Centennial Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 4400 West Girard Avenue, Philadelphia, Pennsylvania 19104
- CMS Provider Number
- 395950
- Inspections on file
- 22
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Centennial Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple chronic conditions reported two incidents of alleged verbal abuse by a staff member. The facility did not complete a thorough investigation as required by policy, omitting key witness statements and failing to document all relevant information, resulting in an unsubstantiated finding.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
A resident with Peripheral Vascular Disease was repeatedly administered oxygen therapy per physician order, but there was no documented assessment of the need for oxygen in the clinical record, despite facility policy requiring such documentation.
A resident experienced a significant weight loss over a short period, but the facility did not perform a timely reweigh as required by its policy. This lapse was confirmed by the registered dietician and identified through staff interviews and record review.
A resident with COPD was not administered oxygen therapy according to the physician's order, receiving 2.5L/min instead of the prescribed 3L/min via nasal cannula. The discrepancy was discovered during observation, and the nurse confirmed the error after rechecking the flow meter at eye level.
A resident with a history of cerebral amyloid angiopathy and prior brain hemorrhages experienced a fall and was later diagnosed with an acute intraparenchymal hemorrhage and hydrocephalus. Facility staff did not conduct a thorough investigation, consult the medical director, or develop an individualized care plan addressing toileting, supervision, or transfer assistance, as required by facility policy.
A resident with Peripheral Vascular Disease was observed receiving oxygen therapy as ordered, but the facility failed to document the administration of oxygen in the medical record, as required by policy. Staff confirmed the resident was on oxygen, but the Treatment Administration Record lacked documentation of this care.
A licensed nurse placed two Gabapentin tablets directly on top of the medication cart while preparing to crush and administer them to a resident with a PEG tube, contrary to the facility's infection control policy requiring proper prevention and control methods.
Licensed nurses did not administer scheduled morning medications within the required timeframe, instead giving them significantly later than ordered for three residents with complex medical needs. This occurred due to late starts and ongoing delays in the medication pass, resulting in noncompliance with physician orders and facility policy.
The facility did not update PASRR forms to include mental health diagnoses for four residents, despite policy requirements. These residents developed conditions such as delusional disorder, anxiety disorder, and major depressive disorder during their stay, which were not reflected in their PASRR assessments. The facility administrator confirmed the documentation was incomplete.
The facility did not accurately post daily nurse staffing information, omitting total hours required, actual hours worked for each shift, and details on call outs and unit assignments. This issue was observed on multiple occasions, indicating a pattern of non-compliance.
A deficiency was identified involving the incomplete PASRR form for a resident diagnosed with Psychosis. The PASRR Level 1 form, crucial for identifying mental disorders and ensuring appropriate care, was not properly filled out, leaving sections unmarked that should have indicated the resident's mental disorder and potential chronic disability. This oversight was confirmed by the DON.
A facility failed to adhere to physician orders for a resident with a below-knee amputation, who was required to wear bilateral shrinkers on both lower extremities at all times, except during self-care or skin checks. An observation confirmed that the resident was not wearing the shrinkers as ordered, which was verified by an LPN.
A significant medication error occurred when a nurse administered only one tablet of Keppra instead of the prescribed two tablets for a resident's seizure management. This was confirmed through observation, physician order review, and nurse interview.
The facility failed to notify the State Long-Term Care Ombudsman of emergency transfers and discharges for July and August 2024. Although lists were sent to the local ombudsman, an email revealed that notices should have been sent to the state ombudsman, who could only record notices from September and October 2024. This was confirmed by the facility's social worker, indicating non-compliance with state regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Thoroughly Investigate Alleged Verbal and Mental Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of verbal and mental abuse involving a resident with multiple chronic conditions, including Multiple Sclerosis, Fibromyalgia, and bipolar disorder, who was alert, oriented, and able to make autonomous choices. Two separate incidents were reported in which a staff member allegedly used derogatory language toward the resident. The facility's policy requires a comprehensive investigation, including interviews with all relevant witnesses and staff, but this was not completed as required. The Director of Nursing (DON) acknowledged knowing the identities of both the alleged perpetrator and the supervisor involved in disciplining the staff member, yet failed to include their witness statements in the investigation. Additionally, the investigation was deemed unsubstantiated primarily because the accused staff member had resigned and no other staff or residents reported hearing the incident. The omission of key witness statements and incomplete documentation led to the deficiency in the facility's response to the alleged abuse.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the care plan documentation, which did not include all necessary elements to ensure comprehensive care for the resident.
Failure to Assess Need for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Peripheral Vascular Disease was observed to be receiving oxygen therapy via nasal cannula at 2 liters per minute on multiple occasions. The physician's order specified oxygen at 2 liters per nasal cannula as needed every shift, with instructions to notify the physician if oxygen saturation was less than 94% or as needed for shortness of breath. Despite these orders and ongoing administration of oxygen, there was no documented evidence in the clinical record that the resident had been assessed for the need for oxygen therapy. Staff interviews confirmed the resident was on oxygen, and facility policy required documentation of the procedure in the medical record, which was not present.
