Brookmont Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Effort, Pennsylvania.
- Location
- 510 Brookmont Drive, Effort, Pennsylvania 18330
- CMS Provider Number
- 395462
- Inspections on file
- 22
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Brookmont Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to timely identify and address significant weight loss and nutritional needs for two residents. One resident experienced a 10% weight loss without timely intervention or care plan updates. Another resident, with multiple health issues, lost 11.9% of body weight and developed a pressure ulcer, but nutritional interventions were delayed. The facility did not adhere to its policies on weight and nutritional assessments.
A resident with post-surgical care for a tibia fracture and acute pain did not receive prescribed pain medication for severe pain after the expiration of physician orders. The facility failed to notify the physician or obtain new orders, resulting in inadequate pain management. The DON confirmed the oversight and acknowledged the failure to provide effective pain management.
A facility failed to document the disposition of controlled medications for a resident discharged to the hospital. The resident received Tramadol during their stay, but the remaining tablets were not accounted for upon discharge. This was confirmed by the Nursing Home Administrator.
The facility failed to maintain resident dignity and respect, with multiple residents reporting long wait times for call bell responses and rude staff interactions. One resident was left waiting in the bathroom for 51 minutes, while another experienced a distressing encounter with a nurse aide. The Nursing Home Administrator acknowledged the issues but could not explain the delays, which negatively affected residents' quality of life.
The facility was found to have multiple deficiencies in maintaining a clean and safe environment for residents. Observations included strong odors, debris, and maintenance issues such as broken light switches and cracked walls. Interviews with the NHA and DON confirmed the expectation of daily maintenance, which was not met.
A facility failed to create a comprehensive care plan for a resident with type two diabetes, sarcoidosis, and on anticoagulant therapy. The care plan did not address the resident's medical conditions or necessary interventions for managing diabetes and monitoring anticoagulant therapy. This deficiency was confirmed by the NHA and DON during a survey.
The facility failed to follow medication labeling and expiration protocols. An inspection revealed unlabeled medications in a medication cart and expired Latanoprost eye drops that were not discarded as per manufacturer instructions. The DON and NHA confirmed the need for proper labeling and adherence to expiration guidelines.
The facility failed to ensure that residents were only disenrolled from Medicare health plans with their request, consent, knowledge, and/or complete understanding. Residents were approached to switch from Medicare Advantage plans to traditional Medicare without adequate information or proper consent, and their cognitive abilities were not assessed to ensure informed decision-making.
The facility failed to provide adequate housekeeping and maintenance services, resulting in soiled bed linens and maintenance issues in resident rooms. Two cognitively intact residents reported that their bed linens were not changed regularly, and they performed their own bathing without staff assistance. Observations also revealed a cracked wall and peeling veneer in another resident room. The DON and NHA confirmed that the facility did not adhere to its policies for maintaining a clean and safe environment.
The facility failed to develop comprehensive care plans for several residents, omitting critical medical conditions and prescribed therapies. This included the lack of care plans for viral hepatitis, cirrhosis of the liver, anticoagulant therapy, and insulin use for diabetes, as confirmed by the DON and Nursing Home Administrator.
The facility failed to monitor and assess a resident's constipation and did not follow physician orders for bowel protocols for two residents. There was no evidence of timely intervention, documentation, or physician notification during extended periods without bowel movements.
A facility failed to provide person-centered pain management for a resident with lumbar radiculopathy and spondylosis. The care plan lacked non-pharmacological interventions, and opioid pain medication was administered outside the prescribed parameters. The DON confirmed these deficiencies.
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on three of five medication carts. Required signatures were missing on the Inter Shift Drug Record sheets for several dates, indicating that the task was not completed as mandated. Interviews with staff and the DON confirmed the expectation for signatures at shift changes.
The facility failed to maintain sanitary food storage and service practices in two resident pantry areas, with multiple instances of improperly stored food and a soiled ice machine area. Staff confirmed the observations and acknowledged the lack of adherence to facility policy.
The facility failed to implement individualized approaches to restore normal bladder function and provide maintenance incontinence care for two residents. One resident was not toileted as scheduled on multiple occasions, while another did not receive the required two-hour checks and changes. A third resident reported long waits for toileting assistance and sitting in a wet brief for extended periods. The Director of Nursing confirmed these failures.
