Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edgehill Nursing And Rehab Cen during CMS and state inspections, most recent first.
The facility failed to employ a qualified director of food and nutrition services. The Director of Dining Services was responsible for ordering, receiving, storing, preparing, and serving food, but the personnel file showed only ServSafe certification and no CDM, CFM, national food service management certification, or qualifying degree. The NHA stated the RD was part-time, and the President of Culinary & Nutrition Services confirmed the employee only had ServSafe.
Food was not stored in accordance with food service standards. An Assistant Food Service Director observed two opened containers of thickened juices with no open date, milk stored on black serving trays with a sticky buildup of milk, and cereal removed from its original packaging and kept in facility bowls and lids with no open or use-by dates.
The facility did not ensure investigation results were reported within the required timeframe to the administrator and other officials for a resident misappropriation event. The facility reported that a resident’s $50 was missing, but the event was later rejected by the State agency and was not resubmitted until much later. The resident later received the $50 from the facility.
The facility failed to notify the State LTC Ombudsman of facility-initiated emergency hospital transfers for two residents. One resident was transferred after weight loss and dysphagia were documented, and another was transferred after abnormal lab results were noted. Records contained no evidence that the Ombudsman was informed, and the NHA confirmed the omission.
The facility failed to develop and implement person-centered care plans for two residents. One resident with cognitive impairment, incontinence, hemiplegia, anxiety, depression, and RA reported rough handling during incontinence care, and staff documented that the aide continued care without addressing the resident’s pain concerns; the DON confirmed there was no care plan for pain during incontinence care. Another resident with CHF, CKD, AFib, HTN, weakness, and a stage III pressure ulcer had provider recommendations for heel boots and floating the heels, but those prevention measures were not included in the care plan.
The facility failed to follow physician orders for two residents. One resident with heart failure and edema had ACE wraps ordered for morning use, but the wraps were repeatedly unavailable and were not applied. Another resident with a cholecystostomy tube had an order to notify the MD if drainage output was less than 25 cc/day, but the record showed multiple low-output entries with no documented MD notification.
Medication Error Rate Exceeded Allowed Threshold: The facility had a medication error rate of 6.9%. During medication administration, an LPN prepared expired acetaminophen for one resident, and in another instance, an LPN could not locate sitagliptin for a second resident in the med cart or Pyxis, so it was not administered.
Failure to disinfect blood pressure equipment during medication administration. An LPN used a sphygmomanometer without disinfecting it before and after checking BP for two residents, and the same issue was observed with a third resident. Facility policy required vital sign equipment to be cleansed before and after each resident use.
The facility failed to implement Enhanced Barrier Precautions (EBPs) for a resident with a Foley catheter and two residents with wounds, as required by their policy. Observations showed a lack of necessary supplies and signage to alert staff and visitors about the precautions, which was confirmed by the Regional Nurse.
The facility failed to maintain an effective antibiotic stewardship program, lacking protocols and a system to monitor antibiotic usage. Over ten months, infections were treated with antibiotics without proper documentation or review, as confirmed by a regional nurse. The facility did not adhere to CDC guidelines, contributing to the deficiency.
The facility failed to ensure nurse aides received the required 12 hours of continued education per year. Three nurse aides did not meet the training requirements for 2023-2024, with one completing only 7.5 hours and two others completing 10 hours each. This deficiency was confirmed by HR staff.
The facility failed to provide necessary treatment for pressure ulcers for two residents. Despite physician orders for heel suspension devices, observations revealed that residents' heels were in contact with surfaces without offloading measures. Staff confirmed the absence of required devices, indicating non-compliance with treatment plans.
The facility failed to monitor and address the nutritional needs of three residents, resulting in significant weight loss. One resident lost 9.02% of their weight without new dietary interventions, another lost 9.98% without weekly weight checks, and a third resident's nutritional needs were not reassessed after being taken off hospice care.
A facility failed to provide proper care and assessments for a resident's intravenous therapy. The resident, admitted with a urinary tract infection and receiving IV antibiotics through a PICC line, had no documented IV line care or maintenance, such as dressing changes or assessments. Additionally, the length of the external catheter was not measured upon admission, as required by facility policy. An interview confirmed the absence of orders for PICC line management.
