Fairlane Gardens Nursing And Rehab At Reading
Inspection history, citations, penalties and survey trends for this long-term care facility in Reading, Pennsylvania.
- Location
- 21 Fairlane Road, Reading, Pennsylvania 19606
- CMS Provider Number
- 395627
- Inspections on file
- 21
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Fairlane Gardens Nursing And Rehab At Reading during CMS and state inspections, most recent first.
The facility failed to provide adequate supervision and follow ordered safety interventions for multiple residents at risk for elopement, self-harm, and choking. A resident with depression and a history of suicidal ideation, ordered for 1:1 observation and a Wander Guard after climbing out a window, repeatedly expressed suicidal thoughts and engaged in self-harm–related behaviors, including attempting to insert metal knives into an electrical outlet, while documentation did not show continuous 1:1 monitoring. Another resident with cognitive deficits and an elopement risk care plan was near an exterior door that staff had propped open and left unsupervised, while he verbalized not wanting to be there and asking how to get out. A third resident with dysphagia, schizophrenia, and dementia, ordered for a puree diet, close monitoring during meals, and use of a sippy cup, had multiple documented episodes of taking inappropriate foods and fluids, coughing and choking on items such as peanut butter sandwiches, and ultimately experienced a severe choking event after eating a sandwich from a cart left in the dining room; later observation showed this resident being given beverages in regular mugs instead of the ordered adaptive equipment.
The facility failed to develop and implement comprehensive, measurable care plans to address significant behavioral and psychosocial needs for two residents. One resident with anxiety, depression, and a history of suicidal ideation repeatedly expressed suicidal thoughts, engaged in destructive behaviors such as climbing out a window and attempting to insert metal knives into an electrical outlet, and removed a Wander Guard while on 1:1 observation, yet the care plan did not include interventions for passive death/suicidal ideation or destructive behaviors. Another resident with dysphagia, schizophrenia, and dementia had multiple documented episodes of choking, food-seeking, rummaging for food, taking food from carts and trash, and attempting to take another resident’s drink, but the care plan did not address these food-focused behaviors or include specific interventions until after a later choking event, as confirmed by the DON.
Surveyors observed debris and various colored substances on hallway floors and in several rooms throughout all nursing units, indicating a failure to maintain a clean and safe environment for residents.
Surveyors found multiple deficiencies in environmental cleanliness and safety, including debris, stains, damaged fixtures, and insect presence throughout all nursing units and common areas. The shower room was noted to have a musty odor, residues, worn safety features, and missing curtain hooks, indicating inadequate housekeeping and maintenance.
Staff failed to follow physician orders for medication administration and monitoring, including not checking vital signs or obtaining daily weights as required for several residents with conditions such as hypertension, atrial fibrillation, congestive heart failure, and chronic kidney disease. These deficiencies were confirmed through record review and staff interviews, with the DON acknowledging the lapses.
Two residents had MDS assessments that did not accurately reflect their care: one was recorded as not receiving an antipsychotic when they had, and another was documented as not receiving tracheostomy care when they did. These discrepancies were confirmed by record review and staff interview.
Two residents with orders for restorative nursing programs to maintain or improve range of motion and mobility did not consistently receive these services as ordered, with documentation missing for multiple days. Interviews with the DON and Director of Rehabilitation confirmed the lack of evidence that the required interventions were provided.
A review of nursing schedules showed that the facility did not meet the required minimum NA-to-resident ratios for both day and evening shifts over a 21-day period, with insufficient NA coverage documented on multiple shifts.
A review of nursing schedules showed that the facility did not meet the required minimum LPN-to-resident ratios on multiple day and night shifts within a 21-day period, as mandated by regulation.
A review of nursing schedules showed that, for 20 out of 21 days, the facility did not provide the required minimum of 3.2 hours of direct nursing care per resident per day, with daily care hours ranging from 2.47 to 3.03.
A resident with a known banana allergy was repeatedly served yogurt containing bananas, as confirmed by clinical records, resident interview, and facility documentation. The resident ingested a small amount on at least one occasion, and similar incidents occurred multiple times.
The facility failed to consistently provide restorative nursing services to two residents, one with a traumatic brain injury and functional quadriplegia, and another with chronic pain and osteoarthritis. The care plans required passive range of motion exercises and assisted ambulation, but documentation showed these services were not provided consistently. The Nursing Home Administrator confirmed the lack of evidence for the completion of these programs.
