Cathedral Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 600 East Cathedral Road, Philadelphia, Pennsylvania 19128
- CMS Provider Number
- 395467
- Inspections on file
- 30
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cathedral Village during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and other comorbidities had a care plan requiring use of a sit‑to‑stand mechanical lift with two staff for all transfers, but a CNA attempted a bed‑to‑chair transfer without using the prescribed two‑person stand‑up lift, instead standing the resident at the bedside and then lowering the resident to the floor when the resident could not stand. The CNA had access to the Kardex and assignment sheet but did not ensure the transfer method matched the care plan, while another CNA reported believing the resident was a stand‑and‑pivot transfer. Review of several days of documentation showed inconsistent recording of the resident’s transfer status, with entries alternating between two‑person assist/total dependence and one‑person assist, extensive assistance, independence, or not applicable, and the NHA confirmed the transfer was not performed according to the plan of care and that mechanical lifts require two staff.
A resident with CVA, depression, hemiplegia, and ADL self-care deficits had a care plan requiring two staff (paired care) for all ADLs due to limited mobility, dementia, and resistive behaviors. Despite this, a CNA provided care alone and, while attempting to clean the resident’s hand, the resident became agitated, pulled away, and sustained a skin tear to the right hand. The administrator later confirmed that paired care was required and was not followed, constituting a failure to implement the care plan.
Multiple residents with significant neurological and mobility impairments did not receive necessary assistance with nutrition, incontinence care, and positioning after a nurse assistant was found asleep during their shift. As a result, residents were left soiled, unkempt, and in uncomfortable or unsafe positions, with some not receiving timely feeding or hygiene care.
Surveyors observed that food items in the facility's food service department were not accurately labeled with the correct date of receipt or preparation, and in some cases, lacked any received date. Staff confirmed that original dates were removed and replaced with the current date during the survey, and no documentation was provided to verify actual delivery or preparation dates, in violation of facility policy and professional standards.
A resident with arthritis, muscle weakness, and a history of falls was found on the bathroom floor after reportedly calling for help and not receiving staff assistance. Despite facility policy requiring thorough investigation of neglect allegations, no incident report or investigation was completed by the facility, as confirmed by the DON.
A licensed nurse administered an incorrect dosage of Citalopram to one resident and crushed medications for another resident against physician orders, resulting in a medication error rate of 11.54%, which exceeds the acceptable threshold.
A Licensed Nurse failed to follow physician orders for two residents by administering an incorrect dose of Citalopram to one resident and crushing medications that were ordered not to be crushed for another. These actions resulted in a significant medication error rate of 11.54%.
A resident with severe cognitive and physical impairments, known for combative behaviors, was not provided the required two-person assistance during incontinence care. While being assisted by only one nurse aide, the resident became combative, leading to an incident where the aide moved the resident's arm, resulting in a fracture. Facility investigation confirmed neglect due to failure to follow the care plan.
The facility failed to meet food safety standards, with inadequate sanitizer concentration in dishwashing and improper labeling and storage of food items. Observations revealed unlabeled briskets and meats labeled only with distributor dates, while potentially hazardous foods were stored beyond the allowed 72 hours, violating facility policies.
The facility did not properly dispose of garbage and refuse, as observed during a tour of the Food Service Department. Debris, including used latex gloves, paper, and plastic waste, was found around the trash compactor, along with large puddles of oily liquid discharge. These issues were confirmed by the Assistant Food Service Director.
A resident's dignity was compromised when a staff member used a loud cell phone in the resident's room, disrupting their sleep. The resident, with conditions including Permanent Atrial Fibrillation and Type 2 Diabetes, reported the incident, and the staff member apologized. The facility's policy prohibits cell phone use in residents' rooms, highlighting a deficiency in maintaining resident rights.
A Nurse Aide verbally abused a resident after a piece of paper accidentally hit the resident. The aide, upset over a work assignment change, used inappropriate language towards the resident, who had a history of Type 2 Diabetes Mellitus and cardiac issues. The incident was confirmed by the facility's investigation.
A resident with COPD and dependent on supplemental oxygen was observed receiving oxygen at 4 Liters/Min instead of the physician-ordered 2 Liters/Min. This discrepancy was confirmed by the DON.
A facility failed to maintain a medication error rate below five percent, as a nurse administered incorrect dosages and forms of Memantine and Ferrous Sulfate to a resident. The errors, confirmed by the DON, resulted in a medication error rate of 7.14%, exceeding the regulatory threshold.
The facility failed to adhere to its infection control policy by not disinfecting a sphygmomanometer between uses on multiple residents during medication administration. This oversight was confirmed by a Licensed Nurse and a Registered Nurse, highlighting a deficiency in the facility's infection prevention and control program.
The facility failed to meet required nurse aide staffing ratios on multiple occasions, as evidenced by a review of staff schedules and punch reports. On several days, the facility did not provide the necessary hours of nurse aide care based on the resident census, with no additional staff available to cover the shortfall. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to maintain the required LPN-to-resident staffing ratios on six days, as evidenced by a review of nursing staff schedules and punch reports. On multiple occasions, the facility did not provide the necessary hours of LPN care during the day, evening, and overnight shifts, leading to a deficiency in staffing requirements.
The facility did not meet the required 3.20 hours of direct nursing care per resident on three occasions. With varying census numbers, the facility provided between 3.14 and 3.17 hours of care per resident, falling short of the mandated minimum. This was confirmed by the Nursing Home Administrator upon review.
A resident with physical impairments was served hot water by a nursing assistant who did not check the temperature, resulting in a second-degree burn. The dietary department was responsible for cooling beverages, but the assistant served the water directly from the dispenser. The facility lacked a policy on hot beverage temperatures at the time.
A facility failed to ensure six employees, including an unlicensed staff member, had the necessary skills and competencies to provide nursing care, resulting in an Immediate Jeopardy situation. Employee E21, who worked as an RN without proper licensure or competency evaluation, placed 63 residents at risk. The facility lacked evidence of competency evaluations for other nurses, and the Director of Nursing confirmed that required evaluations had not been completed in the past year.
