Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
247% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements including timely completion of Minimum Data Set (MDS) assessments, PASARR screening, care planning, medication administration, medication storage, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to complete MDS assessments timely for several residents, lack of evidence of Level 1 PASARR screening for mental disorders for one resident, incomplete care plans related to wound care and bed rails, failure to assess and obtain informed consent for bed rails, medication errors including wrong medication administration and incorrect route for Nitroglycerin, improper medication storage with expired insulin and other drugs, and failure to properly clean and disinfect blood glucose monitors.
Deficiencies (8)
Failure to ensure Minimum Data Set (MDS) assessments were completed within 14 days after the Assessment Reference Date (ARD) for four of seven sampled residents.
Failed to provide evidence of a Level 1 pre-screening for mental disorders/intellectual disabilities for one of 35 residents reviewed.
Did not ensure development and implementation of a comprehensive resident centered care plan for two residents related to wound care and bedside rails.
Did not ensure resident was appropriately assessed for risk of entrapment and did not obtain informed consent related to bedrails for one resident.
Failed to maintain a medication error rate of less than 5% during medication administration pass; three medication errors out of 26 opportunities observed.
Failed to ensure a resident was free of a significant medication error related to administration of Nitroglycerin tablets via the wrong route.
Failed to ensure all drugs and biologicals were stored in accordance with professional standards; expired insulin and other medications found in medication carts.
Failed to ensure staff followed proper infection control practices by not cleaning and disinfecting a blood glucose monitor after use.
Report Facts
Residents reviewed: 35
Medication administration opportunities observed: 26
Medication errors observed: 3
Medication error rate: 11.54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Nursing Home Administrator | Confirmed facility was unable to provide evidence of Level 1 PASARR screen for Resident R54 |
| Employee E2 | Director of Nursing | Confirmed findings related to bedrail assessments and lack of informed consent |
| Employee E8 | Licensed Practical Nurse | Confirmed findings of bilateral bed rails in up position and lack of care plan for bed rails |
| Employee E9 | Licensed Practical Nurse | Observed administering wrong medication and Nitroglycerin via wrong route; failed to clean blood glucose monitor |
| Employee E10 | Licensed Practical Nurse | Observed during medication cart inspection with expired insulin and unclear vial dates |
| Employee E11 | Licensed Practical Nurse | Observed during medication cart inspection with insulin vial labeled to discard after 28 days |
Inspection Report
Deficiencies: 1
Date: May 20, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, and homelike environment in resident care areas and dining experience, specifically focusing on one of five nursing units (dementia unit).
Findings
The facility failed to maintain a clean and homelike environment in the dementia unit, with observations of dirty bathrooms including feces and urine smell. Staffing shortages in housekeeping contributed to the failure to clean. One resident was hospitalized with UTI and ESBL infection, linked to the unsanitary conditions.
Deficiencies (1)
Failure to maintain a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Report Facts
Residents Affected: 3
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Registered Nurse | Interviewed regarding family concerns about resident rooms and environment |
| Employee E4 | Housekeeping Director | Confirmed bathroom was dirty due to housekeeping staff shortage |
| Employee E6 | Nurse Aide | Helped clean resident R2 after toileting, did not inform housekeeping of dirty bathroom |
| Employee E7 | Infection Control Staff | Confirmed resident R1 treated for UTI and ESBL infection linked to dirty bathroom |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 7
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to maintain safe and comfortable air temperatures on the 300 nursing unit, resulting in residents being at risk for hypothermia.
Complaint Details
The visit was complaint-related due to concerns about unsafe air temperatures on the 300 nursing unit and other care deficiencies. Immediate jeopardy was identified related to cold temperatures affecting 19 residents. The immediate jeopardy was lifted after corrective actions were implemented.
