Green Meadows Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Malvern, Pennsylvania.
- Location
- 283 East Lancaster Avenue, Malvern, Pennsylvania 19355
- CMS Provider Number
- 395519
- Inspections on file
- 21
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Green Meadows Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to keep the automatic sprinkler system free of extraneous weight, with multiple wires and flex conduit observed attached to or laying across sprinkler piping in several areas above the ceiling. Facility leadership confirmed these items were present and supported by the sprinkler system.
The facility did not provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas were completed, as required by NFPA 99. This deficiency was confirmed by both the Administrator and the Director of Maintenance, and affected all smoke zones within the component.
Fifteen rooms on a dementia care unit were found without fresh water or with water cups dated weeks prior, while other rooms had currently dated water. Staff interviews confirmed knowledge of the hydration lapse, and facility leadership was unaware until informed by surveyors.
Three resident rooms lacked privacy curtains, and eighteen rooms had soiled or stained privacy curtains on the 1st floor dementia care unit. This failure to provide adequate privacy and maintain clean equipment was confirmed by facility leadership.
A resident's clinical record and care plan indicated Full Code status, while a POLST signed by the resident reflected a DNR preference. The DON confirmed the inconsistency, showing the facility did not ensure the resident's advance directives were accurately documented.
A resident's MDS assessment was inaccurately coded to indicate the presence of an indwelling catheter, despite no clinical evidence supporting this. Staff confirmed the error during an interview, acknowledging the assessment did not accurately reflect the resident's status.
A resident with major depressive disorder was prescribed Mirtazapine, but staff did not monitor for side effects or document the medication's effectiveness. The DON confirmed that no such monitoring was conducted.
A resident with encephalopathy and an order for a Kennedy Cup was repeatedly observed drinking from a regular cup with a straw instead of the prescribed assistive device. Staff interviews confirmed knowledge of the resident not using the Kennedy Cup as ordered, and the care plan documented the need for meal assistance due to intellectual disability.
Two residents did not receive their prescribed medications as ordered because the facility was waiting for pharmacy delivery, as confirmed by the DON. The medications included treatments for hypertension, hyperlipidemia, COPD, post-surgical aftercare, and hypopituitarism, and were not available for administration as scheduled.
The facility failed to meet required staffing levels for nurse aides on several occasions, with insufficient coverage during day, evening, and night shifts. These deficiencies were confirmed by staffing documents and the DON.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day on several occasions in February 2025. The nursing hours ranged from 2.80 to 3.19, as confirmed by the DON.
The facility did not comply with its food labeling and storage policy, as observed in the dry storage area of the kitchen. Eight opened bags of uncooked pasta lacked labels with the food item name and use-by date and were not properly sealed. The Dietary Director confirmed these deficiencies, which violated the facility's 2017 policy.
A facility failed to document catheter care for a resident with a suprapubic catheter, as required by their policy. The policy mandates catheter care every shift and as needed, with documentation and reporting of any concerns. However, a review of the resident's clinical record showed no evidence of such documentation, a deficiency confirmed by the DON.
A resident's UA C+S test results were finalized but not reported to the physician for three days, delaying treatment for a urinary tract infection. The DON confirmed the delay in communication.
Sprinkler System Not Maintained Free of Extraneous Weight
Penalty
Summary
Surveyors determined that the facility failed to maintain the automatic sprinkler system free of extraneous weight in three of twelve smoke compartments. During observations conducted above the ceiling in multiple areas, including the 2nd floor above the Nurses' Station, the North Hall by a resident room, and the 3rd floor above the Nurses' Station, various items such as multiple wires and flex conduit were found laying across or attached to the sprinkler piping system and its brackets. These findings were confirmed during an interview with the Administrator and Director of Maintenance, who acknowledged the presence of these items attached to and supported by the sprinkler pipe system. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Remove existing wiring (various items) from sprinkler piping, in the locations noted, and install separate hanging devices as needed using an above ceiling permit program. Education of the requirements will be provided to the appropriate staff. Audits of above ceiling work will be conducted, monthly x3. Findings will be reviewed in monthly QAPI meetings.
Failure to Document Annual Electrical Receptacle Inspections
Penalty
Summary
Surveyors determined that the facility failed to provide documentation verifying that annual inspections and testing of electrical receptacles in resident care areas had been completed. During a document review, it was found that there was no evidence to confirm that electrical receptacles had been tested within the last 12 months in any of the twelve smoke zones of the component. This lack of documentation was identified during a review conducted between 9:30 AM and 10:35 AM on December 18, 2023. At the exit conference, both the Administrator and the Director of Maintenance confirmed that there was no documentation available to show that the required annual electrical inspections had been performed. The deficiency specifically relates to the absence of records for the testing of electrical receptacles in resident care areas, as required by NFPA 99 standards.