Failure to Timely Reweigh After Substantial Weight Loss
Penalty
Summary
The facility failed to reweigh a resident in a timely manner after a substantial weight loss was identified. According to the facility's policy, residents with suspected weight changes are to be reweighed promptly. Review of the resident's records showed a weight drop from 140.6 lbs. to 133.6 lbs. over six days, amounting to a 4.98% loss, which meets the criteria for substantial weight loss per MDS guidelines. Despite this, the resident was not reweighed as required, a fact confirmed by the registered dietician. This deficiency was identified through staff interviews, record reviews, and examination of facility policy.
Oxygen Therapy Not Administered per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) was not administered oxygen therapy in accordance with the physician's order. The physician's order specified that oxygen should be administered at 3 liters per minute via nasal cannula continuously every shift. However, during an observation, the resident was found to be receiving oxygen at 2.5 liters per minute, as confirmed by both the resident and a licensed nurse. The nurse initially read the oxygen concentrator flow meter as 3 liters per minute while standing, but upon rechecking at eye level, confirmed it was actually set at 2.5 liters per minute and then adjusted it to the correct level. The resident's care plan indicated the need for oxygen therapy to maintain oxygen saturation at or above 92%, with an intervention to administer oxygen at 2 liters per minute via nasal cannula. The discrepancy between the physician's order, the care plan, and the actual administration of oxygen was noted during the survey. The Director of Nursing confirmed that the oxygen gauge should be read at eye level, highlighting a lapse in proper procedure that led to the resident not receiving oxygen as ordered.
Failure to Investigate and Care Plan After Resident Fall
Penalty
Summary
The facility failed to administer and use its resources effectively and efficiently for one resident, as evidenced by the lack of a thorough investigation and care planning following a significant incident. Staff interviews, clinical record reviews, and policy examination revealed that after a resident was found lying on the floor in their bedroom/adjoining bathroom, no individualized care plan was developed or implemented to address bowel incontinence, toileting needs, staff supervision, or assistance with transfers. The facility's policy required a comprehensive investigation of all incidents and accidents, including consultation with the medical director and development of a care plan by the interdisciplinary team to ensure a safe environment. However, administrative staff confirmed that these steps were not taken for this resident. Further, the medical director reported that the resident was sent to the emergency room and diagnosed with an acute large intraparenchymal hemorrhage and hydrocephalus, with a history of cerebral amyloid angiopathy and prior intracranial hemorrhages. Despite the facility's policy mandating a completed investigation and review by the DON, and consultation with the medical director, staff interviews confirmed that a complete and thorough investigation was not conducted or recorded. The administrative staff did not utilize available resources, including medical director consultation, to identify the root cause of the fall and ensure a safe environment, resulting in a deficiency.
Failure to Document Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that clinical records for a resident receiving oxygen therapy were properly completed in accordance with accepted professional standards and facility policy. The facility's policy requires that oxygen therapy be administered per physician's order and that the procedure be documented in the medical record. A resident with a diagnosis of Peripheral Vascular Disease was observed on multiple occasions to be receiving oxygen at 2 liters per minute via nasal cannula, as ordered by the physician. However, review of the Treatment Administration Record for the relevant month showed no initials or documentation indicating that oxygen was administered to the resident, despite direct observations and staff confirmation that the therapy was being provided.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
A deficiency was identified when a licensed nurse failed to follow infection control procedures during medication administration to a resident. During a medication pass, two white tablets of Gabapentin were observed placed directly on top of the medication cart by the nurse, who stated she was preparing to crush them for administration via the resident's PEG tube. The nurse then proceeded to crush and administer the medication to the resident. The facility's infection control policy requires methods of prevention and control to be implemented to protect residents, visitors, and personnel from pathogenic microorganisms and infectious diseases. The observed practice of placing medication directly on the medication cart surface did not align with these infection control procedures.
Failure to Administer Medications on Time per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered on time as ordered by physicians for three residents. Facility policy required medications to be given within one hour of the prescribed time unless otherwise specified. Observations on March 12, 2025, revealed that two licensed nurses were still administering morning medications well after the scheduled 9:00 a.m. administration time. One nurse reported a late start to her medication pass due to arriving late for work, and both nurses confirmed that they were still in the process of administering medications to multiple residents past the scheduled time. For the three residents reviewed, each had complex medical conditions requiring timely medication administration, including diagnoses such as respiratory failure, atrial fibrillation, heart failure, COPD, diabetes, epilepsy, chronic kidney disease, hypertension, and convulsions. Medications such as Eliquis, Buspirone, Symbicort, Levetiracetam, Lidocaine cream, Docusate Sodium, Metformin, and Lacosamide were all administered significantly later than the ordered 9:00 a.m. time, as observed between 11:10 a.m. and 11:29 a.m. These actions were not in accordance with physician orders or facility policy.
