Aventura At Prospect
Inspection history, citations, penalties and survey trends for this long-term care facility in Prospect Park, Pennsylvania.
- Location
- 815 Chester Pike, Prospect Park, Pennsylvania 19076
- CMS Provider Number
- 395203
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Aventura At Prospect during CMS and state inspections, most recent first.
The facility failed to ensure that meals were served at a palatable taste and appropriate temperature during a test tray evaluation of a lunch meal. Review of the facility’s test tray standards showed that starches and vegetables should be delivered at 135–165°F, but three pureed items—intended to be mac and cheese, mashed potatoes, and mixed vegetables—were served at 110°F. The food was described as bland with an unfamiliar taste, and the pureed vegetables tasted more like pureed meat. The NHA participated in the tasting and agreed with the surveyor’s findings regarding the substandard temperature and taste.
The facility failed to provide a resident and the resident’s representative with timely and reasonably priced access to the resident’s medical records. Despite a written HIPAA-compliant authorization and a policy requiring records to be available within 48 hours, the facility issued a high-cost invoice for over 1,400 pages and conditioned release of the records on payment. A later request for a complete electronic copy resulted instead in an incomplete paper set missing key portions of the chart, including MDS and CNA flow sheets, and the records were still being compiled weeks later. The Director of Medical Records reported difficulty providing electronic records, while the NHA confirmed that records could be sent electronically and that the resident’s records were not released as requested in a timely manner or at a reasonable cost.
A resident with multiple chronic conditions reported new symptoms, including body aches, cold symptoms, and vomiting, but did not receive timely or adequate monitoring and assessment by nursing staff. Only one set of vital signs was documented despite ongoing symptoms, and communication lapses occurred during shift changes. The resident was later found unresponsive and could not be resuscitated.
A resident with severe mobility limitations was not given the required two-person assistance during bed repositioning, as specified in their care plan and nursing Kardex. A nurse aide attempted to roll the resident alone while changing bed sheets, resulting in the resident rolling off the bed. Facility staff confirmed that proper procedures and care plan instructions were not followed.
Aventura at Prospect was found non-compliant with the Life Safety Code due to staff's lack of access to keys or knowledge of codes for egress doors, affecting emergency exits and potentially hindering safe evacuation.
The facility's fire alarm system was found to be deficient and non-operational, affecting the entire facility. The system had been out of operation since March 21, 2025, as confirmed during an exit interview with the administrator and maintenance director.
The facility's pest control program was ineffective, leading to a persistent infestation of rodents and other pests. Residents reported rodents entering through air conditioning units, and observations confirmed entry points and pest activity in the kitchen and other areas. Despite repeated treatments, structural issues remained unaddressed, allowing pests to enter.
The facility failed to maintain a safe environment and provide adequate supervision for residents, as evidenced by unlocked storage rooms with cleaning supplies, unsecured razors in a cognitively impaired resident's bathroom, and improperly stored medications in residents' rooms. These deficiencies indicate a lack of adherence to facility policies on hazardous materials and resident supervision.
The facility failed to maintain nutritional care for two residents, leading to significant weight loss and inadequate dietary management. One resident did not receive prescribed double protein portions or low phosphorus foods due to staff unawareness, while another resident's weights were not recorded for two months, despite being at risk for malnutrition.
A resident with heart failure, end-stage renal disease, and diabetes did not receive insulin as ordered on days scheduled for dialysis. The nursing staff failed to administer insulin at 12:30 p.m. on multiple occasions, and there was no documentation of communication with the physician. The DON confirmed the lack of coordination with the dialysis center and meal service.
A facility was found to have a medication error rate of 35.8%, significantly above the acceptable threshold. Errors included incorrect dosages of Gabapentin and Vitamin D3 administered by licensed nurses, contributing to the high error rate.
The facility did not consider the food preferences of several residents, as evidenced by meal observations, resident interviews, and council meeting minutes. Despite a policy requiring comprehensive assessments of food preferences, residents repeatedly requested changes to the menu, which were not implemented. Interviews with dietary staff confirmed a lack of coordination to meet residents' dietary needs.
The facility failed to meet professional standards for food service safety, with deficiencies in food storage, preparation, and sanitation. Observations revealed outdated and unlabeled food items in the refrigerator and freezer, rodent infestation in the dry storage room, and inadequate sanitation practices in the dishwashing area. These issues were confirmed by the food service director and registered dietitian.
The facility failed to implement a comprehensive infection prevention and control program, lacking evidence of measures to prevent Legionella and other waterborne bacteria. Additionally, the facility did not demonstrate ongoing analysis of infection surveillance data or proper documentation when residents returned from acute care hospitals.
The facility did not designate a qualified infection preventionist for its infection prevention and control program. A review of the facility's policy indicated the need for an Infection Preventionist to conduct surveillance for HAIs. However, the Director of Nursing could not provide documentation of employing an Infection Preventionist with specialized training, resulting in non-compliance with training requirements.
A facility failed to protect a resident's personal property, as their belongings were not accounted for upon discharge. The resident's inventory was completed at admission, but after their death, a note stated no belongings were present, and the discharge inventory was not used. Staff interviews revealed that the discharge inventory process was not followed, leading to the deficiency.
A facility failed to thoroughly investigate the misappropriation of a resident's property, involving missing funds from the resident's bank account. The resident identified two employees as alleged perpetrators, but the facility could not substantiate the claims. The investigation report lacked documentation of agency involvement and police notification, and did not review bank charges with the resident.
The facility did not ensure that the Infection Preventionist and Medical Director attended the QAPI meetings for one quarter. There were no sign-in sheets for February, March, April, or June 2024, and the May 2024 sheet lacked signatures from these key members. The facility has not employed an Infection Preventionist since February 2024, and the Medical Director has not attended or designated a representative for the meetings.