The facility failed to notify a physician and complete assessments for significant weight loss in two residents, as required by care plans and policy. One resident lost 9.02% of their weight in less than a month, while another lost 9.98% in a similar timeframe. Despite care plans requiring physician notification, there was no documentation of such actions, confirmed by a Regional Nurse.
The facility did not complete required yearly performance reviews for two nurse aides, Employees E10 and E13. Employee E10, hired in 2022, missed a review in 2023, while Employee E13, hired in 2009, missed reviews in both 2023 and 2024. This issue was confirmed by HR, citing turnover in the DON position as a possible reason.
A facility failed to implement a consultant pharmacist's recommendation to increase a resident's Clindamycin dosage, despite physician approval. The resident continued to receive the original dosage as per the MAR, leading to a deficiency in pharmacy and nursing services.
The facility failed to employ a qualified director of food and nutrition services. Employee E6, the Food Service Director, lacked necessary qualifications such as a CDM, CFM, or relevant degree. Additionally, the Registered Dietitian worked only part-time, contributing to the deficiency in qualified staffing for the department.
The facility's QAPI program was found deficient due to a lack of systematic identification, reporting, and prevention of adverse events. Despite identifying falls as a concern, no action plan or performance tracking was documented. An interview confirmed poor documentation and absence of data collection, analysis, and monitoring.
The facility did not designate a qualified infection preventionist with the required specialized training in infection prevention and control. The infection preventionist was in the process of completing a CDC training program but had not yet finished it, leading to a deficiency in regulatory compliance.
A facility failed to develop a comprehensive care plan for a resident with a colostomy following hospital readmission and surgery. The resident, with multiple diagnoses including dementia and Parkinson's, was dependent on assistance for personal care. Despite these needs, the facility did not establish a care plan with goals and interventions for colostomy care, as confirmed by the DON.
A resident with multiple sclerosis, who was incontinent and dependent on staff for toileting and bathing, did not receive adequate incontinence care or showers as per her preference. Despite her care plan requiring checks every two hours, she was found with soaked pants, having not been changed for five hours. The facility's failure to adhere to the care plan and policy resulted in inadequate grooming and personal hygiene care.
A resident with dementia and Parkinson's Disease experienced severe abdominal pain and confusion, but there was a two-day gap in nursing documentation before the resident was sent to the ER for chest pain and shortness of breath. The DON confirmed the lack of assessment and documentation, leading to a deficiency in care.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services. Staff interviews and a review of the personnel file for Employee E10 showed that E10 was serving as the Director of Dining Services with responsibilities for ordering, receiving, storing, preparing, and serving food, but did not meet the statutory qualifications for the role. The personnel file showed E10 obtained ServSafe certification on November 20, 2025, but did not have a certified dietary manager credential, certified food manager credential, national certification for food service management and safety from a national certifying body, or an associate's or higher degree in food service management or hospitality from an accredited institution. The Nursing Home Administrator stated that the Registered Dietitian was employed part-time, and the President of Culinary & Nutrition Services confirmed that E10 only had ServSafe certification, which was described as food safety education and not food service management.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Food was not stored and prepared in accordance with professional food service standards. Review of the facility’s undated policies for Refrigerator and Frozen Food Storage and Dry Storage showed that food items should be labeled, dated, and sealed. During a tour of the main kitchen with the Assistant Food Service Director, observations in the reach-in refrigerator found two opened containers of thickened juices with no open date, even though the box specifications indicated they should be consumed within seven days of opening. The same refrigerator also contained two black serving trays being used to store milk, and the trays had a significant buildup of milk that was sticky to the touch. In the dry storage area, cereal had been removed from its original packaging and stored in facility bowls and lids with no open or use-by dates.
Failure to Timely Report Investigation Results for Misappropriation
Penalty
Summary
The facility did not ensure that the results of all investigations were reported within 5 working days to the administrator or designated representative and to other required officials in accordance with State law for one resident reviewed. Facility policy titled "Resident Abuse & Neglect Prevention Program" states that the DON, administrator, or social services designee will keep the resident and/or representative informed of the progress of the investigation, and that alleged and substantiated incidents will be reported to the Pennsylvania Department of Health and other required agencies. The facility reported a misappropriation event involving Resident R38 after the resident’s $50.00 was missing, but the report indicated it would be updated when the investigation was completed. On interview, Resident R38 stated he received the $50.00 from the facility on August 12, 2025. Review of the facility’s May 2025 reportable events showed the misappropriation report was rejected by the State agency on May 30, 2025 and was not resubmitted until August 12, 2025.
Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers to the hospital for two residents. Resident R9’s clinical record showed a nursing progress note dated April 25, 2025, documenting weight loss and dysphagia, after which the resident was transferred to the local hospital for evaluation. Resident R5’s clinical record showed a nursing progress note dated June 17, 2025, documenting abnormal lab results, after which the resident was transferred to the local hospital for evaluation. Review of both residents’ records found no documented evidence that the Ombudsman was made aware of the unplanned hospital transfers, and the Nursing Home Administrator confirmed this during interview on August 14, 2025.
Failure to individualize care plans for pain during incontinence care and pressure injury prevention
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident R4 related to activities of daily living and pain during incontinence care. R4’s quarterly MDS dated May 3, 2025, showed moderate cognitive impairment, frequent urinary incontinence, and bowel incontinence, with diagnoses including hemiplegia/hemiparesis, anxiety, depression, and rheumatoid arthritis. The care plan revised August 1, 2025, identified the resident’s need for assistance with bathing, grooming, and personal hygiene, and included an intervention to monitor for pain and medicate as appropriate prior to activity or rehabilitation, but there was no care plan developed to address pain during incontinence care before the incident involving the resident and nurse aide E6. On July 1, 2025, Resident R4 reported that nurse aide E6 tossed him/her around like a piece of meat. Facility investigation documentation stated that while E6 was attempting to provide incontinence care, the resident expressed that the aide was being rough, and the aide continued the care without addressing the resident’s concerns. E6’s written statement indicated the aide entered the room to change R4 without knowledge of the resident’s condition and started to change the resident, describing R4 as very fussy. A later interview with nurse aide E5 confirmed that R4 tends to have discomfort during incontinence care and that if the resident complains of pain during care, staff should stop and alert the nurse. The facility also failed to develop and implement a comprehensive care plan for Resident R15 related to pressure ulcer prevention. R15 had diagnoses including congestive heart failure, muscle weakness, stage 3 chronic kidney disease, abnormal liver function studies, chronic atrial fibrillation, and hypertension. Clinical documentation showed a stage III pressure ulcer to the sacrum and boggy heels, and subsequent notes recommended compression stockings, feet elevation, heel boots when in bed, and floating the heels with pillows. Although R15’s care plan addressed actual skin impairment and potential for pressure ulcer development related to limited mobility, it did not include the recommended preventative interventions for heel boots or floating the heels while in bed, and the DON confirmed those interventions were not in the resident’s care plan.
Failure to Follow Physician Orders for ACE Wraps and Cholecystostomy Drainage Monitoring
Penalty
Summary
The facility failed to provide care in accordance with physician orders for two residents. One resident had heart failure and lower extremity edema, and the care plan and skin/wound note directed staff to apply ACE wraps to the lower extremities in the morning and remove them at night. A physician order also directed ACE wraps to be applied in the morning for edema. However, the clinical record documented multiple days when the ACE wraps were unavailable, and the resident stated that staff could not find the wraps and they were therefore not being applied. Another resident had acute cholecystitis and a cholecystostomy tube, with a care plan identifying risk for infection and an order to call the physician if cholecystostomy drainage bag output was less than 25 cc/day. The treatment record documented several dates when the drainage output was less than 25 cc, but there was no documented evidence that the physician was notified on those occasions.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, with a reported rate of 6.9%. During observation of medication administration, a Licensed Nurse prepared to administer Acetaminophen 325 mg, 2 tablets by mouth three times daily for pain to one resident, but the medication was found to be expired and was stopped before administration. The nurse confirmed the finding during the observation. In a separate observation, another Licensed Nurse attempted to locate Sitagliptin Phosphate 100 mg, 1 tablet daily for diabetes mellitus type II for a second resident, but the medication could not be found in the medication cart or in the Pyxis after the supervisor was asked to search for it. The medication was not administered to the resident, and the nurse confirmed the finding during the observation.
