Edenbrook Of Yeadon
Inspection history, citations, penalties and survey trends for this long-term care facility in Yeadon, Pennsylvania.
- Location
- Lansdowne And Lincoln Ave, Yeadon, Pennsylvania 19050
- CMS Provider Number
- 395374
- Inspections on file
- 35
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Edenbrook Of Yeadon during CMS and state inspections, most recent first.
A resident with rheumatoid arthritis and Huntington’s disease, who required a two-person assist for bed mobility, was being provided continence care when a CNA repositioned the resident alone, without obtaining the required second staff member. The CNA reported she could not find help and did not want to wait because the resident was wet. During this care, the resident slid with a pillow to the floor, and the facility identified the cause as failure to follow the care plan for two-person assistance, constituting neglect.
A facility failed to maintain a sanitary and comfortable environment when an ice machine on one floor repeatedly leaked water, resulting in wet and damaged flooring, pooling water, and the presence of a black substance. In a nearby room, a resident with schizophrenia and moderate cognitive impairment was found in an environment with a wet floor, unsanitary bathroom conditions, and soiled toilet facilities. Staff interviews confirmed ongoing awareness of the water leakage and its effects.
A resident with chronic back pain received PRN opioid medication multiple times without required documentation of pain assessment elements or evidence that non-pharmacological interventions were attempted prior to medication administration, contrary to facility policy and professional standards. The DON confirmed that pain location, pain scale, and non-pharmacological interventions were not included in the orders or documentation.
Two residents with kidney disease and diabetes who required dialysis did not have proper communication and documentation maintained between the facility and the dialysis provider. In one case, the required communication binder was missing, and in another, the binder was incomplete on several occasions, with only pre-dialysis information documented and post-dialysis assessments missing.
The facility did not maintain accurate or complete documentation for binding arbitration agreements, with several agreements missing signatures, dates, or being incomplete, and some residents lacking signed agreements altogether. Staff interviews revealed confusion and inconsistencies regarding the completion and tracking of these agreements.
Two residents did not receive care according to physician orders: one was given Midodrine HCL despite SBP readings above the ordered threshold, and another had skin checks signed as completed even though a tight wanderguard prevented proper assessment. These actions were not in accordance with facility policy and physician directives.
A resident with severe cognitive impairment and multiple diagnoses did not have their representative invited to participate in the care planning process, nor was the representative provided with a copy of the care plan, despite facility policy requiring such involvement.
A resident with severe cognitive impairment and high fall risk was found with their bed pushed against the wall and a wedge under the sheets, actions that restricted movement and acted as a physical restraint. Staff confirmed this setup, but there was no documentation of a restraint assessment or physician order for this intervention.
Multiple residents were left without appropriate group or individualized activities, as scheduled activities were either not conducted or lacked engagement, and residents with dementia and physical limitations did not consistently receive required one-to-one bedside activities for sensory stimulation.
A resident with multiple diagnoses and documented limited range of motion in both upper and lower extremities did not receive the recommended restorative nursing program for ROM after discharge from therapy. The lack of communication between the rehab and nursing departments resulted in the resident not receiving services to maintain or improve mobility.
A resident with chronic respiratory failure and a history of pleural effusion was administered oxygen therapy after readmission from the hospital without a current physician order. Staff confirmed that oxygen was being provided at 3.5 LPM despite the absence of an active order, as the previous order had been discontinued upon hospital transfer.
Two newly hired nurse aides began working without documented evaluations of their competency in essential hands-on care skills. Despite multiple requests during the survey, the facility could not provide evidence that these staff members had been assessed for their ability to perform required resident care tasks.
A resident with an indwelling IV line and multiple medical conditions was observed receiving IV medication from a nurse who failed to follow enhanced barrier precautions as required by facility policy. The nurse wore only gloves, did not use additional PPE, and did not perform hand hygiene or change gloves during the procedure.
Surveyors found that the facility did not maintain a clean and homelike environment, as evidenced by unattended food trays, broken furnishings, dirty floors, and delayed meal service. A resident was observed barefoot in the dining room with food on the floor, and staff delayed distributing lunch trays after delivery. Additional issues included broken tiles, stained curtains, and improper handling of milk during meal service.
Two residents experienced verbal abuse from nurse aides, including the use of profanity, threats, and refusal to provide care during requests for assistance with toileting and hygiene. These incidents were substantiated through resident and witness statements, as well as facility documentation.
A resident with epilepsy and encephalopathy exhibited repeated behavioral issues, including yelling, foul language, and agitation, which interfered with care and created a disruptive environment. Despite multiple documented incidents and staff acknowledgment of ongoing behaviors, no comprehensive care plan or consistent interventions were developed to address these behaviors.
A resident with severe cognitive and physical impairments who required substantial assistance with eating did not receive timely feeding help on multiple occasions. Staff delayed feeding for 30 to 60 minutes after meal trays were delivered, leaving the resident's food untouched and the resident waiting for assistance, as confirmed by staff interviews and direct observation.
Trash, food, and debris were found on the ground around dumpsters in the receiving area, and one dumpster was left with its back door open, exposing trash. These conditions were observed during a kitchen tour with the Food Service Director.
An activity aide without documented training or qualifications was observed providing hands-on feeding assistance to two residents, one with dysphagia and another requiring a mechanically altered diet. The aide's job description did not include feeding duties, and the administrator confirmed that only nursing staff should provide such assistance.
A resident's room was found to have multiple flies present, with one fly observed on the resident's sheet and others flying in the room. The window screen in the room had a hole, and both a resident and staff confirmed the ongoing presence of flies over several days.
Edenbrook of Yeadon failed to ensure complete and accurate treatment administration for a resident who underwent aortic valve replacement and CABG. The facility's transition to paper documentation during a switch to an Electronic Administration Record system led to incomplete records for required incision care, leaving gaps in documentation for two days.
The facility failed to maintain safe water temperatures in the TCU Nursing Unit, with temperatures exceeding the policy range of 100-110 degrees Fahrenheit, posing a risk of burns to residents. Staff interviews revealed a lack of awareness and adherence to the water temperature policy, contributing to the unsafe conditions.
The facility failed to implement Enhanced Barrier Precautions for residents with sacral wounds, as staff were observed providing care without wearing gowns, contrary to the facility's policy. Additionally, there was no signage indicating the need for these precautions in the residents' rooms.
