Chestnut Hill Lodge Health And Rehab Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyndmoor, Pennsylvania.
- Location
- 8833 Stenton Avenue, Wyndmoor, Pennsylvania 19038
- CMS Provider Number
- 395334
- Inspections on file
- 32
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Chestnut Hill Lodge Health And Rehab Ctr during CMS and state inspections, most recent first.
A resident with dementia, prior cerebral hemorrhage, osteoporosis, gait abnormalities, and an active 1:1 order for fall risk experienced an unwitnessed (initially unreported) fall in the shower room while being assisted by a CNA, who later admitted the resident slipped while rising from a shower chair. The CNA did not inform licensed nursing staff of the fall or perform/trigger a required head-to-toe assessment, instead returning the resident to the dining area. Later, another CNA noticed a nosebleed and brought the resident to the nurses’ station, but the overseeing nurse did not recognize or act on significant facial swelling and bruising until alerted by the nursing supervisor during rounds. Only then was the resident assessed, the NP contacted, and EMS called, with subsequent hospital evaluation revealing a subdural hematoma, facial fracture, and rib fractures, demonstrating a failure to promptly report the fall and notify the physician of a significant change in condition.
A resident with dementia, prior cerebral hemorrhage, osteoporosis, gait abnormalities, and a physician order for 1:1 monitoring experienced a slip and fall while rising from a shower chair during supervised bathing. The assigned 1:1 aide moved the resident to the dining room without obtaining an RN head-to-to-toe assessment, did not notify licensed nursing staff, and did not report the fall, initially claiming not to know what happened. Later, a nursing supervisor observed marked facial swelling, bruising, and bleeding and questioned both the aide and the agency charge nurse, who had not identified or reported the injuries during medication administration. The resident was eventually sent to the ER, where imaging showed a subdural hematoma, facial fractures, and rib fractures. In a subsequent interview, the aide admitted the shower fall and stated fear of getting into trouble as the reason for not reporting it, and the facility substantiated neglect due to the failure to report the incident and the resulting delay in assessment and treatment.
A facility failed to update a care plan in a timely manner for a resident with behavioral issues, including pulling the fire alarm on multiple occasions. Despite the resident's diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and schizoaffective disorder, the care plan was not revised to address these behaviors until confirmed by the DON.
The facility did not maintain continuous illumination of the means of egress, affecting one level. A ceiling light fixture in the basement laundry's exit vestibule was found unlit during an observation, and this was confirmed in an interview with the Administrator and Regional Maintenance Director.
The facility failed to maintain and inspect its electrical systems per NFPA 70, Article 314, resulting in deficiencies such as a broken optical sensor light switch, an unsecured junction box, and a missing cover on an electrical receptacle. Additionally, free-hanging electrical junction boxes were found above the drop ceiling outside Clean Storage. These issues were confirmed during an exit interview with the Administrator and Regional Maintenance Director.
The facility failed to maintain proper hazardous area enclosures, affecting one level. Observations revealed that the Soiled Laundry room door in the E-Wing was compromised due to paper towels stuffed into the door frame strike plate, preventing it from latching. This was confirmed during an exit interview with the Administrator and Regional Maintenance Director.
A facility failed to comply with NFPA standards by using an unapproved extension cord in a resident room to power electronics. This was observed and confirmed during an interview with the Administrator and Regional Maintenance Director.
A facility failed to provide adequate grooming and hygiene services to a resident who was dependent on staff for all activities of daily living. Despite the resident's preference for showers and physician orders indicating scheduled shower days, the resident only received bed baths. Staff assumed showers might be too strenuous, although no clinical restrictions were noted.
The kitchen in the food and nutrition services department was inadequately maintained, leading to an ineffective pest control program. Issues included improper drainage, water damage, and pest infestations. Observations revealed soiled water overflow, lime deposits, and missing grouting in the dish room, along with grease and dust accumulation in the hot food preparation area. The dry food storage area had mice droppings and dead roaches, and the three-compartment sink was leaking.
The facility failed to respect the dignity of two residents by labeling their clothing with names in visible areas, such as on a shirt collar and a jacket belt, compromising their right to a dignified existence.
A resident with cognitive impairment and a preference for Vietnamese was not accurately assessed for language needs, leading to a lack of a communication care plan. Despite documentation indicating the resident's language preference, the facility failed to reflect this in the Care Area Assessment, confirmed by staff interviews.
The facility failed to create timely baseline care plans for residents, including those with language barriers, a surgically wired jaw, and mental health needs. A resident with limited English proficiency did not have a care plan reflecting language services, while another with a wired jaw lacked emergency procedures in their care plan. Additionally, residents with communication and mental health needs did not have appropriate care plans developed.
