Fairview Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 184 Bethlehem Pike, Philadelphia, Pennsylvania 19118
- CMS Provider Number
- 395782
- Inspections on file
- 42
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Fairview Rehab And Care Center during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain a safe, clean, and homelike environment on one nursing floor, noting peeling wallpaper, an exposed electrical outlet, stained and missing ceiling tiles, unpainted spackled wall areas, a loose baseboard on the floor, and blinking lighting at the nurse’s station. A resident’s window screen had a deliberate tear to allow feeding of birds and squirrels, with food observed on the windowsill and outside ledge; this condition was known to the NHA and only recognized on-site by the Maintenance Director, demonstrating a failure to ensure proper environmental maintenance and safety in accordance with facility policy.
The facility failed to maintain a safe, clean, and comfortable environment on one nursing unit, as evidenced by repeated strong urine and fecal odors in the hallway and in a specific room, where a resident with a Foley catheter reported that her bed, floor, sheets, and surrounding area remained soiled after leakage overnight. In another room, dried vomit was observed next to a bed and had not been cleaned, as confirmed by a CNA. The Housekeeping Director reported he had not been notified of these soiled areas and stated that nursing staff are responsible for initial cleanup and then notifying housekeeping for disinfection. Additional observations showed hair left on the floor in a shower room after a haircut and dirty socks and a towel left on the floor in another shower room, further demonstrating a lack of timely cleaning and removal of soiled items.
A resident with hypertension and cancer was admitted on two antihypertensive medications. The facility’s policy required that BP readings below 100/60 mmHg or above 140/90 mmHg be followed by multiple additional BP checks and reported to the physician. The resident had a documented hypotensive BP of 86/53, followed by a long gap with no further BP measurements, and later had multiple hypertensive and hypotensive readings. There was no documentation of required follow-up BP measurements or physician notification for these abnormal values, and the Medical Director confirmed staff did not follow the facility’s BP management policy.
The facility failed to maintain a functional call bell system on one nursing unit, where multiple room call bells did not activate lights or signals at the bedside, outside rooms, or at the nurses’ station, contrary to facility policy requiring residents to have a means to call staff. Several residents reported ongoing, intermittent call bell problems over an extended period, and one resident described receiving a temporary numbered call device that staff could not match to her room and bed, resulting in unanswered calls and the need to reach staff through the receptionist. A CNA confirmed nonfunctioning call bells, an LPN reported a bed’s call bell had been out of service for months, and the unit manager was unaware of the scope of the failures. Maintenance records showed minimal documented call bell issues, and the administrator and a vendor later confirmed that the main call bell box required replacement.
The facility did not maintain an effective pest control program for insects on all units. A cognitively intact resident with cancer and hypertension reported frequently seeing roaches and other insects in his room and throughout the building and stated that the administrator had been informed but pest control services were ineffective. During a resident council meeting, multiple alert and oriented residents reported seeing roaches and mice and said they had notified staff. Surveyors later observed a live roach on an upper floor near the activities office, which was confirmed by a housekeeping aide, demonstrating ongoing pest activity despite existing pest control services.
Three residents were not given the required SNF-ABN (CMS-10055) after their Medicare coverage ended, despite remaining in the facility. The facility failed to notify them or their representatives of the estimated costs for continued care and did not document their understanding or choices regarding non-covered services.
A resident and their family requested copies of the resident's medical and financial records, but the facility did not provide them as requested. Staff interviews and record review confirmed that the records were not given and there was no documentation of fulfillment of the request.
A resident with a suprapubic urinary catheter and a history of pressure ulcer and UTI was found to have their catheter leg bag placed unsanitarily on top of the sink in their room, as confirmed by staff interview.
The facility did not maintain a working call system in resident rooms and bathrooms on one nursing unit, resulting in residents having to yell for help or use ineffective hand-held bells. Some residents' call bells were missing, out of reach, or non-functional, and the wireless backup system only alerted staff at the nursing station, not throughout the unit. Maintenance and administration confirmed ongoing issues with the aging call system.
A resident with multiple medical conditions, including a history of falls, reported slipping on water and hitting her head while moving to her wheelchair. Despite her report and subsequent physician orders for x-rays, there was no documentation of the fall in the clinical record, and facility staff confirmed that no investigation into the alleged incident was conducted.
A resident with multiple medical and psychiatric diagnoses, including substance abuse, was found with drug paraphernalia and suspected drugs on multiple occasions. The care plan lacked detailed interventions to prevent possession of drugs and paraphernalia or to provide adequate supervision, despite physician recommendations for close monitoring. Facility leadership confirmed the absence of a comprehensive, person-centered plan addressing these issues.
A resident with multiple medical and psychiatric conditions was allowed to leave the facility on at least two occasions for a leave of absence without a physician's order, as required by facility policy. Documentation confirmed the absences and return, but no order was present in the resident's records, and the administrator acknowledged the oversight.
A resident with severe cognitive impairment and multiple diagnoses became increasingly lethargic, resulting in missed medications. The LPN was unable to reach the physician and did not escalate the issue to the nursing supervisor as required. The physician was not notified of the significant change in condition or missed medications until several hours later, after the family requested hospital transfer. The resident was later admitted to the hospital with renal failure.
Two residents experienced incomplete and inaccurate clinical record documentation. For one, a required daily respiratory assessment and specific vital sign values were not documented by the LPN, despite a note of lethargy. For another, nursing staff failed to document the administration or omission of prescribed medications, including levothyroxine and Klonopin, in the MAR.
A resident received four additional doses of Trulicity due to a transcription error in medication orders. The hospital order specified weekly administration, but it was incorrectly transcribed as daily. The error was acknowledged by the responsible nurse, and the resident showed no adverse symptoms.
The facility failed to meet the required staffing levels for nurse aides on both the daylight and night shifts over several days. On multiple occasions, the facility did not provide the mandated one nurse aide per 10 residents during the daylight shift and one nurse aide per 15 residents during the night shift. This deficiency was confirmed by the Nursing Home Administrator and identified through a review of staffing documents.
The facility failed to meet the required LPN staffing levels on two specific days. With a census of 155 residents, the facility provided 48.27 LPN hours instead of the required 48.60. Similarly, with 160 residents, only 50.33 LPN hours were provided instead of 51.20. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident on 16 out of 21 days reviewed. Nursing schedules showed care hours below the mandated level, with the lowest being 2.74 hours per resident on one day.
The facility did not meet the required minimum staffing levels for nurse aides during the night shift on multiple days. Specifically, the facility failed to provide the necessary number of nurse aide hours per resident, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum staffing levels for LPNs on both the day and evening shifts for one day during the reviewed week. Specifically, the day shift had insufficient LPN hours scheduled for the resident census, and the evening shift also fell short of the required LPN hours. This was confirmed through an interview with the Nursing Home Administrator.
The facility did not ensure the required minimum of 3.2 nursing care hours per resident per day on five out of seven days reviewed. The nursing staff care hours were below the required standard, with the lowest being 2.64 PPD. The Nursing Home Administrator confirmed the deficiency.
A resident with multiple health conditions, including dementia and diabetes, fell from a whirlpool chair in a LTC facility due to a nurse aide's failure to use the required safety belt. The resident sustained a hip fracture and was hospitalized. The aide admitted to not securing the belt, leading to the resident's fall.
The facility failed to conduct monthly medication regimen reviews (MRRs) by a licensed pharmacist and ensure timely physician review for several residents. Despite policy requirements, many residents had incomplete or missing MRRs over a six-month period, with some reviews lacking physician acknowledgment. Interviews confirmed the absence of a process for current MRRs, highlighting a significant lapse in adherence to established procedures.
The facility failed to implement effective infection control measures, including the use of PPE and catheter care, across three floors. A resident with an ileostomy and wounds did not receive care with the required PPE, and PPE carts were missing outside rooms of two residents on enhanced barrier droplet precautions for COVID-19. Additionally, a resident with a suprapubic catheter had their catheter bag on the floor, with no PPE or waste containers available, despite enhanced barrier precautions being ordered.
