Deer Meadows Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 8301 Roosevelt Boulevard, Philadelphia, Pennsylvania 19152
- CMS Provider Number
- 395425
- Inspections on file
- 36
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Deer Meadows Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, prior CVA, and an ADL care deficit had a care plan requiring use of a mechanical lift with two staff for all transfers. Despite facility policies mandating adherence to individualized care plans for mobility and fall prevention, a CNA attempted to transfer the resident from a recliner to bed using a walker and single-staff assist. During this transfer, the resident’s left knee gave out, the CNA lowered the resident to the floor, and the resident sustained a significant avulsion laceration to the left knee.
A resident with severe cognitive impairment and dementia did not have a person-centered care plan addressing dementia care or activities, as required by facility policy. Observations showed the resident repeatedly sitting alone in front of a television with no individualized engagement, and staff confirmed the absence of a care plan for dementia care or activities.
The facility did not provide an ongoing activities program to meet the physical, mental, and psychosocial needs of residents on two nursing units. Scheduled activities, including one-on-one room visits and group sessions, were not conducted as planned, and residents were often left sitting in common areas without engagement. Staff cited staffing shortages and insufficient activity materials as reasons for the lack of activities, and documentation showed that some residents received no individualized activities for an extended period.
A resident with multiple acute and chronic conditions had a physician order for vital signs to be recorded every shift, but a nurse failed to document vital signs for one shift and instead duplicated the previous shift's readings, resulting in incomplete and inaccurate clinical records.
A resident with a PICC line did not receive dressing changes as ordered, with the last documented change occurring nearly two weeks prior to observation. The PICC line was missing a disinfecting swab cap, and the resident's room and IV pole were found heavily soiled. These issues were confirmed by staff, and the resident reported concerns about missed care and wasted IV medication.
Deer Meadows Rehabilitation Center failed to maintain an effective pest control program, as evidenced by observations and interviews during a survey. Roaches and mice were reported in various areas, including resident rooms on Bair 1. Staff and residents confirmed the presence of pests, and pest control reports indicated ongoing issues with roaches and mice. The Nursing Home Administrator acknowledged the problem, highlighting the facility's non-compliance with pest control requirements.
A resident with heart failure, thrombocytopenia, morbid obesity, and gout received medications two hours late, contrary to the facility's policy requiring administration within one hour of the prescribed time. The delay was confirmed by the resident and the facility's administrator.
The facility failed to provide necessary treatment and services for pressure ulcer care and prevention for four residents. A resident developed a new pressure ulcer, and the physician was not notified promptly, delaying treatment orders. Additionally, three residents were observed without required heel boots, contrary to physician orders and care plans, indicating a lapse in preventive measures.
A resident's rights were violated when facility staff searched his room and removed personal items without permission while he was at dialysis. The staff discarded food and took medications, despite an assessment confirming the resident could self-administer them safely. The Nursing Home Administrator acknowledged the oversight and confirmed that permission should have been obtained.
The facility did not maintain safe temperature levels on the [NAME] Pavilion Second Floor, as required by their policy. The temperature was observed to be 86 degrees, exceeding the policy range of 71 to 81 degrees Fahrenheit. An LPN noted the area often gets hotter, and the Director of Maintenance explained that while residents' rooms are heated by wall units, the hallways are heated by the boiler. Manual adjustments to the air handlers could regulate the temperature.
A facility failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene due to cognitive impairment and physical limitations. The resident's hands were contracted, requiring a palm guard, and their fingernails were significantly long, necessitating trimming. An LPN confirmed the need for nail trimming, highlighting a deficiency in the resident's personal care.
The facility failed to implement fall interventions for two residents, both with cognitive impairments and at risk for falls. One resident did not have the required bilateral floor mats in place, while another had only one mat due to the other being cleaned. These lapses were confirmed by staff, indicating non-compliance with prescribed fall prevention measures.
A facility failed to monitor and modify interventions for a resident's nutritional needs, resulting in significant weight loss. Despite a physician's recommendation for an updated weight and dietitian consult due to poor appetite, the facility delayed obtaining a new weight and addressing the consult. This led to a 9.3% weight loss over one month.
The facility failed to administer oxygen therapy as ordered for two residents. One resident received 3 liters of oxygen instead of the ordered 2 liters, while another resident received 2.5 liters without an active physician order. These discrepancies were confirmed through observations and staff interviews.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident, a former firefighter with PTSD linked to 9/11, had a care plan that did not address specific triggers. Another resident's care plan also lacked identification of PTSD triggers. The deficiency was confirmed by a unit manager.