The facility failed to ensure a safe environment by leaving medication unattended on medication carts in two nursing units. On Station 2A, medication in applesauce was accessible to three cognitively impaired, mobile residents. Similarly, on Station 2B, medication in vanilla pudding was left unattended, posing a risk to three cognitively impaired, mobile residents. The Nursing Home Administrator acknowledged that medication should not be left unattended.
The facility failed to ensure accurate MDS assessments for two residents. One resident's assessment incorrectly stated they were not on an opioid, despite receiving tramadol. Another resident's assessment inaccurately noted the use of a chair alarm, which was not ordered or used. These discrepancies were confirmed by the Nursing Home Administrator.
The facility failed to provide adequate grooming and personal hygiene services for two residents requiring assistance with activities of daily living. One resident, with hand contractures and diabetes, was observed with long fingernails and a beard, despite preferring them short. Another resident, with diabetes and hypertension, had long, discolored fingernails with sharp edges, leading to a self-inflicted scratch. Both residents had requested nail care, which was not provided as needed. The DON stated that nail care was scheduled on shower days, twice a week, which did not meet the residents' needs.
A resident with hearing difficulties and medical conditions such as diabetes and congestive heart failure did not receive timely hearing aids, despite a recommendation from an audiologist nearly a year prior. The facility failed to address this recommendation until much later, as confirmed by the Nursing Home Administrator.
A resident with aspiration pneumonia and dysphagia was not provided with the adaptive eating equipment as ordered by a physician. The resident was observed being served a meal on a regular plate instead of in bowls, leading to food spillage. This was confirmed by the DON, highlighting a failure to adhere to the care plan.
Failure to Supervise Residents at Risk for Elopement, Self-Harm, and Choking
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring for residents identified as being at risk for elopement and self-harm. One resident with diagnoses including acute kidney failure, anxiety, depression, and a history of suicidal ideation was assessed as having no memory impairment and being able to walk independently. After this resident climbed out of a window by removing safety brackets, screws, and the screen, the physician ordered a Wander Guard and 1:1 supervision due to elopement risk, and the care plan reflected 1:1 observation and Wander Guard use. Despite this, clinical and behavioral notes over the following weeks documented ongoing agitation, irritability, mood changes, accusatory statements, suicidal thoughts, and passive death ideation, including statements about stabbing herself or overdosing, while the resident remained on ordered 1:1 observation. On multiple occasions, the resident engaged in behavior indicating potential self-harm while 1:1 supervision was supposed to be in place. A nurse documented that the resident removed her Wander Guard while on 1:1 observation. Later, staff documented that the resident had two metal butter knives at her bedside, walked to an electrical outlet, and attempted to put the knives into the outlet while on 1:1 observation. A nurse aide’s written statement confirmed that the resident obtained butter knives and moved toward the outlet, and that later in the shift, while outside with other residents, the resident made a statement about wanting to harm herself. Subsequent psychology and psychiatry notes recorded continued suicidal thoughts, passive death ideation, and the resident’s admission that she had stuck knives in the outlet hoping to cause a fire so she could get out of the facility. On March 24, a Patient Watch Observation Sheet for this resident, who remained on 1:1 supervision due to destructive behavior, agitation, exit-seeking, and attempts to cause physical destruction, was observed on her dresser and was not completed, with no documented evidence that 1:1 supervision was in place at all times. The facility also failed to maintain a safe environment to prevent elopement for another resident at risk. An employee exited through a hallway door marked as alarmed with instructions to keep it closed and propped it open. While the door remained propped open and unsupervised, a resident with nicotine dependence, cognitive communication deficit, and a care plan identifying elopement risk walked into the hallway by the open door and verbalized not knowing why he was there, not wanting to be there, and asking how he could get out. The door stayed open and unsupervised for approximately ten minutes, posing a safety risk for residents at risk for elopement. In addition, the facility failed to provide adequate supervision and ordered interventions to prevent choking for a resident with dysphagia, schizophrenia, and dementia. This resident had memory impairment, required set-up assistance with eating, and could walk without assistance. Physician orders required staff monitoring during all meals and snacks to ensure the proper diet, a puree texture diet, and use of a sippy cup for all drinks with encouragement to drink slowly for choking prevention. Nursing and psychiatry documentation over several months showed repeated episodes of the resident taking food from other residents’ plates, trash cans, and medication carts, coughing episodes after consuming inappropriate foods such as sandwiches and peanut butter, and ongoing food-focused behaviors including pacing and repeatedly seeking food and fluids. One nurse note described the resident being found on the floor turning blue and coughing up a semi-chewed peanut butter sandwich, and another documented a choking episode in the dining room. On March 19, facility documentation showed that the resident was observed in the dining room eating a peanut butter and jelly sandwich obtained from a cart left in the dining room, after which she alerted therapy staff that she did not feel well and was assessed by nursing to be choking, with drooling, cyanosis, and inability to speak. A Life Vac device was used to remove a large piece of sandwich. Subsequent observation on March 24 revealed that this resident was in the dining room drinking from a regular mug, and later was provided another regular mug with a beverage, rather than the ordered sippy cup. These observations demonstrated that the facility did not consistently provide the physician-ordered adaptive equipment or adequate supervision to prevent choking for this resident.