Findings
The facility failed to maintain room temperatures between 71 and 81 degrees Fahrenheit on the 300 nursing unit, placing 19 cognitively impaired residents at immediate jeopardy due to cold temperatures. Heating units in multiple rooms were non-operational since November 2024, and maintenance requests were not promptly addressed. Residents were moved to warmer areas and monitored until temperatures were restored. The immediate jeopardy was lifted on January 23, 2025.
Deficiencies (7)
Failure to maintain safe and comfortable air temperatures between 71 and 81 degrees Fahrenheit on the 300 nursing unit, resulting in immediate jeopardy to resident health.
Failure to transfer or discharge a resident with adequate reason and proper documentation (Resident R212).
Failure to develop a baseline care plan for Resident R212 within 48 hours of admission.
Failure to assist Resident R201 in gaining access to vision services; no consultation with optometrist or ophthalmologist obtained.
Failure to develop and implement an individualized person-centered care plan addressing dementia care needs for Resident R88.
Failure to provide timely and quality laboratory services/tests for Residents R72, R204, and R169.
Failure to maintain resident care equipment in safe, operating condition; multiple clogged sinks and rusted equipment observed.
Report Facts
Residents affected by cold temperatures: 19
Total residents on 300 nursing unit: 32
Critical lab potassium level: 6.6
Room temperatures recorded: 56
Room temperatures recorded: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E4 | Registered Nurse | Interviewed regarding resident care, lab results, and transfer of Resident R212 and R169. |
| Employee E7 | Maintenance Staff | Conducted air temperature measurements and confirmed heating system issues. |
| Employee E8 | Nursing Staff Member | Observed heating system failures and resident conditions on 300 nursing unit. |
| Employee E9 | Licensed Nursing Staff | Reported heating unit failures and confirmed use of maintenance communication system. |
| Employee E11 | Registered Nurse | Documented heating unit failures in maintenance communication logs. |
| Employee E3 | Regional Administrative Staff | Conducted room temperature audits on 300 nursing unit. |
| Employee E6 | Social Worker | Interviewed regarding care plan for Resident R191 with PTSD. |
| Employee E10 | Physician | Provided nephrology consult and progress notes for Resident R72. |
| Employee E2 | Director of Nursing | Interviewed regarding transfer and care of Resident R212. |
Inspection Report
Deficiencies: 1
Date: Dec 3, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically focusing on the review and revision of behavior health care plans for residents.
Findings
The facility failed to review and revise the behavior health care plan for one of nine residents reviewed (Resident R1), despite documented incidents of agitation, refusal of medications, and physical altercations. The care plan lacked updates addressing Resident R1's refusal of care and medications.
Deficiencies (1)
Failure to develop and revise a complete behavior health care plan within 7 days of comprehensive assessment for Resident R1.
Report Facts
Residents reviewed: 9
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Nurse Practitioner | Noted Resident R1 was seen at bedside, unpleasant with surroundings, and confirmed refusal to take medications |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to conduct a thorough investigation related to an injury sustained by a resident (Resident R1).
Complaint Details
The complaint investigation found that the facility did not properly investigate injuries sustained by Resident R1, including bruises and a cut above the right eye. The investigation was incomplete despite facility policy requiring thorough review of injuries of unknown origin.
Findings
The facility failed to ensure a thorough investigation of Resident R1's injuries, which included bruises and a cut above the right eye. Documentation and staff interviews revealed inconsistent monitoring and delayed recognition of injuries. The follow-up investigation noted a skin tear on the right eye and confirmed the resident does not get up unassisted.
Deficiencies (1)
Facility failed to ensure a thorough investigation was conducted related to an injury sustained by Resident R1.
Report Facts
Skin tear measurement: 4
Skin tear measurement: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse | Interviewed on October 23, 2024, regarding Resident R1's mobility status | |
| Employee E9 (nurse aide) | Provided statement about Resident R1's condition on October 2, 2024 | |
| Employee E7 (nurse aide) | Provided statement about noticing bleeding on Resident R1 on October 3, 2024 |
Inspection Report
Deficiencies: 1
Date: Apr 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights regarding room changes, specifically to determine if the facility provided written notice before changing a resident's room.
