Caring Heart Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6445 Germantown Avenue, Philadelphia, Pennsylvania 19119
- CMS Provider Number
- 395819
- Inspections on file
- 27
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Caring Heart Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility failed to ensure accurate completion of medication administration records and provision of ordered medications for two residents. One resident with asthma, diabetes, and other conditions had multiple undocumented or omitted doses of nebulized bronchodilator, pregabalin for CVA, insulin lispro with required blood glucose checks, and topical analgesic gel. Another resident with anxiety and complex medical conditions had several scheduled doses of Ativan 2 mg every 12 hours documented as omitted. Facility policies required licensed nursing staff to administer medications as ordered and maintain complete, accurate, and timely MAR and medical record documentation, which did not occur, as confirmed by the ADON.
The facility did not conduct timely care plan conferences or ensure updates for four residents, resulting in lapses in resident participation and communication with social workers. Several residents had not had care conferences or social service progress notes for months, and some reported not having contact with a social worker since staff changes occurred. The current Director of Social Work confirmed the lapse in care conferences.
Surveyors observed multiple instances of unclean and unsafe conditions, including dirty and sticky floors, soiled and improperly stored equipment, and feces spread on the floor in resident rooms. Staff interviews confirmed that such conditions were not uncommon, particularly for residents with specific care needs, and that cleaning was sometimes delayed.
A resident at risk for elopement was left with a cup of medications at bedside while receiving a breathing treatment, despite not being authorized to self-administer. Additionally, the elevator key, intended to restrict resident access, was stored in a location visible and accessible to residents and visitors. Staff confirmed these practices were not in line with facility policies for medication administration and elopement prevention.
Staff failed to follow Enhanced Barrier Precautions for two residents, including improper disposal of used gowns after wound care and lack of required PPE use during personal care. In both cases, staff either did not use or did not properly discard PPE as required, despite the residents' conditions necessitating these precautions.
A resident with diagnoses including PTSD did not receive a trauma assessment or have a care plan developed to address their PTSD-specific needs. The care plan only noted general risks related to mood changes without interventions tailored to PTSD, and staff confirmed the absence of a focused assessment or care planning for this diagnosis.
The facility did not maintain a clean and homelike environment, as evidenced by water-damaged ceiling tiles and peeling wall panels observed in resident rooms. Two residents reported issues with meal service, including cold food left at the bedside after dialysis and inconsistent practices regarding reheating meals. During a dining observation, residents experienced delayed meal service and were provided only plastic silverware without explanation, contrary to facility policy.
Three residents with complex medical needs, including wounds, indwelling catheters, and behavioral safety concerns, did not have comprehensive care plans addressing their specific needs. Despite physician orders and ongoing care requirements, the facility failed to document appropriate interventions, goals, or supervision in the care plans, as confirmed by staff interviews and record reviews.
The facility did not update care plans for two residents after significant changes in their care needs. One resident who experienced a fall and received a scoop mattress for fall prevention did not have this intervention reflected in the care plan. Another resident with COPD had a care plan that both restricted and permitted smoking, creating conflicting instructions. These deficiencies were confirmed through record review and staff interviews.
Nursing staff did not clarify or implement complete physician orders for a resident with lymphedema and chronic lower extremity wounds. The resident's care lacked specified wound cleansing, dressing, compression wrapping, and leg elevation as recommended by medical specialists. Staff were unclear about treatment application, and the resident was observed without proper leg support or a care plan for leg elevation.
A resident with CHF was not weighed daily as ordered, and significant weight gains were not reported to the physician or dietitian as required by facility policy. The DON confirmed missing documentation and lack of required notifications.
A resident with COPD and pulmonary hypertension did not receive proper respiratory care when the humidifier chamber of the oxygen concentrator was found empty and the oxygen tubing was not dated, despite a physician's order for continuous oxygen via nasal cannula. This was confirmed through observation and staff interview.
Two residents receiving dialysis care did not have complete and documented communication between facility nursing staff and the dialysis provider, as required by policy. Required information such as vital signs, lab results, and assessment of the dialysis access site was missing from communication binders on multiple occasions, with staff sometimes relying on undocumented verbal communication instead.
A resident with osteoarthritis, dementia, and mobility issues was recommended for a restorative nursing program (RNP) after discharge from physical therapy, with the care plan requiring one-person assist for ambulation. However, there was no documented evidence in the clinical record that the RNP was being completed, and the ADON confirmed that there was no designated area for staff to document completion of the RNP.
A resident with multiple complex conditions was receiving hospice care, but the facility failed to maintain required communication and documentation with the hospice provider. Despite daily visits reported by staff, the hospice communication log contained significant gaps and lacked details about the care provided, contrary to facility policy.
Essential kitchen equipment, including a plate warmer and steamtable wells, was not maintained in safe operating condition. The plate warmer was non-operational and, after repair, could not accommodate the plates, leaving them unheated. The food service director indicated that two plate warmers were needed for proper operation, and two steamtable wells remained broken pending repair.
A resident with allergies to apricots and corn was served a meal containing corn due to a failure in the facility's menu planning system. The computer program used to generate menus did not account for individual ingredients in mixed dishes, leading to the oversight. The resident's meal ticket listed the allergies, but the system failed to prevent the allergen from being served.
A facility failed to notify a resident's responsible party about a change in treatment, specifically a COVID-19 diagnosis and oxygen use. The nursing supervisor claimed to have informed the resident's daughter by phone, but there was no documentation to support this, and the daughter reported learning of the situation during a visit. This lack of communication and documentation violated the facility's policy.
A facility failed to provide advanced notice for a care plan meeting for a resident with cognitive impairment. The resident's daughter was not informed of the meeting date until the day it occurred, despite her prior inquiry. The social worker claimed to have notified her earlier, but no documentation supported this, leading to a deficiency citation.
A resident was moved to a different floor designated for LTC without prior written notification to her or her responsible parties, violating facility policy and resident rights. The move was made after a care plan meeting determined the resident's long-term care status, but the required notification was not provided.
A facility failed to promptly investigate an alleged neglect incident involving a resident with dementia and other health issues. The resident's daughter found her mother in a soiled gown on consecutive days and reported it to the nursing supervisor. Despite being given a grievance form, the issue was not addressed in a timely manner, and the investigation into the nurse aide's actions was delayed, violating several Pennsylvania Code regulations.
The facility failed to implement fall prevention measures for three residents, resulting in a hazardous environment. A resident sustained a head laceration due to the absence of required floor mats, despite physician orders. Observations confirmed the absence of fall mats for two other residents, who were also at risk for falls.
The facility failed to adhere to food safety standards, with improper use of dish machines, poor cleanliness, and expired or improperly stored food items. Observations revealed issues such as sticky surfaces, expired food, and unsanitized meal trays, confirmed by the Food Service Director.