A facility failed to create a comprehensive care plan for a resident with anemia. Despite physician instructions to monitor hematocrit and hemoglobin levels and consider transfusion if necessary, no care plan was developed to address these needs.
A facility failed to update a resident's care plan to include physician orders for tube feeding management and dietary requirements. The resident had diagnoses of Protein Calorie Malnutrition and Oropharyngeal Phase Dysphagia. Despite orders for daily tube site care and a specific diet, the care plan was not revised, as confirmed by a RN.
The nursing staff failed to schedule necessary specialist examinations for a resident with vertigo and cerebral palsy, and another resident continued using a discontinued oral rinse. The lack of follow-through on physician orders and medication administration practices was confirmed by the DON.
A facility failed to maintain a medication error rate below five percent when a nurse administered the incorrect form of Aspirin to two residents. One resident was prescribed Aspirin Enteric-Coated for CVA treatment but received a chewable tablet instead. The nurse confirmed the errors, resulting in a medication error rate of 5.7%.
A facility failed to assess potential restraints for a resident, including a bed against the wall and an abdominal binder, as required by their policy. The resident, with multiple diagnoses, had no care plan for these restraints, and the DON confirmed the lack of assessment, violating regulatory requirements.
A facility failed to monitor a resident's weight accurately, leading to discrepancies in weight records. The resident, with a complex medical history, had missing post-dialysis weight entries, and the facility's dietician relied on inconsistent data from the dialysis center. This resulted in a lack of intervention for significant weight loss, violating the facility's weight monitoring policy.
The facility failed to maintain proper communication between the facility and a dialysis provider for two residents requiring dialysis. The facility's policy requires a communication form to be completed and sent with residents to the dialysis center, but numerous forms were missing over several months. This deficiency was confirmed by staff interviews, including the DON.
The facility failed to maintain a safe and homelike environment for two residents due to inadequate pest control and cleaning. Despite a pest control policy, residents reported ongoing insect infestations, with traps left unattended in their rooms. Observations confirmed the presence of numerous bugs, and the maintenance director could not explain the oversight.
A resident with cognitive impairment and incontinence was not provided timely assistance with toileting and personal hygiene, as observed by surveyors. The resident was found in bed with soiled sheets and clothing, emitting a strong odor of urine, and had not received morning care. A nurse aide confirmed the lack of care, and the resident expressed a desire for personal grooming, indicating a failure to follow the care plan and facility policies.
Failure to Report Shower Fall and Timely Notify Physician After Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification to the physician of a fall incident and resulting injuries sustained by Resident R1, as required by the facility’s “Change of Condition” and “Falls Prevention and Management” policies. These policies direct CNAs to immediately notify a nurse of any change in a resident’s condition and require prompt notification of the resident, attending physician, and resident representative for significant changes, accidents/incidents, or transfers. The falls policy also requires a complete head-to-toe assessment after any fall, that the resident not be moved until assessed by an RN unless there is a life-threatening situation, and that 911 be called immediately if the resident is unconscious, has difficulty breathing, or a severe injury is suspected. Resident R1 had a significant medical history including traumatic hemorrhage of the cerebrum, altered mental status, prior cerebral infarction, osteoporosis, muscle wasting, encephalopathy, mobility and gait abnormalities, dementia, restlessness and agitation, paranoid personality disorder, and muscle weakness. The resident had an active physician order for 1:1 monitoring due to falls and required partial/moderate assistance for tub/shower transfers, with a BIMS score of 3 indicating severe cognitive impairment. The care plan included a fall-related problem with interventions such as 1:1 nursing supervision at all times and environmental and cueing strategies to encourage use of the call bell and anticipate needs. On the evening in question, CNA Employee E1, assigned to provide continuous 1:1 supervision, took the resident to the shower room and, by her later admission, the resident slipped and fell while getting up from the shower chair, landing on the left side. Employee E1 stated she did not see any injury, dried the resident, and took the resident to the dining room without reporting the fall to licensed nursing staff. Earlier, in her initial written statement, Employee E1 claimed she did not see the resident fall and only noticed swelling and bruising on the left side of the face after dinner but did not look closely at the face. She later admitted during an interview with the Nursing Home Administrator that the resident had fallen in the shower room and that she did not report the incident because she was afraid she would get into trouble. Subsequently, another CNA, Employee E3, observed the resident with a nosebleed in the dining area at approximately 6:00 p.m. and brought the resident to the nurses’ station, informing the licensed nurse and CNA of the nosebleed. The agency nurse, Employee E2, who had oversight of the memory care unit, later reported she was not aware of the resident’s facial swelling, bruising, or bleeding until about 7:30 p.m., when the nursing supervisor, Employee E4, notified her. When Employee E4 arrived for the 7:00 p.m. shift and conducted rounds around 7:15 p.m., she observed the resident in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Employee E4 questioned Employee E1, who said she did not know what had happened, and questioned Employee E2 about why the injuries had not been noticed earlier, leading to an argument about responsibility for assessing residents and reporting possible abuse or injuries. Nursing notes later documented that at 9:18 p.m. the resident was observed lying on a couch as EMTs arrived, with swelling and bruising over the left mandibular area that felt tender, and that the resident was unable to explain what had happened. At 9:42 p.m., nursing documentation described left facial swelling and bruising and a nosebleed from the left nostril, with pressure applied to stop the bleeding and an order obtained to send the resident to the emergency room. Facility documentation submitted to the State Survey Agency and the facility’s investigation report confirmed that the resident was ultimately transferred to the hospital, where imaging revealed a subdural hematoma, a left zygomatic fracture, and acute right 3rd–4th rib fractures. Interviews with the DON and Nursing Home Administrator confirmed that CNA Employee E1 failed to notify licensed nursing staff of the fall and injuries, resulting in a delay in treatment after the fall in the shower room.