A resident reported verbal abuse by a nursing aide after requesting a TV channel change. The administration met with the resident and reported the incident to the State Survey Agency, but failed to process the complaint as a grievance, violating resident rights regulations.
The facility failed to respond to resident council concerns about meal portion sizes for four consecutive months. Despite repeated requests for larger portions, there was no documented follow-up or communication from the administration. During a resident group meeting, all residents present expressed dissatisfaction with the administration's lack of response. The Nursing Home Administrator confirmed this failure.
The facility failed to provide the required advanced notice of Medicare Non-Coverage (CMS 10123) for three residents, as the notices were not delivered at least two calendar days before the termination of Medicare services. This was confirmed through a review of clinical records and an interview with the Nursing Home Administrator.
The PASRR assessments for three residents were found to be incomplete or incorrect, failing to document mental health and neurocognitive conditions accurately. This was confirmed through clinical record reviews and staff interviews, indicating a failure in the facility's process for completing PASRR assessments as required by policy.
The facility failed to develop a comprehensive care plan for a resident with heart failure, high blood pressure, schizophrenia, and a history of ileus. The care plan did not address the resident's history of ileus, constipation, or schizophrenia, despite documented complaints and psychiatric notes.
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents requiring intravenous therapy and tracheostomy care. Documentation of staff competencies and skill sets was not provided, and an interview confirmed the lack of evaluation for these competencies.
The facility failed to provide necessary pharmaceutical services for two residents, resulting in missed doses of Debrox Otic solution and Zaditor ophthalmic solution. The residents reported that the facility often ran out of medications due to staff not ordering them on time and insufficient supply from the pharmacy.
A resident, diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus, was not informed of the results of an abdominal x-ray ordered to rule out an ileus. The resident indicated that no one had informed him of the results, and review of the records confirmed this lack of communication.
The facility failed to post the complaint hotline number for the State Survey Agency on three nursing units. Observations and interviews confirmed the absence of the required postings in the main lobby and on the First and Second floors.
The facility failed to promptly resolve resident complaints and grievances. During a resident council meeting, eight residents, including one who had not received medications and Ensure as ordered by his physician for several months, expressed concerns about the administration's failure to address their grievances. The social service director confirmed that no follow-up or immediate interventions were implemented.
The facility failed to monitor bowel movements for a resident with a history of ileus and did not ensure another resident wore an Aspen Collar as prescribed. The Director of Nursing confirmed these lapses, which led to discomfort and improper treatment for the residents.
A cognitively impaired resident experienced multiple falls due to inadequate supervision, despite being completely dependent on staff for all activities of daily living. The resident's falls included incidents where the resident fell from a Geri-chair and was found on the floor in the dining room and hallway. The Director of Nursing confirmed that the resident was not properly supervised according to the facility's 1:1 supervision policy.
The facility failed to ensure that a resident with a history of depression, bipolar disorder, and suicidal attempts received timely behavioral health services. Despite a recommendation for a psychology consult on January 29, 2024, the resident was not seen by a psychologist. Additionally, the social service director did not follow up on the resident's concerns after the resident expressed frustration and made a statement about harming himself.
The facility failed to ensure a resident's medication regimen was free from unnecessary medications. A physician's order for Clonazepam was renewed without proper documentation or justification, and a psychiatric consult did not specify the expected duration of the medication trial.
The facility failed to ensure that laboratory studies were promptly obtained and communicated as ordered by the physician for a resident. A valproic acid level test conducted on one occasion showed a low level, but the result was not notified to the physician until three days later. A follow-up test was ordered but not completed, and another test conducted months later also showed a low level, with the result not promptly communicated to the physician.
The facility failed to ensure a resident with moderate cognitive impairment and altered mental status had the capacity to understand a binding arbitration agreement. The Admission Director signed the agreement without verifying the resident's mental status.
The facility failed to ensure safe oxygen storage on the first floor nursing unit. Approximately 12 oxygen cylinders were stored in an open hallway area without proper signage. A Nursing Assistant was unaware of the protocol requiring storage in a locked room. The Nursing Home Administrator confirmed the unsafe practice and admitted to not educating staff about safe handling procedures.
The facility failed to ensure its nurse aide staff received the required 12 hours of annual in-service training, affecting five employees. The facility could not provide the necessary training records during the survey, and the Nursing Home Administrator confirmed the lack of documentation.
A facility failed to follow its discharge procedures for a resident with short-term memory problems and hepatic encephalopathy, leading to the resident exiting against medical advice without proper documentation or notification to the physician, family, or State authorities. The resident, who required supervision for safety due to confusion and unsteady gait, was discharged without identification documents, creating an Immediate Jeopardy situation. Staff interviews revealed lapses in consulting psychiatry, notifying the State Long Term Care Ombudsman, and ensuring proper documentation for discharge against medical advice.
A facility failed to ensure that a resident with hepatic encephalopathy and moderately impaired cognition received psychiatric consultations as ordered by the physician. Despite multiple orders for psychiatric and psychological consults, the facility did not carry out these consultations, as confirmed by the Director of Nursing.
The Nursing Home Administrator and the DON failed to manage the proper discharge of a cognitively impaired resident, leading to an Immediate Jeopardy situation. The resident, with a history of delirium and hepatic encephalopathy, was discharged without proper planning or notification to relevant parties. The resident's safety interventions were not followed, and he left the facility without necessary support or belongings.
The facility failed to administer medications as prescribed for two residents. One resident was left with unopened medication packets without instructions, and another missed three days of a prescribed medication due to supply issues. These actions violated the facility's medication administration policy.