The facility failed to maintain essential equipment, including a dish machine and a handwashing sink, in safe and operating conditions. The dish machine was improperly used with incorrect temperatures and non-dispensing sanitizer due to a broken booster and disconnected tubing. Logs inaccurately recorded temperatures, and staff lacked education on sanitizing procedures. In the laundry area, a broken handwashing sink left staff without means to sanitize after handling soiled items, with no alternative options provided.
The facility failed to provide a dignified dining experience on the third floor, as residents were not served simultaneously, and a resident with a vision impairment was not assisted according to policy. The resident's food was served on Styrofoam plates instead of bowls, and the nurse aide stood while assisting, contrary to the policy of sitting next to residents. Additionally, clothing protectors were unavailable, leading staff to use towels instead.
The facility failed to maintain a clean and safe environment, as observed in a nursing unit and the 2nd floor patio. A family member reported cleanliness issues, and observations confirmed trash and clutter in shower rooms, stained and broken fixtures, and cigarette butts on the patio. These deficiencies compromised the homelike environment expected in the facility.
The facility failed to recognize beds against the wall as a potential restraint and did not assess the functional status of three residents with severe cognitive impairments. Observations showed these residents had their beds against the wall without bed rails, and their care plans lacked documentation of this preference. The facility's policy requires a restraint-free environment, but no assessments for bed rail use were conducted, and the Director of Nursing confirmed the non-use of bed rails.
The facility failed to develop comprehensive care plans for six residents, resulting in deficiencies in addressing their care needs. A resident with a risk for falls did not have her bed placement preference documented, while two residents with severe cognitive impairment also lacked care plans for bed placement. Another resident with respiratory issues was observed without oxygen administration, and their care plan did not address refusals. Additionally, a resident receiving hospice services did not have this included in their care plan.
The facility failed to monitor and modify nutritional interventions for several residents, leading to significant weight loss and potential malnutrition. A resident with malnutrition experienced continued weight loss without intervention from the dietitian. Another resident with a history of weight loss and difficulties swallowing also lost significant weight, with no documented dietary adjustments. Additionally, a resident with dysphagia and another with significant weight loss had no documented nutritional assessments or interventions.
The facility did not adhere to the planned menus, failing to provide milk and the correct desserts as listed, and did not notify residents of these changes. A resident on a pureed diet was only given yogurt instead of the specified meal items. These actions did not meet the nutritional needs and preferences of the residents, as confirmed by staff interviews and observations.
The facility failed to maintain an effective pest control program, with flies observed in resident rooms, a conference room, and the nursing area. Pest control logs documented fly sightings, but weekly reports showed no evidence of treatment. In the kitchen, sticky coffee stains and stagnant water were found, contributing to the pest issue.
A facility failed to create a baseline care plan within 48 hours for a resident with polysubstance disorder, septic shock, and depression. Despite receiving medications like Suboxone and a nicotine patch, the resident's substance abuse disorder was not addressed in a care plan. Interviews confirmed unmanaged pain and the absence of a care plan, acknowledged by the DON and ADON.
The facility failed to implement an effective discharge planning process for two residents, as required by policy and regulations. One resident's care plan was outdated and lacked necessary information on support systems and external agency involvement, while another resident's care plan did not reflect discharge goals or address potential barriers. These deficiencies highlight a lack of adherence to the facility's discharge planning policy.
A resident with diagnoses including hemiplegia and general weakness was observed multiple times without the prescribed right palm guard, which was necessary to maintain functional status in range of motion and mobility. Despite orders and recommendations for its use during morning care, the resident was not wearing the palm guard, as confirmed by observations and interviews with the DON.
A facility failed to provide adequate care for a resident with a PICC line by not adhering to professional standards of practice. The facility's policy required regular dressing changes and assessments, but these were not performed as ordered. The resident's dressing had not been changed since admission, and there was no documentation of required assessments. An interview confirmed the deficiency in care.
A resident with fractures and multiple trauma did not receive prescribed Enoxaparin injections on two consecutive days due to unavailability. The facility failed to notify the physician, request alternative treatment, or document efforts to obtain the medication, violating their policy on unavailable medications.
A licensed nurse in an LTC facility made several medication administration errors, including incorrect dosing and medication substitution, leading to a medication error rate of 19.23%. Errors involved administering Fluticasone Propionate incorrectly, failing to provide buPROPion HCl due to unavailability, and attempting to crush extended-release medications for a resident.
The facility failed to store and administer medications according to professional standards. A resident's medication was left unattended on a breakfast tray, and another resident had medications left on an overhead table, including a cut nicotine tablet and a Symbicort inhaler. Additionally, a unit manager's office was left open with medication blister packs visible. These incidents highlight lapses in medication management and security.
A resident, who was cognitively intact, experienced an unwitnessed fall in her room, resulting in a forehead laceration that required staples. The facility failed to report to the State Survey Agency that the required floor mats were absent at the time of the fall and omitted details about the medical treatment received. The incident occurred when the resident fell out of bed while reaching for her call bell.
A resident with multiple health conditions, including Alzheimer's, had a nephrostomy tube dislodged. Although the physician's answering service was notified, the facility failed to inform the resident's family, violating resident rights and nursing services regulations.
The facility failed to provide a means for residents to file grievances anonymously across all eight nursing units, despite a policy allowing for anonymous submissions. During a facility tour, no grievance boxes were found, and the Social Work Director confirmed the absence of lock boxes, requiring residents to submit grievances directly to staff or under the office door.
The facility did not post daily nurse staffing information in a prominent place accessible to residents on the Second, Third, and Fourth floors. Observations showed that the data was only available in the first-floor lobby, making it hard for residents, especially those on the locked third-floor unit, to access without staff help. This issue was discussed with the Nursing Home Administrator and DON.
A facility failed to maintain complete medication administration records for a resident. The MAR for March 2024 lacked documentation for several scheduled doses of Atorvastatin, Diazepam, Hydroxychloroquine, and Pantoprazole. The DON confirmed the absence of documentation, indicating a failure to adhere to professional standards.
The facility failed to maintain a clean and homelike environment across three floors. Observations included soiled fall mats, trash under beds, heavy urine smells, and broken sanitizer units. A housekeeping staff member was seen texting instead of cleaning. These issues were confirmed by the head of housekeeping and the DON.
The facility failed to ensure adequate supervision in the smoking area, where a staff member was inattentive, allowing two residents to share a lighter. Additionally, a lighter was found unsecured in a resident's room, violating the facility's smoking policy.
A resident with multiple wounds consistently refused treatments, including wound care and blood draws, due to pain and a desire to be left alone. Despite these refusals being documented over several days, the facility failed to update the care plan to include interventions for these refusals until later, violating their policy for comprehensive individualized care plans.
The facility did not maintain accurate daily nurse staffing information. Observations on multiple floors showed outdated or missing postings, with the lobby displaying incorrect data. Interviews confirmed the postings were not current, violating regulatory requirements.
