Bryn Mawr Extended Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryn Mawr, Pennsylvania.
- Location
- 956 Railroad Avenue, Bryn Mawr, Pennsylvania 19010
- CMS Provider Number
- 395311
- Inspections on file
- 33
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bryn Mawr Extended Care Center during CMS and state inspections, most recent first.
A resident with multiple wounds requiring daily NSS cleansing and calcium alginate dressings received wound care from an RN who failed to follow infection control standards. The RN did not perform hand hygiene between glove changes, cleansed three separate wound areas without changing gloves or performing hand hygiene between sites, used the same saline-soaked gauze to wipe drainage from one wound and then cleanse another area, and applied clean dressings with the same contaminated gloves. The RN also opened all wound areas at once, treated an excoriated thigh area with alginate and a dressing instead of a moisture barrier cream, and placed bundled soiled dressings on the bedside table and a soiled draw sheet on the resident’s chair, as later confirmed by the DON.
A resident did not receive multiple scheduled medications at the correct times, with some doses significantly delayed and others not documented as given, in violation of facility policy and professional standards for medication administration.
The facility failed to install an automatic sprinkler system in the Main electrical (switchgear) Room in the basement, affecting one of three levels. This deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations, indicating incomplete sprinkler protection as per NFPA standards.
The facility failed to maintain its automatic sprinkler system, affecting the entire facility. An inspection revealed that the wet system's tamper did not report to the panel due to water accumulation in the pit, which requires monitoring and pumping. Additionally, the dry system's last FDC hydrotest date was unknown and needs immediate testing. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain HVAC equipment inspection, affecting the entire facility. A review revealed that 73 fire dampers were deficient due to inaccessibility or damage, with no evidence of repairs. This was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
The facility failed to maintain and inspect the emergency generator, affecting the entire facility. Documentation for critical tests and inspections, such as monthly battery testing and annual fuel sampling, was unavailable. Additionally, the emergency generator set location lacked battery back-up emergency lighting, as confirmed during an exit interview with facility leadership.
The facility failed to maintain self-closing doors in hazardous areas, affecting one of three levels. Observations revealed that the Food Services office door was binding, the Dry Storage door closure was broken, and the 2nd floor D wing's storage closet hardware was broken, preventing proper latching. These issues were confirmed during an exit interview with facility leadership.
The facility failed to maintain smoke barrier doors to resist smoke passage. A door on the first floor was blocked by a wheelchair, and another in the Chateau Dining area was dragging on the floor, preventing them from closing smoke tight. These issues were confirmed during an exit interview with the facility's administration.
The facility was cited for improper storage of medical gases after a free-standing oxygen cylinder was observed in the Med room on the first floor. This was confirmed during an exit interview with the facility's administration.
The facility failed to meet operational standards by installing heat detectors and Halotron fire extinguishers in the Main Electrical Room without Department-approved plans. This was confirmed during an exit interview with the facility's leadership.
The facility did not provide a resident-centered activities program as required, with observations and interviews revealing that scheduled activities were often not conducted, lacked variety, and did not reflect resident interests or preferences. Multiple residents reported not being included in activity planning, not being offered activities of interest, and that the activities listed on the calendar were not actually provided. Staff interviews and observations confirmed inconsistencies and a lack of meaningful engagement, resulting in unmet physical, mental, and psychosocial needs.
A nursing assistant was overheard by a family member making a profane and derogatory statement to a resident with multiple medical and cognitive conditions, constituting verbal abuse as defined by facility policy.
A resident with multiple complex diagnoses, including diabetes, recent significant weight loss, and impaired mobility, was admitted without a baseline care plan to address their risk for pressure ulcers. Although assessments identified the risk and some treatments were in place, there was no documented care plan or interventions such as a turning/repositioning program or foot dressings, contrary to facility policy.
A licensed nurse delayed the administration of scheduled morning medications to a resident by two hours while watching a training video on the computer, resulting in the resident not receiving medications such as Allopurinol, Amlodipine, Cholecalciferol, Dorzolamide, and Metoprolol at the prescribed time, contrary to facility policy and physician orders.
A resident who was always incontinent and required substantial assistance with toileting hygiene experienced significant delays in receiving incontinence care on multiple occasions. Despite making her needs known and informing staff, care was not provided promptly, with staff either occupied with other residents or delaying their response after turning off the call bell.
A resident with diabetes, limited mobility, and cognitive impairment developed a right heel wound after staff failed to consistently implement physician-ordered interventions, such as the use of multi-podus boots, and did not update the care plan to address the risk of diabetic ulcers. The wound progressed, requiring debridement and antibiotics, after the resident was observed pressing their feet against the bed's footboard without proper offloading.
The facility did not ensure staff supervision in the designated smoking area, as required by policy and resident care plans. Multiple residents were observed smoking outside without staff present, and both staff and resident interviews confirmed that supervision was not consistently provided. This failure to supervise residents during smoking activities resulted in a deficiency related to accident hazard prevention.
A resident with an indwelling urinary catheter and a history of urinary retention did not have a recommended follow-up appointment with a urologist scheduled after a consult indicated the need for further discussion of treatment options. This failure was confirmed by the unit manager and was not in accordance with facility policy for continence management and resident care.
A resident's pharmacy review recommendations regarding Eszopiclone and Cyclobenzaprine were not properly addressed or documented by the physician, with no clear evidence of review or rationale for declining the pharmacist's suggestions, as confirmed by the DON.
