Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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, legal blindness, and an order for fall mats on both sides of the bed fell after being transferred into bed. The aide moved the wheelchair away and continued care before placing the mats, and the resident was later found on the floor bleeding from the mouth and diagnosed in the ER with a maxillary fracture.
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 strong and heavy urine odor was observed on the dementia unit near resident rooms and in the hallway, and the Unit Manager, an LPN, and housekeeping staff all confirmed the odor. Housekeeping reported one resident room had been cleaned but the flooring may have been saturated with urine, and a CNA reported changing the resident in that room. The facility’s housekeeping policy called for monthly bed washing and disinfecting to control odor and maintain cleanliness.
Inaccurate MDS Hearing Coding: A resident with COPD and documented moderate to severe bilateral hearing loss was coded as having adequate hearing on the quarterly MDS. The resident was observed to be hard of hearing, unable to hear the surveyor well, and stated that she did not have a hearing aid and needed staff to speak louder. The SW director and SW assistant confirmed the hearing item was coded in error.
Failure to complete a baseline care plan within 48 hours of admission for a resident with a nephrostomy tube. The resident had diagnoses including obstructive and reflux uropathy, a physician order for nephrostomy care q shift and PRN, and an MDS showing a BIMS score of 13. Surveyors observed the resident awake in bed with the nephrostomy bag lying on the bed, and the Charge Nurse and DON confirmed there was no baseline care plan.
A resident who required partial/moderate assistance with showering did not receive the scheduled shower or bed-making assistance. The resident, who had a BIMS score of 14 and diagnoses including spinal stenosis, reported that an aide said she was the resident’s aide but never returned to provide the shower. The DON confirmed the resident did not receive the shower as scheduled.
Improper Positioning of Nephrostomy Drainage Bag: A resident with an indwelling catheter/nephrostomy was observed in bed with the drainage bag lying flat on the bed instead of being properly positioned below the bladder. The resident said the tube was too short, and the charge nurse confirmed the bag placement. The DON stated the facility used the Foley catheter policy for nephrostomy care and had no baseline care plan.
Failure to obtain a physician assessment for a resident with significant unplanned weight loss. The resident had dementia, muscle weakness, dysphagia, and Type 2 DM, and weight records showed a notable decline over 2 months. Notes documented the weight loss, unplanned etiology, and nutrition interventions such as double portions, fortified foods, and Boost Glucose Control TID, but the chart did not show a documented MD evaluation of the cause.
Medication Error Rate Exceeded 5 Percent: An LPN administered Geri-Dryl Allergy Relief and Benadryl Allergy Oral Tablet to a resident, but only Benadryl was ordered. The same LPN also gave Vitamin D 25 mcg when the order was for Vitamin D 50 mcg. The facility’s medication error rate was calculated at 5.88%, exceeding the 5% threshold.
Incomplete and inaccurate reporting of a resident fall: A CNA was assisting a resident with evening care when the resident was transferred to bed and later found on the floor beside the bed with bleeding from the mouth. The resident was sent to the ER and diagnosed with a closed maxillary fracture. Although the incident report stated all fall precautions were in place, the resident had an order for floor mats when in bed, and a witness plus the DON confirmed the mats were not in place at the time of the fall.
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 Place Ordered Fall Mats After Bed Transfer
Penalty
Summary
The facility failed to ensure that fall-prevention interventions were in place after a resident was transferred into bed. Resident R48 was admitted with diagnoses including cerebral ischemia, legal blindness, and anxiety disorder, and had severe cognitive impairment with a BIMS score of 3. The physician order dated December 09, 2024 directed that fall mats be placed on both sides when the resident was in bed and moved away from the bedside when out of bed. Facility documentation stated that after the nurse aide transferred the resident from the wheelchair to the bed, the wheelchair was moved away from the bedside and the resident was left in the center of the bed while the aide continued evening care. According to the facility investigation, the nurse aide heard a noise and found the resident on the floor bleeding from the mouth. The charge nurse also found the resident lying beside the bed, and the resident was sent to the ER where a closed fracture of the maxillary bone was diagnosed. A witness statement from the agency nurse aide indicated the floor mats were not on the floor at the time of the fall and that the aide intended to place them after finishing care. The Assistant DON confirmed that the resident had an order for floor mats to be in place while in bed, and the facility failed to ensure the mats were in place after the resident was transferred into bed, resulting in the resident falling out of bed and sustaining a fractured jaw.
