Accela Rehab And Care Center At Somerton
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 650 Edison Avenue, Philadelphia, Pennsylvania 19116
- CMS Provider Number
- 395084
- Inspections on file
- 40
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Accela Rehab And Care Center At Somerton during CMS and state inspections, most recent first.
A resident with COPD, chronic respiratory failure, and other comorbidities had physician orders for nightly AVAPS therapy with specific ventilator settings and continuous oxygen at 3 L/min, with SpO2 to be maintained between 88%–92% and all AVAPS refusals documented. Review of records showed SpO2 consistently documented at 94%–99%, missing or unclear documentation for more than half of the required evening/night AVAPS applications, missing entries for cleaning respiratory equipment, and unexplained “N/A” and “0” notations for AVAPS on multiple shifts. Nursing notes described a critical drop in SpO2 to 60% with confusion, conflicting documentation about whether AVAPS was applied during a prior shift when the resident reportedly refused, and subsequent transfer to the ED for shortness of breath with CO2 at the upper end of normal. The care plan noted AVAPS use and later refusal but lacked follow‑up interventions, AVAPS refusals were not documented as reported to the physician, and an NP reported being unaware of the specific AVAPS and oxygen orders, leading surveyors to cite the facility for failing to consistently administer and document ordered respiratory care.
A resident with COPD, acute and chronic respiratory failure, pneumonia, toxic encephalopathy, and dementia had new physician orders for continuous O2 at 3 L/min with SpO2 maintained at 88–92% and for nightly use of a Trilogy V60 (AVAPS) device with specific settings, including documentation of any refusals. Despite a cognitive status that allowed participation in care planning, the resident reported being unable to distinguish between CPAP, BiPAP, and AVAPS. Review of the care plan showed it was not timely revised to include goals and interventions related to recent hospitalization, change in mental status, assistance with AVAPS application, resident refusal of AVAPS, frequency of AVAPS use, or maintaining ordered O2 saturation parameters, in violation of facility policy and nursing service requirements.
Surveyors observed that the facility did not maintain a clean and sanitary environment on one nursing unit. The shower room tub had piles of dirty clothing, razors, and a soiled brief, with additional dirty items touching an exposed trashcan. In the soiled utility room, overflowing trashcans and a ripped bag of soiled clothing spilling onto the floor were also found. These conditions were confirmed by staff and the administrator.
A resident alleged that an LPN entered their room without permission, searched personal belongings, and attempted to take the resident's coat without explanation. Another resident and an LPN witnessed the incident, and the event was reported to the social worker. However, facility documentation lacked statements from those involved, resulting in a failure to determine potential misappropriation and ensure resident safety.
A resident with heart failure and hypertension was given antihypertensive medication despite physician orders to hold the dose for low systolic blood pressure. The medication was administered on several occasions when the resident's blood pressure was below the ordered threshold, and there was no documentation that the medication was held as required. The DON confirmed the error during interview.
A resident with intact cognition and serious medical conditions had a change in code status from full code to DNR, with the POLST form signed by a family member instead of the resident. Although staff reported the resident verbally agreed to the change and to the family member signing, there was no documentation in the clinical record confirming the resident's consent or agreement for the family member to sign on their behalf, resulting in incomplete and inaccurate medical records.
Accela Rehab and Care Center at Somerton failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day on 14 out of 21 days reviewed. The facility's staffing levels were insufficient, with care hours per patient per day ranging from 2.97 to 3.15, below the mandated 3.2 PPD. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not ensure the privacy and confidentiality of personal medical information for several residents. A schedule of resident appointments, including sensitive details such as room numbers, medical services, and transportation arrangements, was left visible to the public at the nurse's station. A nurse aide confirmed this was a routine practice, and the Nursing Home Administrator acknowledged the breach of privacy expectations.
A resident's narcotic medication was misappropriated due to the facility's failure to adhere to narcotic counting procedures and documentation policies. The resident, with a prescription for Oxycodone Acetaminophen, was missing 28 tablets, and the facility could not account for them. Interviews revealed that required narcotic counts between shifts were not conducted, and discrepancies were found in medication administration records.
The facility failed to follow physician orders for vital signs and hypoglycemic protocols for three residents. A resident with chronic conditions did not have vital signs recorded as ordered. Two residents with diabetes experienced low blood sugar levels without appropriate interventions or physician notification, as confirmed by the DON.
Two residents in the facility received inadequate respiratory care related to oxygen therapy. One resident's oxygen tubing was not dated as required, and another resident was connected to an oxygen concentrator with insufficient capacity, contrary to the physician's order. These deficiencies were confirmed by nursing staff and the Director of Nursing.
The facility failed to maintain accurate drug records and reconcile controlled substances for two residents. For one resident, 28 tablets of Oxycodone were missing, and the original narcotic book was discarded. Staff interviews confirmed that required narcotic counts between shifts were not conducted. Additionally, an unopened vial of Lorazepam for another resident was found without proper documentation, and vials were not counted between shifts as required.
A facility failed to obtain physician orders for a resident to store medication at bedside and did not ensure the medication was stored securely. The facility's policy requires an assessment of the resident's abilities for safe self-administration and mandates secure storage of medications. An inhaler was found in an unsecured nightstand, and the resident stated they kept it there because staff often could not find it. The DON was unaware of the lack of assessment and unsecured storage.
