Garden Spring Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Willow Grove, Pennsylvania.
- Location
- 1113 North Easton Road, Willow Grove, Pennsylvania 19090
- CMS Provider Number
- 395077
- Inspections on file
- 34
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Garden Spring Rehab And Care Center during CMS and state inspections, most recent first.
An LPN used a blood glucose meter for multiple residents with diabetes, hepatitis C, and HIV, cleaning the device only with 70% isopropyl alcohol wipes instead of the required EPA-registered germicidal wipes. The correct disinfectant was not available on the medication cart, and staff confirmed this practice, which did not follow facility policy or manufacturer instructions. This failure led to Immediate Jeopardy due to the increased risk of transmitting bloodborne pathogens.
Surveyors observed multiple deficiencies including dirty linens, unsecured oxygen tanks, and unsanitary conditions such as a black substance on an air conditioning unit and a commode chair with a dirt ring. Staff failed to address these issues during their rounds, and a resident reported ongoing problems with cleanliness and linen changes.
Two residents who required staff assistance for ADLs, including personal hygiene and grooming, were observed with long, dirty fingernails and lacked documented evidence of receiving necessary nail care. One resident, dependent due to severe physical limitations, and another with a tracheostomy and upper extremity weakness, both needed help with nail care, which was not provided as required.
A resident with a feeding tube and a history of stroke and dysphagia did not receive the full amount of water flush ordered by the physician. The water flush pump was set to deliver 660 ml per day instead of the prescribed 800 ml, as confirmed by an LPN and the DON.
A resident with severe immobility and communication impairment, identified as at risk for pressure ulcers, was observed in bed without the prescribed cushioned heel boots or heel elevation. The DON confirmed the omission of this required intervention.
A resident with a tracheostomy and feeding tube, requiring Enhanced Barrier Precautions, received tracheostomy suctioning from an LPN who wore only gloves and not a gown, contrary to facility policy and posted instructions. The DON confirmed that both gown and gloves should have been used during this high-contact care activity.
The facility did not meet the required NA to resident ratios on two occasions. During a day shift, the ratio of one NA per ten residents was not maintained, and during a night shift, the ratio of one NA per 15 residents was not met. These deficiencies were identified through a review of nursing schedules.
The facility did not meet the required 3.2 hours of direct resident care per resident on three occasions, providing only 3.19, 3.17, and 2.89 hours on specific days.
The facility did not follow its policy to conduct pre-employment background checks for a newly hired RN. The checks, including license verification and a criminal background check, were completed two months after the RN began working. This was confirmed by the Administrator, who acknowledged the lack of documentation for these checks prior to employment.
A facility failed to follow physician's orders for a resident with hypotension, administering midodrine despite the resident's systolic blood pressure exceeding the prescribed limit. The medication was given 17 times in September and six times in October 2024, contrary to the physician's directive. The DON confirmed the error, highlighting a lapse in adhering to medical orders.
The facility failed to provide written notification to residents and their representatives about hospital transfers, including reasons for the moves and Ombudsman information. This deficiency was identified for five residents who were transferred due to changes in condition, with no documentation supporting that they or their representatives received the required information. The Administrator confirmed the lack of written notices during an interview.
The facility failed to prevent and manage pressure ulcers for three residents, as staff did not consistently reposition them or conduct weekly skin assessments. One resident with protein calorie malnutrition and hemiplegia had stage four and three pressure ulcers, with lapses in repositioning and incontinence checks. Another resident with an unstageable heel ulcer did not have a prescribed heel boot applied, and a third resident with multiple sclerosis was not repositioned as required. The DON confirmed the lack of documented skin assessments.
A facility failed to administer medications as ordered for a resident with diagnoses of gastroesophageal reflux disease, pain, and neuropathy. Physician's orders required the administration of Acetaminophen, gabapentin, and omeprazole at 6:00 a.m. daily, but there was no evidence of administration on a specific day. This was confirmed by the DON.
A facility failed to maintain a medication error rate below five percent due to late administration of medications by an LPN. Medications for two residents with various diagnoses were administered significantly later than the prescribed time, resulting in a 35.7% error rate. The DON confirmed the medications should have been administered by the correct time.
The facility did not ensure call bell access for two residents, one with Alzheimer's and another with hemiplegia, both dependent on staff and at risk for falls. The call bells were found out of reach, contrary to care plans.
A resident with Alzheimer's and mobility issues was found in bed without prescribed fall prevention measures, such as floor mats and a low bed position, indicating a failure to follow the care plan.
The facility failed to provide written notice to residents and their representatives before making room changes, as required by their policy. This deficiency was identified for four residents, who were moved to different rooms without receiving the necessary advance written notice that included the reason for the change. Clinical record reviews and interviews confirmed the lack of notification, violating residents' rights.
