Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care Pavilion Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food was not consistently palatable or served at an acceptable temperature for several residents. Residents reported cold meals, undercooked items, dry chicken, and food with no flavor, and one resident said getting a replacement meal was difficult. A test tray found cranberry juice and dessert served too warm, and the FSD confirmed the findings.
Crash carts on two nursing units were not maintained as required. On the first-floor east unit, the crash cart did not contain an oxygen tank and the daily emergency code cart equipment check form had not been completed since the documented date. On the first-floor west unit, the crash cart was observed without oxygen and with masks, nasal cannulas, and suction tubing scattered in disarray. The DON and ADON confirmed the findings, and the DON stated oxygen would have to be obtained separately from the unit oxygen storage room if needed.
The facility failed to maintain an effective pest control and sanitation program on two nursing units, resulting in mice, cockroaches, rodent droppings, and structural entry points such as holes and leaking ceilings in multiple resident rooms and bathrooms. Several residents reported seeing mice, and surveyors observed unprotected dry foods, open beverages, food debris under beds, and cluttered personal belongings in broken cardboard boxes that created harborage for pests. Pest control operator reports documented rodent droppings around air cooling/heating units in every bedroom, excessive clutter and improperly stored resident belongings and food, accumulated bedside foods including perishable items not refrigerated, and holes and voids in room structures where dead mice had been found, all contrary to the facility’s own pest control policy.
Food service sanitation standards were not maintained when the kitchen had multiple dirty and unsanitary conditions, including uncovered trash, clogged drains, grease and dust buildup, personal drinks stored in a reach-in refrigerator, and damaged refrigerator gaskets. The chemical sanitizing dish machine was also not dispensing sanitizer into the final rinse, so dishes were not being sanitized, and the machine remained out of service on follow-up observation.
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.
Failure to Monitor and Respond to Significant Weight Loss: The facility did not adequately monitor nutritional status or respond to significant weight changes for multiple residents. One resident with Parkinson’s disease and depression had marked weight loss, but the MD was not notified and the weight loss was not promptly rechecked or assessed. Another resident with malnutrition and dysphagia had large weight fluctuations while on tube feedings, with weights questioned as inaccurate but not clearly verified. A third resident had a prior order for house shakes to support weight gain, but after a hospital return there was no admission weight, no nutritional assessment, and no documentation explaining why the order was not resumed, followed by significant weight loss.
Food and drink were not consistently palatable or served at acceptable temperatures for multiple residents. Residents reported cold meals, poor taste, incorrect or incomplete orders, and undrinkable coffee, while a test tray with the FSD showed several hot items below 135 degrees and cold items above 50 degrees, with the FSD confirming the items were outside acceptable service temperatures.
A facility failed to ensure residents received education before influenza vaccines were administered to eight reviewed residents. Review of consent/declination forms and clinical records showed no documentation of vaccine education, and the DON confirmed the facility did not provide this education and had no process in place for it.
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 substance use disorder stated a desire to attend AA/NA meetings, but none were available at the facility. The resident’s care plan included support resources such as AA, yet the DON confirmed the facility does not offer AA or NA meetings, and peer program documentation showed those meetings were not part of the program.
Delayed Resident Mail Delivery: A resident with schizoaffective disorder and DM2, who had a BIMS score indicating cognitive intactness, reported not receiving expected mail from SSA. Staff confirmed that mail was sent to the front desk and activities with no set delivery time, and resident mail was held in office boxes until full before being sorted and distributed, with no daily mail delivery schedule or specific delivery day.
The facility failed to complete required screening for a newly hired nurse aide. The employee’s PA criminal record check was not done until after surveyors requested the file, reference checks were missing, and the file showed the employee had not lived in PA for 2 years and had attested to criminal charges in another state, yet the required Federal criminal record check was not obtained. The HR Director confirmed the State and Federal checks were not completed as required.
The facility failed to provide evidence that it notified the State LTC Ombudsman of facility-initiated transfers and discharges for three reviewed months. Surveyors requested the records during the entrance conference and again in follow-up interviews, and the NHA confirmed the notices were not documented after the prior DSW left the facility.
