Harborview Rehabilitation Care Center At Doylestow
Inspection history, citations, penalties and survey trends for this long-term care facility in Doylestown, Pennsylvania.
- Location
- 432 Maple Avenue, Doylestown, Pennsylvania 18901
- CMS Provider Number
- 395277
- Inspections on file
- 34
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Harborview Rehabilitation Care Center At Doylestow during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen dishwashing area, including an exposed ceiling with missing tiles, black-like substances on walls and ceiling surfaces, water droplets above an exit door, and an accumulation of a black substance below the dishwashing machine, indicating a failure to maintain sanitary food service conditions.
A resident with obesity, chronic kidney disease, and bilateral hip arthritis, who required substantial staff assistance for showers and was totally dependent for shower transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, the resident reported not having had a shower, and there was no documentation that showers were provided, offered, or refused. A Nursing Supervisor confirmed the absence of documentation that showers had been offered or given, demonstrating a failure to maintain the resident’s ADL care related to showering.
Surveyors found that essential mechanical equipment was not maintained in safe, working order. In the kitchen, the ventilation system above the dishwasher had a broken, non-functioning fan that had been inoperable for several weeks, and no measures were implemented to prevent the compromised ventilation from affecting food contact surfaces. In the back hall elevator, the ventilation fan was broken with dust accumulation inside the elevator, the bottom side panel wall was cracked, and the door tracks contained dirt and debris, all indicating inadequate maintenance of critical equipment.
Surveyors found multiple environmental deficiencies across three nursing units, including damaged and unsanitary conditions in supervised bathing areas and a resident room. On different floors, issues included broken and cracked flooring, cracked and peeling baseboard molding, stained ceiling tiles above showers, holes in a wall above a sink, stained privacy curtains between beds and in bathing areas, peeling paint on shower stall floors, and a bag of wet linens left on the floor. These conditions failed to ensure a safe, clean, and comfortable environment as required under 42 CFR 483.10(i) Safe Environment and related state regulations.
A resident with memory impairments and impaired decision-making, who required supervision, was able to leave the facility undetected through the front entrance. Staff failed to initiate the required missing resident action plan after noticing the resident was not present, and the absence was only discovered when police notified the facility after finding the resident offsite. This lapse in supervision and failure to follow policy led to an Immediate Jeopardy deficiency.
Staff did not securely store medications and biologicals on two nursing units, leaving items such as iodoform gauze, normal saline, anti-fungal cream, and Lidocaine patches unattended and accessible in resident rooms and common areas. An unlocked and unattended treatment cart with medicated cream was also observed in a hallway.
The facility exhibited widespread environmental deficiencies across all nursing units, including non-functional toilets, stained and broken ceiling tiles, holes in walls, and missing or broken fixtures. Residents were observed laying directly on mattresses without sheets, and several rooms had exposed drywall and unpainted spackle, compromising the safety, sanitation, and comfort of the environment.
The facility's First Floor nursing unit exhibited several environmental deficiencies, including damaged and stained tiles, soiled toilets, and cluttered personal items in resident rooms. The dining room had missing and stained ceiling tiles, exposing rusted pipes. These issues indicate a failure to maintain a sanitary and comfortable environment for residents.
The facility's First Floor nursing unit failed to provide a working resident call system for four residents, affecting their ability to summon assistance. Observations showed call lights were lit but silent, and residents reported non-functional call bells. The DON confirmed ongoing issues with the system.
Harborview Rehabilitation and Care Center at Doylestown failed to serve food at palatable and acceptable temperatures to residents on the First Floor nursing unit. The food cart was delayed in distribution, resulting in meals being served below the required temperature. Residents reported that their meals were often cold and unappetizing, confirming the deficiency in food service standards.
The facility's dietary department was found to have unsanitary conditions and non-functional equipment. Observations revealed soiled and rusted convection ovens, with one set being non-operational. The range top stove had only half of its burners working, and both bottom ovens were non-functional. These issues were confirmed by the Director of Dietary.
The facility did not conduct timely criminal background checks for three newly hired employees, as required by its policy on abuse prevention. Background checks for these employees were delayed by several months, contrary to the policy that mandates screening before employment. The Administrator acknowledged the oversight.
A facility failed to accurately complete the MDS assessment for a resident. The resident's indwelling urinary catheter was discontinued, but the MDS assessment incorrectly indicated its presence. This inaccuracy was confirmed by the DON.