The facility failed to post accurate and current nurse staffing information. During a tour, it was observed that the staffing information posted in the lobby was outdated. The DON confirmed the posted data was incorrect.
Failure to Properly Disinfect Blood Glucose Meter Between Residents
Penalty
Summary
The facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four residents who required fingerstick blood glucose testing. Facility policy and the manufacturer's instructions required that blood glucose meters intended for reuse be cleaned and disinfected between resident uses with an EPA-registered disinfectant detergent or germicide wipe. However, observations revealed that an LPN used only 70% isopropyl alcohol wipes to clean the blood glucose meter before and after each use, rather than the required EPA-registered germicidal wipes. The medication cart used by the LPN did not contain the appropriate disinfectant wipes as specified by the manufacturer and facility policy. Clinical record reviews showed that the affected residents had diagnoses including diabetes mellitus, viral hepatitis C, and human immunodeficiency virus (HIV), all of which can be transmitted via bodily fluids. Orders for these residents required frequent blood glucose monitoring and insulin administration based on sliding scale protocols. The LPN confirmed that the same blood glucose meter was used for multiple residents, and that only alcohol wipes were used for cleaning between uses, contrary to both policy and manufacturer instructions. Interviews with facility staff, including the DON and Infection Preventionist, confirmed that the expectation was to use EPA-registered germicidal wipes for disinfecting blood glucose meters. The failure to follow these procedures was observed directly by surveyors and acknowledged by staff, resulting in the determination of Immediate Jeopardy due to the increased likelihood of transmitting bloodborne pathogens between residents.
Removal Plan
- LPN 1 was removed from schedule immediately and will not be returning to the facility.
- Director of central supplies ensured that each of the eight medication carts had the disinfecting agents that meet the requirements of the Environmental Protection Agency (EPA) registered cleaning products as noted in the manufacturer's instructions.
- All nurses will be educated on the Obtaining a Fingerstick Glucose Level, policy and procedure. In addition, they will be educated on the necessity of using the approved EPA registered germicidal wipe as required in the manufacturer's instructions and where to obtain them. Education provided by the DON/designee. No licensed nurse will be permitted to begin their shift until they have been educated on the proper use and disinfection of the glucometer.
- Newly hired licensed nurses will be educated at orientation on the Obtaining a Fingerstick Glucose Level, policy and procedure using the approved EPA registered germicidal wipe requirements as noted in the manufacturer's instructions. All agency licensed nurses will be educated before they begin their first shift in the facility.
- Central supply department received education regarding ensuring that the EPA germicidal wipes are in the carts.
- DON/designee will complete random glucometer cleaning and disinfecting observation audits daily for seven days plus weekly for four weeks and monthly for three months ensuring education has been effective.
- DON/designee will be monitoring steps of the action plan for continued compliance.
- Central supply/designee will monitor ensuring the EPA germicidal wipes are in the carts.
- Audits will be brought to QA&A for review and recommendations.
- QAPI committee will determine the need for further audits.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents and staff on both nursing units that were toured. Observations included an air conditioning unit covered in a black substance, a large brown stain on a fitted sheet, and pillows without case covers in a resident's room. A resident reported that his linens were dirty and that the air conditioner had the black substance on it, and staff provided new pillowcases but did not change the dirty sheet or address the air conditioner. Additionally, an uncapped 50 milliliter syringe was found lying on a resident's bed while tube feeding was infusing, and staff did not remove it during their visit. Further observations revealed worn fitted sheets and unsecured oxygen tanks in resident rooms, contrary to the facility's policy requiring oxygen cylinders to be secured to prevent tipping. In the shower room, a commode chair had a black dirt ring, wash cloths were left on grab bars, a thermometer was covered in a dried black substance, and the shower curtain had gray stains. The administrator confirmed that these environmental issues should have been addressed.
Failure to Provide Adequate Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate grooming and hygiene services for two residents who required assistance with activities of daily living (ADLs). One resident, with diagnoses including aphasia, hypertension, and severe physical limitations, was assessed as dependent on staff for personal hygiene, grooming, and bathing. Observation revealed this resident in bed with long, dirty fingernails, and there was no documentation that staff had assisted with nail care. Another resident, who had a tracheostomy, heart failure, and upper extremity weakness, was also assessed as needing staff assistance for personal hygiene, grooming, and bathing. This resident was observed in bed with long, dirty fingernails and stated he wanted his nails trimmed but needed staff help. There was no documented evidence that staff provided the necessary nail care for either resident. The Director of Nursing confirmed that nail care was expected to be performed during routine care and as needed, but records did not show that this was done for the two residents identified.
