Westmoreland Manor
Government - County
408 Beds
Independent
Data: November 2025
Trust Grade
25/100
#517 of 653 in PA
Photo by Westmoreland Manor
Photo by Westmoreland Manor
Photo by Westmoreland Manor
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Westmoreland Manor has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. Ranking #517 out of 653 nursing homes in Pennsylvania places it in the bottom half, while its county rank of #11 out of 18 shows that there are only a few local options that perform better. While the facility is improving, having reduced issues from 12 in 2024 to 8 in 2025, it still faces challenges, including two serious incidents involving resident safety and care violations. Staffing is a relative strength, with a rating of 4 out of 5 stars and a turnover rate of 39%, which is below the state average. However, there were serious findings, such as a resident suffering a fractured hip due to abuse by another resident and a hot liquid spill causing injury, highlighting ongoing safety and care management issues that families should consider.
- Trust Score
- F
- In Pennsylvania
- #517/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 39% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 40 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 21%
Review needed
12 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 8 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Pennsylvania average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 39%
Near Pennsylvania avg (46%)
Typical for the industry
The Ugly 27 deficiencies on record
2 actual harm
May 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of six residents reviewed ...
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Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of six residents reviewed (Resident 3) was free from abuse perpetrated by a resident with aggressive behaviors (Resident 2), resulting in an incident in which one of six residents reviewed suffered a fractured hip (Resident 3).
Findings include:
The facility's abuse policy, dated February 1, 2025, revealed that the facility would implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieved the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was cognitively impaired, had no behaviors, received anti-psychotic and anti-depressant medications, and had diagnoses that included dementia and depression.
A quarterly MDS assessment for Resident 3, dated March 11, 2025, revealed that the resident was cognitively impaired, had verbal behaviors directed towards others and other behaviors not directed towards others, received anti-depressant medications, and had diagnoses that included dementia and depression.
The behavior care plan for Resident 2, dated December 4, 2024, and revised on May 29, 2025, revealed that he had diagnoses that included dementia, anxiety, depression, and insomnia. His behaviors included going through/entering others spaces/belongings, rummaging, anxious/restless, agitation, sleeplessness, pacing, refusing care, verbalizing persistent beliefs not true, wandering, picking at self, yelling at others, angry/hostile towards staff, paranoia, delusions, accusatory of others, threatening and inappropriate comments towards staff/others, following others closely on the unit or exit seeking, and having hallucinations of others wanting to harm/kill him. Staff were to monitor and document changes in his mood and behavior and determine if there was a specific trigger to the change, have him seen by the psychiatrist as ordered, redirect and intervene if having behaviors with others, entering others spaces/rooms, getting angry, exit seeking, etc., and provide 1:1 close observation.
A behavior note for Resident 2, dated May 14, 2025, at 10:15 a.m. revealed that he pushed Resident 3 causing her to fall.
A nursing note for Resident 3, dated May 14, 2025, revealed that at 10:15 a.m. Resident 3 walked down the hall and tapped Resident 2 on his left shoulder and Resident 2 turned around and used both hands to push her to the ground. Resident 3 landed on her right hip and continued to lie on the floor until staff arrived. She was exhibiting signs of severe pain to her right hip with difficulty moving it. The physician was notified and orders were received to transfer the resident to the hospital for evaluation and treatment. She was admitted to the hospital with a right hip fracture.
The facility's investigation, dated May 14, 2025, revealed that video footage was reviewed and Resident 2 was standing near the nurse's station on the unit. Resident 3 was walking up the hallway in the direction of Resident 2 and was nearing Resident 2, when Resident 2 turned and began to walk in the opposite direction. When Resident 3 caught up to Resident 2, she reached forward with her left hand and began to tap Resident 2 on the left arm/shoulder area. When Resident 3 tapped Resident 2 on the shoulder, he turned around quickly and pushed Resident 3, causing her to lose her balance and fall to the ground onto her side. The facility's investigation indicated that abuse was substantiated.
Interview with the Director of Nursing on May 29, 2025, at 4:24 p.m. confirmed that Resident 2 pushed Resident 3, which resulted in Resident 3 falling and fracturing her hip, substantiating abuse.
28 Pa. Code 211.12 (d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation...
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Based on review of policies, clinical records, and information provided by the facility, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed into the resident's grievance for one of six residents reviewed (Resident 5).
Findings include:
The facility's policy regarding grievances and concerns, dated February 1, 2025, revealed that the facility recognizes that residents have the right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Every grievance must include investigative form(s) as necessary, including but not limited to: Witness statements, investigative notes, copies of documentation evidence, summary of investigative process, and summary of investigation findings. Every grievance investigation will be summarized by the Grievance Officer, or designee and findings recorded whether the incident was confirmed or not.
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 23, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly referred to as a stroke) with right side hemiplegia (paralysis on one side of the body) and diabetes (a chronic condition where the body either does not produce enough insulin or cannot effectively use the insulin it produces).
Information provided by the facility revealed that Resident 5 filed a grievance via a resident/family grievance form on May 19, 2025, with concerns that last night was the last straw with Licensed Practical Nurse 1. The other nurse (a woman which the resident does not know her name) came to my room about 10:00 p.m. to give me my medication. When I saw the insulin she was going to give me, I stopped her and explained that was not the right insulin. She explained that Licensed Practical Nurse 1 prepared the insulin. I told her it's wrong and I refused to take it. The resident went on to explain that over the course of about one year Licensed Practical Nurse 1 does and says things to her and about her that he knows upsets her. For instance, he will stand outside my bedroom door and say to nobody that he is sorry for kicking her bed. Licensed Practical Nurse 1 told her once that she would be put in jail for violating HIPPA because I told my husband the floor was yellow because someone had COVID. Another time recently she was in the bathroom (unit bathroom) and Licensed Practical Nurse 1 came in and slammed cupboards and made all kind of noise. I think he was trying to scare me. The resident also presented several non-specific interactions that she believes are deliberate, passive-aggressive and attempts to gas light her. The resident also recalled that a little while ago Licensed Practical Nurse 1 told everyone that I hallucinate. I don't hallucinate. Lastly the resident added, I already requested that Licensed Practical Nurse 1 not provide care. I also don't want him preparing my meds. I don't want him to do anything with me or my care.
A summary of the grievance investigation, dated May 26, 2025, revealed that a concern was received from Resident 5 listing concerns involving a staff member. The resident stated that a certain staff member does and says things deliberately to gas light her. She also stated that there was a different nurse that attempted to administer the incorrect insulin to her. Resident 5 has had ongoing concerns with the first nurse and every attempt has been made to keep him out of her sight, for instance, he only works down the opposite hall. However, going forward, the nurse has been removed from the nursing unit. Education has been provided to the second nurse regarding checking the order to ensure she has the correct insulin and to not rely on the word of other nurses.
The facility's investigation revealed no documented evidence that Resident 5's concerns regarding her issues with Licensed Practical Nurse 1 doing and saying things to her and about her that he knows upsets her were investigated and/or addressed, as well as no documented evidence that a statement was obtained from Licensed Practical Nurse 1 regarding the resident's concerns.
Interview with the Director of Nursing on May 29, 2025, at 4:15 p.m. confirmed that there was no documented evidence that Resident 5's concerns regarding her issues with Licensed Practical Nurse 1 doing and saying things to her and about her that he knows upsets her were investigated and/or addressed, as well as no documented evidence that a statement was obtained from Licensed Practical Nurse 1 regarding the resident's concerns.
28 Pa. Code 201.29(i) Resident Rights.
May 2025
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on a review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of ...
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Based on a review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of 58 residents reviewed (Resident 48) resulting in a hot liquid spill with injury. This deficiency was cited as past non-compliance.
Findings include:
The facility policy regarding hot liquids safety, dated February 1, 2025, indicated that in order to promote safety, appropriate precautions will be implemented to maximize choice of beverages while minimizing potential for injury. Hot liquids will be severed at a temperature not greater than 140 degrees Fahrenheit (F).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated January 6, 2025, revealed that the resident was understood, could understand others, and had a diagnosis which included cerebral vascular accident (CVA - commonly known as a stroke) with left-side hemiplegia (paralysis on one side of the body).
