Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Delaware Valley Skilled Nursing & Rehabilitation C during CMS and state inspections, most recent first.
A facility failed to provide effective pain management for two cognitively intact residents by administering PRN oxycodone without documented attempts at non-pharmacological interventions first. One resident had spina bifida and major depressive disorder and received oxycodone 15 mg repeatedly for chronic severe pain without documented non-drug measures, while another resident with PVD, T2DM with neuropathy, a new R BKA, and chronic pain received multiple PRN oxycodone doses for moderate pain without documented non-pharmacological interventions. The NHA confirmed the findings.
LPNs provided IV-related care through a PICC line for a resident with sepsis and severe cognitive impairment, but the facility had no documentation that the LPNs completed required IV therapy education, demonstrated competency, or received RN supervision. The resident had orders for IV ceftriaxone and PICC flushes, and the eMAR showed multiple LPNs documenting saline administration through the PICC.
Failure to assess and monitor a surgical wound: A resident with PVD, DM2, diabetic neuropathy, and a recent BKA had physician orders for daily wound care and q-shift monitoring of the stump incision, including the wound bed, drainage, odor, surrounding skin, and signs of infection. The record repeatedly showed the wound had not been evaluated by nursing staff, even after a wound care CRNP documented a full-thickness surgical wound and a vascular surgeon later noted necrosis and dehiscence. A photo showed blackened tissue and redness, and the resident was ultimately transferred to the hospital for poor wound healing and dehiscence, requiring surgical debridement and a wound vac.
Failure to Monitor Weight and Nutritional Intake: A resident with dementia, a femur fracture, hypothyroidism, and anemia was identified as at risk for nutritional decline and ordered supplements, but the record lacked documentation of physician or RP notification. The resident had inconsistent weight monitoring, no required reweight after a notable loss, no documented weight for one month, and extensive gaps in meal and fluid intake charting. The RD did not timely address the significant weight loss, and a later dietary note changed feeding assistance without documented notification to the physician or RP.
Controlled drug records and the MAR were not accurately reconciled for a resident receiving Oxycodone HCL 15 mg PRN for chronic severe pain. Multiple controlled-drug log entries showed the medication was removed or used without matching MAR documentation, and one MAR administration entry had no corresponding controlled-drug record entry. The DON reviewed the discrepancies with surveyors.
Failure to document non-pharmacological interventions and PRN psychotropic order limits: Two residents received PRN psychotropic medications without charted non-pharmacological measures before administration, and the orders were continued beyond the 14-day limit without documented prescriber rationale or extended duration. One resident had severe cognitive impairment and PRN orders for Ambien and lorazepam, while another resident with schizophrenia and intact cognition had a PRN lorazepam order for agitation and hallucinations. DON and NHA interviews confirmed the missing documentation.
Failure to Implement EBP for a Resident with Chronic Wounds. A resident with severe cognitive impairment and multiple chronic arterial wounds was observed without EBP in place. Protective gowns and gloves were not readily available for high-contact care, the record did not show a physician order for EBP, and the care plan did not include EBP as an intervention.
Failure to Train Staff on PICC Line Care: A resident with sepsis and severe cognitive impairment returned from the hospital with a PICC line for IV ceftriaxone and saline flushes. Several LPNs documented PICC line flushes, but personnel records showed no documented PICC-specific education, training, or competency validation for those nurses. The facility could not provide evidence of a structured training program or ongoing competency assessment for PICC line management.
A resident with sepsis and a UTI did not receive all prescribed IV antibiotic doses due to medication unavailability, and the facility failed to notify the physician or representative as required. Additionally, staff did not consistently complete required shift count documentation for controlled substances, with missing signatures on the medication cart log.
A resident with dementia expressed suicidal ideation to staff, leading to an evaluation by social services and implementation of frequent safety checks. However, the facility did not update the resident's care plan to include interventions or measurable objectives addressing the risk of self-harm or psychosocial needs, as confirmed by the Nursing Home Administrator.