The facility failed to provide a functional communication system for a Spanish-speaking resident with dementia, leading to increased agitation and unmet communication needs. Staff interviews confirmed the lack of interventions and communication tools.
The facility failed to develop and implement a trauma-informed care plan for a resident with a history of trauma. Despite a psychological evaluation indicating the need for psychotherapy and identifying trauma-related issues, the facility did not create a specific care plan or provide additional psychological services. The resident expressed fear about sharing a bathroom with male residents, which was not addressed by the facility.
The facility failed to date a multi-dose Lantus Solostar insulin pen when opened, as observed during a medication administration pass by an LPN. This was confirmed by the LPN and the DON, indicating non-compliance with the facility's policy on medication labeling and storage.
The facility failed to implement consistent infection control procedures during medication administration. An LPN placed a Mucinex tablet directly on the medication cart surface without a protective barrier and had a personal cell phone in the cart. The LPN and Nursing Home Administrator confirmed these lapses.
The facility failed to communicate necessary resident information to the receiving health care provider for five residents who were transferred to the hospital and expected to return. This deficiency was confirmed during an interview with the DON.
Failure to Timely Address Significant Weight Loss and Nutritional Needs
Penalty
Summary
The facility failed to timely identify significant weight loss and monitor residents' weights consistently and accurately, leading to deficiencies in nutritional interventions for two residents. Resident 72 experienced a 10% weight loss within sixty days, which was not addressed promptly. The resident's care plan was not updated after the significant weight loss was noted, and weekly weights were not obtained as ordered. The Registered Dietitian confirmed these oversights during an interview. Resident 27, who had multiple diagnoses including congestive heart failure, chronic kidney disease, and moderate protein-calorie malnutrition, experienced a significant weight loss of 24.4 lbs. or 11.9% in approximately two weeks. Despite the weight loss and the development of a new Stage 2 pressure ulcer, nutritional interventions were not implemented until six days after the pressure ulcer was identified. The Registered Dietitian confirmed that the nutrition progress note was not completed until five days after the resident returned from the hospital. The facility's policies on weight assessment and nutritional assessment were not followed, as evidenced by the lack of timely comprehensive nutritional assessments and interventions for both residents. The Nursing Home Administrator confirmed the facility's failure to timely assess and implement nutritional interventions for Resident 27, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer pain medication as prescribed by the physician for a resident who required pain management services. Resident 10, who was admitted with post-surgical care for a fracture of the right tibia and acute pain due to trauma, had specific physician orders for pain medication based on a pain scale. The orders included Acetaminophen for mild pain, Oxycodone and Tramadol for moderate pain, and Oxycodone for severe pain. However, after February 9, 2025, there were no active physician orders for severe pain management, and the staff did not notify the physician or obtain further orders, despite the resident continuing to experience severe pain. An interview with the Director of Nursing confirmed that the facility did not provide effective pain management and failed to administer the correct pain medication for severe pain. The DON acknowledged that no action was taken to update the physician or obtain additional orders after the expiration of the previous orders on February 9, 2025. This inaction led to the deficiency in providing appropriate pain management for Resident 10.
Failure to Document Controlled Medication Disposition
Penalty
Summary
The facility failed to implement procedures to ensure accurate documentation of the disposition of controlled medications upon the discharge of a resident. Resident 109 was admitted to the facility and later discharged to the hospital. During their stay, 30 tablets of Tramadol 50 mg, dispensed as half tablets totaling 60 tablets of 25 mg each, were delivered for the resident. The Medication Administration Record (MAR) for November documented that the resident was administered three doses of Tramadol. However, upon the resident's discharge to the hospital, there was no documentation regarding the disposition of the remaining 57 tablets of Tramadol 25 mg. This lack of documentation was confirmed by the Nursing Home Administrator during an interview.