A nursing note for Resident 48, dated February 23, 2025, at 9:55 p.m. revealed that an eight-ounce (oz) cup of coffee was prepared upon the resident's request. The cup was provided with a lid on and placed on the resident's bedside table. The resident prefers drinking his coffee out of an open cup and uses his right dominant hand. The resident removed the lid and proceeded to pick up the cup when it slipped out of his hand. The resident stated it was an accident. The resident is alert and oriented. The resident reported mild pain at time of incident. Light yellow blister on top of his left thigh near his groin measuring two centimeters (cm) by three cm by 0.2 cm. The surrounding tissue was intact with a light-red area measuring five cm by three cm. There was another light-yellow blister that is located to his lateral (to the side of, or away from, the middle of the body) of his left thigh measuring one cm by one cm by 0.2 cm and the surrounding tissue is light red measuring five cm by 1.3 cm. The affected area was cleansed with saline and an adaptic dressing (helps prevent dressing adherence) was applied and then covered with a dry dressing. Staff were to be educated on measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before submitting to the resident.
A statement completed by Nurse Aide 1, dated February 23, 2025, revealed that at approximately 8:00 p.m. on February 23, 2025, Resident 48 requested for her to use one of his own K-Cups to brew him a fresh cup of coffee. The nurse aide used the Keurig in the A1 staff room to make it. The resident requested no lid on his coffee cup and to make it black. The nurse aide set his cup on his bedside table where he requested and asked him if he needed anything else, he stated no. Approximately five to ten minutes later the nurse aide heard him yelling out in pain. The nurse aide ran to his room where the resident stated, I dropped my coffee on my hand. The on-shift licensed practical nurse ran in behind the nurse aide, and the resident told her his hand was hurting from spilling his coffee. It was observed that his left thigh had two red areas and blisters forming on the red areas. No red areas or blisters on his hand were seen. The nurse aide was educated at the end of the shift that all drinks from the Keurig should temp at 140 degrees F and below for all residents.
Interview with Resident 48 on May 6, 2025, at 12:53 p.m. revealed that he asked staff to get him a cup of coffee using one of his K-Cups that his family provides him, and that he requested that staff not put a lid on the cup and to set it on his over-bed table. He indicated that he was in bed and felt tired that night and the next thing he spilt the cup of coffee onto his left thigh.
Interview with Nurse Aide 1 on May 7, 2025, at 3:15 p.m. revealed that she was providing care to Resident 48 and he stated to her not to forget his coffee and that he did not want a lid on the cup. She went to the A1 staff lounge where the Keurig was located and brewed the resident his coffee with the K-Pod he provided. After the coffee was brewed, she did not obtain a temperature on the coffee because this was how they did it in the past. She set the Styrofoam cup containing the coffee on the resident's over-bed table and left. Approximately four to five minutes went by, and she heard him scream and went to investigate. She indicated that she saw that he had spilled his coffee down onto his left thigh.
Interview with the Director of Nursing on May 6, 2025, at 2:35 p.m. confirmed that there was no documented evidence that the temperature was obtained on the coffee prior to being served to Resident 48. She indicated that the hot liquid safety policy was for the kitchen staff and not for nursing staff.
Following the incident on February 23, 2025, the facility's corrective actions included:
Resident 48 was assessed and treatment to his left thigh was obtained. The resident was ordered Kennedy cups (a lightweight spill-proof drinking cup) to receive his hot liquids in.
An audit of other residents who receive hot liquids from a Keurig or other electrical devices was completed.
Nurse Aide 1 received education on measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before giving to the residents.
The facility's policy regarding hot liquid safety was reviewed and revised to include the procedure for temping liquids from a Keurig or other electrical device.
The facility's food temperature log was reviewed and revised to include the temperatures of liquids before being served.
Facility staff as well as agency staff education on the revised hot liquid safety policy, food temperature log, as well as measuring the temperature before providing heated liquids/foods and ensuring liquids are about 140 degrees F before giving to the residents was completed.
Audits to identify any issues with following a resident's care plan for assistance with bed mobility/transfers were started.
The results of these audits will be brought to Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F689 on March 24, 2025.
28 Pa. Code 201.18(b)(1) Management.
28 Pa Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 58 residents reviewed (Residents 84, 196, 208, 229).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section A was to record the discharge status of the resident. Section A2105 was to be coded with the location of the resident's discharge, indicated that the intent of Section J1900 was to be coded with number of falls of no injury, injury or major injury since admission/entry or reentry or prior assessment whichever is more recent. indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Sections N0415I Antiplatelet Medications (medication used to prevent blood from clotting), N0415K anticonvulsant medications was to be coded if the resident took the medication during the seven-day lookback period.
A significant change MDS assessment for Resident 84, dated April 8, 2025, revealed that the resident was cognitively intact, required assistance with activities of daily living, and had medical diagnoses that included seizure disorder and cerebral palsy.
Physician's orders for Resident 84, dated April 3, 2025, included an order for the resident to receive 150 milligrams (mg) of Oxcarbazepine (an anticonvulsant). A review of the resident's April 2025 Medication Administration Record (MAR) revealed that the resident received Oxcarbazepine during the seven-day look-back period.
A quarterly assessment for Resident 196, dated February 18, 2025, revealed that the resident is cognitively intact, required assistance with activities of daily living, and had medical diagnoses that included coronary artery disease, history of heart attack and high blood pressure.
Physician's orders for Resident 196, dated October 14, 2023, included an order for the resident to receive 75 mg of Clopidogrel Bisulfate (an antiplatelet) daily for history of heart attack. A review of the resident's February 2025 MAR revealed that the resident received Clopidogrel Bisulfate during the seven-day look-back period.
An interview with the Director of Case Management on May 8, 2025. at 11:30 a.m. confirmed that the MDS assessments for Residents 84 and 196 were inaccurately coded.
The RAI User's Manual, dated October 2024 revealed that if the assessment was the first assessment since the most recent admission/entry or reentry, then Section A0310E was to be coded (1) Yes. Section J1700, the resident's fall history on admission/entry or re-entry, was to be completed if Section A0310E was coded (1) Yes. If the resident had a fall any time in the month prior to admission/entry or reentry, then Section J1700A was to be coded (1) Yes. If the resident had a fracture related to a fall in the six months prior to admission/entry or re-entry, then Section J1700C was to be coded (1) Yes.
A nursing note for Resident 208, dated August 15, 2024, at 7:14 p.m. revealed that the resident was observed on the floor in the dining room and complained of her left upper thigh hurt. She was transferred to the hospital and admitted with a left hip fracture.
A quarterly MDS assessment for Resident 208, dated October 3, 2024, revealed that Section A0310E was incorrectly coded (0) No, indicating that this was not the resident's first MDS assessment since being readmitted (from the hospital). By coding Section A0310E as (0) No, the computerized MDS software did not allow Sections J1700A and J1700C to be completed to reflect that the resident had a fall and fracture in the past 30 days.
Interview with Director of Case Management on May 7, 2025, at 3:19 p.m. confirmed that Resident 208's MDS was coded incorrectly.
A nursing note for Resident 229, dated March 1, 2025, indicated that the resident was discharged to personal care home on that date. However, a discharge tracking MDS for Resident 229, dated March 1, 2025, indicated that Resident 33 was discharged to the hospital.
An interview with the Director of Case Management on May 8, 2025, at 3:06 p.m. confirmed that Resident 229's discharge tracking MDS was coded incorrectly.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 58 reside...
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Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's orders for one of 58 residents reviewed (Resident 106).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
The facility's policy regarding medication orders, transcription of substituted, dated February 1, 2025, indicated that the registered nurse or licensed practical nurse transcribing the order would be notified by the pharmacy of the substitution and would then discontinue the order for the original brand name medication in the electronic record and enter a new order with the drug substituted by the pharmacy.
An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 106, dated April 23, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain).
Physician's orders for Resident 106, dated April 21, 2024, included an order for the resident to be administered 250 milligrams (mg) of calcium citrate twice a day for Vitamin D deficiency.
Observations of medication administration on May 7, 2025, at 8:20 a.m. revealed that Resident 106 was administered 950 mg of calcium citrate that contained 200 mg of calcium.
Interview with Licensed Practical Nurse 2 on May 7, 2025, at 2:23 p.m. confirmed that the physician's order was to administer 250 mg of calcium citrate, but the card dispensed from the pharmacy was for calcium citrate 950 mg with 200 mg calcium. She was not sure why the pharmacy would have provided a different medication.
