Germantown Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Philadelphia, Pennsylvania.
- Location
- 6950 Germantown Avenue, Philadelphia, Pennsylvania 19119
- CMS Provider Number
- 395360
- Inspections on file
- 22
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Germantown Home during CMS and state inspections, most recent first.
A resident with dementia, seizure disorder, and malnutrition exhibited escalating aggressive behaviors, including striking staff and another resident with a cane. Despite multiple documented incidents, the care plan was not formally reviewed or revised to address these behaviors until after several episodes had occurred, contrary to facility policy requiring timely updates following significant changes in condition.
Seven residents with serious wounds, including pressure ulcers, diabetic foot ulcers, venous ulcers, and arterial ulcers, did not have comprehensive care plans that included required Enhanced Barrier Precautions (EBP) or, in one case, wound-specific interventions. The facility's care planning process did not meet policy or regulatory requirements, as evidenced by missing goals and interventions in the care plans.
A resident with a suprapubic catheter and end stage renal disease was observed on two occasions with their catheter drainage bag touching the floor, contrary to facility policy. Two LPNs confirmed the findings during interviews.
The facility did not develop or implement required policies and procedures for administering influenza and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
The facility did not provide or document education on the benefits and potential side effects of the COVID-19 vaccine to residents or their representatives prior to immunization, as required by policy. Staff interviews confirmed that education was only given if a resident declined the vaccine, and record reviews for several residents showed no evidence of education being provided or documented.
A resident with diabetes, heart disease, and hypertension had a pharmacy recommendation to discontinue sliding scale insulin due to minimal use and current guidelines. The physician disagreed with the recommendation but did not document a rationale for this decision in the clinical record, as required by facility policy.
A resident who was admitted to hospice care with a diagnosis of cerebral atherosclerosis had a significant change MDS assessment that was incorrectly coded to indicate that hospice care was not being provided, despite physician orders and hospice team evaluation. This error was confirmed by the facility's Nursing Home Administrator.
The facility failed to provide timely notice of non-medical coverage to a resident, resulting in a violation of resident rights. The resident remained at the facility after Medicare coverage ended, but the representative was not informed until later. The social services department did not receive the necessary email from the rehab department to issue a Notice of Medicare Non-Coverage (NOMNC) before the termination of services.
The facility failed to ensure accurate resident assessments, as two residents had discrepancies in their MDS documentation. One resident's MDS inaccurately recorded the presence of a urinary catheter, despite its discontinuation months earlier. Another resident's discharge status was incorrectly documented as a hospital discharge, while records confirmed a discharge to home. Staff interviews confirmed these errors.
A facility failed to develop a comprehensive care plan for a resident's oxygen use, despite a physician's order for oxygen at 2 LPM at bedtime due to hypoxia. The resident, with asthma and obstructive sleep apnea, was observed using the oxygen concentrator as prescribed. The facility's policy requires care plans to reflect all resident needs, including oxygen use, which was not done in this case.
A facility failed to update a resident's care plan regarding the discontinuation of a urinary catheter. The resident, admitted with a stage 4 pressure ulcer, had the catheter removed following a physician's order due to wound healing progress. Despite observations and resident confirmation of the catheter's removal, the care plan was not revised to reflect this change. Interviews with the Nursing Home Administrator and DON confirmed the care plan was not updated as required.
Two residents experienced significant delays in receiving necessary vision and hearing services. One resident with cognitive communication deficit and another with aphasia faced prolonged waits for hearing aids due to delayed consultations and follow-ups. Additionally, a resident with diabetic retinopathy did not receive prescribed eyeglasses in a timely manner due to lack of follow-up with the external service provider.
The facility failed to employ a qualified director of food and nutrition services. Employee E4, the Food Service Director, was responsible for food service operations but lacked necessary qualifications such as being a Certified Dietary Manager or having a relevant degree. The Administrator confirmed that Employee E4 had been promoted over a year ago without completing required certifications, and the facility could not provide evidence of certification, violating statutory qualifications.
Failure to Timely Revise Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised in a timely manner to address ongoing and escalating aggressive behaviors. According to facility policy, care plans must be updated whenever there are changes in a resident's condition, not just during quarterly reviews. Resident R1, who had diagnoses including dementia, seizure disorder, and malnutrition, exhibited a series of aggressive behaviors over several weeks, including raising a cane toward a roommate, striking a nurse, verbally abusing staff, and ultimately striking another resident with a cane. Despite these documented incidents, the care plan was not reviewed or revised until after multiple aggressive episodes had occurred. Facility documentation and staff interviews confirmed that the interdisciplinary team was aware of the resident's behavioral changes and was informally monitoring the situation, but no formal updates were made to the care plan until after a significant incident. The care plan was only revised to include a psychiatric consult following the escalation of aggressive behaviors. Prior to these events, the resident was not considered a behavioral risk and had no documented history of aggression. The delay in updating the care plan did not align with facility policy, which requires prompt revisions in response to significant changes in a resident's status.