Deficiencies in Resident Dignity and Staff Response Times
Penalty
Summary
The facility failed to maintain the personal dignity, respect, and quality of life for seven residents, as evidenced by untimely responses to call bells and disrespectful interactions from staff. Resident 11 reported that staff took up to two hours to respond to call bells, leaving him waiting in the bathroom for 51 minutes without toilet paper. He also expressed that staff were rude and dismissive, and his concerns were not taken seriously by the director of nursing. Resident 16 similarly reported long wait times for call bell responses, which occurred across all shifts. Resident 7 experienced a distressing interaction with a nurse aide who yelled at her and attempted to force her to wear pants she did not want to wear. The resident was left exposed in bed, feeling disrespected and upset. Other residents, including Residents 3, 4, 9, and 12, also reported excessive wait times for call bell responses, sometimes up to two hours, and described staff as rude and disrespectful. These delays in response led to residents sitting in their own waste and feeling embarrassed and uncomfortable. The Nursing Home Administrator acknowledged the facility's expectation for residents to be treated with dignity and respect but could not explain the reported issues with staff response times. The deficiencies were noted under Pennsylvania Code regulations related to management, resident rights, and nursing services, highlighting the negative impact on residents' quality of life due to inadequate staffing and disrespectful staff behavior.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions. Upon entering the facility, a strong urine smell was detected, and similar odors were noted in specific resident rooms. In one room, there were gouges in the paint on the wall, debris on the floor, and a used glucose monitoring strip on the baseboard heater. Additionally, the light switch was broken, preventing the light from being turned off, and the nightstand handle was missing. Another room had a cracked and chipped door, with dirt, debris, and food crumbs on the floor and fall mats. A strong odor of feces was also present in one of the rooms, with dirt and debris on the floor, a cracked and chipping bedroom door, and spots on the privacy curtains. Further observations revealed maintenance issues such as a broken cabinet door hinge in the Nourishment Room and a dark brown water stain in a bathroom toilet. The wall in one room was cracked, crumbling, and flaking, while another room had a used wet washcloth hanging on the toilet seat and black marks on the wall. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility is expected to be maintained daily to ensure a clean and sanitary environment for residents, which was not achieved in these instances.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident, identified as Resident 13, who was admitted with multiple medical conditions including type two diabetes, sarcoidosis, and long-term use of anticoagulants and insulin. The clinical record review revealed that the resident was prescribed Lantus SoloStar for diabetes management and Apixaban for anticoagulation therapy. However, the care plan did not address the resident's medical conditions or the necessary care and services required to manage these conditions. Specifically, the care plan lacked details on the resident's daily insulin use and interventions to monitor for signs and symptoms of hypo or hyperglycemia, as well as the anticoagulant therapy and interventions to monitor for bleeding and related side effects. During an interview with the Nursing Home Administrator and Director of Nursing, it was confirmed that the care plan did not include the resident's medical conditions and failed to ensure that comprehensive care plans were developed to meet the resident's medical and treatment needs. This deficiency was identified during a survey conducted on May 23, 2024, and was in violation of 28 Pa. Code 211.12 (d)(5) regarding nursing services.
Medication Labeling and Expiration Protocols Not Followed
Penalty
Summary
The facility failed to adhere to medication expiration and labeling protocols, as evidenced by observations and staff interviews. During an inspection of the Center Hall medication cart, an opened hemorrhoid ointment and a pain-relieving gel were found without proper labeling, lacking resident identification or usage instructions. This indicates a failure to comply with the facility's policy on medication storage, which requires medications to be maintained in their dispensed packaging and properly labeled. Additionally, a review of the East Hall medication cart revealed an opened bottle of Latanoprost eye drops without an expiration date, despite the manufacturer's instructions to discard the medication six weeks after opening. The eye drops were opened on a specific date and should have been discarded six weeks later, but this was not done. The Director of Nursing and Nursing Home Administrator confirmed that medications should be dated when opened and discarded according to the manufacturer's guidelines, highlighting a lapse in following the facility's medication administration policy.