Findings
The facility failed to provide written notice, including the reason for the change, before changing the room of one resident (Resident R2) among 11 residents reviewed, despite policy allowing room changes for medical necessity or level of care changes.
Deficiencies (1)
Failure to provide written notice, including reason, before a resident's room change.
Report Facts
Residents reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E1 | Administrator | Interviewed regarding room change and notice |
| Employee E2 | Director of Nursing | Interviewed regarding room change and notice |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, grievance access, communication, respiratory care, medication storage, and food service quality at St John Neumann Center for Rehab & Healthcare.
Findings
The facility was found deficient in multiple areas including failure to honor residents' dignity during feeding, lack of access to grievance forms, inadequate communication devices for non-English speaking residents, unsafe medication administration and storage practices, inappropriate respiratory care equipment availability, medication errors exceeding 5%, and failure to serve food at safe and palatable temperatures.
Deficiencies (9)
Failed to provide care and services to enhance residents' dignity related to feeding residents, serving meals on disposable paperware, and providing incontinent care for four residents.
Failed to ensure residents had access to grievance forms and contact information for grievance officials on five nursing units.
Failed to provide a communication device to maintain optimal communication for one resident with a language barrier.
Failed to ensure resident environment was free of accident hazards related to medication administration and hazardous materials accessibility.
Failed to ensure appropriate size of indwelling urinary catheter was used for one resident.
Failed to provide appropriate respiratory care and services including availability of extra tracheostomy tubes and ambu bags for emergency procedures for three residents.
Failed to ensure medication error rates were below 5 percent; medication errors observed in two residents.
Failed to ensure all drugs and biologicals were labeled according to professional standards and stored properly in locked compartments on three nursing units.
Failed to provide food that was palatable and served at proper temperature for nine residents.
Report Facts
Residents reviewed: 36
Residents affected: 4
Residents affected: 5
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 2
Medication error rate: 10.71
Unidentified loose pills: 31
Unidentified loose pills: 7
Food temperature: 53.4
Food temperature: 69.33
Food temperature: 67.3
Food temperature: 70.7
Food temperature: 139.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E6 | Unit Manager | Named in feeding and incontinent care deficiency |
| Employee E7 | Nurse Aide | Named in feeding deficiency |
| Employee E8 | Nurse Aide | Named in feeding deficiency |
| Employee E13 | Director of Social Work | Named in grievance access deficiency and communication device deficiency |
| Employee E20 | Nurse Aide | Named in communication device deficiency |
| Employee E21 | Licensed Practical Nurse | Named in communication device deficiency |
| Employee E22 | Nurse Aide | Named in communication device deficiency |
| Employee E23 | Registered Dietitian | Named in communication device deficiency |
| Employee E24 | Speech Language Pathologist | Named in communication device deficiency |
| Employee E12 | Registered Nurse | Named in medication administration hazard and medication storage deficiencies |
| Employee E3 | Licensed Nurse | Named in medication administration hazard and medication error deficiencies |
| Employee E15 | Unit Manager | Named in respiratory care deficiency |
| Employee E1 | Facility Administrator | Named in respiratory care deficiency |
| Employee E2 | Director of Nursing | Named in respiratory care deficiency |
| Employee E31 | Registered Nurse | Named in medication error deficiency |
| Employee E32 | Licensed Nurse | Named in medication error deficiency |
| Employee E10 | Licensed Nurse | Named in medication storage deficiency |
| Employee E11 | Licensed Nurse | Named in medication storage deficiency |
| Employee E19 | Food Service Director | Named in food temperature deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 9, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to conduct thorough skin assessments and provide appropriate wound care treatment for a resident with pressure ulcers and documented skin impairments.
Complaint Details
The complaint investigation revealed substantiated findings that the facility failed to properly assess and treat pressure ulcers for Resident R1, resulting in wound deterioration and re-hospitalization.