A resident with diabetes and anemia did not receive breakfast as ordered, with staff failing to document meal monitoring and providing an unsuitable late meal, resulting in the resident refusing the food. The deficiency was confirmed by both the resident and a nursing supervisor.
A resident with polymyalgia rheumatica did not receive a recommended rheumatology consultation after both the physiatrist and physician agreed it was needed, and no appointment was scheduled as confirmed by the Unit Manager.
A resident with multiple chronic conditions was placed on hospice care, but the facility failed to maintain complete hospice documentation, including an updated plan of care and required correspondence from hospice staff. The administrator was unable to provide the missing records when requested.
Staff failed to consistently use required PPE, including gowns and gloves, during high-contact care activities for two residents on enhanced barrier precautions, including one with a history of C. difficile, MRSA, and ESBL, and another with an indwelling catheter. Observations and interviews revealed confusion and lack of awareness among staff regarding proper PPE use, despite clear signage and care plan documentation.
A resident with chronic pain and a wound was not properly assessed or medicated for pain, leading to uncontrolled pain and harm. The facility failed to provide timely Oxycodone, and the resident's severe pain and suicidal ideation were not communicated to the physician. Staff delays and policy failures contributed to the deficiency.
The facility breached residents' privacy by displaying transmission-based precaution signage that revealed personal medical information, such as peg tubes and tracheostomies, for five residents. This action violated the facility's policies on resident rights and confidentiality.
The facility did not adhere to resident meal preferences, leading to complaints about incorrect meals being served. A resident received chicken and cranberry juice instead of her requested meal, while another consistently received incorrect meals. A grievance log and resident council meeting further highlighted ongoing issues with meal service not matching resident requests.
A resident experienced a fall during a leave of absence, resulting in hospitalization. The facility failed to promptly notify the resident's physician, as required by their policy. Upon return, the resident exhibited pain and an abrasion, but there was no documented evidence of physician notification. This deficiency was confirmed by the Regional Nurse.
A facility failed to accurately complete a resident's discharge assessment. A nursing note indicated the resident was discharged to home, but the MDS assessment incorrectly coded the discharge status as a short-term general hospital. This error was confirmed by the RN Assessment Coordinator.
A resident experienced a delay in receiving timely laboratory services after complaining of headache, dizziness, and lightheadedness. Lab work was ordered, but the urine sample was not sent promptly, and a subsequent sample leaked and was discarded. The lab's attempt to contact the facility was unsuccessful, and no follow-up was conducted.
A resident who experienced headache, dizziness, and lightheadedness had lab work ordered, including CBC and CMP. Although the lab work was completed, the results were not printed or communicated to the physician. The results showed some values out of range, including a low blood sodium level.
A resident's room lacked a functional call bell system, with the wired bell removed and a tap bell placed out of reach. The resident's calls for assistance went unanswered due to the bell's inaudibility at the nurse's station, where music was playing. Staff were unaware of the issue, leading to delayed responses to the resident's needs.
The facility did not ensure that nurse aides received the required 12 hours of continuing education annually. A review of personnel files revealed that three out of five nurse aides, including Employees E6, lacked documentation of these educational hours. The Nursing Home Administrator confirmed the absence of records during the survey, violating Pennsylvania Code requirements for personnel policies and staff development.
A resident with acute respiratory failure and hypoxia did not receive continuous oxygen therapy as ordered. Family members observed the resident without an oxygen mask multiple times, and a nursing assistant admitted to forgetting to replace the mask after providing care.
A resident reported that the hallway temperature in the B wing was uncomfortably cold, requiring her to keep her room door closed. An observation confirmed the temperature was 69 degrees, attributed to closed fire doors due to a malfunctioning magnetic door lock system, which trapped cold air from the air conditioning.
A resident was found unresponsive, and due to a misidentification of the resident's code status by a licensed nurse, CPR was not initiated immediately. The delay was further compounded by the actions of the Nursing Supervisor and the Acting DON, leading to a 14-minute delay before CPR was started. The resident was eventually transported to the hospital with a pulse after paramedics took over CPR.
The Nursing Home Administrator and DON failed to ensure timely CPR for a resident due to a misidentification of the resident's code status, resulting in a significant delay. The resident was found unresponsive, and the licensed nurse mistakenly identified the resident as DNR, leading to a 14-minute delay before CPR was initiated.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to maintain appropriate infection prevention and control practices during wound care for one resident. The resident had been readmitted with diagnoses including cerebral infarction, right-sided hemiplegia, and aphasia following stroke, and had physician orders for daily cleansing and dressing of wounds on the right ischium and sacrum with NSS, calcium alginate, and a clean dry dressing. During observed wound care, the RN performed initial hand hygiene and donned gloves before preparing a clean field and rolling the resident onto her left side. After placing an absorbent pad, the RN removed soiled bandages from the ischial and sacral wounds and uncovered an additional area on the left inner thigh. The RN then removed soiled gloves and donned clean gloves without performing hand hygiene, and proceeded to cleanse all three wounds with NSS without changing gloves or performing hand hygiene between wounds. When a drip from the sacral wound was noticed, the RN used a saline-soaked gauze to wipe the drip and then used the same gauze to cleanse the thigh wound. Alginate was applied to all three wounds and covered with adhesive bordered gauze using the same gloves that had been used for cleansing. After dressing the wounds, the RN gathered soiled dressings and trash into the absorbent pad and placed this bundle on the resident’s bedside table, and placed the soiled draw sheet on the resident’s chair before later disposing of them. The DON confirmed that multiple hand hygiene indications were missed, that all three wounds should not have been open at the same time, that the thigh area was excoriation that should have been treated differently, and that soiled materials should not have been placed on the bedside table or chair.