The facility failed to maintain an effective antibiotic stewardship program for eight months, as required by its policy. Antibiotic use was only monitored in January and February 2024, with no documentation for the following months. The Director of Nursing confirmed the failure, and the Infection Preventionist had not been present since June 2024, contributing to the lack of documentation. This deficiency violated regulations related to the responsibility of the licensee, management, and nursing services.
The facility did not have a designated Infection Preventionist (IP) working at least part-time, as required by their policy. Documentation showed that infections and antibiotic use were only monitored in January and February 2024. The IP confirmed she had not been present at the facility since June 2024, and the DON confirmed the lack of a part-time IP.
The facility failed to provide adequate dining space on the third floor, as the dining room was used as a conference room. Residents, including those with dementia, were observed eating in the hallway or their rooms, contrary to the facility's policy of ensuring a dignified dining experience. Staff had to use overbed tables to serve meals, highlighting the lack of proper dining arrangements.
The facility failed to maintain essential dining and resident equipment in working order across all floors. Observations revealed black mold, broken cabinets, and non-functional refrigerators and ice machines. Dietary staff confirmed equipment issues had persisted for around a year. Additionally, scales were not calibrating properly, with only one usable scale since June 2024.
Surveyors observed that the facility failed to maintain a clean and homelike environment across three resident floors. Dining areas had stained chairs and ceiling tiles, while resident rooms showed signs of disrepair, including stained and missing ceiling tiles, dirty floors, and cracked tiles. Interviews with the Nursing Home Administrator and DON confirmed these findings, highlighting a lack of maintenance and oversight.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for three residents, resulting in a deficiency. A resident was discharged without a NOMNC, and two others were given discharge dates but remained without the required notice. The DON confirmed the facility's non-compliance with issuing NOMNCs as required.
The facility failed to conduct a timely criminal background check for a newly hired employee, Employee E23, as required by its policy on abuse prevention. The background check was completed over two months after the employee's hiring, only after the file was requested. This was confirmed by the Director of Human Resources, violating the facility's procedures and state regulations.
A resident with multiple diagnoses and a guardian experienced several falls at the facility, leading to hospital transfers. On two occasions, the facility failed to notify the guardian of these transfers, as documented in the clinical records. This lack of communication constitutes a deficiency in the facility's responsibility to provide timely notification.
The facility failed to provide scheduled activities for residents on the third floor. Observations revealed outdated activities calendars from September, with no updated calendar for October due to difficulties in its creation and the absence of a Director of Activities. Residents were observed unoccupied in the hallway, and no activities were scheduled or occurring, as confirmed by the Assistant Director of Activities.
A resident with adjustment disorder and paranoid schizophrenia did not receive prescribed Lorazepam due to a medication shortage. Despite facility policy requiring physician notification for unavailable medications, there was no documented evidence that the physician was contacted for further instructions, leading to a deficiency in care.
The facility failed to document necessary competencies for nursing staff, including medication administration, infection control, catheter care, and wound care, for four nurses. The HR Director confirmed the absence of these evaluations, attributing it to the previous staffing educator's absence for three months while assisting another facility.
The facility did not complete yearly performance reviews for two nurse aides, E18 and E19, who had been employed for over a year. This issue was identified during a review of personnel records and interviews with the HR director, Employee E8. The staff educator, Employee E12, responsible for ensuring these reviews, had been absent for over three months, contributing to the oversight.
A facility failed to administer Lorazepam to a resident with adjustment disorder and paranoid schizophrenia due to a lack of follow-up on medication orders. Despite policy requirements for urgent action, there was no documented evidence of follow-up with the pharmacy or additional steps taken to obtain the medication, resulting in the resident not receiving the prescribed medication for several days.
The facility failed to label medications with the date they were opened, as observed during medication administration to two residents by LPNs. This was contrary to the facility's policy requiring the date of opening to be recorded on multi-dose containers.
The facility failed to maintain an effective QAPI program as required by its policy. The QAPI committee, responsible for overseeing the program, did not demonstrate evidence of its activities, as confirmed by the Nursing Home Administrator. The policy requires the committee to meet quarterly and include representatives from various departments, but the facility did not adhere to these requirements.
A resident expressed a desire to receive the pneumococcal vaccine but had not been offered it by the facility. The resident's clinical record lacked documentation of being educated about or offered the vaccine in the past year. The DON confirmed that no residents had been offered the vaccine, and the facility had been operating without an Infection Preventionist since July, with no established practice for annual vaccine offerings.
A resident with a history of alcohol use and falls was inadequately supervised, leading to multiple falls and a hip fracture. Despite finding alcohol in the resident's room and unusual behavior suggesting intoxication, the facility failed to implement effective interventions. The DON was unaware of several incidents, highlighting a breakdown in communication and response.
A resident reported missing cigarettes, but the facility did not conduct a thorough investigation as required by its policy. Additionally, allegations of theft by the Activities Director were not immediately addressed, allowing the director to continue working with residents for two days before suspension. These actions highlight deficiencies in incident investigation and resident protection.
The NHA and DON failed to manage a resident's alcohol consumption, leading to falls and a hip fracture. Despite suspicions and evidence of alcohol use, staff did not provide adequate monitoring or a care plan, resulting in Immediate Jeopardy.
The facility failed to maintain an effective pest control environment, with repeated instances of unprepared rooms preventing treatment, inadequate documentation of pest sightings, and unresolved maintenance issues like unsealed holes. Observations confirmed pest activity, and staff interviews revealed awareness but no corrective actions taken.
A resident admitted with stage three pressure ulcers did not have a wound care plan developed, despite a skin assessment confirming the wounds. The oversight was acknowledged by the Nursing Home Administrator and DON, who confirmed that such wounds should be included in the baseline care plan.
The facility failed to implement wound care orders for four residents with pressure ulcers, as recommended by a wound care specialist. Despite repeated recommendations, no physician orders were placed for the necessary treatments, which was confirmed by the Nursing Home Administrator and the DON. This deficiency violated nursing services regulations.
The facility failed to ensure accurate physician assessments for four residents, as discrepancies were found between physician notes and observations by a nurse practitioner and surveyor. Residents exhibited conditions such as edema, weakness, and contractures, which were not accurately documented by the attending physician. Interviews with the Nursing Home Administrator and DON confirmed these inaccuracies.
Failure to Maintain Safe, Clean, and Homelike Environment on Second Floor
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on the second floor, contrary to its “Homelike Environment” policy requiring a clean, sanitary, and orderly setting. Surveyors observed multiple environmental issues, including peeling wallpaper in a resident room, an exposed electrical outlet behind a bed caused by a bubbling wall, and several brown-stained ceiling tiles in both a resident room and its bathroom. Another resident room had black and brown stained ceiling tiles near the window. In the common room, one ceiling tile was missing and another was brown-stained, and there were large wall areas patched with white spackle that had not been painted. In the second-floor hallway, several wall and ceiling areas had also been repaired with white spackle but not painted, and a piece of baseboard was found on the floor near the nurse’s station. The lighting at the nurse’s station was observed to be blinking constantly. A resident on the second floor reported that birds repeatedly appeared at the resident’s window and explained that there was an arrangement with the Maintenance Director to leave a small hole in the window screen so the resident could feed birds and squirrels. The surveyor observed a torn area in the window screen approximately three inches by three inches, with the window open about two inches and a weight partially blocking the hole. Scrambled eggs and cereal were present on the windowsill and outside window ledge. During interviews, the Maintenance Director initially stated he was unaware of the hole but then confirmed its presence upon observation, while the Nursing Home Administrator acknowledged knowing about the hole and that it was intentionally left small so the resident could feed animals through it.