Failure to Provide Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable taste and appropriate temperature, as identified during a test tray evaluation of a lunch meal. Review of the facility’s undated Test Tray Evaluation form showed that acceptable delivery temperatures for starches and vegetables should be 135–165°F. During a lunch meal service test tray conducted on March 18, 2026, at 12:25 p.m. with the food service employee and the Nursing Home Administrator, three pureed items—intended to be pureed mac and cheese, mashed potatoes, and mixed vegetables—were evaluated. The measured temperature of the food was 110°F, which was below the facility’s stated standard, and the items were described as bland with an unfamiliar taste; the pureed vegetables in particular tasted more like pureed meat. The Nursing Home Administrator also tasted the food and agreed with the surveyor’s findings regarding the temperature and taste deficiencies.
Failure to Provide Timely, Reasonably Priced Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical records in a timely manner and at a reasonable cost, as required by regulation and the facility’s own policy. The facility policy on Release of Information, revised November 2009, states that residents may obtain photocopies of their records with at least 48 hours’ notice (excluding weekends and holidays), and that a fee may be charged for copying services. For one resident, a written, HIPAA-compliant authorization signed by the resident’s Power of Attorney was submitted on October 13, 2025. The facility generated an invoice on October 23, 2025, billing $732.08 for 1,424 pages of records. The Director of Medical Records (Employee E12) stated that the resident’s son was told he would have to pay this amount to receive the records, in accordance with facility policy, and that he declined to pay. A subsequent written request for “any and all records” with a HIPAA-compliant authorization, dated January 3, 2026, was submitted through a third party on behalf of the resident. On February 9, 2026, that party emailed Employee E12, warning that regulatory agencies would be notified if the records were not provided without further delay. E12 responded on February 10, 2026, that the records would be prepared that week, and later reported that the resident’s son picked up a paper copy on February 17, 2026. On February 22, 2026, the requesting party reported that the resident had requested an electronic version via an electronic form but instead received an incomplete paper copy missing multiple important parts of the chart, and requested a PDF copy of the PCC chart. E12 replied on February 25, 2026, that the missing records would be provided as soon as possible, and on March 3, 2026, stated that MDS documents and nine more months of CNA flow sheets were still being compiled and would be scanned by the end of the week. By March 10, 2026, the requester was still following up, and on March 19, 2026, E12 stated she had been printing and scanning as fast as she could and did not know how to send the chart electronically. The Nursing Home Administrator confirmed that records can be sent electronically via a link and confirmed that the resident’s records were not released upon request in a timely manner or at a reasonable cost.
Failure to Timely Monitor and Assess Resident with Acute Symptoms
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including chronic kidney disease, heart failure, COPD, anemia, and schizophrenia, was not timely or adequately monitored and assessed after reporting new symptoms. The resident, who was cognitively intact, complained of generalized body aches and cold symptoms during the overnight shift and was given Tylenol per orders. Despite these complaints and the resident being observed in the bathroom at unusual times, there was no documented evidence that the nurse checked the resident's vital signs or performed further assessment during the shift. On the following day, the resident was found with a bucket and reported nausea and vomiting that began early in the morning. The nurse aide promptly informed the charge nurse, noting that this was not typical for the resident and requested immediate attention. The resident continued to vomit throughout the morning and after lunch, and was later observed undressed, rocking back and forth, and expressing feeling neither hot nor cold. Despite these ongoing symptoms, only one set of vital signs was documented for the entire day, and the resident's status was not effectively communicated during the change of shift report. The lack of timely and thorough assessment, including failure to monitor vital signs after the onset of new symptoms and inadequate communication between staff, contributed to the deficiency. The resident was ultimately found unresponsive in the evening, and resuscitation efforts were unsuccessful. The survey identified that the facility failed to ensure prompt and adequate monitoring and assessment of the resident's changing medical condition.
Failure to Provide Required Two-Person Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, functional quadriplegia, and functional limitations in both upper extremities, was not provided with the required level of assistance during bed mobility. The resident's care plan and nursing Kardex specified that two staff members were needed to assist with bed mobility and repositioning. Despite these documented requirements, a nurse aide attempted to roll the resident alone while changing bed sheets, resulting in the resident rolling off the bed. Facility documentation and staff interviews confirmed that the nurse aide did not follow the resident's care plan, which mandated two-person assistance for bed mobility. The Director of Nursing stated that residents should always be rolled toward the caregiver, and the Nursing Home Administrator confirmed that the care plan was not followed. This failure to provide adequate supervision and assistance directly led to the accident involving the resident.
Egress Door Deficiency at Aventura at Prospect
Penalty
Summary
Aventura at Prospect was found to be non-compliant with the National Fire Protection Association's Life Safety Code during a complaint survey. The facility, a two-story, fully sprinklered, wood frame building, failed to maintain egress doors with special locking arrangements. Observations made on April 2, 2025, revealed that staff members did not have access to keys or knowledge of the codes necessary for the rapid removal of occupants. This deficiency affected several key exit points, including the emergency exit door at the 1 north entrance, exit doors #3 and #4 in the first-floor corridor, and the front lobby door on the first floor. During an exit interview with the facility's administrator and maintenance director, it was confirmed that the staff's inability to access or operate the egress doors was a deficiency. The lack of access to keys or knowledge of the codes for these doors could potentially hinder the safe and efficient evacuation of residents in an emergency. The survey findings highlight a critical lapse in the facility's adherence to safety protocols required for the protection of its occupants.
Plan Of Correction
1. Current staff will be educated on the door codes for emergent exits and location of egress doors. 2. Emergency evacuation policy will be updated to identify designated egress doors and mechanisms for use. Staff will be educated on hire and during the monthly fire drills on the door codes for emergent exits and location of egress doors. 3. NHA/Designee will conduct random audits of staff awareness of door codes and location of egress doors weekly for four weeks and monthly for two months.
