closed, appropriate signage posted, and staff provided with N95 or higher-level respirators. The Pennsylvania Department of Health Respiratory Virus Outbreak Toolkit further directed masking of HCP, residents, and visitors during respiratory virus outbreaks and specified airborne, contact, and eye protection for SARS-CoV-2, including closed doors, fit-tested N95 respirators, gowns, gloves, and dedicated or disinfected equipment. Facility-provided documentation showed that 18 of 28 residents on the Two South unit were Covid-19 positive, and the facility’s own Covid-19 signage required hand hygiene, use of gown, N95 or PAPR, eye protection, gloves for high-contact care, and keeping doors closed. During observations on the Two South unit, multiple instances of noncompliance with these requirements were found. Several rooms housing residents with active Covid-19 infections had doors open, including rooms with one or both residents Covid-positive. In multiple cases, there was no Covid-19 or transmission-based precautions signage posted on or near the doors, or only Enhanced Barrier Precautions signage was present despite active Covid-19 infection. PPE caddies on some Covid-positive residents’ doors lacked N95 masks or any masks at all, and one room with a Covid-positive resident had no PPE caddy. One room displayed Covid-19 precautions signage even though neither the current resident nor the former roommate was documented as Covid-positive in the medical record. In total, these observations showed failures in door closure, appropriate signage, and availability of required PPE for residents with active Covid-19 infections, affecting 21 of 28 residents on the unit. The Nursing Home Administrator confirmed the facility failed to ensure an environment free from the potential spread of infection for these residents.
Inadequate Supervision During Bed Mobility Leading to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision during bed mobility for one resident during personal care, resulting in a fall from bed. The resident had been newly admitted with diagnoses including diabetes, hypertension with heart failure, and chronic kidney disease. On admission, documentation indicated the resident required maximum assistance of two staff for transfers and assistance of two for bed mobility to roll. During a full bed bath, a nursing assistant pulled the resident toward her and turned the resident onto his side, then turned away to get a sheet and brief. While the assistant’s attention was diverted, the resident reached for a nearby chair, struck the chair, and then fell to the floor. A progress note documented that the resident rolled out of the left side of the bed during personal care, hit his face on the armrest of a chair at the head of the bed, and then hit the floor. The resident was observed lying supine with head and shoulders resting against the chair, with moderate bleeding from a laceration on the bridge of the nose, a laceration below the right eye, and subconjunctival bleeding in the right eye. The resident was able to state full name and date of birth and complained of double vision and pain in the right eye. Based on review of facility policies, clinical records, and staff interviews, the facility acknowledged that it failed to provide adequate supervision during bed mobility for this resident, and this was cited as past noncompliance.
Failure to Provide Appropriate ADL Care and Behavioral Management
Penalty
Summary
The facility failed to provide appropriate care and services to two residents who required assistance with activities of daily living (ADLs). For one resident with hemiplegia, arthritis, and a pressure ulcer, the clinical record and staff interviews revealed that the resident was totally dependent on staff for bed mobility and transfers. During a dressing change, the resident was positioned near the edge of the bed and slid off onto the floor. Documentation indicated that only one staff member was present during the procedure, despite the resident's care plan and assessment indicating total dependence, which would require two staff members to safely provide care and maintain the resident's position. The facility's post-fall documentation was incomplete, failing to note whether side rails were in place or if current interventions were followed. Another resident with a history of subdural hemorrhage and dementia exhibited new behavioral disturbances, including confusion, agitation, yelling, grabbing staff, and attempting to leave the facility. Despite these changes, the clinical record did not document that the physician or an alternate provider was notified of the resident's altered behavior, which was not typical for this individual. The resident subsequently fell, sustaining injuries that required hospital evaluation. The facility's documentation and care planning did not reflect the new behavioral symptoms or appropriate interventions in response to the resident's condition. Interviews with facility leadership confirmed that the facility did not provide the necessary treatment and services related to ADLs for these two residents. The deficiencies were identified through review of facility documents, clinical records, and staff interviews, and were cited under 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.