Removal Plan
- Resident 1 was placed on 1:1 observation.
- Resident 1 was provided plastic utensils.
- Resident 1's wander guard placement was checked every shift.
- An audit was completed of all residents who verbalized wanting to harm themselves.
- The facility will review psychiatry notes and progress notes daily for any changes in behaviors.
- Education was provided to nursing staff on behaviors and self harm; staff must sign and acknowledge the trainings on their next scheduled work day.
- Education was provided to staff on the expectations of 1:1 duties; staff must sign and acknowledge the trainings on their next scheduled work day.
- Staff assigned will complete the 1:1 form.
- Audits will be completed of the psychiatry notes and progress notes to ensure changes in behaviors have interventions in place.
- Resident 2 will be redirected during periods of behavioral symptoms and placed on 1:1 supervision as needed.
- An audit was completed of residents seeking food outside their diets.
- Food trays will no longer be left in the dining room, and food brought to the nursing stations will be taken into the locked pantry.
- Education was provided to nursing and dietary staff on food distribution and collection; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed on food distribution and collection.
- Resident 2 was provided her sippy cup.
- An audit was completed to ensure adaptive equipment was available and provided.
- Adaptive equipment will be provided to residents as ordered.
- Education was provided to nursing and dietary staff on providing adaptive equipment; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed to ensure adaptive equipment is available and provided.
- The exit door was closed.
- An audit of exit doors was completed to ensure they were secured.
- Education was provided to staff on door security; staff must sign and acknowledge the trainings on their next scheduled work day.
- Audits will be completed to ensure exit doors are secured and not propped open.
Failure to Develop Comprehensive Care Plans for Suicidal Ideation and Food-Seeking Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans with measurable interventions to address identified medical, mental, and psychosocial needs for two residents. For the first resident, who was admitted with diagnoses including acute kidney failure, anxiety, depression, and a history of suicidal ideation, the clinical record showed multiple episodes of self-harm risk and destructive behaviors. These included climbing out a window after removing safety brackets and a screen, repeatedly reporting suicidal thoughts and passive death ideation with statements about stabbing herself or overdosing, removing a Wander Guard bracelet while on 1:1 observation, and exhibiting agitation, mood changes, and accusatory statements toward staff and a roommate. Staff also documented that this resident obtained two metal butter knives and attempted to insert them into an electrical outlet while on 1:1 observation. Despite these documented behaviors and mental health concerns, the resident’s care plan did not address her passive death/suicidal ideation or destructive behaviors, and did not include specific interventions for those behaviors, as confirmed by the Director of Nursing. The second resident had diagnoses including dysphagia, schizophrenia, and dementia, and exhibited repeated food-seeking behaviors and choking episodes that were documented over several months. Nursing notes described the resident coughing after taking and eating a half sandwich from another resident’s plate, being found on the floor turning blue and coughing up a semi-chewed peanut butter sandwich, and having a history of rummaging and taking food from trash cans and pudding from medication carts. The physician ordered a pureed diet and later a sippy cup with encouragement to drink slowly, yet staff continued to document episodes of the resident drinking too quickly and coughing, eating a peanut butter and jelly sandwich and coughing up unchewed pieces, and repeatedly seeking food and fluids, including taking pudding from the med cart, pacing and begging for food and water, and attempting to take water from another resident, which led to a physical altercation. Psychiatry also noted ongoing food-focused behaviors and taking items off carts. The care plan did not address the resident’s food-seeking behaviors or include specific interventions for those behaviors until after a choking incident in the dining room, a delay confirmed by the Director of Nursing.
