Care Pavilion Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6212 Walnut Street, Philadelphia, Pennsylvania 19139
- CMS Provider Number
- 395893
- Inspections on file
- 57
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 49
Citation history
Health deficiencies cited at Care Pavilion Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found widespread environmental and maintenance deficiencies across several units and the boiler room, including resident rooms with fallen fans, frayed bed-remote wiring, holes in floors and baseboards, loose ceiling panels, non-functioning or uncovered bathroom lights, and exposed PTAC/HVAC components. Dining and pantry areas had unstable tables, missing floor tiles, leaking water lines with towels on the floor, built-up debris on cabinetry, missing hardware, and windows without screens that did not fully close. A resident reported that staff frequently flush briefs, contributing to a persistently clogged toilet full of feces. Common areas and bathrooms under renovation had unlocked doors, missing fixtures, exposed concrete with deep floor holes, and fallen ceiling panels, while staff confirmed that residents must use shower rooms on other units due to this construction. Additional observations included dark hall areas from non-functioning ceiling lights, a broken and loose employee bathroom door and frame, two unsecured oxygen tanks in a medication room, standing water throughout the boiler room from a leaking hot water holding tank, and an open roof-access door in a stairwell.
Surveyors found that MDS assessments were not accurately coded for two residents. One resident’s Significant Change MDS omitted hospice services and documented arterial foot ulcers despite progress notes and a wound consultant note confirming these conditions. Another resident’s quarterly MDS did not include a schizophrenia diagnosis even though the clinical record and physician orders showed ongoing treatment with antipsychotic medications for schizophrenia. The Assessment Coordinator confirmed both omissions and could not provide clear criteria or guidelines supporting the removal of the schizophrenia diagnosis from the MDS.
The facility failed to update care plans to reflect current physician orders and clinical conditions for two residents. One resident receiving hospice services for a gangrenous right foot with arterial ulcers had active orders for hospice care and DNR status, but the care plan still listed both DNR and Full Code and did not include the arterial ulcers, gangrene, or hospice needs. Another resident with dysphagia and enteral nutrition orders for Glucerna 1.2 at 65 ml/hr via feeding pump continued to have a care plan referencing a prior Nepro regimen at 70 ml/hr for 15 hours. The DON and an LPN acknowledged that the care plans had not been updated to match the residents’ current orders and conditions.
Two residents experienced accidents due to inadequate supervision and failure to follow safety protocols. A resident with alcohol dependence and a history of falls went on an escorted LOA with family; the care plan lacked interventions for SUD education or counseling related to LOA, there was no sign-in/sign-out log, and there was no documented assessment or increased supervision upon the resident’s return. The next day, staff found the resident on the floor with a forehead laceration, smelling of alcohol, surrounded by multiple beer containers, and later diagnostic imaging showed a C1 fracture. In a separate event, a cognitively intact, wheelchair-dependent resident with a left BKA was transported by a contracted van with a CNA escort; the facility’s wheelchair transport safety policy required full securement and restraints, but the resident reported having no safety belt and an unsecured wheelchair. When the driver hit a bump, the resident slid out of the wheelchair and the chair fell onto them, and the CNA confirmed the wheelchair had been only partially locked and that she had not received transport safety education after the incident. Documentation from the transport company indicated the driver failed to properly secure the resident and was at fault.
A resident was receiving hospice services over an extended period, but the clinical record did not include documentation of the resident’s clinical condition or the resident’s choice to elect hospice care. Physician orders for hospice services were also absent for a significant portion of this time, even though hospice care was being provided. These documentation gaps in progress notes and physician orders were identified during record review and confirmed with the DON, constituting a violation of medical record requirements.
A resident with a history of hemiplegia and high risk for pressure ulcers did not have required skin checks and bathing documented by nursing staff, despite physician orders and facility policy. Nursing staff also incorrectly documented the presence and treatment of a pressure ulcer for ten days, when the area was actually a healed scar, leading to an inaccurate care plan and incomplete medical records.
A resident with end stage renal disease and moderate cognitive impairment sustained first and second degree facial burns after smoking with oxygen in use in the designated outdoor smoking area. Despite facility policy prohibiting smoking while on oxygen and requiring supervision, staff were distracted by other duties during a busy courtyard event, allowing the resident to access the area unsupervised and ignite a cigarette, resulting in injury.
A resident with a history of homelessness, anxiety disorder, and substance abuse was identified as being at risk for elopement, but the care plan did not include interventions to prevent elopement or address the need for staff oversight at the main entrance. The resident, who was nonverbal and wheelchair-bound, was able to exit the facility when a visitor held the door open, and was later found and returned by staff.
A large quantity of mouse droppings was observed in multiple resident rooms across all nursing units. Two residents reported seeing mice in their rooms, and the Housekeeping Director confirmed the presence of significant mouse droppings in at least one room. Pest sighting logs documented recent reports of mice and roaches in several rooms.
A resident did not receive scheduled morning medications because crackers, needed to take the pills, were unavailable. The LPN documented the medications as administered in the electronic record before the resident actually took them, contrary to facility policy. The nurse's competency record showed awareness of proper procedures, but the staff orientation checklist was incomplete, and the resident's care plan noted a history of medication refusal.
A resident with diabetes and end stage renal disease did not have their blood glucose checked at a scheduled time as ordered by the physician. Later that morning, the resident was found unresponsive with a critically low blood sugar, requiring emergency intervention and transfer to the hospital. Documentation did not support that the required blood glucose assessment was completed prior to the incident.
A resident with a history of opioid use disorder was granted an escorted leave of absence for a family emergency, but the facility lacked a defined process to screen or approve escorts. The resident left with a friend not listed as an approved contact and did not return as scheduled. The next day, the resident's daughter reported the resident had died from a drug overdose while on leave. Staff confirmed there was no established process for defining or screening escorts.
A resident with multiple wounds and a wound vacuum did not have Enhanced Barrier Precautions (EBP) interventions in their care plan, and staff failed to use required PPE during wound care. Staff placed items from the floor near the resident's open wound, changed gloves from their pocket, and left wound care supplies on the floor. The resident's room also had stale flowers attracting flies.
A resident with a history of stroke and incontinence was left in a bowel movement for several hours due to staff shortages on a holiday. The facility's documentation showed no record of care provided during this time, and the Nursing Home Administrator confirmed the incident, attributing it to staffing issues.
The facility failed to report alleged violations and investigation results to state agencies as required. A resident with a history of stroke was left in a soiled brief for hours, and another resident was injured by a housekeeper's cart. The facility did not notify the state agency about these incidents or the investigation outcomes.
A facility failed to ensure a resident's call bell was within reach, violating their policy. The resident, who had a stroke and was non-verbal with left side weakness, was dependent on staff for all self-care needs. The call bell was placed on the resident's paralyzed right side, making it inaccessible. The resident's family expressed concern about the inability to call for help.
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on multiple occasions. During the day shift, the facility did not ensure a minimum of one NA per 12 residents on three days. Similarly, during the evening shift, the facility did not meet the required staffing levels on four days. Additionally, during the night shift, the facility did not ensure a minimum of one NA per 20 residents on two days. These deficiencies were confirmed with the Nursing Home Administrator.
The facility did not meet the required LPN staffing levels for two out of 21 shifts reviewed. Specifically, the day shift had 10.33 LPNs for a census of 328 residents, requiring 13.12 LPNs, and the night shift had 7.32 LPNs, requiring 8.20 LPNs. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 nursing care hours per resident per day for six out of seven days reviewed. The care hours provided ranged from 2.08 to 3.02 PPD, falling short of the regulatory requirement. This deficiency was confirmed with the Nursing Home Administrator.
A resident reported receiving cold food and warm drinks. Upon testing, the Food Service Director confirmed that several food and drink items were served outside the facility's required temperature ranges, with hot foods below 135°F and cold items above 41°F, contrary to policy.
Staff failed to ensure each resident had a personal, labeled, and sanitized bedpan, resulting in shared and unsanitary bedpans being used by multiple residents. Observations and interviews revealed confusion among staff about bedpan storage and assignment, and residents reported bedpans were reused between roommates, contrary to facility policy.
Staff served meals to residents on one nursing unit using plastic utensils due to a shortage of regular utensils. A resident and multiple staff confirmed that all residents received breakfast with plastic utensils, and dietary staff stated the facility did not have enough regular utensils available. This practice did not support the maintenance and enhancement of resident dignity.
Staff did not ensure a clean and comfortable environment for residents, as evidenced by two residents having filled urinals left on their bedside tables and a persistent roof leak in a shower room. Staff interviews confirmed that urinals should have been emptied, but this was not done despite multiple opportunities.