The facility did not develop comprehensive care plans for two residents. One resident with vascular dementia and other conditions lacked interventions for urinary incontinence in their care plan. Another resident with heart failure and renal insufficiency had no documented interventions for visual function, communication needs, and urinary incontinence. The DON confirmed these omissions.
The facility failed to maintain a safe and sanitary environment across all nursing units. Observations included stained ceiling tiles, broken soap dispensers, crumbling plaster, non-functioning hot water, cracked walls, and missing ceiling tiles. Additional issues were uncovered battery packs, dirty floors, debris in hallways, and improper storage of wet linens.
A resident with mood disorder, amnesia, bipolar disorder, and depression was not adequately supervised, leading to an elopement incident. The resident was last seen before dinner, and his meal tray was untouched, indicating he had not returned. The facility was unaware of his whereabouts until the following day, and it was confirmed that there were no physician orders for unsupervised absence.
A facility failed to prevent a resident's elopement despite being assessed as high risk, resulting in Immediate Jeopardy. The resident, with a history of brain injury and psychosis, eloped twice, once sustaining injuries. Additionally, the facility did not maintain a safe environment, as evidenced by a resident's fall due to a broken handrail and missing handrail returns on a nursing unit.
The facility exhibited widespread environmental deficiencies across all nursing units, including stained and damaged ceiling tiles, broken fixtures, and unsanitary conditions in rooms and common areas. These issues were observed on all three floors, indicating a failure to maintain a safe and comfortable environment.
The facility failed to develop comprehensive care plans for three residents, neglecting to address identified risks such as elopement, communication issues, and fall prevention. Despite assessments highlighting these needs, the care plans lacked necessary interventions, as confirmed by the DON.
The Nursing Home Administrator and DON failed to manage the facility effectively, leading to a resident eloping twice. Despite being identified as high risk for elopement, the facility did not implement preventive interventions until after the incidents, resulting in an Immediate Jeopardy situation.
The facility did not post current nurse staffing information as required. On a survey conducted, it was found that the staffing information displayed was outdated by several days. This issue had been previously cited, indicating a recurring problem with compliance.
A resident with multiple sclerosis, depression, and anxiety did not receive timely assistance from staff, as required by her care plan. She waited over 40 minutes for her soiled brief to be changed and to receive help getting out of bed, despite staff being aware of her needs.
Unsanitary Conditions in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen dishwashing area. During a kitchen tour conducted at 1:30 p.m. on March 16, 2026, surveyors observed an exposed ceiling with several missing tiles in the dishwashing machine area, along with a black-like substance on the walls and ceiling surfaces. There were droplets of water above the exit door in this area, and an accumulation of a black substance was noted below the dishwashing machine. These environmental conditions in the dishwashing area were cited as noncompliance with 28 Pa. Code 201.18(b)(3) related to management responsibilities for maintaining sanitary conditions.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically scheduled showers, for one resident. The resident had diagnoses including obesity, chronic kidney disease, and arthritis in both hips, and a Minimum Data Set assessment showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for shower transfers. Facility documentation indicated the resident was scheduled to receive showers on Tuesdays and Fridays on the evening shift. During an interview, the resident reported not having had a shower in a month, and there was no documented evidence that the resident received, was offered, or refused a shower during the previous 30 days. In a subsequent interview, the Nursing Supervisor confirmed there was no documentation that showers were offered or provided to this resident.
Failure to Maintain Kitchen Ventilation and Elevator in Safe Operating Condition
Penalty
Summary
Surveyors identified that mechanical equipment in the kitchen and back hall elevator was not maintained in safe, operating condition. During a kitchen tour, the ventilation system above the dishwasher was observed to have a broken, non-functioning fan. The Director of Dining Services reported that this ventilation system had been inoperable for over three weeks, and facility documentation showed that the local Department of Health had been notified of the inoperable ventilation system on February 13, 2026. No interventions were implemented to prevent the compromised ventilation from affecting food contact surfaces while the system remained unrepaired. The Administrator confirmed that the ventilation system was not working. During the facility tour, surveyors also observed that the back hall elevator had a broken ventilation fan with an accumulation of dust inside the elevator. Additionally, the bottom side panel wall of the elevator was cracked, and the door tracks contained an accumulation of dirt and debris. These conditions demonstrated a failure to keep essential mechanical equipment in safe and properly maintained condition, as required by 28 Pa. Code 201.18 (b)(3)(e)(2.1) Management.