The facility failed to maintain effective infection control practices, as observed in the handling of urinary catheters and respiratory equipment for four residents. A resident's catheter bag was on the floor, another's oxygen tubing was unbagged on the floor, and a third resident's catheter equipment was on a floor mat being stepped on by a nurse aide. Additionally, a nebulizer was improperly placed on a windowsill, and a tracheostomy tubing was found in a trash container while in use. These issues were confirmed by the Unit Manager.
The facility failed to maintain an effective pest control program, leading to the presence of pests in two units. A surveyor observed a live roach in the second-floor nursing station, and an LPN confirmed frequent sightings. The maintenance book showed the last pest treatment was in October, with continued sightings of roaches and mice. Additionally, fruit flies were observed in a resident's room.
The facility failed to maintain essential kitchen equipment in safe working condition, as the main kitchen grill and oven were missing knobs, making them unsafe to operate. Despite being aware of the issue, the facility continued to use the grill for several weeks without the necessary parts, violating safety procedures and state regulations.
A medication error occurred when an LPN, distracted by another resident, administered medications prepared for one resident to another, cognitively impaired resident. The error involved multiple medications, including Oxycodone ER and Trazadone, leading to the resident's transfer to the ER due to low blood pressure and lethargy. The facility's policy requires identity verification before medication administration, which was not followed in this instance.
A nursing aide in an LTC facility misappropriated a resident's property by tearing down and trashing magazine pictures after a verbal altercation. The resident, with a history of bipolar disorder, accused the aide of further physical abuse, but this was not corroborated by camera footage or witnesses. The facility's investigation confirmed the misappropriation as mental abuse.
The facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. Residents complained about the quality and temperature of the food, and a test tray observation confirmed that food temperatures did not meet the facility's standards. This violates 28 Pa. Code 201.29(j) Resident rights and 28 Pa. Code 211.6(c) Dietary services.
Failure to Follow Transfer Care Plan Resulting in Resident Fall and Knee Laceration
Penalty
Summary
The deficiency involves the facility’s failure to follow the resident’s care plan for transfers, resulting in a fall and injury. Facility policy on fall prevention and ADL/mobility requires that care be provided according to the resident’s individualized care plan and that appropriate interventions be implemented and communicated to reduce fall risk. The resident’s comprehensive care plan, revised in early September 2023, documented an ADL care deficit related to decreased activity, wound, back pain, and a prior CVA, and specified that the resident required use of a mechanical lift with two staff members for all transfers. The resident had a diagnosis of Parkinson’s disease and a BIMS score of 14, indicating cognitive intactness. On the evening of February 16, 2026, contrary to the care plan, a CNA assisted the resident to stand using a walker and attempted to ambulate the resident from a recliner chair to the bed without using the mechanical lift or a second staff member. According to the CNA’s statement, the resident initially walked well until the left knee gave out, causing the resident to fall; the CNA reported obtaining a firm grip and slowly assisting the resident to the floor. Nursing notes documented that the resident was found sitting on the floor with a bleeding left knee and a skin tear, initially described as approximately 6 cm by 6 cm, and later hospital records described an approximately 8 cm by 8 cm avulsion laceration of the left knee with serosanguineous drainage and a skin flap with dusky discoloration. The facility’s investigation and counseling record for the CNA confirmed that the care plan for a two-person assist transfer was not followed and that this failure led to the resident losing balance and being lowered to the floor, resulting in the left knee skin tear.
Failure to Develop Comprehensive Dementia Care and Activities Plan
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan addressing dementia care and activities for a resident with severe cognitive impairment. The facility's policy requires an interdisciplinary team to create care plans that include needs such as ADLs, behaviors, and primary diagnoses. Despite this, a resident admitted with acute kidney failure and dementia did not have a care plan in place for dementia care or activities, as confirmed by review of the clinical record and interviews with staff. Observations over two days showed the resident repeatedly sitting alone in front of a television, with no evidence of engagement in individualized or group activities. A nursing assistant reported that there were no one-on-one activities available for the resident, and the DON confirmed the absence of a care plan addressing dementia care or activities. The deficiency was identified through review of facility policies, clinical records, staff interviews, and direct observation.
