Harborview Rehabilitation And Care Center At Lansd
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansdale, Pennsylvania.
- Location
- 25 West Fifth Street, Lansdale, Pennsylvania 19446
- CMS Provider Number
- 395256
- Inspections on file
- 34
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Harborview Rehabilitation And Care Center At Lansd during CMS and state inspections, most recent first.
A resident with cervical disc disorder and edentulism did not have care plans developed or implemented for recommended cervical ROM exercises or dental needs. Staff confirmed the absence of a restorative nursing program, no documentation of ROM exercises, and no care plan addressing denture use or the resident's complaints of pain with dentures.
Two residents with behavioral and mental health diagnoses engaged in close interactions, including kissing and being alone together, which were observed and reported by staff but not documented in their clinical records. Despite staff awareness and intervention, the facility failed to maintain complete and accurate documentation of these events as required by policy.
A resident with psychosis and schizophrenia, who expressed dissatisfaction with the facility environment and food, was able to leave the facility without a comprehensive elopement care plan in place. The resident was later found offsite and returned without injury. Facility leadership confirmed the absence of a person-centered care plan addressing elopement risk.
The facility failed to serve hot beverages at safe temperatures, resulting in a burn injury to a resident. Additionally, inadequate supervision led to another resident with dysphagia consuming inappropriate food, causing a choking incident and aspiration pneumonia. These deficiencies highlight lapses in adherence to safety protocols and supervision requirements.
The facility failed to store drugs and biologicals according to professional standards in two medication storage rooms. On the 2nd floor, Latanoprost eye drops requiring refrigeration were improperly stored in a medication cart. On the 3rd floor, expired nutritional supplements and medications were found, including Glucerna and Simethicone drops. These deficiencies were confirmed with staff members.
The facility failed to promptly resolve grievances related to billing, room changes, and missing items for several residents. A resident with heart failure experienced delays in room change requests and issues with missing orthopedic shoes, while another resident with multiple sclerosis faced unresolved billing concerns. Additionally, residents were not informed about the status of the activity van, leading to dissatisfaction and a violation of resident rights.
The facility failed to provide timely podiatry care for two residents, one with Type II Diabetes and another with multiple sclerosis, both requiring regular foot care due to their conditions. Despite recommendations for follow-up treatment every 60 days, no further podiatry appointments were scheduled after July 2024, as confirmed by the DON.
A resident with dysphagia and other health conditions choked on a hoagie due to insufficient supervision during meals, despite having a care plan requiring supervision. The facility lacked enough nursing staff to oversee residents with behavioral health needs, resulting in the resident developing aspiration pneumonia.
The Nursing Home Administrator and DON failed to manage hot beverage temperatures, resulting in a resident burn. Coffee was served at unsafe temperatures, contrary to facility policy, leading to a blister on a resident's hip. Staff were unaware of the policy and did not check temperatures before serving.
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy. During an observation, it was noted that there was no signage or PPE for residents with specific medical conditions necessitating such precautions, including those with Foley catheters, feeding tubes, and infections. An interview confirmed the lack of policy implementation.
The facility did not maintain safe water temperatures across all floors, as reported by residents and confirmed by surveyors. Two residents experienced temperature fluctuations, with one noting a sudden increase while showering. The facility lacked a specific water temperature policy, relying on state regulations. Surveyors found temperatures exceeding the 110-degree limit, and the Maintenance Director identified a faulty regulator as the issue.
The facility failed to ensure that a staff member completing the MDS was licensed to practice nursing in Pennsylvania. Employee E15, working remotely from outside the U.S., completed and signed multiple sections of the MDS for several residents without a valid nursing license. Interviews revealed a lack of awareness and documentation regarding her licensing status, with the Director of Nursing and Administrator unable to provide a copy of her license.
A facility failed to provide ASL translation for a resident's representative during a care plan meeting, despite the representative's need for such services due to being deaf. The facility's policy only accommodated translation services if the resident required it, leading to a deficiency in communication. Staff communicated with the representative through writing, but did not provide a sign language interpreter, as the facility was unwilling to cover the associated costs.