Plan Of Correction
Facility will ensure documentation of annual inspections of electrical receptacles in resident care areas is completed and will include in building Management Software task list as an annual inspection. Education on the inspection of and documentation of electrical receptacles utilizing the annual inspection report in building Management Software task list will be provided to the appropriate staff. Audits will be completed semi-annually to check on schedule and confirm results are filed in life safety book. Findings will be reviewed in monthly QAPI meetings.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
Surveyors observed that the facility failed to provide adequate hydration to residents in fifteen out of thirty-two rooms on the first floor dementia care unit. During observations conducted over three consecutive days, it was found that rooms 100 through 115 either had no cups of fresh water available for residents or the cups present were dated between November 14 and December 1, indicating that the water had not been replaced for an extended period. In contrast, rooms 116 through 132 had currently dated cups with fresh water. Specific rooms, such as 113 and 114, were noted to have water cups dated as far back as November 14, and room 101 had a cup dated December 1. All other rooms in the 100 to 115 range had no water cups at all. Interviews with staff confirmed awareness of the lack of fresh water in these rooms. A registered nurse acknowledged knowledge of the issue, and when the findings were presented to the Nursing Home Administrator and Director of Nursing, they denied prior knowledge of the hydration lapse and indicated they would investigate. The deficiency was cited under federal and state regulations requiring facilities to ensure residents are offered sufficient fluid intake to maintain proper hydration and health.
Plan Of Correction
The facility cannot retroactively correct this issue. All residents were provided fresh water cups for hydration. A facility-wide audit was conducted by the DON/Designee to assure that residents were provided fresh water cups for hydration. The DON/Designee educated nursing staff on the importance of assuring that residents were provided fresh water cups for hydration. Random room audits will be conducted to assure that residents are provided fresh water cups for hydration. Audits will be done weekly for four weeks, then monthly for three months or until compliance is achieved. Results will be discussed at the monthly QAPI.
Deficiency in Resident Room Privacy and Cleanliness
Penalty
Summary
Surveyors observed that three out of thirty-two resident rooms on the 1st floor dementia care unit did not have privacy curtains, and eighteen rooms had privacy curtains that were soiled or had brown stains. These observations were made over a three-day period. The lack of privacy curtains and the presence of soiled curtains were confirmed during interviews with the Nursing Home Administrator and the Director of Nursing. The deficiency was identified as a failure to provide adequate privacy and maintain clean equipment in resident rooms, as required by regulations.
Plan Of Correction
Soiled curtains were immediately replaced with clean privacy curtains and privacy curtains were hung in rooms that were missing privacy curtains. Facility-wide audit conducted by NHA/Designee to ensure resident rooms have privacy curtains and are free from soilage. NHA/Designee provided education to housekeeping and maintenance staff on assuring that resident rooms have privacy curtains in place and free from soilage. NHA/Designee will audit random rooms to ensure privacy curtains are present and free from soilage. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Ensure Consistent Advance Directives for Code Status
Penalty
Summary
The facility failed to ensure that advance directives regarding code status were accurately reflected in the clinical record for one resident. Specifically, a review of the resident's clinical record showed a physician's order and care plan indicating Full Code status, while a Physician's Order for Life Sustaining Treatment (POLST) signed by the resident indicated a Do Not Resuscitate (DNR) status. This discrepancy meant that the resident's wishes as documented in the POLST were not aligned with the orders and care plan maintained by the facility. The Director of Nursing confirmed during an interview that the clinical record did not match the POLST signed by the resident. The deficiency was identified through clinical record review and interviews, and it was determined that the facility did not ensure appropriate advance directives were in place and consistent for the resident involved.
Plan Of Correction
Resident 114 code status was reviewed with resident/representative and confirmed desire for DNR status. Care plan, Physician order, and POLST reviewed and revised. Facility-wide audit of POLST, Physician order, and care plan was done to assure clinical record and POLST are consistent with residents' wishes. DON/Designee educated licensed nursing staff and social services staff on the importance of assuring POLST, Physician order, and care plan are consistent with residents' wishes. Random audits will be conducted of resident's clinical record to assure that POLST, Physician order, and care plan are consistent with residents' wishes. Audits will be done daily x 5 days, then weekly x 4, then monthly x 2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.