An unlicensed staff member, Employee E21, provided care as an RN to 63 residents without a verifiable nursing license or educational background, resulting in an Immediate Jeopardy situation. The facility failed to verify the authenticity of the employee's credentials, allowing them to administer medications and perform complex assessments without proper qualifications.
The facility failed to serve food at palatable temperatures on the second and third floor nursing units. Residents reported cold food, and test trays confirmed that food temperatures were below the facility's standards. A resident also noted that her breakfast was lukewarm, highlighting ongoing issues with food service.
The facility failed to inform residents or their representatives about an investigation into a staff member, Employee E21, who provided care under a fraudulent nursing license. Employee E21 worked 30 shifts, caring for 63 residents, while under investigation for identity theft and fraud. This lack of communication violated resident rights and facility policy.
The facility failed to provide scheduled showers for several residents due to insufficient staffing. A cognitively impaired resident was observed with unkempt hair, and family members expressed concerns about missed showers. Documentation revealed significant gaps in recorded showers, with some residents not receiving any showers for weeks, violating state care policies.
The facility failed to serve meals in accordance with resident preferences, resulting in significant delays. Residents on the 2nd and 3rd floors experienced long waits for lunch, with some not served until well after the scheduled time. Breakfast was also served late to several residents. The delay was due to the dietary employee handling both meal plating and order taking, as confirmed by the Food Service Director.
The facility failed to maintain an effective antibiotic stewardship program by not reviewing antibiotic usage for appropriateness or adherence to criteria for three consecutive months. Despite using multiple antibiotics for numerous residents, the necessary reviews were not conducted, violating the facility's policy and regulatory standards.
The facility failed to thoroughly investigate an identity theft allegation involving a nurse, Employee E21, who provided care to 63 residents using a fraudulent RN license. Despite the serious nature of the allegations, the investigation did not include interviews with the affected residents or the staff responsible for hiring and verifying the nurse's credentials.
A resident with multiple health issues exhibited new belligerent and uncooperative behaviors, which were documented and addressed by staff and physicians. Despite daily monitoring and a physician's order for Ativan, the care plan was not updated to include these behaviors, as confirmed by a licensed nurse.
A resident with Parkinson's disease did not receive their Carbidopa-Levodopa medication at the prescribed times, as required by physician orders. The facility's policy mandates timely administration, but records show multiple instances of early, late, or missed doses over several weeks, leading to a deficiency in care.
A resident with limited ROM did not receive appropriate care as per physician orders. Despite an order to wear a splint on the left upper extremity at all times, observations confirmed by nursing staff showed the resident was not wearing the splint on multiple occasions. This failure contravenes the facility's restorative care policy aimed at preventing decline and maintaining function.
A resident with dementia and Parkinson's Disease fell in the dining room when attempting to stand from a wheelchair without footrests. The resident, who had a history of falls and cognitive impairments, grabbed a table and fell forward. The facility failed to use necessary assistance devices, such as footrests, to prevent the accident.
A resident with osteoporosis and a pathological fracture experienced constant pain, affecting sleep and daily activities. Despite physician orders for Acetaminophen and Oxycodone, the facility failed to administer pain medication on a day the resident complained of severe pain. The DON confirmed no pain assessment was conducted, highlighting a deficiency in pain management practices.
A medication cart on the second floor was found unattended and unlocked, with a drawer open, contrary to facility policy requiring carts to be locked when not attended by authorized personnel. A licensed staff member, who had left the cart to assist a resident, returned shortly to secure it.
The NHA and DON failed to ensure that staff had the required licenses, resulting in an unlicensed individual providing RN care. Employee E21 worked independently for 23 shifts without verifiable credentials, leading to an immediate jeopardy situation due to discrepancies in identification documents.
A nurse aide breached infection control protocols by inserting her finger into a resident's food to check its temperature, contrary to the facility's policy. The policy requires testing food temperature by placing a hand over the food without direct contact. This incident occurred while the aide was assisting a resident with dining.
Failure to Follow Care-Planned Transfer Method Resulting in Unsafe Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from accident hazards and that transfers were performed in accordance with the resident’s care plan. The resident had diagnoses including Alzheimer’s disease, chronic kidney disease, and depression, and the care plan in place since July 21, 2025 specified that the resident required a sit‑to‑stand mechanical lift with two staff for all transfers. On the date of the incident, a nurse aide (Employee E3) attempted to transfer the resident from bed to chair without using the prescribed two‑person stand‑up lift and instead stood the resident up from the edge of the bed. When the resident was unable to stand, the aide guided the resident down to the floor mat and then sought assistance from other staff. Interviews and documentation showed that the aide performing the transfer did not verify or follow the resident’s transfer status as outlined in the care plan and available in the Kardex and assignment sheet. Another nurse aide (Employee E4) reported having given shift report and that the aide had access to the Kardex and assignment information, but believed the resident was a stand‑and‑pivot transfer. Review of transfer documentation from several days around the incident revealed inconsistent recording of the resident’s transfer needs, with some entries showing two‑person assist and total dependence, and others documenting one‑person assist, extensive assistance, independence, or not applicable. The Nursing Home Administrator confirmed that the aide did not ensure the transfer method was consistent with the plan of care and that any mechanical lift requires two staff to operate.
Failure to Implement Paired Care Interventions Resulting in Skin Tear
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions requiring paired care for a resident with significant self-care deficits. The resident had a history of CVA, depression, and hemiplegia, was cognitively intact, and was assessed as dependent on staff for toileting hygiene and shower/bathing, and needing partial/moderate assistance with personal hygiene. The comprehensive care plan identified an ADL self-care performance deficit related to dementia, hemiplegia, and limited mobility, and an intervention revised in October 2025 specified that two staff members were to participate in all care for this resident (paired care). A subsequent care plan dated in November 2025 documented that the resident was resistive to care and used foul language or made derogatory statements toward staff. On the date of the incident, a nurse aide provided care to the resident alone, without a second staff member, contrary to the paired care intervention in the care plan. During this care, the resident became agitated while the aide was attempting to clean the resident’s hand. The resident quickly pulled the hand away and sustained a skin tear to the top of the right hand. The resident reported that the aide had hurt the hand and stated an intention to report the aide. The Nursing Home Administrator confirmed that the resident required paired care and that the nurse aide failed to implement the care plan interventions by not providing paired care at the time of the incident.