Failure to Provide Heart Failure Treatment and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and services related to heart failure for one resident who had a history of atrial fibrillation, COPD, and diabetes. Despite a significant and rapid weight gain of 17 pounds over three days, and subsequent continued weight increases, there was no documentation in the clinical record or progress notes that this change was recognized or addressed by nursing or medical staff. The resident's care plan did not include goals or interventions for heart failure after the diagnosis was made, and the diagnosis was not added to the facility's diagnosis list. Orders for weights and diuretic medication (Lasix) were present, but the monitoring and response to the resident's changing condition were inadequate. Multiple provider and nursing notes failed to reference or address the resident's substantial weight gain and associated symptoms, such as increased lower extremity edema, respiratory distress, and confusion. The facility's staff did not document or communicate the full extent of the weight gain to the physician, and there was a lack of timely intervention or adjustment of the care plan in response to the resident's deteriorating condition. The deficiency was confirmed by the Nursing Home Administrator and Director of Nursing during interviews.
Failure to Provide Required Support and Services for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to ensure that a resident with intellectual disabilities received appropriate treatment and services to support their highest practicable mental and psychosocial well-being. The resident, who had diagnoses including end stage renal disease, breast and lung cancer, and intellectual disabilities, was repeatedly sent to medical appointments without a caregiver or attendant, despite documented needs and multiple communications from external providers. Provider notes indicated that the resident was left at the front door of the cancer center alone, experienced fear and distress when unaccompanied, and was unable to receive necessary treatments on at least one occasion due to the absence of a facility staff member. The facility was repeatedly informed by providers that a caregiver was required to accompany the resident, but failed to consistently provide this support. Additionally, the facility failed to ensure that the resident attended scheduled medical appointments, resulting in missed treatments and multiple appointment cancellations due to the lack of an escort. Staff interviews and provider documentation confirmed ongoing issues with the facility's failure to send a caregiver and to facilitate the resident's attendance at appointments. The Nursing Home Administrator acknowledged that the facility did not schedule ordered appointments and did not ensure that residents with intellectual disabilities received appropriate services as required.
Failure to Schedule Appointments and Provide Transportation for Medically Complex Resident
Penalty
Summary
The facility failed to schedule medically necessary appointments and provide transportation for a resident with significant medical needs, including end stage renal disease, breast and lung cancer, and intellectual disabilities. The resident had a documented severe cognitive impairment, as indicated by a BIMS score of 03. Multiple provider notes and appointment records show that the resident missed numerous scheduled appointments for Faslodex (fulvestrant) injections, CT scans, and urology follow-ups due to the facility either not scheduling the appointments, cancelling them, or failing to provide an escort or transportation. Communication between the facility and outside providers repeatedly referenced missed or cancelled appointments, with staff acknowledging the ongoing issue and the need for a caregiver to accompany the resident. The appointment history from April through August shows a pattern of cancelled or missed appointments, including essential cancer treatments and diagnostic procedures. Provider notes document that the facility cancelled several appointments due to lack of an escort and failed to ensure the resident attended scheduled visits. During an interview, the Nursing Home Administrator confirmed the facility's failure to schedule ordered appointments and provide transportation for the resident, resulting in the deficiency.
Failure to Notify Physicians and Assess for Diabetic Emergencies
Penalty
Summary
The facility failed to notify physicians of elevated or decreased capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for six residents. Facility policy required staff to report complications such as hypoglycemia and to notify providers of significant changes in blood glucose levels, but multiple instances were found where blood sugar values outside of ordered parameters were not communicated to physicians or followed up on. For example, one resident had numerous blood glucose readings above 400 mg/dL over several months without documentation of physician notification or follow-up, despite physician orders to notify for values above 400 mg/dL. Another resident experienced a severe hypoglycemic event, with a blood sugar of 31 mg/dL, and was transferred to the hospital, but there was no evidence of timely intervention or notification as required by policy and physician orders. Several other residents with diabetes had repeated episodes of blood glucose levels outside of the parameters set by their physicians, with no documentation of notification or follow-up. These included blood glucose readings both above and below the thresholds that should have triggered immediate action according to facility policy and physician orders. In some cases, residents were admitted to the hospital for complications related to hyperglycemia or hypoglycemia, and documentation showed that staff failed to recognize or respond to these acute changes in condition as required. The facility's own policies, as well as manufacturer instructions for glucometers and insulin, outlined clear procedures for monitoring, documenting, and responding to abnormal blood glucose levels. However, review of clinical records, staff interviews, and policy documents revealed that these procedures were not consistently followed. The failure to notify physicians and assess residents for acute diabetic complications directly contributed to adverse outcomes and placed residents in immediate jeopardy.