A resident with dementia and nutritional risk experienced significant weight loss over a 30-day period. Despite assessment by an RD and ongoing recommendations, the care plan was not reviewed or revised to address the change in nutritional status or weight trends, and no new interventions were documented.
The facility failed to follow physician orders for bowel protocols, therapeutic devices, and preventative measures for residents, leading to extended periods without bowel movements and improper application of devices. Additionally, inaccurate documentation of food and fluid intake for a resident with heart disease resulted in delayed identification of condition changes, leading to hospitalization.
A resident experienced significant weight loss and dehydration due to the facility's failure to consistently monitor weights and implement effective nutrition management interventions. Despite being cognitively intact and having a history of weight fluctuations, the resident's declining oral intake was not timely addressed, leading to hospitalization and the need for a feeding tube.
The facility failed to provide evening snacks to residents, as required by policy, when the interval between dinner and breakfast exceeded 14 hours. Residents reported not being offered snacks, and observations confirmed insufficient snack options. The Registered Dietitian could not explain the inconsistency in offering snacks.
A resident with multiple health conditions and at risk for pressure sores was not adequately monitored or cared for, leading to the development of a new wound. The facility failed to follow its Skin Impairment Protocol, and the wound was not properly evaluated. Despite the care plan including an air mattress and regular repositioning, these measures were not effectively implemented.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis. Despite a physician's order for an emergency kit at bedside, the resident's care plan lacked interventions for emergency care, and no kit was observed at the bedside. Interviews with the resident and DON confirmed the absence of the emergency kit.
The facility failed to provide timely dental services for two residents, one with a broken dental bridge and another with poor dentition and a high-risk heart condition. Despite scheduled appointments and identified needs, there was no follow-up or evidence of dental care provided, leading to unresolved dental issues.
A resident with cognitive impairments and mobility assistance needs suffered a dislocated shoulder, but the facility failed to fully investigate the incident or identify the root cause. Despite signs of pain and an odd sound reported by a nurse aide, the facility's investigation was incomplete, and no specific concerns or corrective actions were identified. The facility's QAPI program did not effectively address the incident or ensure quality care.
Failure to Document Non-Pharmacological Pain Interventions Before PRN Opioid Administration
Penalty
Summary
The facility failed to provide effective pain management for two residents and failed to document attempts at non-pharmacological interventions before administering prescribed opioid pain medication. Facility policy stated that the physician will order appropriate nonpharmacological and medical interventions to address an individual's pain, but the clinical record and medication administration documentation did not show that this occurred before opioid use for the residents reviewed. Resident 10 was admitted with diagnoses including spina bifida and major depressive disorder and was cognitively intact with a BIMS score of 15. The resident had a physician order for oxycodone HCL 15 mg every 8 hours as needed for chronic severe pain. Review of the eMAR from December 2025 through March 2026 showed that oxycodone 15 mg was administered 166 times without any documented attempts at nonpharmacological interventions. Resident 2 was admitted with peripheral vascular disease, type 2 diabetes with diabetic neuropathy, a new right below-knee amputation, and chronic pain, and was also cognitively intact. The plan of care directed staff to provide non-pharmacological interventions for pain as indicated and to monitor pain characteristics, and the physician ordered oxycodone HCL every 8 hours as needed for moderate pain. Review of the MAR showed multiple administrations of oxycodone from late December 2025 through January 2026 without documented attempted non-pharmacological interventions prior to administration. The NHA reviewed and confirmed the findings during interview.
LPNs Administered PICC Line IV Care Without Required Competency Documentation
Penalty
Summary
The facility failed to ensure nursing services met professional standards of quality by allowing LPNs to administer IV-related care through a PICC line without documented IV therapy education, competency validation, or required RN supervision. Pennsylvania regulations and facility policies required nurses performing IV therapy to be knowledgeable and competent, and to follow the Nurse Practice Act for RN and LPN scope of practice requirements, but the facility could not produce records showing that the involved LPNs met those requirements. Resident 63 was admitted with sepsis and had severe cognitive impairment, with a BIMS score of 3 on the significant change MDS. The resident had physician orders for ceftriaxone 2000 mg IV daily for five days via PICC, along with orders to flush the PICC with 10 mL normal saline before and after medication administration and during each shift. The eMAR showed multiple LPNs documented normal saline administration via the PICC line on several shifts, but personnel records and facility documentation did not show completion of the required IV therapy education, documented competency, or supervision by an RN for Employees 3, 4, 5, and 6.