Edenbrook of Yeadon failed to maintain comfortable water temperatures in two nursing units, as required by their policy. A resident reported no hot water in her bathroom sink, and observations confirmed the water temperature was significantly below the acceptable range. The hot water tank was malfunctioning, leading to inadequate water temperatures in the First and Second Floor Nursing Units.
The NHA failed to manage the facility effectively, resulting in unsafe water temperatures in the TCU Nursing Unit. Observations showed excessively high water temperatures, and staff interviews revealed a lack of awareness about safe temperature ranges. This placed residents at risk for burns, leading to an Immediate Jeopardy situation.
A resident with multiple injuries from a previous fall required follow-up orthopedic care, but the facility failed to obtain necessary medical records from two hospitals, delaying potential surgery. Despite attempts by staff, the records were not sent, highlighting a deficiency in managing the resident's medical documentation.
A facility failed to readmit a resident after hospitalization, despite an anticipated return. The resident, with adjustment disorder, was sent to the ER after hitting a CNA. The facility informed the hospital they couldn't manage the resident's behavior, leading to a violation of resident rights and nursing services codes.
A resident experienced respiratory and emotional distress after a licensed nurse improperly removed and reinserted a tracheostomy tube without following facility protocols. The nurse failed to replace the disposable inner cannula and did not maintain proper infection control practices, leading to an Immediate Jeopardy situation. The resident, with a history of cerebral infarction and chronic respiratory failure, was unable to vocalize distress due to the absence of a Passy Muir valve.
A resident's privacy was compromised during tracheostomy care when a nurse, feeling nervous under observation, failed to close the privacy curtains, leaving the resident visible from the hallway. The incident occurred with the resident's husband and Unit Manager present, and the resident's roommate awake in the room.
A facility failed to complete a resident's assessment in a timely and accurate manner, as evidenced by an incorrectly coded MDS upon discharge. The resident was discharged with her daughter, but the MDS inaccurately indicated a discharge to a short-term general hospital. This error was confirmed by the Resident Assessment Coordinator, revealing a lapse in adherence to the facility's assessment policy.
A facility failed to update a resident's PASARR to reflect new mental health diagnoses, including schizoaffective and depressive disorders. Despite the facility's policy requiring updates upon significant changes, the PASARR Level I screen did not indicate the resident's mental health conditions. An interview with a social worker confirmed the oversight.
A facility failed to develop a care plan for a resident receiving oxygen therapy. The resident was observed in bed with oxygen administered via nasal cannula, but their care plan lacked documentation for oxygen therapy. This oversight was confirmed by an LPN during an interview.
A resident was observed receiving oxygen therapy via nasal cannula without a physician order. A review of the clinical record confirmed the absence of such an order, and a staff member acknowledged the oversight. This deficiency was identified during a review of clinical records.
A facility failed to restore bladder function for a resident with a suprapubic catheter and complex medical history. Bloody urine was observed, and although the resident was on antibiotics, a urology appointment was missed due to transportation miscommunication, preventing further evaluation.
The facility failed to assess and document the external catheter length and arm circumference for a resident with a PICC line, as required by physician orders and professional standards. Despite the need for weekly measurements to monitor for complications, staff interviews confirmed the absence of documentation since the resident's admission.
The facility failed to maintain proper food storage and sanitation standards. Observations revealed uncovered and undated food items, improper freezer temperatures, and unsanitary conditions in the kitchen. The FSD confirmed issues with the freezer and acknowledged the presence of debris and dust in various areas.
A facility failed to maintain proper infection control during tracheostomy care and in the laundry department. A nurse did not adequately sanitize the area before performing tracheostomy care on a resident, and the laundry department lacked accessible handwashing facilities due to a non-functional sink blocked by chemicals.
The facility failed to ensure a safe, sanitary, and functional environment for six residents and 15 resident rooms across two floors. Observations revealed dirty leftover food, unsanitary conditions in restrooms, and unclean rooms with various contaminants. Additionally, lunch trays were not promptly removed, and a strong urine smell was detected on the first floor.
The facility failed to establish and implement effective grievance policies and procedures, as evidenced by multiple residents' complaints about call bell response times and food quality not being documented or resolved. Despite informing the administration and nurse supervisor, the issues were not adequately addressed, and residents or their representatives were not informed of the resolutions.
Failure to Follow Two-Person Assist Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s plan of care for required assistance during bed mobility. The resident had diagnoses including rheumatoid arthritis and Huntington’s disease and required a two-person assist for bed mobility per the care plan. During continence care on January 9, 2026, a nurse aide repositioned the resident in bed without obtaining a second staff member to assist, despite the documented requirement for two-person assistance. According to the incident report and the nurse aide’s written statement, the aide did not use a second person because she could not find help, stated that everybody was with their clients, and did not want to wait because the resident was wet. During this episode of care, the resident slid with her pillow to the floor. The facility determined that the probable cause of the fall was the failure to follow the plan of care requiring two-person assistance with bed mobility, resulting in the resident not being kept free from neglect.
Failure to Maintain Sanitary and Comfortable Environment Due to Ongoing Water Leaks and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment on one of two nursing floors observed. On the first floor, an ice machine located between the nurse's station and a resident room was found to be leaking water onto the floor. A white towel and a blue gown were placed on the floor in front of the machine, and parts of the flooring in this area were peeled off, exposing the understructure. Behind the ice machine, water was pooling, and specks of a black substance were observed on the floor and wall. Staff interviews confirmed that the ice machine had been leaking periodically for at least two months, with multiple work orders and repairs documented, but the issue persisted. Inside a resident's room adjacent to the affected area, the floor near the doorway was wet and covered with white sheets, and a yellow caution sign was propped against the wall. The bathroom in this room had a toilet with no tank cover, dried dark brown substance caked on the toilet seat, and the toilet bowl was filled with feces and tissue paper. The resident in the room, who had a diagnosis including schizophrenia and moderately impaired cognition, was present during the observation but did not respond to the surveyor. Staff interviews confirmed awareness of the ongoing water leakage and its impact on the resident's room.