Inaccurate MDS Assessment for Catheter Status
Penalty
Summary
A deficiency was identified when a review of a resident's admission Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter, as documented in section H, Bladder and Bowel. However, further examination of the clinical record revealed no evidence that the resident actually had an indwelling catheter at the time of the assessment. This discrepancy was confirmed during an interview with a licensed staff member, who acknowledged that the MDS had been coded incorrectly and that the resident did not have an indwelling catheter. The failure to accurately assess and document the resident's status resulted in an inaccurate MDS assessment for this individual.
Plan Of Correction
Resident 29 was discharged. Section H of MDS submitted within the last 14 days will be reviewed to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Administrator/Designee will educate clinical reimbursement staff on ensuring MDS coding is consistent with clinical record for resident assessment of bowel and bladder status. Random audits of Section H of MDS submitted will be conducted to assure clinical record and MDS coding is consistent with resident assessment of bowel and bladder. Audits will be done weekly x4, then monthly x2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.
Failure to Monitor Antidepressant Therapy
Penalty
Summary
The facility failed to ensure that appropriate monitoring for side effects and effectiveness was conducted for an anti-depressant medication prescribed to a resident diagnosed with major depressive disorder. The resident had a physician's order for Mirtazapine to treat depression, but a review of the clinical record did not show any evidence that staff monitored for side effects or documented the effectiveness of the medication. An interview with the Director of Nursing confirmed that no monitoring for side effects or effectiveness of the anti-depressant was performed. This lack of monitoring was identified through clinical record review and was previously cited in earlier surveys.
Plan Of Correction
Resident 35's clinical record was revised to show evidence of monitoring of side effects of the anti-depressant medication and its effectiveness. DON/Designee conducted a facility-wide audit of current residents on antidepressant medications to ensure monitoring of side effects and its effectiveness are in place. DON/Designee educated nursing staff on the importance of monitoring side effects and its effectiveness for residents on antidepressant medications. DON/Designee will randomly audit residents with antidepressant medication to ensure effectiveness and side effects are monitored. Audits will be done weekly x4 then monthly x2 or until compliance is achieved. Results will be discussed at monthly QAPI.
Failure to Provide Prescribed Assistive Drinking Device
Penalty
Summary
A deficiency was identified when a resident with a medical diagnosis of encephalopathy and an order for a regular diet with a Kennedy Cup, built-up fork, and spoon was not provided with the prescribed assistive drinking device. The resident's physician order, dated May 21, 2025, specified the use of a Kennedy Cup, which is a spill-proof cup with a secure lid and J-shaped handle, to assist with drinking. Observations conducted over three consecutive lunch services revealed that the resident was instead drinking from a regular cup with a straw, contrary to the physician's order. Interviews with facility staff, including the unit manager RN, confirmed awareness that the resident was not using the Kennedy Cup as ordered. The Nursing Home Administrator and Director of Nursing were not aware of the resident's lack of access to the prescribed assistive device until the issue was presented to them. The resident's care plan indicated a need for assistance with meals due to intellectual disability and a stable weight, further supporting the necessity for the assistive device. The failure to provide the required Kennedy Cup constituted noncompliance with regulations regarding assistive devices for eating and drinking.
Plan Of Correction
The facility cannot retroactively correct this issue. Resident 7 was given a Kennedy cup for all meals. DON/Designee conducted a facility-wide audit of residents who have orders for adaptive equipment to ensure appropriate adaptive equipment was in place during meals. DON/Designee educated Nursing/Dietary staff on the importance of assuring that assistive devices ordered are in place during meals. DON/Designee will conduct meal observations weekly x 4 then monthly x 3 or until compliance is achieved to verify adaptive equipment ordered is present during meals. Results will be discussed at the monthly QAPI.
Failure to Provide Timely Pharmacy Services
Penalty
Summary
The facility failed to ensure that pharmaceutical services were provided in a timely manner to meet the needs of two residents. For one resident admitted with multiple diagnoses including hypertension, hyperlipidemia, COPD, and post-surgical aftercare, physician admission orders were written for several medications to begin on a specified date. However, review of the Medication Administration Record (MAR) showed that these medications were not administered as ordered, and staff notes indicated they were waiting for delivery from the pharmacy. Similarly, another resident admitted with hypopituitarism had physician orders for Desmopressin Acetate and Hydrocortisone to begin on a specified date. The MAR revealed these medications were also not administered as ordered, with staff documentation stating they were awaiting pharmacy delivery. The Director of Nursing confirmed that both residents did not receive their prescribed medications on time due to unavailability from the pharmacy.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple occasions between February 1, 2025, and February 21, 2025. Specifically, the facility did not provide the mandated one NA per 10 residents during the day shift on five days, one NA per 11 residents during the evening shift on two days, and one NA per 15 residents during the night shift on four days. These deficiencies were confirmed by a review of staffing documents and an email confirmation from the Director of Nursing (DON) on March 8, 2025.