Failure to Assess and Monitor Surgical Wound
Penalty
Summary
The facility failed to provide necessary care and services to ensure appropriate assessment and ongoing monitoring of a surgical wound for a resident admitted with peripheral vascular disease, type 2 diabetes mellitus, diabetic neuropathy, and a recent right below-knee amputation. The facility policy required admission skin assessments, documentation of wound measurements and characteristics, and weekly skin assessments. Physician orders directed licensed nursing staff to cleanse and dress the right lower leg stump and to monitor and document the wound every shift, including the wound bed, drainage, odor, surrounding skin, and signs of infection. The clinical record showed repeated documentation from December 18, 2025, through February 6, 2026, indicating the surgical wound had not been evaluated. Although a wound care CRNP assessed the stump and documented a full-thickness surgical wound with light sanguineous drainage, stapled edges, and intact surrounding skin, the record continued to lack evidence that licensed nursing staff performed or documented routine assessments of the wound as ordered. A vascular surgeon later documented necrosis and dehiscence after staple removal and issued new orders for daily wound care and ongoing monitoring for infection, worsening necrosis, or further dehiscence. The record also showed delayed wound healing and concern for possible surgical debridement. A photograph from the contracted wound care provider showed blackened tissue along the incision with surrounding redness, indicating deterioration of the wound. Despite wound treatments being documented, the facility did not provide documented evidence that staff completed a comprehensive assessment of the surgical site on admission or monitored and documented the wound condition as ordered, including changes in appearance as the wound declined. The resident was later transferred to the hospital for poor wound healing and dehiscence and required surgical debridement and placement of a wound vacuum device.
Failure to Monitor Weight and Nutritional Intake
Penalty
Summary
The facility failed to monitor a resident’s weights consistently and accurately and did not timely identify changes in nutritional parameters for Resident 47. The resident was admitted with diagnoses including unspecified dementia, a displaced intertrochanteric fracture of the left femur, hypothyroidism, and anemia. The admission MDS showed the resident was severely cognitively impaired, was not on a therapeutic diet, and could feed self after set up. The care plan identified the resident as at risk for nutritional decline and directed staff to monitor and report signs of malnutrition and weight loss parameters, while the RD assessment documented the resident weighed 146.2 lbs., had an overweight BMI, and was ordered a regular diet with Prosource twice daily and Ensure twice daily. The record did not contain documented evidence that the physician or resident representative was notified of the resident’s nutritional risk or the interventions initiated. Weight documentation showed the resident weighed 146.4 lbs. on September 2, 2025, then 139.4 lbs. on October 8, 2025, reflecting a 4.7 percent loss, but the facility did not obtain a reweight as required by policy. On October 23, 2025, the resident weighed 120.2 lbs., a loss of 19.2 lbs. from the prior weight and a significant weight loss by the facility’s definition, yet no reweight was obtained to verify the accuracy of the change. No weight was documented for November 2025, and the next recorded weight was 130.6 lbs. on December 2, 2025. The record also showed significant gaps in meal and fluid intake documentation, including multiple days in September and October when breakfast, lunch, and fluid intake were not documented. The clinical record did not contain evidence that the RD identified and addressed the significant weight loss between October 8 and October 23, 2025. A dietary note later documented a change to feeding assistance to promote PO intake, but there was no documented evidence that the physician or resident representative was notified of the significant weight loss or the intervention changes. During interview, the facility did not provide additional documentation showing consistent meal or fluid intake monitoring, timely weight monitoring, or required reweights for Resident 47.