Interview with the Pharmacy Supervisor for Data Entry on May 8, 2025, at 10:07 a.m. confirmed that a pharmacist had changed the medication, because the previous medication was on backorder. There was no notation in the chart that the pharmacy had informed the facility, and after speaking to the pharmacist it was determined that the dose was not equivalent. The pharmacy should have called the facility to inform them of the change.
There was no documented evidence in Resident 106's clinical record to indicate that the medication was clarified with the physician.
Interview with the Director of Nursing on May 8, 2025, at 8:32 a.m. confirmed that pharmacy changed and sent a medication that was not an equivalent, that the current physician's order did not match the medication that was administered to Resident 106, and that nursing staff should have clarified the order with the physician.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is i...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) was flushed as ordered by the physician for two of 58 residents reviewed (Residents 77, 207).
Findings include:
The facility's policy regarding flushing intravenous catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated February 1, 2025, indicated that the catheter was to be flushed with 0.9 percent sodium chloride (sterile salt water solution) before and after medication administration.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 77, dated April 2, 2025, revealed that the resident was cognitively impaired, required assistance for daily care needs, and had diagnoses that included heart failure, high blood pressure, and extended spectrum beta lactamase in the urine (an infection in urine).
Physician's orders for Resident 77, dated April 28, 2025, included an order for the resident to receive 500 milligrams of Invanz (intravenous antibiotic medication) for urinary tract infection.
Review of the April and May 2025 Medication Administration Record (MAR) for Resident 77 revealed no documented evidence that the resident's PICC line was flushed after the antibiotic was administered as per facility policy.
An interview with the Clinical Compliance Officer on May 8, 2025, at 9:41 a.m. confirmed that there was no documented evidence that Resident 77's PICC line was flushed after the antibiotic was administered as per facility policy.
A quarterly MDS assessment for Resident 207, dated April 23, 2025, revealed that the resident was cognitively intact, required assistance for daily care needs, received antibiotics, received IV medications, and had diagnoses that included peripheral vascular disease (poor circular of the extremities), and diabetes.
A nursing note, dated April 17, 2025, revealed the resident returned from the hospital following amputation of her left big toe and had a PICC line in her right arm.
Physician's orders for Resident 207, dated April 18, 2025, included an order for the resident to receive 1500 mg of Vancomycin (antibiotic) intravenously (IV) daily until April 23, 2025, and the IV access site was to be flushed with 10 ml of normal saline solution before and after medication administration at bedtime. Physician's order for Resident 207, dated April 22, 2025, included an order for the resident to receive 1750 mg of Vancomycin intravenously daily until April 24, 2025. A care plan, dated April 21, 2025, indicated that IV flushes were to be provided as ordered.
Resident 207's MAR's for April 2025 indicated that the resident received IV Vancomycin intravenously daily at 10:00 a.m., and not at bedtime, from April 18 through 24, 2025; however, there was no documented evidence that staff flushed the resident's IV catheter with saline solution before and after any of the IV administrations of Vancomycin.
Interview with the Clinical Corporate Officer on May 7, 2025, at 12:44 p.m. confirmed that there was no documented evidence that Resident 207's PICC line was flushed with saline solution before and after every administration of antibiotics.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medicati...
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Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication error rate of less than five percent.
Findings include:
The facility's policy regarding medication administration: rights, dated February 1, 2024, indicated that when administering the medication, the electronic medical record should be checked against the prescription label for each resident. To ensure accountability and the six 'rights' (right resident, right drug, right dose, right time, right route, right dosing form), guidelines were set for medication administration.
Observations during medication administration on August 21, 2024, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent.
An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 106, dated April 23, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included renal failure (kidney failure) and peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain).
Physician's orders for Resident 106, dated April 21, 2024, included an order for the resident to be administered 250 milligrams (mg) of calcium citrate twice a day for Vitamin D deficiency.
Observations of medication administration on May 7, 2025, at 8:20 a.m. revealed that Resident 106 was administered 950 mg of calcium citrate.
Interview with Licensed Practical Nurse 2 on May 7, 2025, at 2:23 p.m. confirmed that the physician's order was to administer 250 mg of calcium citrate, but the card dispensed from the pharmacy was for 950 mg of calcium citrate.
A quarterly MDS assessment for Resident 147, dated April 2, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included multiple sclerosis (a chronic, progressive disease of the central nervous system that can affect the brain, optic nerves, and spinal cord).
Physician's orders for Resident 147, dated July 18, 2022, included an order for the resident to be administered two drops into each eye of artificial tears solution one percent (carboxymethylcellulose sodium) three times a day for dry eyes.
Observations of medication administration on May 7, 2025, at 8:40 a.m. revealed that Resident 147 was administered one drop of artificial tears solution one percent (carboxymethylcellulose sodium). Interview with Licensed Practical Nurse 2 at that time confirmed that she was finished with her medication administration to Resident 147, and that she instilled one drop into each eye. At 8:44 a.m. Licensed Practical Nurse 2 confirmed that she should have administered two drops in each eye.
Interview with the Director of Nursing on May 8, 2025, at 8:32 a.m. confirmed that the current physician's order did not match the medication that was administered to Resident 106, and that the correct number of eye drops were not administered to Resident 147 and should have been.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standa...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 58 residents reviewed (Residents 191, 208).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 191, dated February 21, 2025, revealed that the resident was understood and could understand others. A care plan for the resident, dated September 10, 2024, revealed that the resident has an altered cardiovascular status related to congestive heart failure (CHF - a condition where the heart can not pump enough blood to meet the body's needs, leading to fluid buildup in the lungs, legs, and other parts of the body) and hypertension (high blood pressure). Staff was to administer medications as ordered by the physician.
Physician's orders for Resident 191, dated February 20, 2025, and discontinued on April 30, 2025, included an order for the resident to receive one 25 milligram (mg) tablet of Hydralazine (used to treat high blood pressure) every eight hours for hypertension. Staff was to hold the medication for a systolic blood pressure (the top number of the blood pressure) reading of less than 120 millimeters of mercury (mmHg).
Physician's orders for Resident 191, dated April 30, 2025, included an order for the resident to receive one 25 mg tablet of Hydralazine two times per day for hypertension. Staff was to hold the medication for a systolic blood pressure reading of less than 120 mmHg.
Review of Resident 191's Medication Administration Record (MAR), dated March, April, and May 2025, revealed that the resident's systolic blood pressure was less than 120 mmHg on March 16, 2025, at 10:00 p.m.; March 31, 2025, at 10:00 p.m.; April 3, 2025, at 2:00 p.m.; April 10, 2025, at 2:00 p.m.; May 2, 2025, at 6:00 a.m.; and on May 6, 2025, at 6:00 a.m.; however, there was no documented evidence that Hydralazine was held as ordered by the physician.
Interview with Clinical Compliance on May 7, 2025, at 12:50 p.m. confirmed that Resident 191's Hydralazine was not held as ordered on the above dates and times.
A quarterly MDS assessment for Resident 208, dated April 19, 2025, indicated that the resident was cognitively impaired and had diagnoses that included hypertension (high blood pressure) and dementia. A care plan, dated July 2, 2024, indicated that the resident's medications were to be administered as ordered by physician.
Physician's orders for Resident 208, dated February 15, 2025, included an order for the resident to receive 12.5 mg of metoprolol tartrate (treats atrial fibrillation) twice a day. The medication was to be held if the resident's systolic blood pressure (the top number of a blood pressure reading) was less then 130 millimeters of mercury (mmHg), or if the heart rate was less than 60 beats per minute.
Resident 208's Medication Administration Records (MAR's) for February and March 2025 revealed that the resident's systolic blood pressure was less than 130 mmHg at 9:30 a.m. on February 12, 23, 26, and March 2, and 5 and at 6:00 p.m. on February 1, 4, 23, and March 2, 2025; however, there was no documented evidence that metoprolol tartrate was held as ordered by the physician.
Interview with Clinical Compliance on May 7, 2025, at 12:50 p.m. confirmed that Resident 208's metoprolol was not held as ordered on the above dates and times.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
May 2024
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical records, and facility investigation information, as well as staff interviews, it was determined that the facility failed to prevent the misappropriation ...
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Based on review of facility policies, clinical records, and facility investigation information, as well as staff interviews, it was determined that the facility failed to prevent the misappropriation of medication for one of 48 residents reviewed (Resident 34).
Findings include:
The facility's policy regarding abuse, dated February 4, 2024, indicated that misappropriation included the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated February 1, 2024, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of chronic pain.