Inaccurate and Incomplete MDS Assessments Identified
Penalty
Summary
The facility failed to ensure that comprehensive Minimum Data Set (MDS) assessments were accurate and fully completed for several residents. Specific deficiencies included incorrect or incomplete coding in multiple MDS sections: cognitive patterns (Section C), mood (Section D), active diagnoses (Section I), swallowing/nutritional status (Section K), and special treatments, procedures, and programs (Section O). For example, residents who were sometimes or usually understood were incorrectly coded as rarely understood, resulting in the omission of required cognitive and mood interviews. Additionally, active diagnoses such as bipolar disorder, post-traumatic stress disorder, and dementia were not documented in the MDS for residents with those conditions, despite supporting clinical records and psychiatric evaluations. Further, the facility failed to accurately document special treatments and services, such as hospice care and continuous oxygen therapy, for residents who were actively receiving these interventions. In one case, a resident's weight used for the MDS assessment was outdated by more than 30 days, contrary to requirements. These findings were confirmed by interviews with the Registered Nurse Assessment Coordinator and the Nursing Home Administrator/Director of Nursing, who acknowledged the incomplete and inaccurate MDS assessments for multiple residents.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for five out of twelve residents reviewed. Facility policy requires an interdisciplinary care plan for every resident, updated as needed and in accordance with state and federal requirements. However, documentation revealed that for several residents, care plans did not include goals and interventions for all active diagnoses or care needs. For example, one resident with a diagnosis of dementia did not have dementia care addressed in their care plan, despite the diagnosis being present for several months. Another resident with bipolar disorder and PTSD did not have these conditions included in their care plan, even though they were documented in psychiatric evaluations and the facility's diagnosis list. Additional deficiencies were noted for residents with complex medical and psychosocial needs. One resident with a history of depression and documented behavioral incidents, including verbal aggression and self-harm threats, did not have a care plan addressing depression, despite being prescribed medication for this condition. Another resident with a diagnosis of depression, cancer of the colon, and COPD did not have care plans for hospice care or oxygen therapy, even though orders for these services were present in the clinical record. Observations also indicated that a resident who valued group activities was repeatedly found alone in their room, suggesting a lack of individualized activity planning in accordance with their preferences. Interviews with facility leadership confirmed the failure to develop and implement comprehensive care plans for the identified residents. The deficiencies were cited under state regulations for resident care policies and nursing services, as the care plans did not reflect all current diagnoses, treatments, and resident preferences as required.
Failure to Accurately Assess and Document Resident Activity Preferences
Penalty
Summary
The facility failed to ensure that the Activities Director accurately completed, directed, or delegated the accurate completion of the activities component of the comprehensive assessment for residents, particularly those with severe cognitive impairment. Review of facility documents, clinical records, and staff interviews revealed that for 28 residents with severe cognitive impairment, there was no attempt to obtain information on resident preferences from family, significant others, or staff interviews, as required when residents are unable to communicate their preferences directly. Instead, the assessments consistently documented that all activity preference questions were answered as 'Very Important' and that this information was obtained from the resident, even when the resident's cognitive status indicated they were unable to reliably communicate such preferences. Analysis of the Minimum Data Set (MDS) comprehensive assessments showed a pattern of uniform responses. Of the 100 assessments reviewed, 66 were completed by the Activities Director, with 92.4% of these having all answers marked as 'Very Important.' Similar patterns were observed in assessments completed by other staff, with a high percentage of uniform responses and little variation, regardless of the resident's cognitive ability. In several cases, residents had BIMS scores indicating severe cognitive impairment or were rarely understood, yet the documentation still reflected that all preferences were obtained directly from the resident and marked as 'Very Important.' Interviews with the Activities Director confirmed responsibility for completing the activities component of the MDS and acknowledged the uniformity of responses, attributing it to the answers provided during interviews. However, there was no evidence that alternative sources, such as family or staff, were consulted for residents unable to communicate their preferences. The deficiency was communicated to the Nursing Home Administrator, highlighting the facility's failure to follow required procedures for accurately assessing and documenting resident activity preferences, especially for those with severe cognitive impairment.