Failure to Disinfect Blood Pressure Equipment
Penalty
Summary
The facility failed to maintain an effective infection control program related to cleaning techniques for medical equipment during medication administration for two residents observed by surveyors. Facility policy on Preparing for Medication Administration stated that before medication administration, the medication cart should be stocked with required supplies and vital sign equipment should be cleansed before and after each resident use. During medication administration to Resident R51, an LPN used a sphygmomanometer to check blood pressure without disinfecting it before and after use, and the LPN confirmed this finding. During medication administration to Resident R29, the same issue occurred when an LPN used the sphygmomanometer without disinfecting it before and after checking blood pressure. The same LPN also used the sphygmomanometer without disinfecting it before and after checking blood pressure for Resident R42, and later confirmed the findings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in the implementation of Enhanced Barrier Precautions (EBPs) for residents with indwelling medical devices and wounds. The facility's policy, dated March 2024, outlines the use of EBPs, including the use of gowns and gloves during high-contact resident care activities to prevent the spread of multidrug-resistant organisms (MDROs). However, observations revealed that for Resident R51, who had an indwelling Foley catheter, there were no enhanced barrier precaution supplies available, nor were there signs posted outside the room to alert staff and visitors about the necessary precautions. Similarly, for Resident R39, who had open wounds to the sacrum and heels, and Resident R32, who had a pressure injury on the right heel, there were no enhanced barrier precaution supplies or signage present. Interviews with the Regional Nurse confirmed that the facility did not implement the required EBPs for these residents, despite their conditions necessitating such precautions. This lack of implementation was in direct violation of the facility's own policy and state regulations, as noted in the report.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a period of ten months, as determined by a review of facility documentation, policies, and staff interviews. The program lacked a system to effectively monitor antibiotic usage and did not include antibiotic use protocols. The facility's surveillance tool was found to be inadequate, as it did not document symptoms, tests ordered, or reviews to determine the appropriateness of antibiotic orders for infections treated with antibiotics. Throughout the months of January to September 2024, the facility's documentation revealed multiple instances where infections were treated with antibiotics without proper documentation or review. For example, in February 2024, all 33 infections treated with antibiotics lacked documentation of symptoms, tests ordered, or appropriateness reviews. Similar deficiencies were noted in other months, with varying numbers of infections treated without adequate documentation. An interview with a regional nurse confirmed the absence of antibiotic use protocols and a system to monitor antibiotic usage effectively. The facility's failure to adhere to CDC guidelines and implement the core elements of an antibiotic stewardship program contributed to the deficiency. The lack of integration of pharmacists into the clinical care team and failure to track antibiotic use patterns further exacerbated the issue.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of continued education per year, as mandated by regulations. This deficiency was identified through a review of personnel files and staff interviews, which revealed that three out of four nurse aides did not meet the training requirements for the calendar year 2023-2024. Specifically, Employee E10, hired on November 7, 2022, completed only 10 hours of training, missing 2 hours. Employee E12, hired on October 8, 1999, also completed only 10 hours of training, missing 2 hours. Employee E13, hired on March 5, 2009, completed only 7.5 hours of training. An interview with Employee E9 from Human Resources confirmed these findings, indicating a failure in the facility's staff development and training processes.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for two residents, as observed and documented by surveyors. Resident R39, who was admitted with dementia and Parkinson's disease, had open wounds on the sacrum and heels due to pressure injuries. Despite physician orders for heel suspension devices to offload pressure from the heels, observations on multiple occasions revealed that the resident's heels were in contact with the mattress or footrest without any offloading measures. Interviews with staff confirmed the absence of heel suspension devices in the resident's room, indicating a failure to adhere to the prescribed treatment plan. Similarly, Resident R32, diagnosed with dementia and chronic obstructive pulmonary disease, had a pressure injury on the right heel. Physician orders required the use of a heel suspension device while in bed, but observations showed the resident's heels were touching the mattress without offloading measures. A heel boot was found next to the resident's dresser, unused, and staff confirmed the lack of proper offloading measures. These findings demonstrate the facility's failure to implement necessary interventions to prevent and treat pressure ulcers, as outlined in their policies and physician orders.