Physician's orders for Resident 34, dated February 4, 2024, included an order for the resident to receive one 5-325 milligrams (mg) tablet of Norco (a combination of hydrocodone-acetaminophen) by mouth every eight hours as needed for Moderate-Severe pain of 5-10 (on a scale of 1-10 with 10 being the worst pain), not to exceed 3 gm per 24 hours.
Information submitted by the facility, dated March 5, 2024, revealed that on March 2, 2024, at 8:50 p.m. narcotics were delivered by the pharmacy for the B3 nursing unit. Registered Nurse Supervisor 1, who accepted and signed in the narcotics, stated that five cards were delivered to the facility. She documented five new narcotic card entries on the nursing office narcotic accountability form, attached copies of the five proof of use sheets to the delivery manifest, and documented that the narcotics were received in the facility's pharmacy communication. When the shift change occurred at 11:00 p.m. all narcotic cards were counted in the medication carts and compared to the unit narcotic accountability form. The count for narcotic cards was 42, which matched the accountability form. When the next shift change occurred at 7:00 a.m., the narcotic review was completed again per policy. The count again totaled 42 cards. However, at this time there were 43 entries on the narcotic accountability form.
An investigation, initiated on March 3, 2024, at 7:00 a.m., determined that after the narcotics were documented and received in the facility by Registered Nurse Supervisor 1, Registered Nurse 2 then took the medications and the forms to the B3 nursing unit. It was determined that four cards were delivered to the nursing unit. Registered Nurse 2 and the B3 Unit registered nurse both recorded that four cards were received. Video footage was reviewed and it was confirmed that Registered Nurse 2 had the narcotics and that she was viewed on camera entering the unit on a few occasions and entering the medication room alone.
The investigation was completed on March 7, 2024, at 4:00 p.m. and misappropriation was substantiated. The card of narcotics went missing and Registered Nurse 2 was the last person to be seen, in person and on camera, in possession of the narcotics card. There was no evidence that all five narcotics cards were delivered to the B3 unit. Video footage and statements supported the conclusion that only four cards were delivered and documented as such.
All appropriate parties were notified and a full audit of all facility narcotics was completed to ensure that all narcotics were accounted for. All residents received their narcotic medications as ordered. No doses were missed as a result of the narcotic card that went missing. Registered Nurse 2 was suspended pending the investigation that began on March 3, 2024, at 7:00 a.m. and completed March 7, 2024, at 4:00 p.m. Registered Nurse 2 was terminated on March 7, 2024.
Interview with the Clinical Coordinator on May 9, 2024, at 1:25 p.m. confirmed that the investigation initiated on March 3, 2024, at 7:00 a.m. was completed on March 7, 2024, at 4:00 p.m. and concluded that misappropriation of Resident 34's medication did occur.
28 Pa. Code 201.14(a) Responsibility of License.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one ...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for one of 48 residents reviewed (Resident 66).
Findings include:
Resident 66's Medication Administration Record (MAR) for May 2024 revealed that the resident was receiving medications at 6:00 a.m. The resident's care plan, dated January 21, 2020, indicated that the resident did not want any medications or care until after 7:00 a.m.
Interview with Resident 66 on May 6, 2024, at 10:40 a.m. revealed that she receives early dialysis (medical process of removing toxins from the blood) treatment and that she does not mind getting her medications early. She stated that her care plan was never updated after she switched to the early dialysis time.
Interview with the Director of Nursing on May 9, 2024, at 11:51 a.m. confirmed that Resident 66's care plan was old and should have been revised to reflect that her preferences regarding when she received her medications had changed.
28 Pa. Code 201.24(e)(4) admission Policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with weekly showers for one of 48 resid...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with weekly showers for one of 48 residents reviewed (Resident 151).
Findings include:
The facility's policy regarding showers, dated February 4, 2024, indicated that residents would be offered a shower at least once a week.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 151, dated April 26, 2024, indicated that the resident was alert and oriented, and it was very important to choose between a tub bath, shower, bed bath, or sponge bath. The resident's care plan, dated July 7, 2023, included that the resident was to receive a shower in the morning.
A nursing note, dated April 4, 2024, at 4:59 p.m., revealed that Resident 151 tested positive for COVID-19 and had his room changed.
The resident's bathing records for April 1 to 30, 2024, revealed that the resident did not receive a weekly shower on April 5 and 12, 2024, and received a bed bath.
Interview with the Director of Nursing on May 8, 2024, at 10:25 a.m. confirmed that Resident 151 was not showered on April 5 and 12, 2024, due to testing positive for COVID-19.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the facility policies for a tube feeding were follo...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure the facility policies for a tube feeding were followed for one of 48 residents reviewed (Resident 159).
Findings include:
The facility's policy regarding feeding tubes (a tube inserted directly into the stomach), dated February 4, 2024, revealed that the formula and tubing must be identified with the date and time it was started and is to be used no longer than 24 hours.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 159, dated April 3, 2024, indicated that the resident was cognitively impaired, required assistance of staff for care, had a feeding tube for nutrition, and had diagnoses that included stroke and dementia. A care plan for Resident 159, dated September 2, 2020, indicated that the tube feeding formula, hydration, and flushes were to be administered per order.
Current physician's orders for Resident 159 included an order for the resident to receive Isosource 1.5 calories/milliliter (Cal/mL) (a tube feeding formula) at 38 ml/hr for 21 hours. Resident 159's Medication Administration Record (MAR) for May 2024 indicated that the tube feeding was infused at 38 mL/hr for 21 hours.
Observations of Resident 159 on May 8, 2024, at 9:26 a.m. revealed that the bag of Isosource 1.5 was hanging on the tube feeding pump; however, the label was blank and did not have the date and time of when the tube feeding bag was prepared. Interview with Registered Nurse 3 at that time confirmed that the label on Resident 159's bag of Isosource 1.5 did not have the date and time of when it was prepared and hung.
Interview with the Director of Nursing on May 8, 2024, at 12:44 p.m. confirmed that staff were to ensure the tube feeding labels contained the necessary identifying information such as the date and time the formula was hung.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was ...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing/hand hygiene was completed during wound care for one of 48 residents reviewed (Resident 122) and failed to ensure proper infection control practices while handling soiled linens after resident care (Resident 228).
Findings include:
The facility's policy regarding dressings changes and clean technique, dated February 4, 2024, revealed that clean technique is to be used for all dressing changes unless otherwise ordered by the physician. Washing of hands and application of non-sterile gloves is to be performed prior to removal of soiled dressing, after removal of soiled dressing and before cleansing the wound, and after cleansing the wound and before application of clean wound treatment. Gloves are to be removed and hands washed after completion of treatment and discarding waste.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 122, dated April 23, 2024, revealed that the resident was cognitively intact, required assistance with care needs, had a Stage 3 pressure ulcer (pressure wound involving the fat layers beneath the skin) to the right proximal great toe, a Stage 4 pressure ulcer (pressure wound with full thickness tissue loss with exposed bone, tendon or muscle) to the right distal great toe, a venous ulcer to the right lower leg present, was receiving intravenous (administered into a vein) antibiotic medication for an infection of his right foot, and had diagnoses that included osteomyelitis and chronic peripheral venous insufficiency.
Physician's orders for Resident 122, dated April 18, 2024, included an order to wash the proximal right great toe tip with normal saline solution (NSS-a sterile solution used for the moistening of wound dressings and wound debridement), pat dry, then apply adaptic (a non-adherent dressing) (cut to fit) then dry dressing every day shift. Physician's orders, dated April 18, 2024, included an order to wash the posterior left lower extremity with NSS, pat dry, apply adaptic then dry dressing every day shift and as needed for soilage/displacement. Physician's orders, dated April 19, 2024, included an order to irrigate the distal right great toe tip with NSS, apply Nu gauze (gauze inserted into wounds) packing strip to wound cavity depth and undermining, cover with dry dressing and kling (roll gauze used to secure dressings) every day shift and as needed for soilage/displacement. Physician's orders, dated April 19, 2024, included an order to apply Amlactin external lotion to lower extremities topically every day shift.