Failure to Maintain Clean, Odor-Free Resident Rooms and Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment on one of three nursing units, including resident rooms and shower rooms. Facility policy on cleaning and disinfecting resident rooms requires housekeeping surfaces to be disinfected regularly and when visibly soiled, and specifies that floor mopping solution be replaced every three rooms or at least every 60 minutes. Despite this, surveyors observed a strong urine odor on the first-floor unit hallway on multiple occasions. On one observation, there was a strong odor of urine and feces near a specific room, and the Unit Manager confirmed a significant fecal odor and urine spilled next to a resident’s bed. Shortly thereafter, a resident who used a Foley catheter reported that the catheter had leaked during the night, leaving her bed, floor, sheets, and surrounding area soiled, and stated that these areas had not yet been cleaned. In another room on the same unit, surveyors observed a large pile of dried brown bodily fluid consistent with vomit next to a bed, and a nursing assistant confirmed that a resident had vomited earlier that morning and that the area had not been cleaned. The Unit Manager confirmed these conditions and contacted the Housekeeping Director, who stated he had not been notified about the affected rooms and reported that nursing staff are responsible for cleaning bodily fluids and then notifying housekeeping to disinfect. Additional observations with the Housekeeping Director revealed that the first-floor shower room had a significant amount of hair on the floor from a recent haircut, and the third-floor shower room had dirty socks and a dirty towel left on the floor in a shower stall. On subsequent days, surveyors again noted a strong urine odor upon entering the first-floor unit, which the Unit Manager and later the Administrator confirmed, identifying a specific room as the apparent source of the odor.
Failure to Follow Blood Pressure Management Policy for Hypertensive Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its own blood pressure management policy and professional standards of quality care for one resident with a history of hypertension and malignant neoplasm of the rectum and colon. The facility’s policy defined hypertension as BP over 140/90 mmHg and hypotension as BP less than 100/60 mmHg, and required that such abnormal readings be reported to the physician and followed by several additional BP measurements at different times of day. The resident was admitted on antihypertensive medications (amlodipine 10 mg daily and lisinopril 40 mg daily). On one date, the resident’s BP was recorded as 86/53, which met the facility’s definition of hypotension. No further BP readings were documented between that date and a later date in October, despite the policy requirement for multiple follow-up readings and physician communication for hypotensive values. Subsequent BP records for the same resident showed multiple readings that met the facility’s definitions of either hypertension or hypotension, including values such as 142/90, 141/97, 166/129, 143/97, 95/57, and 142/100. According to facility policy, each of these abnormal readings required additional BP measurements and notification of the physician. The clinical record contained no documentation of follow-up BP measurements for these abnormal readings and no indication in the progress notes that the physician was informed of them. Although physician orders showed that the resident’s antihypertensive medications were discontinued on the same date as the initial hypotensive reading, the deficiency centers on the lack of required follow-up measurements and failure to report subsequent abnormal BP values. In an interview, the Medical Director confirmed that staff did not comply with the facility’s policy regarding obtaining additional BP measurements after abnormal readings and reporting the results to the physician.
Failure to Maintain Functional Call Bell System on First-Floor Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the first-floor nursing unit was adequately equipped with a functional resident call bell system, as required by facility policy. The policy stated that residents must be provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. During interviews and testing on the first-floor unit, multiple resident room call bells, including those for two roommates and additional rooms (125, 126, 127, 128, 130, and 131), were found not to activate lights at the bedside, outside the rooms, or at the nursing station. A nursing assistant confirmed that these call bells were not working. A licensed nurse reported that one bed’s call bell had been nonfunctional for approximately two months, and a temporary small black call bell receiver had been provided instead. The unit manager stated she was not aware that these call bells were not functioning and verified that they were not sending signals to notify staff. Further review showed that the maintenance log for the prior three months contained only three tickets related to a call bell issue in one first-floor room, and the most recent call bell audit had been conducted several months earlier. At a resident council meeting, multiple alert and oriented residents reported that call bell problems had been occurring intermittently for about a year and a half. One resident later reported being given a small black call bell labeled with a number rather than her room and bed, and stated that night-shift nurses did not have a key list to match the numbered device to specific residents, resulting in her call not being answered. She also reported having to contact the receptionist and be transferred to the nursing station when her calls were not answered, and on another occasion stated that her call bell use again did not result in a response until she called through the receptionist. The administrator acknowledged prior issues with some call bells, stated that this was the first time he became aware of a major problem on the first floor, and a vendor later reported that the main call bell box needed replacement, with further repairs possibly required.
Inadequate Pest Control Program for Insects on All Units
Penalty
Summary
The facility failed to maintain an adequate pest control program for insects on all three units (1st, 2nd, and 3rd floors). A cognitively intact resident, admitted with malignant neoplasm of the rectum and colon and hypertension, reported frequently seeing roaches and other insects in his room and throughout the building. He stated that he had informed the administrator of the problem and that pest control services had been ineffective in managing the insect presence. His clinical record confirmed that he was alert and oriented, and his most recent MDS showed a BIMS score of 15/15. During a resident council meeting with multiple alert and oriented residents, several residents reported seeing roaches and mice and stated they had reported these issues to staff. Surveyors informed the Nursing Home Administrator and the DON of these pest reports during an interview. Direct observation by surveyors on the third floor near the activities office revealed a live roach, which was confirmed by a housekeeping aide. These resident reports and surveyor observations demonstrated ongoing pest activity despite existing pest control services, indicating that the facility’s pest control program was not effectively preventing or managing insects across all reviewed units.
Failure to Provide SNF-ABN Notification for Non-Covered Medicare Services
Penalty
Summary
The facility failed to provide required notification to residents regarding their potential financial liability for services no longer covered by Medicare. Specifically, after issuing the Notice of Medicare Non-Coverage (NOMNC) to three residents whose Medicare coverage was ending, the facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN; Form CMS-10055) as required. This form is necessary to inform residents or their representatives of the estimated costs for continued care and to document their understanding and choices regarding ongoing services not covered by Medicare. Documentation review confirmed that each of the three residents remained in the facility after their Medicare coverage ended, but there was no evidence that the SNF-ABN was issued to any of them. An interview with the Nursing Home Administrator further confirmed that the required notice was not provided. This omission resulted in a lack of documented communication to the residents or their representatives about their financial responsibility for non-covered services.
Failure to Provide Resident Access to Medical and Financial Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical and financial records upon request. During a care conference, the resident and their family requested a full set of these records. Despite this request, the records were not provided, as confirmed by both the resident and the facility administrator. Interviews revealed that there was no written documentation in the clinical record indicating that the requested records had been given to the resident. The deficiency was identified through staff interviews and review of the clinical record, which confirmed the absence of documentation and fulfillment of the resident's request.
Unsanitary Catheter Bag Placement
Penalty
Summary
A review of clinical records and staff interviews revealed that a resident with a history of a stage 4 sacral pressure ulcer, urinary tract infection, and klebsiella pneumoniae infection was admitted with a physician's order for a suprapubic urinary catheter. During an interview, it was observed that the resident's urinary catheter leg bag was lying on top of the sink in the resident's room in an unsanitary condition. This observation was confirmed by the unit manager, who acknowledged the unsanitary placement of the catheter bag above the resident's sink. The deficiency was cited under regulations requiring appropriate catheter care and maintenance of sanitary conditions to prevent urinary tract infections.
Failure to Maintain Functional Resident Call System in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that a functioning resident call system was available in each resident's bathroom and bathing area on the second floor nursing unit, affecting all seven residents reviewed. Observations and interviews revealed that the installed call bell system was not working properly, with some residents resorting to yelling for help or using hand-held silver bells, which could not be heard from a distance. In several cases, the call bells were either missing, out of reach, or non-functional when tested. For example, one resident's call bell was not present in the room, and another's was placed on a dresser out of reach. Testing of the call systems confirmed they were non-functional in multiple rooms and bathrooms. To compensate for the non-working wired call bell system, the facility provided a wireless call bell system for some residents. However, this system only notified staff at the nursing station and did not provide portable notifications to staff elsewhere in the unit. Additionally, no working call light system was observed in the bathrooms for several residents. Maintenance staff confirmed the deficiencies during testing, and the Nursing Home Administrator acknowledged ongoing problems with the call bell system due to its age and lack of available replacement parts.