Failure to Provide Ongoing Activities Program for Resident Well-Being
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of each resident on two nursing units. Review of the activity calendar and direct observations revealed that scheduled activities, such as one-on-one room visits, were not conducted as planned. Residents were observed sitting in common areas, such as in front of the TV or in the dining room, without engagement in meaningful activities. Staff interviews confirmed that one-on-one visits were not occurring due to staffing issues, and there was a lack of sufficient activity materials, such as fidget items, to support scheduled group activities. Clinical documentation for a resident with dementia, muscle weakness, dysphagia, and anemia showed no record of one-on-one activities for the past 30 days, with activity tasks marked as not applicable. Staff reported that some residents spent most of their time sitting in front of the TV, and residents expressed interest in other activities like coloring and listening to music, which were not provided. The deficiency was further supported by the lack of available activity supplies and the inability to conduct planned activities due to resource limitations.
Failure to Accurately Document Resident Vital Signs per Physician Order
Penalty
Summary
A deficiency was identified when a facility failed to maintain clinical records in accordance with professional standards for one resident. The resident, who was cognitively intact and had diagnoses including COPD, sepsis, acute respiratory failure, acute pulmonary edema, and pleural effusion, had a physician's order for vital signs to be taken every shift for 30 days. Review of the clinical record showed that there was no documentation of vital signs for the night shift on a specific date. During an interview, a licensed nurse admitted to not documenting the vital signs she allegedly took, stating they were similar to those from the previous shift, and subsequently recorded identical vital signs for both the evening and night shifts.
Failure to Follow PICC Line Care Protocol and Maintain Clean Environment
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice and physician orders for a resident receiving intravenous therapy. Review of the clinical record showed that the resident, who was admitted with diagnoses including orthopedic aftercare, local skin infection, Type 2 Diabetes, and sepsis, had a physician order for a PICC line dressing change every five days by a registered nurse. Documentation revealed that the last dressing change was performed on April 4, 2025, and no further dressing changes were recorded up to the time of observation on April 16, 2025. During this observation, the PICC line dressing was still dated April 4, and a clave was missing its disinfecting swab cap, as confirmed by an LPN. Additionally, the resident's room was found to have a heavily soiled floor and an IV pole with a thick unknown substance, as confirmed by the Director of Nursing. The resident expressed concerns that IV medication was being wasted and that the PICC line dressing had not been changed for several weeks. These findings indicate that the facility did not follow its own policy for monitoring and changing PICC line dressings at established intervals, nor did it maintain a clean environment for the resident receiving intravenous therapy.
Pest Control Deficiency at Deer Meadows Rehabilitation Center
Penalty
Summary
Deer Meadows Rehabilitation Center was found to be non-compliant with the requirement to maintain an effective pest control program, as outlined in 42 CFR Part 483.90(i)(4). Observations and interviews conducted during an abbreviated survey revealed significant pest issues on one of the facility's nursing units, specifically Bair 1. On March 10, 2025, a unit manager was observed killing roaches in the hallway, and both staff and residents reported sightings of roaches and mice in various areas, including resident rooms. Resident R5 reported seeing numerous roaches and mice in her room, and roach bait was observed to be full of roaches. Another resident, R6, also reported seeing roaches and bugs in his room. A review of pest control reports from the previous two months indicated ongoing pest issues. On February 7, 2025, roach activity was noted throughout Bair 1. On February 25, 2025, mice activity was reported in the maintenance shop and heavy mice activity was observed in the kitchen. Rooms 113, 100, and 102 were reported to have mice and roaches, with recommendations for better sanitation in room 100. On March 5, 2025, roach activity was reported in room 106 on Bair 1, but treatment was hindered by the presence of a sleeping resident. The Nursing Home Administrator confirmed the presence of roaches and mice in the facility during an interview on March 10, 2025.
Plan Of Correction
The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusion stated in the statement of deficiencies. Rooms with exterminator baited boxes that were full were removed from the rooms. Deep cleaning and exterminator treatment of all rooms in Bair 1 was completed on 3/25/2025. Bair 2 deep cleaning/exterminator treatment will be completed by 4/1/2025. All staff will be educated by staff educator/designee about logging all pest concerns by room number or location in the exterminator log book. Deep cleaning and treatment will be completed by the exterminator for rooms and identified locations. The Director of Housekeeping will complete a weekly audit of rooms in Bair 1 for sanitation, and baited boxes. If a box is full, it will be removed, and the room will be logged in the exterminator book for another treatment. The audit will be completed weekly for 4 weeks, then monthly for 2 months. The Director of Maintenance will complete a weekly audit on a different day from the Housekeeping Director for baited boxes. If a box is full, it will be removed, and the room will be logged in the exterminator book for another treatment. The audit will be completed weekly for 4 weeks, then monthly for 3 months. Reports of audits will be presented at Monthly QAPI until substantial compliance is achieved.