Environmental Deficiencies in Supervised Bathing Areas and Resident Room
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, and comfortable environment on all three nursing units, specifically in supervised bathing areas and at least one resident room. On the first floor, the supervised bathing area had a broken and cracked floor, cracked and peeling rubber baseboard molding around the shower partition panel, a black substance on the base and corner of the shower partition panel separating the bathing and drying areas, and two stained ceiling tiles above the shower. On the second floor, the supervised bathing area had two stained ceiling tiles above the shower and two holes in the wall above the sink, and in one resident room the privacy curtain between two beds had orange and brown stains. On the third floor, the supervised bathing area privacy curtain had brown stains along the entire bottom, both shower stall floors had peeling blue paint, and a bag of wet linens was observed on the floor. These conditions were cited under 42 CFR 483.10(i) Safe Environment and related state regulations and had been previously cited on an earlier survey. No specific resident medical histories or conditions were described in the report, and the observations were focused on environmental conditions in common bathing areas and a shared resident room.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
A deficiency occurred when a resident with a history of bipolar disorder, depression, anxiety disorder, and memory impairments eloped from the facility. The resident, who was assessed as requiring supervision when walking and had impaired decision-making, was last seen by staff near the entrance. The facility's policy required staff to monitor residents at risk for elopement and to initiate a missing resident action plan if a resident could not be located. On the day of the incident, the resident was able to leave the facility, likely through the front door when it was opened for visitors. The receptionist, responsible for monitoring the entrance, did not observe the resident leaving. Subsequently, both a nurse and an aide noticed the resident was missing from the unit but did not initiate the missing resident action plan as required by facility policy. The facility did not become aware of the resident's absence until approximately 90 minutes later, when local police contacted them after finding the resident about two miles away. The resident was taken to the hospital for evaluation and was found to have no injuries related to the elopement. The failure to provide adequate supervision and to follow established procedures for monitoring and responding to a missing resident resulted in a deficiency and an Immediate Jeopardy situation.
Removal Plan
- The facility conducted a count of all residents to ensure all were accounted for.
- All doors were checked by maintenance and were found to be in good working order.
- All safety devices were checked to ensure they were in place, including electronic devices applied to residents to prevent doors from opening (Wanderguard).
- Resident 1's room was changed from the first floor to the third, and a Wanderguard was placed on the resident. The resident's care plan was updated to include risk for elopement.
- Elopement drills were conducted to ensure that all staff are proficient in the facility's procedure if a resident was missing. Additional future drills were scheduled.
- All residents were audited to ensure they were assessed for risk of elopement, and that care plans were in place for those at risk.
- The facility educated all staff in the facility on the facility's procedure for finding a missing resident. Receptionist staff were educated on their responsibilities to ensure only authorized people leave the building.
- The Director of Nursing or designee was to initiate audits and report results to the QAPI (Quality assurance, performance improvement) committee.
- All staff members were required to be trained on this plan before being permitted back to work.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored on two of three nursing units. On the second and third floor nursing units, surveyors observed unsecured medications and treatment supplies in multiple locations. Specifically, in one resident room, two bottles of iodoform gauze, an opened bottle of normal saline solution without a cap, and a tube of anti-fungal cream were found on a bedside table. In the second floor dining room, a box of Frosty Heat Lidocaine patches was left on a window sill. Additionally, on the third floor, the treatment cart was found unlocked and unattended in the hallway with a tube of medicated cream on top, accessible to anyone nearby. These observations demonstrate that the facility did not adhere to requirements for the secure storage of drugs and biologicals, as medications and treatment items were left unattended and accessible in resident and common areas.
Widespread Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment across all three nursing units, as evidenced by numerous deficiencies observed during a survey. On the first floor, issues included non-functional toilets in rooms 101 and 107, with the latter also having a floor mat with a strong odor. The second floor presented a range of problems, such as scattered black spots, holes in walls, stained and broken ceiling tiles, and dripping faucets in multiple rooms. Additionally, there were issues with missing or broken fixtures, such as toilet bar handles and dresser handles, and exposed drywall without paint or spackle. The third floor also exhibited significant environmental deficiencies. The shower room had hair and dirt covering the drain, and several rooms had broken or missing tiles, holes in walls, and unpainted spackle. In some rooms, the toilets were non-functional, and residents were observed laying directly on mattresses without sheets. Other issues included broken window blinds, missing curtains, and exposed heating elements in bathrooms. These observations indicate a widespread failure to maintain the facility in a condition that ensures the safety, sanitation, and comfort of residents, staff, and the public. The deficiencies were noted in various aspects of the facility's infrastructure, including plumbing, flooring, walls, and fixtures, affecting the overall living conditions for the residents.