Failure to Follow Physician's Order for Feeding Tube Water Flush
Penalty
Summary
A deficiency occurred when staff failed to implement a physician's order for a resident with a history of stroke, dysphagia, and a feeding tube. The physician's order specified that the resident's feeding tube should be flushed with 200 ml of water every six hours, totaling 800 ml daily. However, observation revealed that the water flush was being administered via a pump set at 30 ml per hour for 22 hours, resulting in only 660 ml of water being delivered per day, which is 140 ml less than ordered. Interviews with an LPN and the Director of Nursing confirmed that the pump was not programmed to deliver the total amount of water as prescribed by the physician.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident with diagnoses including aphasia, hypertension, severe physical limitations, and immobility was not provided with required interventions to prevent pressure ulcers. The resident was assessed as being at risk for pressure ulcers and unable to communicate needs. The care plan specified that cushioned heel boots should be applied to both feet while the resident was in bed to protect skin integrity. However, during multiple observations, the resident was found in bed without the heel boots in place and with heels not elevated. The DON confirmed that the resident should have had the heel boots on while in bed.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to follow its own infection prevention and control policies regarding Enhanced Barrier Precautions for a resident with a tracheostomy and feeding tube. According to the facility's policy, staff are required to wear both a gown and gloves during high-contact care activities, such as tracheostomy care, for residents with indwelling medical devices. Clinical record review and the resident's care plan confirmed the need for these precautions. However, during an observation, an LPN performed tracheostomy suctioning for the resident while only wearing gloves and not a gown, despite signage outside the room instructing staff to use both. The Director of Nursing later confirmed that a gown should have been worn during this care activity.
Non-compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident ratios on two separate occasions within a 21-day review period. On January 19, 2025, during the day shift from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one NA per ten residents. Additionally, on January 17, 2025, during the night shift from 11:00 p.m. to 7:00 a.m., the facility did not meet the required ratio of one NA per 15 residents. These deficiencies were identified through a review of the nursing schedules for the specified period.
Plan Of Correction
1. The facility is unable to retroactively correct the CNA hours for the dates mentioned. 2. The facility will schedule CNA's to meet the ratio of 1 CNA to 10 residents for 7a - 3p shifts, and 1 CNA to 15 residents on 11pm - 7am. Call outs will be monitored by NHA/DON and/or designee. 3. NHA or designee will educate the scheduling coordinator on the state ratio requirements. The ratios will be monitored weekly x4 weeks. 4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed. 5. Date of compliance: 2/20/25
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 resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules over a 21-day period from January 3 to January 23, 2025. Specifically, on three days—January 5, January 17, and January 19, 2025—the facility provided less than the required hours of care, with 3.19, 3.17, and 2.89 care hours per resident, respectively.
Plan Of Correction
1. The facility is unable to retroactively correct the state general nursing hours for the dates mentioned. 2. The facility will schedule CNA's, LPNs, and RNs to meet state general nursing hours of 3.2 hours of direct care. Call outs will be monitored by NHA/DON and/or designee. 3. NHA or designee will educate the scheduling coordinator on the state general nursing hour requirements. The daily general staffing hours will be monitored weekly x4 weeks. 4. Findings will be summarized and brought to the quality assurance and performance improvement committee and reviewed for any further monitoring or changes needed. 5. Date of compliance 2/20/25
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to adhere to its policy on conducting background screening investigations for new hires. Specifically, the facility did not verify the professional license and complete a criminal background check for a newly hired Registered Nurse, identified as Employee 5 (E5), before their employment began. E5 started working on August 16, 2024, but the required checks were not completed until October 16, 2024. This oversight was confirmed by the Administrator during an interview on October 18, 2024, who acknowledged the absence of documented evidence for the license verification and background check prior to E5's employment, as mandated by the facility's policy dated October 23, 2023.