Observations during wound care on May 8, 2024, at 11:55 a.m. revealed that Registered Nurse 7 and Licensed Practical Nurse 8 gathered supplies for Resident 122's wound care and placed them on the top of the treatment cart and placed a red garbage bag to collect soiled materials. Registered Nurse 7 and Licensed Practical Nurse 8 put gloves on their hands and gowned due to the resident being on Enhanced Barrier Precautions (precautions to prevent spread of infection). Registered Nurse 7 removed the old kling wrap and dressing from the resident's left lower extremity and placed it in the red bag then proceeded to attempt to measure the wound but could not visualize it well due to it being on the back of the resident's leg (the resident was sitting in his wheelchair). Licensed Practical Nurse 8 switched places with Registered Nurse 7 and measured the wound. He then cleaned the wound and gave the dirty gauze to Registered Nurse 7, at which time she threw it in the red bag. With the same gloved hands, Registered Nurse 7 gave Licensed Practical Nurse 8 the clean dressing and he placed the clean dressing on the wound then wrapped it with kling gauze. Licensed Practical Nurse 8 and Registered Nurse 7 changed their gloves. The dressings to the two areas on Resident 122's right great toe came off in his sock when it was removed to do his treatments. Licensed Practical Nurse 8 measured the areas to Resident 122's right great toe and Registered Nurse 7 proceeded to clean the areas to the right great toe. The soiled gauze was discarded in the red bag. Registered Nurse 7 handed Licensed Practical Nurse 8 a sterile Q-tip and the packing gauze strip and he proceeded to pack to distal right great toe using the stick end of the sterile Q-tip to pack the wound. When he was finished, Registered Nurse 7 cut the gauze packing strip. Registered Nurse 7 then placed a dressing over the toe wounds, wrapped the toes with kling gauze, and applied the Amlactin external lotion to lower extremities. Registered Nurse 7 removed her gloves and gown. Licensed Practical Nurse 8 removed his gown and kept his gloves on and took the red bag to discard it. Registered Nurse 7 exited the room and proceeded up the hall with the treatment cart.
At no point during the entire process of Resident 122's wound care did Registered Nurse 7 or Licensed Practical Nurse 8 use antibacterial hand sanitizer or wash their hands after removing their soiled gloves and before reapplying clean gloves, between handling soiled dressings and applying clean dressings, and between treatments to left lower extremity and areas to right great toe.
Interview with Registered Nurse 7 and Licensed Practical Nurse 8 on May 8, 2024, at 12:12 p.m. confirmed that each time they changed their gloves during wound care for Resident 122, they should have washed their hands prior to putting on new gloves, but they did not.
Interview with the Director of Nursing on May 8, 2024, at 3:12 p.m. confirmed that each time Registered Nurse 7 and Licensed Practical Nurse 8 changed their gloves during wound care for Resident 122, they should have washed their hands prior to putting on new gloves, but they did not.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 228, dated April 30, 2024, revealed that the resident was cognitively intact and required extensive assistance for daily care needs.
Observations on May 6, 2024, at 11:01 a.m. revealed that Nurse Aide 9 gave Resident 228 a bed bath and threw a soiled towel and wash cloth on the floor while providing care. Interview with Nurse Aide 9 on May 6, 2024, at 11:27 a.m. confirmed that she should not throw soiled linen on the floor while providing care and that the soiled items should be placed in bags and taken to the dirty utility room.
Interview with the Clinical Coordinator on May 7, 2024, at 2:14 p.m. confirmed that soiled linen should not be thrown on the floor and that staff should place all laundry in bags and it should be taken to the dirty utility room.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations, as well as staff and resident interviews, it was determined that the facility failed to provide a safe and comfortable homelike environment in one of seven dining rooms (A1).
Fi...
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Based on observations, as well as staff and resident interviews, it was determined that the facility failed to provide a safe and comfortable homelike environment in one of seven dining rooms (A1).
Findings include:
The facility's policy for safe and homelike environment, dated February 4, 2024, indicated that the facility, in accordance with residents' rights, will provide a safe, clean, comfortable, and homelike environment. This includes ensuring that the resident can receive care and services safely.
An interview with a group of residents on May 7, 2024, at 2:00 p.m. revealed that the A1 dining room tables are peeling and are rough, and they had concerns about skin tears.
Observations in the A1 dining room on May 8, 2024, at 9:06 a.m. revealed that eight of eight tables were peeling and had sharp edges.
An interview with the Maintenance Director on May 8, 2024, at 9:08 a.m. confirmed that all eight tables located in the A1 dining room were peeling and had sharp edges.
An interview with the Director of Nursing on May 8, 2024, at 1:18 p.m. confirmed the tables in the A1 dining room were peeling and that it was not a comfortable, safe and homelike environment.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medica...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications for one of 48 residents reviewed (Resident 82).
Findings include:
The facility's policy regarding psychotropic medication (any medication that affects brain activities associated with mental processes and behavior), dated February 4, 2024, indicated that staff are to utilize non-pharmacological interventions (individualized approaches to care not primarily based on medication) when clinically indicated to reduce the need for psychotropic medication.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 82, dated March 6, 2024, indicated that the resident was usually understood, had cognitive impairment, required partial to moderate assist with transfers to bed/wheelchair/toilet, had a bed alarm used daily, and had diagnoses that included dementia and anxiety.
Physician's orders for Resident 82, dated December 26, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Lorazepam (a psychotropic medication to treat anxiety) every six hours as needed for anxiety.
A psychiatric evaluation for Resident 82, dated February 21, 2024 recommended to continue positive psychosocial and non-pharmacological approaches to enhance the resident's wellness.
Review of the Medication Administration Records (MAR) for Resident 82 for January and February 2024 revealed that the resident was administered 0.5 mg of Lorazepam on January 1, 2024, at 2:42 a.m. and 7:02 p.m.; January 2, 2024, at 5:57 p.m.; January 3, 2024, at 1:00 a.m.; January 4, 2024, at 12:42 a.m. and 9:37 p.m.; January 6, 2024, at 12:11 a.m. and 10:43 p.m.; January 7, 2024, at 7:23 p.m.; January 14, 2024, at 6:26 p.m.; January 20, 2024, at 6:14 a.m.; January 31, 2024, at 6:46 p.m.; February 8, 2024, at 4:02 a.m.; and February 11, 2024, at 5:44 p.m. There was no documented evidence that non-pharmacological interventions were attempted prior to administering Lorazepam on the above-mentioned dates and times.
An interview with the Director of Nursing on May 9, 2024, at 11:54 a.m. confirmed that there were no non-pharmacological behavioral interventions attempted for Resident 82 prior to the administration of Lorazepam on the above-mentioned dates and times.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly l...
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Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 48 residents reviewed (Resident 25) and failed to label multi-dose containers of insulin with the date they were opened in one of six medication carts reviewed (A1).
Findings include:
The facility's policy regarding medication label changes, dated February 4, 2024, indicated that in the event that an order change was made, allowing for the administration of the same medication, but requiring a label change, staff were to place an auxiliary label stating Direction Changed over the old directions on the label.
Physician's orders for Resident 25, dated March 21, 2024, included an order for the resident to receive 20 units of Lantus insulin one time a day for diabetes.
Observations during medication administration on May 8, 2024, at 9:00 a.m. revealed that Resident 25 received 20 units of Lantus insulin; however, the label on the resident's box of Lantus insulin indicated that the resident was to receive 25 units of Lantus insulin at bedtime.
Interview with Licensed Practical Nurse 4 on May 8, 2024, at 9:18 a.m. confirmed that the label on Resident 25's bottle of Lantus did not include the morning dose, and a Change in Direction label should have been placed on the bottle.
The facility's multi-dose vial storage policy, dated February 4, 2024, indicated that the facility will date all multi-dose vials when opened, for the purpose of infection control and to ensure product stability.
Manufacturer's instructions for Humalog and Lantus insulin, dated February 2024, revealed that the insulin vial was to be discarded 28 days after it was opened.
Physician orders for Resident 26, dated March 25, 2021, included an order for the resident to receive 8 units of Humalog in the evening. Physician orders for Resident 26, dated March 5, 2024, included an order for the resident to receive 12 units of Lantus at bedtime.
Manufacturer's instructions for Lispro insulin, dated February, 2024, revealed that the insulin vial was to be discarded 28 days after it was opened.
Physician orders for Resident 74, dated January 8, 2024, included an order for the resident to receive Lispro two times a day.
Manufacturer's instructions for Levemir insulin, dated February 2024, revealed that the insulin vial was to be discarded 42 days after it was opened.
