Highland Manor Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Exeter, Pennsylvania.
- Location
- 750 Schooley Avenue, Exeter, Pennsylvania 18643
- CMS Provider Number
- 395566
- Inspections on file
- 30
- Latest survey
- September 11, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Highland Manor Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain cleanliness and order in the laundry department and the second hallway ice machine area. The ice machine lacked an air gap and drained directly into a floor drainpipe, with a sticky black substance present on the floor. In the laundry area, both dirty and clean sections were cluttered with debris, overflowing garbage, soiled items, and visible dirt, with clean linens and equipment in direct contact with the floor. These unsanitary conditions were confirmed by the Nursing Home Administrator.
Several residents experienced significant delays in staff response to call bells, particularly when needing incontinence care or toileting assistance. Residents reported frequent waits of over an hour, with some left in soiled briefs for extended periods. Staff were observed entering rooms, turning off call bells, and leaving without providing care, resulting in residents remaining in distress and without timely assistance.
A resident with severe cognitive impairment sustained a fractured humeral neck, but the LTC facility failed to conduct a thorough investigation into the injury's origin. The resident fell from bed during care, initially showing no signs of fracture or pain. Five days later, an X-ray revealed a humeral fracture, but the facility did not document any investigation into the injury's cause, attributing it to the fall without evidence.
A resident at risk for falls did not have the required bilateral fall mats in place as per their care plan. Observations confirmed the absence of mats, and staff acknowledged the oversight. The DON confirmed the facility's responsibility to implement care plan interventions.
A facility failed to follow physician orders for a resident with chronic lung conditions, who was prescribed the use of an incentive spirometer every two hours while awake. Despite the order, there was no documented evidence of the treatment being implemented from mid-November to mid-December. The issue was compounded when the resident's thoracic surgeon reported ongoing problems with the resident's lung not expanding, leading to further medical intervention.
A resident at risk for skin breakdown developed a deep tissue injury on the right heel despite having a care plan with interventions like floating heels and weekly skin assessments. The facility did not update the care plan with revised pressure-relieving interventions after the injury was discovered, and there was a lack of consistent completion of preventative tasks by staff.
A resident with low back pain and muscle weakness received narcotic pain medications without attempts at non-pharmacological interventions. The facility's records showed multiple administrations of Tramadol and Oxycodone without prior non-drug interventions, confirmed by staff interviews.
A physician failed to respond to a pharmacist's recommendation for a gradual dose reduction of Abilify for a resident with major depressive disorder and schizophrenia. The consultant psychiatric CRNP addressed the recommendation instead, and the physician did not document justification for the continued use of the medication.
The facility did not document the accounting and disposition of medications for a resident who was admitted and then discharged after expiring. Upon review, there was no evidence in the clinical record of the resident's remaining medications or their disposition, which was confirmed by the Nursing Home Administrator.
The facility did not maintain proper exit signage as required by NFPA 101 standards. An observation revealed that the illuminated exit sign at the B Hall Nurse's Station was partially obscured by a ceiling mirror, affecting one of two floors. This issue was confirmed during an exit interview with the facility's management team.
The facility did not maintain proper hazardous area enclosures, as observed in two locations. A storage room door was tied open, and a Laundry door needed adjustment to latch fully. These issues were confirmed during an exit interview with facility management.
The facility failed to maintain the automatic sprinkler system, as observed when sprinkler head assemblies in the Laundry area were found "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
The facility failed to maintain smoking regulations, as cigarette butts were found in a trash receptacle at the outdoor smoking location, and the area lacked a noncombustible receptacle with a self-closing lid for ashtrays. This deficiency was confirmed during an exit interview with facility management.
The facility did not adhere to the required fire drill procedures, as ten out of twelve drills were conducted within one week of each other, failing to meet the standard of varying times and conditions. This issue was confirmed by the Facility Administrator and management team.
The facility did not maintain fire door inspection records for the past year, with the last inspection conducted in March 2023. This deficiency affected both floors and was confirmed during an exit interview with the facility's management team.
The facility failed to maintain the generator set as required, lacking weekly battery voltage readings. This deficiency was observed during a documentation review and interview, affecting both floors. The absence of these readings indicates non-compliance with NFPA 101 and NFPA 110 maintenance protocols.