Fire Alarm System Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system, which was found to be deficient and non-operational during a document review and observation conducted on April 2, 2025. The fire alarm system had been out of operation since March 21, 2025, affecting the entire facility. This deficiency was confirmed during an exit interview with the administrator and maintenance director on the same day.
Plan Of Correction
1. There was a malfunction of the fire panel on 3/21/2025. Facility was on fire watch as per policy when the fire panel is malfunctioning. Vendor was contacted to correct the problem. Fire alarm system was restored to full function on 4/3/2025. 2. Maintenance department will maintain a fully functioning fire alarm system. 3. NHA/designee will conduct audits of fire alarm system weekly for eight weeks and monthly for one month.
Ineffective Pest Control Program Leads to Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent infestation of rodents and other pests. Residents expressed dissatisfaction with the pest control measures, reporting a rodent problem in the building, particularly through air conditioning and heating units in their rooms. Observations confirmed the presence of entry points for pests, such as voids and holes around air conditioning units and an unsealed doorway threshold leading to the trash area. Mice droppings were found in the dry food storage area of the main kitchen, indicating a vermin infestation. The pest control operator's reports from May to July 2024 documented repeated treatments for common household pests, including rodents and roaches, in various areas of the facility such as the main kitchen, nursing units, lobby, and employee break rooms. Despite these treatments, the reports noted ongoing pest activity and structural issues that facilitated pest entry. The nursing home administrator acknowledged the persistent pest problems and the need for maintenance to address structural deficiencies, such as sealing holes in air conditioning units and ensuring doors close properly to prevent pest access.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. The facility's policy on hazardous areas, devices, and equipment was not adhered to, as evidenced by unlocked housekeeping storage rooms containing cleaning supplies on two units. Additionally, a storage cabinet in a central hall bathroom was found open, containing nail clippers and razors, which should have been double locked for resident safety. The maintenance log showed no evidence of work orders related to these unlocked storage rooms. Resident R51, who was severely cognitively impaired and required supervision with activities of daily living, was found to have five razors in their bathroom, contrary to the facility's policy on shaving and hazardous materials. The resident's medical record lacked documentation of supervision during shaving procedures. Interviews with staff confirmed that razors were provided to the resident by a nurse aide, but the required documentation and safety measures were not followed. Resident R126 was observed with a cup containing several types of pills in their room, which they claimed were obtained from the nurses. The pills included Acetaminophen and Trazadone, and were not properly secured or documented. Additionally, Resident R446 had multiple bottles of eye drops in a biohazard bag on their bedside table, with new bottles on the nurse's cart, indicating a lack of proper supervision and storage of medications. These findings highlight the facility's failure to maintain a safe environment and provide adequate supervision to prevent accidents and ensure resident safety.
Failure to Maintain Nutritional Care for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, R113 and R118, as observed through care and services, clinical record reviews, and interviews. Resident R113, who was cognitively intact and diagnosed with heart failure, end-stage renal disease, and diabetes mellitus, experienced a significant weight loss of 7.5% over three months and a continuous weight loss of 15 pounds over four months. Despite a nutritional supplement being ordered, there was no documentation of its consumption, and the resident expressed a preference for chocolate-flavored supplements. Observations revealed that Resident R113 did not receive the prescribed double protein portions or low phosphorus foods, as dietary staff were unaware of the care plan requirements. Resident R118, admitted with diagnoses including GERD, dysphagia, gastrostomy status, and aphasia, was at risk for malnutrition. The care plan indicated the need to maintain adequate nutritional status without significant weight changes. However, no weights were recorded for June and July 2024, and the dietitian confirmed these findings. The lack of recorded weights and adherence to dietary plans for both residents highlights the facility's failure to ensure proper nutritional care.
Failure to Administer Insulin as Ordered for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident received medications consistent with professional standards of practice due to a lack of ongoing communication and collaboration with the dialysis care center. The resident, identified as R113, had diagnoses of heart failure, end-stage renal disease, and diabetes mellitus, requiring insulin administration in conjunction with meals. However, the nursing staff omitted the administration of insulin at 12:30 p.m. on multiple days when the resident was scheduled for hemodialysis treatments, without any documentation of communication with the attending physician regarding these omissions. The Director of Nursing confirmed the lack of coordination between the facility's meal service and the dialysis center visits, acknowledging that the nursing staff did not follow the physician's orders for insulin administration. This deficiency was identified through clinical record reviews and staff interviews, highlighting the failure to adhere to the facility's medication administration policy and the standards of nursing practice.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 35.8% error rate identified during a survey. This deficiency was observed in the administration of medications to residents, where errors were noted in the dosages given. Specifically, a licensed nurse administered 600 mg of Gabapentin to a resident instead of the prescribed 300 mg. This error was confirmed by the nurse at the time of observation. Additionally, another licensed nurse was observed administering medications to a different resident at an incorrect time, with discrepancies in the dosage of Vitamin D3. The nurse gave two 1000 mg tablets instead of the prescribed 2000 mg tablet. These errors contributed to the high medication error rate, which was significantly above the acceptable threshold, indicating a failure in the facility's medication administration process.