Failure to Maintain Clean and Safe Environment Across All Nursing Units
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents across all four nursing units. During observations conducted on December 10, 2025, surveyors noted the presence of debris and black, red, and brown substances on the hallway floors of Units 1A, 1B, 2A, and 2B, as well as in multiple resident rooms, specifically rooms 107, 115, 116, 122, 129, 201, 206, 216, 217, and 305. These findings indicate that the facility did not maintain cleanliness and environmental safety as required by federal and state regulations.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all four nursing units. Specific findings included debris and dark or black substances splattered on hall floors and in multiple resident rooms, red and brown spots on floors and ceilings, and damaged walls and ceilings in various locations. Additional issues included a broken radiator with sharp, loose parts in the resident lounge, damaged mirrors in several bathrooms, and the presence of flying winged insects around the nurse's station and in resident rooms. There was also a strip of peeling wood sticking out from a closet door, contributing to unsafe conditions. Further observations in the shower room revealed a musty smell, grey and brown residue on floor tiles, a yellow substance on a shower chair, worn non-skid strips, residue on all shower curtains, missing hooks from shower curtains, a black substance on a non-skid mat, and a brown and red substance on the floor in front of the scale. These findings indicate that housekeeping and maintenance services were insufficient to maintain a sanitary, orderly, and comfortable interior, as required by federal and state regulations.
Plan Of Correction
Splatter on floors, ceilings, and walls were cleaned. Radiator in unit 2 lounge will be repaired. Mirrors will be replaced in rooms 217, 224, 308, 309, 310. Exterminator to be in to address flying winged insects? The wall in room 300 was repaired. Shower room curtains cleaned, odor free; shower chair replaced. Non-skid mat in 3rd shower room cleaned. A cleaning schedule will be put into place, to include resident rooms and shower rooms. Floor care will be placed on a routine schedule. All housekeeping and maintenance will be re-educated on cleaning of the facility. Audits will be completed by the IDT team daily x4 weeks then weekly x4; then monthly x2 with results to be reported to the QAPI committee.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to administer medications and perform monitoring in accordance with physician orders for four residents. For one resident with hypertension, staff administered blood pressure medication on multiple occasions when the resident's systolic blood pressure was below the physician-ordered threshold and failed to document heart rate checks prior to administration as required. Another resident with atrial fibrillation and hypertension did not have blood pressure monitoring documented as ordered by the physician, despite repeated instructions in the care plan and physician notes to do so. A third resident with congestive heart failure and diabetes did not have daily weights obtained as ordered by the physician on several occasions across multiple months. The fourth resident, with hypertension and chronic kidney disease, received blood pressure medication without documented heart rate checks on numerous occasions, contrary to physician orders. These deficiencies were confirmed through review of facility policy, clinical records, and staff interviews. The Director of Nursing acknowledged that daily weights were not completed as ordered and that medications were administered outside of established parameters for the affected residents. The lack of adherence to physician orders and documentation requirements was evident in the medication administration records and care plans reviewed.
Plan Of Correction
Unable to correct past events. Current residents' medication and weight orders reviewed for proper evidence of documentation of residents' BP, HR, and weights. Current licensed staff re-educated on medication administration policy and procedure, weight policy and procedure, along with documentation policy and procedure. Random audits to be completed by DON/designee to ensure appropriate documentation of resident heart rate and BP prior to medication administration and appropriate weight documentation. Audits to be conducted weekly for 4 weeks and monthly for 2 months, with results to QAPI committee.
Inaccurate MDS Assessments for Medications and Treatments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident, Section N (Medications) of the MDS assessment indicated that the resident was not on an antipsychotic medication during the seven-day review period, while a review of the Medication Administration Record showed that the resident did receive lurasidone, an antipsychotic, during that time. For another resident, Section O (Special treatments, procedures, and programs) of the MDS assessment indicated that the resident did not receive tracheostomy care during the seven-day review period, but the Treatment Administration Record confirmed that tracheostomy care was provided during that period. These discrepancies were confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS assessments did not accurately reflect the residents' actual care and required modification. The deficiency was cited under CFR 483.20(g) for accuracy of assessments, and it was noted that this issue had been previously cited.
Plan Of Correction
- Resident 27's MDS was modified to indicate the use of an anti-psychotic medication during the seven-day review period. - Resident 18's MDS was modified to reflect tracheostomy care received during the seven days look-back period. - MDS of current residents on anti-psychotic medications and residents with tracheostomy care within the past 90 days were reviewed for accuracy. MDS coordinators were re-educated on accuracy of MDS. Random audits will be completed by NHA/Designee on the accuracy of the MDS of the residents who are currently on antipsychotic medications and tracheostomy care. Weekly x4, Monthly x2, with results to QAPI committee.