Failure to Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide documentation that a licensed pharmacist performed monthly medication regimen reviews (MRR), including review of the medical chart, for two of five residents during the period from January through June 2025. Clinical record review and staff interviews confirmed that the required MRRs were not completed or documented as required by facility policy and state regulations. The deficiency was identified when surveyors requested MRR documentation for the specified residents and the facility was unable to provide evidence that these reviews had been conducted at least monthly.
Failure to Maintain Resident Dignity During Care and Bathroom Assistance
Penalty
Summary
The facility failed to maintain resident dignity for two residents as evidenced by direct observations and interviews. For one resident with diagnoses of heart failure and dementia, a nurse was observed examining the resident's stomach while the resident's gown was pulled up, without the privacy curtain or room door closed, allowing visibility from the hallway. This compromised the resident's privacy during care. Another resident with anoxic brain injury, atrial fibrillation, and diabetes reported, along with his spouse, that after requesting assistance to use the bathroom, staff told him to wait until after lunch service and suggested he use his brief instead. The spouse's offer to assist was declined, and the resident had to hold his need to use the bathroom. These incidents were confirmed by the Nursing Home Administrator and Director of Nursing as failures to provide care in a manner that maintains resident dignity.
Failure to Display Medicare and Medicaid Application Information
Penalty
Summary
The facility failed to display written information regarding how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by these programs on both the First Floor and Second Floor nursing units. This deficiency was identified during observations conducted on both nursing floors, where the required information was not present. The Nursing Home Administrator confirmed during an interview that the facility did not have the necessary written information displayed as required by regulations.
Failure to Monitor and Address Resident Weight and Nutrition Status
Penalty
Summary
The facility failed to properly monitor and address the nutritional status and weight changes of four residents, as required by its own policies and physician orders. The policy specified that residents' weights should be obtained upon admission, weekly for the first four weeks, and monthly thereafter, or more frequently if at risk. However, clinical record reviews revealed that weights were either not obtained as ordered or significant weight changes were not acted upon or verified for accuracy. For example, one resident experienced a sudden weight gain of 29 pounds in one month, which was noted by a nurse practitioner but not addressed by the physician or registered dietitian. Another resident had a documented weight loss from 175 to 125.8 pounds over a short period, with no evidence that this loss was verified or evaluated by clinical staff. Additional residents also had inconsistent or missing weight documentation, with no follow-up or intervention from the physician or registered dietitian despite notable fluctuations. In several cases, weights were not recorded for scheduled intervals, and when significant changes were documented, there was no evidence in the clinical records that these changes were reviewed or that a plan of care was developed. Interviews with the medical director and registered dietetic technician confirmed that the facility did not consistently monitor or respond to weight changes for multiple residents. The residents involved had complex medical histories, including diagnoses such as diabetes, dementia, stroke, metabolic encephalopathy, COPD, anemia, and recent fractures. Despite these risk factors, the facility did not ensure that weights were obtained or that significant changes were addressed, as required by policy and physician orders. This lack of monitoring and intervention was confirmed by both clinical record review and staff interviews.