Controlled Drug Record and MAR Discrepancies
Penalty
Summary
The facility failed to implement procedures to maintain accurate records of controlled drugs and ensure accurate drug administration for one resident. The facility policy titled Controlled Substances stated it would comply with laws and regulations related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Resident 10 was admitted with diagnoses including Spina Bifida and Major Depressive Disorder, and had an order for Oxycodone HCL 15 mg, a Schedule II opiate narcotic, to be given every 8 hours as needed for chronic severe pain. A review of Resident 10's Controlled Drug Receipt/Record/Disposition Form and MAR from December 2025 through March 2026 showed multiple discrepancies. Twelve entries on the controlled drug record indicated Oxycodone HCL 15 mg was removed or utilized, but there was no corresponding MAR documentation showing administration on those dates and times. In addition, one MAR entry showed Oxycodone HCL 15 mg was administered on March 7, 2026 at 6:03 PM, but there was no corresponding entry on the Controlled Drug Receipt/Record/Disposition Form showing the medication was removed or accounted for. The DON was interviewed on March 12, 2026, and the discrepancies were reviewed.
Failure to Document Non-Pharmacological Interventions and PRN Psychotropic Order Limits
Penalty
Summary
The facility failed to ensure that psychotropic medications were used in accordance with regulatory requirements for two residents. The record review and staff interviews showed that non-pharmacological interventions were not documented before PRN administration of psychotropic medications, and that PRN orders were continued beyond the 14-day limit without documented prescriber rationale or a specified extended duration. Resident 63 was admitted with diagnoses including sepsis and had a significant change MDS showing severe cognitive impairment with a BIMS score of 3. The resident had a PRN order for Ambien 5 mg at bedtime for sleep, and the eMAR showed administrations on multiple dates. The record lacked documentation that non-pharmacological interventions were attempted before each dose. Resident 63 also had a PRN order for lorazepam 0.5 mg every 12 hours for anxiety, with administrations documented on multiple dates in March 2026. The record again lacked documentation of non-pharmacological interventions before each administration, and the order did not include a documented clinical rationale or specified duration to extend use beyond 14 days. Resident 6 was admitted with diagnoses including gastrostomy and schizophrenia, and the quarterly MDS showed intact cognition with a BIMS score of 14. The resident had a PRN order for lorazepam 1 mg topically every 6 hours for agitation and hallucinations, and the eMAR showed multiple administrations in January and February 2026. The record lacked documentation of non-pharmacological interventions before each administration, and the order did not identify a clinical rationale or specified duration extending the medication beyond 14 days. Interviews with the DON and NHA confirmed the findings, and the facility did not provide documentation showing non-pharmacological interventions or prescriber justification for continued PRN use beyond 14 days.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Wounds
Penalty
Summary
Enhanced Barrier Precautions were not implemented for a resident with multiple chronic wounds and severe cognitive impairment. The resident was admitted with orthopedic aftercare for surgical amputation and had an admission MDS dated January 12, 2026 showing a BIMS score of 3. Clinical record review identified six chronic arterial wounds located on the left lateral foot, left foot, great toe, left heel, right lateral foot, right metatarsophalangeal joints, right lower leg, and Achilles region. The facility policy on Infection Control Program-Enhanced Barrier Precautions, last reviewed May 13, 2025, stated that EBP were to be used for high-risk residents such as those with wounds or indwelling devices and during high-contact care activities including wound care, hygiene, and changing briefs and linens. On March 10, 2026, observation of the resident in the room showed no evidence that EBP were in place. Protective gowns and gloves were not readily available for staff use upon entry to the room for high-contact care activities, including wound care. The clinical record did not identify a physician order for EBP, and the resident's comprehensive care plan did not include EBP as an intervention for the resident's chronic wounds and increased risk for transmission of infection. During an interview on March 11, 2026, the DON and NHA reviewed the findings, and the facility did not demonstrate that EBP were implemented for the resident.