A resident with severe cognitive impairment was subjected to non-consensual sexual contact by another resident with a history of inappropriate behavior. Despite previous incidents and documented risks, the facility failed to adequately monitor and protect the vulnerable resident, resulting in an Immediate Jeopardy situation.
The dietary services department was found non-compliant with food service safety standards due to maintenance issues in the main kitchen. Observations revealed water-damaged, missing, and soiled ceiling tiles, exposing electrical wiring and causing sanitation concerns. A burst water pipe in January 2025 delayed meal preparation. Health inspection reports cited damaged tiles and pest control reports indicated cockroach treatment was ongoing. A purchase order for new ceiling tiles was placed, but repairs were incomplete.
The facility failed to implement pressure ulcer prevention interventions for three residents. Two residents with severe cognitive impairment did not have the required heel protectors while in bed, and a resident with COPD did not receive ear mates to prevent pressure injuries from oxygen tubing. These deficiencies were observed during staff interviews and resident observations.
A resident with severe cognitive impairment and multiple medical conditions was not provided reasonable access to their personal funds, as the facility failed to escort them to the business office for their monthly allowance. The responsible party only assisted once in the previous year, and the resident's financial statement showed a single withdrawal. The DON confirmed the facility's responsibility to accommodate the resident's access.
A facility failed to update a resident's code status to reflect their wishes for no resuscitation and comfort care only, as indicated in their POLST. Despite being on hospice care, the resident's record incorrectly showed a Full Code status, which was confirmed by an LPN.
The facility did not maintain a clean and homelike environment in two nursing units. A resident reported a leak from the unit above, leading to water damage and discoloration on ceiling tiles. Observations revealed soiled linen and trash on the floor of a linen closet, leftover food on a nightstand, and a peeling wall panel.
A facility failed to provide timely vision and audiology services for a resident with epilepsy, Parkinson's Disease, cataracts, severe glaucoma, and cognitive impairment. The resident's family had requested medical attention for the resident's vision and hearing issues, but no follow-up appointments were scheduled after an initial audiology appointment was missed due to impacted ears. Additionally, a referral to ophthalmology for end-stage glaucoma was not acted upon, as confirmed by the DON.
A facility failed to provide necessary treatment to maintain or improve a resident's range of motion. The resident, with severe cognitive impairment and hemiplegia, was observed with a right-hand contracture and no splint, despite recommendations for one. Staff interviews confirmed the absence of a splint and lack of a physician order, and the clinical record showed no documentation of splint use.
A facility failed to provide adequate supervision for residents with known aggressive behaviors, leading to multiple altercations. A resident with dementia and poor impulse control was involved in several incidents, including fights with other residents, resulting in injuries. Despite care plans for aggression, the facility did not prevent these incidents, indicating a failure to maintain a safe environment.
The facility failed to follow physician orders for catheter specifications for two residents. One resident had a catheter with a 16FR/10ML instead of the ordered 16FR/30 cc balloon, and another had a 14FR/30 cc instead of the ordered 14FR/10 cc balloon. These discrepancies were confirmed by nursing staff.
The facility failed to monitor and modify nutritional interventions for two residents, resulting in significant weight loss. One resident with severe cognitive impairment and dysphagia lost 7.2 pounds in one month, which was not addressed by the Registered Dietitian. Another resident with moderate cognitive impairment and malnutrition lost 12.6 pounds in one month, with the issue not addressed until a month later. The facility's inaction contributed to the deficiency.
A facility failed to follow physician orders for a resident's tube feeding. The resident, diagnosed with Adult Failure to Thrive and Gastrostomy, was prescribed Jevity 1.2 Cal Enteral Liquid at 60 ml/hr. However, it was observed that Jevity 1.5 was administered instead. This was confirmed by the Unit Manager, a Licensed Nurse.
A facility failed to provide oxygen therapy according to professional standards and the care plan for a resident with COPD. The resident was prescribed 3 liters of continuous supplemental oxygen, with instructions to change and date the tubing weekly. However, the tubing was not dated, and the oxygen was set at 4.5 liters instead of the prescribed 3 liters, as confirmed by the resident's nurse.
A facility failed to maintain complete dialysis communication records for a resident receiving hemodialysis. The records lacked information on bruit, thrill, infection signs, and nurse signatures over several months. This was confirmed by a licensed nurse during an interview.
A resident did not receive prescribed testosterone medication for over a week due to the facility's failure to follow procedures for obtaining unavailable medication. Despite notifying the physician, there was no documented response, and nursing staff did not communicate or implement proper procedures to ensure the medication was acquired and administered.
The facility failed to provide palatable and properly prepared meals, as observed during meal services where the hamburger steak was overcooked and inedible. Residents frequently requested substitute meals due to unappetizing food and unmet preferences. Interviews with residents and staff confirmed inadequate food preparation skills among dietary employees, and the facility's policies on food quality were not effectively implemented.
The Nursing Home Administrator and DON failed to manage a resident with a history of sexually inappropriate behavior, leading to an Immediate Jeopardy situation. The resident engaged in unwanted sexual contact with another resident who had severe cognitive impairment. Despite previous incidents and warnings, the facility did not effectively intervene, resulting in a serious breach of regulations and the victim being sent to the emergency room.
A facility failed to implement Enhanced Barrier Precautions for a resident with a PEG tube and chronic wound. A nurse was observed cleaning the resident's PEG tube site without wearing the required PPE, despite a physician's order for gown and gloves during high-contact care activities. This lapse in infection control was confirmed with the nurse.
The facility failed to provide food and drink at palatable temperatures for several residents. Observations and interviews revealed that food was often not warm enough, with some residents reporting cold, mushy, or unappetizing meals. A test tray evaluation confirmed that several food items were served outside the acceptable temperature range, which was acknowledged by the Food Service Director.
The facility's pest control program was found to be ineffective, as multiple residents reported sightings of mice and insects in their rooms. Pest sighting logs confirmed these reports, documenting numerous incidents of mice and droppings across various floors. Interviews with the maintenance director and Administrator verified the ongoing pest issues.
The facility did not meet the required nurse aide staffing ratios as per Pennsylvania state regulations, failing to provide the mandated number of nurse aides per residents during various shifts over a three-week period. This non-compliance was observed on multiple dates and discussed with the facility's administration.
The facility did not meet the required LPN staffing ratio on a day shift, with an actual ratio of 91.12 instead of the required 92.80. This deficiency was identified during a review of staffing data and discussed with the Administrator.
The facility failed to provide the required minimum of 3.2 hours of direct resident care per resident in a 24-hour period on multiple days, as revealed by a review of nursing staffing sheets. This deficiency was identified for several days within the period reviewed, and the findings were discussed with the facility's administration.
A resident reported verbal abuse by a staff member and a separate incident of physical harm, but the facility failed to investigate either allegation. Despite the resident's cognitive intactness and history of PTSD and anxiety, the facility did not complete the investigation process, leaving forms incomplete and failing to notify responsible parties. Interviews confirmed the lack of investigation, violating resident rights and state codes.
A resident with a surgical wound and wound vac did not receive prescribed wound care for a week after admission. Despite care plan interventions and hospital discharge instructions for regular dressing changes, there were no treatment orders or documentation of wound care until the wound vac was removed two weeks later. The DON confirmed the lack of treatment orders and wound care during this period.
A facility was found deficient as the call system on one nursing unit was not functioning, preventing residents from contacting caregivers. Observations revealed that the call bell system at the nurses' station was not displaying or sounding alerts. Staff confirmed the system was turned off, and the monitor was not indicating where residents were calling for assistance.
A facility failed to implement a comprehensive care plan for a resident with COPD, as required by policy. The care plan lacked documentation for using a pulse oximeter before, during, and after therapy, and the nursing staff and therapists did not perform and document blood oxygen levels as required by the treatment plans.