The facility failed to notify the State Long Term Ombudsman of emergency transfers and discharges for three residents. One resident was discharged to the hospital and did not return, another was discharged and cut off by insurance, and a third was discharged, readmitted, and discharged again without returning. The facility lacked a process for notifying the Ombudsman.
The facility failed to maintain functioning air conditioning units across all three nursing units, affecting resident rooms and dining areas. Observations revealed several PTAC units were non-functional, with issues such as not blowing cool air and having detached front panels. Residents reported discomfort due to warm room conditions. Facility documentation indicated multiple units required repairs, including cooling section and control box replacements.
Failure to Develop and Implement Care Plans for ROM and Dental Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing both range of motion (ROM) and dental needs for a resident diagnosed with Cervical Disc Disorder with Myelopathy. The resident was discharged from occupational therapy with recommendations for cervical ROM exercises, but there was no evidence that these exercises were performed or documented. Interviews with facility staff, including the Director of Nursing, confirmed that there was no restorative nursing program in place at the time and no care plan related to cervical ROM for the resident. Additionally, the resident was observed to be edentulous and not wearing dentures due to pain, instead gumming food during meals. The resident reported needing new dentures, and staff interviews confirmed the absence of a care plan addressing dental needs, denture use, or the resident's preferences and complaints regarding dentures. The Minimum Data Set (MDS) did not accurately reflect the resident's edentulous status, and there was no documentation or care planning for non-compliance with denture use or for the resident's dental discomfort.
Failure to Document Resident Interactions and Behavioral Events
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents with behavioral and mental health diagnoses. Specifically, the clinical records for two residents, both with histories of dementia, mood disorders, anxiety, depression, and bipolar disorder, did not reflect significant events and interactions that occurred between them. Although social services and staff were aware of a close relationship between the two residents, including kissing and being alone together in private areas, these interactions were not documented in the residents' progress notes over the past three months. Staff interviews confirmed that such events occurred, and that staff intervened and reported the incidents to nursing management, but there was no corresponding documentation in the clinical records. Additionally, the facility's policy on behavior management and monitoring was not followed as required, as evidenced by the lack of documentation regarding the residents' interactions and the behavioral concerns that prompted room changes and increased monitoring. The absence of accurate and complete records for these residents, despite their complex behavioral histories and the facility's awareness of their interactions, constitutes a failure to maintain medical records in accordance with accepted professional standards.
Failure to Develop and Implement Elopement Care Plan for Resident with Psychosis and Schizophrenia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing elopement risk for a resident with a history of psychosis and schizophrenia. The resident was admitted with significant mental health diagnoses, including psychosis and schizophrenia, which are associated with symptoms such as hallucinations, delusions, and disorganized thinking. Despite these risk factors, the clinical record review showed that no care plan was in place to address the resident's risk of elopement. On April 23, 2025, the resident was discovered missing from his room, prompting a search and notification of local authorities, facility administration, and the resident's guardian. The resident was later found at a local convenience store and returned to the facility without injury. Interviews with the resident revealed ongoing dissatisfaction with the facility environment and food, as well as a stated intent to leave again if possible. The Administrator and DON confirmed that the care plan was not comprehensive regarding elopement prevention and resident safety.