Failure to Provide Appropriate Respiratory Care and Oxygen Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for one resident. Review of the facility's policy indicated that only licensed clinicians with demonstrated competence should administer oxygen as ordered by a provider, and in emergencies, a provider's order should be obtained as soon as possible. However, for the resident in question, the need for oxygen was not documented in the resident's orders, baseline care plan, or admission Minimum Data Set (MDS), despite the resident having diagnoses such as diabetes, COPD, obstructive and reflux uropathy, and high blood pressure. Observations showed the resident was using a nasal cannula with oxygen administered on two separate occasions, but there was no evidence of a provider's order or care planning related to oxygen use. Interviews with the DON and NHA confirmed that the facility did not ensure clinician competence in administering oxygen, failed to obtain a provider's order, and did not document the resident's oxygen needs in the care plan or MDS.
Failure to Maintain Consistent Dialysis Communication for Residents
Penalty
Summary
The facility failed to maintain consistent and complete communication regarding dialysis care for two residents who required hemodialysis. According to the facility's Hemodialysis Care Policy, staff are required to document and communicate specific information before and after each dialysis treatment, including vital signs, weights, medication administration, meal and fluid intake, and any additional alerts. This information is to be recorded on the Dialysis Communication Tool and shared between the facility and the dialysis provider. However, a review of the clinical records for two residents with end-stage renal disease and dependence on dialysis revealed multiple instances where dialysis communication forms were either incomplete or missing entirely on several treatment dates. For one resident with diagnoses including end-stage renal disease, intellectual disabilities, and anemia, several dialysis communication forms were found to be incomplete or absent over a period of weeks. Similarly, another resident with a history of right below the knee amputation, hypertension, anemia, and dialysis dependence also had multiple dates where required communication forms were incomplete or missing. The Director of Nursing confirmed that the facility did not ensure consistent dialysis communication for these residents, as required by policy and physician orders.
Physician Failed to Review Resident's Total Program of Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care as required. Specifically, for one resident with diagnoses including dementia, anemia, and a history of stroke, there were significant fluctuations and a notable decrease in weight over a short period. Despite these changes, the clinical record and progress notes did not document that the weight loss was verified for accuracy or addressed by the physician or registered dietician. A nurse practitioner note and a physician's 60-day recap note also failed to mention any evaluation or intervention regarding the resident's weight loss. Interviews with the medical director revealed reliance on nursing staff to communicate weight changes, but during physician recap visits, all available information was reviewed. However, the documentation did not reflect that the physician had reviewed or addressed the resident's weight loss. The nursing home administrator confirmed that the facility did not ensure the physician reviewed the resident's total program of care, as required by state regulations.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health care and services as required by its own Behavior Management Program policy. The policy mandates that the interdisciplinary team (IDT) assess, track, and review behaviors that negatively impact residents, conduct clinical record reviews, identify root causes, and discuss interventions and care plan updates in weekly meetings. Despite this, documentation revealed that the resident exhibited multiple episodes of yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. These behaviors included yelling at staff, making threats, attempting to hit staff, and physically interacting with another resident in a disruptive manner. The resident had a documented history of depression and was prescribed Cymbalta for depression and suicidal thoughts. The Minimum Data Set (MDS) assessments and progress notes indicated ongoing behavioral symptoms, including feelings of depression and multiple incidents of disruptive and aggressive behavior. However, the clinical record lacked evidence that the facility provided, attempted to provide, or arranged for behavioral health services or ancillary support in response to these behaviors. The care plan did not address the need for behavioral health assistance related to the resident's actions and threats, despite repeated incidents and documentation of concerning behaviors. Interviews with facility leadership confirmed that sufficient and timely social services were not provided to meet the resident's behavioral health needs. The lack of appropriate behavioral health interventions and failure to update the care plan in response to ongoing behavioral issues constituted a deficiency in providing necessary care and services to maintain the resident's highest practicable well-being.