Failure to Accurately Document and Administer Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medication administration documentation in the medical records for two residents, contrary to its own policies and professional standards. Facility policies required licensed nursing staff to administer medications as ordered by the physician, observe residents consuming medications, and record administration on the medication administration record (MAR) as part of an accurate, complete, and timely medical record. For one resident with asthma, hypertension, depression, hypoxia, diabetes mellitus, and severe stenosis with myelomalacia, clinical record review showed multiple instances where ordered medications and treatments were not documented as administered. These included missed 5:00 p.m. doses of formoterol fumarate nebulizer solution for asthma on several dates, missed 5:00 p.m. and 9:00 a.m. doses of pregabalin for a cerebral vascular accident diagnosis, and failure to obtain and record blood glucose readings with corresponding insulin lispro injections for diabetes at specified times. For the same resident, the MAR also showed that topical 1% gel ordered for bilateral knee pain was not applied at 5:00 p.m. on multiple dates as ordered. For a second resident with anxiety disorder, end stage renal disease, sepsis, and spina bifida, the MAR indicated that although Ativan 2 mg was documented as given at certain times, there were multiple occasions when the ordered 2 mg doses every 12 hours were documented as omitted and not administered as prescribed. An interview with the assistant director of nursing confirmed the lack of medical record documentation indicating that these residents received their ordered medications and treatments in accordance with professional standards of nursing practice and the facility’s medical record documentation policy.
Failure to Conduct Timely Care Plan Conferences and Ensure Resident Participation
Penalty
Summary
The facility failed to conduct timely care plan conferences and ensure updates for four residents, as evidenced by observations, clinical record reviews, and interviews. The facility experienced a period with one less social worker, specifically the Director of Social Services, which contributed to lapses in care plan meetings. For one resident, the last documented care plan meeting was several months prior, and there was no indication that the resident's representative was invited to participate. Additionally, two residents reported not having contact with a social worker since the previous one left the facility. Further review of clinical records revealed that several residents had not had care conferences or social service progress notes documented for extended periods. One resident was observed in bed receiving a breathing treatment and stated she had not seen or spoken to a social worker in months. Another resident approached the surveyor seeking assistance from a social worker, stating he had not had contact since the previous social worker left. The current Director of Social Work confirmed that there was no overlap with the previous director and acknowledged a lapse in holding care conferences for the affected residents.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on two of three nursing units, as evidenced by multiple observations and interviews. In one resident's room, dirty floor mats with spills, peeling baseboards, blue plastic caps, tube feed residue under and around the bed, and a trash can without a liner containing trash were observed. Another resident's room had a floor mat that was peeled and stuck to the floor, and a bathroom trash can without a liner containing soiled gloves. A third resident's room had a dirty and sticky floor. These conditions were directly observed by surveyors during their inspection. Additionally, in another resident's room, feces were found spread all over the floor. A housekeeping staff member acknowledged the mess but indicated they were about to go on break and would clean it up after returning. An LPN interviewed stated that encountering feces smeared on the floor was a normal occurrence due to the resident's behaviors related to a colostomy bag. These findings demonstrate that the facility did not maintain sanitary and homelike conditions as required by their own policy and regulatory standards.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for a resident identified as being at risk for elopement and accidents. During an observation, a resident was found in bed with a breathing treatment in progress and a cup containing six to eight pills at the bedside. The licensed nurse confirmed that she had poured the medications but allowed the resident to delay taking them until after the breathing treatment, despite the resident not being authorized to self-administer medications. This action was not in accordance with the facility's medication administration policy, which requires medications to be administered by licensed staff as ordered and in a manner to prevent contamination or infection. Additionally, the facility's elopement prevention measures were found to be inadequate. The elevator on the second floor required a key for access, but the key was stored in a grievance form box on the wall, visible and accessible to residents and visitors. A staff member acknowledged that the key was not supposed to be stored there but was able to retrieve it easily. Facility leadership confirmed that the key lock was implemented as an additional measure because staff had become desensitized to wander guard alarms. These findings indicate lapses in both medication administration and elopement prevention protocols, as outlined in the facility's own policies.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program related to Enhanced Barrier Precautions for two residents. For one resident with a history of MRSA infection, wound care orders included the use of Enhanced Barrier Precautions due to the presence of a wound and a Foley catheter. During an observed wound treatment, two licensed nurses did not properly discard their used gowns in a protective bag as required, instead carrying the exposed gowns outside the resident's room and placing them in an open trash box attached to the treatment cart. Both staff members confirmed this practice at the time of the observation. For another resident with hemiplegia, respiratory failure, malnutrition, and requiring continuous oxygen therapy, an indwelling urinary catheter, and a feeding tube, a nurse aide was observed providing personal care without wearing the required personal protective equipment (PPE). Upon interview, the aide stated she was unaware that a gown was required unless performing wound or catheter care. These findings were based on direct observation, staff interviews, and review of clinical records and facility policies.
Failure to Assess and Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and individualized care plan were completed for a resident diagnosed with post-traumatic stress disorder (PTSD). According to the facility's own Trauma Informed Care policy, care and services should be tailored to address the needs of trauma survivors, including identifying triggers and updating care plans with interventions based on input from the resident, family, and mental health professionals. However, review of the clinical record for a resident with diagnoses of major depressive disorder, vascular dementia, and PTSD revealed that the care plan did not specifically address the resident's PTSD diagnosis or include interventions tailored to this condition. Further review showed that the care plan only identified a general risk for mood changes related to depression, anxiety, and PTSD, without any interventions specific to PTSD. Staff interviews confirmed that the care plan lacked a specific focus on PTSD and that the resident had not been given a trauma assessment to determine their needs. The facility's process of referring residents with a PTSD diagnosis for psychiatric consultation and trauma assessment was not followed in this case, resulting in the omission of necessary care planning for the resident's PTSD.
Failure to Maintain Clean Environment and Person-Centered Dining
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on one of its nursing units, as evidenced by multiple observations and resident interviews. One resident reported a water leak in the bedroom from the unit above, resulting in water pouring from the ceiling, and subsequent observations confirmed water-damaged and discolored ceiling tiles in both the bedroom and bathroom. Additionally, a wall panel in another room was observed to be peeling off. These environmental deficiencies were directly observed and reported by residents. The facility also failed to provide a person-centered dining experience as outlined in its own policies. One resident who returned late from dialysis reported that lunch trays were left at the bedside and were cold upon return, with staff stating they were not allowed to reheat the food. Staff interviews revealed inconsistent practices regarding reheating food, with some indicating that trays could be sent back to the kitchen for reheating, while others stated that microwaves on the unit were primarily for employee use. Furthermore, during a dining observation, residents were served lunch significantly late and were provided only plastic silverware, with no explanation given for this deviation from policy. These actions and inactions resulted in a failure to meet the residents' rights to a safe, clean, and homelike environment and to receive appropriate support during daily living activities, including dining.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for three residents. For one resident with difficulty walking, weakness, and osteoporosis, a physician's order was in place for wound care of a left buttock pressure ulcer, but the care plan did not include any focus, interventions, or goals related to this wound. This omission was confirmed by a licensed nurse during an interview. Another resident with quadriplegia, multiple pressure ulcers, and an indwelling urinary catheter did not have a baseline care plan for Enhanced Barrier Precautions related to their wounds and catheter care, despite these being present and documented in the clinical record. A third resident, admitted with hemiplegia, respiratory failure, malnutrition, and requiring continuous oxygen, a urinary catheter, and a feeding tube, was noted in nursing documentation to be on 1:1 supervision for safety due to behaviors such as pulling on medical tubing. However, there was no care plan in place for this supervision, and the DON confirmed that no physician order or care plan existed for the required supervision. These findings were based on review of clinical records, observations, and staff interviews, and were not in accordance with facility policy and state regulations regarding resident care plans and nursing services.