Physician orders for Resident 169, dated December 20, 2023, included an order for the resident to receive 6 units of Levemir one time a day.
Observations of A1 medication cart on May 9, 2024, at 12:45 p.m. revealed that the Humalog, Lantus, Lispro, and Levemir vials for Residents 26, 74, and 169 were opened and not dated.
Interview with Licensed Practical Nurse 5 on May 9, 2024, at 12:45 p.m. confirmed that the insulin vials for Residents 26, 74, and 169 were not dated when opened to indicate the date they expire and should have been.
Interview with the Director of Nursing on May 9, 2024, at 1:00 p.m. confirmed that all insulin vials should have been labeled with the dates that they were opened and discarded in accordance with manufacturer's instructions.
28 Pa. Code 211.9(h) Pharmacy Services.
28 Pa. Code 211.12(d)(1) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
Findings inclu...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.
Findings include:
The facility's policy regarding feeding with dignity, dated February 4, 2024, revealed that staff will cleanse hands between residents when direct contact is made. Staff were not to touch food with their bare hands, and they were to wear gloves and wash hands in between glove changes.
Observations during the lunch meal in the A3 unit dining room on May 7, 2024, at 12:12 p.m. revealed that Nurse Aide 6 placed Resident 115's plate in front of her. Nurse Aide 6 picked up the top of the hamburger bun from the resident's plate with his bare hand and placed the mechanical soft prepared hamburger from a bowl onto the lower hamburger bun. He then replaced the top of the hamburger bun. The resident then took the hamburger and took a bite of it.
Interview with Nurse Aide 6 on May 7, 2024, at 12:59 p.m. confirmed that he touched Resident 115's sandwich without using a glove or a barrier.
Interview with the Corporate Compliance/Certified Registered Nurse Practitioner (CRNP - is a registered nurse who has advanced education and clinical training in a health care specialty area) on May 7, 2024, at 3:55 p.m. confirmed that staff were to use gloves or a barrier when touching residents' food items.
28 Pa. Code 211.6(f) Dietary Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 48 residents reviewed (Residents 97, 228) who were receiving hospice services.
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 97, dated February 7, 2024, indicated that the resident was cognitively impaired and had a diagnosis of malnutrition.
Physician's orders for Resident 97, dated March 3, 2022, included an order for the resident to be treated by hospice (end-of-life services). A care plan for Resident 97, dated March 3, 2022, indicated that the resident was receiving hospice services due to a terminal illness related to malnutrition.
As of May 9, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice nurse aide charting. The last hospice nurse aide charting located on the resident's chart was dated January 2024.
Interview with the Director of Nursing on May 9, 2024, at 12:55 p.m. confirmed that Resident 97's hospice nurse aide charting was not in the residents' clinical record and/or in the hospice provider's clinical record.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 228, dated April 30, 2024, indicated that the resident was cognitively intact and had a diagnosis of cerebral vascular accident (an interruption in the flow of blood to the cells in the brain).
Physician's orders for Resident 228, dated April 27, 2024, included an order for the resident to be treated by hospice (end-of-life services). A care plan for Resident 228, dated April 25, 2024, indicated that the resident was receiving hospice services due to a terminal illness cerebrovascular disease.
As of May 9, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained updated hospice registered nurse or nurse aide charting. The last hospice registered nurse charting located on the resident's chart was admission notes dated April 27, 2024.
Interview with the Director of Nursing on May 9, 2024, at 12:55 p.m. confirmed that Resident 228's hospice registered nurse and nurse aide charting was not in the residents' clinical record and/or in the hospice provider's clinical record.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending June 13, 2023; August 15, 2023; and August 29, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 9, 2024, identified repeated deficiencies related accuracy of assessments, tube feeding management, label/store drugs and biologicals, and infection prevention and control.
The facility's plan of correction for a deficiency regarding accuracy of assessments, cited during the survey ending June 13, 2023, revealed that accuracy of assessments would be monitored by QAPI. The results of the current survey, cited under F641, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding accuracy of assessments.
The facility's plan of correction for a deficiency regarding tube feedings, cited during the survey ending August 15, 2023, revealed that tube feeding would be monitored by QAPI. The results of the current survey, cited under F693, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding tube feeding.
The facility's plan of correction for a deficiency regarding labeling and storage of drugs and biologicals, cited during the survey ending June 13, 2023, revealed that labeling and storage of drugs and biologicals would be monitored by QAPI. The results of the current survey, cited under F761, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding label and storage drugs and biologicals.
The facility's plan of correction for a deficiency regarding infection prevention and control, cited during the survey ending August 29, 2023, revealed that infection prevention and control would be monitored by QAPI. The results of the current survey, cited under F880, revealed that the QAPI committee was ineffective in maintaining compliance with infection prevention and control.
Refer to F641, F693, F761, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to t...
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Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a written notice regarding emergency transfer to the hospital was provided to the resident's responsible party and the Office of the State Long-Term Care Ombudsman for three of 48 residents reviewed (Residents 63, 82, 118).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated April 24, 2024, indicated that the resident was usually understood and could usually understand, required assist with care needs, received hemodialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had diagnoses that included end-stage renal disease (kidneys no longer work as they should).
A nursing note for Resident 63, dated April 12, 2024, at 10:03 p.m. revealed that the resident was transferred to the hospital after traumatic removal of her right subclavian dialysis catheter (an indwelling catheter used for exchanging blood to and from the dialysis machine). Bleeding from the site was unable to be stopped and the resident was sent to the emergency room.
There was no documented evidence that a written notice of Resident 63's transfer to the hospital was provided to the resident's responsible party and/or to the State Ombudsman.
A quarterly MDS assessment for Resident 82, dated March 6, 2024, indicated that the resident was usually understood and usually understands what is being said, had cognitive impairment, required partial to moderate assist with transfers to bed/wheelchair/toilet, had a bed alarm used daily, and had a diagnosis of dementia.
A nursing note for Resident 82, dated January 17, 2024, at 6:57 a.m. revealed that the resident was transferred to the hospital after a fall resulting in pain to her right shoulder.
There was no documented evidence that a written notice of Resident 82's transfer to the hospital was provided to the resident's responsible party and to the State Ombudsman.
A quarterly MDS assessment for Resident 118, dated March 8, 2024, indicated that the resident was rarely or never understood and nonverbal, was cognitively impaired, was dependent for care needs, had a feeding tube (a mechanical device surgically implanted into the stomach to provide nutrition, fluids and medications to a person who is unable to eat or drink by mouth), and had a diagnosis of Huntington's disease (a rare, inherited condition that affects the nerve cells in the brain and causes movement, cognitive and psychiatric problems).
A nursing note for Resident 118, dated March 29, 2024, at 10:42 p.m. revealed that the resident was transferred to the hospital after a change in condition resulting in hypoxemia (low levels of oxygen in the blood) and possible ileus (a lack of movement in the intestines that can lead to blockage).
There was no documented evidence that a written notice of Resident 118's transfer to the hospital was provided to the resident's responsible party and to the State Ombudsman.
Interview with the Nursing Home Administrator on May 9, 2024, at 11:17 a.m. confirmed that there was no documented evidence that a written notice of emergency transfer to the hospital was provided to the resident's responsible party and to the State Ombudsman for Residents 63, 82 and 118. She revealed that she was not aware that the resident's responsible party and the State Ombudsman needed to be notified in writing about emergency transfers to the hospital; therefore, they were not notified as required.
28 Pa. Code 201.14(a) Responsibility of Licensee.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were perfor...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed while obtaining a blood glucose for two of 19 residents reviewed (Residents 2, 18), and failed to ensure the blood sugar monitoring device (glucometer) was appropriately cleaned between residents.
Findings include:
The facility's policy for disinfection of the glucose monitoring machine, dated February 1, 2023, indicated that the machine should be wiped with Clorox wipes before and after each resident care. Once in the resident's room the machine was to be placed on a clean paper towel on a flat, dry, clean surface. After obtaining the blood glucose level, remove gloves and wash hands, and clean the blood glucose device with Clorox wipes.
The diagnosis record for Resident 18, dated December 16, 2021, included the diagnosis of diabetes.
Physician's order for Resident 18, dated June 28, 2023, indicated that she was to have Novolog insulin (rapid acting insulin) provided twice a day depending on the blood glucose result and the coverage scale as ordered.