Failure to Adhere to Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that physician's orders were implemented correctly for one of the 26 sampled residents, identified as Resident 65. The resident had a diagnosis of hypotension and was prescribed midodrine to be administered three times a day, with the condition that it should not be given if the resident's systolic blood pressure (SBP) exceeded 120 mm Hg. However, a review of the medication administration records showed that the medication was administered 17 times in September and six times in October 2024, despite the resident's SBP being greater than 120 mm Hg on those occasions. The Director of Nursing confirmed in an interview that the medication was administered outside the established parameters for Resident 65, indicating a failure to adhere to the physician's orders. This deficiency was cited under CFR 483.25 Quality of Care and had been previously cited on November 16, 2023, under 28 Pa. Code 211.12(d)(1)(5) Nursing services.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital. This deficiency was identified through clinical record reviews and staff interviews, which revealed that five residents were transferred to the hospital due to changes in their conditions without receiving the required written information. Specifically, there was no documentation to support that Residents 41, 48, 50, 81, and 117, or their responsible parties, were informed in writing about the transfers, the reasons for the moves, or provided with Ombudsman information. The deficiency was confirmed during an interview with the Administrator, who acknowledged that the residents or their representatives were not given written notices regarding their transfers. The lack of documentation and communication regarding these transfers indicates a failure to comply with the requirement to notify residents and their representatives in writing, including providing information about appeal rights and Ombudsman contact details.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development or worsening of pressure ulcers for three residents with skin impairments. Resident 1, diagnosed with protein calorie malnutrition, muscle weakness, and hemiplegia, had a stage four pressure ulcer on the sacrum and a stage three ulcer on the left shoulder. The care plan required staff to reposition the resident every two hours and check for incontinence every hour. However, documentation showed that these interventions were not consistently performed, with significant lapses in August and September. Additionally, there was no evidence of weekly skin assessments since May 2024. Resident 2, with diagnoses including protein calorie malnutrition and anemia, had an unstageable pressure ulcer on the left heel. Despite a physician's order to apply a heel boot, observations revealed the boot was not in place during multiple checks. The LPN confirmed the oversight, and the DON acknowledged the boot should have been applied. Furthermore, no weekly skin assessments were documented since March 2024. Resident 3, suffering from multiple sclerosis and anxiety, had a stage four pressure ulcer on the sacrum and was entirely dependent on staff for mobility. The resident reported infrequent repositioning, and documentation confirmed that staff failed to reposition her every two hours on numerous occasions in September. The DON confirmed the lack of documented weekly skin assessments for all three residents.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for one of five sampled residents. The clinical record review revealed that the resident had diagnoses including gastroesophageal reflux disease, pain, and neuropathy. Physician's orders dated July 26, 2024, instructed staff to administer Acetaminophen and gabapentin at 6:00 a.m. daily, and an order dated July 27, 2024, directed the administration of omeprazole at the same time daily. However, there was no evidence that these medications were offered or administered on August 7, 2024, as per the physician's orders. This was confirmed by the Director of Nursing during an interview on August 8, 2024.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent on one of its nursing units. According to the facility's policy, medications should be administered within one hour of their prescribed time. However, during a medication pass observation, it was noted that an LPN administered medications significantly later than the prescribed time. Specifically, medications for two residents, who had various diagnoses including major depressive disorder, multiple sclerosis, depression, allergies, hypertension, and pain, were administered at 9:30 a.m. and 9:40 a.m., respectively, instead of the prescribed 8:00 a.m. The clinical record review showed that the medications for these residents were ordered to be given at 8:00 a.m. daily. The delay in administration resulted in a medication error rate of 35.7%, as there were 28 opportunities with 10 errors observed during the medication pass. The Director of Nursing confirmed that the medications should have been administered by 9:00 a.m., indicating a clear deviation from the facility's medication administration policy.
Failure to Provide Call Bell Access for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not providing access to the call bell system. Resident 4, diagnosed with Alzheimer's disease, gait abnormalities, and muscle weakness, was observed in bed with the call bell wrapped around an armchair, out of reach, despite being dependent on staff for care and at risk for falls. Similarly, Resident 5, who had hemiplegia, hemiparesis, and heart failure, was found with the call bell on a dresser under stuffed animals, out of reach, while in bed and later while sitting in a wheelchair. This resident, who was alert and also dependent on staff, expressed an inability to find the call bell, highlighting the facility's failure to ensure the call bell was within reach as per the care plan.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that safety interventions for falls were in place for a resident diagnosed with Alzheimer's disease, abnormalities of gait and mobility, and muscle weakness. The resident was assessed as being at risk for falls and was dependent on staff for care. The care plan specified that the bed should be in a low position with floor mats on both sides while the resident was in bed. However, observations revealed that the resident was in bed without the floor mats in place, and the bed was not in a low position, indicating a failure to implement the prescribed safety measures.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents and their representatives before making room changes, as required by their policy. This deficiency was identified for four residents, who were moved to different rooms without receiving the necessary advance written notice that included the reason for the change. The facility's policy, last reviewed on October 30, 2023, mandates that such notice be given and documented in the resident's medical record. Clinical record reviews revealed that residents were moved on various dates in May and June 2024 without documented evidence of notification. Interviews with residents and the Director of Nursing confirmed the lack of notification. Specifically, Resident 9 expressed unawareness of the reasons or timing of their room change, and the Director of Nursing acknowledged the absence of documentation for the notifications. This failure to notify residents and their representatives is a violation of the residents' rights as outlined in the facility's policy and relevant state codes.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and current nurse staffing information. During a tour of the facility on February 27, 2024, at 9:15 a.m., it was observed that the staffing information posted in the lobby was dated for January 23, 2024. During an interview later that day at 2:00 p.m., the Director of Nursing confirmed that the posted staffing data was incorrect.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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