Failure to Ensure Proper Medicare Disenrollment
Penalty
Summary
The facility failed to ensure that resident Medicare beneficiaries were only disenrolled from Medicare health plans with the beneficiary's or the beneficiary's representative's request, consent, knowledge, and/or complete understanding. This deficiency was identified for four out of the 23 residents sampled. The facility's actions included approaching residents to disenroll from their Medicare Advantage plans and switch to traditional Medicare without providing adequate information or obtaining proper consent. Specifically, the facility did not explain the impact of the insurance change on deductibles, copays, and supplemental coverage, nor did they assess and document the residents' cognitive abilities to ensure they were capable of making informed decisions. Resident 168 and Resident 269 were both cognitively intact and had their primary insurance payers changed from Medicare Advantage plans to traditional Medicare without fully understanding the implications. Resident 269 stated that she was confused during the admission process and did not recall anyone explaining the insurance change's impact on her copays, prescription plan, deductibles, or supplemental insurance coverage. Similarly, Resident 95 was aware of the insurance change but did not initiate the request and did not sign any authorization forms. Her son, who was contacted by the facility, felt pressured to make a quick decision without being fully informed of the pros and cons of switching plans. The facility's Director of Marketing admitted to assisting residents with the Medicare disenrollment process without a specific policy or procedure detailing the circumstances under which the facility can assist with a plan change. The information packet provided to residents lacked essential details required by the facility's policy, such as deductible costs, copays, and the specific name of the drug plan covering the beneficiary's medication. The Nursing Home Administrator confirmed that the facility did not assess residents' cognitive abilities before asking them to sign disenrollment forms and was unable to explain why some residents did not understand or authorize the insurance changes.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to ensure a clean and safe environment for its residents. Observations in resident room E-58 revealed multiple dark brown water stains in the toilet bowl, light brown stains on the fitted sheet, and a yellow stain on the pillowcase of one resident's bed. Another resident's bed in the same room had soiled bed linens with yellow and light brown stains. Both residents, who are cognitively intact, reported that their bed linens were not changed regularly, and they performed their own bathing at the sink without staff assistance. The facility's policy indicated that bed linens should be changed on shower days or as needed, but this was not adhered to, as confirmed by the Director of Nursing (DON). The residents' documentation reports showed that one resident received a shower, and the other refused a shower the day before the surveyor's observation, yet their bed linens were not changed accordingly. Further observations in resident room E-56 revealed maintenance issues, including a cracked, crumbling, and flaking wall behind the heating and cooling unit and a peeling veneer on the bedside nightstand, leaving a rough edge exposed. The Nursing Home Administrator (NHA) confirmed that the facility is expected to maintain a clean and sanitary environment daily. These deficiencies indicate a failure to uphold the residents' right to a safe, clean, comfortable, and homelike environment as required by regulations.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans that addressed the medical needs of several residents. Resident 82, who was admitted with diagnoses of viral hepatitis C and cirrhosis of the liver, did not have these conditions included in their comprehensive care plan. This omission was confirmed by the Director of Nursing during the survey. Additionally, Resident 48, who was receiving Xarelto for congestive heart failure and atrial fibrillation, did not have their anticoagulant therapy and necessary monitoring for potential side effects included in their care plan. Similarly, Resident 80, who was receiving insulin for type 2 diabetes, did not have their insulin use and necessary interventions for monitoring hypo or hyperglycemia included in their care plan. Resident 53, who was also receiving insulin for diabetes and Apixaban for atrial fibrillation, had similar omissions in their care plan. The care plan failed to identify the resident's daily insulin use and anticoagulant therapy, as well as the necessary interventions to monitor for bleeding and related side effects. These deficiencies were confirmed by the Nursing Home Administrator and Director of Nursing during the survey.
Failure to Follow Bowel Protocols and Monitor Constipation
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not demonstrating consistent monitoring and thorough assessment of a resident displaying constipation and by not following physician orders for bowel protocols prescribed for two residents. Resident 116 experienced five days without a bowel movement, and there was no documented evidence of nursing staff consulting with the physician or assessing the resident's physical status during this period. Physician orders for bowel management were only noted after the period of constipation had ended, indicating a lack of timely intervention and documentation by the nursing staff. Resident 48 had physician orders for a bowel regimen, but during a five-day period without a bowel movement, there was no documented evidence that the prescribed bowel protocol was administered. Additionally, there was no documentation that the physician was notified of the extended period without bowel activity. This lack of adherence to the prescribed bowel regimen and failure to notify the physician represents a significant lapse in the continuity of care. Similarly, Resident 36 had physician orders for a bowel regimen, but during two separate five-day periods without a bowel movement, there was no documented evidence that the prescribed bowel protocol was followed. The nursing staff also failed to notify the physician of the extended periods without bowel activity. The Director of Nursing was unable to provide evidence that nursing staff assessed and consulted with the physician regarding the residents' constipation or followed the prescribed bowel protocols, highlighting a systemic issue in the facility's management of bowel care for residents.