Failure to Administer Medications According to Physician Orders and Facility Policy
Penalty
Summary
Facility staff did not ensure that a resident received medications in accordance with professional standards of practice and facility policy. The facility's policy requires staff to verify and administer medications at the correct time, dose, route, and for the correct resident. However, review of the electronic medication administration record (e-MAR) revealed multiple instances where medications, including artificial tears, Biotene oral rinse, escitalopram, levothyroxine, pregabalin, Restasis eye drops, and ziprasidone, were administered significantly later than their scheduled times or not administered at all. For example, artificial tears scheduled for 8:00 a.m. were given at 12:34 p.m., and levothyroxine scheduled for 6:00 a.m. was not documented as administered on two consecutive days. These delays and omissions in medication administration were identified through a review of the clinical record and facility policy. The findings indicate that the resident did not consistently receive medications as ordered, which is not in accordance with the facility's established procedures and professional standards of practice.
Incomplete Sprinkler System Installation in Electrical Room
Penalty
Summary
The facility failed to install required sprinkler system components, specifically in the Main electrical (switchgear) Room located in the basement. This deficiency was identified during an observation on April 15, 2025, at 11:25 a.m. The absence of an automatic sprinkler system in this area was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. This oversight affects one of the three levels of the facility, indicating incomplete automatic sprinkler protection as per the requirements outlined in NFPA 101 and NFPA 13 standards.
Plan Of Correction
1) The facility contractor is submitting plans to the Plan Review Department for approval of modifications to the fire suppression system for approval. 2) The Maintenance Director and/or designee will inspect the Main Electrical Room once a suitable fire suppression system is installed. 3) To prevent the potential for reoccurrence, the Administrator will educate the Maintenance Director and/or designee on the importance of a suitable fire suppression system is installed. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will check the fire suppression system is in place as required monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system components, impacting the entire facility. During a document review on April 15, 2025, it was found that the sprinkler inspection report from April 2, 2025, identified several deficiencies. The wet system's tamper in the pit did not report to the panel during the inspection, and it was noted that the pit consistently fills with water, requiring the facility to monitor and pump out the water for proper inspection and maintenance. Additionally, the dry system's last Fire Department Connection (FDC) hydrotest date was unknown, necessitating an immediate test. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Wet System - The tampers in the report to the alarm panel. B. Dry System - The Maintenance Director or Designee will ensure to FDC hydrotest date is confirmed and completed. 2) The Maintenance Director and/or designee inspected the tampers, confirmed reporting to the alarm system, and the pit does not have accumulating water. 3) To prevent the potential for reoccurrence, the Administrator educated the Maintenance Director and/or designee on the importance of ensuring the tampers report to the alarm system and the pit does not have accumulating water. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will inspect the pit weekly for one month, and monthly for the next two months. If an issue is identified, the vendor will be contacted to restore the tamper connection to the alarm and assure there is no accumulation of water in the pit. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain HVAC Equipment Inspection
Penalty
Summary
The facility failed to maintain the inspection of its Heating, Ventilating, and Air Conditioning (HVAC) equipment at the required intervals, affecting the entire facility. During a document review on April 15, 2025, it was discovered that a fire damper inspection report dated May 9, 2022, identified 73 dampers as deficient due to inaccessibility or damage. At the time of the survey, there was no evidence available to confirm that these deficiencies had been repaired. This finding was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) The facility vendor is in the process of identifying, repairing, and determining if the dampers are all necessary and if necessary to make modifications, will contact the Plan Review Department for approval of modifications to the fire suppression system. 2) The Maintenance Director and/or designee reviewed and confirmed the fire dampers are operable. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring fire dampers are inspected and operable. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee ensure fire dampers remain operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain and Inspect Emergency Generator
Penalty
Summary
The facility failed to maintain and inspect the emergency generator, which affected the entire facility. During a document review, it was found that the facility could not provide documentation for several critical tests and inspections. These included the monthly testing of battery electrolyte specific gravity or conductance testing, an annual 90-minute load bank test or a report indicating the unit meets 30% of the nameplate, and an annual fuel sample report. This lack of documentation was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations. Additionally, an observation revealed that the emergency generator set location in the basement, specifically the transformer room, lacked battery back-up emergency lighting. This deficiency was also confirmed during the exit interview with the facility's leadership team. The absence of these critical components and documentation indicates a failure to comply with the necessary maintenance and testing requirements for the emergency power systems as outlined by NFPA standards.