Plan Of Correction
1. NHA, Maintenance, and housekeeping managers have reviewed the areas noted in the 2567. Facility have created work plans to address each of the areas based on priority with the maintenance teams. Facility have already started the process of renovating some of the rooms and areas noted in the 3/12/2025, 2567 DOH visit with an anticipated date of completion of 4/15/2025. 2. Once the areas in the 2567 are addressed, the environmental and maintenance team will conduct an audit of other resident care areas. NHA will create a phased plan, based on priority, to correct areas identified by the audit. 3. NHA/Designee will conduct education with housekeeping and maintenance department staff. Re-education will consist of best practices for maintaining a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 4. NHA/Designee will conduct facility environmental round audits weekly x 4 weeks, then bi-weekly x 1 month.
Environmental Deficiencies on First Floor Nursing Unit
Penalty
Summary
The facility failed to maintain a sanitary, functional, and comfortable environment for residents on the First Floor nursing unit. In resident room 107, there was a large hole in the wall behind the toilet, damaged ceiling tiles, and stained and missing floor tiles. The toilet bowl was soiled, and a basin filled with a bag of soiled linen was placed on top of the bathtub. The room lacked a paper towel holder, and personal hygiene items were cluttered on the window sill and dresser. The over-the-bed table was cracked and soiled, and the bed linens were stained. In the first floor dining room, several ceiling tiles were stained, one had a hole, and another was missing, exposing rusted pipes and wires. Room 101's bathroom had stained tiles, fallen wall tiles, a soiled toilet bowl, and a broken toilet seat. Room 108's bathroom had damaged floor tiles and a damaged wall behind the toilet. Room 104's bathroom had stained tiles and no paper towel holder. These observations indicate a failure to provide a safe and sanitary environment for residents.
Plan Of Correction
Maintenance will start to repair the hole in the wall behind the toilet in the bathroom and replace the damaged ceiling tile near the vent in the bathroom. The bathroom floor will be cleaned and missing floor tiles will be replaced as needed. Housekeeping cleaned the toilet bowl and removed the trash and basin from the tub in room 107. Maintenance will re-hang the paper towel holder. Nursing will remove the items stored on the window sill in room 107 and assist the resident in organizing their dresser. The facility will replace the over the bed table in room 107. Linen from the second bed was removed and replaced with clean linen. Maintenance department will replace ceiling tiles that are stained or missing in the first floor dining room. Housekeeping will clean the bathroom floor in room 101. Maintenance will re-affix the seven tiles to the bathroom wall in bathroom 101. Housekeeping cleaned the toilet bowl and repaired the toilet seat in the same bathroom. Maintenance will repair the damaged tile in room 108's bathroom and make repairs to the wall behind the toilet. Maintenance will re-hang a paper towel holder in room 104 bathroom and have the floor cleaned. The facility will conduct an audit of resident rooms and bathrooms to ensure a safe/comfortable/sanitary environment is maintained. NHA will work with Maintenance and Housekeeping departments to review the results and create a plan to address areas identified on this audit. Maintenance and Housekeeping staff will be re-educated on maintaining a sanitary, functional, and comfortable environment. NHA/Designee will conduct environment rounds weekly for 4 weeks, then as deemed necessary by the QAPI Committee. All results will be reported to the QAPI.