Failure to Document and Implement Comprehensive Pain Management Practices
Penalty
Summary
The facility failed to ensure professional practice standards related to pain management for one resident with chronic back pain. According to the facility's pain management policy, staff are required to assess and document pain characteristics such as onset, duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying symptoms. The policy also requires that non-pharmacological interventions be attempted prior to administering PRN analgesics, with all interventions and their effectiveness documented. However, review of the resident's records showed that these standards were not followed. The resident, who was admitted with chronic back pain, reported frequent pain and had physician orders for both Tylenol and Percocet to be given as needed for pain. The medication administration records indicated that while Tylenol was not administered, Percocet was given multiple times over several days. Each administration of Percocet lacked documentation of the required pain assessment elements, including pain onset, duration, location, severity, and related factors. There was also no documentation of any non-pharmacological interventions being attempted prior to medication administration, as required by facility policy. Interviews with facility staff, including the Director of Nursing, confirmed that pain location, pain scale, and non-pharmacological interventions should be included in physician orders and documented in the resident's records. The Director of Nursing acknowledged that these standards were not met for this resident, as the orders and documentation did not include the necessary pain assessment details or evidence of non-pharmacological interventions. The deficiency was cited under multiple state regulations related to medical director oversight, pharmacy services, resident care policies, and nursing services.
Failure to Maintain Effective Communication and Documentation for Dialysis Residents
Penalty
Summary
The facility failed to maintain effective communication and documentation with the dialysis provider for two residents requiring dialysis services. For one resident, the required communication binder, which contains essential information and communication pages between the facility and the dialysis team, could not be located on the nursing unit. Staff confirmed that the binder was not available and was not with the resident as required. This binder is intended to ensure ongoing assessment and monitoring of the resident's condition before and after each dialysis treatment, as outlined in the facility's policy. For another resident, review of the dialysis communication binder revealed incomplete documentation on multiple occasions. Specifically, only the pre-dialysis section was completed with vital signs and a nurse's signature, while the sections to be completed by the dialysis nurse and the post-dialysis evaluation by the facility nurse were left blank on several dates. Staff interviews confirmed that the protocol requires nurses to document pre- and post-dialysis assessments in the binder, but this was not consistently done. Both residents had significant medical histories, including kidney disease, diabetes, and dependence on dialysis, underscoring the importance of thorough communication and documentation.
Failure to Maintain Accurate Arbitration Agreement Documentation
Penalty
Summary
The facility failed to maintain accurate and complete documentation of binding arbitration agreements for five out of six reviewed residents. Specifically, for three residents, the arbitration agreements were found to be undated, with only initials from family members in the signature section, and the remainder of the forms were blank or incomplete. Additionally, two residents did not have signed arbitration agreements available for review. The facility's list of residents with binding arbitration agreements was also found to be inaccurate, as it included individuals who did not have such agreements on file. Interviews with facility staff revealed inconsistencies and confusion regarding the completion and existence of these agreements. The assistant administrator initially stated that the agreements were completed in person with family members, but later retracted this statement and could not confirm whether the agreements were actually reviewed or agreed to. The Nursing Home Administrator acknowledged that the facility's tracking system was incorrect and that it was unclear if the agreements were valid or properly executed.
Failure to Follow Physician Orders for Medication Administration and Skin Checks
Penalty
Summary
The facility failed to obtain, follow, and clarify physician orders related to medication administration and skin checks for two residents. For one resident with a history of cerebrovascular accident, heart failure, hypertension, and depression, there was a physician order for Midodrine HCL to be administered every eight hours, with instructions to hold the medication if the systolic blood pressure (SBP) was greater than 90. Despite this, the medication was repeatedly administered when the resident's SBP was documented above 90, as evidenced by multiple entries in the medication administration record and nursing notes over two consecutive months. The Director of Nursing confirmed that the medication was given incorrectly and that the physician order had been entered incorrectly, but the deficiency was based on the administration of the medication contrary to the documented order at the time. For another resident identified as being at risk for skin integrity issues and elopement, there was a physician order to check the skin integrity under a roam alert bracelet every shift and document any impairments. Observations revealed that the resident's wanderguard was applied too tightly, making it impossible to assess the skin beneath without removing the device. A licensed nurse had to cut off the device to perform the assessment. Despite this, the treatment administration record showed that the skin check was signed out as completed, and the nurse later confirmed that the check could not have been performed due to the tightness of the device and swelling of the resident's ankle. These deficiencies were identified through review of facility policies, clinical records, direct observations, and staff interviews. The failures involved not following physician orders for medication administration and not properly assessing and documenting skin integrity as ordered, resulting in noncompliance with resident care policies.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was given the opportunity to participate in the care planning process, as required by facility policy. The policy states that residents and/or their legal representatives should receive advance communication about scheduled care conferences for the development of individualized care plans. In the case reviewed, the resident had severe cognitive impairment, as indicated by a BIMS score of 7, and was dependent on staff for socialization and activities due to dementia, physical limitations, and hearing impairment. Despite these needs, the resident's representative was not invited to participate in the care planning meeting and was not provided with a copy of the comprehensive care plan. Documentation showed that a care review was completed, and the resident refused to participate, but there was no evidence that the representative was notified or involved. Interviews with the representative and the Social Services Director confirmed the lack of invitation and absence of documentation regarding the representative's participation or receipt of the care plan.
Failure to Prevent Use of Physical Restraint Without Assessment or Physician Order
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by policy and regulation. Facility policy states that physical restraints may only be used to treat medical symptoms and must never be used for staff convenience or discipline. For one resident with severe cognitive impairment, functional limitations in range of motion, and a high risk for falls, observations revealed that the resident's bed was pushed against the wall and a wedge was positioned under the sheets on one side. The use of the bed against the wall was confirmed by a registered nurse, who acknowledged that this could act as a restraint. A review of the resident's clinical record showed no documentation of a physical restraint assessment or a physician's order authorizing the bed to be pushed against the wall. The resident's care plan identified a high risk for falls but did not include the use of the bed against the wall as an intervention. The deficiency was identified through review of facility policy, clinical records, direct observation, and staff interview.
Failure to Provide Scheduled Group and Individualized Activities
Penalty
Summary
The facility failed to provide both group and individualized activities to meet the needs of multiple residents on the Main Nursing Unit. Observations revealed that several residents were left sitting in the dining room without any form of stimulation, such as music or television, during scheduled activity times. Specifically, the scheduled 'Coffee & Chat' activity consisted only of distributing coffee without any social engagement, and the 'Fun & Fit Exercise' activity was not conducted as planned. These deficiencies were confirmed through staff interviews and review of the activities calendar. Additionally, residents with significant cognitive and physical limitations, who were assessed as requiring one-to-one bedside activities for sensory stimulation and socialization, did not consistently receive these services. Documentation showed that one resident only had three documented one-to-one activities in a month, and another had no documented one-to-one activities prior to the previous month. The Activities Director confirmed that these residents were mostly bed bound and did not attend group activities, yet the required individualized activities were not provided as assessed.