Failure to Consider Resident Food Preferences
Penalty
Summary
The facility failed to consider the food preferences of seven residents, as determined through reviews of policies, procedures, staff interviews, meal observations, resident interviews, and resident council meeting minutes. The policy required the dietitian and multidisciplinary team to conduct comprehensive assessments of each resident's food preferences and dislikes, but this was not adhered to. Observations during meal services revealed that several residents requested substitute food items instead of the planned menu entrees. A group meeting with residents further highlighted dissatisfaction with the meals served, as residents reported that their dietary preferences were repeatedly ignored by the dietary department. The resident council meeting minutes from April, May, and June 2024 showed ongoing concerns about the lack of variety and preference in the menu, with specific requests for different breakfast items, fresh fruits, and alternative milk options. Despite these repeated requests, there was no documented follow-through on the residents' menu suggestions. Interviews with the director of dietary services and the registered dietitian confirmed a lack of coordination among staff to meet the residents' nutritional and dietary needs and preferences.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies in food storage, preparation, and sanitation practices. Observations revealed that the walk-in refrigerator contained numerous food items that were outdated or beyond their use-by dates, including cottage cheese, mozzarella cheese, parmesan cheese, and cream cheese with visible mold. Additionally, fresh strawberries and a prepared lasagna were not discarded according to policy, and various food items were found unlabeled and undated. The walk-in freezer also contained unlabeled and undated items, such as a bag of French fries and jars of sauce. The dry food storage room was found to be in poor condition, with inadequate lighting and evidence of rodent infestation, including pest droppings, rubbings, and nesting materials. Opened food packages were improperly stored on the floor, and the room had structural issues such as voids and holes that could facilitate pest entry. The floor was sticky and tacky, further complicating the storage environment. Unlabeled and undated food items, such as cake mixes, cereal, and rice, were also observed in this area. Sanitation practices were inadequate, as the three-compartment sink lacked the necessary chemical sanitizer, and the mechanical dish machine was not functioning properly to sanitize dishware effectively. The litmus paper used to test the sanitizer concentration did not register acceptable levels, and the garbage area outside the food and nutrition services department had doors that did not seal properly, allowing potential pest entry. These deficiencies were confirmed through interviews with the director of food service and the registered dietitian.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, as evidenced by the lack of adherence to their own 'Legionella Water Management Program' policy. This policy, revised in July 2017, outlines the need for identifying areas in the water system that could promote the growth and spread of Legionella or other waterborne bacteria. The policy specifies the need for control measures, monitoring of control limits, and documentation of the program. However, the facility was unable to provide evidence of established measures for the prevention of Legionella and other waterborne bacteria, nor could they demonstrate ongoing analysis of surveillance data or documentation of follow-up activities in response to identified issues. Additionally, the facility's 'Surveillance for Infections' policy, revised in September 2017, requires the gathering of surveillance data, documentation, calculation of infection rates, and interpretation of this data. The facility was unable to provide evidence of a process for obtaining pertinent information such as discharge summaries, lab results, current diagnoses, treatment, and infection or multi-drug resistant organism colonization status when residents were transferred back from acute care hospitals. This lack of evidence indicates a failure to effectively monitor and prevent infections within the facility, as required by the policies in place.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program, as required by regulations. A review of the facility's policy on infection surveillance, revised in September 2017, indicated that an Infection Preventionist should conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other significant infections. However, during an interview with the Director of Nursing, it was revealed that the facility did not provide documentation showing that an Infection Preventionist with specialized training in infection prevention and control was employed. This lack of documentation and designation led to the facility not meeting the requirement for professional and specialized training in infection prevention and control.
Failure to Account for Resident's Personal Belongings
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, as evidenced by the case of a resident whose belongings were not accounted for upon discharge. The facility's policy on personal property requires that residents' belongings be inventoried and documented upon admission and updated as necessary. In this case, the resident's inventory sheet was completed upon admission, listing several personal items. However, after the resident's death, a progress note indicated that the resident did not have personal belongings, and there was no discharge inventory completed. Interviews with facility staff revealed a lack of adherence to the policy regarding the inventory of personal belongings. The Director of Nursing indicated that nursing staff are responsible for taking inventory at discharge, while an activities employee confirmed that she completed the admission inventory but noted that the discharge inventory section of the form is never utilized. This failure to properly document and account for the resident's belongings at discharge led to the deficiency identified by the surveyors.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation regarding the misappropriation of a resident's property, specifically involving Resident R70. The resident, who had a Brief Interview of Mental Status (BIMS) score of 14, reported missing funds from their personal bank account. Resident R70 identified two employees, a housekeeper and an activities aide, as the alleged perpetrators who accepted the resident's debit card to purchase cigarettes. Despite the termination of both employees, the facility was unable to substantiate the misappropriation of funds. The investigation report lacked critical information, such as involvement of another state agency and notification of the local police department. Although verbal information about the incident number and the officer's last name was provided, there was no evidence of follow-up after the investigation was initiated. Additionally, the report included a printout of the resident's bank statements but did not indicate whether the facility reviewed the charges with the resident to identify fraudulent transactions. This lack of thorough investigation and documentation led to the deficiency.
Failure to Ensure Required Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the required members attended the Quality Assurance Process Improvement (QAPI) committee meetings for one of the four quarters from February 2024 through June 2024. A review of the QAPI committee meeting sign-in sheets revealed that there were no sign-in sheets for February, March, April, or June 2024. The sign-in sheet for May 2024 lacked signatures from the Infection Preventionist and the Medical Director. An interview with the Director of Nursing and the interim Nursing Home Administrator revealed that there has not been an Infection Preventionist employed at the facility since February 2024. Additionally, the Medical Director has been invited to the QAPI meetings but has not attended or designated someone to attend since their employment in 2024.
Failure to Initiate Grievance Process for Resident Complaint
Penalty
Summary
The facility failed to initiate the grievance process for a resident who reported an incident of alleged verbal abuse. The resident, identified as R2, reported to the administration that a nursing aide yelled at them when they requested a change in the TV channel. This incident occurred on May 9, 2024. Although the Nursing Home Administrator and the Director of Nursing met with the resident to discuss the concern and reported the allegation to the State Survey Agency, the complaint was not processed as a grievance, which is a requirement under the resident rights regulation 28 Pa. Code 201.29(a)(d)(k).