PASRR screening was not appropriately completed for three residents. One resident’s PASRR was not updated to include documented diagnoses of anxiety, depression, bipolar disorder, and alcohol abuse, and two other residents had MDS diagnoses of depression, psychotic disorder, dementia, anxiety, and brain dysfunction, but their PASRR Level 1 forms stated they did not have a mental disorder.
Failure to develop baseline care plan for a resident with tracheostomy and sacral pressure ulcer. A resident was admitted from the hospital with a trach and pressure injury, but the care plan was not initiated until later and did not include the resident’s trach, respiratory care, or sacral wound needs. The DON confirmed no care plan had been developed for these needs.
Failure to Provide ROM Support and Splinting: Two residents with significant neurologic impairments and contractures did not have documented evidence of ongoing ROM support or splint use after OT services ended. One resident with hemiplegia was observed with a flexed elbow and no splint or brace, while another resident with quadriplegia had bilateral hand contractures and the OT acknowledged omitting the planned resting hand splints from the discharge plan.
Enteral feeding was not provided as ordered for two residents. One resident with dysphagia had the wrong formula hanging and the pump turned off after the LPN disconnected the tube for care and did not restart it, while another resident with FTT and protein calorie malnutrition was left off tube feeding so he could go downstairs to smoke and was reconnected later after being returned to bed.
Failure to maintain and monitor a resident’s midline catheter was cited after staff did not have physician orders for the catheter’s care, maintenance, or assessment, despite the resident receiving IV Micafungin and Zerbaxa through the line. The record and observation showed the midline remained in place with an old dressing, while facility policy required frequent assessment, aseptic care, dressing checks each shift, and monitoring of the IV site and catheter patency.
Improperly Functioning Oxygen Concentrator: A resident receiving O2 via nasal cannula at 2.5 L/min was observed with an oxygen concentrator showing a red wrench indicator and a yellow low-O2 indicator. The DON confirmed the red light should not have been on and stated the concentrator needed service; the DON also said unit nurses are responsible for ensuring respiratory equipment is in working order.
The facility failed to ensure that three newly hired nursing staff members had available skills competency evaluations. Review of personnel files showed that two nurse aides and an LPN had been hired, but no competency evaluations were available for surveyor review. The HR Director confirmed the evaluations were the responsibility of the staff educator and were not available.
A resident did not have the prescribed amlodipine available on the unit, and an LPN searched another resident’s med card, removed the same medication and dose, and administered it to the resident. The nurse stated he frequently borrows non-narcotic meds from other residents when a resident’s medication is not available, as long as the medication and dose are the same.
Failure to provide dental services for a resident with schizoaffective disorder and DM2 was identified when the resident was observed with missing teeth and brownish, broken teeth. The resident stated a need to see a dentist and reported no dental visit in 3 years, and the record contained no documented dental assessment.
Improper trash disposal was observed in the food service and receiving areas. A trash can near the kitchen door was uncovered and full of kitchen waste, the compactor dumpster was full and unusable, and staff were seen placing kitchen trash, housekeeping trash, and dirty briefs into an open construction dumpster. The FSD, MD, and Administrator confirmed the conditions, and the facility reported once-weekly trash pickup for the compactor serving the entire facility.
A nurse provided wound care to a resident’s actively bleeding foot in a communal dining area while multiple other residents were present. The resident had moderate cognitive impairment and diagnoses of anxiety and suicidal ideation. The LPN confirmed the care was done in the dining room after a disagreement with the overnight nurse, and the DON stated wound care is not to be performed in public areas and that the facility had protocols prohibiting such care.
Dish machine not sanitizing dishes. The kitchen dish machine sanitizer pump was not operating, and testing showed no sanitizer in the final rinse even though the unit was identified as a chemical sanitizing low-temp machine. The FSD could not get the machine to pump sanitizer, and the Administrator confirmed the dish machine was not working and dishware could not be properly sanitized. The facility served residents on disposable dishware and silverware while the machine remained out of service.
Unsafe and improperly secured handrails were observed in the 3 [NAME] unit, including missing endcaps on multiple hallway railings and a handrail by the lobby elevator that was falling off the wall. Surveyors noted these conditions during tour observations, and the NHA confirmed the loose handrail at the time it was seen.