The facility failed to maintain a clean and safe environment, with observations of black substance buildup in showers, cracked tiles, and mold-like substances in various areas. Water damage and mildew odors were noted, along with peeling joint tape and brown water stains on ceilings. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to provide timely responses to residents' requests for assistance, as evidenced by five residents reporting extended wait times for staff to respond to their nurse call bell system. This resulted in residents being left in the bathroom for long periods, soiling themselves, and feeling the need to perform tasks independently due to delayed assistance. The DON confirmed the expectation for dignity and respect but could not explain the untimely responses.
The facility failed to ensure fresh water was consistently readily accessible to residents, affecting five out of 14 residents reviewed. Residents reported having to ask for water, and observations revealed outdated water cups and lack of accessible water. Staff interviews confirmed these findings, and the facility did not adhere to its policy of providing fresh water every shift and changing cups every three days.
Failure to Maintain Sanitary Conditions in Laundry and Ice Machine Areas
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and orderly environment in both the laundry department and the second hallway ice machine area. The ice machine was found to be draining directly into a floor drainpipe without an air gap, which is necessary to prevent contaminated water from backing up into the potable water supply or the ice consumed by residents. The floor beneath the drainage pipe was covered with a thick layer of sticky black material, indicating a lack of proper cleaning and maintenance. In the laundry department's dirty room, two slop sinks were filled with lint, debris, plastic hangers, and a plastic bag containing soiled wheelchair or lift belts, with a leaking faucet observed. The area also contained a dirty mop bucket with garbage and broken equipment, an overflowing garbage can, and floors littered with plastic, paper, dirty gloves, and clumps of lint, all with a buildup of sticky black substance. The clean area was similarly unkempt, with overflowing garbage, visible dirt, dried liquid stains, used gloves, and a large pile of lint on the floor. Clean linen and clothing racks had mechanical lift pads in direct contact with the floor, and a dirty washcloth was also found on the floor. These conditions were confirmed by the Nursing Home Administrator during the survey.
Failure to Respond Timely to Resident Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner that promotes and enhances each resident's dignity and quality of life by not responding in a timely manner to residents' requests for assistance. Multiple residents reported and were observed to have experienced significant delays in staff response to call bells, particularly when in need of incontinence care or assistance with toileting. For example, one resident activated her call bell at 9:41 AM for hygiene care after a bowel movement and did not receive assistance until 12:30 PM, despite her daughter notifying the nurse on duty. Another resident reported frequent waits of over an hour for staff to answer her call bell, resulting in repeated episodes of soiling herself. Observations confirmed that a resident was left in a visibly soiled brief for at least 35 minutes after activating the call bell, with staff entering the room, turning off the call bell, but not providing care until much later. Additional interviews revealed that residents often waited extended periods, sometimes over an hour, for staff to respond to their needs, especially during certain shifts and weekends. In some cases, staff would enter the room, turn off the call bell, and leave without providing the requested assistance, stating they would return but failing to do so in a timely manner. The DON confirmed that staff are not supposed to turn off call bells until care is provided. These actions and inactions resulted in residents being left in soiled conditions and experiencing distress while waiting for basic care needs to be met.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident who sustained a fractured humeral neck. The facility's policy requires that incidents of unknown origin be reported and investigated thoroughly, including reviewing events leading up to the incident and interviewing staff. However, the facility did not follow this policy in the case of the resident who was severely cognitively impaired and unable to explain the injury. The resident was involved in a fall from bed during care, where they landed on their knees on a fall mat. Initial assessments and X-rays did not reveal any fractures or acute findings, and the resident did not exhibit signs of pain immediately following the fall. It was only five days later that the resident showed signs of shoulder pain, and an X-ray revealed a humeral fracture, which was suspected to be a refracture of an old injury. Despite the discovery of the fracture, the facility did not document any attempts to investigate the source of the injury. The Director of Nursing confirmed that there was no evidence of an investigation into how the resident sustained the humeral neck fracture, and the facility attributed the injury to the fall without documented evidence. This lack of investigation into the injury of unknown origin constitutes a deficiency in the facility's compliance with its own policies and regulatory requirements.
Plan Of Correction
Step I - Unable to retroactively address for Resident 23. Step 2 - Review of last 30 days of falls to assure there was no occurrence of injury noted few days later attributed to fall. DON or designee. Step 3 - Education to nursing staff that occurrences of injury few days later require an investigation to assure injury was not related to something other than the fall. Staff educator or designee. Step 4 - Random audits on incidents with injury noted days later to assure the investigations occur. Weekly times 4, monthly times 2 - DON or designees. Step 5 - Results of audits to QAPI. Monthly times 2.