Failure to Consistently Provide Restorative Nursing Programs for Range of Motion and Mobility
Penalty
Summary
The facility failed to consistently provide required restorative nursing programs (RNP) to two residents with orders for interventions to maintain or improve range of motion (ROM) and mobility. One resident, with diagnoses including muscle weakness and difficulty walking, had a physician's order and physical therapy recommendation for ambulation RNP twice daily. However, there was no documentation that the resident was offered the RNP as ordered for 30 consecutive days. Another resident, with anoxic brain damage, persistent vegetative state, and bilateral hand contractures, had orders for passive ROM to the upper extremities and fingers twice daily. Documentation was lacking to show that the RNP was offered as ordered on 18 out of 30 days. Interviews with the Director of Nursing and the Director of Rehabilitation confirmed the absence of documentation supporting that the RNPs were provided as ordered for both residents. The clinical records and staff interviews indicated that the required treatments and services to prevent a decrease in ROM and to maintain or improve mobility were not consistently implemented according to physician orders and therapy recommendations.
Plan Of Correction
Unable to correct past events. Current residents on RNP were reviewed for appropriate documentation to support the offering of RNP as ordered. Current nursing staff re-educated on RNP policy and procedure. Random audits to be completed by DON/Designee to ensure offering of RNP with appropriate documentation x4 weekly x2 monthly and report results to QAPI committee.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) to resident ratios for all 21 days reviewed, as evidenced by a review of nursing time schedules from July 24, 2025, to August 13, 2025. Specifically, the facility did not provide at least one NA for every ten residents during the day shift on multiple dates, including July 24, 25, 26, 27, 28, 30, 31, and August 1, 2, 3, 4, 6, 9, 10, and 11, 2025. Additionally, the facility did not meet the minimum requirement of one NA for every eleven residents during the evening shift on all days from July 24 through August 7, and again from August 9 through 13, 2025. These findings are based solely on the documented nursing schedules and do not reference any specific residents or their conditions.
Plan Of Correction
This is unable to be corrected as it is a past event. The use of an outside Recruiting Group has assisted with filling vacancies and qualified ancillary staff assist with NA coverage. Daily staffing huddles occur in which census, open holes, call offs etc. are addressed. Education to be completed with Nsg Administration, Scheduling and HR on the importance of maintaining DOH guidelines as it pertains to NA ratio. Audits to be completed daily by NHA/designee x4 weeks, then bi-weekly x2 weeks, then monthly x2 with results to QAPI meeting. Unable to correct past event.
Failure to Meet Minimum LPN-to-Resident Ratios
Penalty
Summary
The facility failed to comply with the required minimum licensed practical nurse (LPN) to resident ratios as specified by regulation. A review of nursing schedules over a 21-day period revealed that the facility did not meet the minimum ratio of one LPN per 25 residents during the day shift on nine separate days. Additionally, the facility did not meet the minimum ratio of one LPN per 40 residents during the night shift on six separate days. These findings were based solely on the review of the facility's nursing time schedules for the specified period. No information was provided regarding the specific residents affected, their medical history, or their condition at the time of the deficiency.
Plan Of Correction
The use of an outside Recruiting Group has assisted with filling vacancies and qualified ancillary staff assist with LPN coverage. An internal agency has been developed that does assist with providing less desirable shift (2nd and 3rd) coverage. Daily staffing huddles occur in which census, open holes, call offs, etc., are addressed. Education to be completed with Nursing Administration, Scheduling, and HR on the importance of maintaining DOH guidelines as it pertains to LPN ratio. Audits to be completed daily by NHA/designee x4 weeks, then bi-weekly x2 weeks, then monthly x2, with results to QAPI meeting. P 5530
Failure to Meet Minimum Nursing Care Hours Requirement
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per 24-hour period. A review of nursing schedules over a 21-day period revealed that, for 20 out of those 21 days, the total direct care hours per resident fell below the mandated threshold. The reported daily care hours ranged from 2.47 to 3.03, with only one day meeting or slightly exceeding the required minimum. This deficiency was identified through the examination of documented nursing time schedules for the specified period.
Plan Of Correction
Unable to correct past events. The use of an outside Recruiting Group has assisted with filling vacancies and qualified ancillary staff assist with maintaining PPD. An internal agency has been developed that does assist with providing less desirable shift (2nd and 3rd) coverage. Daily staffing huddles occur in which census, open holes, call offs, etc., are addressed. Education to be completed with Nsg Administration, Scheduling, and HR on the importance of maintaining DOH guidelines as it pertains to PPD. Audits to be completed daily by NHA/designee x4 weeks, then bi-weekly x2 weeks, then monthly x2, with results to QAPI meeting.