Failure to Address Resident Council Concerns on Meal Portions
Penalty
Summary
The facility failed to respond to concerns from the resident council regarding meal portion sizes for four consecutive months (November 2023, December 2023, January 2024, and February 2024). This deficiency was identified through a review of resident council minutes, resident council group interviews, individual resident interviews, and staff interviews. The resident council had repeatedly requested larger meal portions, but there was no documentation indicating follow-up actions or communication from the nursing home administration to address these concerns. During a resident group meeting on March 13, 2024, all eight residents present expressed dissatisfaction with the administration's lack of response to their requests for larger meal portions. The Nursing Home Administrator confirmed the facility's failure to address these concerns in a timely manner.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for three residents. The Notice of Medicare Non-Coverage (NOMNC) CMS-10123 is intended to inform recipients when care received from the skilled nursing facility is ending and how to contact a Quality Improvement Organization to appeal. The Medicare provider must ensure that the notice is delivered at least two calendar days before covered services end. However, the review of the clinical records and facility documentation revealed that the notices for three residents were not delivered within the required timeframe. Specifically, the notices for the residents indicated that their Medicare skilled A services would end on specific dates, but the facility did not ensure the notices were delivered at least two calendar days before these dates. This was confirmed during an interview with the Nursing Home Administrator.
Deficiencies in PASRR Assessments
Penalty
Summary
The PASRR (Preadmission Screening and Resident Review) assessments were not appropriately completed for three residents, leading to deficiencies in identifying and documenting their mental health and neurocognitive conditions. Resident R83, who was diagnosed with schizophrenia, had a PASRR Level I assessment that failed to include schizophrenia as a mental disorder. This omission was confirmed by the Social Service Director. Resident R148, diagnosed with a neurological traumatic brain injury, had a PASRR assessment that did not accurately reflect the resident's neurocognitive disorder, which was also confirmed by the Social Service Director. Resident R13, with multiple mental health diagnoses including psychotic disorder and PTSD, had a PASRR screen that contained another resident's name, and the facility could not provide evidence of a completed PASRR for this resident, as confirmed by the Director of Nursing. The facility's Admission policy, revised in August 2022, states that all new admissions are to be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process. However, the review of clinical records and staff interviews revealed that the PASRR assessments for the three residents were either incomplete or incorrect, failing to meet the requirements set forth by the policy and the Omnibus Budget Reconciliation Act (OBRA) of 1987. These deficiencies indicate a failure in the facility's process for accurately completing and documenting PASRR assessments, which are crucial for ensuring appropriate placement and services for residents with mental illness or intellectual disabilities.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus did not address the resident's history of ileus and constipation. The resident had complained of nausea, abdominal discomfort, and constipation, and had an episode of vomiting, but these issues were not included in the care plan. Additionally, the resident's care plan did not address the diagnosis of schizophrenia, despite a psychiatric note indicating the need to re-evaluate the diagnosis and psychotropic drug use due to episodes of the resident eating cardboard and experiencing auditory and visual hallucinations. This deficiency was confirmed by the Director of Nursing.
Failure to Ensure Nurse Aide Competency
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents. This deficiency was identified for five nursing staff members (Employees E13, E14, E15, E16, and E17). The review of personnel files and staff interviews revealed that the facility provided care to residents requiring intravenous therapy and tracheostomy care. However, the facility did not submit documentation of staff competencies and skill sets related to the management of residents with tracheostomy, intravenous therapy, and medication administration. An interview with the Nursing Home Administrator and Regional staff confirmed that there was no documentation available to show that licensed nursing staff had been evaluated for these competencies.
Failure to Provide Necessary Pharmaceutical Services
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents, resulting in missed medication doses. Resident R66 did not receive six doses of Debrox Otic solution as ordered by the physician, with the Medication Administration Record indicating that the medication was not available on multiple occasions in February and March 2024. Resident R66 confirmed in an interview that the facility often ran out of his medications due to staff not ordering them on time and the pharmacy not delivering enough supply. Similarly, Resident R68 did not receive 13 doses of Zaditor ophthalmic solution for allergic conjunctivitis as ordered by the physician. The Medication Administration Record for Resident R68 showed missed doses in February and March 2024, with the resident stating that staff did not order the medication appropriately and the facility frequently ran out of supplies. These deficiencies were identified through a review of facility documentation, clinical records, and staff interviews.
Failure to Inform Resident of Medical Condition
Penalty
Summary
The facility failed to ensure that a resident was informed of his medical condition. Resident R83, who is cognitively intact and diagnosed with heart failure, high blood pressure, schizophrenia, and a history of ileus, complained of nausea, vomiting, and abdominal discomfort. An abdominal x-ray was ordered to rule out an ileus. However, during an interview, the resident indicated that no one had informed him of the x-ray results, which were available almost two weeks prior. Review of the records confirmed that there was no documented evidence that the resident was informed of the results.
Failure to Post Complaint Hotline Number
Penalty
Summary
The facility failed to post the complaint hotline number for the State Survey Agency as required on three nursing units: the First, Second, and Third floors. This deficiency was identified through observations and interviews conducted on March 13, 2024. During the observation at 1:18 p.m., it was noted that the main lobby area, as well as the First and Second floor nursing units, did not have the complaint hotline number posted. The Nursing Home Administrator confirmed during an interview at the same time that the complaint hotline number was not posted.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to promptly resolve resident complaints and grievances as required by their policy. During a resident council group meeting, eight residents, including Resident R66, expressed concerns about the administration's failure to address their grievances in a timely manner. Resident R66 specifically mentioned that he had raised concerns about not receiving medications and Ensure as ordered by his physician for several months, but these issues were not resolved, and he did not receive any response from the staff. An interview with the social service director confirmed that Resident R66 had raised his concerns on March 8, 2024, and was given a grievance form to fill out. However, the social service director admitted that she did not follow up with the resident about his grievance, nor did she implement any immediate interventions to address the issues. This lack of follow-up and resolution of grievances is a violation of the residents' rights as outlined in the facility's policy and state regulations.