Failure to Implement Fall Prevention Plan
Penalty
Summary
The facility failed to implement a person-centered fall and injury prevention plan for Resident 104, who was at risk for falls due to decreased mobility, medications, and a history of falls. The care plan for this resident included the use of bilateral fall mats on the sides of the bed, which were initiated on December 13, 2024. However, observations on December 17, 2024, revealed that the mats were not in place while the resident was in bed, despite the care plan intervention requiring them. The deficiency was confirmed by Employee 5, a Registered Nurse, who acknowledged that the mats were not in place as per the care plan. Additionally, the Director of Nursing confirmed that it was the facility's responsibility to ensure the implementation of interventions developed in each resident's comprehensive person-centered care plan. The failure to implement the care plan intervention for bilateral mats was a lapse in mitigating the resident's risk of injury from falls.
Plan Of Correction
Step 1 - Mats were added to floor bilaterally when resident 104 was in bed. Step 2 - Review of current residents with falls in past 30 days to assure that fall mats on plan of care are in place for resident. DON or designee. Step 3 - Education to nursing personnel on importance of implementation of fall preventatives to prevent injuries on residents with falls are in place as specified on care plans. Staff educator or designee. Step 4 - Random audits for residents with fall risk to assure that care planned items are in place for resident. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI monthly times 2.
Failure to Implement Physician Orders for Lung Treatment
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a medical treatment for a resident with chronic lung conditions. Resident 15, who was admitted with diagnoses including pneumothorax and post coronary artery bypass, had a physician's order dated November 18, 2024, to use an incentive spirometer every two hours while awake. This device is intended to exercise the lungs and prevent infections by expanding them. However, a review of the resident's medication and treatment administration records from November 18, 2024, through December 17, 2024, showed no documented evidence that the spirometry orders were implemented. The deficiency was further highlighted when the facility received a call from the resident's thoracic surgeon on December 17, 2024, indicating that the resident's chest tube was not draining and the lung was not expanded, an issue that had persisted since the resident's hospital stay. The Director of Nursing confirmed during an interview on December 18, 2024, that there was no documented evidence of the spirometry treatment being carried out as prescribed. This lack of adherence to the physician's orders and failure to document the treatment contributed to the deficiency identified by the surveyors.
Plan Of Correction
Step 1 - Unable to retroactively fix this issue for resident 15. Step 2 - Review of residents in facility to assure there are no other residents that are using incentive spirometry without orders. DON or designee Step 3 - Education to nursing staff on need for orders from MD and documentation requirements for resident who are to utilize special equipment. Staff Educator or Designee Step 4 - Random audits of resident requiring special equipment to assure MD orders and required documentation is in place. Weekly times 4 monthly times 2 - DON or Designee Step 5 - Results to QAPI Monthly times 2
Failure to Prevent Pressure Injury Development
Penalty
Summary
The facility failed to prevent the development of a pressure injury for a resident identified as being at risk for skin breakdown. The resident, who had diagnoses including dementia, muscle wasting, and a history of a femoral neck fracture, was admitted with a care plan that included interventions such as floating heels while in bed, weekly skin assessments, and a pressure redistribution mattress. Despite these measures, a deep tissue injury (DTI) was discovered on the resident's right heel during morning care by a hospice aide. The injury was reported, and the facility's contracted wound healing specialists were notified. However, the facility did not revise the resident's care plan to include updated pressure-relieving interventions following the discovery of the injury. The resident's clinical records and facility documentation revealed a lack of consistent completion of preventative pressure injury tasks by staff. The Director of Nursing confirmed that the facility did not develop and implement necessary interventions to prevent the pressure injury after the resident's condition changed significantly and hospice services were initiated. This deficiency was identified as a failure to adhere to resident care policies and nursing services regulations as outlined in the Pennsylvania Code.