Failure to Develop Comprehensive Care Plans for Residents with Wounds
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for seven residents who were assessed with various types of wounds, including Stage III and IV pressure ulcers, diabetic foot ulcers, venous ulcers, and arterial ulcers. Specifically, the care plans for these residents did not include goals or interventions related to Enhanced Barrier Precautions (EBP), as required by the facility's own policy and federal regulations. In one case, there was also no evidence of goals or interventions related to a venous ulcer. These deficiencies were identified through observations, clinical record reviews, facility policy review, and staff interviews. The residents affected had significant wounds, such as full-thickness ulcers exposing muscle or tissue, yet their care plans lacked necessary documentation and planning for EBP and, in one instance, for wound-specific care. The facility's policy required the use of the Resident Assessment Process (RAP) for such conditions, but this process was not properly followed for the identified residents.
Failure to Prevent Catheter Drainage Bag from Touching Floor
Penalty
Summary
The facility failed to ensure proper positioning of a urinary catheter drainage bag for a resident with an indwelling suprapubic catheter, as required by facility policy. The policy, last reviewed on June 20, 2019, specifically states that drainage bags should never touch the floor to reduce infection risk. Clinical record review showed the resident had end stage renal disease and aphasia, with physician orders for regular catheter and drainage bag changes. On two separate occasions, direct observation revealed the resident's catheter drainage bag was in contact with the floor. These findings were confirmed in interviews with two LPNs present at the time of each observation.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering influenza and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Provide and Document COVID-19 Vaccine Education
Penalty
Summary
The facility failed to provide and document education regarding the benefits and potential side effects of the COVID-19 vaccine to residents or their representatives prior to immunization. Review of clinical records for seven residents who received the COVID-19 vaccine showed no evidence that such education was provided or documented. The facility's policy indicated that education would be provided, particularly in cases of vaccine declination, referencing CDC guidelines. However, interviews with staff revealed that education on the risks and benefits of the COVID-19 vaccine was not routinely completed unless a resident declined the vaccine. Documentation for each of the seven residents who received the COVID-19 vaccine did not include any record of education being provided about the immunization. This lack of documentation and provision of education was confirmed through review of facility records and staff interviews. The deficiency was cited under 28 Pa Code 201.18(b)(1)(d) Management and 28 Pa Code 211.12(c)(d)(1) Nursing services.
Lack of Documentation for Physician's Rationale on Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a rationale was documented in response to a pharmacy recommendation for one resident. According to the facility's policy, the pharmacy consultant is required to review all resident charts monthly and suggest therapeutic changes as needed. If a physician or nurse practitioner declines a pharmacy recommendation, the policy requires that the reason for not accepting the recommendation be documented in the resident's progress notes. In this case, the clinical record review for a resident with diagnoses of Type 2 diabetes, heart disease, and hypertension showed that the consultant pharmacist recommended discontinuing sliding scale insulin (SSI) due to minimal use and current geriatric guidelines. The pharmacist requested that, if no changes were made, the physician should provide a comment. The physician disagreed with the pharmacist's recommendation but did not provide any rationale or comment in the resident's clinical record, as required by facility policy. This omission resulted in a lack of documentation explaining the physician's decision to continue the current diabetes management regimen. The deficiency was identified during a review of the resident's clinical record and the facility's pharmacy consultation policy.
Inaccurate Resident Assessment for Hospice Services
Penalty
Summary
The facility failed to accurately complete a resident assessment for one of 35 residents reviewed. A review of the clinical record for this resident showed that the individual was assessed and evaluated by the hospice care team and subsequently admitted to hospice services with a diagnosis of cerebral atherosclerosis. Documentation included a physician order for hospice care services. However, the significant change Minimum Data Set (MDS) assessment completed for the resident did not indicate that hospice care was being provided, as Section O was marked 'no' for hospice care. This discrepancy was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the MDS was coded incorrectly for hospice care. The deficiency was identified through review of facility documentation, clinical records, and staff interviews, and it was determined that the facility did not ensure the resident's assessment accurately reflected the care and services being provided.
Failure to Provide Timely Notice of Non-Coverage
Penalty
Summary
The facility failed to provide timely notice of non-medical coverage to a resident, identified as Resident 117, as required by regulations. The resident was readmitted to the facility and remained there after the last day of Medicare coverage, which was September 2, 2024. However, the resident's representative was not informed of the last coverage date until September 18, 2024, which was after the coverage had already ended. The social service note from that date indicated that the resident's representative was informed of the right to appeal the last coverage date and expressed a desire for the resident to continue therapy. The facility's social worker, Employee E12, confirmed that the social services department relies on an email from the rehab department to determine the last date of coverage, but they did not receive such an email for Resident 117. Consequently, the facility did not issue a Notice of Medicare Non-Coverage (NOMNC) before the termination of Medicare A services, violating resident rights under 28 Pa. Code 201.29(f).