Plan Of Correction
1.) A. Upon observation on April 15, 2025, the Maintenance Director and/or Designee performed the monthly testing of battery electrolyte specific or conductance testing. B. Annual 90-minute load bank or report indicating unit meets 30% of name plate - was not due for annual testing; however, it was completed. C. Annual fuel sample report although not due was completed. D. In the basement, the emergency generator set location (transformer room) a battery back-up emergency light was installed. 2.) The Maintenance Director and/or designee although not due had the Annual 90-minute load bank and Annual fuel sample reports completed. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all reports are completed timely and available for review. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit both the monthly and annual testing reports and ensure the back-up battery operated emergency lighting is in place and operable monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Maintain Self-Closing Doors in Hazardous Areas
Penalty
Summary
The facility failed to maintain self-closing doors at hazardous locations, affecting one of three levels in the facility. During an observation on April 15, 2025, several deficiencies were noted: at 12:40 p.m., the door at the Food Services office was binding in the frame, preventing it from latching; at 12:45 p.m., the door closure at the Dry Storage was broken, preventing the door from closing; and at 2:10 p.m., the hardware on the 2nd floor D wing's storage closet was broken, preventing the door from latching. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Food Service Office Door and frame was replaced and latches as required. B. Dry Storage door closure was repaired and closes properly. C. 2nd Fl. D Wing storage closet, hardware was replaced and the door latches as required. 2) The Maintenance Director and/or designee inspected all self-closing doors in hazardous locations to ensure that the doors latch and close as required. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of self-closing doors in hazardous locations close and latch as required. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will audit all self-closing doors in hazardous locations monthly for 3 months to ensure compliance. If an issue is identified, the door/s will be fixed immediately and the Maintenance Director and/or designee will be reeducated. Findings will be reported to facility QAPI for continued review and recommendations.
Smoke Barrier Door Deficiencies
Penalty
Summary
The facility failed to maintain smoke barrier doors to resist the passage of smoke, affecting one of three levels. During an observation on April 15, 2025, it was noted that a smoke barrier door on the first floor next to room 112 was blocked by a wheelchair, preventing it from closing smoke tight. Additionally, the smoke barrier door in the Chateau Dining area was dragging on the floor, which also prevented it from closing smoke tight. These deficiencies were confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) A. Immediately upon observation on April 15, 2025, the wheelchair next to room 112 was removed so as not to prevent the door from closing smoke tight. B. Chateau Dining the smoke barrier door was repaired so that it does not drag the floor, preventing the door from closing smoke tight. 2) The Maintenance Director and/or designee audited all smoke doors for obstructions and door dragging the floor preventing the door from closing smoke tight. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee and staff on the importance of all smoke doors closing smoke tight without obstructions. 4) To monitor and maintain ongoing compliance, the Maintenance Director and/or designee will audit 3 smoke doors for closing smoke tight without obstruction for the next 3 months. If an issue is identified, the Maintenance Director or designee will immediately notify the administrator and correct the problem. Findings will be reported to facility QAPI for continued review and recommendations.
Improper Storage of Oxygen Cylinder
Penalty
Summary
The facility was found to be non-compliant with the proper storage of medical gases, specifically oxygen cylinders. During an observation on April 15, 2025, at 12:20 p.m., it was noted that on the first floor, in the Med room across from the conference room, there was a free-standing oxygen cylinder. This indicates that the facility did not adhere to the required storage protocols for medical gases as outlined in NFPA 101 and NFPA 99 standards. The deficiency was confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations on the same day at 2:45 p.m. The improper storage of the oxygen cylinder suggests a lapse in following the guidelines that require cylinders to be stored securely and in a manner that prevents potential hazards. The report does not mention any specific residents or staff being directly affected by this deficiency at the time of the observation.
Plan Of Correction
1.) Immediately upon observation on April 15, 2025 the one free standing oxygen cylinder on the first floor in the Med Room across from the conference room was immediately removed. 2.) The Maintenance Director and/or designee audited the number and location of oxygen tanks and confirmed they were being stored properly. 3.) To prevent the potential for reoccurrence the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of ensuring all oxygen cylinders held in a holder and not free standing. 4.) To monitor and maintain ongoing compliance the Administrator and/or designee audit all oxygen tanks monthly for 3 months. Findings will be reported to facility QAPI for continued review and recommendations.
Failure to Obtain Approval for Fire Safety Alterations
Penalty
Summary
The facility was found to be deficient in meeting the minimum standards for operation as required by the Department and other state and local agencies. During a document review, it was observed that in the basement's Main Electrical (switchgear) Room, two heat detectors were programmed into the fire panel, and four Halotron fire extinguishers were installed after the removal of existing ADX Halon units. These alterations and renovations were conducted without obtaining Department-approved plans, as confirmed during an exit interview with the Administrator, Maintenance Director, and Regional VP of Operations.
Plan Of Correction
1) Our vendor will submit plans to the Plan Review Department for approval of modifications to the fire suppression system. 2) No other areas affected. 3) To prevent the potential for reoccurrence, the Administrator and/or designee educated the Maintenance Director and/or designee on the importance of making sure all plans are approved prior to initiating alterations and renovations. 4) To monitor and maintain ongoing compliance, the Administrator and/or designee will review all plans to make alterations and/or renovations and will seek approval from DOH as required prior to following through with said plans. Findings will be reported at the facility QAPI for continued review and recommendations as changes occur.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activities program that met the interests and physical, mental, and psychosocial well-being of residents on both nursing units. Despite having a policy and job description outlining the need for comprehensive, individualized, and diverse activities, observations and interviews revealed that scheduled activities were either not conducted as planned or were limited in variety and engagement. The activities calendar showed repetitive offerings such as daily greetings, room visits, and bingo, with little evidence of adaptation to resident preferences or abilities. Observations of scheduled activities, such as Taco Tuesday and fitness sessions, showed minimal resident engagement, with some activities not occurring as scheduled or being limited to passive participation like watching staff prepare food or sitting at tables without active involvement. Multiple residents reported that they were not included in activity planning, were not offered activities of interest, and that the activities listed on the calendar were not actually provided. Several residents stated that no one from the activities department had visited their rooms to discuss or offer activities, and that the only activity regularly offered was bingo, which was not of interest to all. Some residents expressed a desire for more meaningful engagement and noted that they had never been taken outside the facility for activities or allowed outside, contrary to what was indicated in the facility's policy. Staff interviews confirmed inconsistencies in the delivery of activities, with some staff unable to describe or recall the activities scheduled or conducted. Observations further revealed that activities such as room visits were sometimes limited to offering snacks for purchase rather than providing meaningful engagement. The Life Enrichment Director and assistants demonstrated a lack of awareness regarding resident preferences and the actual implementation of the activities program, resulting in unmet needs for resident engagement and well-being.