Failure to Provide Behavioral Health Services for Resident with Ongoing Behavioral Issues
Penalty
Summary
The facility failed to provide appropriate behavioral health services to a resident diagnosed with depression and exhibiting ongoing behavioral issues. The resident had a documented history of depression, was prescribed Cymbalta for depression and suicidal thoughts, and had multiple documented incidents of yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. Despite these behaviors, the facility's clinical record lacked evidence that behavioral health services were provided, attempted, arranged, or requested for the resident. The facility's Behavior Management Program policy required assessment, tracking, and interdisciplinary review of behaviors negatively impacting residents' quality of life, including documentation, root cause analysis, and care plan updates. However, review of the resident's care plan showed it did not address behavioral health assistance related to the resident's actions and threats, including self-abuse, physical and verbal abuse, and threats to others. Progress notes and social services documentation indicated repeated behavioral incidents, but interventions were limited to brief check-ins and did not include referrals or engagement with behavioral health professionals. Interviews with facility leadership confirmed the failure to ensure the resident received appropriate behavioral health services to maintain their highest practicable well-being. The deficiency was identified through review of facility policy, clinical records, and staff interviews, and was cited under relevant state regulations for management and nursing services.
Failure to Provide Sufficient Social Services for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to provide sufficient and timely social services to meet the needs of a resident with a history of depression, morbid obesity, diabetes, and atrial fibrillation. The resident had documented behavioral issues, including yelling, verbal aggression, threats of self-harm, and physical aggression toward staff and other residents over a six-month period. Despite these ongoing behaviors and a diagnosis of depression with a history of suicidal thoughts, the social services documentation showed only routine assessments and brief check-ins, with no evidence of attempts to provide, arrange, or request behavioral health or ancillary services to address the resident's escalating behaviors. The resident's care plan acknowledged socially inappropriate and disruptive behaviors, such as verbal aggression and inappropriate touching, but did not include interventions or referrals for behavioral health assistance related to the resident's threats and actions of self-abuse, physical, and verbal abuse toward others. Physician orders indicated a need for social services consultation for aggressive and combative behavior, but there was no documentation that such services were provided or arranged. The social worker's notes primarily reflected general well-being checks and did not address the specific behavioral incidents or the need for specialized behavioral health support. Interviews with facility leadership confirmed the lack of sufficient and timely social services for the resident. The clinical record lacked evidence of any proactive measures by the social worker to address the resident's behavioral health needs, despite multiple documented incidents of aggression, threats, and self-harm. This failure to provide appropriate social services was found to be out of compliance with state regulations regarding resident rights, social services, and nursing services.
Expired Medications and Biologicals Improperly Stored in Medication Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored in accordance with professional standards and facility policy. During an observation of the First Floor Medication Room, multiple expired items were found, including petroleum gauze dressings, Aquacel dressings, Zinc Oxide ointment, Puracol Ultra Powder, Lemon Glycerin Swabs, Povidone-Iodine prep pads, and an Iodoform Packing Strip. These items were not separated from other medications as required by the facility's policy, which states that expired medications and biologicals should be stored separately until destroyed. Staff interviews confirmed the presence of expired items in the medication room. An LPN acknowledged the expired status of the items during the observation, and both the Nursing Home Administrator and the DON later confirmed that the facility had not properly stored medications and biologicals in one of the two medication rooms. The findings were cited under 28 Pa. Code regulations for pharmacy and nursing services.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and develop a care plan for the self-administration of medications for three residents. Observations revealed that Resident R1 had a medicine cup on its side with one pill still in it and another pill on the over-bed table. Resident R2 was observed with a medicine cup containing one pill, and a pill was found on the floor in Resident R3's room. A review of the clinical records for these residents showed no assessment or care plan for self-administration of medications. The Nursing Home Administrator confirmed the lack of assessment and care planning for these residents.