Failure to Revise Care Plans for Fall Prevention and Smoking Supervision
Penalty
Summary
The facility failed to revise and update the care plans for two residents in accordance with their changing needs and interventions. For one resident with a history of cerebrovascular accident and hemiparesis, who was cognitively intact and used a wheelchair, a fall occurred resulting in a forehead laceration that required hospital treatment. Although a scoop (perimeter) mattress was implemented as an adaptive device to prevent further falls, the care plan was not updated to reflect this intervention. This omission was confirmed by both clinical record review and staff interview. For another resident admitted with COPD and an adjustment disorder, the care plan contained conflicting interventions regarding smoking. While the care plan identified the need to eliminate respiratory irritants such as cigarette smoke, it also documented the resident's preference and designation as a safe smoker, allowing smoking in designated areas at scheduled times. This inconsistency in the care plan was identified through review of the clinical records and care plan documentation.
Failure to Clarify and Implement Physician Orders for Skin and Wound Care
Penalty
Summary
Nursing staff failed to clarify and obtain appropriate physician's orders for the treatment of skin impairments for one resident. The facility's policy required licensed nurses to verify and clarify physician orders, document adverse effects or refusals, and correct discrepancies with the physician or nurse supervisor. For the resident in question, clinical records showed a history of lymphedema and chronic lower extremity wounds, with recommendations from hospital discharge, wound specialist, and podiatrist for specific wound care, compression wrapping, and leg elevation. However, the treatment orders in place did not specify all required interventions, such as cleansing with soap and water, application of sterile pads, or compression wrapping, and there was no clarification of the podiatrist's recommendation for leg elevation. Observations revealed the resident had a weeping right lower extremity wound and was seated in a wheelchair without leg rests, with feet directly on the floor and no care plan for leg elevation or scheduled naps to elevate the legs. Interviews with the resident and LPN confirmed that the current treatment orders were unclear, and staff were unsure about the application of prescribed skin treatments or their compatibility with other treatments. Documentation inconsistencies were also noted regarding the frequency and location of skin treatment applications. These failures resulted in the resident not receiving care in accordance with physician orders, resident preferences, and established care plans.
Failure to Document Daily Weights and Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to obtain and document daily weights as ordered for a resident with congestive heart failure, and did not notify the physician or dietitian of significant weight gains as required by both physician orders and facility policy. The resident was admitted with an order for daily weights and specific parameters for physician notification if weight gain exceeded two pounds in a day or five pounds in a week. However, there were multiple days where weights were not recorded, and significant weight gains were documented without corresponding notifications to the physician or dietitian. Clinical records showed gaps in daily weight documentation for several days, and when a five-pound weight gain and a three-pound weight gain occurred, there was no evidence that the physician or dietitian was informed. The Director of Nursing confirmed the lack of documentation and failure to notify the physician of these significant weight changes. The facility's own policy required ongoing weight monitoring and prompt notification of significant changes, which was not followed in this case.
Failure to Provide Proper Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and pulmonary hypertension due to lung disease and hypoxia. According to the physician's order, the resident was to receive continuous oxygen at 3 liters per minute via nasal cannula. During an interview, the resident reported that the humidifier chamber of the oxygen concentrator was not filled with water, and this was confirmed by direct observation. Additionally, the oxygen tubing in use was not dated. These findings were verified with the unit manager, a registered nurse. The deficiency was identified through observation, clinical record review, and staff interview, and it was determined that the facility did not follow its own policy and physician's orders regarding oxygen administration for the resident.
Incomplete Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure complete and documented communication between facility nursing staff and the dialysis care provider for two residents receiving dialysis services. According to facility policy and a long-term care agreement with the dialysis provider, communication regarding residents' health status, including vital signs, lab results, medication changes, and signs or symptoms of infection, must be consistently documented and shared using a dialysis communication binder. However, review of the communication binders for two residents revealed multiple instances where required information was missing on several dates. The communication sheets, which are divided into sections for both facility and dialysis staff to complete before, during, and after treatment, were found to be incomplete, lacking vital information such as vital signs, assessment of the dialysis access site, and documentation of infection symptoms. Interviews with facility and dialysis staff confirmed that, at times, information was communicated verbally rather than documented as required by protocol. One nurse stated that facility staff sometimes call the dialysis nurse to relay information but do not document these communications. The dialysis nurse also indicated that while the communication binder is reviewed prior to treatment, verbal communication is sometimes used for irregular concerns. These practices resulted in incomplete records and a lack of documented communication as required by facility policy and the agreement with the dialysis provider.
Failure to Document Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for restorative therapy for one resident. The resident, who had diagnoses including osteoarthritis, dementia, and mobility abnormalities, was admitted with a care plan requiring one-person assistance for ambulation using a rolling walker. After discharge from physical therapy, the therapy summary recommended a restorative nursing program (RNP) to maintain the resident's current level of function and prevent decline, and indicated that the RNP had been developed and instructed to the interdisciplinary team. However, review of the clinical record showed no documented evidence that the RNP was being completed with staff. During an interview, the Assistant Director of Nursing confirmed that residents on the RNP program did not have a designated area for documentation when the RNP was completed.
Failure to Maintain Communication and Documentation with Hospice Provider
Penalty
Summary
The facility failed to ensure an effective communication process between the facility and hospice care agencies for a resident receiving hospice services. According to the facility's own policy, there should be ongoing coordination and documentation of care provided by hospice staff, including written agreements specifying services and a communication log detailing the care and interventions delivered. However, review of the hospice communication log for the resident revealed significant gaps, with progress note entries missing for many dates over an 11-week period. The notes that were present did not include any information about the services provided by hospice staff during their visits. The resident involved had a complex medical history, including quadriplegia, depression, and dysphagia, and was admitted to hospice care following a hospital stay for sepsis, infected sacral decubitus, pneumonia, and influenza. Despite daily visits reported by facility staff, there was no documented communication from the hospice provider regarding the care delivered during these visits. Staff interviews confirmed that no additional notes were provided by the hospice agency, indicating a lack of documented communication as required by facility policy.