Unreported Shower Fall and Delayed Assessment Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from neglect when staff did not follow fall prevention and post-fall assessment policies, and did not report a fall with injury. Facility policy required that when a resident is found on the ground or has fallen, an RN must perform a complete head-to-toe assessment before the resident is moved, and 911 must be called immediately if the resident is unconscious, has difficulty breathing, or a severe injury is suspected. The resident involved had extensive medical history including traumatic cerebral hemorrhage, altered mental status, cerebral infarction, osteoporosis, encephalopathy, mobility and gait abnormalities, dementia, restlessness and agitation, paranoid personality disorder, and muscle weakness. The resident’s MDS showed cognitive impairment with a BIMS score of 3 and a need for partial/moderate assistance with tub/shower transfers, and the care plan included 1:1 nursing supervision at all times related to falls and confusion, with a physician order for 1:1 monitoring every shift due to falls. On the day of the incident, the resident was assigned a 1:1 nurse aide for continuous supervision. The aide later admitted that the resident slipped and fell while getting up from a shower chair in the shower room. After the fall, the aide helped dry the resident and took the resident to the dining room for dinner, stating that the resident did not appear to be in pain. The aide did not perform or obtain a head-to-toe assessment by an RN before moving the resident, did not notify licensed nursing staff of the fall, and did not report the incident to anyone at the time. In a written statement, the aide initially claimed not to have seen the fall and stated that she only saw swelling and bruising on the left side of the resident’s face after dinner, and that she did not look at the resident’s face earlier. Later that evening, the nursing supervisor coming on for the 7 PM shift observed the resident sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. When questioned, the 1:1 aide said she did not know what had happened, and the agency charge nurse responded that the supervisor should ask the aide and stated she had 30 residents to manage. The supervisor questioned why the nurse had not noticed the injuries when administering medications earlier. The supervisor then reassessed the resident, noted continued nose bleeding, and contacted the nurse practitioner, who directed that 911 be called and the resident be sent to the hospital. Imaging in the emergency room revealed a subdural hematoma, a left zygomatic fracture, a mandibular fracture, and two fractured right ribs. In a subsequent interview with the Nursing Home Administrator, the aide initially denied any incident until confronted with the resident’s report, via interpreter, that the resident had fallen because the floor was slippery; the aide then admitted the fall in the shower room and stated she had been afraid to report it. The facility’s investigation substantiated neglect based on the aide’s failure to report the fall and injuries, resulting in a delay in assessment and medical treatment.
Failure to Update Care Plan for Resident's Behavioral Issues
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner for a resident with behavioral issues. The resident, who was admitted with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, and schizoaffective disorder, exhibited behavior of pulling the fire alarm on multiple occasions. On January 24, 2025, the resident was in the vicinity when a fire alarm went off, and on January 27, 2025, and February 11, 2025, the resident was documented to have pulled the fire alarm, prompting police and fire department intervention. Despite these incidents, the resident's care plan was not updated to reflect this behavior until confirmed by the Director of Nursing on February 19, 2025.