Insufficient Nursing Staff Leads to Resident Neglect
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, affecting 16 out of 22 residents. Observations and interviews revealed multiple instances of neglect, including delayed response to call lights, inadequate personal hygiene care, and missed meals. Residents reported long wait times for assistance, with some call lights going unanswered for up to two hours. Several residents were observed with unkempt hair, long toenails, and dirty rooms, indicating a lack of basic care. Additionally, grievances filed by residents highlighted issues such as missed showers, inadequate meal service, and insufficient staff presence. The report also noted specific grievances from residents, such as being told not to request assistance during certain times due to staff being too busy, and instances where residents were left without proper meals. One resident reported that personal items, such as leftover pizza, were not available when requested, leading to inadequate meal options. The facility's failure to provide sufficient nursing staff was confirmed by the Nursing Home Administrator, acknowledging the impact on residents' physical, mental, and psychosocial well-being.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for one resident, identified as Resident R7. The facility's policy on General Dose Preparation and Medication Administration requires staff to verify the correct medication, dose, route, rate, time, and resident each time a medication is administered. However, on March 14, 2025, Resident R7, who has a medical history including coronary artery disease, chronic kidney disease, and type 2 diabetes, was observed receiving her morning dose of insulin aspart at 10:22 a.m., which was significantly later than the scheduled time of 7:30 a.m. as per the physician's orders. During an interview, an LPN confirmed that the insulin administration was intended as the morning dose scheduled before breakfast. The Medication Administration History report documented the administration time as 8:53 a.m., indicating a discrepancy in the timing. The Nursing Home Administrator confirmed that insulin administrations are not covered under the facility's flexible medication policy, acknowledging the failure to prevent significant medication errors for Resident R7. This deficiency was identified under the regulations 28 Pa. Code 207.2(a), 28 Pa. Code: 211.10(c)(d), and 28 Pa. Code: 211.12(d)(1)(5).
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
Woodhaven Health and Rehab Center was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. Specifically, the facility failed to inform the family of a resident about a significant decline in the resident's health status. The resident, who had been admitted with diagnoses including peripheral vascular disease and type 2 diabetes mellitus with diabetic neuropathy, experienced a worsening of a pressure ulcer on the right lateral heel. The wound, initially assessed on October 28, 2024, showed a significant increase in size and severity by January 8, 2025, with the presence of eschar tissue and a mild wound odor, indicating a decline in the wound's status. Despite the facility's policy requiring notification of the responsible party or guardian in the event of a significant change in a resident's physical condition, there was no evidence in the clinical record that the resident's family was informed of this deterioration. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the failure to notify the family in a timely manner for this resident.
Plan Of Correction
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the state and federal laws. Director of Nursing educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a residents physical condition by the Regional Director of Clinical Services. Nursing Home Administrator or designee is touching base with the family weekly to review any changes. The DON or designee will complete a 30 day look back to ensure proper notification was completed for residents with any changes with their wound assessments. Facility wound nurse will be educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a resident's physical condition by the Director of Nursing. Licensed nursing staff will be educated on the policy and procedure for resident change in condition policy and the proper notification to responsible parties and physicians with a significant change in a resident's physical condition by the Director of Nursing or designee. To monitor and maintain ongoing compliance the DON or designee will audit 5 resident wound notes weekly x4 and monthly x2 to ensure proper notification was completed.
Unqualified Life Enrichment Director in Activities Department
Penalty
Summary
The facility failed to ensure that the Activities Department was directed by a qualified professional. The Life Enrichment Director, Employee E2, was hired on December 27, 2023, without evidence of the necessary qualifications as required by state and federal regulations. Her personnel record lacked documentation of education in therapeutic services, social work, occupational therapy, or recreational services. Despite this, she performed her duties, including completing quarterly and annual assessments, without oversight from a qualified staff member. This was confirmed by both the Director of Nursing and Employee E2 during interviews conducted on June 13, 2024.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide two residents, identified as R38 and R57, with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of the facility's policy on advance directives, clinical records, and staff interviews. The facility's policy, reviewed on January 1, 2024, mandates compliance with maintaining written policies and procedures regarding advance directives, including informing and providing written information to all adult residents about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive. Resident R38 was admitted with diagnoses including diabetes, high blood pressure, congestive heart failure, and morbid obesity. Resident R57 was admitted with conditions such as morbid obesity, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, and a wound to the right lower leg. The clinical records for both residents lacked documentation indicating they were given the opportunity to formulate an advance directive. This was confirmed during an interview with the Director of Nursing and a social worker, who acknowledged the absence of such documentation in the clinical records.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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