Failure to maintain required staff training program: The facility did not have evidence that five newly hired staff members, including nurse aides, an LPN, a housekeeper, and a maintenance technician, completed required competency training. Personnel files lacked documentation for multiple required topics such as resident rights, behavior management, changes in condition, dementia management, infection control, hand hygiene, QAPI, OSHA hazard communication, and emergency response. The HR Director stated that new staff education was the responsibility of the staff educator, who was no longer at the facility, and that the files reviewed were all that was available.
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.
Food Served at Improper Temperature and Poor Quality
Penalty
Summary
Food and drink were not consistently palatable, attractive, or served at a safe and appetizing temperature for five of nine residents reviewed. During resident interviews on unit 1E, one resident reported ongoing problems with cold food, including chicken and sausage that were undercooked and could not be eaten, and stated that obtaining a suitable replacement was difficult, especially at supper. That resident also reported often ordering food out or having family bring food because of the meal issues and staff attitudes when requesting replacements. Other residents interviewed reported that the food was not very good, was cold, was not warm enough when served, or was horrible and had no flavor, and one resident stated that chicken was dry and fish was sometimes undercooked. During a test tray observation conducted by the Food Service Director, the cranberry juice was served at 66 degrees and the cherry cobbler dessert at 79 degrees, both above an acceptable range. The mashed potatoes substituted for French fries had an off flavor, and the juice and dessert were described as too warm. The Food Service Director confirmed the test tray results during the interview that followed.
Crash carts lacked required oxygen and were disorganized
Penalty
Summary
The facility did not ensure professional standards of practice related to access to life-sustaining medical equipment on two nursing units, the first-floor east unit and the first-floor west unit. A review of the facility policy on CPR certification stated that crash carts, emergency medical supplies, and AEDs are available for use. During a tour of the second-floor unit, the crash cart was observed by the nurses station with all contents present, and the daily emergency code cart equipment check form was reviewed. On the first-floor east unit, the crash cart was located by the nurses station but did not contain an oxygen tank, and the daily emergency code cart equipment check form had not been completed since the documented date. The unit manager confirmed the form was not filled out accurately because there was no oxygen tank on the crash cart. On the first-floor west unit, the crash cart was observed without oxygen and with items including masks, nasal cannulas, and suction tubing scattered in disarray throughout the cart. The DON and ADON confirmed these findings, and the DON stated that in an emergency the nurse would need to go to the crash cart first and then obtain oxygen from the unit oxygen storage room if needed.
Failure to Maintain Effective Pest Control and Sanitation in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program on the first- and third-floor nursing units, despite a policy requiring an ongoing program to keep the building free of pests and rodents and assigning responsibility to facility staff and maintenance services. Observations in multiple resident rooms showed evidence of mice, cockroaches, rodent droppings, and structural issues that could allow pest entry, such as a hole behind a toilet and stained, leaking ceiling tiles. A pest control operator’s reports documented rodent droppings around every air cooling/heating unit in resident bedrooms and requested that the facility clean these areas so rodent activity could be monitored, as well as seal holes and voids in resident rooms where dead mice had been found. In several rooms on the first-floor nursing unit, residents reported and staff confirmed the presence of mice and cockroaches. One alert and oriented resident reported a hole behind the toilet and a leaking bathroom ceiling, and surveyors observed unprotected dry foods and open soda cans stored at the bedside and on the floor. Two roommates in another room reported seeing mice in their bedroom, and surveyors observed food debris under both beds and unsecured dry foods stored at the bedside. Pest control reports for this unit cited sanitation issues, including clutter of resident personal belongings that allowed harborage for mice, and requested that resident belongings such as clothes and food be properly stored. On the third-floor nursing unit, surveyors observed rodent droppings in a resident room, which the maintenance director confirmed, and noted that another resident’s personal belongings were stacked in broken and torn cardboard boxes next to the bed, creating additional harborage areas. A roommate in this room reported that the rodent issue had been ongoing and that mice were also seen in the bathroom, where the toilet did not flush properly and sometimes overflowed with sewage. Surveyors observed an accumulation of foods at the bedside, including juices, coffee with creamer, snacks, and leftovers, without use of the nursing pantry refrigerator for perishable items or tightly sealed containers for nonperishables. Pest control reports for this unit documented accumulated food serving as a source for roaches and mice and identified holes and voids in the floorboard of a closet where dead mice had been found, with a request that all voids in resident rooms be sealed.