Failure to Ensure Continuous Illumination of Egress
Penalty
Summary
The facility failed to ensure continuous illumination of the means of egress, specifically affecting one of two levels. During an observation on December 16, 2024, at 11:25 a.m., it was noted that a ceiling light fixture inside the exit vestibule of the basement laundry was not illuminated. This deficiency was confirmed during an exit interview with the Administrator and the Regional Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The missing ceiling light fixture was replaced and the light is now working. 2. Maintenance Director, or designee will conduct an initial audit of all lights in exit egresses are working. 3. Maintenance Director will educate maintenance staff to check all egress exit lights during monthly Life Safety Rounds to ensure they are working. 4. Maintenance Director, or designee will conduct audit of exit egress lighting, weekly x 4 weeks then monthly x2 months to ensure that all exit egress lighting is working. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.
Electrical System Deficiencies in Facility
Penalty
Summary
The facility failed to maintain and inspect its electrical systems in accordance with NFPA 70, Article 314, resulting in several deficiencies across different areas. During an observation on December 16, 2024, between 10:30 a.m. and 12:30 p.m., surveyors identified multiple issues. In the B wing Shower Room, a broken optical sensor light switch was found at 10:40 a.m. At 11:35 a.m., an unsecured junction box was observed above the B wing Lining closet. Additionally, at 12:15 p.m., a missing cover on an electrical receptacle was noted inside the C wing Day Room. These deficiencies were confirmed during an exit interview with the Administrator and Regional Maintenance Director. Further inspection on the same day at 11:00 a.m. revealed additional electrical system issues in the A/E Wing. Above the drop ceiling outside of Clean Storage, several free-hanging electrical junction boxes were discovered. This finding was also confirmed during the exit interview with the facility's Administrator and Regional Maintenance Director. These observations indicate a failure to adhere to the required standards for electrical system maintenance and inspection, affecting the safety and compliance of the facility.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The broken electrical sensor in B-Wing Shower has been fixed, the unsecure junction box in B-Wing linen closet has been anchored, and the missing outlet cover in C-Wing Day Room has been replaced. 2. Maintenance Director, or designee, will conduct an initial audit throughout the facility to look for other electrical sensors that are broken, unsecure junction boxes, and missing outlet covers and will fix or replace them. 3. Maintenance Director will educate maintenance staff on checking for broken, unsecure, or missing electrical components while making maintenance rounds. 4. Maintenance Director, or designee, will conduct audits, weekly x 4 weeks then monthly x 2 months, to ensure that all electrical components such as broken sensors, unsecured junction boxes, and missing outlet covers are in place and secured properly. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action. This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The free-hanging electrical junction boxes located above the drop ceiling in A/E Clean Storage Room have been securely anchored. 2. Maintenance Director, or designee, will conduct an initial audit of all Clean Storage Rooms to ensure all electrical junction boxes are securely anchored. 3. Maintenance Director will educate maintenance staff on the need to ensure all electrical junction boxes are securely anchored. 4. Maintenance Director, or designee, will conduct audits, weekly x 4 weeks then monthly x 2 months, of junction boxes in Clean Utility Rooms to ensure they are securely anchored. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.
Hazardous Area Enclosure Deficiency
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures, specifically affecting one of the two levels of the facility. During an observation on December 16, 2024, at 11:30 a.m., it was noted that the door to the Soiled Laundry room in the E-Wing was compromised. Paper towels were found stuffed into the door frame strike plate, which prevented the door from latching properly. This deficiency was confirmed during an exit interview with the Administrator and Regional Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The paper towel stuffed in the E-Wing Soiled Laundry Room Door has been removed. 2. Maintenance Director, or designee will conduct an initial audit of all Soiled Laundry Room doors throughout the facility to ensure that there are no additional Soiled Laundry Room doors with paper towels stuffed in the latching mechanism keeping them from properly latching. 3. Nursing and Housekeeping staff will be educated on not impeding the proper closing of doors by stuffing paper towels into the latching mechanism. 4. Maintenance Director, or designee will conduct audits, weekly x 4 weeks then monthly x 2 months of Soiled Laundry Doors to ensure paper towels are not being stuffed into the latching mechanism keeping them from properly latching. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.
Improper Use of Extension Cord in Resident Room
Penalty
Summary
The facility failed to maintain electrical wiring and equipment in accordance with NFPA standards, affecting one of two levels within the facility. During an observation on December 16, 2024, at 10:55 a.m., it was noted that resident room E-115 was using a black 2-foot medium duty multi-outlet extension cord to power electronics in the room. This use of an unapproved electrical device was confirmed during an exit interview with the Administrator and Regional Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
This Plan of Correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in this Statement of Deficiencies. 1. The 2' black medium duty-multi outlet extension cord powering personal electronic devices in room E-115 has been removed. 2. Maintenance Director will conduct an initial audit of all resident rooms and patient care vicinities to identify any additional multi-outlets being used for non-Patient Care Related Electrical Equipment and will remove them. 3. Maintenance Department will be educated on the use of multi-outlet extenders in resident care areas including their application in PCREE and non-PCREE scenarios throughout the facility. 4. Maintenance Director will conduct audits, weekly x 4 weeks then monthly x 2 months of all resident care areas in the facility to ensure that multi-outlet extenders in resident care areas are only used for PCREE scenarios and are UL Rated 1363A, or UL 60601-1. 5. Results of audits will be brought to the monthly QAPI meeting to determine if there is a need for any further action.