Failure to Train Licensed Nursing Staff on PICC Line Management
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for licensed nursing staff to ensure they had the knowledge and competencies needed to safely manage a PICC line for Resident 63. The report states that federal regulation requires an effective training program for all new and existing staff, and that the facility assessment must be used to determine the amount and types of training needed to ensure staff competencies meet resident care needs. Facility policies on medication administration and intravenous therapy stated that IV fluids, electrolytes, and medications are to be administered by nurses knowledgeable and competent in infusion therapy, with reference to RN/LPN scope of practice under the Nurse Practice Act. Resident 63 was admitted with sepsis and had severe cognitive impairment, with a BIMS score of 3 on a significant change MDS. After returning from the hospital, the resident had a PICC line in the right upper arm. Physician orders required Ceftriaxone Sodium to be administered daily for five days through the PICC line, and the line was also to be flushed with 10 mL normal saline before and after medication administration and during each shift. The December 2025 eMAR showed the antibiotic was documented as administered four times and normal saline flushes were documented 14 times through the PICC line by licensed nursing staff. Review of personnel records showed that four LPNs who documented PICC line flushes had no documented education, training, or competency validation related to PICC line management. The facility could not provide evidence of a structured training program, competency validation, or ongoing education specific to PICC line care for licensed nursing staff. During interview, the Nursing Home Administrator confirmed the facility could not provide documentation of such training or competency validation and confirmed the facility had not developed or implemented a PICC line management training program.
Failure to Ensure Timely Medication Administration and Accurate Controlled Drug Documentation
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed intravenous antibiotic for one resident who was readmitted from the hospital with sepsis and a urinary tract infection, and who required IV medication via a PICC line. Despite a physician's order for Meropenem to be administered every 12 hours for five days, the medication was not available for administration on two separate occasions, resulting in missed doses. Facility policy required staff to check the automated medication dispensing system, contact the pharmacy for STAT delivery, notify the physician and resident representative if the medication was unavailable, and document these actions. However, the clinical record lacked documentation that the physician or resident representative was notified of the missed doses, and the resident did not receive the full course of prescribed antibiotic therapy. The Nursing Home Administrator confirmed that backup pharmacy resources were available but not utilized to prevent the missed doses. Additionally, the facility failed to maintain accurate controlled drug shift count documentation on one of two medication carts reviewed. Facility policy required Schedule II medications to be counted and verified at each shift change by both oncoming and outgoing nurses, with signatures required to verify accuracy. Review of the controlled medication shift change log revealed missing signatures on multiple occasions, and staff interviews confirmed that the required sign-offs were not completed. The Nursing Home Administrator acknowledged the facility's failure to consistently adhere to procedures for verifying and documenting controlled substance counts.
Failure to Update Care Plan for Resident Expressing Suicidal Ideation
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives and timetables to address the needs of a resident who expressed suicidal ideation. Clinical record review showed that the resident, who had dementia, was admitted with multiple diagnoses and, on one occasion, communicated to staff a desire to harm herself. Although the social services department evaluated the resident and initiated every 15-minute checks, the resident's care plan was not updated to reflect her expressed suicidal ideation or to include interventions addressing her mental health risk. The care plan lacked documentation of strategies to monitor, support, and ensure the resident's safety regarding her psychosocial needs. The Nursing Home Administrator confirmed that the care plan had not been updated to address these concerns.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who experienced a significant change in condition related to weight loss. The resident, who had dementia and was at nutritional risk with a mechanically altered diet, lost 6.8% of body weight over a 30-day period. Although a registered dietitian assessed the resident and continued to recommend interventions following the weight loss, the care plan, originally developed months earlier, was not updated to reflect the resident's new nutritional status or to address ongoing weight trends. During the survey, it was found that there was no documented evidence that the care plan had been reviewed or revised after the significant weight loss was identified. No new interventions were added, nor were existing interventions updated to address the change in the resident's condition. The Nursing Home Administrator confirmed that the care plan should have been updated to reflect the resident's current needs following the weight loss.