Failure to Monitor and Address Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of three residents, leading to significant weight loss. Resident R12 experienced a weight loss of 9.02% between July and August 2024, without any new dietary interventions being initiated despite the resident's nutritional risk and the absence of a recent hospitalization. The facility did not notify the physician or revise the care plan appropriately, as confirmed by the Regional Nurse. Resident R39 also suffered a significant weight loss of 9.98% within a month, and the facility failed to complete the required weekly weight checks. Although the resident's care plan included nutritional interventions, such as providing lactose-free milk and requesting a multivitamin supplement, the facility did not follow through with the necessary monitoring and adjustments. Resident R2, who was taken off hospice care, did not have monthly weights documented for several months, and the Registered Dietitian did not reassess the resident's nutritional needs after the change in hospice status. Despite observations of poor eating habits, the facility did not adjust the care plan to reflect the resident's current needs, as confirmed by interviews with facility staff.
Failure in IV Therapy Care and Assessment
Penalty
Summary
The facility failed to provide care and assessments consistent with professional standards of practice related to intravenous therapy for Resident R54. The facility's policy on Central Vascular Access Device (CVAD) Dressing Change requires assessment of the vascular access site upon admission, during dressing changes, and at least once every shift when not in use. However, there was no documentation of any IV line care or maintenance, such as dressing changes or assessments, for Resident R54. Additionally, the length of the external catheter was not obtained upon admission, as required by the facility's policy. Resident R54 was admitted with a diagnosis of a urinary tract infection and was receiving intravenous antibiotic therapy through a peripherally inserted central catheter (PICC) line. Despite this, there were no orders or documentation for the care and management of the PICC line, and progress notes did not indicate that the IV line was assessed or monitored each shift and/or with each infusion. An interview with the Regional Nurse confirmed these deficiencies, highlighting the lack of proper orders and documentation for the PICC line care.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a physician assessment was completed for unplanned weight loss in two residents, R12 and R39, as required by their care plans and facility policy. Resident R12 experienced a significant weight loss of 9.02% between July 10, 2024, and August 1, 2024, with a BMI indicating underweight status. Despite the dietitian documenting the weight loss and revising the care plan, there was no evidence that the physician was notified or that an assessment was completed. Similarly, Resident R39 experienced a 9.98% weight loss from August 29, 2024, to September 11, 2024, and was identified as being at nutritional risk. The care plan required weekly weights and notification of the dietitian and physician for significant weight changes, but there was no documentation of physician notification or assessment. The facility's policy on weighing residents mandates that significant weight changes be communicated to the dietitian, physician, family, and RNAC, with documentation in the resident's medical record. However, interviews with the Regional Nurse confirmed the absence of evidence that the physician was notified of the weight loss for both residents, as required by the care plans and facility policy. This deficiency was identified under the Pennsylvania Code sections related to nursing services, physician services, and clinical records.
Failure to Conduct Yearly Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct required yearly performance reviews for two out of four nurse aides reviewed, specifically Employees E10 and E13. Employee E10, hired on November 7, 2022, did not receive a performance review in 2023. Similarly, Employee E13, who was hired on March 5, 2009, did not have a performance review completed in either 2023 or 2024. This deficiency was confirmed during an interview with Employee E9 from Human Resources, who acknowledged the absence of these reviews and attributed it to the turnover of several Directors of Nursing, which may have contributed to the oversight.
Failure to Implement Pharmacy Review Recommendations
Penalty
Summary
The facility failed to implement identified pharmacy review irregularities for a resident. A consultant pharmacist recommended increasing the dosage of Clindamycin to 300 mg every 6 hours for a resident, and this recommendation was approved by the physician. However, the resident's medication administration record (MAR) showed that the resident continued to receive Clindamycin 300 mg three times daily, both on July 25, 2024, for 10 days, and again on August 8, 2024, for 21 days. The recommended dosage increase was not implemented, resulting in a deficiency in pharmacy services and nursing services as per the relevant Pennsylvania codes.
Deficiency in Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings related to Employee E6. During an interview, Employee E6, who held the position of Food Service Director, revealed responsibilities that included oversight of ordering, receiving, storing, preparation, and service of food. However, a review of Employee E6's personnel file indicated that they did not possess the necessary qualifications, such as being a certified dietary manager (CDM), a certified food manager (CFM), or holding a national certification for food service management and safety. Additionally, Employee E6 did not have an associate's or higher degree in food service management or hospitality from an accredited institution. The Registered Dietitian, Employee E7, confirmed that they only worked part-time at the facility, further highlighting the deficiency in qualified staffing for the food and nutrition services department.