Verbal Abuse of Resident by Nursing Assistant
Penalty
Summary
A facility failed to ensure that a resident was free from verbal abuse, as required by its own policy and state regulations. The incident involved a nursing assistant who was overheard by a resident's family member using a profane and derogatory statement directed at a resident with multiple medical conditions, including high blood pressure, chronic kidney disease, type II diabetes, dementia with behavioral disturbance, cognitive communication deficit, history of TIA, delusional disorder, and unspecified psychosis. The facility's documentation confirmed that the staff member made the inappropriate comment to the resident, constituting verbal abuse as defined by the facility's policy.
Failure to Develop Baseline Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop a baseline care plan with appropriate interventions to prevent pressure injury or trauma for a resident diagnosed with diabetes and other significant health conditions. Upon admission, the resident was assessed as cognitively impaired, with fluctuating inattention and disorganized thinking, bilateral lower extremity impairment, wheelchair dependence, incontinence, and substantial assistance required for hygiene and bed mobility. The resident's diagnoses included a progressive neurological condition, hypertension, diabetes mellitus, cerebrovascular accident, dementia, malnutrition, Parkinson's disease, and a psychotic disorder. The resident had experienced significant recent weight loss and was identified as being at risk for developing pressure ulcers, as indicated by the Braden assessment and clinical evaluation. Despite these findings, the clinical record did not contain a care plan addressing the resident's risk for pressure ulcers or interventions to prevent skin breakdown, particularly in light of the resident's uncontrolled diabetes, decreased bed mobility, and substantial weight loss. Although the MDS assessment indicated that skin and ulcer treatments were in place, such as pressure-reducing devices for the chair and bed, there was no evidence of a turning/repositioning program or application of dressings to the feet at the time of admission. The absence of a baseline care plan within the first 48 hours of admission was not in accordance with the facility's policy and regulatory requirements.
Delayed Medication Administration Due to Nurse Inattention
Penalty
Summary
A licensed nurse failed to administer scheduled morning medications to a resident in accordance with facility policy and physician orders. The nurse was observed on the nursing unit two hours after the scheduled medication administration time, engaged in watching a training video on the facility computer instead of performing the medication pass. Upon inquiry, the nurse confirmed she was preparing to administer the resident's morning medications, which were due two hours earlier, and acknowledged that she still had additional residents to medicate. Facility policies require that medications be administered safely, timely, and in accordance with physician orders, specifying that medications must be given at the correct time. The nurse's actions resulted in a delay of medical treatment for the resident, as the medications, including Allopurinol, Amlodipine, Cholecalciferol, Dorzolamide, and Metoprolol, were not administered at the prescribed time.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and able to communicate her needs, did not receive timely assistance with incontinence care. The resident's clinical record indicated she was always incontinent of bowel and bladder and required substantial to maximal assistance with toileting hygiene. On two separate occasions, the resident reported having a bowel movement and requested assistance multiple times. Despite informing staff, there were significant delays before care was provided. On one occasion, the assigned nurse was aware of the resident's need and relayed the information to the nurse aide, who was occupied with another resident. The nurse ultimately provided the care after a delay. On another occasion, the resident's call light was engaged, and a nurse aide entered the room, turned off the call bell, and told the resident she would return after assisting another resident. The resident continued to wait for incontinence care for an extended period, with care not provided until nearly 35 minutes after the initial request.
Failure to Implement Interventions to Prevent Diabetic Wound
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of a diabetic wound for a resident with multiple risk factors, including diabetes, limited mobility, malnutrition, and dementia. The resident was assessed as cognitively impaired, required substantial assistance with hygiene and bed mobility, and had a history of pressing their feet against the bed's footboard, which was observed by staff and confirmed by the resident. Despite a physician's order to apply multi-podus boots to both feet while in bed to relieve pressure, the resident was observed not wearing the boots, and the care plan did not address the risk of developing diabetic ulcers to the lower extremities. Clinical documentation revealed that discoloration on the resident's right heel was first noted, and subsequent wound assessments identified the wound as being related to the resident's diabetes and pressure from the footboard. The wound progressed, requiring debridement and antibiotic therapy after becoming infected. Staff interviews confirmed awareness of the resident's behavior of sliding down in bed and pressing their feet against the footboard, which contributed to the wound's development. The wound physician emphasized the importance of proper footwear and positioning to prevent further injury, noting that the wound may not heal due to the resident's chronic conditions and ongoing risk factors. Observations and interviews indicated that the resident was not consistently using the prescribed multi-podus boots, and staff acknowledged the connection between the lack of proper offloading and the development of the wound. The facility's failure to update the care plan to address the resident's risk for diabetic ulcers and to ensure consistent implementation of physician-ordered interventions directly contributed to the resident developing a significant wound that required advanced medical intervention.