Medication Administration Delay
Penalty
Summary
The facility failed to administer medications in a timely manner, resulting in a significant medication error for a resident. According to the facility's policy, medications should be administered within one hour of their prescribed time unless otherwise specified. However, on December 24, 2024, a resident received multiple medications two hours late, which was outside the timeframe indicated in the facility's policy. The medications were scheduled to be administered at 5:00 p.m., but were not given until approximately 7:11 p.m. to 7:18 p.m. The resident involved had a medical history that included heart failure, thrombocytopenia, morbid obesity, and gout. The delay in medication administration was confirmed through interviews with the resident and the facility's administrator. The administrator acknowledged that the medications were administered two hours late, which was not in compliance with the facility's policy. This incident was identified as a deficiency under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Plan Of Correction
The provider submits the following plan of correction in good faith and to comply with Federal regulation. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusion stated in the statement deficiencies. Resident physician notified on 1/13/2025 that resident received his 5pm medications 2 hours late on 12/24/2024. LPN that administered medication late on 12/24/2025 will be educated about facility medication administration policy. DON or designee will educate licensed nursing staff about Facility medication administration policy and notifying physician if medication is not administered within 2 hours as ordered by 1/24/2025. The DON/Designee will conduct random med pass observations of 5 residents per unit to ensure medications are administered timely. Audits will be done weekly x 4 weeks then monthly x 2 months. Result of medication pass audit will be presented at monthly QAPI until substantial compliance is achieved.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing of pressure ulcers and prevent the development of new ulcers for four residents. Resident R53, who was cognitively impaired and at risk for pressure ulcers, developed a new open area on the right hip. Despite the facility's policy requiring immediate notification of the physician and documentation of treatment orders, there was no evidence that the physician was informed of the new skin impairment until two days later. Additionally, the treatment administration record lacked documentation of wound treatment or assessment on the day following the identification of the wound. For Residents R90, R277, and R14, the facility failed to ensure compliance with physician orders for heel boots to be worn at all times while in bed to prevent pressure ulcers. Observations revealed that these residents were lying in bed with their heels touching the mattress without any offloading measures, despite having orders and care plans indicating the need for heel boots. The Unit Manager confirmed that these residents should have been wearing heel boots while in bed, indicating a lapse in adherence to prescribed preventive measures.
Violation of Resident's Rights to Personal Possessions
Penalty
Summary
The facility failed to honor a resident's right to be treated with respect and dignity, specifically regarding the retention and use of personal possessions. During a state survey, staff searched the room of a resident who was at dialysis, without obtaining permission. They went through his personal belongings, removed over-the-counter medications, and discarded some food items from his refrigerator. The resident, who had been at the facility for over a year, expressed that he had never experienced such an invasion of privacy before and felt his rights were violated. Interviews with the Unit Manager and the Nursing Home Administrator confirmed that the staff did not have the resident's permission to search his room or remove his belongings. The Unit Manager acknowledged that there was no apparent safety risk that justified the search, and an assessment had determined that the resident could safely self-administer his medications. The Nursing Home Administrator confirmed that the resident was upset about the incident and that staff should have obtained permission before taking any action. The clinical record review also showed no evidence of a safety risk that would warrant such actions.
Failure to Maintain Safe Temperature Levels
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels on the [NAME] Pavilion Second Floor. The facility's policy, last reviewed in November 2021, mandates that temperatures be maintained between 71 and 81 degrees Fahrenheit, with specific interventions required for temperatures outside this range. On November 19, 2024, a surveyor observed that the nursing station on the second floor was uncomfortably warm, and an LPN noted that it often gets even hotter. The Director of Maintenance explained that while residents' rooms are heated by wall units, the hallways are heated by the boiler, and they could manually adjust the air handlers to regulate the temperature. However, the temperature at the nursing station was measured at 86 degrees, exceeding the facility's policy range.