Failure to Provide Assistance with ADLs Due to Staff Neglect
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically related to nutrition, incontinence care, and positioning, for five residents. Clinical records revealed that these residents had significant medical conditions, including progressive neurological disorders, dementia, Parkinson's disease, aphasia, hemiparesis, and spinal stenosis, resulting in high levels of dependency for basic care needs such as eating, oral hygiene, toileting, personal hygiene, and mobility. The Minimum Data Set assessments indicated that these residents required maximal or total assistance from staff for these activities. On the date in question, facility documentation and staff statements confirmed that several residents did not receive required incontinent care, and one resident was found with food in their mouth after the evening meal had ended. Observations included residents being unkempt, soiled, and uncomfortable, with one resident lying flat with food in their mouth unsupervised, another with a bowel movement that had soiled their clothing, and another in bed with their head and feet hanging off opposite sides of the mattress. Two additional residents were found wet and in need of incontinent care that appeared to have been delayed for an extended period. The deficiency was linked to a nurse assistant being observed asleep in a resident room by multiple staff members, resulting in the neglect of care for these residents. Staff interviews confirmed that the nurse assistant had been sleeping during their shift, which directly contributed to the residents not receiving timely and appropriate care as required by their conditions and care plans.
Failure to Accurately Label and Date Food Items in Food Service Department
Penalty
Summary
Surveyors found that the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a tour of the Food Service Department, multiple food items, including eye of round bottom, raw ground beef, and boxes of chicken thighs, were observed to be labeled with the same date as the survey date, rather than the actual date of receipt or preparation. The Food Service Director acknowledged that the original dates had been removed and replaced with the current date specifically due to the survey, and was unable to provide documentation verifying the actual delivery or preparation dates of these items. Further observations revealed that several other food items, such as chicken thighs, jumbo wings, brisket, beef chuck, beef hot dogs, and veal, were not labeled with a received date at all. This failure to accurately label and date food items is contrary to the facility's own policy, which requires all received food products to be clearly marked with the date received and prohibits reliance on distributor dating. The deficiency was confirmed through staff interviews and direct observation, with no evidence provided to support proper food rotation, storage, or safety practices.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of neglect involving one resident. According to facility policy, all events involving evidence of abuse or neglect should be thoroughly investigated, including obtaining statements from all potential persons who might have had contact with the resident within the relevant timeframe. However, when a resident was found on the bathroom floor after attempting to call for help and not receiving a response, no incident report or investigation was initiated by the facility. The Director of Nursing confirmed that there was no documentation or investigation available regarding the resident's allegation that staff did not respond to their request for assistance, which led to the resident attempting to ambulate independently and subsequently falling. The resident involved had a history of arthritis, polyosteoarthritis, and muscle weakness, and required supervision or assistance for walking and toilet transfers. The resident was identified as being at risk for falls due to pain with movement and osteoarthritis, and used both a walker and wheelchair for mobility. Despite these documented needs and risks, the facility did not follow its own policy to investigate the circumstances surrounding the resident's fall and the alleged lack of staff response, resulting in a failure to rule out neglect.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, during medication administration for two of three residents observed. One resident was administered a total of 30 mg of Citalopram (Celexa) by a licensed nurse, despite the physician's order specifying only 20 mg daily for Generalized Anxiety Disorder. In another instance, the same nurse crushed and prepared to administer Clopidogrel 75 mg and Senna Plus Stool Softener tablets to a different resident, even though the physician's orders explicitly stated that these medications should not be crushed. Both errors were confirmed by the nurse at the time of observation. The facility's medication error rate was calculated at 11.54%.
Significant Medication Administration Errors by Licensed Nurse
Penalty
Summary
A Licensed Nurse (E6) failed to administer medications in accordance with physician orders for two residents during observed medication administration. For one resident (R67), the nurse administered both a 20 mg and a 10 mg tablet of Citalopram (Celexa), totaling 30 mg, despite the physician's order specifying only 20 mg daily for Generalized Anxiety Disorder. The nurse confirmed this error during an interview at the time of the finding. For another resident (R32), the same nurse dispensed and crushed Clopidogrel 75 mg and Senna Plus Stool Softener tablets, even though the physician's orders explicitly stated that these medications should not be crushed. The nurse also confirmed this deviation from the orders during an interview. The facility incurred a medication error rate of 11.54% as a result of these incidents.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, quadriplegia, multiple sclerosis, dementia, and a history of combative behaviors was not provided the required two-person assistance during incontinence care. The resident was assessed as being totally dependent on staff for toileting and bed mobility, with documented behaviors of physical and verbal aggression. Facility policy and the resident's care plan both specified the need for two staff members to be present during care due to the resident's behavioral and physical needs. On the day of the incident, only one nurse aide provided care to the resident, despite the care plan's requirement for two staff members. During the care, the resident became combative, grabbing the nurse aide's thigh with both hands. The nurse aide attempted to remove the resident's hand by moving the resident's arm, at which point a loud pop was heard and the resident cried out in pain. The resident was subsequently assessed, sent to the emergency department, and diagnosed with a closed fracture of the right humerus. The facility's internal investigation substantiated neglect, confirming that the required two-person assistance was not provided during care, which directly resulted in actual harm to the resident. Interviews with facility leadership confirmed the resident's behavioral history and the failure to follow the care plan on the day of the incident.
Deficiencies in Food Safety and Sanitization Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in their food storage and sanitization processes. During an inspection, it was observed that a kitchen staff member was manually washing dishware using a three-compartment sink, but the sanitizer concentration was found to be inadequate at 100 parts per million (ppm) instead of the required 200 ppm. Additionally, the facility's documentation for the pot sink temperature sanitizing concentration log showed faulty test strips, which were taped to the log and appeared white, indicating inaccurate readings. This lack of proper concentration solution maintenance was confirmed by the Assistant Food Service Director. Further observations in the main refrigerator revealed that two 10-pound briskets were unlabeled and undated, and other meats such as burgers, lamb, pork boneless loin, and beef roasts were only labeled with the distributor's received date. Potentially hazardous foods, including Buffalo chicken breast, turkey breast, cooked salami, and smoked ham, were found to have been stored for more than 72 hours, contrary to the facility's policy. These findings indicate a failure to comply with the facility's policies on labeling, dating, and storing food, which are essential for ensuring food safety.
