Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caring Heart Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Liberty Center For Rehabilitation And Nursing | 1 mi | ★★★★★ | 1 | 0 |
| Cliveden Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Wesley Enhanced Living At Stapeley | 1.2 mi | ★★★★★ | 10 | 0 |
| Maplewood Nursing And Rehab Center | 1.8 mi | ★★★★★ | 17 | 0 |
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