Food Service Sanitation and Dish Machine Failure
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, the sink in the mop room was observed clogged and full of dirty water, the trash can near the door was uncovered and contained kitchen waste open to the air, and the drain collection funnel under the prep sink was full of dried, caked trash. Additional observations showed a thick covering of grease and dust on the fan guard in the prep room, personal drinks and a black metal drink container with a first name sticker inside a reach-in refrigerator, dirty torn and loose door gaskets on the refrigerator, a stainless-steel shelf covered with crumbs, dust, and dirt, and the top of the coffee urn covered with dark brown grounds, dirt, dust, and dried stains. The kitchen also had a reach-in refrigerator with dirty and torn door gaskets, and the air conditioning unit next to the tray line was missing its cover and had a thick build-up of grease, dust, and dirt blowing into the kitchen area. In the dish room, the chemical sanitizing low-temperature dish machine was tested and no sanitizer was present in the final rinse, confirming that the machine was not sanitizing dishes. The Food Service Director could not get the machine to pump sanitizing chemical into the rinse water, and the facility later observed the trash can in the corner still uncovered and full of trash, with the dish machine still out of service.
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.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to monitor residents for changes in nutritional status and failed to implement appropriate interventions in response to identified nutritional changes for three residents. The cited policy required nursing staff to monitor and document weight and dietary intake, report significant changes to the physician, and have the physician collaborate with nursing and the multidisciplinary team to assess nutritional status and authorize interventions based on identified causes. In the cases reviewed, the physician was not notified of significant weight loss, and the dietitian did not initiate documented interventions or provide documented guidance in response to the changes. For one resident with hypertension, Parkinson’s disease, and depression, the record showed a regular soft and bite-sized diet with thin liquids and documented weights that dropped from 143.4 pounds to 122.2 pounds over a short period. A dietary assessment noted variable intake and later identified the weight loss as significant, but the resident was not reweighed until 11 days after the reweight was requested. Progress notes from the nurse practitioner documented review of records, vital signs, labs, and consults, but did not document assessment or follow-up for the significant weight loss. The dietitian acknowledged the weight loss, stated the physician had not been notified, and the DON later reported that staff said the resident had refused weights, but those refusals were not documented in a timely manner. For another resident with malnutrition, respiratory failure, cerebral infarction, and dysphagia who required tube feedings, the care plan identified a goal of weight stability and the resident’s weights changed from 165 pounds to 106 pounds over a short period. A nutrition note stated the weight loss trigger was likely inaccurate because the resident did not lose 20 pounds over a few days, and the dietitian confirmed the weights were inaccurate and needed to be re-weighed. For a third resident with anxiety, depression, left hip dislocation, cocaine abuse, traumatic subdural hemorrhage, hypertension, and seizures, the record showed an order for house shakes twice daily to promote weight gain, but after the resident returned from the hospital there was no admission weight, no nutritional assessment, and no documentation explaining why the house shake order was not resumed. The resident later had a significant weight loss, and the dietitian confirmed the lack of admission weight and nutritional assessment on return.
Food and Drink Served at Improper Temperatures
Penalty
Summary
Food and drink were not provided at palatable temperatures and were not consistently palatable for multiple residents reviewed, including Residents R9, R42, R60, R63, R67, R72, R89, R144, R246, R288, R294, R299, R315, R329, and R339. During interviews, residents reported that meals were cold, not cooked properly, not what they ordered, not good tasting, and in some cases undrinkable, including complaints about coffee being too strong or bitter. Several residents also stated that breakfast portions were inadequate or that requested items such as shakes, double portions, hot cereal, and eggs were not being provided. A test tray evaluation conducted with the Food Service Director found multiple items outside acceptable service temperatures: fish, bow tie pasta, broccoli, pureed fish, mashed potatoes, and pureed broccoli were below 135 degrees, while applesauce and cranberry juice were above 50 degrees. The Food Service Director confirmed these items were outside acceptable temperature and therefore not palatable, and the facility’s Test Tray Evaluation Form showed that all foods and drinks except coffee and milk did not meet the standard of service temperature.