Failure to Investigate Resident's Alleged Fall
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a resident's reported fall. The resident, who had multiple diagnoses including hypertension, cerebral infarction, arthritis, a history of falling, diabetes, schizophrenia, and substance abuse, informed nursing staff that she had fallen the previous week, slipping on water near her bed while attempting to walk to her wheelchair and hitting her head. She reported pain to the right side of her head, and the physician was notified with orders for x-rays. However, there was no documentation in the clinical record of any falls for the entire month, and the Assistant Director of Nursing confirmed that no investigation was initiated into the resident's allegation as reported to staff.
Failure to Develop Comprehensive Care Plan for Resident with Substance Abuse History
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented history of substance abuse. The resident had multiple diagnoses, including hypertension, cerebral infarction, arthritis, history of falls, diabetes, schizophrenia, and substance abuse. Despite previous incidents where the resident admitted to smoking drugs in her room and was found in possession of drug paraphernalia, the care plan only included basic interventions such as installing a smoke detector, temporarily restricting leave of absence visits, and supervised visitation. Subsequent events included the discovery of a crack pipe and suspected crack cocaine in the resident's possession, as reported by the nursing supervisor and confirmed by the NHA. The physician's notes also documented concerns about ongoing cocaine use and recommended close monitoring for signs and symptoms of drug abuse. Review of the resident's clinical record and care plan revealed that there was no detailed or updated plan addressing the prevention of drug and paraphernalia possession, nor were there specific interventions for supervision tailored to the resident's substance abuse history. Interviews with facility leadership confirmed that the care plan lacked detailed strategies for supervision and prevention of drug access, despite repeated incidents and physician recommendations for close monitoring. The deficiency was cited under relevant state codes for failure to provide adequate resident care planning and nursing services.
Failure to Obtain Physician Order for Resident Leave of Absence
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for a leave of absence (LOA) from the facility. According to the facility's policy, each resident leaving the premises, except for transfers and discharges, must be signed out. Review of documentation showed that a resident with multiple diagnoses, including hypertension, cerebral infarction, arthritis, history of falling, diabetes, schizophrenia, and substance abuse, left the facility on at least two occasions for LOA visits with her sister. Nursing notes and a physician's note confirmed these absences and the resident's return to the facility. However, a review of the resident's physician orders for the relevant month did not include any order authorizing the LOA. During an interview, the Nursing Home Administrator acknowledged that there was no physician's order approving the resident's absences. This failure to obtain and document a physician's order for the LOA was not in accordance with facility policy and regulatory requirements.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
Fairview Nursing and Rehabilitation Center was found to be noncompliant with federal and state requirements regarding timely notification of significant changes in a resident's condition. The facility's policy requires nursing staff to notify the attending physician or physician on call when there is a significant change in a resident's physical, emotional, or mental condition. In the case reviewed, a resident with severe cognitive impairment, Alzheimer's disease, depression, bradycardia, altered mental status, and somnolence was readmitted to the facility following a hospitalization. Upon readmission, the resident was alert and able to communicate simple needs. On a subsequent day, the resident was observed by an LPN to be lethargic with minimal verbal response during a medication pass. As a result, several physician-ordered medications were omitted for that shift. The LPN attempted to contact the physician but did not receive a response and reported feeling uncomfortable administering medications due to the resident's status. According to facility policy, the next step would have been to inform the nursing supervisor if the physician could not be reached, but the RN supervisor could not recall being notified of the situation. The physician was not contacted until several hours later, after the resident's family requested hospital transfer due to the resident's increased lethargy. The physician then gave orders for hospital transfer, and the resident was subsequently admitted to the hospital with a diagnosis of renal failure. There was no documented evidence that the physician was notified of the significant change in the resident's condition or the missed medications in a timely manner, as required by both facility policy and federal regulations.
Plan Of Correction
F0580 1. MD notification of change and condition for Resident R1 occurred later in the day and resident sent to hospital. 2. The DON or designee audited all residents with a documented change in condition within the past 72 hours to ensure physician notification was completed and documented. Any missed notifications were completed immediately, and physician instructions were followed. 3. All licensed nursing staff will be re-educated on: Facility policy for "Notification of Change in Condition." 4. DON or designee will audit all change in condition events weekly for 4 weeks, then monthly for 1 month. Findings will be reported to QAPI committee.
Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical record documentation for two residents. For one resident, a physician order required a daily respiratory assessment on every day shift, including documentation of lung sounds, pulse, and O2 saturation. However, there was no documented evidence that the assigned licensed nurse completed or recorded the required respiratory assessment or the resident's vital signs on one of the days. Additionally, a nursing note indicated the resident appeared lethargic with little verbal response, but only stated that vital signs were within normal limits without specifying the actual values. For another resident, who was admitted and discharged within a short period, the medication administration record lacked documentation regarding the administration or omission of prescribed medications, specifically levothyroxine and Klonopin, on a particular day. These findings were based on a review of clinical records and staff interviews, demonstrating incomplete and inaccurate documentation in the residents' medical records.
Plan Of Correction
F0842 1. Resident R1 and Resident R2 were sent to hospital before discovery of missed medications. R2 did not return to facility. MD made aware of Resident R1 missing medications. 2. The DON or designee audited the MARS for all residents for the previous 72 hours to identify any other missed or late medications. Any identified missed medications were addressed immediately, physicians notified, and corrective actions taken. 3. All licensed nurses were re-educated on the facility's Medication Administration Policy, including: Documentation requirements for missed or late doses, Immediate physician notification requirements, what to do while passing medication and needed medication not in cart. 4. DON or designee will audit the MAR for missed Synthroid, klonopin, and respiratory assessments daily for 2 weeks, then weekly for 1 month, to verify: All medications are administered as ordered. Any missed or late doses are documented with a reason and physician notification. Findings will be reported to QAPI.
Medication Transcription Error Leads to Overdose
Penalty
Summary
The facility failed to ensure that a resident was free of significant medication errors, as evidenced by a transcription error involving the medication Trulicity. Upon review of the clinical records and facility policies, it was found that a nurse did not follow the appropriate hospital order when transcribing admission orders for a resident. The hospital order specified that Trulicity should be administered once every seven days, but the physician orders incorrectly indicated a daily administration. This error led to the resident receiving four additional doses of Trulicity. The incident was identified when the facility reviewed the resident's medication administration records. The Director of Nursing confirmed that the nurse responsible for transcribing the orders acknowledged the error. Despite the error, the resident did not exhibit any signs or symptoms of hypo or hyperglycemia. The physician was notified, and the facility took steps to address the error, but the deficiency was cited as past non-compliance.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the daylight and night shifts over several days. Specifically, on three occasions, the facility did not provide the mandated one nurse aide per 10 residents during the daylight shift. Additionally, on 15 occasions, the facility did not meet the requirement of one nurse aide per 15 residents during the night shift. This deficiency was identified through a review of staffing documents and confirmed by the Nursing Home Administrator during an interview. The facility's staffing records from December 2024 to January 2025 showed discrepancies between the actual hours worked by nurse aides and the hours required to meet the staffing regulations.
Plan Of Correction
Review of CNA Staffing Ratios: The facility reviewed CNA staffing ratios for the following dates: Day Shifts: 12/22/24, 1/1/25, 1/19/25. Night Shifts: 12/17/24, 12/18/24, 12/21/24, 12/22/24, 12/23/24, 12/31/24, 1/3/25, 1/4/25, 1/5/25, 1/15/25, 1/16/25, 1/17/25, 1/18/25, 1/19/25, 1/20/25, 1/21/25. The review determined that no grievances were filed, or care affected due to staffing ratios. Expanded Review: Additional dates were reviewed to ensure that CNA staffing ratios were met and to confirm that care was not adversely impacted. Education on Staffing Ratios: The scheduling coordinator will be educated on the CNA staffing ratio requirements. Day Shift: Minimum of 1 CNA per 10 residents. Evening Shift: Minimum of 1 CNA per 11 residents. Night Shift: Minimum of 1 CNA per 15 residents. Monitoring and Audits: The NHA or designee will conduct audits of CNA staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
LPN Staffing Deficiency on Day Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) on the day shift for two specific days. On December 21, 2024, the facility had a census of 155 residents and required 48.60 LPN hours but only provided 48.27 hours. Similarly, on January 19, 2025, with a census of 160 residents, the facility needed 51.20 LPN hours but only provided 50.33 hours. This deficiency was confirmed during an interview with the Nursing Home Administrator on February 3, 2025, who acknowledged the shortfall in LPN hours on the specified shifts.