Failure to Maintain Essential Food Service Equipment in Safe Operating Condition
Penalty
Summary
Essential equipment in the food and nutrition services department was not maintained in safe operating condition, as observed during multiple kitchen inspections. On June 9, 2025, the kitchen lacked an operational plate warmer, and the food service director confirmed that repairs were pending for this essential equipment. Subsequent observation revealed that, after repair, the dinnerware did not fit inside the plate warmer and was instead stacked above the warming mechanism, resulting in plates that were not warm to the touch. Additionally, the food service director stated that the facility required two plate warming units to accommodate all the plates used for resident meals. Further inspection found that two wells in the steamtable unit were not fully functioning, with the food service director reporting that repairs were delayed due to a needed mechanical part.
Failure to Accommodate Resident Food Allergies
Penalty
Summary
The facility failed to provide food that accommodates a resident's allergies, specifically for a resident with Chronic Kidney Disease, Trisomy 21 (Down Syndrome), and Dementia. The resident was allergic to apricots, apricot kernels, and corn. On a specific date, the resident was served a meal that included seasoned mixed vegetables containing corn, despite the resident's known allergy to corn. The meal ticket for the resident did not have a substitute for apricots and listed the allergies at the bottom, but the computer program used by the facility did not account for individual ingredients in mixed dishes, leading to the oversight. The deficiency was identified through a review of the resident's clinical record, facility documentation, and staff interviews. The Regional Dietary Consultant explained that the facility's computer program was supposed to prevent allergic foods from being included in a resident's menu by using entered allergy information. However, the program failed to identify the corn in the seasoned mixed vegetables due to the way the menu item was entered. This resulted in the resident being served a meal containing an allergen, which was confirmed by staff interviews.
Failure to Notify Responsible Party of Change in Treatment
Penalty
Summary
The facility failed to ensure that a resident's responsible party was notified of a change in treatment, specifically regarding a COVID-19 diagnosis and the use of oxygen therapy. The facility's policy requires that the resident, their physician, and the resident's family member or legal representative be informed of significant changes in the resident's condition or treatment. However, in this case, the resident's daughter discovered her mother's COVID-19 diagnosis and oxygen use upon visiting the facility, rather than being informed by the staff as required. The nursing supervisor claimed to have notified the resident's daughter over the phone about the COVID-19 diagnosis and oxygen use, but there was no documentation to support this claim in the resident's clinical records. The resident's daughter stated that she did not receive any phone call regarding her mother's condition and only learned of it during her visit. This lack of communication and documentation led to the deficiency, as the facility did not adhere to its policy of notifying the responsible party of significant changes in the resident's treatment.
Failure to Provide Advanced Notice for Care Plan Meeting
Penalty
Summary
The facility failed to provide advanced notice for participation in a care plan meeting for a resident, identified as Resident R1. The resident was admitted with diagnoses including hypertension, dementia, cerebral infarction, and muscle weakness. The Minimum Data Set Assessment indicated cognitive impairment. The resident's daughter reached out to the facility's social worker to inquire about the care plan meeting date and process but was informed that the social worker did not know. The daughter did not receive any follow-up from the Nursing Home Administrator regarding this inquiry. The resident's daughter reported receiving a call from the social worker on the day of the care plan meeting, August 27, 2024, which was the first notification she received about the meeting. The clinical record lacked evidence of any advanced written or verbal notification to the resident's daughter prior to this call. During an interview, the social worker claimed to have notified the daughter a few days before the meeting, but no documentation could be provided to support this claim. This lack of documentation and communication led to the deficiency cited in the report.
Failure to Provide Written Notification for Room Change
Penalty
Summary
The facility failed to provide written notification to a resident and her responsible parties prior to a room change. The policy of the facility requires that all involved parties receive advanced written notice of room changes, including the reasons for the change, in a language and manner they understand. However, in this case, the resident was moved from the 2nd floor to the 4th floor, designated for long-term care residents, without any written notification being provided to her or her daughters, who are her responsible parties. The deficiency was identified during an interview with the resident's daughter, who discovered the room change upon visiting her mother and inquiring with the nursing staff. The social worker confirmed that the room change was made following a care plan meeting where it was determined that the resident would be a long-term care resident. Despite this decision, no written notification was given to the resident's daughters before the move, which is a violation of the facility's policy and resident rights as outlined in the relevant state codes.
Failure to Investigate Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to conduct a complete and timely investigation into an alleged incident of neglect involving a resident. The resident, who was admitted with diagnoses including hypertension, dementia, cerebral infarction, and muscle weakness, was found by her daughter to be wearing the same soiled gown on consecutive days. The daughter reported this to the nursing supervisor, who provided her with a grievance form. However, the grievance was not promptly addressed, as it remained posted on the board at the nurse's station without further action. Interviews with the nursing supervisors revealed a lack of communication and follow-up regarding the grievance. Nursing supervisor #1 did not retrieve the grievance form from the resident's daughter, and nursing supervisor #2 only became aware of the issue several days later. Despite contacting the daughter for more information, the investigation into the alleged neglect by the nurse aide was not completed in a timely manner. The facility's failure to ensure a thorough and prompt investigation into the potential neglect of the resident violated several Pennsylvania Code regulations related to the responsibility of the licensee, management, resident rights, and resident care policies. This deficiency highlights the facility's inadequate response to allegations of neglect, as evidenced by the delayed investigation and lack of resolution communicated to the resident's family.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically related to falls, for three residents. Resident R65, who was cognitively intact, had a physician's order for bilateral floor mats to be placed next to the bed due to a risk of falls. However, on April 8, 2024, Resident R65 fell out of bed and sustained a head laceration requiring staples because the fall mat was not in place. This incident was confirmed by staff interviews and observations, which also noted the absence of the fall mat during a follow-up visit in August 2024. Similarly, Resident R100, who was at risk for falls due to muscle weakness and lack of coordination, did not have the required bilateral floor mats in place during observations in August 2024, despite a physician's order. Resident R380, with a history of repeated falls and a physician's order for floor mats, was also observed without the mats in place on multiple occasions in August 2024. These failures to adhere to physician orders for fall prevention measures resulted in a hazardous environment for the residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, it was observed that dietary employees were improperly using the dish machine, as the chemical sanitizer was not dispensing correctly, which is necessary for proper sanitation. Additionally, the area under the coffee machine was found to have sticky brown coffee stains and a fruit fly, indicating poor cleanliness. In the dry storage area, an open container of rice was not stored in an air-tight container, and there were expired food items, including cookies and Worcestershire sauce with sticky drippings. Further observations revealed significant cleanliness issues in the walk-in refrigeration, with sticky shelves and a buildup of food debris on the floors. There were also improperly labeled and potentially expired food items, such as lasagna, pickles, and dressings with sticky drippings. The reach-in freezer contained ice cream past its use-by date, and the microwave had significant food buildup. During meal preparation, dietary staff used trays and lids from breakfast without proper cleaning and sanitization, as confirmed by the Food Service Director. These findings indicate a failure to adhere to food safety standards, posing potential health risks to residents.