Lack of Resident Education Before Influenza Vaccination
Penalty
Summary
The facility failed to ensure that residents were provided with education related to influenza vaccines before the vaccines were administered to eight of eight residents reviewed: R8, R9, R14, R17, R20, R128, R260, and R284. Review of the facility’s Infection Prevention and Control Program policy showed that immunization is part of the program and that widespread use of influenza vaccine in the nursing facility is strongly encouraged. However, review of the consent/declination forms and clinical records for the eight residents revealed no documented evidence that they were educated about influenza vaccines prior to administration. The DON confirmed in interview that the facility did not provide such education to these residents and stated that the facility did not have a process in place for educating residents on influenza vaccines before giving the vaccine.
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.
Failure to Provide Access to AA/NA Resources
Penalty
Summary
The facility failed to assist a resident with access to AA/NA resources. Resident R63 stated during interview that they wanted to attend AA/NA meetings and that none were available at the facility. The resident’s care plan identified ineffective coping related to a history of substance use disorder and included interventions to encourage support available and listed resources such as Alcoholics Anonymous. The facility assessment showed that 55% of the facility population had a history of mental illness, including substance use disorder. The DON confirmed that the facility does not offer AA or NA meetings to residents and stated that the facility offers a Peer Program, but review of peer review documentation showed that AA/NA meetings are not offered as part of that program.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to ensure that postal mail was delivered in a timely manner for one resident. The facility policy stated that incoming mail was to be handled securely, respectfully, and distributed timely, with resident mail delivered through the Recreation Department for private and timely distribution. However, staff reported that mail was delivered to the front desk and then to activities with no set time frame, and that resident mail was placed in boxes in the office until the boxes were full before being sorted and delivered. Resident R128 was admitted with diagnoses of schizoaffective disorder and type 2 diabetes mellitus, and the resident's MDS showed a BIMS score of 14, indicating cognitive intactness. During interview, the resident stated that mail had not been received and reported expecting a letter from the Social Security Administration that had not arrived, despite being told by a Social Security representative that the letter had been mailed two weeks earlier. The Director of Therapeutic Recreation confirmed that there was no daily resident mail delivery schedule and no specific resident mail delivery day.
Missing Criminal Background Checks for Newly Hired Nurse Aide
Penalty
Summary
The facility failed to obtain required criminal background checks for one newly hired nurse aide, Employee E19, as part of its personnel screening process. Review of the facility’s Abuse policy dated June 1, 2025 showed that employees are to be screened before working with residents, including verification of references, certification and license, and criminal background checks. Employee E19 was hired on October 1, 2025, but the Pennsylvania Criminal Record Check was not completed until December 1, 2025, at 4:58 p.m., after the personnel file was requested by state surveyors. Reference checks were also not completed. The personnel file further showed that the employee had not lived in Pennsylvania for at least two years and attested to criminal charges in another state, yet the facility did not obtain the required Federal Criminal Record Check. The Human Resources Director confirmed that the State and Federal criminal record checks were not completed as required.
Failure to Notify Ombudsman of Facility-Initiated Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility initiated transfers and discharges for three of three months reviewed, specifically August, September, and October 2025. During the entrance conference on December 1, 2025, surveyors requested evidence of facility initiated transfer and discharge reports sent to the State Long-Term Care Ombudsman. The request was repeated during interviews with the Regional Director of Operations on December 4, 2025, and the Nursing Home Administrator stated that the previous Director of Social Work left the facility in September 2025 and confirmed that the facility did not have evidence that the required notices were sent for the three reviewed months.