Failure to Provide Person-Centered Pain Management
Penalty
Summary
The facility failed to provide person-centered pain management consistent with professional standards of practice for a resident with lumbar radiculopathy and spondylosis. The resident's care plan included pharmacological interventions such as fentanyl patches, lidocaine patches, and Tylenol but did not identify any non-pharmacological interventions. Despite the facility's policy indicating the importance of non-pharmacological interventions, there was no evidence that these were attempted before administering opioid pain medication. Additionally, the resident's Medication Administration Records (MARs) showed that Hydrocodone-Acetaminophen was administered 55 times from March 1, 2024, through April 5, 2024, without documentation of non-pharmacological interventions being attempted first. The facility also failed to administer the opioid pain medication according to the physician's orders. The MARs revealed that Hydrocodone-Acetaminophen was given for pain levels rated between 4-6, which was outside the prescribed parameters for severe pain (7-10). This occurred on multiple dates in March 2024. During an interview, the Director of Nursing (DON) confirmed that the facility did not develop resident-centered non-pharmacological interventions and did not administer the opioid pain medication in accordance with the physician's orders. The facility's failure to adhere to its pain management policy and physician's orders resulted in inadequate pain management for the resident.
Failure to Implement Controlled Drug Reconciliation Procedures
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs on three of five medication carts (Center, North, and West). The facility policy requires that nursing staff count controlled medications at the end of each shift, with both the on-coming and off-going nurses making the count together and documenting any discrepancies. However, a review of the Inter Shift Drug Record sheets for April 2024 revealed that the required signatures were missing for several dates, indicating that the task was not completed as mandated. Specifically, the Center medication cart lacked signatures for April 1 and 2, 2024, the [NAME] medication cart lacked a signature for April 1, 2024, and the North medication cart also lacked a signature for April 1, 2024. Interviews with the involved staff members, including two LPNs and an RN, confirmed that the signatures were expected but not provided. The Director of Nursing (DON) also confirmed that it is her expectation for nursing staff to sign the Control Substance logs at the change of shift to demonstrate that they completed the count of the controlled drugs to identify potential discrepancies. This failure to follow the established procedures for controlled drug reconciliation was observed and acknowledged by the staff and the DON during the survey.
Failure to Maintain Sanitary Food Storage and Service
Penalty
Summary
The facility failed to maintain a sanitary environment and acceptable practices for the storage and service of food in two resident pantry areas. Observations revealed multiple instances of improperly stored food, including Styrofoam bowls, aluminum foil-wrapped leftovers, and various containers without names or dates. Additionally, the freezer contained items such as an opened Gatorade bottle, a Styrofoam cup with an inserted straw, and scattered ice bits, all without proper labeling. These findings were confirmed by staff members during interviews. Further inspection of the Side 2 resident food pantry revealed that the ice machine's condensation drain hose and the floor drain were visibly soiled with a black substance. The interior cabinet supporting the ice machine also had a black substance on its walls and floor tiles. The Nursing Home Administrator confirmed that the ice machine and pantry were not maintained in a sanitary manner and acknowledged that food should be labeled with a use-by date and the resident's name, as per facility policy.
Failure to Implement Scheduled Toileting and Incontinence Care Programs
Penalty
Summary
The facility failed to implement individualized approaches to restore normal bladder function and provide maintenance incontinence care for two residents. Resident 36, who was admitted with diagnoses including cerebral infarction and epilepsy, had a scheduled toileting program for bowels only. The facility failed to toilet the resident as scheduled on 34 occasions in January 2024 and 36 occasions in February 2024. Resident 64, admitted with type 2 diabetes and heart failure, had an incontinence care and comfort toileting program that required checks and changes every two hours. The facility failed to provide the required care 90 times in January 2024, 73 times in February 2024, and 52 times in March 2024. Resident 301, admitted with COPD and dementia, was cognitively intact with a BIMS score of 14 and required assistance with toileting. The resident's care plan included a two-hour incontinence check and change program. However, the facility failed to document the implementation of this program on multiple occasions between March 6, 2024, and April 5, 2024. During an interview, Resident 301 reported waiting long periods for staff assistance with toileting and often sitting in a wet brief for extended periods. The resident had previously raised this concern with the facility, but no changes were made. The Director of Nursing confirmed that the facility failed to consistently implement scheduled toileting plans and the incontinence comfort and care programs. The facility's logs revealed numerous instances where staff did not indicate if the resident was checked every two hours for incontinence and changed if necessary, as per the care plan and the facility's program guidelines.