Plan Of Correction
Review of LPN Staffing Ratios: The facility reviewed the LPN staffing ratios for December 19, 2024, and January 19, 2025. No grievances were filed, and resident care was not negatively affected on those dates due to staffing ratios. Expanded Review: Additional dates were reviewed to ensure that LPN staffing ratios were met and to confirm that resident care levels were not adversely impacted. Education on Staffing Ratios: The scheduling coordinator will be educated on the LPN staffing ratio requirements: - Day Shift: Minimum of 1 LPN per 25 residents. - Evening Shift: Minimum of 1 LPN per 30 residents. - Night Shift: Minimum of 1 LPN per 40 residents. Monitoring and Audits: The NHA or designee will conduct audits of LPN staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. Quality Assurance Reporting: Audit results will be reviewed at the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
Deficiency in Meeting Minimum Nursing Care Hours
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. This deficiency was identified through a review of nursing time schedules over a span of 21 days, where it was found that on 16 of those days, the facility did not meet the required care hours. Specific dates were noted where the care hours per resident fell below the mandated 3.2 hours, with the lowest being 2.74 hours on one of the days. This indicates a consistent shortfall in the provision of adequate nursing care over the reviewed period.
Plan Of Correction
Review of General Nursing Care Staffing Ratios: The facility reviewed the total number of general nursing care staffing ratios for December 18, 2024, December 19, 2024, December 20, 2024, December 21, 2024, December 22, 2024, December 31, 2024, January 3, 2025, January 4, 2025, January 5, 2025, January 15, 2025, January 16, 2025, January 17, 2025, January 18, 2025, January 19, 2025, January 20, 2025, and January 21, 2025. No grievances or care were affected on those dates due to staffing ratios. Expanded Review: Additional dates were reviewed to ensure that ratios were met and to confirm that care was not adversely impacted. Education on Staffing Ratios: The scheduling coordinator will be educated on general nursing care staffing ratios: Minimum of 3.2 hours of direct resident care per resident per day. Monitoring and Audits: The NHA or designee will conduct audits to verify nursing care staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
Deficiency in Night Shift Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides during the night shift on five out of seven days in the week of December 15, 2024. Specifically, the facility did not ensure a minimum of one nurse aide per 20 residents. On December 15, 2024, with a census of 153 residents, only 70.49 nurse aide hours were provided, falling short of the required 76.5 hours. Similarly, on December 16, 2024, 71.6 nurse aide hours were provided for 153 residents, again below the required 76.5 hours. On December 17, 2024, 56.01 nurse aide hours were provided for 152 residents, whereas 76 hours were needed. On December 18, 2024, 69.43 nurse aide hours were provided for 153 residents, short of the 76.5 hours required. Lastly, on December 21, 2024, 69.2 nurse aide hours were provided for 155 residents, while 77.5 hours were necessary. The Nursing Home Administrator confirmed these staffing deficiencies during an interview on December 23, 2024.
Plan Of Correction
Plan of Correction for § 211.12(f.1)(3) Nursing Services: 1. Review of CNA Staffing Ratios: The facility reviewed CNA staffing ratios for the following dates: - Day Shifts: 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/21/24. - Night Shifts: 12/15/24, 12/16/24, 12/17/24, 12/18/24, 12/21/24. The review determined that no grievances were filed, or care affected due to staffing ratios. 2. Expanded Review: Additional dates were reviewed to ensure that CNA staffing ratios were met and to confirm that care was not adversely impacted. 3. Education on Staffing Ratios: The scheduling coordinator will be educated on the CNA staffing ratio requirements. - Day Shift: Minimum of 1 CNA per 10 residents. - Evening Shift: Minimum of 1 CNA per 11 residents. - Night Shift: Minimum of 1 CNA per 15 residents. 4. Monitoring and Audits: The NHA or designee will conduct audits of CNA staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. 5. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
Deficiency in LPN Staffing Levels
Penalty
Summary
The facility failed to meet the required minimum staffing levels for Licensed Practical Nurses (LPNs) on both the day and evening shifts for one of the seven days reviewed during the week of December 15, 2024. Specifically, on December 21, 2024, the day shift had only 25 LPN hours scheduled, while the resident census of 155 required 49.6 LPN hours. Similarly, the evening shift had 37.48 LPN hours scheduled, whereas the same resident census required 41.33 LPN hours. This deficiency was confirmed through an interview with the Nursing Home Administrator, Employee E1, on December 23, 2024.
Plan Of Correction
Plan of Correction for § 211.12(f.1)(4) Nursing Services: 1. Review of LPN Staffing Ratios: The facility reviewed the LPN staffing ratios for December 21, 2024. No grievances were filed or resident care was negatively affected on that date due to staffing ratios. 2. Expanded Review: Additional dates were reviewed to ensure that LPN staffing ratios were met and to confirm that resident care levels were not adversely impacted. 3. Education on Staffing Ratios: The scheduling coordinator will be educated on the LPN staffing ratio requirements: - Day Shift: Minimum of 1 LPN per 25 residents. - Evening Shift: Minimum of 1 LPN per 30 residents. - Night Shift: Minimum of 1 LPN per 40 residents. 4. Monitoring and Audits: The NHA or designee will conduct audits of LPN staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. 5. Quality Assurance Reporting: Audit results will be reviewed at the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
Failure to Meet Minimum Nursing Care Hours
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 day (PPD) on five out of seven days during the week of December 15, 2024. A review of the nursing staff care hours revealed that on December 15, 16, 18, and 20, 2024, the facility provided 3.11, 3.10, 3.09, and 3.12 PPD respectively, which were below the required minimum. Additionally, on December 15, 2024, the facility provided only 2.64 PPD, significantly below the required standard. An interview with the Nursing Home Administrator confirmed the staffing levels did not meet the required minimum PPD of 3.2.
Plan Of Correction
Plan of Correction for § 211.12(i)(2) Nursing Services: 1. Review of General Nursing Care Staffing Ratios: The facility reviewed the total number of general nursing care staffing ratios for December 15, 2024, December 16, 2024, December 18, 2024, December 20, 2024, and December 21, 2024. No grievances or care were affected on those dates due to staffing ratios. 2. Expanded Review: Additional dates were reviewed to ensure that ratios were met, and care affects. 3. Education on Staffing Ratios: The scheduling coordinator will be educated on general nursing care staffing ratios: - Minimum of 3.2 hours of direct resident care per resident per day. 4. Monitoring and Audits: The NHA or designee will conduct audits to verify nursing care staffing ratios for all shifts. These audits will be conducted weekly for four weeks to ensure compliance. 5. Quality Assurance Reporting: Audit results will be presented to the Quality Assurance and Performance Improvement (QAPI) committee for evaluation and further action as needed.
Failure to Use Safety Belt Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate safety measures, resulting in actual harm to a resident who sustained a hip fracture. The incident involved a resident with a history of dementia, Type 2 Diabetes, irregular heartbeat, non-Hodgkin's lymphoma, and adult failure to thrive. The resident was found lying on the shower room floor after falling from a whirlpool chair. The fall occurred because a nurse aide did not secure the resident with the safety belt, as required by the manufacturer's instructions for the shower chair. The nurse aide admitted to not using the seat buckle, thinking it would be okay, which led to the resident lunging forward and falling out of the chair. The resident was subsequently admitted to the hospital for treatment of a fractured left hip. The facility's failure to ensure the use of the safety belt on the bathing lift chair directly resulted in the resident's fall and injury.