Failure to Ensure Safe Beverage Temperatures and Proper Supervision
Penalty
Summary
The facility failed to ensure that hot beverages were served at safe temperatures, resulting in an Immediate Jeopardy situation for residents on the First Floor. The coffee was served at 178 degrees Fahrenheit, exceeding the facility's policy limit of 165 degrees. This led to Resident R97 sustaining a burn on the left hip after spilling the hot coffee. The resident, who had no cognitive impairments, required assistance with setup or cleanup for eating. The incident was not immediately addressed, as the nurse aide did not take the temperature of the coffee before serving it and was unaware of the facility's policy. Additionally, the facility failed to properly supervise Resident R9, who had a history of respiratory failure, dysphagia, and other conditions, resulting in actual harm. The resident, with moderate cognitive impairment, was on a mechanical soft diet but consumed a hoagie, leading to a choking episode that required the Heimlich maneuver. The resident subsequently developed aspiration pneumonia. The care plan for Resident R9 included supervision during meals, which was not adequately provided, allowing the resident to eat food not in accordance with diet orders. The facility's lack of adherence to its policies and inadequate supervision of residents led to these incidents. The dietary and nursing staff were not aware of the temperature requirements for serving hot beverages, and the supervision of residents with dietary restrictions was insufficient, resulting in harm to Resident R9. These deficiencies highlight the need for strict adherence to safety protocols and proper supervision to prevent accidents and ensure resident safety.
Removal Plan
- Facility reviewed and updated the hot liquids policy.
- Prior to hot liquids leaving Dietary, a temperature will be taken by Dietary staff.
- Before serving to residents a temperature will be taken by CNA (nurse aide)/Nurse and be documented.
- If the hot liquid temperature is > 150 degrees, it will not be served and will be cooled down by using ice until the temperature is below 150 degrees.
- The facility will inservice more than 90% of staff and will be at 100%.
- The facility will do audits to ensure effectiveness of staff in-service using questionnaire and/or on the spot interview and results to be reviewed in QAPI.
- The facility to audit temperature daily for one week and twice a week for two weeks and weekly for two months and reported and discussed in QAPI.
Improper Storage and Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards of practice in two out of three medication storage rooms observed. On the 2nd floor unit, an eye drop medication, Latanoprost 0.005%, which required refrigeration before opening, was found in the medication cart instead of being refrigerated. This finding was confirmed with a licensed nurse, Employee E18. Additionally, on the 3rd floor unit, an expired nutritional supplement, Glucerna with carb steady, was found with an expiration date of November 1st, 2024, and was intended for a resident who had not yet received it. Further inspection revealed 19 more expired nutritional supplements in an unsealed box in the medication storage room. The facility's policy mandates that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures. However, observations on the 2nd floor unit revealed several expired medications, including Vitamin B-6, Diphenhydramine Hcl, Reguloid, Bisacodyl suppository, Major sore throat spray, and Zinc Sulfate. These findings were confirmed with the Unit manager, Employee E19. Similarly, on the 3rd floor unit, expired medications such as Mommy's bliss - baby gas relief - Simethicone drops were found, confirmed with licensed nurse, Employee E20. The facility's failure to adhere to its medication storage policy resulted in the presence of expired and improperly stored medications.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances and concerns raised by residents, as evidenced by interviews, clinical records, and resident council minutes. Eleven residents attending the resident council and two additional residents had unresolved issues related to billing clarification, the status of the activity van, room change requests, and missing items. The facility's grievance policy mandates attempts to resolve concerns within three business days, with unresolved issues reported to the Nursing Home Administrator (NHA). However, this policy was not effectively implemented, as residents reported delays and lack of communication from the social worker and other staff. Resident R26, who was admitted with a primary diagnosis of heart failure, expressed frustration over the lack of response from the social worker regarding a request to share a room with her husband, Resident R80. Despite being informed that they would be placed together when a room became available, there was no follow-up, and the resident's missing orthopedic shoe further complicated her care. Occupational Therapy notes indicated that the missing shoe hindered her ability to transfer, yet the issue remained unresolved, with the resident being advised to purchase new shoes. Resident R41, diagnosed with multiple sclerosis, also experienced communication issues with the social worker regarding billing concerns. The resident disputed claims of making appointments that incurred charges to the facility and requested to see the bills, but received no response. Additionally, residents expressed dissatisfaction with the lack of updates on the activity van, which had been out of service since March. The NHA acknowledged the van's status but had not communicated this to the residents, leading to further grievances. The facility's failure to address these concerns violated resident rights as outlined in 28 Pa. Code 201.29(a)(i).