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments, as evidenced by discrepancies in the documentation of two residents' statuses. For Resident R50, observations confirmed the absence of a urinary catheter, which had been discontinued due to wound healing progress. However, the MDS assessment inaccurately recorded the presence of an indwelling urinary catheter, despite a physician's order to discontinue it months earlier. This error was confirmed by the RNAC, who acknowledged the incorrect coding. Similarly, Resident R178's discharge status was inaccurately documented. The Discharge MDS assessment incorrectly indicated that the resident was discharged to a short-term general hospital, while clinical records and staff interviews confirmed that the resident was actually discharged home with family after a successful stay for post-hospitalization management. The Assistant Administrator confirmed the error in the MDS coding, highlighting a failure in accurately reflecting the resident's discharge status.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's use of oxygen, as required by their Resident Centered Care Planning policy. The policy mandates that the care team address individualized resident needs based on a comprehensive, interdisciplinary assessment. Resident R167, who was admitted with diagnoses of asthma and obstructive sleep apnea, had a physician's order for oxygen at 2 liters per minute via nasal cannula at bedtime for hypoxia. However, a review of the resident's care plan revealed that it did not include any plan for the use of oxygen. Observations conducted on September 17, 2024, confirmed that Resident R167 was using the oxygen concentrator as prescribed. During an interview on September 20, 2024, the Nursing Home Administrator and the Director of Nursing acknowledged that the facility's expectation is for all residents utilizing oxygen to have this reflected in their care plans. This deficiency was identified under 28 Pa. Code 211.11(d) regarding resident care plans.
Failure to Update Care Plan for Urinary Catheter Discontinuation
Penalty
Summary
The facility failed to revise and update the care plan for a resident, identified as Resident R50, concerning the use of a urinary catheter. The resident, who was admitted with a stage 4 pressure ulcer in the sacral region and muscle weakness, had a physician's order to discontinue the urinary catheter on June 15, 2024, due to the healing progress of the wound. However, the care plan, which initially included the use of an indwelling catheter for sacral wound management, was last revised on February 2, 2024, and reviewed on August 21, 2024, without reflecting the updated urinary status. Observations on September 17, 2024, confirmed that the resident no longer had a urinary catheter, and an interview with the resident corroborated the discontinuation of the catheter. Despite this, the care plan was not updated to reflect the current status. Interviews with the Nursing Home Administrator and the Director of Nursing on September 20, 2024, confirmed the oversight in updating the care plan, which is a requirement under the facility's Resident Centered Care Planning policy.
Deficiencies in Timely Access to Vision and Hearing Services
Penalty
Summary
The facility failed to ensure timely access to vision and hearing services for two residents, resulting in deficiencies in maintaining their hearing and vision. Resident R142, who has a cognitive communication deficit, was recommended for a hearing aid evaluation in March 2023, but the necessary audiology and ENT consultations were delayed until over a year later. Despite the ENT consultation in May 2024 recommending further audiology evaluation, the resident had not received the hearing aids by September 2024. Similarly, Resident R144, who has aphasia following a stroke, experienced significant delays in receiving hearing aids. An ENT consult in April 2023 cleared him for hearing aids, but the follow-up audiology evaluation was not conducted until over a year later, and by September 2024, the resident was still waiting for the hearing aids. Resident R53, diagnosed with type 2 diabetes and diabetic retinopathy, also faced delays in receiving necessary vision services. Despite an optometry consultation in May 2024 that resulted in a new prescription for eyeglasses, the resident had not received the glasses by September 2024. The facility's failure to follow up with the external service responsible for providing the glasses contributed to this delay. Interviews with staff confirmed the lack of timely follow-up and communication with service providers, resulting in residents not receiving essential vision and hearing aids.
Unqualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as evidenced by the findings from staff interviews and a review of employee credentials. Employee E4, who was serving as the Food Service Director (FSD), was responsible for overseeing the ordering, receiving, storing, preparation, and service of food. However, it was confirmed that Employee E4 did not possess the necessary qualifications, such as being a Certified Dietary Manager (CDM), a Certified Food Manager (CFM), or having a national certification for food service management and safety. Additionally, Employee E4 did not have an associate's or higher degree in food service management or hospitality from an accredited institution and had not received regularly scheduled consultations from a qualified dietitian. The Administrator confirmed during an interview that Employee E4 had been working at the facility for many years and was promoted to FSD over a year ago without completing the required certifications. The facility was unable to provide evidence that Employee E4 was certified, rendering him unqualified to direct the dietary department, thus failing to meet the statutory qualifications outlined in 28 Pa. Code 211.6(c)(d) and 28 Pa Code 201.18(e)(1)(6).
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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