Failure to Conduct Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication regimen reviews (MRRs) were completed monthly by a licensed pharmacist and that recommendations were reviewed timely by the physician for 13 out of 33 resident records reviewed. The facility's policy requires that a system be established for the timely communication of pharmacist recommendations regarding residents' drug therapy to those with authority to implement or respond to these recommendations. However, the facility did not adhere to this policy, as evidenced by the lack of monthly MRRs and the absence of physician review and acknowledgment of pharmacist recommendations. For several residents, including R20, R39, R73, R83, R91, R92, R110, R121, R127, R130, and R132, the facility failed to provide evidence of monthly MRRs. In some cases, only one or two MRRs were completed over a six-month period, and these were often not signed by the attending physician or reviewed in a timely manner. For instance, Resident R20 had only one MRR from July 2024, which was not signed by the physician. Similarly, Resident R73 had only one MRR from August 2024, which also lacked physician acknowledgment. Interviews with the Director of Nursing confirmed that there was no process in place for current MRRs, and several residents, such as R22, R24, and R110, had incomplete or missing MRRs for the requested months. The facility's failure to conduct regular MRRs and ensure timely physician review of pharmacist recommendations indicates a significant lapse in adhering to established policies and procedures, potentially impacting the quality of care provided to the residents.
Infection Control Deficiencies in PPE and Catheter Care
Penalty
Summary
The facility failed to implement an effective infection prevention and control program across three floors, specifically in relation to enhanced barrier precautions, personal protective equipment (PPE), and catheter care. Observations revealed that a wound nurse did not don the required PPE (gown) before treating a resident with an ileostomy and wounds, despite signage indicating enhanced barrier precautions. Additionally, on the third floor, there was a lack of PPE carts outside rooms of residents on enhanced barrier droplet precautions for COVID-19, which was confirmed by a licensed nurse who stated that the carts were being restocked and that residents with cognitive issues might have moved them. Further deficiencies were noted with a resident who had a suprapubic urinary catheter, where the catheter bag was observed on the floor, and there was no PPE or appropriate waste containers outside the resident's room, despite an order for enhanced barrier precautions. These observations were confirmed by a licensed practical nurse. The facility's failure to maintain proper infection control measures was in violation of specific Pennsylvania codes related to the responsibility of the licensee and nursing services.
Failure to Maintain Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for eight out of ten months, from January 2024 through October 2024. The facility's policy, revised in 2016, required antibiotics to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, with usage and outcome data collected and documented using a facility-approved tracking form. However, documentation revealed that antibiotic use was only monitored in January and February 2024, with no documentation for the subsequent months. This lack of monitoring was confirmed by the Director of Nursing, who acknowledged the failure to implement the program effectively. The Infection Preventionist, who was responsible for reviewing antibiotic utilization, had not been present in the facility since June 2024, and confirmed that antibiotic usage had not been documented since February 2024. This absence contributed to the facility's inability to adhere to its own policies regarding antibiotic use protocols and monitoring systems. The deficiency was identified under the regulations 28 Pa Code 201.14(a), 28 Pa Code 201.18(d), and 28 Pa. Code 211.12(c), which pertain to the responsibility of the licensee, management, and nursing services, respectively.
Failure to Designate a Part-Time Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) working at least part-time, as required by their policy. The facility's policy, revised in 2016, states that the IP is responsible for coordinating the implementation and updating of infection prevention and control policies and practices. However, documentation from January 2024 through October 2024 showed that infections and antibiotic use were only monitored in January and February 2024. During an interview, the IP, Employee E12, confirmed that she had not been present at the facility since June 2024, despite still being employed there. The Director of Nursing, Employee E2, also confirmed the lack of a part-time IP at the facility.
Inadequate Dining Space on Third Floor
Penalty
Summary
The facility failed to provide sufficient space for dining and recreation services on the third floor, as observed during a survey. The facility's policy on Resident Rights and Dignity emphasizes the importance of a dignified dining experience, yet the third floor dining room was repurposed as a conference room. This led to residents eating their meals in the hallway or in their rooms, which does not align with the facility's policy of providing a dignified dining experience. The facility's Dining Room Audits policy, which includes regular audits by the dietician and food services manager to ensure a pleasant dining experience, was not adhered to in this instance. During the survey, five residents with dementia were observed eating in the hallway, seated in their wheelchairs across from the nurses' station. Staff had to retrieve overbed tables from resident rooms to accommodate these residents, and meal trays were placed in front of them. Three residents were fed by staff, while two ate independently. The third floor unit manager confirmed that residents typically eat their meals in the hallway or their rooms, with only a few alert and oriented residents going to the first-floor dining room. This situation indicates a lack of adequate dining space and equipment to meet the residents' needs, as required by the facility's policies and regulations.
Failure to Maintain Essential Equipment in Working Order
Penalty
Summary
The facility failed to maintain essential dining and resident equipment in proper working order across all three floors reviewed. On the second floor, black mold was observed under the sink in the serving pantry area, and a cabinet was broken under the steam table. On the first floor, the dining room pantry area had an ice machine that was out of order, a dirty hand sink with dirt residue, and black mold under the cabinet. Additionally, a double fridge was not working and was dirty with liquid residue, a display refrigerator was not turned on, and another refrigerator with a cutting board top was dirty inside. The clear display fridge was also not working. An interview with dietary staff revealed that the equipment had not been working for around a year. Further observations with the regional director of maintenance confirmed that several pieces of equipment were not functioning properly. On the second floor, the double refrigerator and prep refrigerator were not working, with the latter blowing hot air, and the clear display refrigerator was also not cooling. On the first floor, the double refrigerator and clear display refrigerator were not working, and the ice machine was out of service. Additionally, the facility dietician reported issues with scales not calibrating and working, with only the scale on the second-floor nursing unit being usable. This issue had been ongoing since June 2024.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment across three resident floors, as observed by surveyors. On the Third floor, the dining room contained stained and soiled chairs, and the wallpaper was in poor condition. Additionally, the first-floor dining area had numerous stained ceiling tiles and peeling wallpaper. Resident rooms were also found to be in disrepair, with issues such as stained ceiling tiles, missing tiles, and dirty floors. Specifically, Resident R74's room had five stained ceiling tiles, Resident R110's room had a light fixture filled with dead bugs, and Resident R56's room had a missing ceiling tile and stained tiles. Resident R54's room had liquid spills and caked-on dirt on the floor. Further observations revealed that Resident R28's room had a cracked tile floor, wall cracks near windows, and broken shelves exposing clothing. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these findings, with the Administrator noting the availability of additional dining chairs in storage but no audits available for review. These conditions indicate a failure to maintain a safe, clean, and homelike environment for residents, as required by regulations.
Failure to Provide Timely NOMNC
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for three residents, leading to a deficiency in compliance with resident rights. Resident R315 was discharged home without documentation of a NOMNC being reviewed prior to discharge. Additionally, residents R314 and R158 were given discharge dates but remained at the facility, and there was no evidence of NOMNCs being issued. An interview with the Director of Nursing confirmed that the facility was not completing the required NOMNCs for residents prior to the termination of Medicare A services, as mandated by regulations.
Failure to Conduct Timely Background Checks for New Employee
Penalty
Summary
The facility failed to conduct required criminal background checks in a timely manner prior to employment for one of five newly hired employees, identified as Employee E23. According to the facility's policy titled 'Abuse, Neglect, Exploitation and Misappropriation Prevention Program,' background checks must be conducted to ensure that no individual with a history of abuse, neglect, exploitation, or misappropriation of property is employed. However, a review of Employee E23's file revealed that the criminal background check was not completed until over two months after the employee was hired, which was only done after the employee file was requested. An interview with the Director of Human Resources, identified as Employee E28, confirmed that the criminal background check for Employee E23 had not been completed prior to their hiring, as required by the facility's policy. This oversight was a direct violation of the facility's established procedures and Pennsylvania Code 28 Pa. Code 201.19, which mandates timely background checks as part of personnel policies and procedures.