Failure to Provide Adequate Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident R18, who was unable to perform personal hygiene tasks independently. Resident R18 was cognitively impaired and diagnosed with heart failure, high blood pressure, cerebrovascular accident (stroke), and dementia. The resident had impairments on both sides of the upper body and was dependent on staff for personal hygiene. During an observation with an LPN, it was noted that the resident's hands were clenched and required a palm guard due to contraction. Upon opening the resident's hands, the LPN observed that the bilateral palms were a deep red color, and the fingernails were significantly long, requiring trimming. The LPN confirmed that the nails were too long and needed to be trimmed, indicating a failure in providing necessary nail care.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to deficiencies in accident prevention. Resident R4, who was admitted with severe cognitive impairment and a history of falls, had a physician order for bilateral floor mats to be placed every shift. However, during an observation, it was noted that these mats were not in place while the resident was in bed. This was confirmed by an LPN, indicating a lapse in following the prescribed fall prevention measures. Similarly, Resident R110, who was cognitively impaired and at risk for falls due to decreased functional mobility and antipsychotic medication use, also had a physician order for bilateral floor mats. During an observation, it was found that only one floor mat was placed on the right side of the bed, with the left side mat missing because it was sent for cleaning. This was confirmed by the Unit Manager, highlighting another instance where the facility did not adhere to the fall prevention interventions outlined in the care plan.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and modify interventions for a resident's nutritional needs, leading to a significant weight loss. According to the facility's Weight Policy, residents should be weighed at least monthly, and any confirmed weight change should be reported to the physician and registered dietitian for evaluation. However, the facility did not obtain a new weight for the resident until November 19, 2024, despite a physician's note on November 8, 2024, recommending an updated weight and a dietitian consult due to the resident's poor appetite. The resident's weight on November 19, 2024, was 111.5 pounds, reflecting a significant weight loss of 9.3% or 11.5 pounds in one month. Additionally, the registered dietitian did not address the physician's consult regarding the resident's poor appetite until November 20, 2024, which was 12 days after the initial recommendation. This delay in addressing the resident's nutritional needs and the failure to obtain timely weight measurements contributed to the resident's significant weight loss. The registered dietitian confirmed the delay in addressing the consult and the weight loss during an interview on November 22, 2024.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents. Resident R4, who was admitted with Type 2 Diabetes, Hypertension, and Hyperthyroidism, had a physician's order for oxygen therapy at 2 liters via nasal cannula. However, an observation on November 19, 2024, revealed that Resident R4 was receiving oxygen at 3 liters, which was confirmed by a nurse aide. Resident R149, admitted with Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, and Aphasia, was observed receiving 2.5 liters of oxygen via nasal cannula. A review of clinical records showed that Resident R149 had no active physician order for oxygen therapy. This was confirmed by an interview with the Unit Manager, indicating a failure to adhere to the facility's policy requiring a physician's order for oxygen administration.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for two residents diagnosed with PTSD. Resident R34, who had a history of anxiety disorder, major depressive disorder, and PTSD, was admitted with hospital discharge instructions indicating a need for psychiatric consultation due to blackouts related to PTSD. The resident's PTSD was linked to experiences as a firefighter at the World Trade Center, with specific triggers such as gallon bins at Home Depot. Despite these details, the resident's care plan, initiated in September 2024, did not address the actual diagnosis of PTSD or identify past experiences and potential triggers for re-traumatization. Similarly, Resident R106, diagnosed with adjustment disorder with mixed anxiety and depressed mood, and PTSD, had a care plan for ineffective coping related to PTSD dated May 2023. However, the care plan also failed to address the resident's actual diagnosis of PTSD or identify past experiences and possible triggers for re-traumatization. The deficiency was confirmed by the second-floor unit manager, who acknowledged that specific triggers were not specified in the plan of care.
Infection Control Deficiencies in Catheter and Respiratory Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple observations of improper handling of urinary catheters and respiratory care equipment for four residents. Resident R135 was observed with a urinary catheter bag placed on the floor. Resident R17's oxygen tubing, connected to an oxygen concentrator, was lying on the floor without any protective bag. Resident R61 had a urinary catheter bag and tubing on the floor mats, and a nurse aide was stepping on the mat while the catheter equipment was on it. Additionally, a nebulizer machine and tubing were placed directly on a windowsill without being bagged. Resident R90, who had a tracheostomy, was using blue corrugated tubing with a fluid collection bag that was placed in a trash container. These observations were confirmed by Employee E15, the Unit Manager.