Deficiencies in Equipment Maintenance and Sanitation Procedures
Penalty
Summary
The facility failed to maintain essential equipment in safe and operating conditions, specifically concerning the dish machine in the main kitchen and the handwashing sink in the laundry area. The dish machine was observed to be improperly used by dietary employees, with the wash temperature at 120 degrees Fahrenheit and the final rinse temperature at only 90 degrees Fahrenheit, which is below the required 180 degrees Fahrenheit for heat sanitation. The chemical sanitizer was not dispensing correctly, as confirmed by the Food Service Director, due to a broken booster and disconnected tubing. The dish machine log inaccurately recorded temperatures as 180 degrees or higher, despite the booster being broken for months. Additionally, dietary staff had not received education on checking sanitizing levels, and the chemical sanitizer was not being logged as required. In the laundry area, the handwashing sink in the soiled section was covered in plastic and confirmed to be broken, with no alternative hand sanitizing options available for staff handling soiled linens. The Director of Maintenance confirmed the sink had been broken for a while, and there were no other means for employees to wash their hands after handling soiled items. Interviews with laundry workers corroborated the sink's prolonged disrepair, indicating a lack of proper maintenance and oversight in ensuring essential equipment is functional and safe for use.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during the dining experience on the third floor. The facility's policy, titled 'The Person Centered Dining Approach,' emphasizes the importance of person-centered care and hospitality services, including dining. However, during an observation on August 5, 2024, it was noted that the dining experience did not align with this policy. The food cart arrived at 12:27 p.m., and staff began distributing food trays, but residents were not served simultaneously at their tables, contrary to the policy. By 12:30 p.m., only nine out of nineteen residents had received their lunch trays, and the remaining trays were for residents eating in their rooms. The dietary staff left the dining room to serve residents in their rooms, further delaying the service for those in the dining area. Additionally, a resident with a vision impairment requested assistance with feeding from a nurse aide. The resident's food was supposed to be served in bowls but was instead served on Styrofoam plates. The nurse aide stood next to the resident while feeding her, which is against the facility's policy that requires staff to sit next to residents when assisting them with eating. The resident was observed with food on her shirt and was not wearing a clothing protector. The nurse aide revealed that staff had been using towels to protect residents' clothing due to a lack of clothing protectors, which had not been available for several months. The second food cart arrived at 12:37 p.m., and all residents in the dining area were served by 12:45 p.m.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on one of its nursing units and the 2nd floor patio. A family member of a resident reported that the facility was not always clean, specifically mentioning trash and clutter in the shower room. Observations confirmed these concerns, revealing a brown-colored dried stain on the wall, broken tiles exposing drywall, a yellowish stain on the toilet seat, dust on the tissue box, and a stained shower curtain. Additionally, the baseboard molding in the shower room was broken or missing. Another shower room was found cluttered with resident shoes, a geri chair, pillows, blankets, a housekeeping broom, and a mechanical lift. In a resident's room, the baseboard molding was broken, and the blanket was stained. The 2nd floor patio smoking area was littered with numerous cigarette butts throughout the area.
Failure to Assess Bed Placement as Restraint
Penalty
Summary
The facility failed to identify beds placed against the wall as a potential restraint and did not assess the functional status of three residents to determine the necessity of such a restraint. The facility's policy on restraints, revised in December 2019, emphasizes providing a restraint-free environment and requires a comprehensive assessment and documentation process for any restraint use. However, observations revealed that three residents had their beds pushed against the wall without any bed rails, and their care plans did not document this preference or assess the need for such an arrangement. These residents, identified as having severe cognitive impairments, were not evaluated for the potential restraint implications of their bed placement. The clinical records of the residents involved showed no assessments for bed rail use, and interviews with the Director of Nursing confirmed that the facility does not utilize bed rails. The residents had various medical conditions, including severe cognitive impairments, which necessitated careful consideration of their care needs. Despite this, the facility did not document or assess the residents' preferences for bed placement against the wall, which could be considered a form of restraint. This oversight indicates a failure to adhere to the facility's policy and regulatory requirements regarding restraint use and resident care planning.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for six residents, leading to deficiencies in addressing their care needs. Resident R65, who was cognitively intact, had a care plan indicating a risk for falls but did not include her preference for having the bed against the wall. Similarly, Resident R189, with severe cognitive impairment, and Resident R25, with spinal stenosis and muscle weakness, also had their beds against the wall without this preference documented in their care plans. Resident R218's care plan similarly lacked documentation for bed placement preference. The Director of Nursing confirmed that residents' preferences for bed placement should be included in their care plans. Additionally, Resident R40, diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, was observed feeling dizzy with an oxygen tank turned on but not administered. The resident's care plan did not address refusals to use oxygen, despite orders for continuous oxygen use. Resident R225, who was readmitted following hospitalization and signed on for hospice services, did not have hospice services included in their care plan. These findings were confirmed by the Director of Nursing, indicating a failure to ensure comprehensive care plans were developed for these residents.
Failure to Monitor and Modify Nutritional Interventions
Penalty
Summary
The facility failed to adequately monitor and modify nutritional interventions for several residents, leading to significant weight loss and potential malnutrition. Resident R65, who was cognitively intact and diagnosed with malnutrition, experienced a significant weight loss of 6.32% in one month and continued to lose weight over the following months. Despite the facility's policy requiring the dietitian to reassess nutritional needs in such cases, there was no documented evidence that the dietitian was informed or that interventions were modified to address the resident's needs. Resident R100, who had a history of weight loss and was at risk for malnutrition, also experienced significant weight loss. The resident reported difficulties with chewing and swallowing, leading to poor meal intakes. Despite these issues, there was no documented evidence that the dietitian was made aware of the resident's poor intake or that interventions were adjusted to maintain nutritional status. Additionally, the facility failed to obtain and document the resident's weight for July and August, further neglecting the monitoring of the resident's nutritional status. Resident R114, with moderate cognitive impairment and a diagnosis of psychotic disorder, was at risk for malnutrition due to dysphagia and weight loss. The facility did not obtain a weight for the resident in June, and there was no further information available regarding the resident's nutritional status. Similarly, Resident R69 experienced significant weight loss over three months, but there was no documented evidence that the weight loss was addressed or that a nutrition assessment was completed. The dietitian confirmed the lack of documentation and intervention for these residents, indicating a systemic failure to adhere to the facility's nutritional policies.
Failure to Follow Menus and Meet Nutritional Needs
Penalty
Summary
The facility failed to ensure that menus were followed to meet the daily nutritional needs and preferences of residents across all six nursing units. During observations, it was noted that milk, which was part of the menu for breakfast, lunch, and dinner, was not provided to residents during the lunch meal on August 5, 2024. Instead, water or juice was substituted without proper documentation or notification to residents. Additionally, the dessert provided on August 6, 2024, was plain cheesecake instead of the cherry cheesecake listed on the menu, with no documentation to support the unavailability of cherries or other substitutes. The Food Service Director confirmed these discrepancies and acknowledged that residents were not informed of the menu changes. Specific residents were affected by these deficiencies. Resident R114 and Resident R100, who had requested whole milk with all meals, did not receive it as specified in their nutrition assessments and meal tickets. Furthermore, Resident R76, who was on a pureed diet due to dysphagia and at risk for malnutrition, was only provided with yogurt for breakfast instead of the pureed items listed on the meal ticket. This was confirmed by a nurse aide who reported that the kitchen often sent only yogurt for meals instead of the ordered menu items. These failures were in violation of dietary and nursing service regulations.