The facility failed to maintain effective infection control, with improper disposal and storage of suctioning devices and urinary catheter equipment. A resident's suction catheter was improperly stored in a bedside drawer, and another resident's urinary catheter drainage bag was found touching the floor, both confirmed by staff.
The facility failed to maintain a sanitary environment for two residents, as mouse droppings were found in their rooms and remained unaddressed despite being reported. Observations confirmed the droppings, and interviews with staff revealed that deep cleaning was not performed, with daily cleaning not involving moving furniture. A shortage of housekeeping staff on the second floor was also noted.
A facility failed to maintain an effective pest control program on the 2nd floor, as evidenced by mouse droppings found in a resident's room. Despite the resident's reports of seeing mice, there was no documentation of the complaint, and pest control was not informed. This indicates a failure in the facility's pest control program and response to resident complaints.
The facility failed to provide timely Notices of Medicare Non-Coverage (NOMNC) for three residents and did not issue the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two residents who remained in the facility after Medicare coverage ended. This deficiency was confirmed through documentation review and an interview with the Nursing Home Administrator.
The facility failed to notify the Office of the State Long-Term Care Ombudsman of emergency transfers for three residents. A resident was sent to the hospital twice in December, another was discharged to a hospital in November, and a third experienced involuntary jerking movements leading to an emergency transfer in January. These omissions were confirmed by the Nursing Home Administrator and violated regulatory requirements.
The facility failed to provide sufficient nursing staff, resulting in delayed medication administration. LPNs were observed administering morning medications hours after the prescribed times due to large resident assignments. The DON confirmed the staffing inadequacy, which led to the delays.
The facility failed to administer diabetic medications timely for five residents, as per physician orders. Medications were given hours after the prescribed times, contrary to the facility's policy. Licensed nurses confirmed the delays, and the DON acknowledged the failure to follow professional standards.
The facility failed to maintain accurate clinical records for two residents, as medications were administered late and recorded with incorrect times. Two LPNs confirmed the late administration but were unaware of how the incorrect times were entered. The facility could not explain the discrepancies in the records.
The facility did not update the daily nurse staffing information as required, with the posted data showing an outdated date of April 30, 2024. This was confirmed through an observation and an interview with the receptionist.
The facility failed to maintain a safe and functional environment for two residents. One resident's dresser was broken, exposing their clothes, while another resident's bed was not functioning properly, preventing the elevation of the foot of the bed. These issues were confirmed by the Nursing Home Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with multiple diagnoses, including pulmonary embolism and respiratory failure. A Level of Care determination deemed the resident Nursing Facility Ineligible, but there was no documentation of this being communicated to the resident. The discharge notice lacked a specified reason, and the discharge summary was incomplete. An interview confirmed the absence of documentation regarding the resident's ineligibility discussion.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Observations included a crystalized jug of honey, a dirty walk-in cooler, an AC unit blowing air through dusty vents, and cooking equipment with heavy buildup of grease and food spatters. The reach-in refrigerator also had dirty door gaskets and a buildup of dirt and food particles inside.
The facility failed to implement a complete drug regimen review process for three residents. The consultant pharmacist did not provide the required monthly medication regimen reviews, and there was a lack of documentation and follow-up on pharmacy recommendations.
The facility failed to maintain a clean, comfortable, and homelike environment in 2 of 5 nursing units. Observations revealed wet spills, a missing HVAC vent cover with sharp metal, broken headboards, scraped paint, and stained privacy curtains. The Maintenance Director was aware of some issues.
The facility failed to conduct a thorough investigation of missing narcotics involving three residents. The incident report and statements from licensed nurses were incomplete, and the investigation focused on only one possible perpetrator, despite indications of more potential perpetrators.
The facility failed to develop and implement a comprehensive care plan for a resident with a history of UTIs, despite the resident being hospitalized due to a UTI. The care plan did not include measures for UTI prevention, as confirmed by the DON.
The facility failed to maintain an environment free from hazards as cleaning supplies were left in a resident's room on two consecutive days. An interview with the DON confirmed that residents were not supposed to have cleaning supplies in their rooms.
The facility failed to ensure proper care of a urinary catheter bag and did not obtain a physician order for a resident to perform self-catheterization flushes. The resident was observed multiple times with the catheter bag lying on the floor, and it was confirmed that the resident was self-flushing the catheter without a physician order.
The facility failed to maintain accurate records for controlled drugs, with multiple instances of missing signatures and entries in the accountability logbook, as confirmed by a licensed nurse. This was a violation of the facility's policy and state regulations.
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards in the medication room on the first floor Unit A. An opened, unlabeled bottle of the probiotic Acidophilus was found in the top refrigerator without the date it was opened affixed to it. This was confirmed by a licensed nurse at the time of the observation.
The facility failed to properly dispose of trash and recyclables in the receiving and dumpster area. Observations revealed scattered trash, an overflowing recycling dumpster, and old mattresses leaning against a shed. These issues were confirmed by the Food Service Director.
The facility failed to follow proper infection control practices during wound care for a resident. A licensed nurse did not wear a gown as required by the facility's policy on enhanced barrier precautions, despite the resident having a physician's order for specific wound care procedures.
The facility failed to maintain an effective pest control program, with multiple observations and reports of mice and roaches in various areas. Residents and staff confirmed the presence of pests, and pest control logs revealed numerous instances of mice and roaches over several months. The facility's pest control policy was not effectively implemented, resulting in a deficiency in maintaining a safe and sanitary environment.