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.
Strong urine odor on dementia unit
Penalty
Summary
The facility failed to maintain the dementia unit on the 2nd floor in a clean and homelike condition. The cited policy stated that bed washing and disinfecting are performed monthly to control odor, prevent the spread of infections and bacteria, and ensure maximum cleanliness and sanitation for the individual resident. Survey observations on the dementia unit identified a strong and heavy odor of urine between rooms and near a resident room, including in the small hallway leading into the unit. The Unit Manager and an LPN confirmed the odor, and housekeeping staff also confirmed the strong urine odor. Housekeeping staff reported that one resident room had been cleaned but suggested the flooring may be saturated with urine and may need replacement. A CNA reported changing the resident in that room, and the Unit Manager stated she would request the mattress be inspected and replaced if necessary. On a later observation, no urine odor was detected and the Unit Manager reported the mattress in the room had been replaced.
Inaccurate MDS Hearing Coding
Penalty
Summary
The facility failed to ensure that Resident R143’s MDS hearing assessment was completed accurately. Resident R143 was admitted with a diagnosis that included COPD, and the quarterly MDS coded section B0200, Hearing, as adequate. However, a hearing evaluation dated July 25, 2025, showed moderate to severe hearing loss in both ears, and the resident’s care plan included a communication problem related to hearing deficit and ability to hear. During observation on September 29, 2025, Resident R143 was in bed, alert, awake, and responsive, but was not able to hear the surveyor well and asked the surveyor to speak louder. The resident stated that she was hard of hearing, did not have a hearing aid, and that staff had to talk louder for her to hear properly. During interview on October 23, 2025, the Director of Social Worker and a Social Worker Assistant stated that the MDS section B0200 was completed by the new Social Worker Assistant and that the section had been coded erroneously.
Failure to Complete Baseline Care Plan for Nephrostomy Care
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed within 48 hours of admission for Resident R13. The facility policy for Care Planning Process and Care Conference, revised March 19, 2025, states that an interdisciplinary baseline care plan is to be initiated upon admission by the admitting nurse and completed within 48 hours. Review of R13’s clinical record showed admission to the facility with diagnoses including obstructive and reflux uropathy, and a physician’s order dated April 30, 2025 for nephrostomy care every shift and as needed. R13’s MDS dated August 6, 2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and section H documented an indwelling catheter appliance including a nephrostomy tube. The clinical record contained no baseline care plan for the nephrostomy tube. During observation on September 29, 2025, R13 was in bed awake and responsive, and the nephrostomy bag was lying on the resident’s bed. The Charge Nurse confirmed that the resident had a nephrostomy, and the DON later confirmed that there was no baseline care plan.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide the necessary assistance with activities of daily living to maintain proper grooming for one resident who required partial/moderate assistance with showering tasks. The resident’s clinical record showed an admission diagnosis of disorder of muscle and spinal stenosis, and the annual MDS documented a BIMS score of 14, indicating cognitive intactness. The care plan identified a goal for bathing with one staff assisting with bathing/showering. During an interview, the resident stated that on the scheduled shower day, a nurse aide came in, confirmed she was the resident’s aide, but did not provide the shower, said she did not know when the shower would occur, and did not return; the resident also reported the bed was not made and that the resident eventually used the sink to bathe independently. The DON later confirmed that the resident did not receive the shower as scheduled.
Improper Positioning of Nephrostomy Drainage Bag
Penalty
Summary
The facility failed to ensure that urinary drainage systems were properly positioned and maintained to prevent urine backflow and urinary tract infection for one resident with a urinary catheter/nephrostomy. The facility policy for Foley catheter care stated that the drainage bag should be positioned to avoid urine reflux, kept below the level of the bladder, and observed periodically to ensure urine was flowing freely. Resident R13 was admitted with diagnoses including obstructive and reflux uropathy, and the clinical record showed an order for nephrostomy care every shift and as needed. The MDS coded the resident as cognitively intact, and the resident was documented as having an indwelling catheter/nephrostomy tube. During observation on September 29, 2025, the resident was in bed awake and responsive, and the nephrostomy bag was observed lying on the resident's bed. The resident stated that the tube was too short. The charge nurse confirmed that the resident had a nephrostomy and that the bag was lying flat on the resident's bed. The DON later stated that the facility did not have a policy specifically for nephrostomy and used the Foley catheter policy instead, and also confirmed that there was no baseline care plan.