Failure to Update PASRR Forms for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that revisions were made to the Pre-Admission Screening and Resident Review (PASRR) applications to include mental health diagnoses for four residents. The facility's policy required that all residents, regardless of payer source, have a PASRR form completed, and any resident with a mental health disorder should have a complete and accurate PASRR done with a referral for a Level II PASRR if necessary. However, the PASRR forms for Residents R62, R88, R26, and R23 did not reflect their current mental health conditions, which included diagnoses such as delusional disorder, anxiety disorder, major depressive disorder, and bipolar disorder, developed during their stay at the facility. The clinical records for these residents indicated that they developed significant mental health conditions after their initial PASRR assessments, which were not updated to reflect these changes. For instance, Resident R62 developed delusional disorder, anxiety disorder, and major depressive disorder, while Resident R88 developed delusional disorder. Similarly, Resident R26 was diagnosed with bipolar disorder, mood disturbance, major depressive disorder, and anxiety disorder, and Resident R23 developed anxiety disorder, delusional disorder, and major depressive disorder. The facility administrator confirmed that the PASRR forms lacked complete documentation and were not reflective of the residents' current mental health conditions.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information as required by regulations. Observations and reviews of the posted staffing data on multiple occasions, including specific dates in October 2024 and earlier months, revealed that the facility did not include essential details such as total hours required, actual hours worked for each shift, and information on call outs and unit assignments. This deficiency was noted on the 2nd floor unit and was consistent across several weeks, indicating a pattern of non-compliance with the requirement to provide complete and accurate staffing information.
Incomplete PASRR Form for Resident with Psychosis
Penalty
Summary
The deficiency identified in the report pertains to the improper completion of the PASRR-ID for a resident diagnosed with Psychosis. The PASRR, established under the Omnibus Budget Reconciliation Act (OBRA) of 1987, aims to identify individuals with mental illness or intellectual disabilities, ensure appropriate placement, and guarantee necessary services. In this case, the PASRR Level 1 form for the resident, who was admitted with a diagnosis of Psychosis, was not correctly filled out. Specifically, the section that should have indicated the presence of a mental disorder was left unmarked, despite the resident's diagnosis. Additionally, the section of the PASRR form that should have addressed the screening outcome related to potential chronic disability was also incomplete. This oversight was confirmed during an interview with the Director of Nursing. The failure to accurately complete the PASRR form for the resident with a known mental disorder represents a significant lapse in the facility's compliance with regulatory requirements, as outlined in the Pennsylvania Code.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for one resident, identified as Resident R122. The resident was admitted with a diagnosis of Acquired Absence of Left Leg Below Knee and was undergoing orthopedic aftercare following a surgical amputation. A physician's order dated January 22, 2024, required the resident to wear bilateral shrinkers on both lower extremities at all times, except during self-care or skin checks. However, on October 30, 2024, at 10:07 a.m., it was observed that Resident R122 was not wearing the bilateral shrinkers as ordered. This observation was confirmed by a Licensed Nurse, identified as Employee E12, at the time of the findings.
Medication Administration Error
Penalty
Summary
The facility failed to administer medications in accordance with physician orders, resulting in a significant medication error for one resident. During an observation, a Licensed Nurse, identified as Employee E3, administered only one tablet of Keppra Oral Tablet 1000 MG (Levetiracetam) to a resident in the morning, despite the physician's order specifying two tablets for seizure management. This discrepancy was confirmed through a review of the physician's order and an interview with the nurse involved. The facility's policy on Medication Administration and Disposition, revised in June 2023, mandates that medications must be administered as per the written physician orders, which was not adhered to in this instance.
Failure to Notify State Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of initiated emergency transfers and discharges for two out of three months reviewed, specifically July and August 2024. The facility provided a list of involuntary discharges and transfer notices for July, August, and September 2024, indicating that these lists were sent via fax to the local ombudsman. However, a review of the facility's documentation revealed an email communication dated October 17, 2024, between the facility's social worker, the local ombudsman, and the state ombudsman. This communication clarified that discharge notices should be sent to the State Long-Term Care Ombudsman and that the state ombudsman could only record notices from September and October 2024, indicating a failure to properly notify for the earlier months. An interview with the facility's social worker confirmed these findings, highlighting the facility's non-compliance with the requirement to notify the state ombudsman of emergency transfers and discharges. This deficiency is in violation of 28 Pa Code 201.14(a) and 28 Pa Code 201.18(b)(2), which pertain to the responsibility of the licensee and management, respectively.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