A facility failed to meet professional standards by allowing an LPN to pre-sign MARs before administering medications to residents. This included instances where medications were marked as given despite being unavailable, and a resident's blood sugar level was documented without observation. These actions violated the facility's policy and Pennsylvania Code Title 49.
Failure to Provide and Document Ordered AVAPS Therapy and Oxygen Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care to a resident according to professional standards of practice, specifically related to AVAPS therapy and oxygen administration. The resident had a significant medical history including toxic encephalopathy, COPD with exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia, and dementia, and had a BIMS score indicating intact cognition. Physician orders directed that the resident receive AVAPS via a Trilogy V60 ventilator at bedtime with specific settings, that refusals of AVAPS be documented each evening and night shift, and that oxygen be administered at 3 L/min via nasal cannula with SpO2 maintained between 88%–92% each shift. The facility’s own respiratory therapy policy required staff to collaborate with the interdisciplinary team and document assessments, treatments, resident response, and education in the medical record. Review of the electronic treatment administration record (e‑TAR) for February showed that the resident’s SpO2 levels were documented between 94%–99%, which was inconsistent with the physician’s ordered target range of 88%–92% for a COPD resident on AVAPS. Between February 17 and February 25, of 15 required evening/night AVAPS applications, 8 shifts (53%) had missing or unclear documentation of treatment or refusal, and there were also missing entries for cleaning the resident’s respiratory appliances on specified day shifts. The e‑TAR contained entries of “N/A” and “0” for AVAPS application on several evening and night shifts, and the DON could not clarify what these notations meant. The care plan documented AVAPS use and respiratory monitoring interventions, and later noted that the resident refused AVAPS at times, but there were no follow‑up interventions related to refusals, and the clinical record lacked evidence that AVAPS refusals were communicated to the physician. Nursing notes documented that on one evening the resident’s pulse oximetry dropped to 60% and the resident was noted to be confused, at which time AVAPS was applied. Progress notes indicated that the resident had refused AVAPS during the prior night shift, while the e‑TAR for that same period showed AVAPS as applied, demonstrating conflicting documentation. The resident was subsequently transferred to the emergency room for shortness of breath, with CO2 measured at the upper end of normal (45 mmHg), and was later readmitted and placed on AVAPS with 3 L oxygen. An NP interviewed during the survey stated she was unaware of the physician orders regarding AVAPS frequency and oxygen parameters. Based on these findings, surveyors concluded that the facility failed to consistently administer and appropriately document life‑sustaining AVAPS therapy and physician‑ordered oxygen parameters, resulting in actual physical harm and significant clinical decline for the resident, including acute respiratory distress, mental confusion, and elevated CO2 levels that necessitated emergency transfer.
Failure to Revise Respiratory Care Plan After New Oxygen and AVAPS Orders
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and implement a comprehensive care plan related to respiratory care for one resident following changes in condition and new treatment orders. Facility policy on “Comprehensive Person-Centered Care Plans,” revised March 2022, states that assessments are ongoing and care plans are to be revised as information about the resident and the resident’s condition changes. The resident had a medical history that included toxic encephalopathy, COPD with exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, pneumonia, and dementia. A Minimum Data Set assessment completed on February 20, 2026, documented a BIMS score of 14, indicating the resident was cognitively able to participate in care discussions. Physician orders dated February 17, 2026, directed continuous oxygen at 3 L/min via nasal cannula with SpO2 to be maintained between 88–92% every shift, and an additional order at 11:00 p.m. the same day for assistance with applying a Trilogy V60 (AVAPS) device at bedtime with specified ventilator settings, including documentation of any refusal of AVAPS every evening and night shift and PRN for COPD. During an interview on March 3, 2026, the resident stated an inability to differentiate between CPAP, BiPAP, and AVAPS machines. Review of the resident’s care plan showed no timely update or revision of goals and specific interventions addressing the recent hospitalization, change in mental status, assistance with applying AVAPS, the resident’s refusal of AVAPS, the frequency of AVAPS application, or maintaining oxygen saturation between 88–92%, contrary to facility policy and regulatory requirements.
Failure to Maintain Clean and Sanitary Resident and Service Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment in resident-use and service areas on one of its nursing units. During observations on the second floor, surveyors found that the shower room tub contained piles of dirty clothing, three razors, and a soiled brief. Additional dirty clothing, including socks and gowns, was observed along the left side of the tub, in contact with an exposed trashcan containing soiled briefs. In the soiled utility room, two exposed trashcans were overflowing with trash, and a ripped bag of soiled clothing was lying on the floor with its contents spilling out and touching the floor. These findings were confirmed by staff and the facility administrator during the survey.
Failure to Investigate Alleged Violation of Resident Privacy and Property
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation that a Licensed Practical Nurse (LPN) entered a resident's room without permission and searched through the resident's personal belongings while the resident was not present. The resident reported that the LPN attempted to take their coat and did not provide an explanation, resulting in the resident feeling that their privacy and property rights were violated. Another resident, who was the roommate, confirmed witnessing the LPN take the coat, and a second LPN also witnessed the event and reported it to the social worker. Despite being made aware of the incident, facility documentation did not include statements from the involved residents or staff, which resulted in a failure to determine potential misappropriation and ensure resident safety as required by regulation.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency was identified when a resident with diagnoses of heart failure and primary hypertension was administered antihypertensive medication outside of the parameters ordered by the physician. The physician's order specified that Carvedilol should be held if the resident's heart rate was less than 60 or if the systolic blood pressure was less than 110. Clinical record review showed that on multiple occasions, the medication was administered even when the resident's systolic blood pressure was below the specified threshold, including readings of 92 and 85. There was no documentation indicating that the medication was held as per the physician's order on these dates. The DON confirmed during an interview that the medication was given when the resident's blood pressure was significantly low and acknowledged that it should have been held according to the order. This failure to follow physician orders resulted in a significant medication error for the resident.