Deficient Resident Call System on First Floor
Penalty
Summary
The facility failed to provide a functioning resident call system for four out of six residents on the First Floor nursing unit. Observations revealed that the call lights in resident rooms were lit but did not produce an audible alert, preventing staff from responding to residents' needs. Resident 1, who was alert and oriented with diagnoses including heart disease and diabetes, reported that his call bell did not work, and staff did not respond due to the lack of sound. Similarly, Resident 5, also alert and oriented with diagnoses including adult failure to thrive and diabetes, confirmed that his call bell was non-functional. Resident 6, with major depressive disorder and anxiety, stated that the call bell light remained on continuously without sound, indicating it had not worked for some time. Additionally, Resident 2, who was alert and oriented with a diagnosis of sepsis, was found with an unplugged call bell that did not function even when plugged in. The Director of Nursing acknowledged that the call bell system on the First Floor had been inconsistently operational for a while. These deficiencies highlight a significant lapse in the facility's ability to ensure residents can effectively communicate their need for assistance, as required by regulations.
Plan Of Correction
1. Facility issued hand bells to Residents 1, 2, 5, and 6. 2. Facility will conduct a whole house audit on the call bell system and provide additional hand bells or fix the issues. 3. Facility has contacted an electrical company to assess repairs needed for the call bell system. Once the facility receives the service report, it will make a plan to address areas of the system that are in need of parts for repairs or replacement. Assessment was completed and awaiting to locate and to order necessary parts to repair or replace; unsure whether parts will be found by POC date. 4. Nursing Staff, IDT, and maintenance team will be re-educated on the need to provide a working call bell system. Re-education will include steps to take in the event a call bell is determined not to work. 5. NHA/Designee will conduct audits of the call bell system to ensure the system is maintained and functioning properly. Audits will be conducted 3 x week for 2 weeks, then weekly x 4. All results will be reported to the QAPI Committee.
Food Temperature and Palatability Deficiency
Penalty
Summary
Harborview Rehabilitation and Care Center at Doylestown was found to be non-compliant with the requirements for food service under 42 CFR Part 483, Subpart B. The deficiency was identified during an abbreviated survey conducted in response to complaints. The survey revealed that the facility failed to serve food at palatable and acceptable temperatures to residents on the First Floor nursing unit. Specifically, the food cart left the kitchen at 11:46 a.m. and arrived at the nursing unit at 11:47 a.m., but the distribution of food trays did not begin until 11:59 a.m., with the last tray served at 12:05 p.m. This delay resulted in the main entree of penne pasta and Bolognese sauce being served at 122 degrees Fahrenheit and the vegetables at 100 degrees Fahrenheit, both below the facility's standard of 130 degrees Fahrenheit for hot food. Interviews with residents and staff further confirmed the issue. The Director of Dietary stated that food should be served at 130 degrees Fahrenheit and distributed within 10 minutes of the cart's arrival. However, residents reported that their meals were often served cold and were not palatable. Residents 4 and 6 specifically mentioned that their lunch was cold and unappetizing, while Resident 5 described the food as "not good" and frequently cold. Resident 1 also noted that the food was often cold and unappealing, and Resident 2 did not consume much of her meal due to its temperature and taste. These findings indicate a failure to meet the regulatory requirements for food service in the facility.
Plan Of Correction
1. Nursing staff will be re-educated on passing meal trays timely to ensure meals are served at acceptable temperatures. Dietary staff will be educated on preparing food in order to maintain proper service temperatures. 2. Facility Food Service Director/Dietician will hold routine food committee meetings with residents. NHA will review food committee meeting minutes to ensure follow up to residents' concerns. 3. NHA/Designee will conduct test tray audits of resident meals. Audit will be conducted 3 x week for 2 weeks, then weekly x 4. All results will be reported to the QAPI Committee.