Failure to Provide Timely Podiatry Care for Residents
Penalty
Summary
The facility failed to ensure proper foot care for two residents, Resident R26 and Resident R41, as per professional standards of practice. Resident R26, who was admitted in November 2020, has diagnoses of heart failure and Type II Diabetes, which can increase the risk of foot injuries due to nerve damage. Despite being alert and oriented, Resident R26 reported not being seen by a podiatrist since a scheduled appointment on July 10, 2024, which recommended follow-up treatment in 60 days. However, there was no evidence of any further podiatry appointments in the resident's clinical records. Similarly, Resident R41, admitted in September 2021 with multiple sclerosis, which can cause numbness and pain in the feet, also reported not receiving timely podiatry care. The last documented podiatry appointment for Resident R41 was on July 10, 2024, with a recommendation for follow-up treatment in 60 days. The facility's failure to schedule further podiatrist appointments for both residents was confirmed by the Director of Nursing on November 15, 2024, indicating a lapse in maintaining the residents' foot health as required by professional standards.
Insufficient Nursing Staff Leads to Choking Incident
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the safety of residents, specifically impacting one resident, identified as Resident R9. This resident has a complex medical history, including dysphagia, bipolar disorder, Parkinsonism, and schizophrenia, which necessitates special dietary and supervision needs. On July 15, 2024, Resident R9 experienced a choking incident while eating a hoagie in the dining room, despite having a physician's order for a mechanical soft diet. The incident required the Heimlich maneuver and resulted in a diagnosis of aspiration pneumonia, for which the resident was treated with antibiotics. The investigation revealed that Resident R9 was not properly supervised during the meal, as the facility did not have enough nursing staff to oversee residents with behavioral health needs. The resident's care plan, which identified a risk for choking and aspiration due to dysphagia, included interventions for supervision during meals. However, these interventions were not implemented until after the choking incident. An interview with a licensed nurse confirmed the lack of sufficient staff to supervise residents adequately, leading to the deficiency cited under F 689 and relevant state codes.
Failure to Manage Hot Beverage Temperatures Leads to Resident Burn
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to manage the facility effectively, leading to an Immediate Jeopardy situation. The deficiency involved serving hot beverages at unsafe temperatures, resulting in a burn injury to a resident. The facility's policy on hot liquid management, which required coffee to be served at temperatures not exceeding 165°F, was not adhered to. Observations revealed that coffee was being served at temperatures as high as 182.8°F, and staff were unaware of the policy or how to check the temperature before serving. The incident involved a resident with no cognitive impairments who accidentally spilled hot coffee on himself, resulting in a blister on his left hip/buttock area. The resident required treatment with Silvadene cream. Staff interviews confirmed that the temperature of the coffee was not checked before serving, and the dietary and nursing aides were not aware of the facility's policy regarding safe serving temperatures. The Nursing Home Administrator acknowledged the oversight and the potential risk it posed to residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for several residents, as required by their policy revised in June 2023. This policy mandates the use of gowns and gloves during high-risk activities for residents colonized or infected with targeted or epidemiologically important multidrug-resistant organisms (MDROs). During an observation tour on November 19, 2024, it was noted that there was no enhanced barrier precaution signage or personal protective equipment (PPE) available for four residents with specific medical conditions that necessitated such precautions. These residents included one with a Foley catheter for hydronephrosis and urinary retention, another with a feeding tube, a third with a foot ulcer and osteomyelitis requiring a PICC line for intravenous antibiotics, and a fourth with a chronic eye infection. Additionally, the facility did not provide enhanced barrier precaution signage for two other residents who were on barrier precautions. One of these residents had carbapenem-resistant enterobacterales, and the other had a Foley catheter, Candida auris, and a sacral pressure ulcer. An interview with the Registered Nurse Assessment Coordinator and Infection Preventionist confirmed the lack of implementation of the facility's policy, as there was no signage or PPE provided for the residents mentioned. This deficiency was noted under the Pennsylvania Code regulations regarding the responsibility of the licensee and nursing services.