Pest Control Deficiency in Resident and Common Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in multiple areas, including resident rooms on the second and third floors, a first-floor conference room, and the second-floor nursing area. Observations made on August 5 and 6, 2024, confirmed the presence of flies in these areas, with housekeeping staff and facility administration acknowledging the issue. The pest control logs from July 2024 documented repeated reports of fly sightings in various rooms, yet the weekly pest control company reports from the same period showed no evidence of fly sightings or treatments targeting flies. Additionally, during an initial tour of the main kitchen on August 5, 2024, with the Food Service Director, it was observed that there were multiple brown coffee stains under the coffee machine, which were sticky to the touch, and a fruit fly was present. A prep sink next to the stove had broken tile beneath it and a pool of stagnant water, further contributing to the pest issue. These findings indicate a lack of effective pest control measures and maintenance in the facility, leading to the observed deficiencies.
Failure to Develop Baseline Care Plan for Substance Abuse Disorder
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with a history of polysubstance disorder, which included the necessary information to properly care for the resident. The resident, identified as having a severe wound related to drug use, was admitted with diagnoses of septic shock, opioid drug use, and depression. Despite being on medications such as Suboxone for opioid abuse disorder and a nicotine patch for smoking dependence, the facility did not create a care plan addressing the resident's substance abuse disorder and the required support services. Interviews with the resident and facility staff confirmed the absence of a baseline care plan for the resident's substance abuse disorder. The resident expressed that her drug abuse problem was not being managed properly, particularly noting unmanaged pain in her lower extremity. The Director of Nursing and Assistant Director of Nursing acknowledged the oversight, confirming that a baseline care plan for substance abuse disorder was not developed for the resident, which is a violation of the facility's resident care policies.
Deficient Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, which did not align with the facility's policy and federal and state regulations. For Resident R144, the facility did not create a separate discharge planning record that focused on the resident's discharge goals, preparation for post-discharge care, and reduction of preventable readmissions. The care plan for Resident R144 was outdated and lacked information on support systems, barriers, care needs, and external agency involvement, despite the resident's expressed wish to discharge home and the involvement of an outside agency. Similarly, for Resident R226, the facility did not update the care plan to reflect the resident's discharge goals, support systems, and care needs. Although the resident expressed a desire to discharge home with his wife, the care plan did not include information on external agencies or address potential barriers to discharge. The care plan was not updated to reflect the family's consideration of long-term care based on the resident's progress in therapy. These deficiencies indicate a lack of adherence to the facility's discharge planning policy and failure to adequately prepare residents for discharge.
Failure to Provide Necessary Equipment for Resident's Mobility
Penalty
Summary
The facility failed to provide necessary equipment to maintain a resident's functional status in range of motion and mobility. Resident R56, who was admitted with diagnoses including aphasia related to cerebrovascular disease, hemiplegia, hemiparesis following cerebral infarction, general weakness, and unspecified lack of coordination, was observed multiple times without the prescribed right palm guard. The occupational therapy discharge note recommended a restorative nursing program that included applying a right palm guard during morning care and removing it during evening care. A physician's order dated March 27, 2024, also specified the use of the palm guard during a.m. care and its removal during p.m. care. Despite these orders and recommendations, observations on August 5, 6, and 8, 2024, revealed that Resident R56 was not wearing the palm guard while in the dining room. The resident's right hand was observed in a fist, indicating a lack of the prescribed support. Interviews with the Director of Nursing confirmed the absence of the palm guard, and the resident indicated that staff did not apply the hand guard in the morning. This deficiency was noted under 28 Pa. Code 201.18(b)(2) Management and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Adhere to PICC Line Care Protocol
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a Peripherally Inserted Central Line Catheter (PICC line) in accordance with professional standards of practice. The facility's policy required that the external PICC catheter be measured on admission and noted with every dressing change, with transparent dressings labeled and changed every seven days or more frequently if necessary. However, for Resident R529, there was no documentation on the dressing to indicate the date and time of the last change, and the dressing had not been changed since the resident's admission. The treatment administration record (TAR) indicated that dressing changes were signed off as completed on specific dates, but these changes were not actually performed, and the required assessments, such as external catheter length and arm circumference measurement, were not completed as ordered by the physician. An interview with the Director of Nursing confirmed that the PICC line dressing change, assessment, and monitoring were not completed for the resident as ordered by the physician and according to the facility protocol. The resident stated that the dressing was last changed in the hospital, and there was no documentation of a dressing change in the TAR for the shift when it was reportedly changed. This lack of adherence to the facility's policy and physician's orders resulted in a deficiency in the care provided to the resident.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident R100, who was admitted with a diagnosis of fractures and other multiple trauma. The resident had a physician's order for Enoxaparin injection, a medication used to prevent blood clots, to be administered once daily. However, the medication was not administered on two consecutive days, June 20 and June 21, 2024. The clinical records indicated that the medication was on order and awaiting pharmacy delivery, but lacked further information or documentation of actions taken to address the unavailability. The facility's policy on unavailable medications requires staff to take immediate action when a medication is unavailable, including notifying the physician, obtaining alternative treatment orders, and determining the reason for the unavailability. In this case, there was no documented evidence that the physician was informed of the missed doses, that alternative treatment was requested, or that specific orders for monitoring the resident were obtained. Additionally, there was no documentation showing that the licensed nurse determined the reason for the medication's unavailability or the efforts made to obtain it.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by multiple errors observed during medication administration. On August 6, 2024, a licensed nurse, Employee E7, administered Fluticasone Propionate Nasal Suspension incorrectly to Resident R135 by giving one spray to each nostril instead of the prescribed two sprays to alternating nostrils. Additionally, Employee E7 did not administer the prescribed dose of buPROPion HCl to Resident R135 because the medication was unavailable at the time. These actions contributed to the facility's medication error rate. Further errors were observed with Resident R63, where Employee E7 attempted to crush extended-release medications, which could alter the drug's release characteristics and potentially lead to adverse effects. The nurse was prevented from administering these crushed medications. Additionally, Employee E7 administered Magnesium Oxide instead of the prescribed Magnesium Lactate, which has different absorption properties. These errors, confirmed by Employee E7, contributed to the facility's medication error rate of 19.23%, significantly exceeding the acceptable threshold.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards, as evidenced by several observations and interviews. On the second floor, a medication cup containing six pills was found on top of a resident's breakfast tray. The resident's son reported that he found the cup near the foot of the bed and moved it to prevent spillage. An employee confirmed that the resident was not supposed to self-administer medication and suggested that the pills might have been left by a previous shift. On the fourth floor, the unit manager's office door was found wide open, with a stack of medication blister packs visible on a file cabinet near the open door. Additionally, in another resident's room on the fourth floor, a medication cup with half a nicotine tablet and a Symbicort inhaler were found on an overhead table. The resident confirmed that he had cut the tablet himself and that the nurse had left the medications with him about an hour prior. The resident's clinical records showed physician's orders for both the Symbicort inhaler and nicotine gum.