Failure to Provide Restorative Range of Motion Services
Penalty
Summary
A deficiency was identified when a resident with diagnoses including rheumatoid arthritis, COPD, generalized muscle weakness, and poly-osteoarthritis, who had documented impairments in range of motion (ROM) in both upper and lower extremities, did not receive the recommended restorative nursing program for ROM. The resident had previously been discharged from physical and occupational therapy, with a physical therapy discharge recommendation for a restorative nursing program to maintain or improve ROM. However, there was no documented evidence in the clinical record that such services were provided. Observations confirmed the resident had limited movement in both hands and remained in bed during the survey. Interviews with the resident, the Rehab Director, and the DON revealed that the therapist's recommendation for restorative ROM services was not communicated to the nursing department, resulting in the resident not receiving the necessary services to prevent further deterioration of mobility limitations.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with a history of chronic respiratory failure with hypoxia and pleural effusion was readmitted to the facility following a hospital transfer. Upon review of the clinical record, it was found that the resident previously had a physician's order for oxygen therapy via trach collar at 4 liters per minute, which was discontinued when the resident was transferred to the hospital. After the resident's return, there was no new physician's order for oxygen therapy documented in the medical record. Despite the absence of a current physician's order, observations on two separate occasions confirmed that the resident was receiving oxygen via concentrator at 3.5 liters per minute. Interviews with the unit manager and a licensed nurse confirmed that the resident was receiving oxygen without a physician's order, and that the previous order had been discontinued upon hospital transfer. The care plan for the resident continued to reference oxygen therapy, but no corresponding physician's order was present in the record at the time of the observations.
Lack of Documented Skills Competency for Newly Hired Nurse Aides
Penalty
Summary
The facility failed to ensure that two newly hired nurse aides demonstrated competency in the skills and techniques necessary to care for residents. Review of personnel files and facility documentation showed that Employees E16 and E17 were hired as nurse aides, but there was no evidence of any skills competency evaluations conducted for them. Despite requests for documentation of hands-on direct patient care skills evaluations, none were provided for these employees at any time during the survey. The facility's job description for nurse aides includes a range of resident care tasks, but the required competency assessments were not documented for these two staff members.
Failure to Implement Enhanced Barrier Precautions During IV Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) as required by its own infection prevention and control policy for a resident with an indwelling intravenous (IV) line. According to the facility's policy, EBP—including the use of gown and gloves during high-contact resident care activities—must be used for residents at increased risk for acquiring multidrug-resistant organisms (MDROs), such as those with indwelling medical devices. The policy specifically lists activities like IV care as requiring EBP. During an observation, a licensed nurse entered the room of a resident who had an IV line and was receiving intravenous antibiotics. The nurse donned only gloves, omitting the additional personal protective equipment (PPE) required for EBP, and proceeded to set up and administer the IV medication. The nurse did not perform hand hygiene or change gloves during the process. The resident involved had a history of intracranial injury, respiratory failure, and pneumonia, and was actively receiving IV antibiotics at the time of the observation.
Failure to Maintain Clean and Homelike Environment in Resident Care and Dining Areas
Penalty
Summary
Surveyors observed multiple failures to maintain a clean, safe, and homelike environment on the Main Unit. A breakfast tray with leftover food was left unattended on a windowsill in the dining room for an extended period, and the wall railing in the same area was found to be broken. Additional observations included broken floor tiles in the shower room, peeling wallpaper, a stained privacy curtain, and a brown substance splattered behind a resident's bed. A resident's headboard was also found broken and propped against the wall. These conditions were confirmed by a registered nurse. During meal service, staff delayed setting up and serving lunch trays after their delivery, with a gap of 13 minutes before trays were distributed. The dining room floors were dirty with food remnants from breakfast, and a resident was seen barefoot with scrambled eggs beneath her feet. Staff were also observed pouring milk from individual cartons into disposable cups for residents. These observations collectively demonstrate a lack of attention to cleanliness, timely meal service, and maintenance of a homelike environment in resident care and dining areas.
Failure to Prevent Verbal Abuse of Residents
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by two substantiated incidents involving two residents. In the first case, a resident with epilepsy, encephalopathy, and contractures, who required substantial assistance with toileting and personal hygiene, reported that a nurse aide used profanity and made threatening remarks when the resident requested help with continence care. Documentation and witness statements confirmed that both the resident and the aide engaged in a verbal altercation involving curse words, and the aide threatened to involve her husband in the dispute. Another resident corroborated the use of offensive language and threats by the staff member. In the second incident, a resident with a history of cerebrovascular accident, heart failure, and depression, who required minimal assistance with hygiene and had intact cognition, experienced verbal abuse when a nurse aide refused to assist with cleaning after a bowel movement accident. The aide responded with a derogatory comment, refusing to provide care. Another aide intervened to assist the resident, and the incident was reported to nursing staff. Facility documentation and resident statements substantiated the occurrence of verbal abuse in this case as well. Both incidents were confirmed through interviews, resident statements, and facility documentation, demonstrating a failure to ensure that residents were free from verbal abuse as required by facility policy and state regulations. The events involved direct verbal altercations between staff and residents, including the use of profanity, threats, and refusal to provide necessary care.
Failure to Develop Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan addressing behavioral issues for one resident with a history of epilepsy and encephalopathy. Despite multiple documented incidents of the resident exhibiting behaviors such as yelling, screaming, using foul language, and threatening staff, no care plan was created to guide staff in managing these behaviors. Progress notes and behavior monitoring records indicated repeated episodes of agitation, anxiety, and disruptive conduct, some of which interfered with care and created a disruptive environment. Interventions were inconsistently applied, with some instances where redirection was attempted but ineffective, and other instances where no interventions were implemented or documented. Staff interviews confirmed the ongoing nature of the resident's behaviors and the absence of a care plan or consistent interventions to address them. Nurse aides and licensed nurses acknowledged that the resident frequently displayed challenging behaviors and that staff often had to wait for the resident to calm down before care could be provided. The lack of a comprehensive care plan and clear interventions for managing the resident's behaviors constituted a failure to meet regulatory requirements for individualized resident care.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
Facility staff failed to provide timely feeding assistance to a resident with severe cognitive impairment and significant physical limitations. The resident required substantial to maximal assistance with eating, as documented in the Minimum Data Set and care plan, due to contractures, communication deficits, and impaired mobility. The care plan also identified a risk for altered nutritional status related to the need for eating assistance. On multiple observed occasions, lunch trays were delivered to the unit, but the resident did not receive feeding assistance until 30 to 60 minutes after tray delivery. On one day, the resident's tray remained untouched on a tv stand across the room for nearly an hour before staff began feeding. Staff interviews confirmed the delays, with nurse aides and the unit manager acknowledging that the resident was still waiting to be fed well after meal delivery. These actions were not in accordance with the facility's policy to provide timely care and assistance with activities of daily living, including eating.