Failure to Monitor Bowel Movements and Follow Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. Resident R83, who has a history of heart failure, high blood pressure, and ileus, complained of nausea, abdominal discomfort, and constipation. Despite the facility's bowel protocol requiring daily monitoring of bowel movements, there was no documentation of Resident R83's bowel habits. The Director of Nursing confirmed that nursing staff failed to monitor and document the resident's daily bowel habits, leading to the resident experiencing discomfort and requesting medication for constipation after two days without a bowel movement. Resident R146, who had a care plan intervention to wear an Aspen Collar at all times due to chronic progressive disease, mobility deficit, and spinal fusion, was observed without the collar. The clinical record showed an order for the collar to be worn at all times, but documentation indicated multiple instances where the collar was not in place. The Director of Nursing confirmed that the collar was not on order and that the resident had been pulling at it. The collar should have been discontinued by hospice, but this was not done, resulting in the resident not receiving the prescribed treatment.
Failure to Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a cognitively impaired resident, identified as Resident R148, leading to multiple falls. The resident, who was completely dependent on staff for all activities of daily living and had a history of neurological conditions, experienced three falls that required emergency room evaluations. Despite the facility's policy to implement additional or different interventions after reoccurring falls, the resident continued to fall, including an incident where the resident fell from a Geri-chair while a nursing assistant turned away to prepare a meal. Another fall occurred when the resident was found on the floor in the dining room having a seizure, and yet another when the resident was found lying face down in the hallway, despite being assigned 1:1 supervision at the time. During an interview, the Director of Nursing confirmed that the resident was not properly supervised during the fall on February 19, 2024. The unit clerk assigned to supervise the resident was working on the computer at the nurse station when the resident fell. The facility's policy for 1:1 supervision requires that the assigned staff have no other job assignments other than supervising the resident. The failure to adhere to this policy resulted in the resident's fall and subsequent transfer to the hospital.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident 66 received the necessary behavioral health services in a timely manner. The resident, who had a history of depression, bipolar disorder, suicidal attempts, and multiple psychiatric hospitalizations, was re-evaluated on January 29, 2024, and a recommendation was made for a psychology consult. However, there was no evidence in the clinical record that the resident was seen by a psychologist as recommended. The psychology practitioner, who visited the facility weekly, was not aware of the consult made on January 29, 2024, and did not see Resident 66. Additionally, the social service director did not follow up on the resident's concerns raised on March 8, 2024, after the resident expressed frustration and made a statement about harming himself. The social service progress note indicated that the department was in the process of addressing the resident's concerns, but it did not specify the actual concerns or any plans or interventions to address them. This lack of timely and appropriate behavioral health care and follow-up contributed to the deficiency in ensuring the resident's highest practicable mental and psychosocial well-being.
Failure to Ensure Medication Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potential unnecessary medications. Clinical record review for Resident R138 revealed a physician's order for Clonazepam 1 mg to be given every 8 hours as needed for anxiety, initially prescribed for 14 days. This order was renewed without proper documentation or justification for its continuation. A psychiatric consult report indicated a short trial of Clonazepam but did not specify the expected duration. Additionally, a physician progress note ordered the continuation of Clonazepam twice daily without providing a reason for extending the as-needed order beyond the initial 14 days.
Failure to Promptly Obtain and Communicate Laboratory Results
Penalty
Summary
The facility failed to ensure that laboratory studies were promptly obtained and communicated as ordered by the physician for Resident R66. On October 27, 2023, a valproic acid level test was conducted, and the result, which showed the level was below the therapeutic range, was reported on the same day. However, the clinical record revealed no evidence that the result was notified to the physician until October 30, 2023. The physician then recommended rechecking the valproic acid level in one week, but there was no evidence that this follow-up test was completed as ordered. On March 8, 2024, another valproic acid level test was conducted for Resident R66, and the result again showed a low level. The clinical record indicated that the facility staff did not obtain the result from the laboratory system and notify the physician in a timely manner. This deficiency was confirmed during an interview with the Assistant Director of Nursing on March 15, 2024.
Failure to Ensure Resident Capacity for Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement. Resident R99, who was admitted with a diagnosis of altered mental status and cocaine abuse, showed signs of moderate cognitive impairment. The resident scored a 9 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Additionally, physician progress notes and a psychiatric consultation revealed that the resident was a poor historian, forgetful, and exhibited confused and agitated behavior, including urinating in a Styrofoam cup and drinking the urine. Despite these indicators, the resident signed a binding arbitration agreement on September 28, 2023. The facility's Admission Director, Employee 19, also signed the binding arbitration agreement but later confirmed in an interview that he was not aware of the resident's mental status. Employee 19 admitted that he usually asks the staff about residents' mental status but was unsure if he received any response regarding Resident R99's mental status. This lack of awareness and verification led to the resident signing a legally binding document without the capacity to understand its terms, violating the resident's rights and the facility's policies.