Failure to Notify Guardian of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident's guardian of the resident's transfer to the hospital on two occasions following falls. Resident R24, who has a guardian in place for her care, was admitted to the facility with multiple diagnoses including Hypertension, Hyperlipidemia, Schizoaffective Disorder, Chronic Obstructive Pulmonary Disorder, and Brief Psychotic Disorder. The clinical record review revealed that the resident experienced several falls at the facility, resulting in hospital transfers. However, there was no documented evidence that the guardian was notified of these transfers. Specifically, on August 3, 2024, a nursing progress note indicated that the resident fell in the hallway, hit her head, and was transferred to the hospital via 911. Despite this incident, the nursing notes for that day did not document any notification to the guardian. Similarly, on July 17, 2024, after a fall and a drop in blood pressure, the primary care provider recommended sending the resident to the emergency room. Again, there was no documented evidence of the guardian being informed of this transfer. This lack of communication with the resident's guardian constitutes a deficiency in the facility's responsibility to provide timely notification of transfers or discharges.
Lack of Scheduled Activities on Third Floor
Penalty
Summary
The facility failed to provide activities that enhanced resident interactions on the third floor. Observations on October 22, 2024, revealed that resident rooms on this floor had outdated activities calendars from September 2024, and no updated calendar for October 2024 was available. An interview with the Assistant Director of Activities, Employee E11, on October 23, 2024, confirmed that no calendar was created for October due to difficulties in its creation, and there was no Director of Activities employed at the facility. Further observations on October 22, 23, and 24, 2024, showed residents gathered in the third-floor hallway near the nurses' station, sitting unoccupied in chairs or wheelchairs without scheduled activities. Employee E11 confirmed on October 24, 2024, that no activities were scheduled or occurring on the third floor. This deficiency was noted under 28 Pa. Code: 201.18(b)(3) Management and 28 Pa. Code: 207.2(a) Administrators Responsibility.
Failure to Notify Physician for Missed Medication
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of practice by not notifying the physician for further instructions after a missed anti-anxiety medication. The facility's policy on medication shortage or unavailable medication, last revised in April 2018, requires the licensed nurse to urgently initiate action in correspondence with the attending physician and the pharmacy when medications are not received or are unavailable. The policy also states that if the medication is not obtainable, the physician should be called for further orders, and if there is no response, the nursing supervisor should contact the Medical Director. Resident R39, who was admitted with diagnoses of adjustment disorder with anxiety and paranoid schizophrenia, was prescribed 0.5 mg of Lorazepam three times a day for extreme agitation. A psychiatric consultation noted the resident was paranoid, delusional, and psychotic, becoming extremely agitated and combative. Despite the physician's orders, the electronic medication administration record and nursing progress notes indicated that from September 18 through September 29, 2024, the medication was on order and not given. There was no documented evidence that the physician was notified for further instructions, as confirmed by the Director of Nursing during an interview.
Lack of Competency Documentation for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to meet residents' needs, as evidenced by the review of four personnel files. The personnel files of Employees E14, E15, E16, and E17, all licensed nurses, lacked documentation of competencies in medication administration, infection control, catheter care, and wound care. Interviews revealed that the Human Resources Director, Employee E8, confirmed the absence of these competency evaluations and trainings. It was noted that the previous staffing educator, Employee E12, who was responsible for assigning and following up on staff training, had not been present at the facility for about three months, as they were assisting another facility with staffing shortages.
Deficiency in Yearly Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete yearly performance reviews for nurse aides, specifically for two employees, E18 and E19, who had been employed for over a year. This deficiency was identified during a clinical record review and staff interview. On October 23, 2024, the facility's human resources director, Employee E8, was interviewed, and personnel records were requested to verify the completion of 12-hour trainings and yearly performance reviews. It was revealed that no completed yearly performance reviews were available for the nurse aides in question. Employee E8 acknowledged the issue and mentioned that the staff educator, Employee E12, who typically ensures the completion of these reviews, had not been working at the facility for over three months due to assisting another facility with a staffing shortage. The responsibility for completing the reviews generally fell to the Director of Nursing, Employee E2, or the unit manager working closely with the nurse aide.
Failure to Administer Prescribed Medication Due to Lack of Follow-Up
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate receiving, dispensing, and administration of medication for a resident diagnosed with adjustment disorder with anxiety and paranoid schizophrenia. The resident was prescribed 0.5 mg of Lorazepam three times a day for extreme agitation. However, from September 18 through September 29, 2024, the medication was not administered as it was on order and documented as not given. The facility's policy requires urgent action to obtain medications when they are unavailable, including notifying the pharmacy and using emergency stock if necessary. Despite the policy, there was no documented evidence of follow-up with the pharmacy or additional steps taken to obtain the medication for the resident. The nursing administration notes indicated a need for a prescription to reorder the medication, and the pharmacy was contacted, but no further action was documented. An interview with the Director of Nursing confirmed the lack of documented follow-up actions to secure the medication for the resident.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications administered to residents included the date they were opened, as required by professional principles. During an observation, a surveyor noted that an LPN administered insulin to a resident without the medication container being labeled with the date it was opened. Similarly, another LPN was observed administering aspirin to a different resident, and this medication also lacked the date of opening. The facility's policy, revised in April 2019, mandates that the date of opening be recorded on multi-dose containers, but this was not adhered to in these instances.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program as required. The facility's policy outlines that the QAPI program should be overseen and implemented by a QAPI committee, which reports its findings, actions, and results to the administration and governing body. The administration is ultimately responsible for the QAPI program, even if not a member of the committee, and must interpret its results and findings to the governing body. The governing body is tasked with ensuring the QAPI program is implemented and maintained to address identified priorities, is sustained through leadership transitions, and is adequately resourced and funded. The QAPI committee is responsible for collecting and analyzing performance indicators, identifying, evaluating, monitoring, and improving facility systems and processes, and utilizing root cause analysis to identify underlying systematic problems. The policy specifies that the committee should meet quarterly and include various department representatives. During an interview, the Nursing Home Administrator was unable to demonstrate evidence of an active QAPI program. This lack of evidence indicates that the facility did not adhere to its policy requirements for maintaining a QAPI program, which is essential for focusing on indicators of care outcomes and quality of life. The deficiency was identified based on a review of the facility's policy and staff interviews, highlighting a failure to implement and sustain the QAPI program as outlined in the facility's governance and leadership policy.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal vaccines, as evidenced by the case of one resident, identified as R22, who expressed a desire to receive the vaccine but had not been offered it. A review of R22's clinical record showed no documentation of being educated about or offered the pneumococcal vaccination in the past year. An interview with the Director of Nursing, Employee E2, confirmed that the facility had not offered pneumococcal vaccines to any residents. Employee E2 also noted that the facility lacked an Infection Preventionist since July 2024, and there was no established practice for offering vaccines annually.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to a resident with a history of alcohol consumption, resulting in Immediate Jeopardy. The resident, who had diagnoses including arthritis, hypertension, bipolar disorder, depression, and repeated falls, was found with alcohol bottles in her room. Despite a history of falls, the facility did not implement effective measures to prevent further incidents. The resident sustained multiple falls between May and September, with alcohol consumption suspected as a contributing factor. On several occasions, staff found the resident on the floor after falls, and alcohol was discovered in her room. The resident admitted to consuming alcohol on the day of one fall, and staff noted her behavior was unusual, suggesting intoxication. Despite these incidents, there was a lack of communication and follow-up among staff and management. The Director of Nursing was unaware of several falls and the potential link to alcohol use, indicating a breakdown in reporting and response procedures. The facility's inaction and lack of supervision culminated in a serious fall on September 5, resulting in a hip fracture for the resident. Staff interviews revealed that alcohol was repeatedly found in the resident's room, yet no effective interventions were implemented to address the issue. The facility's failure to monitor and supervise the resident adequately, despite clear signs of alcohol use and repeated falls, led to the resident's injury and the identification of Immediate Jeopardy.