Improper Disposal of Garbage and Refuse in Dumpster Area
Penalty
Summary
During a tour of the main kitchen, including the outside receiving and dumpster area, trash, food, and debris were observed on the ground surrounding the dumpsters. Additionally, one dumpster had its back door open, leaving trash exposed. These observations were made in the presence of the Food Service Director. No information regarding residents or their medical history was included in the report.
Unqualified Staff Provided Feeding Assistance
Penalty
Summary
The facility failed to ensure that staff providing feeding assistance were properly qualified and trained, as required by state law. Review of personnel files and direct observation revealed that an activity aide, who was previously hired as a receptionist and later transferred to the activities department, was providing hands-on feeding assistance to two residents during a lunch meal. The activity aide's job descriptions for both positions did not include feeding assistance duties, and there was no evidence in the personnel file of any training or qualifications related to feeding assistance. The two residents involved had documented needs for assistance with eating due to self-care performance deficits, with one resident also exhibiting dysphagia and being at risk for aspiration and weight loss. One resident required a mechanically altered diet per physician order. Despite these needs, the activity aide, who lacked documented training or qualifications, was observed feeding both residents. The nursing home administrator confirmed that nursing staff are responsible for providing feeding assistance, further highlighting the inappropriate assignment of duties.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of flies in a resident's room. During a tour of the first-floor unit, a resident with cardiovascular disease and gastrostomy status was observed in bed, with a fly on the sheet and three additional flies flying in the room. The window screen in the resident's room was found to have a hole, and the resident's roommate confirmed that flies had been present for several days. The roommate also mentioned occasionally opening the window, but was unsure of the source of the flies. Staff confirmed the presence of flies and the damaged window screen during the observation.
Incomplete Documentation of Treatment Administration
Penalty
Summary
Edenbrook of Yeadon was found to be non-compliant with federal and state regulations regarding the maintenance and confidentiality of resident records. Specifically, the facility failed to ensure complete and accurate treatment administration for a resident identified as CL1. This resident was admitted with a cognitive communication deficit and a chest surgical incision following an aortic valve replacement and coronary artery bypass surgery. The physician's orders required specific incision care, including washing with mild soap and avoiding lotions or immersion in water, to be performed every day and evening for four weeks. The deficiency was identified through a review of the treatment administration record, which showed that incision care was documented as completed from January 23 to January 31, 2025. However, the records for February 1 and February 2, 2025, were left blank. An interview with the Director of Nursing and the Administrator revealed that the facility had transitioned to paper documentation during this period due to a switch to an Electronic Administration Record system. This transition resulted in incomplete documentation of the required treatment for Resident CL1.
Plan Of Correction
The facility is unable to retroactively correct. Current facility residents ETAR documentation for the last 2 weeks will be reviewed to determine if the deficient practice affected other residents. Identified residents will be assessed by RN staff where needed, along with the completion of a treatment error report. NHA, DON and/or Designee will conduct weekly audits for 4 weeks to ensure documentation protocol is complete, then monthly for 3 months to ensure compliance. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Unsafe Water Temperatures in TCU Nursing Unit
Penalty
Summary
The facility failed to maintain safe water temperatures in the central shower room and resident bathroom sinks on the TCU Nursing Unit, which posed a risk of serious injury from burns to the residents. Observations revealed that the hot water temperatures in the central shower room and resident bathroom sinks exceeded the facility's policy range of 100-110 degrees Fahrenheit, with temperatures recorded as high as 123.8 degrees Fahrenheit. The thermostat on the hot water tank was initially set to 150 degrees Fahrenheit, and the water inside the tank was 160 degrees Fahrenheit, which contributed to the excessively high water temperatures. Interviews with staff members, including nurse aides, revealed a lack of awareness and adherence to the facility's water temperature policy. Several nurse aides admitted to not using a thermometer to check the water temperature before bathing residents and were unable to state the safe water temperature range. This lack of knowledge and failure to follow protocol further contributed to the unsafe conditions, as residents were exposed to potentially harmful water temperatures during bathing. The Immediate Jeopardy situation was identified due to the facility's failure to ensure that water temperatures did not exceed 110 degrees Fahrenheit, as required by their policy. This deficiency was communicated to the Nursing Home Administrator, highlighting the urgent need for corrective action to protect the residents from the risk of burns.
Plan Of Correction
No residents were harmed. Plumber onsite immediately addressed temperatures. The plumber addressed during onsite visit. He was also scheduled for a follow-up visit the following day to ensure the adjustments that were made were effective. Audited resident sinks and shower rooms and found no additional findings. Facility reeducated on policy. Facility in house staff have been in serviced. NHA/DON and/or designee conducted daily audits for a week, weekly for 4 weeks, then monthly for 3 months to ensure compliance. The administrator or designee will conduct random employee interviews for three months to ensure their competency on methods of on the water temperature policy including acceptable water temperature ranges and appropriate methods to check water temps. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Removal Plan
- The facility turned off the hot water valve to TCU unit when they were alerted about the high temperatures on TCU.
- Adjustments were made after the system was flushed. Hot water maintained and did not exceed 110 degrees. The plumber was called to assess and make recommendations.
- The facility checked the sink temperature in every room on the TCU after the hot water valve was turned back on.
- There were no additional high temps identified.
- The facility water temperature policy will be reviewed to ensure that safe processes for monitoring water temperatures have been fully developed.
- 80% of employee list that were working on the day and evening shift were educated on the water temperature policy including acceptable water temperature ranges (100-110 degrees) and appropriate methods to check water temps.
- Water temperature will be checked using a thermometer reading prior to immersing a resident in water, using water from a shower, or using hot water for the purpose of bathing or soaking.
- Hot water temperatures exceeding 110 degrees Fahrenheit or less than 100 degrees Fahrenheit will be reported immediately to the Charge Nurse or designee.