Observations on August 29, 2023, at 4:20 p.m. revealed that Licensed Practical Nurse 1 was obtaining Resident 18's blood glucose levels. The nurse, with gloved hands, entered the resident's room and placed the blood glucose device directly on her bedside stand. After obtaining a blood sample she proceeded out of the room to the medication cart. She placed the glucose device on the medication cart, removed her gloves, and cleaned the device with alcohol swabs. She placed the device back onto the medication cart and without performing any hand hygiene, she obtained equipment to obtain Resident 2's blood glucose. Licensed Practical Nurse 1 donned gloves and obtained a blood glucose for Resident 2. She proceeded to the medication cart, placed the device on the cart, cleaned the device with alcohol swabs then removed her gloves. Without performing hand hygeine she proceed to remove medications from the medication cart for another resident.
Interview with Licensed Practical Nurse 1 on August 29, 2023, at 4:30 p.m. indicated that she should not have placed the used glucose device on the medication cart before cleaning it, she should have used the hand sanitizer after her glove removal, and that she was to use alcohol for cleaning the device.
Interview with the Director of Nursing and the clinical compliance Certified Registered Nurse Practioner on August 29, 2023, at 5:14 p.m. confirmed that hand hygeine should have been done after Licensed Practical Nurse 1's glove removal, there should have been a barrier placed on the resident's over-the-bed stand/medication cart. and that the glucose machine should have been cleaned with Clorox wipes as per the policy.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Aug 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of 12 residents revie...
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Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment was free of accident hazards for one of 12 residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, indicated that the resident is cognitively impaired, does not speak, is totally dependent on two staff persons for all care needs, has a gastrostomy tube (g-tube - a tube inserted through the abdominal wall for the purpose of administering medications and nutrition), and had diagnoses that include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, affecting left non-dominant side.
Observations on August 15, 2023, at 10:59 a.m. revealed that Nurse Aide 1 lowered the head of Resident 2's bed to a flat position while the enteral feeding continued to infuse, and rolled Resident 2 side to side without the assistance of a second staff person. Nurse Aide 1 stated that Resident 2 had an emesis and that her bed pad and shirt needed changed.
Interview with the Director of Nursing on August 15, 2023, at 3:15 p.m. confirmed that Resident 2 should have been rolled from side to side by two staff members.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to appropriately care for a gastrostomy tube (g-tube - a tube inserted thr...
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Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to appropriately care for a gastrostomy tube (g-tube - a tube inserted through the abdominal wall for the purpose of administering medications and nutrition) for one of 12 residents reviewed (Resident 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 14, 2023, indicated that the resident is cognitively impaired, does not speak, is totally dependent on two staff for daily care needs, had a gastrostomy tube, and had diagnoses that include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, affecting left non-dominant side.
Physician's orders for Resident 2 dated August 18, 2021, included an order to hold enteral feedings (infusing liquid nutrition via a pump directly into the stomach) for two hours after any episode of vomiting, as needed. Physician's orders for Resident 2, dated July, 7, 2023, included an order for the head of the bed to be elevated at least 30 degrees while the enteral feeding is infusing to decrease risk of aspiration (a condition in which stomach contents or fluids are breathed into the lungs through the wind pipe).
Observations on August 15, 2023, at 10:59 a.m. revealed that Nurse Aide 1 lowered the head of Resident 2's bed to a flat position while the enteral feeding continued to infuse. Nurse Aide 1 stated the resident recently had an emesis and that her bed pad and shirt needed changed.
Interview with Licensed Practical Nurse 1 on August 15, 2023, at 11:30 a.m. confirmed that it had been reported to her that Resident 2 had an emesis at 9:00 a.m. Licensed Practical Nurse 1 also confirmed that Resident 2 had an order to hold enteral feedings for two hours after an emesis and for the head of her bed to be elevated at least 30 degrees while the enteral feeding is infusing.
Interview with the Director of Nursing on August 15, 2023, at 3:15 p.m. confirmed that the head of Resident 2's bed should have been elevated at least 30 degrees while the enteral feeding was infusing and that the feeding should have been placed on hold for two hours after the emesis.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.
Jun 2023
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 64 residents reviewed (Residents 127, 182).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410F (Antibiotic Medications) was to be coded with the number of days the resident received an antibiotic medication during the seven-day assessment period.
Physician's orders for Resident 127, dated May 9 and May 16, 2023, included an order for the resident to have Bacitracin ointment (antibiotic ointment) applied topically to the left hand twice a day. The resident's Treatment Administration Records (TAR's) for May 2023 revealed that the resident received Bacitracin ointment daily to her left hand May 9 to May 20, 2023.
A quarterly MDS assessment for Resident 127, dated May 17, 2023, revealed that Section N0410F was coded (0), indicating that the resident did not receive any antibiotic medications during the seven days of the assessment period.
The RAI User's Manual, dated October 2019, revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0410H was to indicate how many days the resident received an opioid during the seven-day review period.
Physician's orders for Resident 182, dated May 8, 2023, included an order for the resident to receive 50 milligrams of Tramadol (narcotic pain reliever) every eight hours as needed for severe pain (pain scale 8-10 out of 10). The resident's Medication Administration Record (MAR) for May 2023 revealed that she received Tramadol May 9 to 31, 2023.
A quarterly MDS assessment, dated March 19, 2023, revealed that Section N0410H was coded with a zero (0), indicating that the resident did not receive an opioid during the review period.
Interview with the Director of Case Management (responsible for completing MDS assessments) on June 12, 2023, at 2:59 p.m. confirmed that Section N0410F of Resident 127's MDS assessment of May 17, 2023, should have been coded for the use of an antibiotic and Section N0410H of Resident 182's MDS assessment of May 19, 2023, should have been coded for the use of an opioid.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly stored in the medication cart.
Findings include:
The facility's policy regarding medication carts, dated February 1, 2023, indicated that the medication cart is accessible only to authorized licensed personnel. The medication cart was to be in full view of the licensed nurse when administering medications
A quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs) for Resident 45, dated March 14, 2023, revealed that the resident was understood, understands, and required supervision for her locomotion on the unit, and had a diagnosis that included dementia. A care plan for the resident, dated July 26, 2021, revealed that the resident displays behaviors or wandering related to dementia.
Observations during medication administration on June 12, 2023, at 8:58 a.m. revealed that Licensed Practical Nurse 1 was outside of Resident 82's room with the medication cart to prepare Resident 82's medication for administration. Resident 45 was sitting in the hallway in her wheelchair near the medication cart. Licensed Practical Nurse 1 prepared Vitamin D3 1,000 international unit (IU) (a vitamin supplement), Hydrochlorothiazide 12.5 milligram (mg) (HCTZ -used to treat edema), Jardiance 25 mg (used to help control blood sugar levels), Methadone 5 mg (a medication used for pain relief and treatment of drug addiction), Lisinopril 5 mg (medication to treat high blood pressure), Movantik 25 mg (used to treat constipation that is caused by prescription pain medicines), and Vitamin B12 500 micrograms (mcg) (a vitamin supplement) by placing them into a medication souffle cup for the resident. Licensed Practical Nurse 1 then prepared Levemir 32 units (a long-acting insulin). Licensed Practical Nurse 1 then left the medication cart with the syringe containing the Levemir, leaving the medication souffle cup containing Resident 82's medications on the top of the medication cart, and proceed down the hall to where another licensed nurse was administering medications at resident room [ROOM NUMBER]. After the second licensed nurse checked Licensed Practical Nurse 1's dosage of Levemir, she then returned to the medication cart and obtained the medication souffle cup to administer Resident 82 his medications.
Interview with Licensed Practical Nurse 1 on June 12, 2023, at 9:02 a.m. confirmed that she should not have left Resident 82's medications on top of the medication cart. She indicated that she always has a second licensed nurse check her insulin doses before administering to the resident.
Interview with the Director of Nursing on June 12, 2023, at 3:38 p.m. confirmed that Licensed Practical Nurse 1 should not have left the medication cart unattended with Resident 82's medication on top of the medication cart.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(d)(1) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for five of 64 residents reviewed (Residents 8, 101, 129, 142, 194).
Findings include:
The facility's policy regarding medication administration, dated February 1, 2023, indicated that all medications were to be administered by licensed medical or nursing personnel in accordance with medical and nursing regulations of Pennsylvania. No medication was to be administered without a written order from the physician. Staff were to ensure accountability and the six rights (right resident, right drug, right dose, right time, right route, right dosing form).