Environmental and Maintenance Failures Across Multiple Units and Boiler Room
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment on multiple nursing units and in the boiler room. On the 3 East unit, one resident room had a fan that had fallen off the wall, a dresser missing a drawer, a bed remote with frayed wires, two holes in the floorboards, a loose ceiling panel, and floor tiles taped together. The 3 East dining room contained five unsteady tables and a cabinet with built-up debris and missing handles. On the 2nd Floor [NAME] unit, fluorescent ceiling lighting was out, leaving an area near several rooms dark, and multiple resident rooms had loose baseboards, holes in walls near sinks, and walls that were scuffed or dirty with dark marks. In one room, the bed headboard was off and leaning against the wall. On the 3 [NAME] unit, surveyors observed a resident room with a toilet clogged and full of feces that could not be flushed; a resident reported that staff flush briefs down the toilet and that this occurs often. Another room had a hole in the baseboard behind a tube feeding pump, another had a non-functioning bathroom overhead light, and another had a bathroom light with no cover and a large hole above the baseboard. In an additional room, the PTAC unit had wires protruding from the underside, drywall was torn apart next to the sink, and the toilet lid cover was too large to close properly. The pantry on this unit had two missing floor tiles, a leaking water supply line with towels on the floor to absorb water, and no refrigerator for resident food storage. The medication room contained two oxygen tanks stored without holders, and the dining room PTAC unit was supported by stacked wood pieces, with three unstable tables and two windows lacking screens, one of which would not close due to a missing frame piece. On the 3rd Floor [NAME] unit, several PTECC/HVAC wall units had missing or loose bottom panels, exposing sharp edges and internal parts. Additional environmental issues were found elsewhere in the building. On the 1st Floor East unit, the employee bathroom door was broken and loose, and the metal door frame was disconnected from the floor, causing the entire unit to move when pushed. The central bathroom on the 2nd Floor [NAME] had an unlocked door and was under renovation, with floor tiles and baseboards removed and open holes in the floor where drain grates had been taken out. The 3 [NAME] unit central shower room was also under renovation, with toilet, shower, and bath fixtures removed, flooring stripped to concrete, multiple deep holes in the floor, and multiple ceiling panels fallen or caved in; the construction area was unsecured, and a resident reported entering the room to use the toilet and finding all fixtures removed, now having to use a shower room on another unit. Staff confirmed the shower room doors had been left unsecured and that residents must use shower rooms on other units. In the boiler room, there was standing water covering most of the floor up to the doorway threshold outside the kitchen, which the Maintenance Director attributed to a leaking hot water holding tank of unknown duration. In the East stairwell, the roof access door was observed open, and the Nursing Home Administrator confirmed it should not be left open.
Inaccurate MDS Coding for Hospice Status and Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents' current diagnoses and medical conditions for two residents. For one resident, progress notes from early November documented that the resident was receiving hospice services and wound treatments to the foot, and a wound consultant note from late October identified arterial ulcers on multiple toes of the right foot. However, the resident’s Significant Change MDS dated in mid-November did not include coding for hospice services or the vascular (arterial) wounds. The Assessment Coordinator later confirmed that these conditions were not coded on that Significant Change MDS. For another resident, the quarterly MDS documented a BIMS score indicating moderate cognitive impairment and listed diagnoses of anxiety and suicidal ideation, but did not reflect the resident’s diagnosis of schizophrenia. The clinical record showed that the resident had documented diagnoses of schizophrenia, alcohol use, suicidal ideation, and anxiety disorder, and physician orders indicated ongoing treatment for schizophrenia with antipsychotic medications since admission. The physician records further confirmed that the resident was actively being treated for schizophrenia. In an interview, the Assessment Coordinator acknowledged that the resident had a schizophrenia diagnosis but stated it had been removed from the MDS based on facility criteria following a CMS audit, and was unable to provide the guidelines or explain how that determination was made.
Failure to Update Care Plans for Hospice, Code Status, Wounds, and Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to update and accurately maintain comprehensive care plans in response to changes in residents’ conditions and physician orders. Facility policy dated October 1, 2024, required nursing staff to update care plans based on physician orders and changes in care needs, and to initiate or update acute care plans as warranted. For one resident with a gangrenous right foot and arterial ulcers on the first through fourth digits, progress notes from mid-August through early December documented hospice services and wound treatments, and active physician orders included hospice care and a DNR order. However, the resident’s care plan, originally dated in 2020 and 2021, still listed both DNR and Full Code status and did not reflect the arterial ulcers, the gangrenous condition of the right foot, or the resident’s hospice care needs. The DON confirmed that the care plan had not been updated to reflect the resident’s wounds, hospice needs, or current code status. A second resident had multiple conditions including dysphagia in the oropharyngeal phase and was receiving enteral nutrition. Physician orders dated in late August specified Glucerna 1.2 via feeding pump at 65 ml/hr until a total volume of 1300 ml was infused each dayshift, with documentation of total volume infused. The resident’s care plan, however, still reflected an older enteral nutrition regimen for Nepro at 70 ml/hr for 15 hours, initiated in November of the prior year, and had not been revised to match the current Glucerna order. During an interview, an LPN reviewed the current tube feeding order and confirmed that the care plan should have been updated to reflect the Glucerna 1.2 at 65 ml/hr via feeding pump. These findings showed that the facility did not ensure care plans were updated to align with current physician orders and residents’ clinical conditions for hospice care, code status, vascular wounds, and tube feeding.
Failure to Supervise Resident With Alcohol Dependence After LOA and Improper Wheelchair Transport Securement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with alcohol dependence following a leave of absence, and failure to ensure proper securement of another resident during wheelchair transport. The facility had a Substance Use Disorder (SUD) policy dated October 24, 2022, which defined SUD, required assessment of residents with a history of SUD, and called for interventions such as resident/family counseling and education on the SUD policy upon admission. A resident with diagnoses including alcohol dependence with withdrawal, hypertension, prostate cancer, and a history of falls was admitted and had a physician’s order to continue Naltrexone for alcohol cessation. Social work documentation noted the resident’s self-report of a history of drinking alcohol, and the admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact and able to make needs known. The resident’s care plan dated September 30, 2025, identified a behavior problem of alcohol abuse related to physical and verbal aggression, but did not include a care plan or interventions addressing education or counseling of the resident or family regarding substance use during a leave of absence or the facility’s SUD policy. Nursing notes documented that on November 7, 2025, at 10:46 a.m., the resident went on an escorted leave of absence with a family member in stable condition. A Release of Responsibility for Leave of Absence form was completed with the resident’s name, date, time of departure, and expected return time, and contained the resident’s signature and an illegible escort signature, but no times were documented next to the signatures. The DON reported that the form was completed by the unit nurse and given to the front desk, and also stated there was no logbook at the front desk to sign residents in and out. The DON further indicated that the resident returned from the escorted leave on the same day. On November 8, 2025, at 2:44 p.m., an incident fall report documented that the resident’s roommate notified the nurse that the resident was on the floor. The nurse found the resident sitting on the side of the bed with a cut on the forehead, holding a cup containing beer, and a bag on the floor with six cans of beer, four of which were opened. Four empty beer cans and one small empty bottle of unknown liquid were also found with the resident, and the resident had a smell of alcohol. The resident stated that they were sitting on the side of the bed, started to fall asleep, and fell, hitting their head. The resident was described as alert and oriented to place, people, and time, and independent with transfers and ambulation at baseline, and had been last seen by staff around 2:00 p.m. in stable condition in the room. Diagnostic imaging at the hospital was positive for a C1 fracture. There was no documented evidence in the clinical record that the resident was assessed upon return from the leave of absence or that any additional supervision was provided after the leave, despite the resident’s history of alcohol dependency. A separate deficiency involved the facility’s failure to ensure that a resident was properly secured during transportation to an outside appointment, resulting in the resident sliding out of a wheelchair in a contracted transportation van. The facility’s undated Wheelchair Transportation Safety Policy required that transportation staff be trained, that vehicles be properly equipped and maintained, and that wheelchairs be fully secured using manufacturer-specified restraint systems before the vehicle moved. The policy also required visual inspection of equipment, confirmation that wheelchair brakes were engaged, and application of safety restraints before raising the lift and moving the vehicle. A cognitively intact, wheelchair-dependent resident with anxiety and a left below-knee amputation, who required partial assistance for sit-to-stand and supervision for transfers, was transported to an appointment with a nursing assistant escort. Documentation submitted to the State Survey Agency indicated that on July 16, 2025, at approximately 2:00 p.m., the resident was returning from an appointment in a contracted transportation van when the driver hit a bump, causing the resident to partially slide out of the wheelchair. The escort reported that the wheelchair was only partially locked. The resident was transported to the hospital, where no fractures were found. In an interview, the resident stated that during the return trip they did not have a safety belt and the wheelchair was not secured, and that when the driver hit a bump, they fell out of the wheelchair and the wheelchair landed on top of them, causing excruciating pain. The nursing assistant escort confirmed that she was seated in the front seat of the van when the driver hit a pothole and the wheelchair moved, and that the driver stopped, re-secured the resident, and returned to the facility. The nursing assistant also confirmed she had not received any education on safety protocols or wheelchair securing or transport protocol since the incident. Facility documentation from July 16, 2025, showed that the transportation company reviewed video of the incident and determined that the driver did not properly secure the resident and was at fault.