Plan Of Correction
1. Review staffing needs, workload, and determining units with the current gaps. 2. Distribution of Assignments: Review staff assignments and the rotation schedule involved with each. 3. Weekend Staffing Log: Assure all weekend shifts are covered and all steps needed for call offs. 4. Identify recruitment strategies. Continue to develop effective recruitment strategies to attract qualified candidates. This includes flyers, sign on/referral bonus, advertising job openings, utilizing on-line job portals, and word of mouth. 5. Streamline onboarding and "processing" process for the facility. This includes looking at any inefficiencies to ensure process is candidate friendly and focuses on selecting the best-suited individuals for the positions. 6. Retention Events: Access the factors that contribute to turnover and taking steps to improve employee retention. Performance review and evaluation: Assuring timely performance reviews are completed and staff are evaluated properly. 7. Training and Development of Staff utilizing facility training portal and in-services. Also partnering with leadership to set up workshops for employee development. 8. Communication: Continue to work on communication channels within the organization. Encourage staff members to provide feedback, share concerns and suggest improvements related to staffing to help identify potential issues early on and facilitate collaborative problem solving.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. A review of the facility's staffing levels revealed that on multiple dates in February 2025, the facility's nursing hours fell below the required minimum. Specifically, on February 8, 9, 10, 11, 13, 14, 15, 16, 17, and 19, the direct care nursing hours per resident ranged from 2.80 to 3.19, all below the mandated 3.2 hours. This deficiency was confirmed by the Director of Nursing via email on March 8, 2025.
Plan Of Correction
1. Review staffing needs, workload, and determining units with the current gaps. 2. Distribution of Assignments: Review staff assignments and the rotation schedule involved with each. 3. Weekend Staffing Log: Assure all weekend shifts are covered and all steps needed for call offs. 4. Identify recruitment strategies. Continue to develop effective recruitment strategies to attract qualified candidates. This includes flyers, sign on/referral bonus, advertising job openings, utilizing on-line job portals, and word of mouth. 5. Streamline onboarding and "processing" process for the facility. This includes looking at any inefficiencies to ensure process is candidate friendly and focuses on selecting the best-suited individuals for the positions. 6. Retention Events: Access the factors that contribute to turnover and taking steps to improve employee retention. Performance review and evaluation: Assuring timely performance reviews are completed and staff are evaluated properly. 7. Training and Development of Staff utilizing facility training portal and in-services. Also partnering with leadership to set up workshops for employee development. 8. Communication: Continue to work on communication channels within the organization. Encourage staff members to provide feedback, share concerns and suggest improvements related to staffing to help identify potential issues early on and facilitate collaborative problem solving.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to its policy on food labeling and storage, as observed during a tour of the main kitchen's dry storage area. Eight opened bags of uncooked pasta were found without labels indicating the food item name and use-by date, and they were not properly sealed. This was in violation of the facility's policy dated 2017, which mandates that all food should be dated upon receipt and properly labeled before storage. The Dietary Director confirmed that the pasta should have been labeled and sealed according to the policy.
Lack of Documented Catheter Care for Resident
Penalty
Summary
The facility failed to provide documented evidence of consistent and adequate catheter care for a resident with a suprapubic catheter. The facility's policy, implemented on March 1, 2024, requires catheter care to be performed every shift and as needed, with documentation of the care provided and any concerns reported to the nurse on duty. However, a review of the clinical record for the resident revealed no documented evidence of catheter care being provided. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of documentation for the resident's catheter care.
Delay in Reporting Lab Results to Physician
Penalty
Summary
The facility failed to report laboratory results to the ordering physician in a timely manner for one resident. Resident 22 had a physician order for a urine analysis and culture sensitivity (UA C+S) test on September 11, 2024, to determine if there was a urinary tract infection. The laboratory report was finalized and available on September 15, 2024. However, the results were not communicated to the physician until September 18, 2024, as noted in the resident's progress notes. This delay in reporting led to a delay in the physician ordering antibiotics to treat the urinary tract infection. The Director of Nursing confirmed the delay in reporting the results during an interview on October 9, 2024.
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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