Failure to Provide Adequate Grooming and Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain adequate grooming and hygiene for a resident, identified as R315. The resident was alert, oriented, and able to communicate her needs, with diagnoses of fractures and malnutrition, and impairments to both sides of her upper and lower body. According to her Minimum Data Set (MDS), she was dependent on staff for all activities of daily living and expressed a preference for choosing between different types of baths. Despite this, the resident reported never being offered a shower since her admission, only receiving bed baths, which she found unsatisfactory. An interview with her nursing aide confirmed that staff only provided bed baths, assuming showers might be too strenuous for the resident. However, the resident's physician orders indicated scheduled shower/bath days twice a week, with no restrictions on showering noted in her clinical records.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. - Resident's R315 Physician orders were clarified to reflect restrictions for showering. - An audit was completed to identify if there were any residents that had restrictions for showers to ensure appropriate documentation was in place. Nursing staff will be educated on obtaining Physician orders and ensuring appropriate documentation is in the resident clinical record if any resident has restrictions for showers. - DON/Designee will audit all new admissions/readmissions to make sure that Physician orders are obtained for any residents with showering restrictions. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Ineffective Pest Control in Kitchen
Penalty
Summary
The main kitchen of the food and nutrition services department was found to be inadequately maintained, leading to an ineffective pest control program. Observations revealed several issues, including improper drainage in the dish room area, resulting in soiled water and food waste overflowing onto the floor. The dish room area also had a white substance resembling lime deposits on the flooring, and the dish machine, work tables, and racks were covered with a white powdery film indicative of hard water and calcium deposits. Additionally, the ceiling tiles in the dish room were water-damaged, stained, and warped, with dead insects collected in the ceiling light fixture screens. The walls and ceiling tiles had dried food debris, and the flooring had missing grouting, which provided a breeding ground for pests. The perimeter of the flooring and cove molding contained a buildup of dirt and discarded food particles. Further observations in the hot food preparation area revealed a heavy accumulation of grease, dust, and food splattering on the ceiling tiles and light screen covering. An industrial-sized piece of equipment, the braise or tilt skillet, was non-functional for several months and had a buildup of grease, food debris, and dust. In the dry food storage area, the perimeter of the flooring had streaking, smudging, and patches of mice droppings. The ceiling light screens were water-damaged and contained dead roaches. Additionally, the three-compartment sink had leaking issues, with a catch pan placed below to capture water. Pest control reports from the previous months indicated that the kitchen was targeted for common household pests, such as roaches and mice, with various treatments and traps used to combat the infestation.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. All items identified as deficient in the kitchen have been cleaned, repaired or replaced. 2. An Initial Audit will be conducted in the Kitchen to identify other items that might be in need of cleaning, repair or replacement. 3. Food Service will be educated on proper cleaning, maintenance and repair procedures for the kitchen and its equipment. 4. Food Service Director will conduct audits, weekly x 4 weeks, then monthly x 2 months in the facility kitchen to ensure the kitchen is being cleaned and maintained. Results will be reviewed at monthly QAPI.
Failure to Maintain Resident Dignity in Clothing Labeling
Penalty
Summary
The facility failed to maintain or enhance the dignity and respect of two residents, as observed during an interview. The residents reported that the facility's laundry service labeled their clothing with their names in visible areas, which compromised their dignity. One resident mentioned that their name was placed on the collar of a shirt in a way that was visible when worn. Another resident showed a jacket with a 2-inch belt that had their name written in large letters on the back, making it conspicuous. These actions by the facility's laundry service did not respect the residents' right to a dignified existence and self-determination.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1. Resident R38's shirt was replaced. Resident R124's belt has been replaced. 2. All residents are at risk to have their right of dignity violated when clothing labeling is visible on the outside of clothing. 3. Laundry and Nursing Staff will be educated on proper process of having clothing labeled with emphasis on labeling clothing in a manner that resident names are not visible on the outside of clothing. 4. Environmental Service Director, or Designee will conduct audits of resident's clothing, weekly x 4 weeks, then monthly x 2 months of all clothing being processed through the laundry to ensure there are no clothes with names of residents visible on the outside of clothing. Results will be reviewed at the monthly QAPI meeting.