Failure to Accurately Document Hospice Services and Orders in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s hospice services were accurately reflected in the clinical record. Clinical record review and staff interviews showed that one resident (R81) received hospice services between August 15, 2025, and December 2, 2025. However, the resident’s progress notes contained no documentation regarding the resident’s clinical condition or the resident’s choice related to the election of hospice services. In addition, review of physician orders revealed there were no physician orders for hospice care documented from September 5, 2025, until November 18, 2025, despite the resident receiving hospice services during this period. These findings were confirmed with the Director of Nursing on December 5, 2025, at 10:25 a.m. The deficiency was cited under 28 Pa Code 211.5(f)(i)(ii) related to medical records, based on the lack of appropriate hospice-related documentation in the resident’s clinical record and the absence of corresponding physician orders for hospice care over a defined timeframe.
Incomplete and Inaccurate Medical Record Documentation for High-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by professional standards and facility policy. Specifically, the resident, who had a history of hemiplegia and was at high risk for pressure ulcers due to impaired mobility and incontinence, had physician orders for twice-weekly skin checks and bathing, with documentation required by licensed nursing staff. However, a review of the resident's records for a period spanning over a year revealed no documented evidence that these skin checks were performed, despite the resident's high risk status and previous history of pressure ulcers. This lack of documentation was confirmed by the Director of Nursing. Additionally, nursing staff erroneously documented the presence and treatment of a pressure ulcer on the resident's left gluteal fold for ten days, when in fact the area was a healed scar and not an open wound. The care plan was also developed based on this incorrect assessment, citing non-compliance with care that was not supported by the ongoing documentation, which indicated the resident was being turned, repositioned, and bathed as required. These actions resulted in inaccurate and incomplete medical records, contrary to facility policy and accepted professional standards.
Resident Burned While Smoking with Oxygen Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and moderate cognitive impairment sustained first and second degree burns to the face after smoking while using oxygen. The resident, who was dependent on renal dialysis and used a wheelchair, returned from on-site dialysis with a portable oxygen tank and entered the designated outdoor smoking area. Despite facility policy prohibiting smoking while oxygen is in use and requiring supervision by designated smoking monitors, the resident was able to access the smoking area with oxygen in use and obtained a cigarette from another resident. At the time of the incident, there was a Bar-B-Q event in the courtyard, resulting in increased activity and a higher volume of residents in the area. The smoking monitors assigned to supervise the area were occupied with multiple tasks, including writing down names of residents entering the courtyard, assisting residents in wheelchairs, and responding to reports of marijuana use. During this period of heightened activity, the resident was not adequately supervised and managed to light a cigarette while the nasal cannula was still in place, causing the oxygen to ignite and resulting in burns. Staff interviews confirmed that the smoking monitors were distracted by other duties and did not notice the resident entering the courtyard or smoking with oxygen in use. The incident was only discovered when a staff member observed a flash and saw the resident's face was burned. The lack of direct supervision and failure to enforce the facility's smoking policy directly contributed to the resident's injury.
Failure to Develop Comprehensive Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address the needs of a resident with a history of homelessness, anxiety disorder, and psychoactive substance abuse. The resident was admitted with these diagnoses and was later identified as being at risk for elopement based on an assessment conducted after admission. Despite this identified risk, the resident's care plan did not include specific interventions to prevent elopement, nor did it address the need for adequate staff oversight at the facility's main entrance, where the resident was frequently observed. On the day of the incident, the resident, who was nonverbal, wheelchair-bound, and exhibited exit-seeking behavior, was able to leave the facility through the main entrance. This occurred when a visitor held the door open, allowing the resident to exit in her wheelchair. The resident was found outside by a staff member and returned to the facility. Documentation and interviews confirmed that the care plan lacked necessary interventions based on the resident's elopement risk and the facility's traffic patterns at the main entrance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the observation of a large quantity of mouse droppings in multiple resident rooms across all six nursing units. During a walkthrough with the Maintenance Director, numerous rooms were found with significant mouse droppings. Interviews with two residents confirmed sightings of mice in their rooms. The Housekeeping Director acknowledged that although rooms are cleaned daily, the observed room had not yet been cleaned and confirmed the presence of a significant amount of mouse droppings. Review of pest sighting logs revealed recent reports of mice and roaches in various rooms on different dates.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
A deficiency was identified when a resident did not receive their scheduled morning medications as prescribed. The resident was observed with a cup of pills left on the bedside table, stating that he could not take his medications because crackers, which he uses to take his pills, were not available. The responsible nurse confirmed that the medications were not administered due to the absence of crackers. However, a review of the electronic medication administration record showed that the nurse had already signed out the medications as administered, despite the resident not having taken them at that time. Further review revealed that the facility's policy requires medications to be documented as administered only after they are given, and any withheld or refused medications must be documented accordingly. The nurse's competency record indicated understanding of this protocol, but the staff orientation and training checklist for the nurse was incomplete. The resident's care plan also noted a history of medication refusal, which was not appropriately addressed in this instance. These findings demonstrate a failure to ensure that nursing staff followed established protocols for medication administration and documentation, compromising the resident's well-being.
Failure to Timely Assess Blood Glucose as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident received treatment and care in accordance with physician orders and professional standards of practice. Specifically, a resident with diagnoses including end stage renal disease, type 2 diabetes mellitus, mild protein-calorie malnutrition, and dependence on renal dialysis had a physician order for Novolog (insulin Aspart) to be administered per sliding scale before meals and at bedtime, with blood glucose checks scheduled at 7:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. Review of the clinical record and electronic medication administration record (e-TAR) revealed no documented evidence that the resident's blood glucose level was assessed at 7:30 a.m. as ordered. On the morning in question, nursing notes indicated that the resident was found unresponsive, unable to swallow, and had a critically low blood sugar reading of 31. Emergency interventions were initiated, including administration of intramuscular glucagon, but the resident's blood sugar remained low. The resident was subsequently transferred to the hospital for further evaluation. Documentation indicated that the blood glucose level was not obtained at the scheduled time due to hospitalization, but records show the resident was not picked up by emergency personnel until later that morning, confirming the missed assessment.
Failure to Establish Escort Screening Process for Resident Leave of Absence
Penalty
Summary
The facility failed to establish criteria or a screening process for determining the suitability of escorts for residents approved for an escorted leave of absence. According to facility policy, residents requesting a leave of absence must have a physician's order indicating the leave is safe, and if an independent leave is deemed unsafe, an escorted leave may be considered. However, the facility did not define the role or qualifications of a safe escort, nor did it have a process to screen or approve individuals serving as escorts. In the case reviewed, a resident with a history of opioid use disorder and drug and alcohol abuse was granted an escorted leave of absence by physician order due to a family emergency. The resident left the facility with a friend who was not listed as an approved visitor or contact in the resident's records. Nursing documentation indicated that the resident was expected to return the same day but did not return as scheduled. Attempts to contact the resident throughout the night were unsuccessful. The following day, the resident's daughter informed the facility that the resident had died from a drug overdose while on leave. Interviews with facility staff, including the administrator and LPN, confirmed that there was no established process to define or screen escorts for safety, and the individual who escorted the resident was not previously identified as a visitor or contact.
Failure to Implement Infection Control Precautions During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for a resident with significant medical needs, including a stage 4 sacral pressure ulcer, hemiplegia, and chronic kidney disease. According to facility policy, Enhanced Barrier Precautions (EBP) should be used for residents with open wounds or indwelling medical devices, requiring staff to wear gowns and gloves during high-contact care. Review of the resident's care plan showed no interventions related to EBP, despite the presence of multiple wounds and a wound vacuum. Observations revealed that staff did not follow EBP protocols during wound care procedures. The wound care nurse and physician assistant did not wear gowns, and the nurse placed a wedge pillow from the floor under the resident's back near the open wound. The end of the wound vacuum, which had touched the floor, was placed on the resident's bed pad. Additionally, gloves were changed by retrieving them from a pocket, and wound care supplies were stored in basins on the floor. The resident's room also contained stale flowers attracting flies. These findings were confirmed with staff present during the observations.