Sanitation and Equipment Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions and functional equipment in the dietary department. During an observation, it was noted that the first set of convection ovens was soiled with dark grease splattered on the racks and inside the doors, which were also rusted, making them difficult to close. The second set of convection ovens was found to be non-operational. Additionally, the range top stove had only three out of six burners functioning, with a black substance splattered and stained on the backsplash. Both bottom ovens of the range top stove were also non-operational. The Director of Dietary confirmed these issues during an interview.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to conduct required criminal background checks in a timely manner prior to employment for three of five newly hired employees. According to the facility's policy titled 'Abuse Neglect Exploitation Mistreatment, and Misappropriation of Property Prevention,' employees must be screened for a history of abuse, neglect, or mistreatment before employment. This includes obtaining information from previous employers and checking with licensing boards and registries. However, the review of employee files revealed that criminal background checks for Employees 3, 4, and 5 were not completed until several months after their hiring dates. Employee 3 was hired on July 30, 2024, Employee 4 on July 19, 2024, and Employee 5 on May 29, 2024, with all background checks conducted only on September 24, 2024. The Administrator confirmed in an interview that these checks were not completed as per the facility's policy.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident. A clinical record review revealed that the resident had an indwelling urinary catheter that was discontinued on July 29, 2024. However, the MDS assessment dated August 27, 2024, incorrectly indicated that the resident still had the catheter during the previous seven days. This discrepancy was confirmed by the Director of Nursing during an interview on September 26, 2024.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as identified in their comprehensive assessments. Resident 7, who was admitted with diagnoses including vascular dementia, kidney disease, and Crohn's disease, had a Minimum Data Set (MDS) Care Area Assessment (CAA) summary indicating that urinary incontinence should be addressed in the care plan. However, there was no evidence that interventions for urinary incontinence were included in Resident 7's care plan. Similarly, Resident 59, admitted with heart failure and renal insufficiency, had an MDS CAA summary noting that visual function, communication needs, and urinary incontinence should be addressed. The care plan for Resident 59 lacked documented interventions for these areas. The Director of Nursing confirmed the absence of documented evidence addressing these care areas in the care plans.
Facility Environment Deficiencies Across Nursing Units
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment across all three nursing units. On the first floor, issues included stained ceiling tiles above the nurses' station, a broken soap dispenser in a bathroom, and crumbling plaster near a shower. Additionally, there were broken light covers and a missing light cover in the shower room. On the second floor, several rooms had maintenance issues such as non-functioning hot water, cracked walls, holes under sinks, and missing or stained ceiling tiles with water dripping from the bathroom ceiling. A mechanical lift had an uncovered battery pack, and a piece of baseboard was detached at the dining room entrance. The third floor presented further deficiencies, including a metal hook on the corridor floor, dirty and sticky floors in rooms, and debris such as dirt, a plastic spoon, and an alcohol swab outside a room. Some rooms had peeling walls and broken floor tiles. A wheelchair in the hallway was found with an open pack of briefs and dirt on the seat cushion. Additionally, a rag and lift sling were left on a chair in the hallway, and the shower room had a marred door, a broken shower floor, and wet linens improperly stored on top of a garbage can. Batteries were found on the floor behind the garbage, and the floor was wet.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision to monitor a resident's whereabouts, resulting in an elopement incident. Resident 8, who had diagnoses including mood disorder, amnesia, bipolar disorder, and depression, was not located by the staff after being last seen before dinner on August 2, 2024. His dinner meal tray remained untouched in his room, indicating he had not returned. The facility was unaware of the resident's location until the following day. Interviews with the Administrator and the Assistant Director of Nursing confirmed that the resident did not have physician orders permitting unsupervised absence from the building.
Failure to Prevent Elopement and Maintain Safe Environment
Penalty
Summary
The facility failed to provide necessary supervision to prevent the elopement of a resident, resulting in an Immediate Jeopardy situation. The resident, who had a history of traumatic brain injury, seizures, and psychosis, was assessed as being at high risk for elopement due to impulsive and unsafe behaviors. Despite this assessment, no additional safety measures were implemented. On two separate occasions, the resident eloped from the facility, once stating an intention to self-harm and another time sustaining injuries after a fall. Additionally, the facility failed to maintain a safe environment free from accident hazards on one of its nursing units. A resident fell while transferring into a wheelchair, and the handrail he grabbed broke off the wall. An investigation revealed multiple areas on the first floor nursing unit where handrail returns were missing, posing a potential risk for further accidents. The deficiencies were identified through clinical record reviews, policy reviews, observations, and staff interviews. The facility's failure to implement adequate supervision and maintain a safe environment led to the Immediate Jeopardy situation and the identification of these deficiencies.
Removal Plan
- The facility immediately audited all residents identified as an elopement risk to ensure proper interventions were in place.
- The facility audited residents' most recent elopement assessments to ensure residents identified as at risk for elopement had interventions included on their care plans.
- The facility educated licensed nursing staff on the elopement assessment scoring system and care planning interventions. Licensed nursing staff were immediately educated on the elopement assessment and scoring system. Other staff, including agency staff, will be re-educated prior to the start of their next shift. 80% of facility licensed nursing staff were re-educated. The remaining 20% of staff will be educated.