Failure to Accurately Assess Language Needs
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed accurately for a resident regarding language and communication needs. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage, cerebral infarction, and dementia, was on comfort care. A Brief Interview for Mental Status (BIMS) assessment indicated moderate cognitive impairment and noted the resident's preferred language as Vietnamese. However, the Admission Assessment MDS did not reflect that the resident spoke a different language, and no care plan for communication was found in the clinical record. Observations and clinical notes further highlighted the communication barrier, as the resident was unable to communicate in English and required interpreter services. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the resident primarily communicated in Vietnamese, and this should have been documented in the Care Area Assessment. The deficiency was identified under 28 Pa Code 211.12 (d)(1) Nursing services.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Facility is unable to retroactively correct this deficiency. An audit was completed to identify all residents that speak a different language who have been admitted to the facility in the last month, to ensure that the Care Area Assessment reflects that those residents speak a different language. Education will be provided to the RNAC to ensure that all residents that speak a different language have it reflected in the Care Area Assessment. DON/Designee will audit all the Admissions Assessment MDS for all new admissions that speak a different language to make sure that the Care Area Assessment reflects that they speak a different language. Audit will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Failure to Develop Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within 48 hours of admission for several residents, leading to deficiencies in addressing their immediate needs. Resident R158, who primarily speaks Vietnamese, did not have a care plan reflecting language barrier services or specific activity programs based on her preferences. Despite the resident's limited English proficiency, the care plan did not include the necessary LEP services, and staff relied on anticipating her needs without frequent use of interpreter services. Resident R315, who was admitted with multiple fractures and a surgically wired jaw, had a care plan that failed to include emergency procedures for removing the jaw wires. Although pliers were available at the bedside for emergencies, this critical intervention was not documented in the care plan. This oversight could potentially delay emergency response in case of aspiration risk, which was noted in the care plan. Resident R417, who communicated primarily in Vietnamese and had moderate cognitive impairment, did not have a care plan addressing communication needs despite triggering a review in the Care Area Assessment. Additionally, Resident R420, admitted with suicidal ideations and bipolar disorder, lacked a care plan addressing his specific mental health needs. These omissions were confirmed by interviews with the Nursing Home Administrator and the Director of Nursing, highlighting a failure to develop appropriate baseline care plans for residents with specific language and mental health needs.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Residents' R417 and R158 Baseline care plans were updated to reflect a different language spoken other than English. An audit was completed for all residents that communicate in a language other than English to ensure that their baseline care plans are complete. Nursing staff will be educated to ensure that baseline care plans are initiated within 48 hours of admission. DON/Designee will audit all new admissions to make sure that residents that do not communicate with English being their primary language have a baseline care plan established. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed. Wired jaw - Resident's R315 baseline care plan was updated to include removing the wires from the jaw in an emergency. No other residents were affected. Nursing staff will be educated to ensure that baseline care plans for any residents with a wired jaw are developed within 48hrs of admission to the facility. DON/Designee will audit all new admissions to make sure that residents with a wired jaw have a plan of care developed to include removing the wires from the jaw in an emergency. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed. Bipolar and suicidal ideation - Resident R420's care plan was developed to reflect his specific health needs related to suicidal ideation and bipolar disorder. An audit of all residents with a diagnosis of Bipolar Disorder and suicidal ideation was completed to ensure that they had care plans developed related to mental health needs related to suicidal ideation and bipolar disorder. Nursing staff will be educated to ensure that care plans are developed for all residents with bipolar disorder and suicidal ideations. DON/Designee will audit all new admissions to make sure that residents that have a diagnosis of bipolar disorder or suicidal ideation have a care plan developed. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Failure to Develop Care Plan for Anemia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with anemia. The resident, identified as R314, was admitted with a diagnosis of anemia, which involves a reduced ability of the blood to carry oxygen due to a lack of healthy red blood cells. A physician's note dated November 20, 2024, referenced a critical hematology report from November 15, 2024, and instructed the facility to monitor the resident's hematocrit and hemoglobin levels, consider a blood transfusion if hemoglobin drops below 7.0, and monitor for signs of fatigue, impact on therapy, oxygen use, and check pulse oximetry as needed. Despite these instructions, the facility did not develop a care plan addressing the resident's anemia diagnosis, leading to a deficiency in meeting the resident's care needs.