Failure to Provide Supervision in Smoking Area
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not ensuring adequate supervision in the designated smoking area. Facility policy requires that residents who smoke must sign a safe smoking agreement, smoke only in designated locations, and, if requiring supervision, only smoke at designated times with staff present. Review of care plans for several residents indicated interventions such as education on smoking risks, storage of smoking items at the nurse's station, provision of supervision during smoking, and use of a smoking apron. Despite these policies and care plan interventions, observations on two separate occasions revealed multiple residents smoking outside in the designated area without any staff present to supervise the activity. Interviews with staff and residents confirmed the lack of supervision, with one staff member stating that some employees preferred to watch from the window rather than be physically present outside, and a resident indicating that staff are never outside during smoking times. The facility's documented smoking list and care plans specifically required supervision for certain residents, but this was not provided as observed. This lack of supervision in the smoking area constitutes a failure to follow facility policy and ensure resident safety as required by federal and state regulations.
Failure to Schedule Follow-Up Urology Appointment for Catheterized Resident
Penalty
Summary
The facility failed to ensure appropriate follow-up care for a resident with an indwelling urinary catheter. The resident, who had a diagnosis of benign prostate hyperplasia with lower urinary tract symptoms, experienced urinary retention and was hospitalized, after which a catheter was inserted. Documentation showed that the resident had a series of urology consults, with the last appointment indicating the need for further discussion of two treatment options with a doctor. However, review of the clinical record did not show that the recommended follow-up appointment was scheduled. This lapse was confirmed by the unit manager, who acknowledged that the facility did not arrange the necessary follow-up for the resident's ongoing catheter management and treatment options, as required by facility policy and resident care standards.
Failure to Document Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy review irregularities were properly addressed for one resident. According to facility policy, when a pharmacist makes a recommendation during the monthly drug regimen review, the physician or prescriber is required to review the recommendation, document any actions taken, and provide a rationale if no changes are made. For one resident, the pharmacist recommended considering a gradual dose reduction of Eszopiclone for insomnia and reevaluating the ongoing use of Cyclobenzaprine due to potential adverse effects. However, documentation showed only an illegible, undated initial and the word 'decline' for the Eszopiclone recommendation, with no evidence that the physician reviewed or addressed the recommendation, nor any rationale provided for declining it. Similarly, for the Cyclobenzaprine recommendation, the physician checked off that the recommendation was declined but did not provide a rationale in the resident's clinical record. Interviews with the DON confirmed the lack of proper documentation and physician response for both recommendations. These findings indicate that the facility did not follow its own policies and procedures for addressing pharmacy recommendations and documenting physician actions and rationales in the resident's health record.
Failure to Provide Timely and Suitable Breakfast to Resident
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Type 2 Diabetes and Anemia did not receive breakfast as required. The resident, who was cognitively intact according to a recent BIMS assessment, had physician orders in place to monitor meal consumption and to receive a no added salt, large portion diet. On the morning in question, documentation on the Medication Administration Record for meal monitoring was left blank for breakfast and both snacks. The resident reported to the nursing supervisor that she did not receive her breakfast, and the supervisor confirmed this, noting that staff may have been confused by a dinner tray left on the resident's table from the previous night. Subsequently, staff brought the resident a cold cereal and milk meal around noon, which the resident refused, stating she did not want cereal for breakfast and that it was too late with lunch approaching. The failure to provide a timely and suitable breakfast, as well as the lack of proper documentation and response to the resident's dietary needs and preferences, led to the deficiency cited under state regulations regarding the responsibility of the licensee and facility management.
Failure to Arrange Required Rheumatology Consultation
Penalty
Summary
The facility failed to provide necessary outside professional services for a resident diagnosed with polymyalgia rheumatica. The resident's progress note indicated that a physiatrist recommended a rheumatology consultation, and the attending physician agreed with this recommendation. However, a review of the clinical record showed no evidence that an appointment with a rheumatologist was scheduled. This lack of follow-through was confirmed by the Unit Manager during an interview.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice documentation was complete for one resident. The resident, who had multiple diagnoses including senile degeneration of the brain, major depressive disorder, generalized anxiety disorder, unspecified psychosis, hypertension, glaucoma, vitamin B deficiency, muscle weakness, and gait abnormalities, was readmitted to the facility and placed on hospice care. Upon review, it was found that the most recent hospice plan of care and recertification period had expired, and there was incomplete or missing correspondence from the hospice staff providing care. The nursing home administrator confirmed that the last day of hospice was reached and was unable to provide further documentation for the missing notes.
Failure to Implement Effective Infection Control with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) with enhanced barrier precautions for two residents. For one resident with a history of sepsis, C. difficile, MRSA, and ESBL, observations revealed that staff, including a licensed nurse and therapy staff, did not consistently wear the required PPE such as gowns and gloves during high-contact care activities, despite signage and care plans indicating the need for enhanced barrier precautions. Interviews with staff and administration showed confusion and lack of awareness regarding the resident's current precaution status and the appropriate use of PPE, with some staff believing only gloves were necessary or being unaware of the requirements altogether. Another resident with an indwelling catheter also required enhanced barrier precautions, as indicated by door signage. However, a nurse aide was observed providing care without wearing a gown and later admitted to being unaware that a gown was required. These failures were identified through direct observation, review of clinical records, and staff interviews, demonstrating a lack of adherence to established infection control policies and procedures for residents requiring enhanced barrier precautions.