Incomplete Reporting of Resident Fall Incident
Penalty
Summary
The facility failed to submit complete and accurate information to the State Survey Agency regarding a fall incident involving a resident, identified as Resident R65. The incident occurred on April 8, 2024, when Resident R65, who was cognitively intact, fell in her room and sustained a laceration to the forehead. The facility's documentation reported that safety measures were in place at the time of the fall, and the resident was transferred to the hospital for evaluation, where a CT scan showed no acute findings. However, the facility's report omitted critical details, such as the absence of the required bilateral floor mats next to the bed, which were ordered by the physician on March 5, 2024, and the fact that the resident's laceration required treatment with four staples during hospitalization. The incident report completed by a Registered Nurse Supervisor indicated that the fall was unwitnessed and occurred at approximately 3:15 a.m. when Resident R65 was found on the ground next to her bed. During an interview, the resident confirmed that she fell out of bed while reaching for her call bell. The facility's failure to include these pertinent details in the report to the State Survey Agency contributed to the deficiency, as it did not accurately reflect the circumstances leading to the resident's injury and the subsequent medical treatment required.
Failure to Notify Family of Dislodged Nephrostomy Tube
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition when a nephrostomy tube became dislodged. The facility's policy requires that residents with nephrostomy or cystostomy tubes receive care consistent with professional standards and that any changes in condition be communicated to the resident's representatives. However, in the case of a resident with multiple diagnoses including hypertension, diabetes, and Alzheimer's disease, there was no documented evidence that the next of kin was informed about the dislodged nephrostomy tube. The nursing note indicated that the resident was alert and oriented to person, time, and place, with baseline confusion, and showed no signs of distress or discomfort. The physician's answering service was notified, but the resident's family was not informed, violating the resident's rights and nursing services regulations.
Failure to Provide Anonymous Grievance Filing
Penalty
Summary
The facility failed to provide residents the ability to file grievances anonymously across all eight nursing units, including Clivden and Mount Airy floors from the second to the fifth. The facility's grievance policy, revised on November 28, 2021, states that grievances can be filed anonymously, but during a tour on August 7, 2024, it was observed that there were no grievance boxes available on any of the units or the first floor to facilitate anonymous submissions. An interview with the Social Work Director, Employee E14, confirmed the absence of lock boxes for anonymous grievances. Instead, residents were instructed to submit grievances by handing them to nursing staff, the Social Work Director, or by sliding them under the door of her office. This practice contradicts the facility's policy, which assures residents the ability to file grievances without fear of reprisal, including anonymously. The deficiency was noted under 28 Pa. Code 201.18(b)(2) Management and 28 Pa. Code 201.29(a)(i) Resident rights.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing staffing information was posted daily in a prominent place readily accessible to residents on the Second, Third, and Fourth floors. Observations conducted on August 5 and 6, 2024, revealed that the staffing data was only posted in the first-floor lobby area. This arrangement made it difficult for residents, particularly those on the locked third-floor nursing unit, to access the information without staff assistance. The deficiency was confirmed during a meeting with the Nursing Home Administrator and Director of Nursing on August 7, 2024.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to ensure the completeness of medication administration records for a resident, identified as Resident R2. A review of Resident R2's physician orders for March 2024 indicated daily medications including Atorvastatin for high cholesterol, Diazepam for anxiety, Hydroxychloroquine for an infection, and Pantoprazole for GERD. However, the medication administration record (MAR) for March 2024 lacked documentation for several scheduled doses: Atorvastatin on March 20, Diazepam on March 16, 17, and 20, Hydroxychloroquine on March 20, and Pantoprazole on March 18. An interview with the Director of Nursing (DON) confirmed the absence of documentation in the MAR for these medications. This deficiency was identified during a review of clinical records and staff interviews, indicating a failure to maintain complete medication administration records in accordance with accepted professional standards.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across three floors, as observed during a survey. On the fifth floor, a resident's fall mat was found soiled with feces. On the second floor, multiple rooms were observed with trash under beds, including plastic cups, paper, food particles, and a moldy sandwich. A heavy smell of urine was noted in several areas, and hand sanitizer units were either empty or broken. A small white pill was found on the floor, and a toilet was dirty with smeared feces. These findings were confirmed by the head of housekeeping and the Director of Nursing. On the third floor, similar issues were observed, including a heavy smell of urine in several rooms, a sticky floor, and water-stained tiles above a resident's bed. A housekeeping staff member was observed texting on the phone instead of attending to cleaning duties. Trash was found under beds, and a sanitizer unit was broken and not filled. These observations indicate a failure to adhere to the facility's policy on routine cleaning and disinfection, compromising the residents' right to a safe and sanitary environment.
Inadequate Smoking Supervision and Policy Violation
Penalty
Summary
The facility failed to maintain a safe environment free from hazards related to smoking supervision for one of the residents reviewed. During an observation of the designated smoking area, it was noted that a staff member, Employee E10, was inattentive, sitting in a corner and looking at her phone while ten residents were smoking. This lack of supervision allowed two residents to share a lighter back and forth, which is against the facility's smoking policy that requires supervision of all smokers and secure handling of smoking materials. Additionally, a lighter was found on the bedside table of Resident R5, which is a violation of the facility's policy that mandates smoking materials be kept in a safe and secure area. When a licensed nurse, Employee E8, was called to the room, the presence of the lighter was confirmed, and Resident R5 was reminded of the smoking policy. The resident agreed to have the lighter locked up, indicating a lapse in adherence to the established procedures for smoking material security.
Failure to Update Care Plan for Resident Refusals
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident R12, to include interventions for refusals of care. Resident R12 was admitted with multiple wounds and had specific orders for wound care. However, the resident consistently refused treatments, including wound care and necessary blood draws, as documented in nursing progress notes. Despite these refusals being noted from December 5, 2023, to December 12, 2023, the care plan was not updated to address these refusals until December 13, 2023. The resident's refusals were due to pain and a desire to be left alone, as noted in the progress notes. The resident also became physically combative during wound care, indicating a significant challenge in providing necessary medical interventions. The facility's policy requires a comprehensive individualized care plan, but the delay in updating the care plan to include interventions for refusals represents a deficiency in meeting this requirement.
Failure to Maintain Current Nurse Staffing Information
Penalty
Summary
The facility failed to accurately display the daily nurse staffing information as required by regulations. On May 7, 2024, it was observed that the staffing information posted in the front lobby was outdated, showing data from April 3, 2024. Further inspection of three out of five floors revealed that no staffing information was posted throughout the building. An interview with the Director of Nursing and the staffing coordinator confirmed that the posted staffing information was not current, and the data in the lobby was inaccurately labeled as it was actually from April 10, 2024. This indicates a failure to maintain up-to-date staffing postings as required by the regulations.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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