- Regular maintenance checks to ensure the plumbing system is functioning properly and temperature limits are being adhered to.
- Staff for future shift will be educated at the beginning of shift. Additional 10% staff will be virtually educated to total of 100% staff education compliance.
- The plumber is scheduled for a follow-up visit proactively to ensure the adjustments that were made were effective.
- The Maintenance staff or designee will complete temp audits hourly for the next 24 hours. The team will continue to monitor water temps daily until further direction of QAPI Committee.
- A random sampling of employee interviews to ensure that they are knowledgeable on how to identify and respond to elevated water temperatures. Audits will occur daily until further direction of the QAPI Committee.
- The Medical Director was updated on this Correction and Removal-Abatement Plan as well as occurrences of which this plan pertains. Monitoring will be initiated and completed by the Administrator and/or designee as indicated above.
- Any discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary.
- Frequency of continued audits will be determined at that time. If issues are identified, re-education will be completed. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed, and revision will be made as deemed necessary.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program related to Enhanced Barrier Precautions for three residents with sacral wounds. The facility's policy on Enhanced Barrier Precautions, dated March 6, 2024, requires the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff members only wore gloves while providing wound care to residents with sacral wounds, failing to adhere to the policy's requirement for gown use. Resident R1 had a stage IV pressure ulcer on the sacrum, and a care plan for Enhanced Barrier Precautions was initiated in April 2024. During an observation, a licensed nurse and a unit manager provided wound care to Resident R1 without wearing gowns, only using gloves. Similarly, Resident R2, who also had a pressure wound, was observed receiving wound care from staff who did not wear gowns, despite the care plan initiated in March 2025 for Enhanced Barrier Precautions. Resident R3, with a stage IV pressure ulcer, was also observed being repositioned by staff who only wore gloves. Additionally, there was no signage posted on the doors or walls of the rooms of Residents R1, R2, and R3 to indicate the need for Enhanced Barrier Precautions. The unit manager confirmed the lack of adherence to Enhanced Barrier Precautions and the absence of appropriate signage.
Plan Of Correction
Residents R1, R2 and R3 were not at risk and not harmed. An audit was completed to ensure enhanced barrier precautions were in place. No other additional findings noted. Employees were educated on enhanced barrier precautions. The facility purchased the additional equipment needed for isolation precautions. NHA, DON and/or Designee will conduct weekly audits on isolation precautions for 4 weeks to ensure enhanced barrier precautions protocol is complete, then monthly for 3 months to ensure compliance. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Deficiency in Maintaining Comfortable Water Temperatures
Penalty
Summary
Edenbrook of Yeadon was found to be non-compliant with the requirements for providing a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. The deficiency was identified during an abbreviated survey conducted in response to two complaints and a reportable event. The survey revealed that the facility failed to maintain comfortable water temperatures in two of its four nursing units, specifically the First and Second Floor Nursing Units. The facility's policy on water temperatures for bathing, dated February 1, 2025, mandates that domestic hot water should ideally be maintained between 105 to 110 degrees Fahrenheit, with an acceptable range of 100-110 degrees. However, observations and interviews indicated that the water temperature in a resident's bathroom sink was only 45.3 degrees Fahrenheit, far below the required range. Further investigation by the maintenance assistant revealed that the hot water tank supplying the First and Second Floor Nursing Units was malfunctioning, with water pouring out of the tank through its emergency overflow line. This necessitated turning off the water supply to the hot water heater, preventing the maintenance of adequate water temperatures. Additionally, the hot water in the Central Shower Room on the First Floor Nursing Unit was found to be 90.1 degrees Fahrenheit, and the shower stall water was 81 degrees Fahrenheit, both below the facility's policy requirements. The maintenance assistant was unable to provide an explanation for the failure to maintain comfortable water temperatures.
Plan Of Correction
Facility had a plumber who was currently on site addressing another concern, evaluated, quoted and fixed the issues identified. The plumber's findings were addressed fixing and/or replacing the boiler (hot water units) for 3 affected areas. Facility staff will be educated on how to address fluctuations with water temps that do not meet the policy. The administrator or designee conducted daily water temp audits for a week, weekly for 4 weeks, then monthly for 3 months to ensure compliance. The administrator or designee will conduct random employee interviews for three months to ensure their competency on methods of on the water temperature policy including acceptable water temperature ranges and appropriate methods to check water temps. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Unsafe Water Temperatures in TCU Nursing Unit
Penalty
Summary
The Nursing Home Administrator (NHA) failed to effectively manage the facility to ensure safe water temperatures in the TCU Nursing Unit, leading to an Immediate Jeopardy situation. Observations revealed that the hot water temperatures in the central shower room and resident bathroom sinks were excessively high, with readings of 121.2 to 123.8 degrees Fahrenheit. The thermostat on the hot water tank was initially set at 150 degrees Fahrenheit and later adjusted to 135 degrees Fahrenheit, but the water inside the tank was still at 160 degrees Fahrenheit. This oversight placed residents at risk for serious injury from burns. Interviews with staff, including maintenance and nurse aides, indicated a lack of awareness and training regarding safe water temperature ranges for bathing residents. Several nurse aides admitted to not using thermometers to check water temperatures before giving showers and were unable to state the safe temperature range. This deficiency highlights the NHA's failure to fulfill essential duties and responsibilities, contributing to the Immediate Jeopardy situation, as residents were exposed to potential safety hazards due to inadequate management and oversight.
Plan Of Correction
No residents were harmed. The NHA will have job descriptions reviewed with them by the Regional Director. The administrator will work with the new company and their regional environmental director to complete an assessment of needs for the facility. The facility is recruiting a new maintenance director to support the needs of the facility. Regional Maintenance is coming in 2x a week to oversee. NHA is in constant communication with Maintenance Assistants. The Regional Director will complete bi-monthly audits for 3 months on risk events to ensure facility procedures were followed including work orders and preventative maintenance tasks. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.