- Staff in all other departments will be re-educated on the elopement policy and providing supervision to those residents identified as at risk for elopement. Facility staff were immediately educated on the elopement policy and providing supervision to those residents identified as at risk for elopement. Other staff, including agency staff, will be re-educated prior to the start of their next shift. 80% of facility non-licensed nursing staff will be re-educated. The remaining 20% of non-licensed staff will be educated.
- Staff providing resident supervision will not be tasked with other responsibilities.
- Activities department staff along with members of the interdisciplinary team will create a schedule for supervised Fresh Air Breaks for those residents requiring supervision.
- Facility will audit newly admitted residents' and current residents' assessments (based on the MDS schedule) weekly for three weeks and then monthly for three months. All results will be reviewed and discussed during facility Quality Assurance Performance Improvement (QAPI) meetings.
- Resident 1 supervision was immediately increased to constant supervision by staff (1:1).
- Resident 1 requested to be sent to the hospital for psychiatric evaluation and was subsequently returned to the facility, and remained on 1:1 supervision.
- Resident 1 was evaluated by facility psychiatric practitioner and his medications were adjusted. Resident 1 requested to be sent to hospital again for a psychiatric evaluation and signed voluntary commitment documents (Act 201). Resident was again transported to a psychiatric hospital.
Widespread Environmental Deficiencies in Nursing Units
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment across all three nursing units, as observed on July 1, 2024. On the First Floor, multiple rooms exhibited issues such as brown spots and stains on ceiling tiles, broken soap dispensers, and holes in the walls. The hallway and shower room also had significant deficiencies, including stained ceiling tiles, peeling paint, and damaged light fixtures. The shower room had ripped flooring, broken light covers, and was cluttered with soiled items. On the Second Floor, similar issues were noted, including leaking sinks, non-functioning hot water, stained privacy curtains, and missing ceiling tiles. The dining room and corridor had soiled walls and peeling baseboards. The Third Floor had dirty and sticky floors, broken tiles, and missing lighting fixtures. The shower room was particularly neglected, with trash on the floor, stained privacy curtains, and missing sink hardware. These observations indicate a widespread failure to maintain the facility's environment in a safe and sanitary condition.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed the individual needs of three residents as identified in their comprehensive assessments. Resident 1, who was admitted with a traumatic brain injury and psychosis, was identified as being at risk for elopement in an evaluation completed on May 9, 2024. However, this risk was not added to the care plan until June 21, 2024, indicating a significant delay in addressing the resident's needs. Resident 2, admitted with cerebral palsy and deafness, was found to have significant hearing impairment according to an MDS assessment on May 16, 2024. The facility identified communication as a problem in the Care Area Assessment summary, but failed to develop interventions to address this issue in the care plan. Similarly, Resident 3, who required assistance with activities of daily living, was identified as having a risk of falling in an assessment completed on December 6, 2023. Despite this, the care plan did not include interventions for fall prevention, and the resident subsequently fell on May 21, 2024. The Director of Nursing confirmed that these care plans did not include the necessary areas of concern.
Failure to Prevent Resident Elopement
Penalty
Summary
The Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility concerning the elopement of a resident, identified as an Immediate Jeopardy situation. The Administrator's job description includes ensuring compliance with resident care policies and maintaining adequate staffing to meet residents' needs. The Director of Nursing is responsible for developing and administering patient care programs. A resident, admitted to the facility and identified as high risk for elopement, managed to leave the facility unsupervised on two occasions. The facility did not implement interventions to prevent elopement until after these incidents occurred, indicating a failure to fulfill essential job functions and responsibilities, contributing to the Immediate Jeopardy situation.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to post current nurse staffing information as required. On July 1, 2024, at 9:15 a.m., it was observed that the nurse staffing information displayed in the lobby was dated June 27, 2024. This indicates that the facility did not update the staffing information daily, as mandated by regulations. This deficiency was previously cited on October 4, 2023, under 28 Pa Code 201.18(b)(3) Management.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident diagnosed with multiple sclerosis, depression, and anxiety. The resident was identified as being incontinent and required staff assistance for activities of daily living, as outlined in her care plan. On the morning of April 29, 2024, the resident was observed in bed and reported that her brief needed changing and that she had not received any care that morning. Despite being aware of her needs, staff did not provide assistance until 11:29 a.m., resulting in the resident waiting over 40 minutes for her soiled brief to be changed and to receive help getting out of bed.
Latest citations in Pennsylvania
Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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