Neglect in Providing Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, identified as Resident R1, who was admitted with a history of cerebral infarction, left side weakness, and aphasia. The resident was assessed as dependent on staff for all self-care activities, including toileting. The care plan indicated a risk for skin impairment due to the resident's hemiparesis, obesity, impaired mobility, and incontinence, requiring staff to keep the resident's skin dry. On April 20, 2025, the resident's family member reported that the resident was left in a bowel movement from 11:30 a.m. until the next shift at 4:00 p.m., despite requests for assistance made to the front desk. The facility's documentation system, used by nursing assistants to record care provided, showed no record of incontinence care for the resident during the first shift on the day in question. The Nursing Home Administrator confirmed the family member's account of the incident and attributed the lack of care to staffing shortages due to the Easter holiday. This incident was determined to be neglect, as the facility was aware of the resident's needs but failed to provide necessary care, potentially resulting in physical harm or emotional distress.
Plan Of Correction
No retroactive correction for this deficient practice. Current residents that are dependent for toileting were audited to ensure timely incontinence care is being provided and documented in the POC Task program. Current CNAs were re-educated on the abuse policy relating to neglect and incontinence care, providing timely incontinence care for dependent residents and completing documentation in the POC Task program. Random audits will be completed by Director of Nursing or designee weekly x 4 weeks and then monthly x 2 months to ensure timely incontinence care is provided and documented in the POC Task program. Results of audits will be reported in monthly QAPI Meetings for further recommendations.
Failure to Report Alleged Violations and Investigation Results
Penalty
Summary
The facility failed to comply with the regulatory requirement to report alleged violations involving neglect and mistreatment to the appropriate state agencies. In the case of Resident R1, who was admitted with a history of cerebral infarction resulting in left side weakness and incontinence, the facility did not report an incident where the resident was left in a soiled adult brief for several hours. The resident's family member informed the Nursing Home Administrator about the incident, but the facility did not notify the state agency as required. Additionally, the facility did not report the results of an investigation involving Resident R2, who sustained an injury when a housekeeper accidentally hit the resident with a cart, resulting in a broken toenail. Although the initial incident was reported, the follow-up investigation was not communicated to the state agency. These failures to report both the initial incident and the investigation results constitute a deficiency in the facility's compliance with reporting requirements.
Plan Of Correction
Event report has been made to the State Survey Agency for residents R1 and R2. A 30 day look back of facility grievances and incident reports was completed to ensure care concerns relating to neglect were reported and investigated per policy. Nursing Administration and Administrators have been educated on proper identification and timeliness of reporting; including to the State Survey Agency. NHA or designee will complete weekly audits of grievances and incident reports x 4 weeks then monthly x 2 months to ensure a timely investigation is initiated and reported to the state agency per policy. Results of audits will be reported in monthly QAPI Meetings for further recommendations.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach for one of the residents reviewed, identified as Resident R1. The facility's policy, dated April 1, 2022, mandates that residents must have access to call bells at all times, ensuring they are within reach before staff leave the resident's room. Resident R1, admitted on April 10, 2025, had a history of cerebral infarction (stroke) resulting in left side weakness and was aphasic, making them non-verbal. The resident was assessed as dependent on staff for all self-care needs, including eating, toileting, bathing, dressing, bed mobility, and transfers. An interview with Resident R1's family revealed that the call bell was positioned on the resident's right side, which was paralyzed, rendering the resident unable to use it. The family member expressed concern that the resident could not call for help when the call bell was placed on their bad side.
Plan Of Correction
Resident R1's call bell has been positioned to enable the resident access to call for staff assistance. Current residents were audited to ensure they have access to their call bell and are able to use it properly. Current nursing staff have been educated to ensure that residents' call bells are in reach and that the residents' are able to properly use the call bell. NHA or designee will conduct random audits of (10) resident rooms weekly x 4 weeks and then monthly x 2 months to ensure call bells are positioned to enable residents to call for staff assistance. Results of audits will be reported in monthly QAPI Meetings for further recommendations.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides (NAs) on multiple occasions, as evidenced by a review of nursing staffing hours and staff interviews. During the day shift, the facility did not ensure a minimum of one NA per 12 residents on three out of seven days reviewed. Specifically, on April 20, 2025, there were 18.12 NAs for 322 residents, requiring 32.80 NAs; on April 21, 2025, there were 24.99 NAs for 329 residents, requiring 32.70 NAs; and on April 22, 2025, there were 28.93 NAs for 333 residents, requiring 33.30 NAs. Similarly, during the evening shift, the facility did not meet the required staffing levels on four out of seven days. On April 20, 2025, there were 17.20 NAs for 328 residents, requiring 29.82 NAs; on April 21, 2025, there were 21.69 NAs for 327 residents, requiring 29.73 NAs; on April 22, 2025, there were 25.51 NAs for 333 residents, requiring 30.27 NAs; and on April 23, 2025, there were 28.11 NAs for 330 residents, requiring 30.00 NAs. Additionally, during the night shift, the facility did not ensure a minimum of one NA per 20 residents on two out of seven days. On April 20, 2025, there were 18.08 NAs for 328 residents, requiring 21.07 NAs, and on April 23, 2025, there were 18.05 NAs for 333 residents, requiring 22.00 NAs. These deficiencies were confirmed with the Nursing Home Administrator on April 29, 2025.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for CNA staffing ratios. Staffing directors will be educated to ensure that we are abiding with DOH guidelines for CNA staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding by DOH CNA staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
Deficiency in LPN Staffing Levels
Penalty
Summary
The facility failed to meet the required nursing staff levels as per the regulation effective July 1, 2023, which mandates a minimum of one Licensed Practical Nurse (LPN) per 25 residents during the day, one LPN per 30 residents during the evening, and one LPN per 40 residents overnight. During a review of nursing staffing hours over a seven-day period, it was found that the facility did not ensure the minimum required number of LPNs for two out of 21 shifts. Specifically, on April 20, 2025, the day shift had 10.33 LPNs for a resident census of 328, which required 13.12 LPNs, and the night shift had 7.32 LPNs for the same resident census, which required 8.20 LPNs. This deficiency was confirmed through an interview with the Nursing Home Administrator on April 29, 2025.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for LPN staffing ratios. Staffing directors will be educated to ensure that we are abiding by DOH guidelines for LPN staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding with DOH LPN staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for six out of seven days reviewed. Specifically, from April 17, 2025, to April 23, 2025, the facility's nursing care hours were consistently below the required threshold. On April 18, 2025, with a census of 332 residents, only 2.90 hours per patient day (PPD) were provided. On April 19, 2025, with 329 residents, the facility provided 3.02 PPD. On April 20, 2025, with 328 residents, the care hours dropped significantly to 2.08 PPD. On April 21, 2025, with 327 residents, 2.56 PPD were provided. On April 22, 2025, with 333 residents, the facility provided 2.80 PPD. Finally, on April 23, 2025, with 330 residents, the care hours were 2.29 PPD. This deficiency was confirmed with the Nursing Home Administrator on April 28, 2025.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. Staffing directors will be educated to ensure that we are abiding with DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding by DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to provide food and drink at palatable and safe temperatures for one resident. According to facility policy, hot foods should be kept above 135°F and cold foods below 41°F. During an interview, a resident reported that their food was cold and their drink was too warm. A test tray observation with the Food Service Director confirmed that the corned beef was served at 120°F, new potatoes at 125°F, lemon meringue pie at 80°F, and cranberry juice at 62°F, all of which were outside the acceptable temperature ranges. The Food Service Director acknowledged that these temperatures did not meet the facility's standards for palatability and safety.
Failure to Maintain Infection Control Practices with Bedpan Reuse
Penalty
Summary
The facility failed to maintain proper infection control practices by reusing bedpans among residents and not ensuring that each resident had a personal, labeled, and sanitized bedpan. Observations revealed that a bedpan with yellow residue was found in a shared restroom used by two residents, and it was not labeled. Another resident's bedpan was found on a tray table, also without a label. Staff interviews confirmed confusion regarding the storage and assignment of bedpans, with some staff stating that bedpans were kept in the medication room, while others indicated they should be stored in residents' drawers and labeled with their names. However, no bedpans were found in the medication room during observation, and central supply staff confirmed that no requests for additional bedpans had been made by nursing staff. Residents reported that bedpans were being reused between roommates, which they described as unsanitary. Facility policy required that reusable resident care equipment be maintained and decontaminated according to manufacturer instructions and assigned to individual residents to prevent cross-contamination. Despite this, the facility did not ensure compliance with its own policy, resulting in shared and unsanitary bedpans being used by multiple residents.