Failure to Accurately Document Resident Consent for Code Status Change
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. Upon admission, the facility's policy required that residents be provided with information about their right to formulate advance directives, and that any changes in decision-making capacity or code status be communicated and documented appropriately. A resident with diagnoses including malignant neoplasm of the brain, COPD, and chronic kidney disease was admitted and later had a code status change from full code to DNR. The resident was cognitively intact, as indicated by a BIMS score of 14, and was their own responsible party without a legal representative. On the date of the code status change, the POLST form was updated to DNR and signed by the resident's family member, despite the resident being their own responsible party. Progress notes indicated that the family member was involved in discussions and signed documentation, but there was no documentation in the clinical record confirming the resident's agreement to the code status change or to having the family member sign on their behalf. Staff interviews confirmed that the resident verbally agreed and nodded assent, but this was not documented in the clinical record as required by facility policy and professional standards.
Non-Compliance with Nursing Care Hour Requirements
Penalty
Summary
Accela Rehab and Care Center at Somerton was found to be non-compliant with the Pennsylvania Long Term Care Licensure Regulations regarding nursing services. Specifically, the facility failed to provide the required minimum of 3.2 hours of direct nursing care per resident per day on 14 out of 21 days reviewed. The deficiency was identified through a review of nursing staffing hours and confirmed by an interview with the Nursing Home Administrator. The facility's staffing levels fell short of the mandated care hours on multiple days in February and March 2025, with care hours per patient per day (PPD) ranging from 2.97 to 3.15, all below the required 3.2 PPD. The report details specific dates and the corresponding care hours and resident census, highlighting the shortfall in nursing care hours. For instance, on February 9, 2025, the facility provided 630.5 care hours for 206 residents, resulting in only 3.06 PPD. Similar deficiencies were noted on other days, such as March 8, 2025, where 635.5 care hours were provided for 214 residents, totaling 2.97 PPD. These findings were corroborated by the Nursing Home Administrator, who acknowledged that the staffing levels did not meet the required minimums.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed with federal and state law requirements. Identification of other residents or areas having the potential to be affected due to the nature of the deficiency: The deficient practice has the potential to affect all residents. Corrective action: 1. Staffing coordinator or designee will be re-educated on number of staff and ratios per state guidelines. 2. Nursing supervisor or designee to audit 4 random resident charts of the identified day, to identify any unmet resident needs due to staffing shortages. 3. Staffing coordinator or designee to audit a random day per week for staffing ratios weekly X4 Monthly X3. 4. Results will be reviewed at the quarterly QAPI meeting.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of personal medical information for six residents. During an observation on March 12, 2025, it was noted that a schedule of resident appointments was left on the desk of the nurse's station, visible to the public. This schedule included sensitive information such as the residents' room numbers, types of medical appointments, pick-up times, appointment times, staff escorts, addresses of appointment locations, and transportation arrangements. The residents affected were scheduled for various medical services, including gastroenterology, dialysis, eye measurements, neurology, and methadone treatment. A nurse aide confirmed that it was routine practice to keep such schedules in a plastic frame on top of the nurse's station, accessible to visitors and other residents. The Nursing Home Administrator acknowledged that this practice did not comply with the privacy and confidentiality expectations for residents' protected health information.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically involving the diversion of narcotic medication. Resident R416, who was admitted with diagnoses including sepsis and cellulitis, had a prescription for Oxycodone Acetaminophen for pain management. An investigation revealed that 28 tablets of this medication were missing, and the facility could not account for them. The narcotic accountability records were incomplete, with missing dates and illegible signatures, and the original records were reportedly discarded, making it impossible to verify the proper handling of the medication. Interviews with the Director of Nursing and staff indicated that the required procedure of counting narcotics between shifts was not followed. On June 9, 2024, the narcotics were not counted between the 7-3, 3-11, and 11-7 shifts, leading to the discovery of the missing tablets on June 10, 2024. Additionally, there were discrepancies in the medication administration records, with instances where tablets were documented as pulled but not administered to the resident. This lack of adherence to policy and documentation failures contributed to the misappropriation of the resident's medication.
Failure to Implement Vital Signs and Hypoglycemic Protocols
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not ensuring vital signs were obtained and hypoglycemic protocols were implemented as per physician orders for three residents. Resident R28, who was admitted with chronic kidney disease, hypertension, and peripheral vascular disease, had physician orders for vital signs to be taken every evening shift on specific days. However, there was no documentation of vital signs being recorded from March 1 to March 10, 2025, as confirmed by the Unit Manager. Resident R65, diagnosed with diabetes, had physician orders for hypoglycemia management, including administering glucose gel and notifying the physician if blood sugar levels were below 70. Despite having low blood sugar readings on multiple occasions, there was no evidence of appropriate interventions or physician notification. Similarly, Resident R123, also with diabetes, experienced severe hypoglycemic events with blood sugar levels as low as 46, yet there was no documentation of nursing interventions or physician notification. These deficiencies were confirmed by the Director of Nursing.