Inadequate Pain Management Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pain management for Resident R381, resulting in actual harm. The resident, who was admitted with a chronic ulcer wound, chronic leg pain, and other conditions, was not properly assessed for pain and did not receive timely pain medication. Upon admission, the resident was prescribed Oxycodone for severe pain, but the medication was not available, and the resident was instead offered Acetaminophen, which was refused. The resident's pain level was not consistently assessed, and there was a delay in obtaining the prescribed Oxycodone. On October 12, 2024, the resident expressed severe pain and suicidal ideation to a physical therapist, indicating a pain level of 10/10. Despite this, there was no evidence that the physician was notified of the resident's condition. Instead, the resident was placed on 1:1 supervision for suicidal ideation. The Director of Nursing later admitted that the staff did not want to bother the physician over the weekend, which contributed to the delay in pain management. The facility's failure to manage the resident's pain effectively resulted in the resident experiencing uncontrolled pain. The lack of timely medication and proper communication with the physician were significant factors in the deficiency. The facility's policies on emergency medication supplies and pain management were not adequately followed, leading to the resident's continued suffering.
Privacy Breach in Transmission-Based Precaution Signage
Penalty
Summary
The facility failed to ensure the personal privacy and confidentiality of residents' medical information related to signage for enhanced barrier precautions. During an observation tour, it was noted that five out of eight residents on transmission-based precautions had signage on their doors that revealed personal and confidential medical information. This included details about medical devices such as peg tubes, tracheostomies, and catheters, which were visible to anyone passing by. The facility's policy on Resident Rights, revised in September 2020, mandates compliance with all resident rights, including the communication of these rights in an understandable language. Additionally, the facility's Transmission Based Precautions and Isolation policy, last revised in April 2024, requires signage to indicate the type of precautions and instruct visitors to stop at the Nurse's Station before entering. However, the signage observed did not adhere to these policies, as it disclosed specific medical conditions and devices, thereby compromising the residents' right to privacy.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that menus were followed, which resulted in several residents receiving meals that did not match their requests. During lunchtime, a resident complained about receiving chicken and cranberry juice, contrary to her lunch ticket that specified roast beef, brown gravy, creamed spinach, egg noodles, and no cranberry juice. Another resident expressed that he consistently received incorrect meals. The grievance log showed a complaint from a resident about being served the wrong food, which was confirmed during an interview. Additionally, during a resident council meeting, multiple residents voiced concerns that the food served did not match their food tickets.
Failure to Notify Physician of Resident's Fall and Hospitalization
Penalty
Summary
The facility failed to promptly notify a resident's physician of a fall with injury that resulted in hospitalization during a leave of absence. The facility's policy requires that the physician and family be notified as soon as a change in condition is identified and the resident is stable. However, in the case of a resident who went on a leave of absence to church, the facility did not document any evidence of notifying the physician after the resident sustained a fall, which was witnessed and resulted in hospitalization. The resident returned to the facility with pain and an abrasion on the right thumb, and pain on the right side, for which as-needed pain medication was administered. Despite the facility's policy outlining the need for prompt notification of significant changes in condition, including accidents or incidents, the clinical record lacked documentation of physician notification. This deficiency was confirmed during an interview with the Regional Nurse.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to accurately complete a resident assessment related to discharge status for one resident. A review of the clinical records and staff interviews revealed that the discharge Minimum Data Set (MDS) for a resident was inaccurately coded. The nursing note dated July 31, 2024, indicated that the resident was discharged to home, while the MDS assessment for the same date incorrectly coded the discharge status as a short-term general hospital (acute hospital). This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator on November 1, 2024.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely laboratory services for a resident who complained of headache, dizziness, and lightheadedness. The resident's nurse practitioner ordered lab work, including a CBC, CMP, urine culture and sensitivity, and an EKG. The urine sample was initially collected on the night shift but was not sent to the lab promptly. A second urine sample was collected and sent to the lab, but the container leaked, and the sample was discarded. The lab attempted to contact the facility, but no follow-up was completed, and no new urine sample was sent out.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify a resident's physician about abnormal laboratory test results. Resident R107, who had complained of headache, dizziness, and lightheadedness, had lab work ordered by a nurse practitioner, including a CBC, CMP, urine culture and sensitivity, and an EKG. Although the lab work was completed, the results were not printed from the lab electronic system, and there was no evidence that the physician was notified of the results. The CBC and CMP results, completed on October 19, 2024, showed some values flagged as out of range, including a blood sodium level of 133, which is below the normal range of 136-144.
Inadequate Call Bell System for Resident
Penalty
Summary
The facility failed to ensure that the call bell system in Resident R21's room was functional and accessible. During an observation, it was noted that the wired call bell had been removed from the wall, leaving the resident with a tap bell placed across from the foot of the bed, out of reach. The resident reported using the bell to call for staff, but no one responded. On one occasion, the resident pressed the tap bell at 1:49 p.m. to request assistance after an incontinence episode, but staff did not respond until 1:58 p.m., despite being present at the nurse's station. Employee E4, responsible for Resident R21, was unaware that the resident did not have a corded call bell. Further observations revealed that the tap bell was not audible at the nurse's station, where music was playing, and staff, including a registered nurse passing medication nearby, did not hear it. On another occasion, the resident pressed the tap bell multiple times to request assistance for lunch preparation, but there was no response until 11:27 a.m. Interviews with the Nursing Home Administrator and the Regional Nurse confirmed that the call system provided for Resident R21 was inadequate, violating the electric requirements for existing construction as per 28 Pa. Code 205.67(j).