Failure to Provide Dignified Dining Utensils
Penalty
Summary
Staff on the 4th floor nursing unit served meals to residents using plastic utensils instead of regular utensils. During the initial tour, it was observed that a resident was eating with plastic utensils, and interviews with both a resident and staff confirmed that all residents received breakfast with plastic utensils. Dietary staff explained that the facility was out of regular utensils and did not have enough to serve all residents, resulting in the use of plastic utensils for meal service. No staff interviewed could provide a reason for the lack of regular utensils beyond the shortage. This failure to provide appropriate dining utensils did not promote the maintenance and enhancement of each resident's dignity, as required by resident rights regulations.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents on one of four nursing units. Observations revealed that one resident had two urinals filled with urine left on the bedside table and dresser, with the resident stating that one urinal had not been emptied since the previous night despite staff being present in the room multiple times across several shifts. Another resident was observed with a filled urinal left on the bedside table. Additionally, the third-floor shower room was found to have a continuous roof leak, with visible ceiling discoloration indicating the issue had persisted for some time. Interviews with staff confirmed that urinals should have been emptied and that the assigned nurse aide did not provide a reason for failing to do so. These findings demonstrate lapses in maintaining cleanliness and addressing environmental hazards within the unit.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from non-consensual sexual contact by another resident with a known history of sexually inappropriate behavior. Resident R137, who had moderate cognitive impairment and a history of depression and alcohol-induced dementia, was admitted to the facility and had previously displayed inappropriate sexual behaviors. Despite these behaviors being documented, the facility did not adequately monitor or intervene to prevent further incidents. On January 31, 2025, Resident R137 was involved in an incident where he attempted to touch another resident, Resident R208, inappropriately. This incident was reported by staff, but no formal incident report was filed, and the care plan for Resident R137 was only updated to include 15-minute checks. However, these measures proved insufficient as Resident R137 later engaged in a more severe incident involving Resident R271. Resident R271, who had severe cognitive impairment and a history of wandering, was found being pinned down and subjected to non-consensual oral sex by Resident R137. This incident was witnessed by staff, who intervened and reported the situation. The facility's failure to adequately monitor and protect Resident R271, despite the known risks posed by Resident R137, resulted in an Immediate Jeopardy situation, highlighting significant lapses in the facility's abuse prevention and response protocols.
Removal Plan
- Resident R271 and Resident R137 were immediately separated and monitored by staff.
- Police were called and arrived at the facility shortly after the incident.
- Both residents (Resident R271 and R137) were sent to the local hospital emergency room for evaluation and remained at the facility.
- Both residents (Resident R271 and R137) responsible parties were made aware of transfer and incident.
- Skin checks were completed on 4-west with no adverse findings.
- Current residents with known sexual behaviors were audited for recent behaviors and appropriate care planned interventions to ensure the safety of other residents.
- Social worker completed random resident interviews to ensure no unwanted sexual behaviors have occurred or were occurring.
- Abuse policy education was initiated house wide for identifying and reporting sexual abuse and sexually promiscuous behaviors including examples of such behaviors.
- Change in Condition policy education was initiated with the nursing staff: Resident's exhibiting behaviors will have a change in condition assessment completed and will be discussed in clinical meeting for further care plan review and intervention implementation. When a behavior is observed, the resident(s) will be put on 1:1 observation until they are able to be assessed by IDT (interdisciplinary team) and the supervisor/DON or designee will be made aware.
- The Change in Condition policy was reviewed and revised.
- The Abuse policy was reviewed and updated to include examples of sexual abuse, warning signs and soft signs (excessive clingyness, low self esteem, recurrent nightmares, or overly friendliness towards strangers) of sexual abuse.
- Residents with documented behaviors will be audited weekly to ensure interventions and care plans are in place. Results of auditing will be reviewed during QAPI meeting to determine further need for ongoing auditing.
Non-compliance in Dietary Services Due to Maintenance Issues
Penalty
Summary
The dietary services department was found to be non-compliant with food service safety standards due to several issues related to the maintenance and sanitation of the main kitchen. Observations revealed that the ceiling area of the main kitchen had porous, bulging tiles that were water damaged, and some tiles were missing, exposing electrical wiring, vents, and coils. Additionally, the ceiling tiles were soiled with food debris, grease, rust, and dirt, particularly along the metal supports of the drop-down ceiling design. These conditions were confirmed during an interview with the Director of Dietary Services and the Maintenance Director, who acknowledged that a water pipe had burst above the main kitchen in January 2025, causing delays in meal preparation and service. Further reviews of the City Department of Health inspection report from December 2024 indicated that the facility had been cited for damaged ceiling tiles in the ware wash area and stained acoustic ceiling tiles throughout the main kitchen, especially over hot stoves and storage areas. Pest control reports from December 2024 to February 2025 showed that the kitchen was being treated for cockroaches, with the pest control operator highlighting areas of food debris near hot food service equipment that required cleaning. Interviews with the Director of Maintenance and the Director of Dietary Services revealed that a purchase order for new ceiling tiles had been placed, but the necessary repairs had not yet been completed.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for three residents, leading to deficiencies in care. Resident R122, who had severe cognitive impairment and was at risk for pressure ulcers, had a physician order for heel protectors while in bed. However, during an observation, it was noted that the resident did not have heel protectors on, and none were present in the room. Similarly, Resident R231, also with severe cognitive impairment and at risk for pressure ulcers, had a physician order for heel protectors. An observation revealed that this resident also did not have heel protectors on while in bed, and none were found in the room. Additionally, Resident R153, diagnosed with chronic obstructive pulmonary disease and requiring continuous supplemental oxygen, was ordered to use ear mates to prevent pressure injuries from the oxygen tubing. The resident reported experiencing a painful sore behind the left ear due to the tubing, and an interview with the resident's nurse confirmed that ear mates were not provided. These findings indicate a failure to adhere to physician orders and facility policies designed to prevent pressure ulcers and related injuries.
Failure to Ensure Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to their personal funds, as required by their policy. The resident, who was diagnosed with epilepsy, Parkinson's Disease, cataracts, severe glaucoma, and severe cognitive impairment, required a responsible party to manage their affairs. Despite this need, the facility did not escort the resident to the business office to receive their monthly allowance. The responsible party reported that they had only assisted the resident once in the previous year, and a review of the resident's financial statement showed only one withdrawal in November 2024. The Director of Nursing confirmed that the facility should have accommodated the resident's access to their funds.
Failure to Update Resident's Code Status
Penalty
Summary
The facility failed to update a resident's code status to reflect their wishes, resulting in a deficiency. Resident R101, who was admitted with conditions including epilepsy, anxiety disorder, hemiplegia following cerebral infarction, and major depressive disorder, was placed on hospice care. The resident's Physician Orders for Life-Sustaining Treatment (POLST) and Medical Orders for Life-Sustaining Treatment indicated a preference for no resuscitation and comfort care measures only. However, the facility did not honor these wishes, as the resident's clinical record incorrectly indicated a Full Code status, which implies all possible life-saving measures should be taken. This discrepancy was confirmed by an LPN during an interview.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in two of the six nursing units toured, specifically 3 west and 3 east. An interview with a resident revealed that approximately two weeks prior, there was a leak from the unit above, causing water to pour from the ceiling. Observations confirmed water damage and brown/yellow discoloration on the ceiling tiles above the sink in the room and bathroom. Additionally, on the 3 east nursing unit, multiple bags of soiled linen and trash were observed on the floor of the soiled linen closet. In another room, leftover food wrapped in foil was found on the nightstand next to the B-Bed, and a wall panel was observed peeling off.
Failure to Provide Timely Vision and Audiology Services
Penalty
Summary
The facility failed to provide timely vision and audiology services for a resident diagnosed with epilepsy, Parkinson's Disease, cataracts, severe primary open-angle glaucoma, and severe cognitive impairment. The resident's family reported that they had requested medical attention for the resident's glaucoma and cataracts, as the resident could only see shadows. Additionally, the family noted the resident's hearing difficulties and requested an audiologist appointment, which had not been fulfilled. A review of the resident's records showed a missed audiology appointment due to impacted ears, with no follow-up appointment scheduled. Furthermore, the resident was referred to ophthalmology for end-stage glaucoma in July 2023, but no appointment was made. The Director of Nursing confirmed the absence of an ophthalmology appointment for the resident.