Plan Of Correction
Step 1 - Unable to retroactively fix resident 26, wound has already resolved. Step 2 - Review of residents deemed high risk for pressure ulcers to assure documentation in place or added to documentation for preventatives. DON or Designee. Step 3 - Education to nursing staff on completing and documenting preventative measures to prevention of pressure ulcers. Staff Educator or designee. Step 4 - Random audits of residents at high risk to assure preventative documentation is in place. Weekly times 4, Monthly times 2 - DON or designee. Step 5 - Results reported to QAPI Monthly times 2.
Failure to Attempt Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident by not attempting non-pharmacological interventions before administering narcotic pain medications. Resident 33, who was admitted with diagnoses including low back pain and muscle weakness, had physician orders for Tramadol and Oxycodone to be given as needed for pain. During November and December 2024, the resident received these medications multiple times without any documented attempts of non-pharmacological interventions prior to administration. The clinical record review and staff interviews confirmed that the facility did not consistently attempt or document non-pharmacological interventions before administering PRN narcotic pain medications. The Nursing Home Administrator and Director of Nursing acknowledged the lack of evidence for such interventions, which is a requirement under 28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.
Plan Of Correction
Step 1 - R-33 MAR was updated to include documentation of non-pharmacological interventions on 12/19/2024. Step 2 - Review of residents receiving prn pain medications to assure the "NPI" documentation in place. Step 3 - Education to licensed staff on the importance of offering and documenting non-pharmacological interventions prior to giving PRN pain medications. Step 4 - Random audits of residents receiving PRN pain medications to assure non-pharmacological interventions are in place and documentation completed. Weekly times 4 monthly times 2. DON or Designee. Step 5 - Results to QAPI Monthly times 2.
Physician Inaction on Pharmacist's Medication Review
Penalty
Summary
The attending physician failed to act upon pharmacist-identified irregularities in the medication regimen of a resident diagnosed with major depressive disorder and schizophrenia. The resident was prescribed Abilify, an antipsychotic medication, and the consultant pharmacist recommended a review for a gradual dose reduction. However, the attending physician did not document an appropriate response or provide justification for the continued use of Abilify in the resident's clinical record. Instead, the facility's consultant psychiatric CRNP responded to the pharmacy recommendation and signed off on it. An interview with the Director of Nursing confirmed that the attending physician did not provide the necessary documentation or justification for the medication regimen.
Plan Of Correction
Step 1 - Medical Director reviewed the pharmacy recommendations and noted the rational and justification for continued use of Abilify and reason for rejection of the GDR. Step 2 - Going forward when CRNP reviews and gives responses to pharmacy recommendations they will be reviewed and signed off by Medical Director. Step 3 - Education to CRNP's and medical director for need of review and signing off of pharmacy recommendations. Step 4 - Audits will be completed going forward of pharmacy recommendations to assure medical director signs off in agreement prior to adding to resident's chart. Monthly times 3. DON or designee. Step 5 - Results to QAPI monthly times 2.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 121 upon discharge. Resident 121 was admitted to the facility on November 19, 2024, and expired and was discharged on November 21, 2024. Upon review of the clinical record during a survey ending on December 19, 2024, there was no documented evidence of the accounting of the resident's remaining medications or their disposition. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 19, 2024, at 2:00 PM.
Plan Of Correction
Step I - Unable to retroactively address for closed chart for resident 121. Step 2 - Unable to go back and fix for any discharged resident. Step 3 - Education to licensed staff on disposition of medications for discharged and expired residents. Staff educator or designee. Step 4 - Random review of discharged residents to assure disposition of medications is completed and documented at time of discharge. Weekly times 4 monthly times 2. DON or designee. Step 5 - Results to QAPI monthly times 2.
Exit Signage Obscured by Ceiling Mirror
Penalty
Summary
The facility failed to maintain proper exit signage in accordance with NFPA 101 standards, specifically affecting one of two floors. During an observation on December 10, 2024, at 11:35 a.m., it was noted that the illuminated exit signage at the B Hall Nurse's Station was partially obscured by a ceiling mirror. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager later that day.
Plan Of Correction
- The illuminated exit signage by B side nurses' station was moved to provide visibility. - The exit signage throughout the facility was assessed to ensure exit signage is not obscured. - Maintenance Director will be educated by NHA/designee to ensure illuminated exit signages are visible and unobscured. - Illuminated exit signage will be randomly audited monthly x3 by Maintenance Director/designee to ensure signage is unobscured and visible. Trends will be reviewed at QAPI monthly.