Review of the clinical record for Resident 8 revealed a quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated May 20, 2023, indicated that the resident was cognitively impaired and had diagnoses that included hypertension (high blood pressure).
Physician's orders for Resident 8, dated July 18, 2022, included an order for the resident to receive 30 milligrams (mg) of diltiazem three times a day for hypertension and to hold the medication if the resident's systolic blood pressure (top number of a blood pressure reading) was less than 120 millimeters of mercury (mmHg). The resident's MAR's for December 2022 and January and February 2023 revealed that the resident's systolic blood pressure was less than 120 mmHg on December 13 at 2:00 p.m., December 17 at 8:00 a.m., December 31 at 9:00 p.m., January 5 at 2:00 p.m., January 16 at 2:00 p.m., and February 4 at 2:00 p.m., and the diltiazem was not held as ordered.
Interview with the Clinical Compliance Officer on June 12, 2023, at 2:39 p.m. confirmed that Resident 8's diltiazem was not held according to the physician's orders on the above mentioned dates and times.
Review of the clinical record for Resident 101 revealed a quarterly MDS assessment, dated February 14, 2023, indicating the resident was cognitively intact, required extensive assist for personal care needs, and had diagnosis that included diabetes.
A physician's order for Resident 101, dated May 6, 2023, included for the physician to be notified if the resident's blood sugar is greater than 300 milligrams per deciliter (mg/dl).
A review of the medication administration record (MAR) for Resident 101, dated May 2023 and June 2023, revealed that on May 4 at 1:00 p.m. the resident's blood sugar was 304 mg/dl, on May 11 at 8:00 a.m. his blood sugar was 377 mg/dl, on May 16 at 1:00 p.m. his blood sugar was 342 mg/dl, on May 17 at 6:00 p.m. his blood sugar was 334 mg/dl, on May 25 at 6:00 p.m. his blood sugar was 305 mg/dl, on May 30 at 1:00 p.m. his blood sugar was 314 mg/dl and at 6:00 p.m. his blood sugar was 329 mg/dl, and on June 10 at 6:00 p.m. his blood sugar was 370 mg/dl. There was no documented evidence that the physician was notified of the elevated blood sugars as ordered.
An interview with the Director of Nursing on June 13, 2023, at 1:12 p.m. confirmed that the physician was not notified of the above-mentioned blood sugars that were greater than 300 mg/dl and he should have been.
Review of Resident 129's clinical record revealed a quarterly MDS, dated [DATE], indicating that the resident was cognitively intact, required extensive assistance for daily care needs, and had diagnosis that included heart failure, respiratory failure, and unspecified pain.
Physician's orders for Resident 129, dated March 6, 2023, included an order for the resident to receive 25 microgram (mcg) of Fentanyl (a medication used for pain) every 72 hours.
A nursing note for Resident 129, dated June 5, 2023, at 8:22 p.m. revealed that the resident received a lower dose of Fentanyl than the ordered dose.
Interview with the Director of Nursing on June 13, 2023, at 1:10 p.m. confirmed that Resident 129 received the wrong dose of Fentanyl and that the dose should have been checked per Rights of Medication Administration before administering the medication.
Review of the clinical record for Resident 142 revealed a quarterly MDS assessment, dated April 5, 2023, indicating that the resident was usually understood and could usually understand others, required extensive assist for personal care needs, and had diagnosis that included diabetes.
A physician's order for Resident 142, dated April 7, 2023, included to administer 6 units of Novolog insulin (medication used to lower blood sugar) every day at 6:00 p.m. if the resident's blood sugar is greater than 300 mg/dl.
A review of the MAR for Resident 142 dated April 2023, May 2023, and June 2023 revealed that on April 8 at 6:00 p.m. the resident's blood sugar was 227 mg/dl, on April 13 at 6:00 p.m. his blood sugar was 298 mg/dl, on April 15 at 6:00 p.m. his blood sugar was 146 mg/dl, on April 30 at 6:00 p.m. his blood sugar was 188 mg/dl, on May 7 at 6:00 p.m. his blood sugar was 222 mg/dl, on May 8 at 6:00 p.m. his blood sugar was 210 mg/dl, on May 16 at 6:00 p.m. his blood sugar was 206 mg/dl, on May 28 at 6:00 p.m. his blood sugar was 197 mg/dl, on June 1 at 6:00 p.m. his blood sugar was 235 mg/dl, and on June 3 at 6:00 p.m. his blood sugar was 221 mg/dl. There was documented evidence that 6 units of Novolog insulin was administered on these dates when it should not have been administered because the resident's blood sugar was not greater than 300 mg/dl.
An interview with the Clinical Coordinator on June 12, 2023, at 9:07 a.m. confirmed that insulin was given on the above-mentioned dates and times when according to the physician's order it should not have been administered.
Physician's orders for Resident 194, dated January 2, 2023, included an order for the resident to receive 5 units of Novolog (insulin) twice a day if the resident's blood is greater than 200.
Resident 194's Medication Administration Records (MAR's) for April and May 2023 revealed that staff administered Novolog to the resident on April 1 at 6:00 p.m. for a blood sugar of 132 mg/dl, April 2 at 6:00 p.m. for a blood sugar of 161 mg/dl, April 7 at 6:00 p.m. for a blood sugar of 154 mg/dl, April 15 at 6:00 p.m. for a blood sugar of 156 mg/dl, April 21 at 6:00 p.m. for a blood sugar of 175 mg/dl, April 25 at 6:00 p.m. for a blood sugar of 188 mg/dl, May 9 at 6:00 p.m. for a blood sugar of 188 mg/dl, and May 20 at 6:00 p.m. for a blood sugar of 154 mg/dl.
Interview with the Clinical Consultant on June 12, 2023 at 4:04 p.m. confirmed that in accordance with the physician's order, Resident 194 should not have received the Novolog insulin on the above dates.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs for one of 64 residents reviewed (Resident 7...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs for one of 64 residents reviewed (Resident 73).
Findings include:
Review of clinical record for Resident 73 revealed a quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs), dated May 16, 2023, revealed that the resident was usually understood and usually understood others, required extensive assistance for personal care needs, received routine pain medication, and had diagnosis that included end-stage renal disease (kidney failure).
Physician's orders for Resident 73, dated January 11, 2023, included for the resident to receive 650 milligrams (mg) of acetaminophen (pain medication) three times a day for pain. An order, dated February 15, 2023, included for the resident to receive 1,000 mg of acetaminophen two times a day for pain.
A review of the medication administration record (MAR), dated February 2023 and March 2023 for Resident 73, revealed that the resident received both 650 mg of acetaminophen three times a day and 1,000 mg of acetaminophen twice a day from February 15, 2023, through March 4, 2023.
A facility investigation for Resident 73, dated March 5, 2023, revealed that a medication error was made and that the order for acetaminophen 650 mg three times a day should have been discontinued on February 15, 2023, when the new order for acetaminophen 1,000 mg was obtained.
An interview with the Director of Nursing on June 12, 2023, at 3:45 p.m. confirmed that the order for 650 mg of acetaminophen was not discontinued when the new order for 1,000 mg of acetaminophen was obtained and it should have been. The resident received more acetaminophen than was ordered from February 15, 2023, to March 4, 2023.
28 Pa. Code 211.12(d)(1) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- • 39% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 harm violation(s). Review inspection reports carefully.
- • 27 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade F (25/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Westmoreland Manor's CMS Rating?
CMS assigns Westmoreland Manor an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Westmoreland Manor Staffed?
CMS rates Westmoreland Manor's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 39%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Westmoreland Manor?
State health inspectors documented 27 deficiencies at Westmoreland Manor during 2023 to 2025. These included: 2 that caused actual resident harm, 24 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Westmoreland Manor?
Westmoreland Manor is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 408 certified beds and approximately 232 residents (about 57% occupancy), it is a large facility located in GREENSBURG, Pennsylvania.
How Does Westmoreland Manor Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, Westmoreland Manor's overall rating (2 stars) is below the state average of 3.0, staff turnover (39%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Westmoreland Manor?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Westmoreland Manor Safe?
Based on CMS inspection data, Westmoreland Manor has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Westmoreland Manor Stick Around?
Westmoreland Manor has a staff turnover rate of 39%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Westmoreland Manor Ever Fined?
Westmoreland Manor has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Westmoreland Manor on Any Federal Watch List?
Westmoreland Manor is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.