Plan Of Correction
1. All undated or outdated food was discarded, the manually washed dishware were re-washed utilizing the dishwasher, and the sanitizer concentration used in the three compartment sink was adjusted to meet the required threshold following the event. 2. The Dining Manager or designee will conduct an audit on current foods being stored in the kitchen and on the nursing units to ensure no undated or outdated food items are present. The Dining Manager or designee will also conduct an audit testing the concentration of the sanitizer in the pot sink to ensure compliance with community policies and requirements by 2/28/25. 3. The Corporate Director of Dining or designee reviewed and if indicated, updated community policies for: "Sanitizing of Equipment Policy" including the "Pot sink Temperature Sanitizing Concentration Log;" "Labeling and Dating of Food Policy;" and "Leftover Foods Policy" by 2/28/25. The Director of Dining or designee will provide re-education on current policies to dining team members: "Sanitizing of Equipment Policy" including the "Pot sink Temperature Sanitizing Concentration Log;" "Labeling and Dating of Food Policy;" and "Leftover Foods Policy" by 3/10/25. 4. The Dining Manager or designee will complete an audit reviewing dates are listed in accordance with policy for foods being stored in the kitchen or nursing units, reviewing the sanitizer.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by observations during a tour of the Food Service Department. During the inspection, significant debris was noted around the trash compactor, including used latex gloves, paper, plastic waste, and piles of leaves. Additionally, large puddles of oily liquid were observed discharging from the trash compactor. These findings were confirmed in an interview with the Assistant Food Service Director, Employee E4.
Plan Of Correction
1. The area surrounding the trash compactor is clean and free from debris and oily liquids. 2. The Dining Manager or designee will conduct an audit on the area surrounding the trash compactor to ensure that it is clean and free of debris and oily liquids and in compliance with community policies and requirements by 2/28/25. 3. The Director of Dining or designee will provide re-education on community policies on properly disposing of garbage to dining team members by 3/10/25. 4. The Dining Manager or designee will complete an audit reviewing the area surrounding the trash compactor, ensuring that it is clean and free from debris and oily liquids weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Resident Dignity Compromised by Staff Cell Phone Use
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R50, due to the unprofessional use of a cell phone by a staff member. Resident R50, who was admitted with diagnoses including Permanent Atrial Fibrillation and Type 2 Diabetes, reported being unable to sleep well because a Licensed Nurse, Employee E9, had a very loud cell phone. This incident occurred on January 30, 2025, at 5:06 a.m., and the nurse did apologize to the resident for the disturbance. During an interview on February 4, 2025, the Nursing Home Administrator and Director of Nursing confirmed that staff were not permitted to use cell phones in residents' rooms. This incident was identified as a failure to ensure the resident's dignity was maintained, as required by the regulations, and was documented as a deficiency in the facility's compliance with resident rights.
Plan Of Correction
1. R50 was evaluated by social service worker, had no ill effects noted from event, and is no longer a community resident. 2. Nursing Home Administrator or designee will complete a random audit on all shifts to monitor for team member compliance with "Cell Phone Policy" to ensure dignity is maintained for current residents by 2/28/25. 3. The Nursing Home Administrator or designee will provide re-education to current team members on the "Cell Phone Policy" including cell phone use in resident care areas is prohibited and the "Dignity Policy" by 3/10/25. 4. The Nursing Home Administrator or designee will complete a random audit on 5 residents who are receiving care to ensure compliance with the community "Cell Phone Policy" and "Dignity Policy" weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to Quality Assurance Process Improvement team for review and recommendations.
Verbal Abuse Incident Involving Nurse Aide
Penalty
Summary
The facility failed to ensure that a resident remained free from verbal abuse, resulting in emotional distress for one resident. The incident involved a Nurse Aide, identified as Employee E10, who verbally abused a resident, referred to as Resident R38. The situation arose when Employee E10 attempted to throw a piece of paper into a trash can, but it accidentally hit Resident R38. In response, Resident R38 informed the Nurse Aide about the incident, which led to the Nurse Aide yelling and using inappropriate language towards the resident. This interaction was witnessed by a Nurse Supervisor who intervened. Resident R38 had been admitted to the facility with diagnoses including Type 2 Diabetes Mellitus, the presence of a cardiac pacemaker, and dependence on supplemental oxygen. The facility's investigation confirmed the verbal abuse, and it was substantiated that Employee E10 used derogatory language towards the resident. The Nurse Aide admitted to being upset about a change in their work assignment and acknowledged losing their temper, which led to the inappropriate outburst.
Plan Of Correction
1. E10 is no longer employed at the community. R38 was evaluated by a licensed team member on 11/21/2024 and no physical injuries were noted. R38 was also provided with emotional support and remains in the community with no ill effects from the event. 2. The social service worker or designee will complete a random audit on all shifts to monitor for team member compliance with the community "Abuse, Neglect, or Exploitation Policy" for current residents by 2/28/25. 3. The Nursing Home Administrator or designee will provide re-education to current team members on the "Abuse, Neglect, or Exploitation Policy" by 3/10/25. 4. The Nursing Home Administrator or designee will complete a random audit on 5 residents who are receiving care to ensure compliance with the community "Abuse, Neglect, or Exploitation Policy" weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Inappropriate Oxygen Administration for Resident with COPD
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and dependent on supplemental oxygen. The resident was admitted to the facility on September 1, 2022, and had a physician's order for oxygen at 2 Liters/Min via nasal cannula to be administered continuously every shift. However, on February 4, 2025, at 11:38 a.m., it was observed that the resident was receiving oxygen at 4 Liters/Min, contrary to the physician's order. This discrepancy was confirmed by the Director of Nursing.