Water Temperature Deficiency Across Facility Floors
Penalty
Summary
The facility failed to maintain safe and comfortable water temperatures for residents, staff, and the public across all three floors. During a group meeting with 11 residents, two residents from the second floor reported issues with water temperature fluctuations, with one resident experiencing a sudden increase in water temperature while showering. An interview with the Nursing Home Administrator revealed that the facility lacked a specific policy on water temperatures, relying instead on state regulations of 110 degrees. However, surveyors recorded water temperatures exceeding this limit, with readings of 115.5 degrees on the first floor and 112.4 degrees in the third-floor shower room. The second-floor shower room registered a temperature of 106 degrees, which changed to colder when the faucet was slightly adjusted. The Maintenance Director identified the need for a new regulator for the faucet.
Unlicensed Staff Completing MDS Assessments
Penalty
Summary
The facility failed to ensure that staff completing the Minimum Data Set (MDS) were properly licensed and registered to practice nursing in Pennsylvania. Employee E15, who works remotely from outside the United States, was found to have completed and signed multiple sections of the MDS for several residents without holding a valid nursing license in Pennsylvania. The Pennsylvania Licensing System Verification website confirmed that Employee E15's name was not listed in the database for nurses licensed to practice in the state. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness and documentation regarding Employee E15's licensing status. The Director of Nursing acknowledged that Employee E15 worked remotely and did not have a copy of her nursing license. The Administrator initially claimed that Employee E15 was performing clerical work and did not require a license, but later admitted that she had completed assessment portions of the MDS. An interview with another RNAC confirmed that Employee E15 completed some sections of the MDS, which were then verified by the RNAC.
Failure to Provide ASL Translation for Resident's Representative
Penalty
Summary
The facility failed to provide American Sign Language (ASL) translation for a resident's representative during a care plan meeting, which is a violation of the resident's right to receive notices in a format and language they understand. The resident, who was admitted with multiple diagnoses including Dysphagia, Anxiety, Type 2 Diabetes, and others, had a Power of Attorney (POA) for medical care. The resident's daughter, who is deaf and uses sign language, required an interpreter for the care plan meeting. However, the facility's policy did not accommodate this need, as they stated they would only provide translation services if the resident themselves required it. Interviews with facility staff, including the Social Worker and Nursing Home Administrator, revealed that the facility was aware of the representative's need for a translator but chose not to provide it due to associated costs. The facility communicated with the family member through writing when she was present at the facility, but did not provide a sign language interpreter for the care plan meeting. The family member declined to use her own interpreter over the phone, leading to the deficiency in communication during the care planning process.
Failure to Notify Ombudsman of Emergency Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long Term Ombudsman of facility-initiated emergency transfers and discharges for three residents. Resident R10 was discharged to the hospital and did not return after hospitalization. Resident R8 was discharged to the hospital, was cut off by insurance, and did not return. Resident R9 was discharged to the hospital, readmitted, and then discharged again, not returning after the second hospitalization. The facility documentation lacked evidence of notification to the Ombudsman for these discharges. An interview with the Nursing Home Administrator revealed that the facility did not have a process in place for providing the Ombudsman with discharge notices.
Non-Functioning Air Conditioning Units in Facility
Penalty
Summary
The facility failed to ensure that the air conditioning units (PTAC units) were functioning properly across all three nursing units, including the 1st, 2nd, and 3rd floors. During observations conducted with the Maintenance Director, several PTAC units in resident rooms and dining areas were found to be non-functioning. Specific issues included units not blowing cool air, units with front panels hanging off, and units that were completely non-functional. Residents confirmed that their rooms felt warm, indicating discomfort due to the malfunctioning air conditioning units. The facility documentation review further revealed that multiple PTAC units required repairs, such as cooling section replacements, control box installations, and front cover repairs. The deficiencies were confirmed with the Maintenance Director during the observations. The report cites violations of 28 Pa Code 201.14 (a) and 28 Pa. Code 201.18(b)(1), which pertain to the responsibility of the licensee and management, respectively.
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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