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Resident's R314 care plan was developed to address needs related to a diagnosis of Anemia. An audit of all residents with a diagnosis of Anemia was completed to ensure there are care plans present to address needs related to Anemia. Education will be done for Nursing staff to ensure that residents with a diagnosis of Anemia have care plans developed. DON/Designee will audit the charts of all new admissions and any residents with a new diagnosis of Anemia to ensure they have comprehensive care plans developed. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Failure to Revise Care Plan for Tube Feeding Management
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R63, regarding tube feeding management. The resident was admitted on February 12, 2024, with diagnoses of Protein Calorie Malnutrition and Oropharyngeal Phase Dysphagia. A physician's order dated April 1, 2024, required daily cleansing of the area around the feeding tube, and another order dated July 22, 2024, specified a Controlled Carb/Renal Diet with Mechanical Soft Texture and Thin consistency. However, on December 2, 2024, it was observed that the care plan had not been updated to include these orders. This was confirmed by a Registered Nurse, Employee E6, during an interview.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. - Resident's R63 care plan was revised to reflect the current goal and interventions with ordered diet. - An audit of all residents with enteral feeds was completed to ensure that goals and interventions with ordered diets were reflected on their current care plans. - Nursing staff and Dietician will be educated to ensure that care plans are revised timely with any diet changes. - DON/Designee will audit for any residents that have had their enteral feeds discontinued to ensure that care plans have been updated. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Failure to Schedule Specialist Examinations and Discontinue Medication
Penalty
Summary
The nursing staff failed to obtain and schedule necessary specialist examinations for two residents, as indicated by physician orders. Resident R16, who has a diagnosis of vertigo and cerebral palsy, was not scheduled for an ENT or neurologist examination despite orders from a nurse practitioner. The resident reported dizziness and a preference to remain in a supine position due to these symptoms, yet no orthotic device was used to alleviate her condition. The lack of follow-through on these orders was confirmed by both the licensed nurse and occupational therapist, as well as the Director of Nursing. Additionally, Resident R315 continued to use Chlorhexidine Gluconate oral rinse after the medication had been discontinued by the physician. The resident, who was admitted with multiple fractures and lacerations from a motor vehicle accident, was observed using the mouth rinse after meals, despite the order being discontinued. This oversight was confirmed by the Director of Nursing, indicating a failure in medication administration practices.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. Appointments: - Appointments for Resident R16 were scheduled for both ENT and Neurology. - An audit of Physician progress notes and physician recommendations for the past 2 weeks were completed to ensure that appropriate follow through was made for any follow up appointments ordered by the Provider. - Education will be provided to Nursing staff to ensure that all Physician recommendations requesting consultation follow up are followed through with. - DON/Designee will audit Physician recommendations to ensure appointments are made as recommended. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed. Medication Left Bedside: - Medication for Resident R315 was removed from the bedside. - All rooms were checked to make sure there were no medications at the resident's bedside. - Education will be provided to nursing staff to ensure that completed/discontinued medications are disposed of per facility protocol. - DON/Designee will complete random audits to ensure that medications that have been completed or discontinued are disposed of per facility protocol. Audits will be done weekly x4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by observations and interviews with staff. On December 3, 2024, a Registered Nurse, Employee E7, administered the incorrect form of Aspirin to two residents during medication administration. Resident R77 was given an Aspirin 81 mg chewable tablet instead of the prescribed Aspirin Enteric-Coated (EC) Tablet Delayed Release 81 mg, as per the physician's order dated September 28, 2020. Similarly, Resident R4 received the same incorrect form of Aspirin, contrary to the physician's order dated August 18, 2023, which specified the Enteric-Coated form for CVA treatment. The Registered Nurse confirmed these errors during interviews conducted at the time of observation. Consequently, the facility's medication error rate was calculated to be 5.7%.
Plan Of Correction
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. - Facility is unable to retroactively correct this deficient practice. - All residents residing in the facility are at risk of being affected. - Education for nursing staff will be completed to ensure that nurses administer the correct medications during medication passes. - DON/Designee will complete random medication pass competencies to ensure facility is free of medication errors. Audits will be done weekly by 4 weeks and monthly x2 months. Results of these audits will be reviewed at the Quality Assurance Meeting to determine if further action is needed.