Findings
The facility failed to conduct comprehensive wound assessments, did not follow hospital wound care recommendations, and failed to provide necessary treatment to promote healing of pressure ulcers for Resident R1. The resident's wounds deteriorated during the stay, leading to hospitalization.
Deficiencies (4)
Failure to conduct a thorough skin assessment of a resident with pressure ulcers and documented history of skin impairment.
Failure to ensure that podiatry wound care recommendations from hospital were administered as recommended.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Report Facts
Residents reviewed: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E3 | Wound Care Nurse | Interviewed regarding wound assessment and tracking; confirmed incomplete wound assessment for Resident R1 |
| Employee E2 | Director of Nursing (DON) | Interviewed regarding wound assessment and treatment; confirmed failure to complete wound assessments and follow hospital wound care orders |
| Employee E3 | Nurse Practitioner | Primary physician team member; stated primary care providers wanted hospital wound care recommendations to continue until seen by wound care physician |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning and dietary service regulations, focusing on care plan development for residents and the palatability and temperature of food served.
Findings
The facility failed to develop a comprehensive care plan for one resident's urinary tract infection treatment and failed to provide food that was palatable and served at the proper temperature for five residents.
Deficiencies (2)
Failed to develop comprehensive care plans to meet care needs for one of nine residents reviewed regarding UTI treatment.
Failed to provide food that was palatable and served at the proper temperature for five of eleven residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 5
Food temperatures: 120
Food temperatures: 120.5
Food temperatures: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Assistant Director of Nursing | Confirmed failure to create a care plan for Resident R6's UTI treatment |
| Employee E3 | Food Service Director | Conducted food temperature test and confirmed food was served too cold |
Inspection Report
Routine
Deficiencies: 8
Date: May 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, clinical records, restorative therapy, personal hygiene, respiratory care, nutrition, medication administration, and other nursing home services.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident toileting needs, delayed provision of clinical records, lack of restorative therapy, inadequate personal hygiene assistance, improper oxygen administration, failure to meet nutritional needs and menu planning, poor food quality and preparation, and inaccurate medication administration documentation.
Deficiencies (8)
Facility did not provide reasonable accommodations of needs related to toileting for one resident (Resident R67).
Facility failed to provide clinical records as requested in a timely manner for one closed record (Resident R248).
Facility failed to provide restorative therapy to maintain ability to ambulate without wheelchair for one resident (Resident R67).
Facility failed to ensure residents unable to perform activities of daily living received necessary personal hygiene and grooming assistance for three residents (Residents R59, R90, R298).
Facility failed to provide appropriate respiratory care for one resident needing continuous oxygen therapy (Resident R298).
Facility failed to meet nutritional needs of residents; menus were not followed, lacked fresh fruits, salads, and appropriate portion sizes for ten residents.
Facility did not prepare food by methods that conserve flavor and appearance; food was not palatable or served at appropriate temperature.
Facility failed to maintain complete and accurate documentation of narcotic medication administration for one resident (Resident R2).
Report Facts
Residents reviewed: 35
Residents reviewed: 40
Medication discrepancies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E13 | Licensed Nurse / Unit Manager / Licensed Practical Nurse | Confirmed toileting accommodation issue and restorative therapy documentation for Resident R67; observed personal hygiene issues for Resident R59. |
| Employee E15 | Wound Care Nurse | Observed personal hygiene issues for Resident R59. |
| Employee E12 | Registered Nurse | Confirmed lack of showering documentation for Resident R298. |
| Employee E11 | Licensed Nurse | Confirmed oxygen was set incorrectly for Resident R298. |
| Employee E24 | Dietary Services Supervisor | Confirmed menu deficiencies and lack of resident feedback incorporation. |
| Employee E19 | Registered Dietician | Confirmed missing weight and food preference documentation for Resident R104. |
| Employee E17 | Licensed Nurse | Confirmed lack of personal hygiene services for Resident R90. |
| Employee E23 | Unit Clerk | Reported grilled cheese sandwiches are rarely grilled. |
| Employee E18 | Food Service Director | Observed preparing grilled cheese sandwiches improperly. |
| Director of Nursing | Confirmed medication administration discrepancies for Resident R2. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
The inspection was conducted to assess the effectiveness of the facility's pest control program following observations, staff interviews, and review of facility policies and documentation.