Inadequate Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care related to oxygen therapy for two residents. Resident R85, who was admitted with diagnoses including heart failure and chronic respiratory failure, was observed receiving oxygen therapy via nasal cannula. However, the oxygen tubing was not dated as required by the physician's order and facility policy. This was confirmed by a registered nurse, indicating a lapse in following the prescribed protocol for oxygen administration. Resident R99, admitted with traumatic brain injury and acute respiratory failure, had a physician's order for oxygen to be administered at 6 liters per minute via a tracheostomy tube. However, observations revealed that the oxygen concentrator in use had a maximum output of 5 liters per minute, which was confirmed by both a registered nurse and the Director of Nursing. This discrepancy indicated that the incorrect oxygen concentrator was being used for Resident R99, failing to meet the prescribed oxygen therapy requirements.
Deficiency in Controlled Substance Accountability
Penalty
Summary
The facility failed to maintain accurate drug records and reconcile controlled substances for two residents, leading to a deficiency in pharmaceutical services. For Resident R416, there was a discrepancy in the narcotic accountability record for Oxycodone Acetaminophen Oral Tablet 5-325 MG. The facility's investigation revealed that 28 tablets were missing, and the original narcotic book containing the records was discarded, making it unavailable for review. Interviews with staff confirmed that the required narcotic counts between shifts were not conducted, and the facility's policy on narcotic accountability was not followed. Additionally, for Resident R141, an unopened vial of Lorazepam concentrates 2mg/ml was found in the medication room refrigerator without a corresponding Controlled Drug Receipt/Proof of Use/Disposition Form in the narcotic accountability binder. Further investigation revealed that there was no record of this Lorazepam in the narcotic book, and the staff confirmed that the vials were not counted between shifts as required. Instead, the vials were only counted once every 24 hours during the day shift, and the accounting was recorded in the pyxis system. The deficiency highlights the facility's failure to comply with its own policies and regulatory requirements for handling and documenting controlled substances. The lack of proper documentation and reconciliation of narcotics poses a significant risk to the safety and well-being of the residents, as evidenced by the missing medications and unaccounted vials.
Failure to Securely Store Resident Medication
Penalty
Summary
The facility failed to obtain physician orders for a resident to store medication at bedside and did not ensure the medication was stored securely. The facility's policy on self-administration of medications requires an assessment of the resident's cognitive and physical abilities to determine if self-administration is safe and appropriate. Additionally, the policy mandates that self-administered medications be stored in a secure location inaccessible to other residents. During an observation, a surveyor found an inhaler belonging to a resident in an unsecured nightstand. The resident mentioned keeping the inhaler in their room because staff often could not locate it. The Director of Nursing was unaware that there was no assessment conducted and that the medication was kept in an unlocked drawer.
Infection Control Deficiencies in Suctioning and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper disposal and storage of used and potentially contaminated suctioning devices and improper handling of urinary catheter equipment. Specifically, for one resident with a tracheostomy, the facility's policy required that suction catheters be wrapped in a glove and discarded in a designated receptacle. However, observations revealed that the resident's open suctioning catheter was stored in the bedside table drawer, along with other open medical items, which was confirmed by interviews with nursing staff. Additionally, another resident with a urinary catheter had their drainage bag touching the floor, contrary to the facility's policy that required catheter tubing and drainage bags to be kept off the floor. This was observed and confirmed by a registered nurse. These deficiencies were identified during a review of the facility's policies, clinical records, and through staff interviews, indicating a lapse in adherence to infection control protocols.
Failure to Maintain Sanitary Environment Due to Mouse Droppings
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for two residents, as evidenced by the presence of mouse droppings in their rooms. Resident R160, who was admitted with a surgical amputation and has an intact cognitive response, reported ongoing concerns about room cleanliness, specifically noting that the room had not been cleaned properly since admission. Observations confirmed the presence of mouse droppings along the baseboards of R160's room, which remained unaddressed despite staff being informed. Similarly, Resident R130, admitted with diagnoses including opioid abuse and pneumonia, also had mouse droppings observed in their room beside the dresser, which were not cleaned up after being reported. Interviews with staff, including a registered nurse and the nursing home administrator, confirmed the presence of mouse droppings in both residents' rooms. The facility's Quality Assurance Performance Improvement System Compliance Plan had identified a concern regarding the deep cleaning of rooms, yet interviews with housekeeping staff revealed that deep cleaning was not being performed, and daily cleaning did not involve moving furniture. The housekeeping supervisor acknowledged a shortage of staff on the second floor, which may have contributed to the deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program on the 2nd floor, as evidenced by the presence of mouse droppings in a resident's room. The facility's pest control policy, revised in May 2008, mandates an ongoing program to keep the building free of insects and rodents. However, during an observation on March 11, 2025, mouse droppings were found by the baseboards between the head of the resident's bed and the nightstand. A registered nurse confirmed the presence of these droppings. The resident, who has an intact cognitive response with a BIMS score of 15, reported seeing mice frequently in his room and the hallway, especially at night, and stated that he had informed the staff about this issue. Despite the resident's reports, there was no documentation of the complaint in the Customer Complaint Record Log, which is supposed to be maintained at the nursing station. The facility administrator confirmed that no report was made, and there was no documented evidence that pest control was informed of the resident's complaint or the presence of mouse droppings. This lack of documentation and communication indicates a failure in the facility's pest control program and its response to resident complaints, leading to the deficiency noted in the survey.