Failure to Address Resident's Communication Needs
Penalty
Summary
The facility failed to consistently provide a functional communication system to maintain a resident's ability to communicate. Resident 318, who was admitted with diagnoses including dementia, depression, and anxiety, primarily speaks Spanish. The resident's care plan, initiated on March 29, 2024, identified her as only Spanish-speaking with a goal to make her basic needs known daily. However, the care plan did not develop interventions to address her communication deficit and primary language needs. This lack of intervention was evident when non-Spanish speaking staff were unable to communicate with the resident, leading to increased agitation that was only resolved when a Spanish-speaking nurse intervened. Interviews with staff confirmed the deficiency. Employee 2, an RN, revealed that non-Spanish speaking staff had no way to communicate with Resident 318 in her language, and there was no communication board in the resident's room. The Director of Nursing confirmed that the facility had not provided any means of communication to facilitate continuous communication between the resident and staff. This failure to address the resident's communication needs violated resident rights and management regulations.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to develop and implement an individualized person-centered plan to provide trauma-informed care for a resident with a history of trauma. Resident 23, who was admitted with diagnoses including bipolar disorder and major depressive disorder, was identified as moderately cognitively impaired. Despite a psychological evaluation indicating the resident's need for psychotherapy and identifying a history of sexual assault and abuse, the facility did not create a trauma-informed care plan to address these needs. The resident's care plan only included general interventions such as administering psychiatric medication and monitoring for side effects, without specific measures to address trauma-related triggers or re-traumatization. Furthermore, the facility did not provide any additional psychological services or behavioral health consultations for Resident 23 following the initial evaluation. During interviews, the resident expressed fear and anxiety about sharing a bathroom with male residents, which was not addressed by the facility. The Nursing Home Administrator and Director of Nursing were unable to provide evidence of trauma-informed care or additional behavioral health services for the resident, indicating a failure to meet professional standards of practice and adequately address the resident's trauma-related needs.
Failure to Date Multi-Dose Medications
Penalty
Summary
The facility failed to adhere to acceptable storage and use-by dates for multi-dose medication on one of three medication carts observed. During a medication administration pass, an LPN was observed with a Lantus Solostar insulin pen belonging to a resident, which was opened but not dated when initially opened. This failure was confirmed by the LPN and later by the Director of Nursing, indicating that the facility did not date multi-dose medications when opened to ensure acceptable storage times. The facility policy requires that the expiration/beyond use date on the medication label must be checked prior to administering and that the date opened should be recorded on the container.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to ensure the consistent implementation of infection control procedures during medication administration for one resident and one medication cart. During an observation of medication administration, an LPN was seen preparing medications for a resident without adhering to proper infection control protocols. Specifically, the LPN placed a Mucinex tablet directly on the surface of the medication cart without using a protective barrier or cleaning the cart surface. Additionally, the LPN used hand sanitizer and split the Mucinex tablet in half before placing it in the medication cup, and then administered the medications to the resident. Furthermore, a personal cell phone was observed inside the top drawer of the medication cart, which is against infection control procedures. The LPN confirmed these observations and acknowledged the failure to adhere to infection control procedures. The Nursing Home Administrator also confirmed that the facility did not consistently implement infection control procedures designed to prevent the spread of infection during medication administration.
Failure to Communicate Necessary Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for five residents who were transferred to the hospital and expected to return. Clinical record reviews revealed that Residents 29, 46, 64, 80, and 269 were transferred to the hospital on various dates, but there was no documented evidence that the facility had communicated specific information, including the residents' care plan goals and all necessary information to meet their specific needs, to the receiving health care provider. This deficiency was confirmed during an interview with the Director of Nursing (DON).
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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