Failure to Assess Potential Restraints for a Resident
Penalty
Summary
The facility failed to identify and assess potential restraints for a resident, specifically a bed placed against the wall and an abdominal binder. The facility's policy on restraints requires a physical restraint assessment to be completed if a device may be a restraint, and to document ongoing re-evaluation of the need for restraints. However, the facility did not complete a restraint assessment for the bed against the wall or the abdominal binder for the resident, who had diagnoses including cerebral infarction, anxiety, dementia, end-stage renal disease, and spondylosis. Observations revealed that the resident's bed was placed with one side against the wall, and there was no care plan developed for this arrangement or for the use of the abdominal binder. The binder was not on the resident during an observation, as it was in the laundry, but was later found clean and ready for use. The Director of Nursing confirmed that no assessment had been conducted for these potential restraints, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Monitor Resident's Weight Accurately
Penalty
Summary
The facility failed to adequately monitor and record the weight of a resident, identified as Resident R5, who was undergoing dialysis. The facility's policy required weights to be recorded post-dialysis on specific days, but there were missing entries for several dates in August and September 2024. Additionally, the facility's policy mandated re-weighing and notifying the dietician in case of significant weight changes, but this protocol was not followed for Resident R5. Resident R5 had a complex medical history, including cerebral infarction, sepsis, and end-stage renal disease, among other conditions. The resident was admitted with an order to record post-dialysis weights, which were not consistently documented. The facility's dietician was confused about whether the facility's nursing staff should record these weights, leading to a lack of intervention for the resident's significant weight loss. The dietician relied on weights provided by the dialysis center, which were later found to be inconsistent and inaccurate. The resident's weight records showed significant fluctuations, with discrepancies between the facility's records and those provided by the dialysis center. A re-weighing conducted during the survey confirmed the inaccuracies in the dialysis center's weights. The facility's failure to adhere to its weight monitoring policy and the dietician's reliance on inaccurate external data contributed to the deficiency in monitoring the resident's nutritional status.
Failure to Maintain Dialysis Communication Records
Penalty
Summary
The facility failed to maintain ongoing communication between the facility and a dialysis provider for two residents, identified as R2 and R5, who required dialysis services. The facility's policy on Dialysis Management mandates the development of a resident binder to send with the resident to the dialysis center, which should include a communication form completed before and after dialysis sessions. However, a review of the dialysis communication records for both residents revealed numerous missing communication forms over the months of July, August, and September 2024. This indicates a lack of adherence to the facility's policy, resulting in incomplete documentation of the residents' dialysis treatments. Resident R2 was admitted with multiple diagnoses, including end-stage renal disease and dependence on renal dialysis, while Resident R5 had chronic kidney disease among other health issues. Interviews with facility staff, including a licensed nurse and the Director of Nursing, confirmed the absence of these communication records. The missing documentation dates for Resident R2 included several days in July, August, and September, while Resident R5's records were incomplete for similar dates. This deficiency was confirmed by the Director of Nursing, who acknowledged the lack of communication records for both residents.
Inadequate Pest Control and Cleaning Practices
Penalty
Summary
The facility failed to ensure a safe, comfortable, and homelike environment for two residents, R12 and R15, due to inadequate pest control and cleaning practices. The facility's pest control policy, last revised in November 2019, assigns the maintenance department the responsibility of coordinating pest control services. However, interviews with residents R12 and R15 revealed dissatisfaction with the facility's cleanliness and ongoing insect infestation. Resident R12 reported bugs crawling in his room and noted that although an exterminator had visited a week prior and left traps, the issue persisted. Resident R15, who requires assistance to leave her room, confirmed the presence of insects and observed their movement at night. Observations of the rooms of residents R12 and R15 revealed multiple sticky traps containing a significant number of large black bugs. The facility's maintenance director, Employee E5, confirmed the presence of these traps but could not explain why they had been left in the residents' rooms. This indicates a failure in the facility's pest control and cleaning procedures, as the traps were not adequately monitored or replaced, contributing to the residents' discomfort and dissatisfaction with their living environment.
Failure to Provide Timely Assistance with Toileting and Personal Hygiene
Penalty
Summary
The facility failed to provide timely assistance with toileting and personal hygiene for one resident, identified as Resident R2. The resident's care plan, initiated in December 2022, indicated that due to cognitive impairment, the resident was incontinent of bowel and bladder and required checks every two hours with incontinence care as needed. The resident's quarterly Minimum Data Set (MDS) assessment from March 2024 noted the need for setup and cleanup assistance for toileting and personal hygiene. However, on May 8, 2024, an observation revealed that Resident R2 was lying in bed with visibly soiled sheets and clothing, emitting a strong odor of urine, indicating a lack of timely care. During the observation, a nurse aide, identified as Employee E9, confirmed the soiled condition of the bedding and admitted that morning care had not yet been provided to Resident R2. Additionally, the resident was observed with disheveled hair and unkempt facial hair, expressing a desire to have his beard shaved. This incident highlights the facility's failure to adhere to its policy of promoting care that maintains or enhances residents' dignity and respect, as well as the specific care plan interventions for Resident R2.
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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