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide timely notices of Medicare non-coverage for three residents, as required by federal regulations. Specifically, the Notices of Medicare Non-Coverage (NOMNC) were not delivered at least two calendar days before the end of Medicare-covered services for Residents R76, R161, and R117. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the NOMNC forms were not provided in a timely manner. Additionally, the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to Residents R76 and R161, who remained in the facility after their Medicare coverage ended. This notice is essential to inform residents of their potential financial liability for services no longer covered by Medicare. The absence of these notices was confirmed through a review of facility documentation and further corroborated by the Nursing Home Administrator during the interview.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers for three residents. Resident R123 was sent to the hospital on two occasions in December 2024, but the facility did not inform the Ombudsman. This oversight was confirmed by the Nursing Home Administrator on March 13, 2025. Similarly, Resident R136 was discharged to a Short-Term General Hospital in November 2024, and the facility again failed to notify the Ombudsman, as confirmed by the Nursing Home Administrator. Additionally, Resident R171 experienced gross involuntary jerking movements and altered vital signs, leading to an emergency transfer to a local hospital in January 2025. The facility did not include this resident on the list sent to the Ombudsman, which was confirmed by the Nursing Home Administrator. These failures to notify the Ombudsman were in violation of the regulatory requirements outlined in 28 Pa. Code 201.14(a) and 28 Pa. Code 201.18(b)(2).
Insufficient Staffing Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff to provide timely medication administration, as evidenced by observations and interviews with staff. On multiple units, Licensed Practical Nurses (LPNs) were observed administering morning medications significantly later than the prescribed times. For instance, on the second floor, LPNs were still administering 9:00 a.m. medications well past 11:00 a.m., with some medications documented as administered after 12:00 p.m. This delay in medication administration was confirmed by the LPNs themselves, who cited large resident assignments as a contributing factor. The report highlights specific instances where residents did not receive their medications at the prescribed times. For example, Resident R1's medications, including Divalproex, Quetiapine fumarate, and others, were documented as administered at 12:04 p.m., despite being scheduled for 9:00 a.m. Similar delays were noted for other residents across different units, with medications being administered hours after the prescribed times. These delays were consistently confirmed by the LPNs responsible for the medication passes. Interviews with the Director of Nursing (DON) further confirmed the facility's failure to provide sufficient staffing for timely medication administration. The DON acknowledged that the staffing levels were inadequate to meet the needs of the residents, resulting in the observed delays. The facility's policy on medication administration, which requires medications to be administered within one hour of the prescribed time, was not adhered to, leading to the deficiency noted in the report.
Failure to Administer Diabetic Medications Timely
Penalty
Summary
The facility failed to administer diabetic medications in accordance with professional standards for five residents. The facility's policy requires medications to be administered within one hour of their prescribed time unless otherwise specified. However, the review of clinical records and medication administration records revealed that medications for Residents R1, R6, R9, R13, and R17 were administered late, not adhering to the prescribed times. For instance, Resident R1's Glipizide and Metformin were administered hours after the prescribed time, and similar delays were noted for the other residents. Licensed nurses confirmed the late administration of medications, and the Director of Nursing acknowledged that the facility did not follow professional standards of practice and physician orders during medication administration. The report highlights that the facility's failure to administer medications timely affected all five residents reviewed, indicating a systemic issue in medication management and adherence to physician orders.
Inaccurate Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate clinical records for two residents, as observed during a survey. Licensed Nurse, Employee E3, was administering medications late for several residents, including Resident R1, whose medications were scheduled for 9:00 a.m. but were documented as administered at 12:04 p.m. Despite this, the administration time was inaccurately recorded as 8:03 a.m. Employee E3 confirmed the medications were administered late and was unaware of how the incorrect time was entered. Similarly, Licensed Nurse, Employee E4, was also administering medications late for Resident R5, with medications scheduled for 9:00 a.m. but documented as administered at 12:38 p.m., while the administration time was inaccurately recorded as 8:45 a.m. Employee E4 also confirmed the late administration and was unaware of how the incorrect time was entered. The facility's Medication Administration Policy requires medications to be administered at the ordered times and signed out immediately when given. However, both employees E3 and E4 were observed administering medications significantly later than scheduled, and the administration times recorded in the clinical records did not reflect the actual times of administration. The facility was unable to provide an explanation for the discrepancies in the clinical records when requested by the surveyors, indicating a failure to adhere to professional standards for maintaining accurate clinical records.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information as required by regulations. On November 5, 2024, at 10:00 a.m., an observation revealed that the staffing data displayed at the front desk of the lobby was outdated, showing the date April 30, 2024. An interview with the receptionist at the same time confirmed that the posted staffing information was indeed from April 30, 2024, indicating a failure to update the information daily as mandated.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment for two residents. During an observation, it was noted that a resident's dresser had a broken top handle and a second drawer shelf that was broken and lacked a cover, leaving the resident's clothes exposed. The shelf cover was found leaning against the wall near the window. Additionally, another resident reported that their bed was not functioning properly, specifically that the foot of the bed could not be elevated. This issue was reported to a nurse aide. The Nursing Home Administrator confirmed both the broken dresser and the malfunctioning bed.