Pest Control Deficiency in Facility Units
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests and rodents in two of its units, specifically the [NAME] Pavilion first and second floors. On November 19, 2024, a surveyor observed a live roach in the second-floor nursing station, and an LPN confirmed that such sightings were frequent. The LPN indicated that staff document pest sightings in the maintenance book, which revealed that the last pest treatment occurred on October 22, 2024. Despite this treatment, there were documented sightings of roaches and mice since then. Additionally, on November 19, 2024, multiple fruit flies were observed hovering over the bedside table in a resident's room. These observations were corroborated by the Unit Manager, RN, during a follow-up on November 21, 2024.
Failure to Maintain Safe Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential food service equipment in safe operating condition, specifically the main kitchen grill and oven. During an initial tour of the kitchen, it was observed that the grill had three burners without knobs, and the oven next to it also had a missing knob. Interviews with various kitchen staff revealed that the grill had been used without knobs for approximately three weeks to a month, with staff continuing to operate it despite the missing parts. The Food Operation Manager was aware of the issue, and a maintenance order had been placed to replace the knobs, but they were on backorder. The facility's procedure for conducting safety and operation inspections was not followed, as the missing knobs were not addressed promptly. The maintenance report confirmed that the facility became aware of the issue on July 1, 2024, and ordered new knobs on July 2, 2024, but they had not been delivered by the time of the inspection. This failure to maintain the equipment in safe working condition was a violation of the facility's policy and state regulations, as the grill was essential for food service operations.
Medication Error Due to Distraction
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving the administration of medications prepared for a different resident. The facility's policy on 'Medication Administration' requires verification of a resident's identity before administering medications, using methods such as checking identification bands or photographs. However, a licensed nurse, Employee E3, became distracted while preparing medications for one resident and mistakenly administered them to another resident, who was cognitively impaired with a BIMS score of 3. This error involved the administration of multiple medications, including Oxycodone ER, Trazadone, Midodrine, Risperidone, Divalproex Sodium, cranberry extract, ferrous sulfate, and a multivitamin. As a result of the medication error, the resident experienced a significant adverse reaction, requiring the administration of Narcan and monitoring of neurological status. The resident's blood pressure dropped to 85/47 mm Hg, and they were transferred to the emergency room for further evaluation and treatment. The clinical nurse progress note indicated that the resident was lethargic with low blood pressure and oxygen saturation, prompting a call to 911 and subsequent transfer to the ER. Employee E3 had previously completed medication pass competency for two residents, as documented in their orientation competencies.
Misappropriation of Resident Property by Nursing Aide
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, which is a form of abuse. The incident involved a certified nursing aide, Employee E3, who was reported to have ripped off and trashed magazine pictures belonging to a resident, identified as Resident R1. This event occurred after a verbal altercation between the resident and the aide. The facility's policy on abuse prevention, which prohibits mistreatment and misappropriation of resident property, was not adhered to in this instance. Resident R1, who has a history of bipolar disorder and anxiety, was involved in a series of interactions with Employee E3 on the evening of the incident. The resident, who has a BIMS score indicating intact cognitive status, was waiting for medication and became verbally abusive towards the aide. The situation escalated, leading to the aide's actions of removing the resident's personal property. The resident reported further physical abuse, claiming the aide kicked her, but this was not corroborated by camera footage or witness statements. The facility's investigation included reviewing camera footage and obtaining witness statements. The footage confirmed the aide's actions of removing the posters but did not show any physical altercation. The resident's refusal of a full body assessment limited the ability to verify the physical abuse claim, although a nurse observed an old bruise on the resident's knee. The facility substantiated the incident as mental abuse, leading to the termination of the aide involved.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed, specifically Ground Wing C. The facility's policy on food and nutrition services, revised on January 3, 2024, outlines specific temperature standards for various food items. However, during a resident council meeting on April 11, 2024, residents complained that the food was often bad, cold, and not what they had requested. Multiple residents confirmed these issues in interviews conducted on April 17, 2024, stating that hot food was often served cold and that their complaints to staff had not resulted in any changes. A test tray observation conducted on April 17, 2024, at 12:02 p.m. with Dietary staff Employee E4 revealed that the food temperatures did not meet the facility's standards. The recorded temperatures for items such as rice, meatloaf, beans, hot coffee, milk, juice, and warm baked apples were all outside the acceptable ranges. Employee E4 confirmed that the test tray food temperatures did not meet the facility's hot food temperature standards. This deficiency violates 28 Pa. Code 201.29(j) Resident rights and 28 Pa. Code 211.6(c) Dietary services.
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.