PASRR Screening Not Properly Completed for Three Residents
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not appropriately completed for three of four residents reviewed. Review of Resident R10’s annual MDS dated October 1, 2025 showed diagnoses of anxiety disorder, depression, bipolar disorder, and alcohol abuse, but the resident’s PASRR dated April 30, 2015 did not include those diagnoses. During interview on December 4, 2025, the Admissions Director confirmed that Resident R10’s PASRR assessment was not updated to include anxiety, depression, bipolar disorder, and alcohol abuse. Review of Resident R13’s quarterly MDS dated October 3, 2025 showed diagnoses including non-traumatic brain dysfunction, dementia, anxiety, depression, and psychotic disorder, but the Pennsylvania PASRR Level 1 form dated January 1, 2025 stated the resident did not have a mental disorder. Review of Resident R19’s MDS dated October 2, 2025 showed diagnoses of depression and psychotic disorder, but the PASRR Level 1 form dated September 26, 2024 stated the resident did not have a mental disorder.
Failure to Develop Baseline Care Plan for Resident with Tracheostomy and Pressure Ulcer
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, R375, that included the minimum healthcare information needed to properly care for the resident. Facility policy stated that a baseline care plan would be developed and implemented for each resident and would include the instructions needed to provide effective and person-centered care that meets professional standards of quality care. Resident R375 was observed resting in bed and had a tracheostomy requiring respiratory care, including suctioning, oxygenation, assessment, care, and maintenance. The resident was also observed to have a pressure ulcer to the sacrum. A nurses note documented that the resident was admitted from the hospital with a tracheostomy and a pressure injury on the sacral area. Review of the care plan showed it was initiated on November 3, 2025, and did not include care needs for the tracheostomy, respiratory care, or sacral pressure ulcer. The DON confirmed that no care plan had been developed for these needs.
Failure to Provide ROM Support and Splinting
Penalty
Summary
The facility failed to ensure that two residents received services to maintain or improve range of motion and prevent further deterioration of ROM and mobility. One resident with hemiplegia/hemiparesis following an unspecified cerebrovascular accident had an MDS BIMS score of 15, indicating cognitive intactness. Occupational therapy discharge documentation stated that the resident was to continue wearing a splint as established, but the note did not specify when the splint should be on or off, and there were no physician orders for splinting or a palm guard. The record also did not show documented evidence that the resident was provided a splint after OT services ended, and during observation the resident’s left elbow was flexed and the resident was not wearing any splint or brace. The resident stated that he could not move his arm and that nobody puts a splint on him. A second resident with quadriplegia, epilepsy, dysphasia, and cerebral infarction had OT notes and discharge summaries indicating contractures in both hands. The resident’s person-centered plan of care addressed pain related to chronic disability and disease process, including contractures, but the clinical record did not show evidence of treatments or services to maintain or improve ROM and mobility or to prevent further decline. During interview, the OT reviewed the resident’s recent therapy services and stated that she did not document the proper discharge plan and mistakenly omitted the application of right and left hand splints when the resident was discharged from therapy. The OT also stated that the resident was supposed to wear resting hand splints on both hands for up to 8 hours, but the discharge plan did not reflect that.
Enteral Feeding Not Provided as Ordered for Two Residents
Penalty
Summary
Adequate nutritional care related to enteral nutrition was not provided for two residents with feeding tubes. One resident was admitted with dysphagia, oropharyngeal phase, and had a physician order for Glucerna 1.2 or equivalent DiabetiSource AC via feeding pump at 65 mL/hr until 1300 mL had infused each day shift. During observation, the formula hanging on the pole was Glucerna 1.5, the pump was turned off, and the feeding tube was hanging from the pump rather than delivering nutrition to the resident. The licensed nurse stated she had disconnected the tube earlier for care and that the nurse aide was supposed to get her to restart the feeding, but that did not happen, and she did not know how long the resident went without the feeding. She also confirmed the formula hanging was the wrong formula compared with the order. A second resident was admitted with adult failure to thrive and protein calorie malnutrition and had a physician order for Jevity 1.5 continuous feed via feeding pump at 85 mL/hr for 15 hours until 1275 mL was infused. During observation, the resident was not connected to the tube feeding formula. The licensed nurse stated she had disconnected the feeding so the resident could go downstairs to smoke, and the resident wanted to be put back into bed first before being reconnected. The nurse obtained help to return the resident to bed and reconnected the tube feeding later, but could not say how long the resident had been without the feeding.