Plan Of Correction
1. R38's oxygen was immediately adjusted to reflect the physician's order for 2 liters/min via nasal cannula at the time of notification. R38 experienced no ill effects from this event. 2. The Director of Nursing or designee will conduct an audit on current residents who are ordered oxygen to ensure compliance with physician's orders by 2/28/25. 3. The Director of Nursing or designee will provide re-education to current licensed staff on the "Oxygen Policy" and "Physician Orders Policy," including the requirement to adhere to the orders of the prescriber by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on up to 5 residents who are ordered oxygen to ensure compliance with the physicians/providers' orders weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by the administration errors involving Resident R51. On February 5, 2025, a Licensed Nurse, identified as Employee E5, administered Memantine 5 mg in tablet form after crushing it, contrary to the physician's order which specified Memantine HCL, ER 7 mg Capsule to be given whole. The nurse confirmed the medication as Memantine 5 mg tab, which was incorrect according to the resident's prescribed treatment plan. The literature review indicated that enteric-coated medications like Memantine ER should not be crushed, highlighting a significant deviation from proper medication administration protocols. Additionally, the same nurse administered Ferrous Sulfate 325 mg RED Type in a crushed form, despite the physician's order to administer it as a whole tablet. The literature review supported that Ferrous Sulfate tablets should not be crushed, further contributing to the medication error rate. These errors were confirmed by the Director of Nursing during an interview, resulting in a calculated medication error rate of 7.14%, which exceeds the regulatory threshold of five percent.
Plan Of Correction
1. R51's medication orders were reviewed and clarified by the physician including the addition of an order that licensed staff may crush crushable medications on 2/10/2025. R51 experienced no ill effects from this event. E5 was re-educated on the "Medication Administration Policy" and the "Do Not Crush" listing. 2. The Director of Nursing or designee will conduct an audit on current residents' medication orders to ensure that residents have an order, if applicable, that licensed staff may crush crushable medications by 2/28/25. The Director of Nursing or designee will audit the medication pass of current residents to ensure compliance with physicians' medication orders and that only applicable medications are being crushed by 2/28/25. 3. The Director of Nursing or designee will provide re-education to current licensed staff on the "Medication Administration Policy" and the "Do Not Crush" listing including the requirement to adhere to the orders of the prescriber by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on the medication pass of 5 residents to ensure compliance with physicians' medication orders and that only applicable medications are being crushed weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Infection Control Deficiency: Improper Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically regarding the appropriate cleaning techniques for medical equipment. During a review of the facility's infection control policy, it was noted that the policy required all reusable equipment to be decontaminated and/or sterilized between residents at the point-of-care. However, observations during medication administration revealed that this policy was not being followed. On February 5, 2025, a Licensed Nurse and a Registered Nurse were observed using a sphygmomanometer to check the blood pressure of multiple residents without disinfecting the device between uses. The specific incidents involved Employee E6 and Employee E7, who both confirmed the failure to disinfect the sphygmomanometer after use on different residents. This oversight occurred during medication administration to Residents R9, R180, and R50. The lack of adherence to the infection control policy, as evidenced by these observations, indicates a deficiency in the facility's infection prevention and control program, as outlined in the regulatory requirements.
Plan Of Correction
1. R9, R180, and R50 experienced no ill effects from this event. E6 and E7 were immediately re-educated on the "Instrument Cleaning and Reuseable Equipment- Infection Control" and the requirement to decontaminate and/or sterilize reuseable equipment between residents at the point of care. The sphygmomanometers utilized were sanitized following this event. 2. The Director of Nursing or designee will audit the sanitization of reuseable equipment between residents during medication pass at the point of care of current residents to ensure compliance with the "Instrument Cleaning and Reuseable Equipment- Infection Control" by 2/28/25. 3. The Director of Nursing or designee will provide re-education to community staff on the "Instrument Cleaning and Reuseable Equipment- Infection Control" and the requirement to decontaminate and/or sterilize reuseable equipment between residents at the point of care by 3/10/25. 4. The Director of Nursing or designee will complete a random audit on up to 5 residents who require vital sign equipment to be utilized for medication parameters to ensure compliance with the "Instrument Cleaning and Reuseable Equipment- Infection Control" including the sanitization of reuseable equipment between residents weekly for 4 weeks and then monthly for 2 months. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Staffing Ratio Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain the required staffing ratios for nurse aides on 8 out of 21 days reviewed. Specifically, the facility did not meet the mandated ratios of one nurse aide per 10 residents during the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the overnight shift. This deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. On several occasions, the facility's census data indicated a need for more nurse aide hours than were actually provided, with no additional higher-level staff available to compensate for the shortfall. The specific dates where staffing deficiencies occurred include July 4, 6, 7, and 8, 2024, as well as November 25, 27, 28, and 29, 2024. For instance, on July 4, 2024, the facility had a census of 79 residents, requiring 59.25 hours of nurse aide care during the day shift, but only 56.00 hours were provided. Similar discrepancies were noted on other dates, with the facility consistently failing to meet the required staffing levels. The Nursing Home Administrator confirmed these findings during a review of the staffing calculations and schedules.
Plan Of Correction
1. Facility to ensure that nurse's aide ratios are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of staffing schedules from 2/22/25-2/28/25 to verify nurse aide ratios each shift. If discrepancies are identified, regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week involving all three shifts for 4 weeks, and then 2 days per month involving all three shifts for 2 months to ensure that nurse aide ratios are consistent with regulatory requirements. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Failure to Maintain Required LPN Staffing Ratios
Penalty
Summary
The facility failed to maintain the required staffing ratios for Licensed Practical Nurses (LPNs) on six out of 21 days reviewed. Specifically, the facility did not meet the mandated LPN-to-resident ratios during the day, evening, and overnight shifts on July 2 and 6, 2024, and November 25, 26, 27, and 28, 2025. The deficiency was identified through a review of nursing staff schedules, punch reports, and interviews with staff. On July 2, 2024, the facility had a census of 80 residents, requiring 25.00 hours of LPN care during the day shift, but only 24.00 hours were provided. On July 6, 2024, with a census of 77 residents, the facility required 15.40 hours of LPN care during the evening shift, but only 8.00 hours were provided. On November 25, 2024, with a census of 73 residents, 23.36 hours of LPN care were needed during the day shift, but only 15.00 hours were provided. On November 26, 2024, with a census of 72 residents, 23.04 hours were required, but only 22.00 hours were provided. On November 27, 2024, again with a census of 72 residents, 23.04 hours were needed, but only 16.00 hours were provided.