Failure to Accommodate Resident Food Allergy
Penalty
Summary
A resident with a documented allergy to bananas was admitted to the facility and subsequently served yogurt containing bananas on multiple occasions. On March 31, 2025, a nurse documented that the resident reported being served yogurt with bananas at dinner, and the resident confirmed in an interview that this had occurred several times previously. Facility investigation records verified that the resident was served and ingested a small amount of yogurt containing bananas on March 31, 2025, and that similar incidents had occurred on three prior occasions. These findings were based on clinical record review, resident interview, and facility documentation.
Failure to Provide Consistent Restorative Nursing Services
Penalty
Summary
The facility failed to provide consistent restorative nursing services to maintain or improve the range of motion and mobility for two residents. Resident 11, who has a traumatic brain injury, functional quadriplegia, and bilateral hand contractures, was identified as being at high risk for further contractures due to immobility. The care plan required staff to provide a restorative nursing program for passive range of motion to the resident's bilateral upper extremities twice a day. However, documentation showed that this service was not offered on 18 out of 30 days. Similarly, Resident 21, who suffers from chronic pain and osteoarthritis, was supposed to receive assistance with ambulation using a four-wheeled walker and gait belt twice a day. Despite being alert and oriented, the resident reported not receiving the necessary assistance for walking. The care plan specified that staff should assist the resident in ambulating 50 to 125 feet with a wheelchair following, but documentation indicated that this was not provided on 17 out of 30 days. The Nursing Home Administrator confirmed the lack of documented evidence for the completion of these restorative nursing programs.
Medication Left Unattended on Medication Carts
Penalty
Summary
The facility failed to maintain an environment free of accident hazards on two of its nursing units, Station 2A and Station 2B. On Station 2A, medication mixed in applesauce was left unattended on top of the medication cart, making it accessible to three cognitively impaired, mobile residents. Similarly, on Station 2B, medication mixed in vanilla pudding was left unattended on the medication cart, also accessible to three cognitively impaired, mobile residents. These observations were made on consecutive days, and the Nursing Home Administrator confirmed that medication should not be left unattended on the medication cart.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents. For Resident 11, the MDS assessment inaccurately indicated that the resident was not on an opioid medication during the seven-day review period, despite clinical records showing that the resident received tramadol, an opioid, during that time. Similarly, for Resident 21, the MDS assessment incorrectly noted the use of a chair or other alarm less than daily, although the resident's clinical record showed no order or use of such an alarm during the review period. These inaccuracies were confirmed by the Nursing Home Administrator during an interview, acknowledging that the MDS assessments did not accurately reflect the residents' statuses and required modification by the facility.
Inadequate Grooming and Personal Hygiene Services
Penalty
Summary
The facility failed to provide adequate grooming and personal hygiene services for two residents who required assistance with activities of daily living. Resident 16, diagnosed with bilateral hand contractures and diabetes mellitus, was observed with long fingernails and a beard, despite expressing a preference for them to be short. Similarly, Resident 40, who had diabetes mellitus and hypertension, was found with long, discolored fingernails with sharp edges, resulting in a self-inflicted scratch. Both residents had requested nail care, which was not provided as needed. The Director of Nursing stated that nail care was scheduled to be completed on resident shower days, which occurred twice a week. However, this schedule did not meet the residents' expressed needs for more frequent grooming, leading to the observed deficiencies.
Failure to Provide Timely Hearing Services
Penalty
Summary
The facility failed to ensure timely treatment and services to maintain hearing abilities for a resident with diagnoses including diabetes mellitus and congestive heart failure. The resident, who had some difficulty hearing and used a hearing appliance, reported not receiving her hearing aids and had been waiting for almost a year. Facility documentation showed that the resident was seen by audiology on August 9, 2023, and it was determined that she would benefit from hearing aids. However, there was no documented evidence that the resident received the hearing aids or that the facility addressed this recommendation until July 11, 2024. The Nursing Home Administrator confirmed that the facility did not address the recommendation until this date.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident with specific dietary needs. Resident 44, who had diagnoses including aspiration pneumonia and dysphagia, was ordered by a physician to receive meals in bowls to assist with eating. Despite this order, the resident was observed being served a meal on a regular plate, resulting in a significant amount of food spilling onto her clothing protector. This observation was confirmed by the Director of Nursing, indicating a lapse in following the prescribed care plan for the resident.
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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