Deficiency in Quality Improvement Program
Penalty
Summary
The facility failed to maintain an effective Quality Improvement Program as evidenced by the lack of systematic identification, reporting, investigation, analysis, and prevention of adverse events and performance indicators. The facility's QAPI plan, revised in May 2023, was supposed to include problem descriptions, specific goals, timelines, feedback, data monitoring, and systematic analysis and action. However, the review of the QAPI Committee Meeting Records for July 2024 showed that although the facility identified falls as an area of concern using the CASPER reports, there was no documented evidence of an action plan being implemented to address this issue or track performance improvements. In August 2024, the QAPI Committee Meeting Records again listed falls as a concern, but there was no evidence of monitoring or evaluation of falls, nor any tracking of medical errors and adverse events. The facility did not analyze the causes of these issues or implement preventive actions. An interview with the Regional Nurse Consultant confirmed the absence of documentation, tracking of events, data collection, analysis, performance indicators, goals, or monitoring of progress, indicating a significant deficiency in the facility's QAPI program.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program, as required by regulations. During an interview, the Regional Nurse, identified as Employee E3, stated that the infection preventionist had not completed the specialized training in infection prevention and control. A review of the educational records confirmed that the infection preventionist was in the process of obtaining the necessary training from the CDC but had not yet completed the program. This lack of completion of specialized training led to the deficiency in meeting the regulatory requirements for infection prevention and control.
Failure to Develop Comprehensive Colostomy Care Plan
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for a resident who required the use of a colostomy. The resident, diagnosed with coronary heart disease, dementia, depression, anxiety, and Parkinson's Disease, was cognitively impaired and dependent on assistance for toileting, bathing, dressing, and personal hygiene. Following a hospital readmission for treatment of a perforated viscus, the resident underwent an exploratory laparotomy and low anterior resection with colostomy. Despite these significant medical interventions, the facility did not create a comprehensive care plan addressing the resident's colostomy care, including necessary goals and interventions. This deficiency was confirmed during an interview with the Director of Nursing.
Failure to Provide Adequate Incontinence and Hygiene Care
Penalty
Summary
The facility failed to provide adequate care to maintain grooming and personal hygiene for a resident diagnosed with multiple sclerosis, who was alert and oriented but had impairments in one side of the upper and both sides of the lower extremities. The resident was incontinent of urine and bowel and dependent on staff for toileting and bathing. Despite the resident's preference for showers, staff opted to give bed baths instead, citing the time it takes to use a Hoyer lift for showers. This resulted in the resident not receiving showers twice a week and going an unspecified duration without having her hair washed. On the day of the survey, the resident was observed with soaked pants, indicating she had not been changed since the previous shift, approximately five hours prior. The resident's care plan specified that she should be checked every two hours for incontinence and assisted with changing briefs. However, the Nursing Home Administrator confirmed that the resident had not received incontinence care since 6:00 a.m., which was a clear deviation from the established care plan and facility policy.
Failure to Document and Assess Resident's Change in Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a change in condition. The resident, diagnosed with dementia and Parkinson's Disease, required partial to moderate assistance with personal care and was incontinent. On February 25, 2024, the resident complained of severe abdominal pain, rated at 10.5/10, and was noted to be confused. Vital signs were taken, and Tylenol was administered with positive results. However, there was a significant gap in documentation, as the next nursing progress note was not recorded until almost two days later, when the resident was sent to the emergency room due to chest pain and shortness of breath. The Director of Nursing confirmed that the nursing notes lacked a timeline and assessments during this period, indicating a failure to assess and document the resident's status adequately. This lack of documentation and assessment during the two-day period contributed to the deficiency, as it was unclear what occurred leading to the resident's hospitalization. The facility did not maintain complete and accurate nursing progress notes, which is a requirement under professional standards of practice.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glenside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wyncote Care Center | 1.7 mi | ★★★★★ | 12 | 0 |
| Hillcrest Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Hopkins Center | 2 mi | ★★★★★ | 26 | 0 |
| Ivy Hill Post Acute Nursing & Rehabilitation Llc | 2 mi | ★★★★★ | 19 | 0 |
| Brookside Healthcare & Rehabilitation Center | 2.1 mi | ★★★★★ | 4 | 0 |
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