Failure to Follow Physician Orders and Document Resident Care
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician orders for a bowel protocol for a resident with Alzheimer's Disease and chronic kidney disease. The resident had physician orders for a bowel regimen that included Milk of Magnesia, Bisacodyl, and Fleet Enema to be administered sequentially if no bowel movement occurred. However, the Medication Administration Record showed no evidence that the prescribed bowel protocol was followed during periods of constipation, leading to extended periods without bowel movements. Additionally, the facility did not consistently apply prescribed therapeutic devices and preventative measures for three residents. One resident was observed without Geri-sleeves and TED stockings, which were ordered to protect skin integrity and manage edema. Another resident was not wearing TED stockings as ordered, and a third resident's heels were not offloaded, and hip precautions were not maintained as prescribed. These observations were confirmed by staff interviews, indicating a failure to adhere to physician orders and care plans. The facility also failed to accurately document food and fluid intake for a resident with a history of heart disease and chronic heart failure. The resident experienced significant weight loss and had poor oral intake, but meal intake records were incomplete, with nearly half of the entries missing. This lack of documentation contributed to a delay in identifying changes in the resident's condition, resulting in critical lab values and hospitalization. The Director of Nursing confirmed the inconsistencies in documentation and the failure to act on the resident's condition changes.
Failure to Monitor Resident Weight and Nutrition
Penalty
Summary
The facility failed to consistently and accurately monitor the weights of a resident, leading to significant weight loss and dehydration. The facility's policy required re-weighing residents whose weight fluctuated by a certain amount, but this was not adhered to for a resident who experienced a significant weight loss over a period of time. The resident, who was cognitively intact, had a history of weight fluctuations and was on a therapeutic diet due to conditions such as hypertension and diabetes. Despite these conditions, the facility did not timely obtain, assess, and monitor the resident's weights to develop effective nutrition management interventions. The resident's weight records showed a progressive decline from 127 lbs to 97.6 lbs over several months, indicating a 20.9% weight loss. The Registered Dietitian (RD) noted the need for re-weighing and identified significant weight loss, but the interventions, such as the use of appetite stimulants and nutritional supplements, were not effectively evaluated or adjusted. The resident's oral intake was inconsistent, and the discontinuation of an appetite stimulant was linked to decreased intake, yet alternative methods for nutrition and hydration were not adequately explored or discussed with the resident and the interdisciplinary team. Ultimately, the resident was admitted to the hospital with dehydration, acute kidney injury, and other complications, necessitating the insertion of a feeding tube. The facility's Director of Nursing confirmed that the facility did not timely address the resident's declining oral intake, which led to the significant weight loss and hospitalization. The report highlights the facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutrition management, resulting in adverse health outcomes for the resident.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to routinely offer evening snacks to residents, as required by their policy, which states that all residents should be provided a nourishing snack at bedtime unless medically contraindicated. During a group meeting with residents, four residents reported that they were not offered snacks in the evening as desired. One resident mentioned that they had not been offered snacks for several months, while another recalled that staff used to offer snacks after supper, but this practice had ceased. All residents in attendance agreed that they were not offered evening snacks. The review of meal delivery times showed that the interval between dinner and breakfast exceeded 14 hours, necessitating the provision of a nourishing snack. However, the available snacks in the nursing unit were insufficient to meet this requirement. Observations revealed limited snack options, including a single rice crispy treat and 15 peanut butter crackers, with minimal items in the refrigerator/freezer. The Registered Dietitian was unable to explain why residents were not consistently offered a nourishing snack at bedtime, despite the extended interval between meals.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to consistently implement measures to promote healing and prevent the development of pressure sores for a resident identified as Resident 43. The resident, who was admitted with diagnoses including Parkinson's disease, heart disease, and diabetes, was moderately cognitively impaired and required substantial assistance for daily activities. Despite being at risk for pressure sore development, the facility did not adequately monitor or address the resident's significant weight loss, which was a risk factor for pressure ulcers. The care plan included interventions such as the use of an air mattress, regular repositioning, and skin assessments, but these measures were not effectively implemented. A new wound was discovered on the resident's sacrum, which was not identified by staff prior to its development. The facility's investigation revealed that the wound was not evaluated for size, drainage, or the condition of surrounding tissue, and the Skin Impairment Protocol was not followed. The resident was later sent to the emergency room due to a change in condition, and hospital documentation recommended consideration for an air mattress, which was supposedly already in place. The interim Director of Nursing confirmed the facility's failure to evaluate the pressure area and implement the necessary protocol.