Plan Of Correction
1. Facility to ensure that LPN ratios are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of staffing schedules from 2/22/25-2/28/25 to verify LPN ratios each shift. If discrepancies are identified, regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the Department of Health's Guidance for Calculating Staff to Resident Ratios and Direct Nursing Care Hours by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week involving all three shifts for 4 weeks, and then 2 days per month involving all three shifts for 2 months to ensure that nurse aide ratios are consistent with regulatory requirements. The results of these audits will be forwarded to the Quality Assurance Process Improvement team for review and recommendations.
Deficiency in Meeting Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the required staffing minimum of 3.20 hours of direct nursing care per resident on three specific days: November 25, 27, and 29, 2024. On November 25, the facility had a census of 73 residents and provided 231.00 direct nursing staff hours, resulting in 3.16 hours of care per resident. On November 27, with a census of 72 residents, 226.00 direct nursing staff hours were provided, equating to 3.14 hours of care per resident. On November 29, again with a census of 72 residents, 228.00 direct nursing staff hours were provided, resulting in 3.17 hours of care per resident. These findings were confirmed by the Nursing Home Administrator during a review of staffing calculations, nursing staff schedules, and staff punch reports on February 4, 2025.
Plan Of Correction
1. Facility to ensure that HPPD requirements are maintained in accordance with regulatory requirements. 2. Staffing Coordinator or designee will conduct an audit of HPPD from 2/22/25-2/28/25 to verify HPPD in accordance with regulation and if discrepancies are identified regulatory requirements will be reviewed by the Nursing Home Administrator and Staffing Coordinator. 3. Nursing Home Administrator or designee will reeducate Staffing Coordinator on the HPPD regulatory requirements by 3/4/25. 4. Staffing Coordinator or designee will conduct audits 2 days per week x 4 weeks and then 2 days per month x 2 months to ensure that HPPD are consistent with regulatory requirements. The results of these audits will be forwarded to Quality Assurance Process Improvement team for review and recommendations.
Failure to Monitor Hot Beverage Temperature Leads to Resident Burn
Penalty
Summary
The facility failed to monitor the temperature of a hot liquid before serving it to a resident, resulting in actual harm. A cognitively intact resident with physical impairments and a history of falls was served hot water by a nursing assistant who was unaware of the water's temperature. The resident, who had difficulty using her hands, attempted to remove the lid from the mug, causing the hot water to spill and result in a second-degree burn on her forearm. Interviews and observations revealed that the dietary department was responsible for serving hot beverages and typically cooled them to a safe temperature before service. However, the nursing assistant served the hot water directly from the dispenser without cooling it. The facility was in the process of developing a policy on hot beverage temperatures at the time of service, but no such policy was in place during the incident.
Unlicensed Staff Providing Care as RN Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that six employees, including Employee E21, possessed the appropriate skills and competencies to provide nursing and related care services, which compromised resident safety and well-being. Employee E21, who was unlicensed, provided care as a Registered Nurse without verifiable educational background or registration as a nurse. This situation placed 63 residents at risk of injury or harm, resulting in an Immediate Jeopardy situation. Employee E21 was hired as a Registered Nurse and worked independently for 23 out of 30 shifts, administering medications and performing complex assessments without any documented competency evaluation. The facility's documentation revealed discrepancies in Employee E21's identification and licensure, which were not clarified by the facility's human resources. Additionally, there was no evidence of competency evaluations for Employee E21 or other selected licensed and registered nurses, indicating a lack of oversight in ensuring staff competencies. The facility's Director of Nursing and Nursing Home Administrator confirmed that nursing staff competencies related to PICC line/midline/IV care and wound care had not been completed in the past year. Despite having a competency evaluation program, the facility failed to implement it, leading to the Immediate Jeopardy situation. This deficiency highlighted the facility's failure to ensure that staff possessed the necessary skills and competencies to provide safe and effective care to residents.
Removal Plan
- Employee A was removed from the schedule and placed on administrative leave.
- Incident reported to local police department and Department of Health in accordance to local and state laws.
- Legal counsel notified of multi state and identity theft investigations and agencies informed.
- Department of State who issues licenses will be informed.
- Legal counsel notified that state's Attorney General is involved.
- An electronic health record audit was completed by the Nursing Home Administrator or designee to review residents who may have received care or treatment from Employee E21.
- Current residents identified from this audit will be interviewed by a Licensed Nurse and Social Worker.
- A physical head to toe skin evaluation of the residents in the assignments of Employee E21 was completed.
- An audit was conducted by the Human Resource Department to ensure that licensed staff have a skills competency completed and present in their employee file.
- Any licensed staff identified not to have had skills competency completed will have the competency completed prior to their next scheduled shift; all staff completed.
- An audit was completed by human resource department on current licensed nurses employed by PSL at the community to ensure compliance with licensure verification, no variances identified.
- The human resource department team members at the community were re-educated on new hire/pre-employment processes for licensed staff by the President of Employee Relations or designee.
- The Human Resource department team members at the community were re-educated by the President of Employee Relations or designee on the requirement to ensure that all licensed staff have a current skill competency checklist completed at new hire during the orientation period and then annually in their employee file to ensure that all licensed staff possess competencies, education, and license as applicable to provide nursing care, all staff completed.
Unlicensed Staff Provided RN Care to Residents
Penalty
Summary
The facility failed to ensure that a professional staff member possessed the required nursing license in accordance with applicable state law. Employee E21, who was unlicensed, provided care as a Registered Nurse to 63 residents. The employee did not have a verifiable educational background or registration as a Registered Nurse, which resulted in an Immediate Jeopardy situation for the residents who received care and services from this individual. Upon review, it was found that Employee E21 presented a fraudulent RN license by obtaining the identity of another person with a similar name. The facility did not follow up on the discrepancy between the name provided and the name on the license. The employee worked in the facility for four months, providing care to residents, including medication administration and performing licensed nurse's assignments, without any verifiable nursing education or competency documentation. The facility's failure to verify the authenticity of Employee E21's credentials and to ensure the employee's competency in performing nursing services placed 63 residents at risk of injury or harm. The employee administered various medications and performed complex resident assessments, which required specialized skills and competencies, without proper verification of qualifications.
Removal Plan
- Employee 21 was removed from the schedule and placed on administrative leave.