Findings
The facility was found not to be maintaining an effective pest control program on two of five units observed, with evidence of mouse droppings, holes in walls, sightings of mice and gnats, and reports of foul odors from dead mice. Pest logs and pest management company reports confirmed ongoing mice activity despite treatment efforts.
Deficiencies (1)
Failure to maintain an effective pest control program to prevent and deal with mice, insects, or other pests on two of five units observed (400 unit and 600 unit).
Report Facts
Dates of pest sightings and treatments: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interviewed and confirmed pest control company treatment and pest log observations | |
| Building Maintenance Manager | Interviewed and confirmed pest log observations and pest management company reports |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to pain management for residents and COVID-19 testing procedures for residents and staff.
Findings
The facility failed to ensure appropriate pain management for one resident who continued to experience pain despite prescribed medications and did not receive as-needed pain medication on multiple occasions. Additionally, the facility did not properly check or document the positive COVID-19 test result of an employee, resulting in delayed notification.
Deficiencies (2)
Failure to provide safe, appropriate pain management for a resident requiring such services.
Failure to perform COVID-19 testing on residents and staff properly, including failure to check and document positive COVID-19 test results for an employee.
Report Facts
Pain levels recorded without administration of as-needed medication: 12
Date of positive COVID-19 test result: May 10, 2023
Date employee was notified of positive COVID-19 test: Jul 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Physical Therapy Assistant | Named in COVID-19 testing deficiency for missed positive test result notification |
| Employee E3 | Infection Preventionist | Interviewed regarding missed COVID-19 positive test result notification for Employee E5 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate pain management for a resident and failure to properly perform and document COVID-19 testing on staff and residents.
Complaint Details
The complaint investigation revealed that Resident R1 was not receiving adequate pain management despite multiple standing orders and documented pain assessments indicating moderate to mild pain levels. The facility also failed to notify Employee E5 of a positive COVID-19 test result in a timely manner, with notification delayed until nearly two months after the test.
Findings
The facility failed to ensure appropriate pain management for one resident who continued to experience pain despite prescribed medications and did not receive as-needed pain medication on multiple occasions. Additionally, the facility did not check or document the positive COVID-19 test result of a staff member in a timely manner, resulting in delayed notification.
Deficiencies (2)
Failure to provide safe, appropriate pain management for a resident requiring such services.
Failure to perform COVID-19 testing on residents and staff properly, including failure to check and document positive test results.
Report Facts
Pain levels recorded without medication administration: 12
Date of positive COVID-19 test: 2022
Date of delayed notification: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee E5 | Physical Therapy Assistant | Named in deficiency for failure to notify positive COVID-19 test result. |
| Employee E3 | Infection Preventionist | Interviewed and confirmed missed notification of Employee E5's positive COVID-19 test. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, and homelike environment and ensuring the nursing home area is free from accident hazards.
Findings
The facility failed to maintain a safe, clean, and homelike environment in two of five units reviewed, with issues such as broken floor tiles, slow draining sinks, rusted radiators, and broken doors. Additionally, the soiled utility room door was left open and unattended, posing a risk to resident safety.
Deficiencies (2)
Facility did not maintain a safe, clean, comfortable, homelike environment for two of five units reviewed (Units 400 and 600), including broken floor tiles, slow draining sink, brown substance on wall, rusted radiator, and broken soiled utility room door.
Facility did not ensure that the resident environment remained free of accident hazards for one of five units (400 unit), specifically the soiled utility room door was left open, unattended, and unobserved, containing biohazard and sharps disposal containers.
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