Unsafe Oxygen Storage on First Floor Nursing Unit
Penalty
Summary
The facility failed to ensure a safe environment related to oxygen storage on the first floor nursing unit. On March 11, 2024, at 11:00 a.m., it was observed that approximately 12 oxygen cylinders were stored in an open hallway area between resident rooms [ROOM NUMBER] and 101, without any signage indicating oxygen storage. During an interview on March 13, 2024, at 1:00 p.m., a Nursing Assistant (Employee E20) stated that staff stored oxygen in the hallway space and was unaware of the facility protocol requiring storage in a locked oxygen storage room. The Nursing Home Administrator confirmed the unsafe storage practice and acknowledged awareness of the problem but admitted to not implementing or educating staff about safe oxygen handling procedures. The Administrator stated that staff were expected to store oxygen cylinders in a locked room with appropriate signage outside the room.
Failure to Provide Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure its nurse aide staff received the required in-service training to be proficient and competent, specifically not meeting the minimum of 12 hours of annual training. This deficiency was identified for five nurse aides (Employees E21, E22, E23, E24, and E25) based on a review of facility documentation and staff interviews. The facility was unable to provide the requested training records for these employees during the survey conducted on March 13, 14, and 15, 2024. The Nursing Home Administrator confirmed the absence of documentation proving that the required training hours were met for the specified employees.
Improper Discharge of Resident with Cognitive Impairments
Penalty
Summary
The facility failed to properly discharge Resident Cl1, who had short term memory problems and required guidance for safety awareness. Despite having policies in place regarding discharge procedures, the facility did not follow them in this case. Resident Cl1, who had a history of delirium and confusion due to hepatic encephalopathy, was allowed to exit the building against medical advice without proper documentation, notification to the resident's physician, family, or State authorities. The resident's safety device was removed, and he was discharged to an unknown location without his identification documents, creating an Immediate Jeopardy situation. Clinical documentation revealed that Resident Cl1 exhibited symptoms of unsteady gait, confusion, and incontinence, requiring supervision and assistance for daily activities. The resident's care plan included interventions for safety risks related to confusion, delirium, and elopement behavior. Despite these documented needs, the facility did not adequately address Resident Cl1's discharge process, leading to the resident leaving the facility without proper support or supervision. The failure to involve the resident's physician, family, and State authorities in the discharge process resulted in a breach of regulatory requirements and put Resident Cl1 at risk. Interviews with staff members confirmed that essential steps in the discharge process were overlooked, including consulting psychiatry or psychology for assessment and treatment, notifying the State Long Term Care Ombudsman, and ensuring proper documentation and witness signatures for discharge against medical advice. The facility's lack of coordination and communication regarding Resident Cl1's discharge highlights systemic deficiencies in ensuring the safety and well-being of residents with cognitive impairments. The events leading to Resident Cl1's improper discharge underscore the importance of thorough assessment, planning, and communication in facilitating safe transitions for vulnerable residents in long-term care facilities.
Failure to Provide Psychiatric Consultations as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a history of delirium and confusion due to hepatic encephalopathy received psychiatric consultations as ordered by the physician. The resident, who was admitted with moderately impaired cognition, exhibited behaviors of inattention, disorganized thinking, increased anxiety, and pacing. The resident also had several elopement attempts and expressed a desire to punch someone. The physician had ordered psychiatric and psychological consults on multiple occasions, but these consultations were not carried out by the facility. The Director of Nursing confirmed that the facility did not consult the psychiatry or psychology departments to assess, evaluate, and treat the resident as ordered by the attending physician. This failure to follow through on the physician's orders for psychiatric consultations was identified during a clinical record review and staff interview, highlighting a significant lapse in patient care policies and nursing services as per the relevant state codes.
Improper Discharge of Cognitively Impaired Resident
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility concerning the proper discharge of a resident, resulting in an Immediate Jeopardy situation. The resident, who had a history of delirium and confusion due to hepatic encephalopathy, exhibited behaviors such as unsteady gait, incontinence, and increased anxiety. Despite these conditions, the resident was discharged without proper planning or notification to relevant parties, including the resident's physician, family, and the State Long Term Care Ombudsman. The resident's care plan included interventions for safety risks and elopement, but these were not adequately followed during the discharge process. On the day of discharge, the resident's wanderguard was removed, allowing him to leave the facility without triggering the alarm system. The resident was cognitively impaired and required supervision for safe transfers and ambulation. The discharge was conducted without ensuring the resident had necessary support, such as a walker, medications, or a safe place to live. The resident's belongings, including identification and credit cards, were left in the facility, and there was no contact with the resident's family or responsible party. Interviews with staff confirmed that the discharge was not properly coordinated, and the facility had no knowledge of the resident's whereabouts after he left. The Nursing Home Administrator and the Director of Nursing admitted to not contacting the resident's physician or family before the discharge. Additionally, the agency responsible for the protection and advocacy of mental disorders was not notified. This lack of proper discharge planning and communication led to the Immediate Jeopardy situation, highlighting significant management failures in the facility.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered in accordance with professional standards for two residents. For Resident R1, who had diagnoses including Chronic Respiratory Failure, Generalized Anxiety Disorder, and Diabetes, there was no order for self-medication. However, an observation revealed that unopened packets of Budesonide and Albuterol Sulfate were left on Resident R1's overhead table. The resident was not given instructions on what to do with the medications, and the nurse confirmed that these medications should not have been left with the resident. For Resident R2, who had a diagnosis of Attention Deficit Hyperactivity Disorder, there was an order for Methylphenidate HCl to be administered three times a day. However, the medication was not administered on three consecutive days because the facility ran out of the medication supply. The MAR indicated that the medication was on hold, but there was no physician order to hold or discontinue the medication. Interviews with Resident R2 and staff confirmed that the medication was not ordered on time and that the pharmacy ran out of stock. These deficiencies indicate a failure to adhere to the facility's medication administration policy, which requires medications to be administered as prescribed and within a specified time frame. The facility's policy also mandates that medications should not be left with residents unless they have been deemed capable of self-administration by the attending physician and care planning team.
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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