Failure to Provide Emergency Dialysis Supplies
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 218, who was admitted with end-stage renal disease and dependent on renal dialysis, had a physician order dated July 29, 2024, for an emergency kit at bedside for the dialysis access site. However, the resident's care plan did not include interventions for emergency care of the Ash Cath, and an observation on August 6, 2024, revealed no emergency kit or supplies at the resident's bedside. Interviews conducted with Resident 218 and the Director of Nursing (DON) confirmed the absence of the emergency kit. Resident 218 stated that he had never seen or been informed of an emergency kit since his admission. The DON acknowledged that each resident receiving dialysis should have emergency supplies at bedside and confirmed the facility's failure to provide the necessary emergency kit for Resident 218.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to promptly refer a resident with a broken dental bridge for necessary dental services and did not provide dental care for another resident with poor dentition and a high-risk heart condition. Resident 4, who was moderately cognitively impaired, had a broken upper bridge noted on July 1, 2024. Although a dental appointment was scheduled for July 17, 2024, there was no documentation of the appointment's outcome or any follow-up by the speech therapist. By the time of the survey ending on August 8, 2024, there was no evidence that the dental appliance had been repaired or replaced. Resident 24, who was cognitively intact and had a history of atherosclerotic heart disease with a xenogeneic heart valve, was identified with broken teeth and dentures upon admission. Despite these findings and a subsequent hospitalization for endocarditis, which highlighted poor dentition as a contributing factor, the facility did not arrange for dental services to address the resident's dental issues. The Director of Nursing confirmed that dental services were not provided to prevent the infection related to the resident's poor dental condition.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to demonstrate the implementation of ongoing Quality Assurance and Performance Improvement (QAPI) programs, specifically in investigating and analyzing the root cause of adverse events. This deficiency was evidenced by the case of a resident who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, and dementia. The resident was moderately cognitively impaired and required extensive assistance for daily activities. An incident occurred where the resident was found to have a dislocated left proximal humerus, but the facility did not fully investigate the circumstances surrounding the injury. The resident's care plan indicated the need for assistance with mobility and toileting, and there were multiple instances where the resident showed signs of pain. On one occasion, a nurse aide reported hearing an odd sound while providing care, but there was no evidence that this was communicated to the nursing staff. The resident was later found to be guarding her left arm and shoulder, leading to an x-ray that confirmed the dislocation. Despite these events, the facility's investigation did not identify any specific concerns with the care provided or determine the root cause of the injury. The facility's QAPI plan outlined goals for infection control, creating a QAPI team, and staff training, but there was no evidence of corrective actions developed from the QAPI review of this incident. The investigation was incomplete, and the facility did not demonstrate an effective QAPI program to ensure quality of care and life by thoroughly investigating resident incidents and maintaining documentation to support their analysis and corrective actions.
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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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Nursing homes near Matamoras
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Josephs Place | 1.7 mi | ★★★★★ | 3 | 0 |
| Milford Rehabilitation And Healthcare Center | 5.2 mi | ★★★★★ | 14 | 0 |
| Homestead Rehabilitation & Health Care Center | 16.2 mi | ★★★★★ | 5 | 2 |
| Highland Rehabilitation And Nursing Center | 16.5 mi | ★★★★★ | 3 | 0 |
| The Valley View Center For Nursing Care And Rehab | 17.8 mi | ★★★★★ | 2 | 0 |
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