Failure to Maintain and Monitor Midline Catheter
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident R375, who had a right upper extremity midline catheter. Facility policy stated that IV catheters should be assessed frequently for complications, cared for using aseptic/sterile technique, with insertion site and dressing condition assessed every shift, infusions monitored, external catheter length measured every seven days, and catheter patency assessed. On December 1, 2025, observation showed the resident had a midline catheter in place, and the dressing documentation showed the midline dressing had last been changed on November 13, 2025. The resident’s record showed a practitioner note dated November 19, 2025, stating the resident had been hospitalized and returned to the facility with recommendations to continue IV antibiotics until November 24, 2025, for pneumonia. Hospital records dated November 18, 2025, showed the midline catheter was inserted on November 13, 2025, with instructions to remove it after antibiotic therapy was completed. The MAR showed the resident received Micafungin IV from November 19 through 24, 2025, and Zerbaxa IV from November 18 through 22, 2025. The clinical record contained no physician orders for the care, maintenance, or assessment of the midline catheter, and the unit manager confirmed there were no orders for the use, care, or maintenance of the catheter.
Improperly Functioning Oxygen Concentrator
Penalty
Summary
The facility failed to ensure the proper functioning of an oxygen concentrator for Resident R357, who was in bed receiving oxygen via nasal cannula at 2.5 liters per minute. During observation, the oxygen concentrator displayed a red wrench indicator and a yellow indicator with an arrow pointing down next to the O2 symbol. On follow-up observation, the same indicators were still illuminated. The DON confirmed that the red light should not have been on and stated that the oxygen concentrator needed to be serviced. The DON also stated that the facility does not have a full-time respiratory therapist and that nurses on the unit are responsible for ensuring respiratory equipment, including oxygen concentrators, is in working order at all times.
Missing Skills Competency Evaluations for Newly Hired Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets necessary to care for residents' needs for three of three newly hired nursing staff reviewed: Employees E19, E27, and E28. Review of the facility assessment stated that competencies are based on current standards of practice and the care and services needed by the resident population, and are verified upon orientation, at least annually, and as needed. Personnel file review showed that E19 was hired as a nurse aide, E27 was hired as a nurse aide, and E28 was hired as a licensed nurse. Further review found that no skills competency evaluations were available for review for any of these three employees at the time of the survey. The Human Resources Director stated that the skills competency evaluations were the responsibility of the facility's staff educator and confirmed that the evaluations for E19, E27, and E28 were not available for review.
Medication Borrowing and Missing Supply
Penalty
Summary
The facility failed to ensure an adequate supply of medications for one resident. Resident R31 had a physician order for amlodipine besylate 10 mg by mouth once daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mmHg. During observation, the resident did not have the prescribed amlodipine available in the medication supply on the nursing unit. While preparing medications for Resident R31, a licensed nurse searched the medication cart for another resident with the same medication and then removed amlodipine from Resident R167's medication card, placed it in the medication cup, and administered it to Resident R31. The nurse stated that he frequently borrows medications from other residents when a resident's medication is not available, as long as the medication and dose are the same, and said this practice is acceptable for non-narcotic medications.
Failure to Provide Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not ensured for one resident, R128. The resident was admitted with diagnoses including schizoaffective disorder and type 2 diabetes mellitus, and the May 1, 2025 MDS showed a BIMS score of 14, indicating the resident was cognitively intact. The same MDS dental section was coded as having no broken or loosely fitting dentures, no edentulous status, no abnormal mouth tissue, no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, and no mouth or facial pain, discomfort, or difficulty chewing. During an observation on December 1, 2025, R128 was noted to have missing teeth and some remaining teeth that were brownish in color. When interviewed at that time, the resident stated having a lot of missing teeth, that some teeth were broken, and that the resident needed to see a dentist because no dental visit had occurred in three years. Review of the clinical record found no documented evidence of a dental assessment.
Improper Trash Disposal and Overflowing Waste Containers
Penalty
Summary
Improper disposal of garbage and refuse was observed in the Food Service Department and receiving area. During an initial tour, a 50-gallon trash can in the corner near the door to the department was observed without a cover and full of kitchen trash, and the same condition was observed again during a follow-up visit the next day. In the receiving area, the compacting dumpster was full and could not be used, and staff were observed placing kitchen trash and housekeeping trash, including dirty briefs, into an open construction dumpster in the parking lot. The Food Service Director and Maintenance Director confirmed these observations, and the Administrator stated that the facility had once-a-week trash pickup for the compactor serving the entire facility with a census of 370 residents, which was not sufficient for current needs.