Failure to Obtain Timely Medical Records for Resident's Orthopedic Care
Penalty
Summary
The facility failed to obtain necessary medical records in a timely manner for a resident who required follow-up orthopedic care. The resident, who was admitted with diagnoses including viral hepatitis, psychoactive substance dependence, depression, and dysphasia, had previously sustained multiple injuries from a six-story fall in March 2023. This resident was under the care of an orthopedic physician for treatment related to the fall, including a follow-up appointment scheduled for June 19, 2024. However, the required medical records from two different hospitals and physicians were not obtained and sent to the current orthopedic physician, which was necessary for the resident's continued care and potential surgery for a right foot deformity. Despite attempts by the facility's licensed nurse and previous unit clerks to acquire these records, they were unsuccessful. The delay in obtaining these records was noted during a nurse practitioner's examination on August 27, 2024, where it was documented that the resident's surgery was being delayed due to the lack of necessary medical documentation. As of August 29, 2024, the records had still not been sent, indicating a deficiency in the facility's ability to manage and coordinate the resident's medical records in accordance with professional standards.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating their own Bed Hold and Readmission Policy. The resident, who was admitted from the hospital with adjustment disorder with mixed anxiety and depressed mood, was sent to the emergency room following an incident where the resident hit a CNA during care. The facility's Director of Nursing and Regional Director of Business Development communicated with the hospital, indicating that the facility could not manage the resident's behavior and thus could not accommodate the resident's return. Despite the resident's discharge assessment indicating an anticipated return, the facility did not allow the resident to return in a timely manner. Interviews with the Social Service Director and the Regional Director of Business Development revealed that the facility had informed the hospital that they could not handle the resident's behavior, and the resident was not readmitted. The facility's actions were found to be in violation of several Pennsylvania codes related to the responsibility of the licensee, resident rights, and nursing services.
Improper Tracheostomy Care Leads to Resident Distress
Penalty
Summary
The facility failed to provide tracheostomy care consistent with professional standards of practice for a resident, resulting in an Immediate Jeopardy situation. The deficiency was identified when a licensed nurse, Employee E14, improperly removed the tracheostomy tube of Resident R130 during a tracheostomy care procedure. This action was not in accordance with the facility's policy, which states that only a Respiratory Therapist or Pulmonologist should remove the tracheostomy tube. The nurse's actions led to the resident experiencing respiratory and emotional distress. Resident R130, who had a history of cerebral infarction, chronic respiratory failure, and tracheostomy status, was observed during a tracheostomy care procedure. The nurse removed the tracheostomy tube and inner cannula, placed them on a gauze, and attempted to clean the inner cannula, which was against the facility's policy of replacing disposable inner cannulas. The resident, unable to vocalize due to the absence of a Passy Muir valve, showed signs of distress by waving her hands and hitting her chest, indicating she could not breathe. Despite the resident's visible distress, the nurse delayed reinserting the tracheostomy tube, which was eventually done without using an obturator. The incident was further compounded by the nurse's failure to maintain proper infection control practices, as she did not change gloves between tasks, including rummaging through the resident's drawers and adjusting the bed. The Director of Nursing confirmed that the nurse's actions were inappropriate and that the inner cannula should have been replaced, not cleaned and reused. The resident's inability to communicate verbally and the nurse's deviation from established procedures contributed to the severity of the situation.
Removal Plan
- The tracheostomy appliance was reinserted. Resident was assessed by Nurse Practitioner and Pulmonologist. Resident was stable with no physical distress noted.
- Employee involved in the incident was suspended pending investigation.
- Current residents with tracheostomy care needs were assessed to ensure equipment was present and tracheostomy was in place and stable.
- In service was initiated with licensed staff in the building and is ongoing. Facility is at 84%. 100% staff educated will be completed.
- The facility has been conducting 5 weekly observations of tracheostomy care being completed. Facility will review during facility's monthly QAPI (quality assurance performance improvement). Facility conducted observations of five residents with no negative findings noted.
- Facility Policy titled Tracheostomy Care was reviewed and revised.
Failure to Maintain Resident Privacy During Tracheostomy Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during tracheostomy care, as observed by surveyors. The incident involved Resident R130, whose bed was positioned near the door, with the privacy curtain on the side facing the door left open and the curtain on the side facing the window only half closed. During the tracheostomy care, the resident's door was open, allowing visibility from the hallway. The resident's roommate was present and awake in the room, and the resident's husband, along with the Unit Manager, were conversing near the door. The Licensed Nurse, Employee E14, was conducting the tracheostomy care without ensuring the privacy curtains were fully closed. Employee E14 admitted to being extremely nervous during the procedure, which contributed to the oversight in maintaining privacy. Despite having prior experience with tracheostomy care, the nurse's discomfort with being observed led to the failure in closing the privacy curtain, thus compromising the resident's privacy. This incident was in violation of the facility's policy on dignity, which mandates the protection of residents' privacy during personal care and treatment procedures.
Failure to Ensure Timely and Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure timely completion of resident assessments, as evidenced by the case of a resident who was discharged without a properly coded Minimum Data Set (MDS). The facility's policy requires comprehensive and standardized assessments of each resident's functional capacity using the Resident Assessment Instrument (RAI) as specified by the state. However, a review of the clinical record for a resident revealed that the MDS was incorrectly coded, indicating a discharge status of 'Short-Term General Hospital' instead of the actual discharge with the resident's daughter. This error was confirmed during an interview with the Resident Assessment Coordinator, who acknowledged the coding mistake. The deficiency was identified during a closed clinical record review, highlighting the facility's failure to adhere to the required assessment timelines and accuracy.
Failure to Update PASARR for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to revise a resident's Pre-Admission Screening and Resident Review (PASARR) for a resident with a mental health diagnosis. The facility's policy requires coordination with the PASARR program and referral for Level II review upon a significant change in status assessment. However, the clinical record review revealed that the PASARR Level I screen completed in 2019 did not indicate the resident's mental health diagnosis, despite the resident having conditions such as schizoaffective disorder, major depressive disorder, anxiety, and psychotic symptoms. The resident's new diagnoses, including schizoaffective disorder and depressive disorder, were added in January 2022, but the facility did not update the PASARR to reflect these changes. An interview with the social worker confirmed that the PASARR was not updated with the new diagnoses, indicating a failure to comply with the facility's policy and regulatory requirements.
Failure to Develop Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident receiving oxygen therapy. During an observation, it was noted that the resident was in bed receiving oxygen via nasal cannula, with the oxygen concentrator set at 2 liters per minute. However, upon reviewing the resident's current care plan, it was found that there was no care plan developed for the administration of oxygen therapy. This deficiency was confirmed through an interview with a licensed nurse, who acknowledged that the care plan had not been updated to include oxygen administration for the resident.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure a physician order was obtained for oxygen therapy for one resident. During an observation, it was noted that the resident was receiving oxygen therapy via nasal cannula while in bed. A review of the resident's clinical record showed no physician orders for the oxygen therapy being administered. An interview with a staff member confirmed that the resident was indeed receiving oxygen therapy without a physician order. This deficiency was identified during a review of 35 clinical records, highlighting a lapse in following proper protocol for obtaining necessary physician orders for treatments provided.