Incomplete and Inaccurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, identified as Resident R1. The resident was admitted with multiple diagnoses, including pulmonary embolism, seizures, and respiratory failure, among others. A Level of Care determination was made on April 18, 2024, indicating that the resident was Nursing Facility Ineligible, but there was no documentation that this determination was communicated to the resident. Additionally, the discharge notice given to the resident on May 8, 2024, lacked a specified reason for the discharge, and the discharge summary was incomplete. The discharge instruction sheet also noted that the facility refused to provide housing arrangements for the resident. An interview with the social services director confirmed the absence of documentation regarding the discussion of the resident's ineligibility. These deficiencies were identified through observations, review of resident records, and staff interviews, indicating a failure to adhere to accepted professional standards in maintaining clinical records.
Food Service Safety Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, several concerns were observed. In the dry storage area, a jug of honey was found to be very dark and crystalized with a receiving date of 2/2022. The walk-in cooler had a dusty and dirty floor littered with debris, and the shelving and dunnage racks were also dusty and dirty, with dark spots on the walls and ceiling. In the kitchen, an AC unit was blowing air through vents covered with dark blackish dust and grime. Cooking equipment, including a tilt skillet and two stack convection ovens, had a heavy buildup of dark substances, burned-on grease, and food spatters. The reach-in refrigerator had dusty and dirty door gaskets with food particles in the cracks, and the inside had a buildup of dirt and food particles on the bottom and sides. These findings were confirmed by the Food Service Director during the tour.
Failure to Implement Complete Drug Regimen Review Process
Penalty
Summary
The facility failed to implement a complete drug regimen review process for three residents. The consultant pharmacist did not provide the required monthly medication regimen reviews for Resident R54, Resident R26, and Resident R61. Specifically, Resident R54's clinical record showed no pharmacy notes since the last review on December 11, 2023. Resident R26's clinical record lacked pharmacy notes for multiple months, including December 2023, January 2024, February 2024, April 2024, and May 2024. Resident R61's clinical record was missing pharmacy medication regimen reviews for March 2024 and April 2024, and there was no physician response to a pharmacy recommendation made in February 2024 regarding the continued need for oxycodone. The Director of Nursing confirmed the absence of documentation for the December monthly medication regimen review. The facility was unable to provide the requested pharmacy medication regimen reviews for Resident R61 for the specified months. These deficiencies indicate a failure to adhere to the facility's policy requiring monthly documented reviews of each resident's medication regimen and appropriate communication of potential or actual medication-related problems to prescribers and facility leadership.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in 2 of 5 nursing units. Observations on April 30, 2024, revealed several wet spills in the hallway entering the second floor off the elevator. In one room, the HVAC unit was missing a vent cover, exposing sharp metal and significant dust accumulation, which a resident confirmed had been in this condition for some time. Another room had a broken headboard and scraped paint on the wall behind the bed. Additionally, two rooms had brown/red stained privacy curtains. Further observations noted two wet spills at the end of the hallway on A-wing. The Maintenance Director confirmed awareness of the missing vent cover in one of the rooms.
Incomplete Investigation of Missing Narcotics
Penalty
Summary
The facility failed to conduct a complete and thorough investigation related to missing narcotics for three residents. The facility's policy on 'Accidents and Incidents - Investigating and Reporting' requires specific data to be included in the report, such as the date and time of the incident, the circumstances, and the names of witnesses. However, the incident report dated January 13, 2024, involving three residents, was incomplete. The statement by Licensed Nurse Employee E23 did not include the name of the outgoing licensed nurse with whom the narcotics count was conducted. Additionally, statements from other licensed nurses (Employees E18, E14, and E15) also lacked the names of the nurses they counted narcotics with, rendering the statements incomplete. Further review of the investigation report provided to the State Agency revealed that it was only completed for one possible perpetrator, Employee E11. Interviews with the Nursing Home Administrator and Director of Nursing indicated that there could be more possible perpetrators, but there was no documented evidence that notification and investigation of other possible perpetrators were submitted to the State Agency. This lack of thorough investigation and incomplete documentation led to the deficiency.
Failure to Develop Comprehensive Care Plan for UTI Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of urinary tract infections (UTIs). The resident, who has a past medical history of UTIs and benign prostatic hyperplasia with lower urinary tract symptoms, was hospitalized due to a UTI. Despite this, the resident's current care plan did not include any measures for the prevention of UTIs. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Remove Cleaning Supplies from Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from hazards related to cleaning supplies left in a resident's room. On April 30, 2024, at 10:01 a.m., observations were made of the A wing, room A1, where Resident R5 had cleaning supplies (Comet) left on the floor, visible to anyone passing by the room. The issue persisted as, on May 1, 2024, at 1:10 p.m., the cleaning supplies were still present in the resident's room. An interview with the Director of Nursing on May 1, 2024, at 1:15 p.m. revealed that residents were not supposed to have cleaning supplies in their rooms.