Infection Control Failure During Wound Care in Dining Area
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when wound care was performed in a communal dining area for Resident R296. The resident’s quarterly MDS dated November 14, 2025, showed a BIMS score of 11, indicating moderate cognitive impairment, and the clinical record also documented diagnoses of anxiety and suicidal ideation. On December 1, 2025, at 10:35 a.m., the resident was seated in the 4th floor social/dining room with three other residents at the table and 16 additional residents in the room when Licensed Nurse E16 was observed providing wound care to the resident’s foot, which was actively bleeding during the procedure. During interview on December 1, 2025, E16 confirmed she was providing care to Resident R296 and stated the wound was first noticed when she arrived for her shift at 7:00 a.m. She reported a disagreement with the overnight nurse, who had been responsible for providing wound care overnight, but said she was instructed that she needed to provide the care. E16 confirmed that she cleaned the resident’s bleeding foot in the dining room. The DON later confirmed that wound care is not to be performed in the dining room and that the facility has protocols prohibiting care in public areas, and stated that staff had been educated on proper infection prevention and control measures.
Dish Machine Not Sanitizing Dishes
Penalty
Summary
The facility failed to keep essential kitchen equipment in safe and functioning order when the dish machine sanitizer pump was not operating, leaving the machine unable to sanitize dishes. During the initial kitchen tour, the dish machine final rinse gauge was observed reading 120 degrees, and the Food Service Director identified the unit as a chemical sanitizing low-temperature machine. Testing showed no sanitizer present in the final rinse, confirming that dishes run through the machine were not being sanitized. The Food Service Director was unable to get the machine to pump sanitizing chemical into the rinse water and could not reach the chemical company representative the same day. The facility then switched to serving residents on disposable dishware and silverware. The Food Service Director stated he was not certain how long the machine had been operating without sanitizer, and the Administrator confirmed that the dish machine was not working and that dishware could not be properly sanitized. On a follow-up visit the next day, the dish machine was still out of service.
Unsafe and Improperly Secured Handrails in Hallways
Penalty
Summary
Handrails in the 3 [NAME] nursing unit were found to be unsafe and not properly secured during a tour on December 2, 2025. Surveyors observed missing endcaps on the railing by the elevator across from room [ROOM NUMBER], the railing by the clean linen room, and the railing by the dining room across from room [ROOM NUMBER]. The report states that endcaps or finishings on handrails are required for safety and to prevent snagging. The findings were reviewed with the Maintenance Director on December 4, 2025, and later that day surveyors observed that the handrail by the elevator in the lobby area was falling off the wall, which was confirmed by the Nursing Home Administrator at the time of observation.
Failure to Maintain Required Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for five newly hired staff members: E19, E27, E28, E29, and E30. The Facility Assessment, dated April 16, 2025, stated that the staff training and education program was designed to ensure knowledge competency for all staff and identified required competencies for abuse, neglect, exploitation, misappropriation, resident rights, identification of condition change, behavior management, substance use disorders, trauma informed care, resident preferences, dementia management, infection transmission and prevention, immunization, QAPI, OSHA hazard communication, hand hygiene return demonstration, and emergency response observation. Review of personnel files showed that E19, E27, E28, E29, and E30 each had no evidence of training related to the listed competencies in their files. E19 and E27 were hired as nurse aides, E28 as a licensed nurse, E29 as a housekeeper, and E30 as a maintenance technician. During interview, the Human Resources Director stated that education for newly hired staff was the responsibility of the facility's staff educator, who was no longer at the facility, and that whatever trainings were in the files for these employees were all that were available for survey review.
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.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Family Home | 1.8 mi | ★★★★★ | 8 | 0 |
| West Park Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 17 | 0 |
| Edenbrook Of Yeadon | 1.9 mi | ★★★★★ | 1 | 0 |
| Renaissance Healthcare & Rehabilitation Center | 1.9 mi | ★★★★★ | 15 | 0 |
| Centennial Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.