Failure to Provide Appropriate ROM Treatment for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion for Resident R231, who had limited range of motion due to severe cognitive impairment, hemiplegia, muscle wasting, and other muscle spasms. The resident's comprehensive care plan indicated a need for assistance with activities of daily living and noted physical mobility limitations due to contractures and neurological deficits. Observations revealed that the resident had a right-hand contracture and was not wearing a splint or orthotic device, which was recommended upon discharge from occupational therapy. Interviews with facility staff, including a registered nurse and the Director of Rehab, confirmed the absence of a splint for the resident, and there was no physician order for one. The occupational therapist noted that when the resident was evaluated, there was no evidence of prior splint use, and the existing splint did not fit due to the severity of the contracture. The clinical record lacked documentation of a splint, indicating a failure to implement recommended therapeutic interventions for the resident's condition.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to ensure adequate supervision and safety for residents, resulting in multiple incidents of resident-to-resident altercations. Resident R93, diagnosed with dementia, alcohol-induced persisting dementia, and anxiety disorder, was involved in several incidents. Despite being care planned for aggression and poor impulse control, R93 was not adequately supervised, leading to altercations with other residents. On June 25, 2024, R93 entered another resident's room and urinated in the sink, leading to a physical fight with Resident R253, who also had a history of aggression. On August 27, 2024, R93 was found with injuries after an altercation with his roommate, Resident R224, who was also care planned for aggression and cognitive deficits. Further incidents occurred, including one on October 9, 2024, where R93 was found sitting in another resident's wheelchair, leading to a physical altercation with Resident R281, resulting in injuries to R281. The facility's failure to provide adequate supervision and intervention for residents with known aggressive behaviors and cognitive impairments contributed to these incidents. The facility's policy on accidents aimed to provide an environment free from controllable hazards and adequate supervision, but the repeated incidents indicate a failure to adhere to this policy, compromising resident safety.
Failure in Incontinence Management and Catheter Care
Penalty
Summary
The facility failed to implement appropriate treatment and services for incontinence management for two residents. Resident R80 had a physician's order for a Supra Pubic Urinary Catheter with a size 16FR/30 cc balloon, but was observed with a 16FR/10ML catheter instead. This discrepancy was confirmed by the Unit Manager, a Licensed Nurse, Employee E28. Similarly, Resident R256 had a physician's order for a Supra Pubic Urinary Catheter with a size 14FR/10 cc balloon, but was found with a 14FR/30 cc catheter. This was confirmed by a Licensed Nurse, Employee E29. These findings indicate a failure to adhere to physician orders regarding catheter specifications for these residents.
Failure to Monitor and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and modify nutritional interventions for two residents, leading to significant weight loss. Resident R251, who had severe cognitive impairment and dysphagia, experienced a 7.2-pound weight loss in one month, which was not properly addressed. The resident's weight was not documented in the quarterly MDS, and despite a noted weight loss, the Registered Dietitian did not obtain a re-weight or address the issue in the nutrition assessment. Observations revealed the resident appeared thin and frail, and there was no documented evidence that the weight loss was addressed by the Registered Dietitian. Resident R214, with moderate cognitive impairment and a diagnosis of malnutrition, also experienced significant weight loss. The resident lost 12.6 pounds in one month, which was not addressed until a month later in a nutrition assessment. The weight loss continued, with the resident losing an additional 6 pounds the following month. The facility's failure to promptly address these significant weight changes and modify care plans accordingly contributed to the deficiency.
Failure to Follow Physician Orders for Tube Feeding
Penalty
Summary
The facility failed to adhere to physician orders regarding tube feeding for Resident R96. The resident, who was admitted with diagnoses of Adult Failure to Thrive and Gastrostomy, had a physician's order dated January 22, 2025, for Jevity 1.2 Cal Enteral Liquid to be administered via feeding pump at a rate of 60 milliliters per hour for 18 hours per day. However, on February 18, 2025, it was observed that the feeding rate was set for Jevity 1.5 instead of the prescribed Jevity 1.2. This discrepancy was confirmed by the Unit Manager, a Licensed Nurse, Employee E28.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide oxygen therapy consistent with professional standards of practice and the comprehensive person-centered care plan for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident was prescribed 3 liters of continuous supplemental oxygen, with instructions to change the tubing every Wednesday and to initial and date the new tubing. However, during an observation and interview with the resident's nurse, it was confirmed that the tubing was not dated to indicate when it was last changed, and the oxygen was set at 4.5 liters instead of the prescribed 3 liters, contrary to the physician's orders.
Incomplete Dialysis Communication Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate records related to dialysis communication for a resident who requires hemodialysis treatment. The resident, identified as R64, had physician orders to receive hemodialysis on Mondays, Wednesdays, and Fridays. However, the Hemodialysis Communication Record for multiple dates between November 2024 and February 2025 was found to be lacking critical information. Specifically, the records did not include details on the presence of bruit and thrill, signs and symptoms of infection, and the signature of the nursing home nurse. This deficiency was confirmed during an interview with a licensed nurse, Employee E3, who acknowledged the lack of information in the records.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident R502, who was newly admitted and identified as alert and oriented. The resident had a physician order for testosterone transdermal gel 10mg to be applied at bedtime daily, starting from February 3, 2025. However, the resident did not receive the medication from February 3, 2025, through February 14, 2025. Despite the physician being notified twice on February 5, 2025, and once on February 8, 2025, there was no documented evidence of a response or action taken to address the medication order. The facility's policy required that if a medication was unavailable, the nurse should contact the pharmacy and, if necessary, the physician for further instructions. However, there was no documented evidence that nursing staff followed these procedures for several days. An interview with Registered Nurse, Employee E19, confirmed the missed doses and the lack of communication between nursing shifts regarding the unavailable medication. This failure to implement proper procedures resulted in the resident not receiving the prescribed medication.
Inadequate Food Quality and Preparation in LTC Facility
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and prepared in portion sizes to meet the needs of the residents. Observations during meal services revealed that the hamburger steak with onions was overcooked, hard, and rubbery, making it inedible for residents on various diets, including regular no added salt large portions, regular consistent carbohydrate, and renal diets. Multiple residents were observed requesting replacement meal trays as they could not eat or swallow the food provided. Interviews with alert and oriented residents confirmed that their food preferences were not being honored, and they often had to ask for substitute foods and drinks. Further interviews with nursing staff corroborated the residents' complaints, indicating a lack of food preparation skills among dietary employees. The nursing staff confirmed that the hamburger steak with onions was inedible and that other items on the meal trays were not appetizing or satisfactory for the residents. The facility's policies on test tray evaluation and altered portions were reviewed, revealing that the responsibility for monitoring food quality and ensuring meal satisfaction lay with the food and nutrition services department and the registered dietitian, respectively. However, these policies were not effectively implemented, leading to the deficiency.
Failure to Manage Resident Behavior Leads to Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility, resulting in an Immediate Jeopardy situation involving a resident with a history of sexually inappropriate behaviors. This resident, who had moderate cognitive impairment and a history of depression and alcohol-induced dementia, engaged in unwanted sexual contact with another resident who had severe cognitive impairment. The facility's documentation and staff interviews revealed that the resident had previously displayed inappropriate sexual behaviors, including making inappropriate remarks and touching others inappropriately. On January 31, 2025, a nurse aide responded to yelling in a resident's room and found the resident with a history of inappropriate behavior attempting to engage in sexual contact with another resident. This incident was reported to the charge nurse. Further incidents occurred, including a severe case on February 12, 2025, where the same resident was found performing oral sex on a resident with severe cognitive impairment. This incident was witnessed by two nurse aides and a licensed nurse, who intervened and reported the situation to the charge nurse. The facility's failure to manage the resident's behavior and protect other residents from harm led to a serious breach of federal and state regulations. The Director of Nursing confirmed the incident, and the facility's documentation indicated that the resident with severe cognitive impairment was sent to the emergency room as a sexual assault victim. The deficiencies identified in the report highlight the failure of the Nursing Home Administrator and the Director of Nursing to fulfill their responsibilities, contributing to the Immediate Jeopardy situation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program concerning Enhanced Barrier Precautions for a resident identified as R96. The resident had a physician's order dated February 12, 2025, requiring the use of gown and gloves during high-contact care activities due to a PEG tube and chronic wound. On February 18, 2025, a licensed nurse, identified as Employee E28, was observed cleaning the PEG tube site of Resident R96 without wearing the required personal protective equipment (PPE), despite the resident being on Enhanced Barrier Precautions. This observation was confirmed with the licensed nurse at the time of the finding.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for five out of ten residents reviewed. Observations and interviews revealed that the food was often not warm enough, with some residents reporting that the food was cold, mushy, or unappetizing. Specific complaints included food not being warm, coffee not being served, and a preference for oatmeal over cream of wheat due to adverse reactions. Additionally, there were issues with dirty trays not being removed promptly. A test tray evaluation conducted with the Food Service Director confirmed that several food items, including roast pork, pasta, green beans, and chicken noodle soup, were served below the required temperature of 135 degrees. Cold items like apple juice and cinnamon apple dessert were above the acceptable temperature of 50 degrees. The Food Service Director acknowledged that these items were outside the acceptable temperature range, confirming the deficiency in food service standards.