Inadequate Bladder Function Restoration and Missed Urology Appointment
Penalty
Summary
The facility failed to provide adequate services to restore bladder function for a resident with a complex medical history, including kidney stones, benign prostatic hyperplasia, neuromuscular dysfunction of the bladder, and a suprapubic catheter. During a wound care treatment observation, the resident was noted to have bloody urine in the suprapubic catheter, which the assigned licensed nurse stated was a consistent condition. Nursing notes from earlier in the month indicated the presence of small blood strands in the urine, and the unit manager was aware and planned to obtain a culture and sensitivity test, with the resident already on antibiotics. The resident's care plan included monitoring and reporting signs and symptoms of urinary tract infections, such as blood-tinged urine. However, a consult request by the unit manager raised questions about the permanency and management of the nephrostomy tube and whether hematuria was normal for the resident's condition. A scheduled urology appointment was canceled due to transportation issues, as a miscommunication led to the resident being scheduled for transport via wheelchair instead of a stretcher, resulting in the missed opportunity for further medical evaluation.
Failure to Document PICC Line Assessments
Penalty
Summary
The facility failed to properly assess and document the status of a PICC line for Resident R179, who was admitted with a right upper arm PICC line for IV antibiotic therapy. According to the facility's policy and professional practice standards, the external length of the catheter and arm circumference should be measured and documented at established intervals to monitor for complications such as catheter-tip migration and deep vein thrombosis. However, a review of the clinical records revealed that there was no documentation of these measurements for Resident R179, despite a physician's order specifying that these assessments should occur weekly with dressing changes. Interviews with facility staff confirmed the lack of documentation. The Unit Manager acknowledged that the measurements should have been recorded in the progress notes, and an LPN admitted to not documenting the required measurements since the resident's admission. This oversight indicates a failure to adhere to both the physician's orders and professional practice standards, resulting in a deficiency in the safe and appropriate administration of IV fluids for the resident.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the Food Service Department, it was observed that an open box of hot dogs was left uncovered and undated in the walk-in refrigerator. Additionally, the walk-in freezer's internal thermometer read 17 degrees above zero, and several food items, including donut holes, sausage links, and tater tots, were not frozen solid. The Food Service Director (FSD) confirmed these findings and acknowledged a recent issue with the freezer that required repair. A review of the Freezer Temperature Log indicated that the freezer temperatures on June 19, 2024, were significantly above the required levels, prompting a call to a fridge technician. Further observations revealed unsanitary conditions in the kitchen, including debris on the floor and dirty baseboards in the hot production area and dish room. A follow-up visit found a thick layer of dust on a PVC pipe above the prep sink, and the walk-in freezer still had an internal temperature of 9 degrees above zero, with soft whipped cream, donuts, and French fries. An open box of beef liver was also exposed to the air. Additionally, a fan near the toaster was covered in dust and dirt. The FSD confirmed these findings during interviews conducted on June 24 and June 26, 2024.
Infection Control Deficiencies in Tracheostomy Care and Laundry Department
Penalty
Summary
The facility failed to ensure proper infection control procedures during tracheostomy care for a resident with a tracheostomy. During an observation, a licensed nurse and a unit manager were seen performing tracheostomy care without adequately sanitizing the area. The nurse initially removed half-eaten food from the resident's overhead table but did not sanitize the entire surface before setting up tracheostomy care supplies. After removing the McDonald's items from the table, the nurse did not sanitize the area again before proceeding with the tracheostomy care. The nurse admitted to being nervous, which contributed to the mistakes made during the procedure. Additionally, the facility failed to ensure proper processing of lines and accessibility to a handwashing station in the laundry department. Observations revealed a pile of soiled clothing on the floor and a sink for handwashing that was inaccessible due to being surrounded by large containers of laundry chemicals. The Director of Housekeeping confirmed that the sink was not working and that the chemicals made it inaccessible to personnel. There was no alternative hand sanitizer or sink available in the laundry area.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a safe, sanitary, and functional environment for six residents and 15 resident rooms across two floors. Observations and interviews revealed multiple deficiencies, including dirty leftover food and takeout containers in Resident R1's room, unsanitary conditions in Resident R1's restroom, and an unopened food package dated February 29, 2024, in the refrigerator at the nursing station. Resident R3's room had dirty window shades, a privacy curtain with large brown spots, crumbs, liquid spills, ants, and multiple dirty containers on the window sill. Additionally, Resident R3's toothbrush and toothpaste were stored on the unsanitary window sill. The unit manager confirmed these findings and also noted a broken toilet paper holder, a large pile of dirty clothing, and various other unsanitary conditions in Resident R3's room. Further observations on the second floor revealed that lunch trays for Residents R14 and R15 were not promptly removed, with Resident R15 expressing a preference for quicker tray removal. The unit manager confirmed that staff were still collecting lunch trays at the time of the inspection. Additionally, a strong urine smell was detected on the first floor's A unit, confirmed by the Administrator and Director of Nursing. These findings indicate a failure to maintain a clean and safe environment for residents, staff, and the public, as required by regulatory standards.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to establish and implement effective grievance policies and procedures, as evidenced by multiple residents' complaints about call bell response times and food quality not being documented or resolved. Resident R2 reported a two-hour delay in call bell response over the weekend and informed the administration, who responded with 'I'll take care of it.' Similarly, Resident R1 experienced delays in call bell response, particularly during the 3 PM-11 PM, 11 PM-7 AM shifts, and weekends, and also complained about the poor taste of food and lack of menu options. Despite informing the nurse supervisor and administration, the issues were not addressed adequately. During a tour with the Unit Manager, another resident, R13, filed a grievance about a 1.5-hour delay in call bell response. The Unit Manager acknowledged having a meeting with staff to address the issue but did not document it as a grievance or communicate the resolution to the resident. A review of the grievance log for December 2023 to March 2024 revealed that grievances related to call bell response, dietary, and care issues were not documented, and residents or their representatives were not informed of the resolutions. The Nursing Home Administrator confirmed that the results of grievances were not communicated to residents or their representatives, despite implementing a call bell audit program in response to concerns raised in a Resident Council meeting.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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