Failure to Ensure Proper Catheter Care and Obtain Physician Orders
Penalty
Summary
The facility failed to ensure proper care of a urinary catheter bag and did not obtain a physician order for a resident to perform self-catheterization flushes. Resident R9, who was admitted with diagnoses including spinal stenosis, lumbosacral, neurogenic bladder dysfunction, and urinary tract infection, was observed on multiple occasions with the urinary catheter bag lying directly on the floor. This was noted on April 30, 2024, May 1, 2024, and May 2, 2024. Licensed nurse Employee E19 confirmed these observations during an interview on May 1, 2024. Additionally, it was revealed during an interview with Resident R9 on May 1, 2024, that the resident was self-flushing her urinary catheter. A review of the resident's physician orders for April and May 2024 showed no order for the resident to self-flush the catheter. Licensed nurse Employee E19 confirmed that there was no physician order for this procedure. These findings indicate a failure to adhere to the facility's catheter care policy and to obtain necessary physician orders for catheter management.
Failure to Implement Controlled Drug Accountability System
Penalty
Summary
The facility failed to implement a system of records for the receipt and disposition of all controlled drugs between shifts, leading to a lack of accurate reconciliation and accountability for one of four medication carts observed on the Second Floor A unit. The facility's policy on controlled substances requires that only authorized licensed nursing and pharmacy personnel have access to controlled drugs, and that these substances are reconciled upon receipt, administration, disposition, and at the end of each shift. However, during an observation on April 30 at 11:25 a.m., it was found that multiple dates and shifts lacked the required signatures from both incoming and outgoing nurses, indicating a failure to follow the policy. Specific dates with missing signatures included December 28, 2023, through April 30, 2024, with numerous instances of missing entries and signatures on the accountability logbook. An interview with a licensed nurse, Employee E11, confirmed that staff had not been signing the shift accountability logbook as required. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The lack of proper documentation and reconciliation of controlled substances was a clear violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.18(b)(2) Management, 28 Pa. Code 211.9(a)(1)(k) Pharmacy services, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with professional standards in the medication room on the first floor Unit A. During an observation conducted with the Unit Manager, it was found that an opened, unlabeled bottle of the probiotic Acidophilus was present in the top refrigerator. Additionally, the opened bottle did not have the date it was opened affixed to it. This was confirmed by a licensed nurse at the time of the observation. The facility policy states that all medications must be properly labeled in accordance with state and federal guidelines, which was not adhered to in this instance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not ensure that trash and recyclables were properly disposed of in the receiving and dumpster area. During a tour of the Food Service Department, it was observed that cardboard, bread racks, milk crates, paper, and other trash were scattered around the generator and staff smoking area. Additionally, the recycling dumpster was overflowing with the lid open, and a mound of cardboard boxes was piled in front of the dumpster. Four old mattresses were also found leaning against a metal shed. These findings were confirmed by the Food Service Director during an interview.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed according to professional standards during wound care for one resident. Specifically, the facility's policy on enhanced barrier precautions was not adhered to during the wound care procedure for Resident R103. The policy requires the use of gowns and gloves during high-contact resident care activities, including wound care, to prevent the transfer of multidrug-resistant organisms (MDROs). However, during an observation, a licensed nurse did not wear a gown while performing wound care on Resident R103's left heel wound, which is against the facility's policy. Resident R103 had a physician's order to cleanse the left heel wound with normal saline solution, pat dry, apply betadine-soaked gauze, cover with an abdominal pad, and secure with Keflex daily and as needed. Despite these specific instructions, the licensed nurse failed to follow the enhanced barrier precautions by not wearing a gown during the wound care procedure. This lapse in protocol was observed and documented, highlighting a deficiency in the facility's infection control practices.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by multiple observations and reports of mice and roaches in various areas of the building. A mouse was observed in Room A24, and residents on the second floor reported seeing mice in their rooms and common areas. The pest control logs revealed numerous instances of mice and roaches in different wings of the facility, including D-wing and A-wing, over several months. Specific incidents included mice in rooms and hallways, roaches in food containers, and roaches on residents and walls in multiple rooms and common areas. Interviews with residents and staff confirmed the presence of pests, with one resident reporting seeing a mouse in the hallway and another resident seeing mice in their room and common areas. The facility's pest control policy, dated May 2008, was not effectively implemented, as evidenced by the ongoing pest issues. The policy stated that the facility should be kept free of insects and rodents, with pest control services provided regularly, but the logs and observations indicated a persistent problem. The facility's failure to adhere to its pest control policy resulted in a deficiency in maintaining a safe and sanitary environment for residents.
Improper Medication Documentation Practices
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality, as evidenced by improper documentation practices during medication administration. Observations revealed that a licensed nurse, Employee E11, pre-signed the Medication Administration Records (MAR) for several residents before actually administering the medications. This practice was observed for six residents, where the MAR entries were marked as completed before the medications were given. This included medications such as Plavix, Hydrochlorothiazide, Lisinopril, and others for different residents. Further observations highlighted specific instances where medications were not available, yet the MAR indicated they had been administered. For example, Gabapentin was not available for one resident, but the MAR was marked as if it had been given. Additionally, a resident was not wearing a prescribed stump shrinker, yet the MAR was marked to indicate it was in use. Interviews with the nurse confirmed that the MAR entries were signed in advance, based on the assumption that the medications would be administered and accepted by the residents. Another instance involved the documentation of a resident's blood sugar level without the actual measurement being observed. The nurse claimed to have taken the blood sugar earlier, but this was not witnessed during the medication pass. These practices are in violation of the facility's policy, which requires that medications be documented as administered only after they are given, and highlight a significant lapse in adhering to professional standards as outlined in the Pennsylvania Code Title 49.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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