Plan Of Correction
Dietary Director met with residents R2, R8, R9, R10, and R11 to ensure that residents know that he and the Dietary Department are aware of concerns with food being too cold and to acknowledge to the residents that the department is working on plans to improve food temperatures for resident consumption to at least 135 degrees. A new plate-warmer has been purchased and installed to aid in keeping foods that are intended to be eaten warm, warm; from the time food leaves tray line until delivery and consumption by residents. Dietary Staff have been educated regarding food temperature requirements/regulations, properly documenting food temperatures during the production and delivery process and the process to follow if they identify food temperatures that are out of regulatory range during production and delivery. Dietary Director will spot check food temperatures 3 X per week, document and report findings X 3 months at the monthly QAPI Meeting for improvement recommendations.
Ineffective Pest Control Program
Penalty
Summary
The facility was found to have an ineffective pest control program, as evidenced by multiple resident interviews and observations of pest activity. Six out of ten residents interviewed reported sightings of mice and insects in their rooms. Resident R4 reported seeing mice in her room, while Resident R5 described finding mouse droppings throughout the facility and even encountering a mouse on his meal tray. Resident R8 also reported seeing mice and bugs, and Resident R10 confirmed the presence of mouse droppings. Resident R2 mentioned seeing mice under her bed, attributing the issue to food crumbs left by her roommate. Resident R3 observed rats entering from under the HVAC unit. A review of the facility's pest sighting logs corroborated these reports, with documented sightings of mice and droppings across various floors and rooms. The logs detailed incidents from August to December 2024, including mice sightings in hallways, rooms, and near HVAC units. Interviews with the maintenance director and the Administrator confirmed the accuracy of these logs, indicating a persistent pest problem that the facility's pest control measures had failed to address effectively.
Plan Of Correction
Environmental Services Director has met with residents R2, R3, R4, R5, R8, and R10 to ensure that the facility fully understands the pest control concerns that the residents have and followed up by having the external pest control company, EcoLab, specifically treat identified concerns. Environmental Services will audit each room to look for signs of pests, such as "droppings." Where any signs of pests are identified, Environmental Services will complete deep cleaning of the room(s) and follow up to ensure that EcoLab treats the room for the specific identified need. Environmental Services Staff will be educated regarding how to identify and monitor for signs of pests and what to do when signs of pests are identified. Environmental Services Director or designee will audit 3 resident rooms per week, document and report findings X 3 months at the monthly QAPI Meeting for improvement recommendations.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide staffing ratios as mandated by Pennsylvania state regulations effective July 1, 2024. Specifically, the facility did not ensure a minimum of one nurse aide per 10 residents during the day, one nurse aide per 11 residents during the evening, and one nurse aide per 15 residents overnight for the period from November 24, 2024, through December 14, 2024. The review of the facility's 'nursing staff ratio' revealed multiple instances of non-compliance across various shifts on specific dates, including November 24, 27, 28, 29, 30, and December 1, 2, 4, 6, 7, 8, 9, 12, and 14. These findings were discussed with the facility's administration on December 16, 2024.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for CNA staffing ratios. Staffing directors will be educated to ensure that we are abiding with DOH guidelines for CNA staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding by DOH CNA staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
LPN Staffing Deficiency on Day Shift
Penalty
Summary
The facility failed to meet the Pennsylvania state regulation requiring a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift. On December 9, 2024, the facility's staffing data showed that the actual LPN staffing ratio was 91.12, falling short of the minimum required ratio of 92.80. This deficiency was identified during a review of the facility's 'nursing staff ratio' for the weeks of November 24, 2024, through December 14, 2024. The findings were discussed with the facility's Administrator on December 16, 2024.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for LPN staffing ratios. Staffing directors will be educated to ensure that we are abiding by DOH guidelines for LPN staffing ratios. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding with DOH LPN staffing ratios. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
Deficiency in Meeting Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified through a review of the facility's nursing staffing sheets for the period from August 30, 2024, to September 12, 2024. During this time, the facility did not meet the required staffing hours on four out of fourteen sampled days. Specific days where the staffing hours fell below the required 3.2 hours include November 24, November 27, November 29, November 30, December 1, December 2, December 3, December 5, December 6, December 7, December 8, December 9, December 12, December 13, and December 14. These findings were discussed with the facility's administration on December 16, 2024.
Plan Of Correction
Facility will ensure that we will abide by the DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. Staffing directors will be educated to ensure that we are abiding with DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. NHA/designee will audit 3X weekly X4 weeks and then monthly X2 months to ensure that facility is abiding by DOH guidelines for total number of hours of general nursing care provided in each 24-hour period. Results will be reviewed during the facilities monthly QAPI Meeting X3 months to determine the need for further review.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal and physical abuse involving a resident. The resident, who was cognitively intact and had a history of intellectual disability, PTSD, and anxiety disorder, reported that a female employee called him a derogatory term related to his sexual orientation. Despite the resident's report to the social worker and the completion of a Resident Concern Form, the facility did not complete the investigation process, leaving sections of the form blank and failing to notify the responsible parties or document any findings or conclusions. Additionally, the facility did not investigate another allegation made by the same resident, who reported to a psychologist that a staff member hit him on the nose with a door. This incident was not reported to the Director of Nursing or the Assistant Director of Nursing, and no investigation was conducted. The psychologist did not report the incident to anyone, and the facility did not document any evidence of an investigation or report the incident to the State Department of Health. Interviews with various staff members, including the Nursing Home Administrator, Director of Social Services, and Assistant Director of Nursing, confirmed the lack of investigation into both allegations. The staff involved in the verbal abuse allegation was terminated for unrelated reasons, and there was no evidence of any follow-up or resolution regarding the resident's concerns. The facility's failure to investigate these allegations violated resident rights and the responsibility of the licensee as outlined in the relevant state codes.
Failure to Provide Wound Care for Resident with Surgical Wound
Penalty
Summary
The facility failed to provide appropriate care for a resident with a surgical wound, as evidenced by the lack of wound care or dressing changes to a wound vac device for a week. The resident, who was admitted with a wound vac for a surgical wound and cellulitis of the right axilla, reported not receiving any wound care upon admission. The resident's care plan included interventions for wound consults and treatments, and hospital discharge instructions specified dressing changes every Monday, Wednesday, and Friday with a pressure setting of 125 mmHg. Despite these instructions, there were no treatment orders or documentation of wound vac care from the resident's admission until the wound vac was removed two weeks later. The Director of Nursing confirmed the absence of treatment orders and evidence of wound care during this period. This deficiency was identified through clinical record reviews and interviews with the resident and staff, highlighting a failure to adhere to prescribed wound care protocols.
Deficient Call System on Nursing Unit
Penalty
Summary
The facility was found to be deficient in providing a working call system for residents on one of its nursing units. A review of the facility's policy and procedure, dated April 1, 2022, indicated that it was the facility's responsibility to ensure that each resident had access to a call bell at all times, including in their rooms, bathing areas, and toilet areas. However, observations on the Fourth floor nursing unit revealed that residents did not have a means of directly contacting caregivers through the resident call system at the centralized nurses' station. Further investigation showed that the call bell system at the centralized nurses' station was not fully functioning. The monitor at the nurses' station was not visually displaying the room numbers for each resident room, nor was it audibly sounding. Interviews with the nursing staff, maintenance director, and assistant administrator confirmed that the system was turned off, the volume was not working, and the monitor was not indicating the resident room, toilet room, or bathing area where residents were calling for assistance.
Failure to Implement Comprehensive Care Plan for COPD
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with chronic obstructive pulmonary disease (COPD). The policy required that a comprehensive care plan be developed by the interdisciplinary care team, including measurable objectives and timeframes to meet the resident's needs. However, the clinical record review revealed that there was no care plan developed and implemented for the diagnosis of COPD, specifically regarding the use of a pulse oximeter before, during, and after therapy, breathing treatments, and when oxygen was used to augment therapy outcomes. Interviews and clinical record reviews indicated that the nursing staff and therapists did not perform and document blood oxygen levels using the pulse oximeter for the resident, as required by the nurse practitioner and physician's assessment and treatment plans. This lack of documentation and implementation of the care plan occurred over a period from September 8, 2024, through September 16, 2024, which was not in accordance with the facility's policies and procedures.
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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