Hazardous Area Enclosure Deficiencies
Penalty
Summary
The facility failed to maintain proper hazardous area enclosures in two specific locations, affecting one of the two floors. During an observation on December 10, 2024, it was noted that the storage room door within the Building Services Corridor was improperly held open by unapproved means, specifically being tied open. Additionally, the Laundry door was found to require adjustment to ensure it could fully latch. These deficiencies were confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
Plan Of Correction
- The unapproved means of holding the storage room door open was immediately removed. The laundry room door was adjusted to ensure the door closes properly. - The hazardous areas throughout the facility will be assessed to ensure doors are closed and free of unapproved means of holding the door open and doors closing properly. - Staff will be educated by Maintenance Director/designee to ensure doors to hazardous areas are not obstructed and properly closed. Maintenance Director will be educated by NHA/designee to ensure doors to hazardous areas close properly with door closures. - The doors to hazardous areas will be randomly audited monthly x3 by the maintenance director to ensure proper closure. Trends will be reviewed at QAPI meeting monthly.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain the automatic sprinkler system, as evidenced by an observation on December 10, 2024. During the inspection, it was noted that the automatic sprinkler head assemblies located within the Laundry area were "loaded" with lint. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager on the same day.
Plan Of Correction
- The sprinkler head assemblies located in the laundry area were immediately cleaned and free of lint. - The sprinkler head assemblies throughout the facility were checked to ensure clean and free of debris. - Maintenance Director will be educated by NHA to ensure sprinkler head assemblies are clean and free of debris. - The sprinkler head assemblies will be randomly audited by the maintenance director to ensure the sprinkler head assemblies are clean and free of debris. Trends will be reviewed at QAPI meeting monthly.
Smoking Regulations Deficiency
Penalty
Summary
The facility failed to maintain smoking regulations in one location, affecting one of two floors. During an observation on December 10, 2024, at 12:07 p.m., cigarette butts were found in a trash receptacle at the outdoor smoking location. Additionally, the area did not have a noncombustible receptacle with a self-closing lid for emptying ashtrays, as required by the smoking regulations. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager on the same day between 12:20 p.m. and 12:35 p.m.
Plan Of Correction
- The cigarette butts were immediately removed from the trash bin. A noncombustible receptacle, with self-closing lid was provided by the smoking area to empty ashtrays. - The facility will be assessed to ensure no other trash receptacles are used to discard cigarette waste. Staff will be educated by Maintenance Director/designee on proper disposal of cigarette butts. Maintenance Director will be educated by NHA/designee to ensure proper receptacles are available by the smoking area. - Smoking area will be audited monthly x3 by maintenance director/designee to ensure cigarette butts are disposed of properly and proper receptacles are available by the smoking area.
Failure to Conduct Fire Drills at Varying Times
Penalty
Summary
The facility failed to maintain proper fire drill procedures, as evidenced by the documentation review and interview. Specifically, it was observed that ten out of the twelve required fire drills were conducted within one week of each other, which does not meet the requirement of holding fire drills at varying times and conditions. This deficiency affected both floors of the facility. During the exit interview, the Facility Administrator, Facilities Manager, and Regional Facilities Manager confirmed the fire drill deficiencies.
Plan Of Correction
- Unable to correct the 10 out of 12 fire drills conducted within 1 week of one another. - Fire drills will be conducted on different days and times throughout the year. NHA will educate Maintenance Director/designee to ensure fire drills are conducted at least quarterly on each shift on different days and times throughout the year. - Fire drills will be audited monthly x3 by Maintenance Director/designee to ensure drills are completed at least quarterly on each shift on different days and times throughout the year. Trends will be reviewed at QAPI meeting monthly.
Failure to Maintain Fire Door Inspection Records
Penalty
Summary
The facility failed to maintain fire doors as required, affecting both floors of the building. During an observation on December 10, 2024, it was found that the facility lacked fire door inspection data for the previous twelve-month period, with the last inspection having been performed in March 2023. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager.
Plan Of Correction
- The fire doors were inspected and documented. - Fire doors will be inspected per regulation. - Maintenance Director will be educated on fire door inspection by NHA/designee. - Audit of fire door inspection will be conducted by maintenance director annually. Trends will be reviewed at QAPI meeting.
Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the generator set as required, which was evidenced by the lack of weekly battery voltage readings. This deficiency was observed during a documentation review and interview process, affecting both floors of the facility. The absence of these readings indicates a failure to comply with the maintenance and testing protocols outlined in NFPA 101 and NFPA 110, which require regular inspections and testing to ensure the generator's functionality. During an observation on December 10, 2024, at 11:28 a.m., it was noted that the facility did not have the necessary documentation for weekly battery voltage readings. This deficiency was confirmed during an exit interview with the Facility Administrator, Facilities Manager, and Regional Facilities Manager later that day. The lack of these readings suggests that the facility did not adhere to the required maintenance schedule, potentially impacting the reliability of the emergency power system.
Plan Of Correction
- Unable to correct missing generator battery voltage readings. - Battery voltage reading will be conducted weekly. - Maintenance Director will be educated on generator battery voltage readings and documentation of same. - Generator battery voltage readings will be audited monthly by maintenance director/designee to ensure voltage is accurate and documented. Trends will be reviewed at QAPI meeting monthly.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in an unclean and unsafe environment for residents. Observations revealed significant issues, including a black substance buildup on the caulking around the shower in the 200 hall and cracked tiles in the center hall shower room. Additionally, the soiled utility room in the center hall had a large amount of black mold-like substance on the walls around the hopper, which was leaking water, and there was a strong smell of mildew present. Further observations noted water damage and mold-like substances in various areas, including room [ROOM NUMBER], which had water damage to the ceiling, old brown water stains, and a dead earwig on a bath blanket. The center hallway also had water damage with brown stains on the ceiling and a piece of plywood covering a hole. The hallway in front of the dining room had brown water stains on the ceiling, with joint tape peeling away and a black substance underneath. These conditions were confirmed by the Nursing Home Administrator, indicating a failure to maintain a clean and sanitary environment for residents.
Failure to Respond Timely to Residents' Requests for Assistance
Penalty
Summary
The facility failed to provide care in a manner and environment that promotes each resident's quality of life by not responding timely to residents' requests for assistance. This was evidenced by experiences reported by five residents who stated that they had to wait extended periods for staff to respond to their requests via the nurse call bell system. Resident 14 reported being left in the bathroom for long periods when his assigned aide was off the floor, and staff did not provide necessary assistance. Resident 11 mentioned waiting over an hour to use the bathroom, resulting in soiling herself. Resident 9 experienced a 2.5-hour wait for assistance after activating the call bell, leading to soiling herself and requiring a complete change of bed linens. Resident 13 stated he had learned to do everything for himself due to long wait times for staff assistance. Resident 10 reported waiting over an hour for staff to answer his call bell, particularly during the evening shift, and felt that short staffing was a problem in the facility. The Director of Nursing (DON) confirmed that it is her expectation for all residents to be treated with dignity and respect but was unable to explain why multiple residents reported untimely staff response times. The deficiency was noted during a review of minutes from the Residents' Council meeting and resident and staff interviews, which highlighted the negative impact on residents' quality of life due to perceived inadequate staffing and delayed responses to their needs.
Failure to Ensure Fresh Water Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that fresh water was consistently readily accessible to residents, which is necessary to promote adequate hydration, resident preference, and comfort. This deficiency was observed in five out of 14 residents reviewed. Resident 11 expressed frustration about having to consistently ask staff for fresh drinking water, which was not routinely provided. Resident 9 reported that staff did not provide fresh drinking water every shift, and the only water she received was from her breakfast tray. Observations revealed that the water cups in the rooms of Residents 9, 12, and 13 were dated six days prior, and Resident 12's cup was out of reach. Resident 13 mentioned that he had to get water himself as no staff provided it. Resident 2 had no water cup or beverage available, despite being independent with self-feeding and drinking thin liquids. Interviews with staff confirmed the observations. Employee 1, a nurse aide, acknowledged that the water cups in the rooms of Residents 11, 12, and 13 were dated six days ago. Employee 2, an LPN, confirmed the absence of fresh water or another beverage for Resident 2. The Director of Nursing (DON) stated that the facility policy required water pass to be conducted once per shift and as needed, with straws, cups, and lids to be changed every three days. The DON and the Nursing Home Administrator (NHA) confirmed that the facility failed to adhere to this policy, resulting in the deficiency of not providing clean water drinking cups every three days and not ensuring fresh ice water was readily accessible to residents as preferred to promote adequate hydration and comfort.
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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