- Incident reported to local police department and Department of Health in accordance to local and state laws.
- Legal counsel notified of multi state and identity theft investigations and agencies informed.
- Department of State who issues licenses to be informed.
- Legal counsel notified that state's Attorney General is involved.
- An audit was completed by human resource department on current licensed nurses employed by PSL at the community to ensure compliance with licensure verification as applicable according to the job description and state laws.
- All licensed staff after the initial audit have also been audited by the Human Resource department prior to employment.
- The policy for employee onboarding process was updated and revised to ensure licensed staff are appropriately licensed and educated as applicable according to the job description and state laws.
- The Human Resource department team members at the community were re-educated by the President of Employee Relations or designee on the updated policy.
- Audits started with no concerns identified and will continue to be completed according to new employee orientation schedule.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at palatable temperatures for residents on the second and third floor nursing units. During an initial tour of the kitchen, it was revealed that each dining room on these floors is equipped with steam tables for serving meals. However, resident concerns about cold food were documented in the dining committee notes for the third floor. Interviews with alert and oriented residents confirmed that food was often served cold, both in the dining room and in their rooms. The Food Service Director acknowledged that dietary staff are responsible for checking food temperatures before meal service. A test tray prepared from the steam table on the third floor showed that the breaded veal was at 127 degrees Fahrenheit and the broccoli at 104 degrees Fahrenheit, both below the facility's temperature standards. Similar temperature issues were observed on the second floor, with veal at 123 degrees Fahrenheit and broccoli at 103 degrees Fahrenheit. Additionally, a breakfast tray delivery cart was observed with trays waiting to be served, and a resident reported that her cream of wheat was lukewarm, indicating a persistent issue with serving food at appropriate temperatures.
Failure to Inform Residents of Staff Investigation
Penalty
Summary
The facility failed to uphold resident rights by not informing residents or their representatives about an investigation into an alleged violation involving a staff member, Employee E21, who provided care to 63 residents. Employee E21, a registered nurse, was found to have presented a fraudulent nursing license and was under investigation for identity theft and fraud. Despite this, the facility did not communicate the investigation to the affected residents or their representatives, which is a violation of the facility's policy on abuse, neglect, or exploitation. Employee E21 worked 30 shifts, providing care to approximately 20 residents per shift, under a false identity. The facility's documentation revealed discrepancies in the names on Employee E21's identification documents and the nursing license presented. The facility's failure to inform residents or their representatives about the investigation into Employee E21's credentials and actions compromised the residents' right to a dignified existence and self-determination, as outlined in the facility's policies and state regulations.
Failure to Provide Scheduled Showers Due to Staffing Issues
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene for six residents, as observed through clinical records, interviews, and direct observations. Resident R10, who is cognitively impaired and dependent on staff for bathing, was noted to have unkempt and dirty hair, indicating missed showers. Family members expressed concerns about the lack of routine showers, and it was revealed that if a shower is missed on a scheduled day, the resident must wait until the next scheduled day. This issue was corroborated by interviews with other residents who reported insufficient staffing leading to missed showers. Documentation review showed significant gaps in recorded showers for the affected residents. Resident R10 was scheduled for showers twice a week, but records indicated the last documented shower was over a month prior. Similar patterns were found for other residents, with some having no documented showers for the entire month of April. The facility's failure to adhere to scheduled bathing times and inadequate staffing were identified as contributing factors to this deficiency, violating state regulations on resident care policies.
Delayed Meal Service for Residents
Penalty
Summary
The facility failed to provide meals in accordance with resident preferences on the Second and Third Floor Nursing Units. Facility documentation indicated that breakfast should be served between 8:00 a.m. and 9:00 a.m., and lunch between 12:00 p.m. and 1:00 p.m. However, observations and resident interviews revealed significant delays in meal service. Residents reported waiting up to 45 minutes to be served lunch, despite arriving at the dining room at the scheduled start time. On April 11, 2024, observations confirmed that residents on both the 2nd and 3rd floors were not served lunch promptly, with some residents still waiting to be served well after the scheduled meal time. Further observations on April 12, 2024, showed that several residents were served breakfast after the designated time, with some receiving their meals as late as 9:34 a.m. The delay in meal service was attributed to the dietary employee responsible for plating meals also taking resident orders, which was confirmed by the Food Service Director. This dual responsibility contributed to the inefficiency and delay in meal service, failing to meet the residents' needs and preferences as required.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program as required by its own policy and regulatory standards. The policy, dated May 31, 2023, outlined commitments to optimize infection treatment and reduce adverse events associated with antibiotic use, including monitoring measures for antibiotic use and outcomes. However, for the months of January, February, and March 2024, the facility did not complete reviews of antibiotic usage for appropriateness or adherence to usage criteria for the antibiotics prescribed. This lack of review was confirmed during an interview with the Director of Nursing on April 15, 2024. In January 2024, the facility used 13 antibiotics for 19 residents, in February 2024, 9 antibiotics for 10 residents, and in March 2024, 17 antibiotics for 24 residents. Despite these prescriptions, the facility did not conduct the necessary reviews to ensure that the antibiotics were used appropriately according to the stewardship program. This oversight was a direct violation of the facility's policy and the regulatory requirements under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Failure to Investigate Identity Theft Allegation
Penalty
Summary
The facility failed to conduct a thorough and complete investigation of an alleged identity theft involving 63 residents by an employee, identified as Employee E21. The investigation was triggered when it was discovered that Employee E21, a registered nurse, had provided a fraudulent RN license by using the identity of another person with a similar name. This employee was under investigation by multiple law enforcement agencies for identity theft and fraud. Despite the serious nature of the allegations, the facility's investigation did not include obtaining statements or conducting interviews with the residents who received care from Employee E21 or the staff responsible for hiring and verifying the credentials of Employee E21. The facility's documentation revealed that Employee E21 provided care to 63 residents over 30 shifts, with approximately 20 residents per shift, from November 23, 2023, to February 24, 2024. However, there was no evidence that the facility took steps to interview these residents or the staff involved in the hiring process. The Administrator confirmed that the investigation lacked these critical components, indicating a failure to adhere to the facility's policy on abuse, neglect, or exploitation, which mandates immediate reporting and thorough investigation of such incidents.