Failure to Obtain Physician Assessment for Significant Weight Loss
Penalty
Summary
The facility did not ensure that a physician assessment was completed for Resident R19 related to significant unplanned weight loss. The resident was admitted with diagnoses of dementia, muscle weakness, dysphagia, and Type 2 diabetes. Weight documentation showed 132 pounds on August 8, 2025, then 123.2 pounds on September 1, 2025, a 6.67% loss, and 121.8 pounds on October 7, 2025. Weight warning notes documented significant weight loss, unplanned weight loss of unknown etiology, and that the resident was receiving double portions, fortified foods, and Boost Glucose Control TID, with oral intake reported as 50-100%. The clinical record did not show that a physician evaluated the resident’s significant weight loss. A weight warning note on September 9, 2025 stated the resident was triggering for significant weight loss and should be weighed to confirm. A later note on October 7, 2025 stated the resident was triggering for significant weight loss and that the RP/MD was aware, but there was no documented assessment of the potential medical causes of the weight loss. The Assistant DON confirmed there was no documented assessment of the resident’s recent significant weight loss, and the Dietitian reported that the facility’s protocol was to notify the charge nurse, who then notifies the physician to obtain a medical evaluation.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent for one of three residents observed during medication administration. During an observation on September 30, 2025, Employee E4, a Licensed Nurse, administered to Resident R137 one tablet of Geri-Dryl Allergy Relief by mouth along with one tablet of Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) by mouth, along with other medications. Review of the physician orders later that morning showed an order for Benadryl Allergy Oral Tablet 25 MG, but no physician order was available for Geri-Dryl Allergy Relief. The record also showed that Employee E4 administered one tablet of Vitamin D Oral Tablet 25 MCG to Resident R137 during the same medication pass. Review of the physician orders showed an order dated December 26, 2023, for Vitamin D Oral Tablet 50 MCG (2000 UT) to be given one tablet by mouth one time a day for supplement. The report states that Geri-Dryl is essentially the same as Benadryl because both contain 25 mg of diphenhydramine hydrochloride, and the facility’s medication error rate was calculated at 5.88 percent. The DON was notified of the findings at the time of the report.
Incomplete and inaccurate reporting of resident fall
Penalty
Summary
The facility failed to submit complete and accurate information to the State Survey Agency regarding a resident fall involving Resident R48. The incident report dated January 11, 2025 stated that a nurse aide was assisting the resident with evening care, transferred the resident to bed, moved the wheelchair away from the bedside, and placed the resident at the center of the bed. Shortly afterward, the aide heard a noise and found the resident lying on the floor beside the bed with bleeding from the mouth. The charge nurse observed the resident on the floor and the resident was transferred to the ER, where the resident was diagnosed with a closed fracture of the maxillary bone. The facility’s reported incident stated that all fall precautions were in place at the time of the fall, but the resident’s physician order dated December 09, 2024 required fall mats on both sides when the resident was in bed and moved from the bedside when out of bed. The facility investigation included a witness statement from Employee 19 dated January 13, 2025, stating the floor mats were not on the floor at the time of the fall and that the mats would be placed after finishing care. The DON later confirmed in interview that Resident R48 did not have fall mats in place at the time of the fall.
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.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,913 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Enhanced Living Pennypack Park | 0.1 mi | ★★★★★ | 11 | 0 |
| The Pines At Philadelphia Rehab And Healthcare Ctr | 0.2 mi | ★★★★★ | 1 | 0 |
| Transitional Care Unit At Nazareth Hospital | 0.2 mi | ★★★★★ | 0 | 0 |
| Roosevelt Rehabilitation And Healthcare Center | 0.7 mi | ★★★★★ | 24 | 0 |
| Immaculatemarycenter For Rehabilitation&healthcare | 0.8 mi | ★★★★★ | 26 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.