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of continuing education per year, as evidenced by the review of personnel files and staff interviews. Specifically, three out of five nurse aide personnel files reviewed, including those of Employees E6, lacked documentation of the mandatory continuing education hours. During an interview, the Nursing Home Administrator confirmed the absence of these educational records for the employees at the time of the survey. This deficiency is a violation of the Pennsylvania Code, which mandates specific personnel policies and staff development requirements.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring continuous oxygen therapy received the prescribed services according to physician orders. The resident, who was admitted in September 2022 for acute respiratory failure with hypoxia, was observed by family members on multiple occasions without the oxygen mask, despite an order for 2 liters of oxygen to be administered continuously via nasal cannula. A grievance was logged by the family, noting this was the third occurrence in a month. A nursing assistant admitted to removing the oxygen mask while providing care on May 14, 2024, and forgetting to replace it, which contributed to the deficiency.
Failure to Maintain Comfortable Temperature in B Wing
Penalty
Summary
The facility failed to maintain a safe and comfortable environment on the B wing nursing care unit. During an interview, a resident reported that the hallway temperature was uncomfortably cold, necessitating keeping her room door closed. She had communicated this concern to the nursing supervisor and during a resident council meeting. An observation tour conducted with the director of maintenance confirmed the hallway temperature was 69 degrees. The director explained that the fire doors at each end of the hallway were closed due to a malfunction in the magnetic door lock system, creating a compartment that trapped cold air from the air conditioning system, leading to the temperature drop.
Failure to Perform Immediate CPR for Full Code Resident
Penalty
Summary
The facility failed to ensure that CPR was provided in accordance with established facility policy for a resident who had elected to be Full Code. The incident involved Resident 207, who was found unresponsive by a licensed nurse, Employee E6. Instead of initiating CPR immediately, Employee E6 mistakenly identified the resident as having a Do Not Resuscitate (DNR) order by looking up the wrong resident in the computer system. This error led to a delay in starting CPR, as Employee E6 left the resident's room to inform the Nursing Supervisor, Employee E30, who also believed the resident was a DNR based on the incorrect information provided by Employee E6. It was only after the Acting DON and the Physician Assistant (PA) confirmed that the resident was a Full Code that CPR was initiated, approximately 14 minutes after the resident was found unresponsive. The delay in initiating CPR was further compounded by the actions of the staff. Employee E6, after misidentifying the resident's code status, left the room to use the computer and get the supervisor, instead of starting CPR immediately. Employee E30, the Nursing Supervisor, also did not verify the resident's code status promptly and relied on the incorrect information provided by Employee E6. The Acting DON and the PA eventually confirmed the resident's Full Code status and called for CPR to be initiated, but this was significantly delayed. The facility's failure to perform CPR immediately for a resident who had elected to be Full Code created a situation of Immediate Jeopardy. The delay in initiating CPR was due to the misidentification of the resident's code status and the subsequent actions of the staff, which did not align with the facility's policy and the American Heart Association guidelines. The resident was eventually transported to the hospital with a pulse after the paramedics took over CPR, but the initial delay in providing life-saving measures was a critical deficiency in the facility's response.
Failure to Provide Timely CPR Due to Misidentification of Code Status
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility by not ensuring that Cardio Pulmonary Resuscitation (CPR) was provided in accordance with established facility policy for a resident, resulting in an Immediate Jeopardy situation. The resident, who had a physician's order for Full Code, was found unresponsive by a licensed nurse. The nurse mistakenly identified the resident as Do Not Resuscitate (DNR) due to looking up the wrong resident in the computer system. This error led to a delay in initiating CPR, as the nurse informed the Nursing Supervisor, who then informed the Acting Director of Nursing (DON) that the resident was a DNR. It was only after the Physician Assistant (PA) confirmed that the resident was a Full Code that CPR was initiated and 911 was called. The paramedics were able to obtain a pulse and transported the resident to the hospital, but the delay in starting CPR was significant, lasting approximately 14 minutes from the time the resident was found unresponsive to when CPR was initiated. Interviews with the involved staff confirmed the sequence of events and the miscommunication regarding the resident's code status. The licensed nurse admitted to looking up the wrong resident in the computer system and leaving the room to get the supervisor, which contributed to the delay. The nurse aide and the Nursing Supervisor also confirmed the timeline and actions taken, including the removal of the resident's Foley catheter and preparing the resident for family viewing under the mistaken belief that the resident was a DNR. The Acting DON and the PA confirmed that they realized the resident was a Full Code only after checking the records, leading to the initiation of CPR and calling 911. The facility's camera footage corroborated the timeline provided by the staff, showing the delay between the nurse and the supervisor entering the resident's room and the initiation of CPR. The Nursing Home Administrator, DON, and Acting DON acknowledged the delay and the misidentification of the resident's code status, which contributed to the Immediate Jeopardy situation. The deficiency was identified as a failure to fulfill essential duties and responsibilities, as outlined in the job descriptions for the Nursing Home Administrator and the Director of Nursing, leading to a critical lapse in resident care.
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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