Failure to Update Care Plan for Behavioral Changes
Penalty
Summary
The facility failed to revise and update the care plan for a resident, identified as R53, who was admitted with multiple diagnoses including sepsis, pneumonia, COPD, respiratory failure, Alzheimer's disease, type 2 diabetes, and hypomagnesemia. Despite the resident exhibiting belligerent, agitated, and uncooperative behaviors starting from late February 2024, which were documented in the nursing notes and addressed by the nursing staff and physicians, the care plan initially developed on January 25, 2023, did not include any interventions related to these behaviors. The nursing staff had been monitoring the resident's behaviors daily, and a physician had been notified, resulting in an order for Ativan to be administered as needed. However, the care plan was not updated to reflect these new behavioral issues and the corresponding interventions. This oversight was confirmed during an interview with a licensed nurse, Employee E2, who acknowledged that the care plan had not been revised to address the resident's newly recognized behaviors.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer medication to a resident in accordance with physician orders, specifically concerning the timing of Carbidopa-Levodopa, a medication used to treat Parkinson's disease. The facility's policy mandates that medications be administered per physician orders, including the correct timing. However, a review of the resident's medication administration records revealed multiple instances where the medication was not given at the prescribed times. These discrepancies were noted on several occasions in February and March 2024, with doses being administered either too early or too late, and in some cases, doses were missed entirely. The resident's family member expressed concerns about the untimely administration of the Parkinson's medication, which is critical for managing the resident's condition. The physician's order explicitly stated that the medication should not be administered on a flexible schedule, emphasizing the importance of precise timing for effective management of the resident's symptoms. Despite this, the facility's staff failed to adhere to the prescribed schedule, leading to a deficiency in the resident's care as per the facility's policy and physician's orders.
Failure to Provide Ordered Splint for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate services according to professional standards of practice. Resident R14 had a physician's order dated February 14, 2024, to keep a splint on the left upper extremity at all times, except during showers. However, observations on April 11, 12, and 15, 2024, revealed that the resident was not wearing the splint as ordered. These observations were confirmed by a Registered Nurse and a Licensed Practical Nurse. The facility's policy on restorative care, dated February 4, 2022, mandates providing services to prevent decline and maintain the highest practicable level of functioning, which was not adhered to in this case.
Failure to Use Wheelchair Footrests Leads to Resident Fall
Penalty
Summary
The facility failed to provide necessary assistance devices to prevent an avoidable accident for a resident with a history of falls. The resident, who had diagnoses of dementia, Parkinson's Disease, and gait abnormalities, was dependent on staff for mobility and used a wheelchair. During an incident in the dining room, the resident attempted to stand from the wheelchair by grabbing a table, resulting in a fall. The incident report indicated that the wheelchair leg rests were not in use at the time of the fall. Interviews with the Director of Nursing confirmed that the resident had significant cognitive impairments and a history of behaviors such as grabbing objects and planting feet on the floor while being pushed in the wheelchair. It was confirmed that footrests should have been used to prevent such behaviors, but they were not in place during the incident, leading to the resident's fall.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R14, who was admitted with diagnoses including osteoporosis with a pathological fracture, vascular dementia, and anxiety. The resident was on a scheduled pain medication regimen and received as-needed pain medication, but there were no non-medication interventions for pain. The resident experienced constant pain, which frequently affected sleep and occasionally impacted daily activities. On April 1, 2024, a physician ordered Acetaminophen 325 mg to be taken every six hours for pain. However, on April 10, 2024, despite the resident's complaint of severe pain, there was no evidence that the pain medication was administered. Additionally, a physician's progress note dated April 5, 2024, included an order for Oxycodone 5 mg as needed, but this medication was not included in the active medication list for the resident. There was no documented reason for not following the physician's recommendation for Oxycodone. The Director of Nursing confirmed the lack of evidence for pain medication administration on April 10, 2024, and acknowledged that no pain assessment was completed when the resident complained of pain. This failure to administer prescribed pain medication and conduct a pain assessment constitutes a deficiency in the facility's pain management practices.
Medication Cart Left Unattended and Unlocked
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with professional standards, as observed with the second-floor medication cart. The facility's policy, dated May 2018, mandates that only authorized personnel can access medications and that medication carts must be locked when unattended. On April 10, 2024, at 11:12 a.m., the second-floor medication cart was found unattended and unlocked outside the nursing office, with the sixth drawer open and visible to anyone nearby, including those using the adjacent elevators. At 11:17 a.m., a licensed staff member, Employee E8, returned to the cart from assisting another resident in the office, closed the drawers, and locked the cart. Employee E8 admitted to leaving the cart unlocked for a brief period, stating she was only away for one minute.
Unlicensed Staff Providing RN Care
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility by not ensuring that professional staff possessed the required licenses or registration in accordance with applicable state law. This deficiency was identified when Employee E21, who was unlicensed, provided care and services as a Registered Nurse (RN) without verifiable educational background, registration, and appropriate skills and competencies. This situation placed residents at risk of injury or harm and resulted in an immediate jeopardy situation. Upon hire, Employee E21 presented a registered nursing license with a name that was active and in good standing. However, discrepancies were found between the name on the nursing license and the names on other identification documents such as the Social Security card and driver's license. The facility's human resources or other staff did not clarify this discrepancy. Employee E21 worked 30 shifts as an RN, with 23 of those shifts being worked independently, before the issue was identified. This oversight by the NHA and DON contributed to the immediate jeopardy situation.
Infection Control Breach During Dining Assistance
Penalty
Summary
The facility failed to adhere to its infection control practices during a dining observation involving a resident. The facility's policy on infection control, revised on January 13, 2022, emphasizes maintaining a sanitary environment. Additionally, the policy on Nutrition and Hydration for Residents Unable to Feed Themselves specifies that nursing assistants should not touch food to test its temperature. During an observation, a nurse aide, identified as Employee E7, was assisting a resident with dining. Employee E7 was observed inserting her index finger into the resident's bowl of cream of wheat to check the temperature, which is against the facility's policy. She then wiped her hand on a napkin and added ice cubes to the cereal. This action was contrary to the policy that requires testing the temperature by placing a hand over the food without direct contact.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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