Removal Plan
- A facility sweep was completed to ensure no residents have any illegal substances or alcohol in their possession. Permission was granted for all room searches. No other illegal substances or alcohol were found within the resident rooms.
- ROBO call was made to all families to remind them not to bring in any illegal substances or alcohol into the facility.
- New admissions to the facility will be reviewed by Social Services to identify any history of or active use of illegal substances or alcohol to identify interventions to ensure the safety of the resident.
- If current residents are identified to be in possession of an illegal substance or alcohol, the physician and family will be notified and interventions will be implemented to ensure their safety and supervision.
- All staff are being educated on steps to address when alcohol is found in a resident room and what steps to take to ensure the safety of the resident at that time. Education was completed for staff working in the building.
- Education will continue until all staff have been in serviced on the safety of residents.
- Residents attending a facility outing will be educated on not purchasing any illegal substance or alcohol on a facility outing prior to the outing. Resident purchases will be closely monitored by the supervising staff to ensure that no illegal substances or alcohol has been purchased during the outing.
- The policy regarding supervision to prevent accidents with the use of illegal substances and alcohol was updated. All staff in the building will be educated or prior to encountering any residents.
- A random audit will be conducted to ensure staff understand the above education. These audits will continue weekly and monthly.
- The facility will continue to conduct random audits of resident rooms per resident permission to ensure that there are no illegal substances or alcohol in the resident rooms. These audits will continue daily, weekly and monthly.
- The facility activities staff will conduct an audit during the facility outing to ensure residents have not purchased illegal substances or alcohol during the facility outing, weekly and monthly.
- Audit results will be reviewed at QAPI.
Failure to Investigate Missing Property and Protect Residents from Alleged Theft
Penalty
Summary
The facility failed to conduct a thorough investigation into a resident's report of missing cigarettes. Resident R2, who has a medical history of cerebral infarction, diabetes, and hypertension, reported that upon returning from a leave of absence, his cigarettes were missing. The activity director acknowledged the missing cigarettes but did not initiate a grievance form or conduct an investigation. The facility's policy requires that all incidents be promptly investigated and documented, but this was not adhered to in this case. Additionally, the facility did not protect residents from potential abuse following allegations of theft by the Activities Director. It was reported that money and jewelry were found in the social worker's office, and the Activities Director was accused of taking some of these items and instructing staff not to report it. Despite being aware of these allegations, the facility allowed the Activities Director to continue working with residents for two days before suspending her, failing to prevent further potential misappropriation of resident property. The facility's inaction in both cases highlights a failure to follow its own policies regarding incident investigation and resident protection. The lack of immediate action in response to the allegations of theft and the failure to investigate the missing cigarettes report demonstrate significant deficiencies in the facility's management and oversight processes.
Failure to Address Resident's Alcohol Consumption Leads to Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility concerning a resident who was storing and consuming alcohol, which led to a fall and a subsequent hospital transfer with a diagnosis of a right hip fracture. The facility's job descriptions for both the NHA and DON emphasize the importance of managing the facility in compliance with regulations and ensuring high-quality care. However, the NHA and DON did not fulfill these responsibilities, as evidenced by their failure to address the resident's alcohol consumption and its impact on her safety. The resident, who had a history of arthritis, hypertension, bipolar disorder, depression, and repeated falls, was suspected by nursing staff of consuming alcohol, which contributed to her falls. Despite finding alcohol bottles in the resident's room and the resident admitting to drinking before falls, the staff did not ensure adequate monitoring or develop a person-centered care plan to address the resident's substance abuse. This oversight resulted in an Immediate Jeopardy situation, highlighting the failure of the NHA and DON to fulfill their essential duties.
Ineffective Pest Control and Maintenance Issues
Penalty
Summary
The facility failed to maintain an effective pest control environment, as evidenced by multiple observations and reports of pest activity, including mice and roaches, throughout the facility. The pest control program was not effectively implemented, with numerous instances where rooms were not prepared for treatment, preventing the pest control company from performing necessary services. Staff failed to document pest sightings in the logbooks, relying instead on verbal reports, which hindered the pest control efforts. The pest control invoices revealed that several rooms were repeatedly not serviced due to residents being present or rooms not being prepared, despite recommendations for better sanitation and thorough cleaning. Additionally, maintenance issues such as unsealed holes in walls and heating/air conditioning units were not addressed, providing potential pathways for pests. Observations confirmed the presence of mice and unsanitary conditions in several rooms, with residents reporting frequent sightings of mice and flies. The facility also failed to act on recommendations to replace soiled linen carts, which were identified as sources of roach activity. Interviews with staff, including the housekeeping director, confirmed awareness of these issues but no corrective actions were taken. The lack of proper documentation, preparation, and maintenance contributed to the ongoing pest problems, as highlighted by the pest control company's repeated recommendations and the facility's inaction.
Failure to Develop Wound Care Plan for Admitted Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for wound care for a resident upon admission. The resident, who was admitted with diagnoses including obesity, gout, muscle weakness, urinary incontinence, and stage three pressure ulcers on the left and right buttocks, did not have a care plan addressing these wounds. A skin assessment conducted by licensed nursing staff upon admission confirmed the presence of dime-sized open areas on the resident's buttocks, which was corroborated by a wound specialist. Despite this, the care plan for the resident did not include any measures for wound care. This oversight was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that wounds present on admission should be included in the baseline care plan.
Failure to Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure appropriate wound care for four residents with pressure ulcers, as identified through clinical record reviews and staff interviews. Resident R1, who had multiple diagnoses including congestive heart failure and chronic kidney disease, did not have physician orders for the wound care recommended by the wound care specialist. Similarly, Resident R2, with stage three pressure ulcers, experienced a delay in the implementation of wound care orders, which were not placed until five days after the recommendations were made. Resident R3, suffering from malnutrition and pressure ulcers, also lacked documented physician awareness and orders for the recommended wound care. Resident R4, with acute kidney failure and a sacral pressure ulcer, similarly had no physician orders for the recommended treatment. The deficiency was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged that wound care orders for these residents had not been entered. The lack of communication and documentation regarding the wound care recommendations from the wound care specialist to the physician resulted in the absence of necessary treatment orders, violating the nursing services regulations as per 28 Pa. Code 211.12(d)(1) and 28 Pa. Code 211.12(d)(5).
Inaccurate Physician Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that physician assessments were accurately completed and documented to reflect the actual condition of the residents. This deficiency was identified through a review of facility policy, clinical record reviews, and interviews with staff and residents. The facility's policy, revised in April 2013, requires attending physicians to perform relevant tasks during visits, including a review of the resident's total program of care and appropriate documentation. However, discrepancies were found in the physician assessments for four residents, where the documented observations did not align with those of the nurse practitioner or the surveyor. For Resident R1, the attending physician documented an admission assessment that did not reflect the resident's actual condition, as noted by the wound care specialist and surveyor. The physician's notes indicated no edema and normal muscle tone, while the nurse practitioner and surveyor observed significant edema and weakness. Similarly, for Resident R2, the physician's assessment described the resident as having normal gait and muscle tone, which contradicted the nurse practitioner's findings of gait instability, contractures, and weakness. Observations confirmed the resident's inability to stand and contracted extremities. Resident R3's physician assessment also failed to accurately depict the resident's condition, with notes indicating normal gait and muscle tone, despite the nurse practitioner's and surveyor's observations of gait instability, contractures, and weakness. Lastly, Resident R4's physician assessment described the resident as healthy with normal muscle tone, conflicting with the nurse practitioner's assessment of generalized weakness and decreased range of motion. The surveyor's observations further confirmed the resident's weakness and limited mobility. Interviews with the Nursing Home Administrator and Director of Nursing corroborated the inaccuracies in the physician's assessment notes.
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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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